Every finding on record at Osage Beach Rehabilitation and Health Care Center

Based on interview and record review, facility staff failed to report an allegation of a physical altercation between two residents (Resident #1 and #2) to the State Survey Agency (SSA) within the required two hour timeframe. The facility census was 80.1. Review of the facility's Administrative Procedure Manual, Reporting policy, dated 11/28/16, showed any partner with either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately. All alleged violations and all substantiated incidents will be reported immediately to the administrator or her/his designated representative and to other officials in accordance with State and Federal law (including to the State survey and certification agency). 2. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/16/26, showed staff assessed the resident as:-Severely cognitively impaired;-Did not exhibit physical or verbal behavioral symptoms directed towards others;-Did exhibit other behavioral symptoms directed towards other one to three days during the lookback period.Review of the resident's care plan, dated 04/15/26, showed the resident occasionally exhibits behaviors to include wandering and verbal outbursts. The care plan did not contain directions for staff on physical behaviors directed toward others.Review of the resident's progress notes, dated 06/28/2026, showed staff documented another resident witnessed Resident #3 and Resident #4 in a verbal altercation outside of another resident's room. Staff documented Resident #3 was walking by and Resident #3 and Resident #4 began threatening each other and putting their fists up at each other. Review showed staff documented Resident #4 then fell backward and hit his/her head on the wall. Staff documented Resident #4 said he/she pushed Resident #3 and Resident #3 said he/she punched Resident #4 on the left cheek. Review showed the progress notes did not contain documentation staff notified the SSA. 3. Review of Resident #4's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and did not exhibit physical or verbal behavioral symptoms directed towards others.Review of the residents care plan, dated 06/10/26, showed the resident was at risk for behaviors and was at risk for as evidenced by delusions, hallucinations, can become angry towards others at times, and not always redirectable.Review of the resident's progress notes, dated 06/28/2026, showed staff documented another resident witnessed Resident #3 and Resident #4 in a verbal altercation outside of another resident's room. Staff documented the Resident #3 was walking by and Resident #3 and Resident #4 began threatening each other and putting their fists up at each other. Review showed staff documented Resident #4 then fell backward and hit his/her head on the wall. Staff documented Resident #4 said he/she pushed Resident #3 and Resident #3 said he/she punched Resident #4 on the left cheek. Review showed the progress notes did not contain documentation staff notified the SSA. 4. During an interview on 07/08/26 at 1:33 P.M., Licensed Practical Nurse (LPN) A said no one witnessed a physical altercation between the residents. He/She said a resident and another aide witnessed the residents putting their fist up at each other and have a verbal altercation. He/She said Resident #3 told him/her Resident #4 punched him/her in the face and Resident #4 said Resident #3 pushed him/her. He/She said he/she did know if it happened or not. He/She said he/she did report the information to the Director of Nursing (DON), who is responsible to report to SSA.During an interview on 07/10/26 at 1:56 P.M., the DON said allegations of physical abuse should be reported to the SSA within two hours. He/She said LPN A called him/her at home after the incident and told him/her what happened. He/She said the incident was not witnessed by staff but was witnessed by Resident #5 who said he/she did not observe the residents hitting each other. He/She said the LPN told him/her Resident #4 said he/she pushed Resident #3 and Resident #3 had hit Resident #4. He/She said since Resident #5 was cognitively intact and reported he/she witnessed the incident, but did not see a physical altercation, so he/she did not report the incident to SSA in the required two hours. He/She said he/she did not know Resident #5 did not witness the entire altercation and the resident reported he/she did not witness a physical altercation. 3053019

1. Review of the facility's Administrative Procedures Manual policy, dated 11/28/16, showed patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow-through designed to minimize the risk of conduct.Review of the facility's policies, undated, did not contain a policy to direct staff on the Care Plan process and instead staff were directed to refer to the RAI Manual. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/25/26, showed staff assessed the resident with severe cognitive impairment.Review of the resident's progress notes, dated 06/23/2026, showed staff documented the resident was seen holding hands and kissing with Resident #2 on the lips reported by a Certified Nurse Aide (CNA). Staff documented the CNA separated them without any objections from either one and the nurse interviewed both residents and neither one remembers anything or if it even occurred. Review of the resident's care plan, 06/26/26, showed the resident believed that another resident is his/her child and will hold his/her hand may give or get a kiss on cheek or lips. Reviewed showed the care plan did not contain staff intervention for hand holding and may give or get a kiss on cheek or lips. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment.Review of the resident's progress notes, dated 06/23/2026, showed staff documented the resident was seen holding hands and kissing Resident #1 on the lips reported by a CNA. Staff documented the CNA separated them without any objections from either one and the nurse interviewed both residents and neither one remembers anything or if it even occurred.Review of the resident's care plan, 06/26/26, showed the resident believed that another resident is his/her child and will hold his/her hand may give or get a kiss on cheek or lips. Reviewed showed the resident's care plan did not contain documentation of an intervention.Review of the facility's incident report, dated 06/23/26, showed Resident #2 leaned forward and gave Resident #1 a peck on the lips and they were holding hands. During an interview on 07/08/26 at 9:49 A.M., the Director of Nursing (DON) said Resident #1 and Resident #2 had a history of kissing each other and holding hands and he/she added the incident to the care plan. He/She said he/she did add the goal to the care plan, but did not add an intervention.During an interview on 07/08/26 at 1:25 P.M., the Care Plan Coordinator said staff are directed to implement a new intervention after each behavior. He/She said he/she did know the resident's had a prior history of holding hands or kissing until the recent incident. He/She said thought the DON had added interventions in Resident #1 and Resident #2 care plan. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment.Review of the resident's care plan, dated 04/15/26, showed the resident occasionally experiences behaviors to include wandering and verbal outbursts. The care plan did not contain direction for staff in regard to physical behaviors directed toward others.Review of the resident's progress notes, showed the following entries:-On 03/26/2026, staff documented Resident #3 went into another resident's room and when the other resident attempted to get the resident out of his/her room, he/she swung and punched him/her in the right shoulder;-On 04/29/2026, staff documented Resident #3 was found in another resident's room and attempted to flip the bedside table in the room;-On 05/19/2026, staff documented Resident #3 sat at the end of the roommates bed. The resident was cussing at the other resident and telling him/her/her to get out of his bed or he/she would make him/her;-On 06/19/2026, staff documented Resident #3 wandered the halls and went to another resident's room. The notes showed Resident #3 took his/her walker and struck the other resident's electric chair then attempted to strike him/her. Staff documented staff approached him/her and he/she became violent and threatened to strike nurse and raised his/her hand to strike the other resident, but there was enough distance, so he/she did not make contact with the other resident redirected.;-On 07/06/2026, staff documented the resident became angry and aggressive towards his/her roommate. Staff documented the resident began swinging his/her fist at the other resident. During an interview on 07/08/26 at 1:25 P.M., the Care Plan Coordinator said he/she did know the resident had a history of physical and verbal altercations with resident and staff. He/She said he/she did not add an intervention for physical aggressive behaviors due to an oversight to not have behavior listed in the care plan. 5. During an interview on 07/10/26 at 1:25 P.M., the Care Plan Coordinator said staff are directed to implement a new intervention after each behavior. He/She said there was no audit system in place to ensure the interventions were added tot the resident's care plan.During an interview on 07/10/26 at 1:56 P.M., the DON said he/she expected new interventions to be added to the resident's care plan when there was a change in behavior. He/She said changes in resident behaviors were discussed during morning meetings and the care plan coordinator was responsible for ensuring the changes were added to the resident's care plan. He/She said there was no audit system to ensure new interventions are added to the care plans. 3053019

Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #2) remained free from sexual abuse, when a resident (Resident #1) entered Resident #2's room and touched his/her chest. The facility census was 81.The administrator was notified on 06/22/26 of Past Non-Compliance which occurred on 06/17/26. The Administrator and Director investigated, notified the residents' responsible parties, and in-serviced staff regarding abuse, sent Resident #1 to the hospital for evaluation, and initiated one on one monitoring. Resident #2 had additional therapy services initiated as a result of this. Staff corrected the deficient practice on 06/18/26. 1.Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 2/1/23, showed Sexual Abuse is defined as non-consensual sexual contact of any type with a patient that includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. 2.Review of the facility's internal investigation report, dated 6/17/26, showed staff documented Resident #1 came into Resident #2's room and placed his/her hand down Resident #2's shirt, touched Resident #2's chest. Resident #2 said Resident #1's hands were cold. Resident #2 said it caused him/her to have childhood memories of being molested. Staff documented 15-minute checks were initiated.3.Review of Resident #1's face sheet showed the resident admitted on [DATE] with diagnoses of vascular dementia with psychotic disturbance, delusional disorders and anxiety disorder. Review of the resident's plan of care, dated 6/18/26, showed staff assessed the resident with inappropriate sexual behaviors and wanders into other residents' rooms. Staff were directed to administer medications as ordered, monitor and observe for change in and behavior, be direct and prompt when telling the resident his behavior is inappropriate and restrict harmful physical action in a cautious non harmful manor.Review of the resident's nurse's notes, dated 6/10/26, showed staff documented the resident was in another residents room and kissed the resident on the cheek. The resident was redirected. Resident prior to incident was wandering the halls and was redirected from other rooms. During an interview on 6/22/26 at 8:26 A.M., the Director of Nursing (DON) said the facility sent Resident #1 to the hospital but there were no open beds available. He/She said Resident #1s medication had previously been changed but did not have time to take effect. He/She said Resident #1 needs a locked unit.4.Review of Resident #2's quarterly MDS, 4/3/26, showed facility staff assessed the resident as cognitively intact, rejects care and diagnoses of seizures and anxiety disorder. Review of the resident's nurses notes, dated 6/17/26, showed staff documented they responded to a resident shouting help, upon entering room, the resident said there was a resident in his/her room going through his/her things and he/she asked the other resident to stop then the resident came over to him/her and reached over the walker and stuck his/her hand in his/her shirt and groped his/her chest. The resident yelled stop and help and pressed the call light. During an interview on 6/22/26 at 8:26 A.M., The DON said Resident #2 has a history of being sexual assault by his/her family members. He/She said Resident #2 has stayed in his/her room since the incident because he/she does not want to interact with Resident #1. During an interview on 6/22/26 at 9:07 A.M., the administrator said Resident #2 has a history of being sexually abuse from his/her family. He/She said Resident #2 has seen his/her therapist since the incident to help him/her transition. During an interview on 6/22/26 at 9:15 A.M., Resident #2 said Resident #1 entered his/her room and started to go through his/her stuff. He/She said the resident then put his/her hand down his/her shirt and touched his/her chest. He/She said he/she was molested as a child, and this brought it all back. He/She said if he/she had a belt he/she would have beat the resident with it. He/She said he/she does not want to face the resident, never wants to see him/her again. During an interview on 6/22/26 at 9:35 A.M., Graduate Registered Nurse (GRN) said he/she heard Resident #2 yell from his/her room for help. He/She entered the room and Resident #2 said Resident #1 had come into his/her room and touched his/her chest. He/She said he/she went to find Resident #1 to ensure he/she was not in another resident's room and had another nurse sit with Resident #2 while he/she went to report the allegations. During an interview on 6/22/26 at 8:26 A.M., the DON said all staff were educated for Resident #1 to be on one on ones and then 15-minute checks when in room, but if up and wandering he/she is always with a staff. Complaint # 3047620

Based on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident (Resident #1) in a manner to prevent accidents when the lift hit a television mounted on the wall and the television fell and struck the resident and he/she sustained an injury to his/her head and arm. The facility census was 77. 1. Review of the Electric Portable Patient Lift owner's operator and maintenance manual, undated, showed the guide recommends two persons transfer in circumstance of combativeness, obesity, contracture etc. It is the responsibility of each facility or medical professional to determine if a one or two person transfer is more appropriate. Review of the facility's Transfers and Lifts policy, undated, showed the lift must be used with two staff members. 2. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool, dated 6/5/25, showed staff assessed the resident as follows: -Cognitively intact; -Totally dependent for transfer assist with two or more staff; -Paraplegia (muscle weakness or paralysis on the lower half of the body); -Obesity; -Utilized wheelchair for mobility. Review of the residents plan of care, dated 12/18/24, showed staff assessed the resident as required the use of the mechanical lift for all transfers with two person assist. Review of the resident's nurse notes, late entry on 6/17/25, showed staff documented on 6/13/25 at 6:30 P.M,. Certified Nursing Assistant (CNA) A reported the television (TV) in the residents room fell off the wall while transferring the resident to bed from the wheelchair. CNA A reported the TV did not hit the resident and there were no red marks/areas on the resident and the resident denied pain. During an interview on 6/17/25 at 9:46 A.M., the resident said CNA A had him/her in the mechanical lift with no other staff present and the mechanical lift struck the TV on the wall and came down and hit him/her in the head and the arm. He/She told CNA A it hit him/her in the head and he/she felt the knot on his/her head and said he/she would get help. He/She said staff often only use one staff assist when they utilize the mechanical lift and that concerns the resident because he/she is paralyzed. During an interview on 6/17/25 at 10:39 A.M., Registered Nurse (RN) B said he/she was told by CNA A the TV fell off the wall during a transfer but did not hit the resident. He/She said he/she worked the next day and the resident never said anything further to him/her. He/She said he/she was not aware if CNA A had performed the mechanical lift on his/her own or had staff present but it is policy to always have two staff present during a mechanical lift. During an interview on 6/17/25 at 10:47 A.M., CNA A said he/she was raising the mechanical lift to assist the resident to bed and the top of the lift hit the TV and the TV came off the wall. He/She said he/she saw the TV hit the residents arm and the resident said it hit his/her head. He/She said he/she checked the residents head and there was no swelling. He/She said he/she reported the incident to RN B and told him/her it hit the residents arm and his/her head. He/She said he/she was operating the mechanical lift by him/herself. He/She said they always try to have two staff during mechanical lifts. CNA A said he/she couldn't remember why her/she did not have another staff in the room to assist with the mechanical lift transfer. MO00255879

Based on interviews and record review, facility staff failed to notify the physician in a timely manner of an injury to one resident (Resident #1) when a television fell from the wall and struck the resident in the arm and head. The facility census was 77. 1. Review of the facility's change in patient status Policy, revised 3/2024, showed the charge nurse is to notify the physician. Review of the facility's Accidents and Untoward Occurrences Policy, reviewed May 2025, showed staff are directed to notify the physician and document content of discussion. 2. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool, dated 6/5/25, showed staff assessed the resident as follows: -Cognitively intact; -Guillain-Barre syndrome (immune system attacks the nerves), Paraplegia (muscle weakness or paralysis on the lower half of the body). Review of the resident's nurse notes, late entry on 6/17/25, showed staff documented on 6/13/25 at 6:30 P.M,. Certified Nursing Assistant (CNA) A reported the TV in the residents room fell off the wall while transferring resident to bed from his/her wheelchair. CNA A reported the TV did not hit the resident and there were no red marks/areas on the resident and reported no pain. Review of the residents nurses notes did not contain documentation staff notified the physician of the change in condition. During an interview on 6/17/25 at 10:39 A.M., Registered Nurse (RN) B said he/she should have called to notify the physician. He/She said he/she did not realize the resident was struck by the television. During an interview on 7/2/25 at 8:08 A.M., the Director of Nursing (DON) said he/she expects all staff to notify the physician of any accidents, especially involving the head. He/She said the rule is when in doubt, call the physician and document. He/She said he/she does not know why the nurse did not call the physician. During an interview on 7/2/25 at 10:02 A.M., the administrator said he/she expects the nurse to assess any accidents and to consult with the physician to see what to do. He/She does not know why the physician was not contacted. MO00255879

Based on observation, interview, and record review, facility staff failed to provide a barrier for the glucometer (a device for monitoring blood sugars) supplies for seven residents (Resident #7, #26, #52, #55, #61, #74, and #79) out of seven sampled residents. Facility staff failed to wear gloves while administering insulin to three residents (Resident #52, #61, and #74) out of seven sampled residents. Facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness).The facility census was 75. 1. Review of the facility's policy titled, Cleaning and Disinfecting Blood Glucose Meters, dated 2019, showed facility staff were directed to apply gloves before performing a blood glucose test, glucose monitoring, administration of insulin, and any other procedure that involved potential exposure to blood or body fluids. 2. Review of Resident #7's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 02/27/25 at 7:50 A.M., showed Registered Nurse (RN) C obtained a blood sample and placed the glucometer directly on the dining room table without a barrier. 3. Review of Resident #26's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 02/27/24 at 7:45 A.M., showed RN C obtained a blood sample and placed the glucometer directly on the dining room table without a barrier. 4. Review of Resident #52's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 02/25/25 at 12:02 P.M., showed RN B obtained a blood sample and placed the glucometer directly on the dining room table without a barrier. Observation on 02/25/25 at 12:03 P.M., showed RN B did not wear gloves when he/she administered insulin to resident. 5. Review of Resident #55's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 02/27/25 at 8:10 A.M., showed RN C obtained a blood sample and placed the glucometer directly on the dining room table without a barrier. 6. Review of Resident #61's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 02/25/25 at 12:05 P.M., showed RN B obtained a blood sample and placed the glucometer directly on the dining room table without a barrier. Observation on 02/25/25 at 12:06 P.M., showed RN B did not to wear gloves when he/she adminstered insulin to resident. 7. Review of Resident #74's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 02/25/25 at 12:10 P.M., showed RN B obtained a blood sample and placed the glucometer directly on the dining room table without a barrier. Observation on 02/25/25 at 12:11 P.M., showed RN B did not to wear gloves when he/she administered insulin to resident. 8. Review of Resident #79's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 02/27/25 at 8:00 A.M., showed RN C obtained a blood sample and placed the glucometer directly on the dining room table without a barrier. 9. During an interview on 02/25/25 at 2:13 P.M., RN B said he/she should have not put the glucose meter on the table due to contamination. He/She said he/she should wear gloves when having the potential for coming in contact with bodily fluids. He/She said when administering insulin, you could have the potential for coming in contact with bodily fluids. He/She said he/she does not have an explanation why he/she didn't wear gloves while administering insulin. During an interview on 02/27/25 at 08:24 A.M., RN C said he/she does not see a problem with putting the glucose meter on the table after obtaining a blood sample. He/She agreed it could be a risk for blood splitter where residents are eating and risk for contamination. During an interview on 02/27/25 at 4:30 P.M., the Director of Nursing (DON) said nurses should wear gloves when administering insulin. He/She said not wearing gloves is a risk of exposure to blood. He/She said staff should probably not lay the glucose meter on the dining room table because there could be a chance another resident could get ahold of the meter with blood still on the glucose strip. He/She said or if the nurse gets blood on glove and then touches the glucose meter and sets the meter on the table there is a chance of blood contamination. During an interview on 02/27/25 at 5:46 P.M., the administrator said it is probably not best practice to lay the glucose meter on the dining table due to potential of cross contamination. He/She said he/she is not sure if gloves should be worn while administering insulin. 10. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: The bacterium Legionella can cause a serious type of pneumonia called Legionnaire's Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit; -Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Water Quality Management Program, dated November 2023 showed procedures included: -Implement a water management program that considers the ASHREA (American Society of Heating, Refrigerating and Air-Conditioning Engineers) standards and the CDC (Centers for Disease Control and Prevention) toolkit that includes control measures such as physical controls, temperature management, checking disinfectant levels, visual inspections and environmental testing for pathogens; -Document the results of the testing and corrective actions taken when water control limits are not met. Review of the facility's EPP policy showed control measures included: -Visual inspection and checking disinfectant levels at the water main entering the facility; -Visual inspection of ice machines; -Checking disinfectant levels at sinks/showers; -Checking temperatures at water heaters, all sinks and showers and the kitchen. Review of the facility's EPP showed the control measures did not indicate normal ranges or frequencies. Review of the program control measures and corrective actions process flow diagram indicated staff were to document all results of routine control measure monitoring and corrective actions where applicable. Review of the Legionella Water Management Plan Review task from the facility's computerized preventative maintenance program (TELS), marked done on time May 1, 2024, showed instructions for staff to: -Identify how often routine monitoring and testing are completed; -Decide where control measures should be applied and how to monitor them. Staff will need to monitor and measure if preventative measures are working; -Establish ways to intervene when control limits are not met; -Document and communicate all activities. Review of the facility's Water Quality Management Program records, showed the records did not contain: -Acceptable ranges for control measures; -Corrective actions to take if control measures are outside acceptable range; -Documentation of routine monitoring of control measures. During an interview on 02/26/25 at 9:50 A.M., the maintenance director said he/she was not familiar with control measures in the water quality management program. The maintenance director said he/she had never looked at the facility specific risk assessment in the water plan. The maintenance director said he/she used a swimming pool test strip to test water quality. The maintenance director said he/she followed the normal ranges listed on the bottle but he/she did not document results and never took any action based on results. During an interview on 02/26/25 at 3:35 P.M., the administrator said he/she and maintenance staff were responsible for implementing the water quality management program. The administrator said he/she had reviewed the plan but was not very knowledgeable of the contents. The administrator said he/she was not aware of any specific inspections or action the maintenance director performed as part of the water management program. The administrator said specific control measure ranges and corrective actions should be included in the water management plan but he/she could not locate them. 45564 50422

Based on interview, and record review, facility staff failed to meet professional standards of care when staff did not document an order for code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) for one Resident #9, did not document a clear order for code status for one Resident #37, and did not document clinical condition or symptoms for use of medications for three Residents (#75, #79, and #80) out of 18 sampled residents. The facility's census was 75. 1. Review of the facility's policy titled, Code Status/Advance Directives Procedure, dated [DATE], showed: -Nursing will discuss with the patient, if unable-the legal/patient representative about code status Do not Resuscitate (DNR) versus cardiopulmonary resuscitation (CPR) as well as other life sustaining measures on the Physician's Orders for Life Sustaining Treatment (POLST) Form; -The POLST Form is completed by Nursing and forwarded to Health Information Department for physician signature; -Code status documentation by nurse: Enter order for DNR versus CPR; -Audit Process: Health Information Department will audit all new admissions by verifying the order, banner icon, and POLST Form (if in place all match). Health Information Department will continue to audit on a monthly basis by running the Advance Directives Report and comparing to ensure Resident Banner, order and POLST form (if used) all match. 2. Review of Resident #9's annual Minimum Date Set (MDS), a federally mandated assessment, dated [DATE], showed staff assessed the resident as moderately cognitively impaired, and readmitted to facility on [DATE]. Review of the resident's Physician's Order Sheet (POS), dated [DATE] through [DATE], showed the POS did not contain documentation of an order for code status. During an interview on [DATE] at 10:28 A.M., the Director of Nursing (DON) said each resident should have an order for code status to indicate either full code (CPR) or DNR. He/She said the admitting nurse is responsible to verify the code status and enter the order, and the health information staff audits after. During an interview on [DATE] at 1:43 P.M., the resident said he/she is a full code and would like staff to perform CPR if needed. During an interview on [DATE] at 1:32 P.M., the Clinical Coordinator said the resident did not have an order for code status and should have one on his/her POS. During an interview on [DATE] at 4:28 P.M., the Health Information staff said he/she was not sure why the resident did not have an order for CPR or DNR since [DATE], when the order was apparently discontinued and did not get re-entered. He/She said he/she completes quarterly audits, but does not necessarily check for code status orders on residents who have been at the facility for a while. 3. Review of Resident #37's admission MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and admitted on [DATE]. Review of the resident's POS, dated [DATE] showed an order for a DNR code status. Review of the resident's POS, dated [DATE] showed an order for a Full Code status. During an interview on [DATE] at 4:48 P.M., the DON said the resident should not have two different orders for his/her code status and did not know why he/she did. He/She said the admitting nurse is responsible to verify the code status and enter the order, and the health information staff audits after. 4. During an interview on [DATE] at 1:32 P.M., the Clinical Coordinator said each resident should have an order for either DNR or CPR, and the admitting nurse is responsible to verify the code status and enter the order. He/She said the health information staff is responsible to check orders a few days after admission and ensure each resident has an order for CPR or DNR and if not, notify the nurse for follow up. During an interview on [DATE] at 4:28 P.M., the health information staff said the nurse is responsible to document the order for code status on admission, he/she audits the medical records a few days after and notifies the nurse of any discrepancy or missing orders. During an interview on [DATE] at 5:48 P.M., the administrator said each resident should have a physician's order for code status to indicate either DNR or CPR. He/She said the nursing staff is responsible to ensure there is an order and the health informatiom department monitors. 5. Review of the facility's policy titled, Medication and Treatment Orders, dated [DATE], showed orders for medications and treatments will be consistent with principles of safe and effective order writing. Orders for medications must include a clinical condition or symptoms for which the medication is prescribed. 6. Review of Resident #75's Entry Tracking MDS, dated [DATE], showed the resident admitted to the facility on [DATE]. Review of the resident's POS, dated [DATE] to [DATE], showed an order for Cefdinir (antibiotic) capsule 300 milligrams (mg), one capsule by mouth twice daily for ten days. Review showed the POS did not contain documentation of a clinical condition or symptoms for the Cefdinir medication. During an interview on [DATE] at 10:53 A.M., the Infection Preventionist/Clinical Coordinator said the resident recently admitted with antibiotic treatment for a urinary tract infection. He/She said on weekends, the admitting nurse is responsible to ensure an antibiotic medication has an indication for use, and he/she is responsible on weekdays, but had not had a chance to review the resident's medications yet. 7. Review of Resident #79's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted to facility [DATE]; -Diagnoses of seizure isorder or epilepsy, Schizophrenia (a chronic mental illness that affects how people think, feel and behave); -Received antipsychotic medication with indication noted. Review of the Resident's POS, dated [DATE] through [DATE], showed an order for Aripiprazole (an antipsychotic medication used to treat schizophrenia) 30 mg tablet, one tablet by mouth daily at 10:30 A.M. Review showed the POS did not contain documentation of a clinical condition or symptoms for the Aripiprazole medication. 8. Review of Resident #80's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted to facility [DATE]; -Diagnoses: Hypo-osmolality and hyponatremia (excess water in the body with low sodium levels in the blood), high blood pressure. Review of the Resident's POS, dated [DATE] through [DATE], showed the physician ordered Amlodipine (used to treat high blood pressure) 5 mg tablet, one tablet by mouth daily at 10:30 A.M. Review of the POS showed it did not contain documentation of a clinical condition or symptoms for the Amlodipine medication. 9. During an interview on [DATE] at 11:00 A.M., the Infection Preventionist/Clinical Coordinator said he/she said the facility recently started using an external company to enter admission orders for residents and the process has not being going smoothly, but he/she expects the admitting nurse to verify all residents' admission orders have an indication for use within the first four hours of admission and notify him/her or the DON for follow-up. During an interview on [DATE] at 1:26 P.M., the MDS Coordinator said residents' medications should have an indication for use and he/she had not seen that on all medication orders at the facility, so he/she was not sure if it was required by facility staff. During an interview on [DATE] at 1:32 P.M., the Infection Preventionist/Clinical Coordinator said all medications listed on the residents' POS should have an indication for use regardless of the type of medication. He/She said he/she is responsible to ensure as needed medications and antibiotics have an indication for use, and the DON oversees all other medications. During an interview on [DATE] at 4:48 P.M., the DON said each prescribed medication listed on residents' POS should have an indication for use regardless of the type of medication. He/She said Resident #79 and #80 admitted to the facility almost two weeks prior and all their medications should have an indication for use. He/She said the pharmacist also reviews the medications for new admissions and give recommendations for medications without an indication for use. He/She said he/she is responsible to oversee but he/she is currently behind. During an interview on [DATE] at 5:17 P.M., Licensed Pharmacist G said he/she tries to review the medications for residents newly admitted within one week and can complete the medication reviews remotely. He/She said he/she had not reviewed the medications for residents admitted after his/her last visit to facility on or about [DATE] and planned to complete those reviews the next day when he/she is at the facility.

Based on observation, interview, and record review, facility staff failed to obtain consents for side rails and failed to complete side rail assessments for five residents (Resident #18, #43, #64, #76 and #77), out of seven sampled residents. The facility census was 75. 1. Review of the facility's Proper use of Side Rails Policy, 12/2016, showed: -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails; -When used for mobility or transfer, an assessment will include a review of the resident's: -Bed mobility; -Ability to change positions, transfer to and from bed or chair, and stand and toilet; -Risk of entrapment from the use of side rails; -That the beds dimensions are appropriate for the resident's size and weight. -Consent for using restrictive deices will be obtained from the resident or legal representative per facility protocol; -Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 2. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/08/25, showed staff assessed the resident as follows: -Severe cognitive impairment; -Impairment to one side of lower extremity (hip, knee ankle, foot); -Required substantial/max assist from staff to roll left and right, sitting to lying in bed, lying to sitting on side of bed. Review of the resident's electronic medical record (EMR), showed the record did not contain a signed consent from the resident or resident representative for the use of bed rails, or a side rail assessment. Observation on 02/24/25 at 12:16 P.M., showed the resident in bed with bed rails to both sides in the upright position. Observation on 02/25/25 at 9:36 A.M., showed the resident in bed with bed rails to both sides in the upright position. Observation on 02/26/25 at 8:42 A.M., showed the resident in bed with bed rails to both sides in the upright position. During an interview on 02/27/25 at 1:26 P.M., the MDS/Care Plan Coordinator said the resident uses bed bed rails and he/she recently did an audit for residents with bed rails but must have missed the resident. 3. Review of Resident #43's annual MDS, dated [DATE], showed: -Cognitively intact; -No impairment; -Not assessed for assist from staff to roll left and right, sitting to lying in bed, lying to sitting on side of bed. Review of the resident's EMR showed the record did not contain an signed consent from the resident or resident representative for the use of bed rails, or a side rail assessment. Observation on 02/24/25 at 8:45 A.M., showed the resident in bed with bed rail on left side in the upright position. Observation on 02/25/25 at 11:30 A.M., showed the resident in bed with bed rail on left side in the upright position. Observation on 02/26/25 at 3:00 P.M., showed the resident in bed with bed rail on left side in the upright position. Observation on 02/27/25 at 5:15 P.M., showed the resident in bed with bed rail on left side in the upright position. 4. Review of Resident #64's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Impairment both sides upper and lower extremities; -Dependent with chair/bed-to-chair transfers; -Substantial/maximal assist with rolling left and right. Review of the resident's EMR showed the record did not contain an signed consent from the resident or resident representative for the use of bed rails or a side rail assessment. Observation on 2/24/25 at 10:21 A.M., showed the resident in bed with both side rails in the upright position. Observation on 2/25/25 at 11:02 A.M., showed the resident in bed with both side rails in the upright position. Observation on 2/27/25 at 10:15 A.M., showed the resident in bed with both side rails in the upright position. 5. Review of Resident #76's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Impairment both sides lower extremity; -Substantial/maximal assist with rolling left and right and chair/bed-to-chair transfers; -Partial/moderate assist with lying to sitting on side of bed. Review of the resident's EMR showed the record did not contain an signed consent from the resident or resident representative for the use of bed rails or a side rail assessment. Observation on 2/24/25 at 9:34 A.M., showed the resident in bed with both side rails in the upright position. During an interview on 02/27/25 at 10:20 A.M., the resident said he/she uses the side rails to help him/her sit up in bed and to help turn over while in bed. 6. Review of Resident #77's admission MDS, dated [DATE], showed: -Cognitively intact; -Impairment both sides lower extremity; -Dependent on staff for assistance to roll left and right, sitting to lying in bed, lying to sitting on side of bed. Review of the resident's EMR, showed the record did not contain an signed consent from the resident or resident representative for the use of bed rails, or a side rail assessment. Observation on 02/24/25 at 10:49 A.M., showed the resident in bed with both side rails in the upright position. Observation on 02/26/25 at 9:30 A.M., showed the resident in bed with both side rails in the upright position. Observation on 02/27/25 at 1:50 P.M., showed the resident in bed with both side rails in the upright position. 7. During an interview on 02/27/25 at 1:26 P.M., the MDS/Care Plan Coordinator said he/she was not sure who was responsible to complete the residents' initial side rail assessments and obtain informed consents, he/she is only responsible to complete the quarterly side rail assessments with informed consent. During an interview on 02/27/25 at 2:05 P.M., Registered Nurse (RN) D said upon admission the resident or resident's family can request side rails. He/She said an evaluation would be completed to ensure resident can use the side rails. He/She said the admitting nurse would do the bed rail assessment in the observations tab and at that time go over the risks of entrapment with the resident or family and ensure they consent to use of side rails. He/She said from there he/she informs the Director of Nursing (DON) that side rails are wanted. He/She said he/she is unsure who does the bed rail assessments after the admission assessment is completed or how often they are done. During an interview on 02/27/25 at 9:44 A.M., the DON said the MDS Coordinator should be doing the bed rail assessment quarterly. He/She said the consents are at the bottom of the bed rail utilization assessment. He/She said upon admission the charge nurse should complete the bed rail assessment, but sometimes it may be the next day after therapy has evaluated the resident and determined bed rails are needed. He/She said all residents should have a consent for bed rails upon determination of need. He/She said it is the charge nurse responsibility for obtaining consent and the MDS Coordinator should be double checking when he/she is doing the quarterly assessments and updating the MDS. He/She said no one is currently overseeing if the MDS Coordinator is checking for the bed rail assessments. He/She said it should be the DONs responsibility to check and ensure consents and bed rail assessments are being done. During an interview on 02/27/25 at 5:43 P.M., the administrator he/she is unsure who does the bed rail assessments or how often they should be done. He/She said there should be consents for all residents who use bed rails. He/She said charge nurses ensure consents are done and the DON should oversee that they are being obtained. 39644 50422

Based on observation and interview, facility staff failed to ensure residents' personal information was protected when staff left the computer screen open in public areas for six residents (Resident #7, #26, #31, #61, #74 and #79) of nine sampled residents. The facility's census was 75. 1. Review of the facility's policy titled, National Healthcare Corporation (NHC) Health Insurance Portability and accountability Act (HIPAA) Privacy Program, dated 12/2024, showed: -NHC is committed to complying with the HIPAA Privacy Rule and maintaining the confidentiality of patient's Protected Health Information (PHI) through appropriate, authorized access, uses, and disclosures; -NHC creates, stores, maintains, uses, transmits, collects and disseminates PHI in an environment that promotes confidentiality and integrity without compromising PHI. 2. Observation on 02/24/25 at 7:45 A.M., showed Registered Nurse (RN) A left the computer screen open and unattended on with Resident #31 medication information visible in Hallway A. Observation showed residents and staff walked by the cart. Observation on 02/24/25 at 8:00 A.M., showed RN A left the computer screen open and unattended with Resident #26 medication information visible in Hallway A. Observation showed residents and staff walked by the cart. Observation on 02/24/25 at 8:05 A.M., showed RN A left the computer screen open and unattended Resident #7 medication information visible in Hallway A. Observation showed residents and staff walked by the cart. During an interview on 02/24/25 at 12:57 P.M., RN A said he/she knows he/she should close the screen when he/she walks away. He/She said it is a risk for HIPAA and it exposes resident information. He/She said he/she just forgets to minimize it. 3. Observation on 02/25/25 at 12:05 P.M., showed RN Bleft the computer screen open and unattended with Resident #61 medication information visible on the insulin cart. Observation showed residents and staff walked by the cart. Observation on 02/25/25 at 12:08 P.M., showed RN B left the computer screen open and unattended with Resident #74 medication information visible on the insulin cart. Observation showed residents and staff walked by the cart. During an interview on 02/25/25 at 2:13 P.M., RN B said he/she should not leave computer screen open exposing resident information when he/she walks away from cart. He/She said it is a risk of privacy and HIPAA. 4. Observation on 02/27/25 at 07:45 A.M., showed RN C left the computer screen open and unattended with Resident #26 medication information visible in the dining room. Observation showed residents and staff walked by the cart. Observation on 02/27/25 at 07:50 A.M., showed RN C left the computer screen open and unattended with Resident #7 medication information visible in the dining room. Observation showed residents and staff walked by the cart. Observation on 02/27/25 at 08:00 A.M., showed RN C left the computer screen open and unattended with Resident #79 medication information visible in the dining room. Observation showed residents and staff walked by the cart. During an interview on 02/27/25 at 8:24 A.M., RN C said he/she should have closed her screen when he/she walked away from the cart. He/She said it is a risk of HIPAA and exposing resident information. During an interview on 02/27/25 at 4:49 P.M., Director of Nursing (DON) said computer screens should not be up with resident information showing. He/She said the risk of leaving computer screen up is anyone going by computer can see the resident information on the screen. He/She said the staff with that computer is responsible for ensuring the residents information is not exposed when they walk away. During an interview on 02/27/25 at 5:46 P.M., the administrator said when staff walk away from their computer, the screen should be minimized because of privacy and HIPAA. He/She said when he/she seeing a screen open he/she will close them.

Based on interview and record review, facility staff failed to document an accurate Minimum Data Set (MDS), a federally mandated assessment, when staff did not accurately code section A of the MDS for two residents (Residents #9 and #41), and section B of the MDS for one resident (Resident #43) out of 18 sampled residents. The facility's census was 75. 1. Review of the facility's policies showed staff did not provide a MDS policy. 2. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, a guideline for staff to complete each resident's MDS, dated [DATE], showed federal regulations require the assessment accurately reflects the resident's status, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. 3. Review of Resident #9's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -readmitted to facility 06/05/23; -Moderate cognitive impairment; -Has not been evaluated by Level II Pre-Admission Screen and Resident Review (PASRR) and determined to have a serious mental illness and/or mental retardation or a related condition; -Diagnosis of Manic Depression. Review of the resident's PASARR Level II determination, dated 02/07/23, showed the resident evaluated with a PASRR related disability: specifically, Serious Mental Illness related to diagnosis of Bipolar I Disorder. During an interview on 02/27/25 at 1:05 P.M., the MDS Coordinator said based on the RAI instructions, section A1500 and A1510 on the resident's MDS were inaccurate and was just an oversight by him/her. He/She said he/she had never seen a copy of the resident's PASARR Level II determination report prior. During an interview on 02/27/25 at 4:45 P.M., the Director of Nursing (DON) said Section A1500 and A1510 on the resident's MDS were inaccurate. 4. Review of Resident #41's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -admitted to facility 11/17/23; -Cognitively intact; -Has not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition; -Diagnoses of Major Depression Disorder and Post Traumatic Stress Disorder (PTSD). Review of the resident's PASRR Level II determination, dated 02/27/24, showed the resident evaluated with a PASRR related disability: specifically, Serious Mental Illness. During an interview on 02/27/25 at 4:00 P.M., the MDS Coordinator said he/she was not aware resident was a level two. He/She said the resident's MDS should reflect the resident's level two. 5. Review of Resident #43's annual MDS, dated [DATE], showed staff assessed the resident as follows: -admitted to facility 03/29/22; -Cognitivley intact; -Adequate vision. During an interview on 02/24/25 at 7:46 A.M., the resident said he/she can't see and is blind. The resident said, I can see only outlines and some shapes. The resident said he/she can not watch TV, because he/she is not able to see it. During an interview on 02/27/25 at 4:45 P.M., the DON said the resident's vision assessment of adequate vision is inaccurate on his/her MDS, the resident is visually impaired. 6. During an interview on 02/27/25 at 9:55 A.M., the DON said the MDS Coordinator had been in his/her role for about seven months and is responsible to accurately complete residents' MDS assessments. He/She said no one double checks the accuracy of the MDS assessments, but as the DON he/she is responsible for the oversight. The facility does not have a Policy for MDS. He/She said facility staff uses the CMS guidelines and the RAI manual as guidance to complete each resident's MDS. During an interview on 02/27/25 at 1:05 P.M., the MDS Coordinator said he/she was responsible to accurately complete each resident's MDS, and uses the CMS guidelines and the RAI manual to complete the MDSs. He/She said all sections including Section A and B of the MDS should accurately reflect each resident at the time of the assessment. During an interview on 02/27/25 at 5:48 P.M., the administrator said he/she expects each resident's MDS to be accurately completed per CMS guidelines. He/She said the DON oversees the MDS Coordinator. 39644 50422

Based on observation and interview, facility staff failed to post, in a form and manner accessible to residents, resident representative, visitors and staff the required telephone number to the Department of Health and Senior Services (DHSS) elder abuse and neglect hotline. The census was 75. 1. Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/2023, showed the names, addresses, and telephone numbers of all pertinent State client advocate groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network are available to all patients and their families and will be posted prominently in the center. 2. Observation of the facility on 02/24/25 at 1:00 P.M., showed the DHSS Abuse and Neglect Hotline number posted at the end of an unoccupied hall and not in a prominently located area within the facility for residents to see. Observation of the facility on 02/25/25 at 8:15 A.M., showed the DHSS Abuse and Neglect Hotline number posted at the end of an unoccupied hall and not in a prominently located area within the facility for resident to see. Observation of the facility on 02/26/25 at 10:15 A.M., showed the DHSS Abuse and Neglect Hotline number posted at the end of an unoccupied hall and not in a prominently located area within the facility for residents to see. Observation of the facility on 02/27/25 at 2:25 P.M., showed the DHSS Abuse and Neglect Hotline number posted at the end of an unoccupied hall and not in a prominently located area within the facility for residents to see. During an interview on 02/27/25 at 2:41 P.M., the Social Service Designee (SSD) said the hotline number was posted up front in the facility, however when he/she went to look he/she realized it was not there. He/She said they are unsure why its not posted any longer. Observation on 02/27/25 at 2:45 P.M., showed the front area of the facility did not contain the DHSS Abuse and Neglect Hotline number posted. During an interview on 02/27/25 at 4:45 P.M., the Director of Nursing (DON) said the hotline number is posted back by his/her office and thought it was posted in the front of the building. The DON said he/she was not aware the number wasn't posted up front. The DON said it is not in a good location, it should be posted visible for everyone to see it. Observation on 02/27/25 at 5:00 P.M., showed the front area of the facility did not contain the DHSS Abuse and Neglect Hotline number posted. During an interview on 02/27/25 at 5:05 P.M., Resident #42 said he/she has never heard anyone talk about the hotline number. He/She said she does not know where the number is located. During an interview on 02/27/25 at 5:07P.M., Resident #76 said he/she does not know where the hotline number is posted. The resident said he/she has not seen this posted around anywhere. During an interview on 02/27/25 at 5:50 P.M., the Administrator said the SSD is responsible making sure the information is posted. The administrator said the information use to be posted in the front, but it is back by the DON's office.

Based on observation, interview, and record review, facility staff failed to provide care to meet basic hygiene needs for three (Resident #5, #24, and #80) out of five sampled residents. The facility census was 75. 1. Review of the facility's policies showed the staff did not provide a bath policy. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/30/25, showed staff assessed the resident as follows: -Brief Interview for Mental Status ((BIMS) - a short cognitive screening tool) score not conducted as the resident is rarely/never understood; -Did not reject care; -Required substantial/max assist from staff with personal hygiene and to shower/bathe. Review of the resident's care plan, dated 02/12/25, showed staff are directed to assist the resident with dressing, personal hygiene, transfers, and showers. Review of the facility's shower schedule showed the resident will be assisted with a bed bath/shower on Tuesdays and Fridays by facility staff. Review of the resident's electronic record for bathing, dated 12/01/24 through 02/27/25, showed staff documented showers were provided on 12/04/24, 12/11/24, 12/17/24, 12/27/24, 01/07/25, 01/24/25, and 02/25/25. Staff did not document refusals. Observation on 02/24/25 at 8:35 A.M., showed the resident in the dining room with greasy hair. Observation on 02/25/25 at 9:23 A.M., showed the resident in bed with greasy hair. During an interview on 02/27/25 at 4:36 P.M., the Clinical Coordinator said the resident does not refuse his/her showers. 3. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -BIMS not assessed; -Did not reject care; -Required substantial/max assist from staff with personal hygiene and to shower/bathe. Review of the resident's care plan, dated 02/06/25, showed the resident needs substantial assist with showers, upper and lower body dressing and personal hygiene. Review of the facility's shower schedule showed the resident will be assisted with a bed bath/shower on Mondays and Thursdays by facility staff. Review of the resident's electronic record for bathing, dated 12/01/24 through 02/24/25, showed staff documented bed/showers provided on 12/05/24, 12/12/24, 12/26/24, 01/09/25, 01/15/25, 01/27/25, 02/03/25, 02/12/25, and 02/13/25. Observation on 02/24/25 at 2:00 P.M., showed the resident in bed with long nails with a dark substance underneath and greasy hair. Observation on 02/26/25 at 10:30 A.M., showed the resident in bed with long nails with a dark substance underneath and greasy hair. During an interview on 02/24/25 at 2:01 P.M., the resident said he/she does not get showers very often. During an interview on 02/27/25 at 1:47 P.M., the resident said it makes him/her mad when he/she does not get a shower, because he/she was told they are to get a shower twice a week when he/she came to the facility. During an interview on 02/27/25 at 4:36 P.M., the Clinical Coordinator said the resident occasionally refuses his/her showers, but he/she was not sure if there was a pattern. 4. Review of Resident #80's admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted to facility 02/14/25; -Severely cognitively impaired; -Did not reject care; -Required supervision with oral hygiene, personal hygiene; -Ability to shower/bathe self: not attempted due to medical or safety concerns. Review of the resident's care plan, dated 02/20/25, showed staff are directed to assist the resident with some or all ADLs, and help him/her keep dentures clean after meals and at bedtime. Review of the facility's shower schedule showed the resident will be assisted with a bed bath/shower on Tuesdays and Fridays by facility staff. Review of the resident's electronic records for bathing, dated 02/14/25 through 02/27/25, showed staff documented one shower was provided on 02/25/25 and one refusal on 02/18/25. Observation on 02/24/25 at 10:07 A.M., showed the resident ambulated with a walker and staff assist down the hallway to his/her room. His/Her hair appeared uncombed and disheveled. Observation on 02/25/25 at 12:17 P.M., showed the resident sat at the dining table in his/her robe, and his/her hair appeared uncombed and disheveled. During an interview on 02/24/25 at 10:19 A.M., the resident said he/she admitted to facility over a week prior and had some oral concerns regarding his/her lower gum and dentures he/she needed staff to help resolve, as well as not being offered a shower yet. During an interview on 02/25/25 at 12:18 P.M., the resident said he/she was still waiting for staff to assist him/her with a shower so he/she could feel refreshed. During an interview on 02/27/25 at 4:36 P.M., the Clinical Coordinator said the resident could refuse his/her showers, but he/she was not aware/notified the resident refused any showers since his/her admission. 5. During an interview on 02/27/25 at 4:22 P.M., Certified Nursing Assistant/Certified Medication Technician (CNA/CMT) F said the shower aide was already gone for the day. He/She said Resident #5 and #80 is scheduled to receive a shower on Tuesdays and Fridays, and Resident #24 is scheduled on Mondays and Thursdays. He/She said the shower aide documents when he/she assists a resident with a shower in the electronic record. During an interview on 02/27/25 at 4:29 P.M., Registered Nurse (RN) C said Resident #5 and #80 is scheduled to receive a shower on Tuesdays and Fridays, and Resident #24 is scheduled on Mondays and Thursdays. The RN said the shower aide documents when he/she assists a resident with a bath/shower in the electronic record, and if the resident refuses. He/She said the shower aide does not always notify the nurse of a refusal, and does not normally document resident refusals on paper. During an interview on 02/27/25 at 4:36 P.M., the Clinical Coordinator said the shower aide is expected to document when he/she assists a resident with a bath/shower in the electronic record, and if the resident refuses once or twice. He/She said if a resident develops a pattern of refusing, then the shower aide is expected to notify the charge nurse and complete a paper shower sheet and have the resident sign his/her refusal, then the nurse or the clinical coordinator would follow-up with the resident. During an interview on 02/27/25 at 4:38 P.M., the Director of Nursing (DON) said the facility has two shower aides who are expected to offer the residents a bath or shower twice per week, and if the resident refuses, the shower aide should document the refusal in the electronic record and notify the charge nurse of the refusal. During an interview on 02/27/25 at 5:48 P.M., the administrator said he/she expects staff to offer residents a bath or shower at least once per week and if a resident refuses, then staff should re-approach the resident and offer alternate options such as a different day or time. The administrator said he/she is not sure why showers are not being completed, because there are two shower aides on staff. MO00249498 39644

Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which resulted in Resident #1 being transported to the hospital after an adverse reaction. The facility census was 76. The administrator was notified on 5/6/24 of past Non-Compliance, which occurred on 4/21/24 when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, sent the resident to the hospital, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 4/23/2024. 1. Review of the facility Medication Administration policy, dated 1/1/2019, showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications should do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Before administration of medication, the nurse should assure he/she administered to the correct patient. 2. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/27/24, showed staff assessed the resident: -Moderately cognitive impaired; -Diagnoses of Anemia, Gastric reflux disease, Benign prostatic hyperplasia (Age-associated prostate gland enlargement that can cause urination difficulty), and anxiety. Review of the resident's plan of care, 2/29/24, showed staff are directed to give medications as ordered. Review of the resident's progress notes, dated 4/20/24 at 11:03 P.M., showed Licensed Practical Nurse (LPN) A documented at 9:10 P.M., this agency nurse entered resident's room and addressed the resident by the name of the roommate and the resident greeted the nurse in what the nurse assumed to be the correct resident. Nurse then proceeded to administer what was thought to be the correct bedtimes medications which were 22 units of Lantus insulin (treats diabetes), 25 milligrams (mg), hydralazine (treats high blood pressure), 1000 mg of metformin (treats diabetes), 300 mg of gabapentin (treats nerve pain).When nurse went back to check foley catheter resident didn't have one and that is when the acknowledgment of medication error had occurred. Nurse then asked the certified nursing assistance (CNA) to get the second nurse. Agency nurse then asked the second aide to take vital signs every 15 minutes and to begin to help him/her eat some sweet foods from the snack cart. He/she ate pudding and another dessert. Second nurse then assisted agency nurse and called the doctor to inform him/her of medication error. The physician prescribed blood sugar checks every 30 minutes because the resident was given insulin and is not a diabetic and does not have blood pressure issues until the next shift and if the blood sugar drops below 100 then send out to the hospital. Review of the resident's hospital records, dated 4/20/24, showed the resident admitted to the hospital due to his blood sugar dropping down to 70 and his blood pressure trending down after his/her skilled nursing facility staff administered the wrong medications. Review of the investigation, dated 4/20/24, showed LPN A adminsitered another resident's medication to Resident #1 because Resident #1 acknowledged staff when he/she said his/her name. LPN A was unfamilair with residents. The residents blood sugar stayed low the resident was sent to emergency room and admitted . Review showed nursing staff in-serviced on proper medication administration on 04/23/24. During an interview on 5/6/24 at 9:14 A.M., the resident said he/she got medications that was his/her roommates and had to spend two days in the hospital because he/she does not have blood pressure issues normally and is not a diabetic. During an interview on 5/6/24 at 10:18 A.M., the administrator said there was a full investigation into a medication error with the resident. The agency nurse gave the resident the wrong medication. The physician was contacted immediately as were the family, vitals checks started, snacks and reverse medications given and the resident was then sent out to the hospital for monitoring. During an interview on 5/21/24 at 11:11 A.M., LPN A said he/she entered the room and addressed the resident and he/she responded, he/she was not aware the resident had a hearing deficit. He/She administered the medication and then went to change the resident catheter and he/she did not have one and this is when the error was noticed. The physician was immediately notified and snacks were given, the physician gave new orders to check blood sugar but the resident started having adverse reactions so he/she was immediately sent to the hospital. During an interview on 5/21/24 at 11:20 the Director of Nursing (DON) said he/she was contacted by the nurses on shift that a major medication error had occurred. LPN A had given the resident his/her roomates medication. He/She had addressed the resident and the resident had responded and the medication was administered. He/She said the review of the MAR showed it flipped the A and B bed as well. He/She said the physician and family was contacted immediately, vital signs were ordered, and the resident was given snacks. The resident was sent out to the hospital shortly after when he/she started having adverse reactions. MO00235022

Based on interview and record review, the facility staff failed to conduct and document an annual facility-wide assessment to determine what resources are necessary to care for it's residents competently during both day-to-day operations and emergencies as required. The facility census was 73. 1. Review of the facility's Facility Assessment Report, dated September 2022 through August 2023, showed the assessment did not contain information on staffing for day-to-day operations and emergencies as required. During an interview on 5/6/24 at 1:14 P.M., the administrator said he/she did not have a full facility assessment completed and is aware it is required to be done annually. He/She said he/she staffs by census. MO00235022 MO00235450

Based on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. Facility staff also failed to store food in a manner to prevent contamination and out-dated use. The facility census was 71. 1. Review of the facility's Machine Warewashing policy, dated November 2017, showed the policy directed staff to air dry all items and ensure all items are completely dry before stacking to prevent wet-nesting. Observation on 12/11/23 at 9:54 A.M., showed Dietary Aide (DA) I removed sanitized plates from the clean side of the mechanical dishwashing station while wet and stacked them together upside down in the plate heater. Observation showed the DA removed sanitized insulated plate holders and domed plate covers from the clean side of the station while wet and stacked them together in the upright position on a service cart. Observation on 12/11/23 at 10:25 A.M., showed DA I removed sanitized insulated plate holders and domed plate covers from the clean side of the mechanical dishwashing station while wet and stacked them together on the service cart. During an interview on 12/11/23 at 10:28 A.M., the Certified Dietary Manager (CDM) said DA I started his/her employment at the facility almost two months ago and he/she trained the DA to allow dishes to air dry before they were put away. Observation on 12/11/23 at 10:39 A.M., showed the food and beverage service station contained: -22 insulated bowls stacked together wet on the shelf above steamtable; -16 plastic service trays stacked together wet on the drink counter; -24 black insulated coffee cups stacked together wet shelf above drink counter; -24 tall clear plastic glasses stacked together wet by coffee cups; -21 clear plastic juice glasses stacked together wet below the tall glasses glasses; -26 insulated domed plate covers stacked together wet in the service window. Observation on 12/11/23 10:51 AM showed Cook L used the one of the tall clear plastic wet stacked glasses to prepare a glass of soda for a resident. Observation on 12/11/23 during the lunch meal service which began at 12:00 P.M., showed DA J and Cook L used the wet stacked cups, glasses, service trays, insulated plate holders and domed plate covers to serve food to residents. Observation on 12/13/23 at 9:21 A.M., showed DA K removed sanitized plastic service trays, insulated bowls, domed plate covers and insulated plate holders from the clean side of the mechanical dishwashing station while wet, stacked them together and put them away. During an interview on 12/13/23 at 9:26 A.M., the CDM said staff should allow dishes to air dry before they are put away and they are trained on this requirement. The CDM said he/she is responsible to monitor dishwashing procedures, which he/she does at random when he/she take dishes to the station, but he/she normally looks for cleanliness and not water. During an interview on 12/13/23 10:06 A.M., the administrator said dishes should be air dried before they are put away and the CDM should have trained all staff who wash dishes to allow them to air dry. The administrator said the CDM is responsible to monitor the way the dishes are washed and put away as needed when he/she is on duty and the cooks would be responsible to monitor it when the CDM is not on duty. 2. Review of the facility's Dry Storage policy, dated November 2017, showed the policy directed staff to securely close opened food packages to protect the product. Review showed the policy did not include information related to the dating of opened food items to prevent out-dated use. Review of the facility's Refrigerator and Freezer Storage policy, dated November 2017, showed the policy directed staff to store foods in their original containers, National Sanitation Foundation (NSF) approved container or wrapped tightly in moisture-proof film, foil, etc. and clearly label the food item with the contents and use by date. Review showed leftovers will be placed in NSF approved containers, covered, labeled, dated and stored in refrigerator or freezer at correct temperature. Observation on 12/11/23 at 9:58 A.M., showed the dry goods pantry contained: -opened and undated bags of egg noodles, elbow macaroni, spaghetti, cornflakes and toasted oats cereal; -opened and undated one gallon bottles of white vinegar, red wine vinegar, apple cider vinegar, soy sauce, corn syrup, pancake syrup and Worcestershire sauce; -an opened and undated 12 ounce (oz.) box of gluten free penne pasta; -an opened and undated 14.4 oz. box of graham crackers; -an opened and undated 32 oz. bottle of browning sauce; -an opened and undated one quart canister of toasted sesame oil; -an opened and undated 68 oz. bottle of olive oil; -an opened and undated six pound bottle of honey; -an opened and undated 58 oz. carton of potato pearls; -an undated 36 oz. box of iodized salted opened to the air. During an interview on 12/11/23 at 10:03 A.M., the CDM said staff are expected to date any opened unused food items. Observation on 12/11/23 at 10:11 A.M., showed an opened and undated bag of boneless chicken breast strips in the three door reach-in freezer. Observation also showed a sign posted on the freezer door which read Date all items after opening Leftovers and other refrigerated items date 3 days out, do not use after that date. Dry goods, seasoning & spices, gallon size condiments & dressings, and frozen items put a opened on date. Most items that fall in there are good for a year. Even snacks that are not prepackaged including sandwiches need dated for 3 days out. Observation on 12/11/23 at 10:21 A.M., showed an opened and undated one gallon bottle of vegetable salad oil on the stand mixer in the cook's station. Observation on 12/11/23 at 10:39 A.M., showed a bin of coffee filters filled with coffee grounds uncovered on the cart by the coffee pot and a bin of ice opened which exposed the ice to the air. Observation showed the ice scoop holder attached to the bin in a manner which did not allow the bin's cover to close. Observation on 12/11/23 at 10:51 A.M., showed Cook L used the ice from the opened bin to prepare a glass of soda for a resident. During an interview on 12/13/23 at 9:26 A.M., the CDM said opened food items should be labeled, dated and sealed before they are put away and staff are trained on this requirement upon hire and annually. The CDM said he/she is responsible to monitor the food storage and he/she tries to look at it every day he/she is there, but he/she routinely looks at it on food delivery days twice a week. The CDM said he/she did not notice the lid to the ice bin did not close. During an interview on 12/13/23 at 10:02 A.M., the administrator said staff should date opened food items and store them sealed. The administrator said all staff go through the pineapple training program and food storage requirements should be something that is covered in that program. The administrator said the CDM is responsible to monitor the food storage daily when in the building and the cooks are responsible to monitor it when the CDM not in the building.

Based on observation, record review and interview, facility staff failed to update three residents (Resident #20, #59, and #68) care plans to include the use of oxygen. The facility census was 71. 1. Review of the facility's policies showed staff did not provide a policy for care plans. 2. Review of Resident's #20's Admission Minimum Data Set (MDS), a federally mandated assessment, dated 10/16/23, showed staff assessed the resident as follows: -Cognitively intact; -Oxygen therapy; -BiPAP therapy (a device that helps with breathing which provides distinct air pressure levels for inhalation and exhalation); -Diagnoses of chronic lung disease, respiratory failure, anxiety, and heart failure. Review of the resident's care plan, dated 10/18/23, showed the care plan did not contain information for the resident use of his/her BiPAP or oxygen therapy. Review of the resident's Physicians Order Sheet (POS), dated 12/01/23, showed staff are directed to apply the BiPAP at bedtime and remove in the morning. Observation on 12/11/23 at 1:04 P.M., showed the resident with his/her oxygen on per a nasal cannula and the BiPAP machine on the bedside table. Observation on 12/12/23 at 8:24 A.M., showed the resident with his/her oxygen on per a nasal cannula on and the BiPAP machine on the bedside table. During an interview on 12/13/23 at 2:56 P.M., the resident said he/she is to have oxygen administered all the time and has been using oxygen since his/her hospitalization . During an interview on 12/14/23 at 08:48 A.M., Certified Nurse Assistant (CNA) E said the resident used supplemental oxygen at all times. During an interview on 12/14/23 at 08:53 A.M., Licensed Practical Nurse (LPN) A said the resident used supplemental oxygen at all times. 3. Review of Resident's #59's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Oxygen therapy; -Diagnoses of chronic lung disease and heart failure. Review of the resident's care plan, updated 10/10/23, showed the care plan did not contain information for the resident use of his/her oxygen therapy. Review of the resident's POS, dated 12/01/23, showed staff were directed to titrate (to change levels of oxygen flow) oxygen to keep oxygen saturation (which measures the amount of oxygen carried in the blood) greater than 92% every shift. Observation on 12/11/23 at 2:15 P.M., showed the resident oxygen on per a nasal cannula. Observation on 12/12/23 at 10:11 A.M., showed the resident oxygen on per a nasal cannula During an interview on 12/14/23 at 8:48 A.M., CNA E said the resident used supplemental oxygen at all times. During an interview on 12/14/23 at 8:53 A.M., LPN A said the resident used supplemental oxygen at all times. 4. Review of Resident's #68's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Mildly cognitively impaired; -Diagnoses of anemia, heart failure, chronic lung disease, non-hip fracture. Review of the resident's care plan, updated 9/20/23, showed the care plan did not contain information for the resident use of his/her oxygen therapy. Review of the resident's POS, dated 12/01/23, showed staff were directed to titrate oxygen to keep oxygen saturation greater than 92%. Observation on 12/11/23 at 11:59 A.M., showed the resident oxygen on per a nasal cannula. Observation on 12/12/23 at 8:55 A.M., showed the resident oxygen on per a nasal cannula. 5. During an interview on 12/14/23 at 8:48 A.M., CNA E said the care plan should include any respiratory care. During an interview on 12/14/23 at 8:53 A.M., LPN A said care plans should include all aspects of oxygen use and treatments. During an interview on 12/14/23 at 9:08 A.M., the Director of Nursing (DON) said the care plan should include all aspects of respiratory care. During an interview on 12/14/23 at 9:34 A.M., the administrator said he/she would expect the care plan to address oxygen use.

Based on observation, interview and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection when staff failed to clean a suction machine for one resident (Resident #8), during perineal care and staff applied oxygen tubing directly from the floor on one resident (Resident #11). Staff failed to change and date respiratory tubing for three residents (Resident #15, #20, and #59). The facility census was 71. 1. Review of the facility's Suction Machine, Care and Use of policy, dated 2006, showed the suction machine bottle should be emptied, washed with soapy water and rinsed after each use. 2. Review of Resident #8's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/18/23 showed staff assessed the resident: -Required artificial intake of greater than 51 percent (%) of fluid and calories; -Feeding tube (tube placed in the stomach to administer nutrition and/or hydration); -Required suctioning; -Diagnosis of stroke. Observation on 12/11/23 at 10:41 A.M., showed a suction machine on the resident's nightstand next to the bed that contained a yellow substance. Observation on 12/12/23 at 08:14 A.M., showed a suction machine on the resident's nightstand next to the bed that contained a yellow substance. Observation on 12/13/23 at 8:10 A.M., showed Licensed Practical Nurse (LPN) A administered the resident's medications through the feeding tube. A suction machine sat on the resident's nightstand next to the bed that contained a yellow substance. During an interview on 12/13/23 at 08:15 A.M., LPN A said the resident has not used the suction machine for about a week and the machine should have been taken from the room. He/She did not know how often the suction machine should be cleaned or sanitized but the nurses are responsible to do it. During an interview on 12/13/23 at 09:49 A.M., the Director of Nursing (DON) said he/she would need to see the suction machine and refer to the policy to know when it should have been cleansed. During an interview on 12/13/23 at 01:25 P.M., the DON said the suction machine should have been cleaned by the nurses at least every seven days or as needed. He/She said after viewing the contents of the machine, it should have been cleaned by the nurses for infection control reasons. During an interview on 12/14/23 at 9:12 A.M., the DON said hands should be washed between glove changes to prevent infection since the tube is a direct line to the stomach. 3. Review of the facility's Hand Hygiene policy, dated June 2023, showed hand hygiene includes both handwashing with either plain or antiseptic-containing soap and water, and use of alcohol-based products that do not require use of water. Review showed staff are to provide hand hygiene before and after removal of gloves and before and after contact with each patient. Review of the facility's Oxygen for Patient Use policy, dated November 2022, showed the policy did not contain direction on oxygen tubing storage or handling. 4. Review of Resident #11's Quarterly MDS, dated [DATE], showed staff assessed the resident: -Required substantial and/or maximum assistance with toileting; -Did not wear oxygen; -Diagnosis of stroke. Observation on 12/13/23 at 2:10 P.M., showed Certified Nurse Aide (CNA) G and CNA H entered the resident's room to provide perineal care on the resident. CNA G applied gloves, transferred the resident to bed, performed catheter care then removed his/her gloves. Observation showed CNA G did not wash his/her hands and applied clean gloves. Observation showed CNA G provided care to the resident's buttocks, removed his/her gloves, applied clean gloves and repositioned the resident. Observation showed CNA G did not wash his/her hands between glove changes. Observation showed CNA H picked up the resident's nasal cannula oxygen tube from the floor and draped it over the side rail. Observation showed CNA G applied the oxygen to the resident's nose. During an interview on 12/13/23 at 02:10 P.M., CNA G said he/she should have washed his/her hands between glove changes and when entering the room. He/She said he/she was really nervous he/she was being watched and forgot. CNA G said he/she did not know the tubing was on the floor but if he/she did he/she would have obtained a new one and applied it instead. He/She said oxygen tubing on the floor is not sanitary. During an interview on 12/13/23 at 02:32 P.M., CNA H said he/she should have got a new oxygen tube for the resident and never let CNA G apply it to the resident because of infection risk. He/She said he/she was nervous and would get the resident a new tubing. During an interview on 12/14/23 at 09:12 A.M., the DON said staff are expected and educated to wash their hands between glove changes to prevent the spread of infection. Also staff are expected to change oxygen tubing if found on the floor or at least make sure it was cleansed for infection control reasons. 5. Review of the facility's policies showed staff did not provide a policy on oxygen tubing changes or cleaning of equipment. 6. Review of Resident's #15's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Oxygen therapy; -Diagnosis of hypertension, anxiety disorder, bipolar disease, asthma, respiratory failure. Review of the resident's Physicians Order Sheet (POS), dated 9/15/23, showed tubing to be replaced and labeled with the date once a day on Wednesday during the night shift. Observation on 12/13/23 at 11:06 A.M., showed the resident's oxygen tube undated. Observation on 12/14/23 at 8:29 A.M., showed the resident's oxygen tubing was dated for 12/13/23. 7. Review of Resident's #20's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Oxygen therapy; -BiPAP therapy (a device that helps with breathing which provides distinct air pressure levels for inhalation and exhalation); -Diagnoses of chronic lung disease, respiratory failure, anxiety, heart failure, and a fracture. Review of the resident's POS, dated 12/01/23, showed the record did not contain an order change the oxygen tubing for the BiPAP machine, or oxygen concentrator. Observation on 12/11/23 at 01:04 P.M., showed the resident used oxygen per a nasal cannula. Observation showed the BiPAP tubing and oxygen concentrator tubing undated. Observation on 12/12/23 at 08:24 A.M., showed the resident used oxygen per a nasal cannula. Observation showed the BiPAP tubing and oxygen concentrator tubing undated. 8. Review of Resident's #59's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Oxygen therapy; -Diagnoses of chronic lung disease, and heart failure. Review of the resident's POS, dated 12/01/23 showed an order for tubing to be replaced and labeled with the date once a day on Friday. Observation on 12/11/23 02:15 P.M., showed the resident used oxygen per a nasal cannula. The breathing treatment tubing and oxygen concentrator tubing undated. Observation on 12/12/23 at 10:11 A.M., showed the resident used oxygen per a nasal cannula. The breathing treatment tubing and oxygen concentrator tubing undated. During an interview on 12/12/23 at 2:46 P.M., CNA O said the night shift changes tubing. During an interview on 12/12/23 at 3:00 P.M., the DON said the night shift should change and date oxygen tubing once a week. During an interview on 12/14/23 at 08:53 A.M., LPN A said if a resident has oxygen therapy, treatments with a nebulizer or BiPAP, orders should be in place to clean and date the equipment weekly. 42484 43327

Based on interviews and record review, facility staff failed to report a missing gift card for one resident (Resident #45) to the Department of Health and Senior Services (DHSS) within the required time frame. The facility census was 71. 1. Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/23, showed abuse, neglect, misappropriation of patient property and exploitation will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors or any other individual in this center. Review showed: -The patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation; -Any partner (staff) having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property, or exploitation must report the event immediately, but not later than two hours after forming the suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do no result in abuse or serious bodily injury; -It is the policy of this facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are report per Federal and State Law; -The facility will 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 or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law. Review of the facility's Customer Satisfaction, Service Recovery Defined Policy, revised June 2006, showed: -Service recovery is a set of actions taken to resolve a customer concern; -Any partner (staff) can recover a break down in service or a perceived break down in service; -All partners (staff) will make it right on the spot when the following occurs: -Lost or misplaced items/belongings; -Broken or damaged personal items/belongings; -Customer certificates are available for all partners to provide financial reimbursement choice up to $100.00 on the spot, they are to be completed and given to the Social Service Director (SSD) who will recover what they need through a team effort; -Specialized Service Recovery may involve dollar amounts over the $100.00 limit set, and may require a more specialized approach; -The Department Head in charge of Specialized Service Recovery will complete service recovery case form, follow up one on one with the customer immediately and again in 12-48 hours of the reported concern, report findings to the center administrator, and give a copy of the form for Quality Assurance (QA) trending purposes. 2. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/23/23, showed staff assessed the resident as cognitively intact. Review of the facility's investigation report, dated 11/06/23, showed the resident reported a $200.00 gift card missing. The resident reported he/she bought the gift card on 11/02/23, noticed the card missing on 11/04/23, and reported it to staff on 11/05/23. The investigation contained a dated receipt from a local store on 11/02/23 which showed the resident had purchased a $200.00 gift card. The investigation showed the Social Service Director (SSD) followed up on 11/06/23, 11/07/23, and 11/08/23 with the local store. The facility investigation did not contain documentation followed up with the outcome of the investigation. The investigation did not contain documentation staff reported the incident to the State survey and certification agency. During an interview on 12/11/23 at 11:50 A.M., the resident said he/she had a gift card in the amount of $200.00 come up missing a few days after he/she purchased it. The resident said he/she told staff when he/she noticed it was gone, but could not remember who he/she told first. During an interview on 12/12/23 at 9:42 A.M., the SSD said on 11/06/23 he/she had a note on his/her office door stating the resident needed to see him/her. The SSD spoke to the resident who reported a $200.00 gift card missing to him/her on 11/06/23. The SSD said he/she did an investigation and could not determine what happened to the gift card. He/She said the facility did not report the missing gift card to DHSS because it took quite a while to get the information and he/she was never able to determine if the gift card was stolen, lost, or given away by the resident. During an interview on 12/13/23 at 1:58 P.M., the SSD said he/she is responsible to investigate any missing items such as a gift card. The SSD said he/she is the department head in charge of specialized service recovery in this facility. The SSD said he/she is responsible to inform the administrator if it needs to be reported to DHSS. During an interview on 12/13/23 at 2:30 P.M., the administrator said he/she was aware the resident was missing a $200.00 gift card. The administrator said when a staff member reports a missing item the SSD is responsible for doing the investigation on items such as a gift card. The administrator said he/she is ultimately responsible to file reports with DHSS. The administrator said he/she did not file a self-report with DHSS regarding the resident's missing gift card because the resident and family were not upset about it missing and the facility planned to replace it. During an interview on 12/14/23 at 9:11 A.M., the DON said he/she expects staff to report missing items. The DON said any grievances regarding money are investigated and handled by the SSD and he/she would report those to him/her. The DON said she was made aware of the resident's missing gift card but he/she did not do the investigation. The DON said any reports of misappropriation are handled by the SSD and administrator. He/She said the SSD or administrator should report these investigations within a two-hour window of finding out to DHSS. The DON said he/she is not sure why the missing gift card was not report to DHSS and the administrator is responsible for that. 48982

Based on observation, record review and interview, facility staff failed to ensure one resident (Resident #20) had a physician order for oxygen usage. The facility cenus was 71. 1. Review of the facility's Oxygen for Patient Use policy, revised November 2022, showed the policy did not contain direction on orders required for oxygen therapy. 2. Review of Resident's #20's Admission Minimum Data Set (MDS), a federally mandated assessment, dated 10/16/23, showed staff assessed the resident as follows: -Cognitively intact; -Oxygen therapy; -Diagnoses of chronic lung disease, respiratory failure, anxiety, and heart failure. Review of the resident's Physicians Order Sheet (POS), dated 12/01/23, showed the record did not contain an order for the use of oxygen. Observation on 12/11/23 at 01:04 P.M., showed the resident with his/her oxygen on per a nasal cannula. Observation on 12/12/23 at 08:24 A.M., showed the resident with his/her oxygen on per a nasal cannula. During an interview on 12/13/23 at 2:56 P.M., the resident said he/she is to have oxygen administered all the time and has been using oxygen since his/her hospitalization . During an interview on 12/14/23 at 08:48 A.M., Certified Nurse Assistant (CNA) E said the resident used supplemental oxygen at all times. During an interview on 12/14/23 at 08:53 A.M., Licensed Practical Nurse (LPN) A said the resident used supplemental oxygen at all times. The resident should have physician orders for the use of oxygen. The LPN said if orders were missing, the nurse should obtain physician orders. LPN A said he/she was not aware the resident did not have an order for oxygen use. During an interview on 12/14/23 at 9:08 A.M., the Director of Nursing (DON) said residents should have physician orders for the use of any respiratory care. If orders were missing, the nurse should obtain physician orders.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of Covid-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for Covid-19. The facility failed to separate three positive Covid-19 residents (Resident #1, #3 and #8) from residents who had tested negative for Covid-19 or had only been exposed to Covid-19 for five residents (Resident #2, #4, #5, #6 and #7) at an increased risk of contracting Covid-19 due to prolonged exposure. The facility census was 71. The Administrator was notified on 10/02/23 at 1:43 P.M., of an Immediate Jeopardy (IJ) which began on 09/19/23. The IJ was removed on 10/02/23 as confirmed by surveyor onsite verification. Review of the Center's for Disease Control (CDC's) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 5/8/23, showed a patient with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Facilities could consider designating entire units within the facility, with dedicated health care personnel (HCP), to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. The Infection prevention and Control (IPC) recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Source control is recommended for individuals in healthcare settings who have had close contact (patients and visitors) or a higher-risk exposure with someone with SARS-CoV-2 infection, for 10 days after their exposure. Review of the facility's Coronavirus (COVID-19) Policy, revised May 2023, showed staff are directed to effectively cohort residents with separate areas with dedicated COVID-19 care. Review showed the facility is directed to follow the CDC recommendations related to COVID-19. Review of the facility policy did not contain directions for asymptomatic residents in regards to quarantine protocols. 1. Review of Resident #1's COVID test results form, dated 09/25/23, showed a positive result. Observation on 10/02/23 at 08:30 A.M., showed Resident #1 who tested positive for COVID on 09/25/23 in a room with Resident #2 who tested negative for COVID on 09/19/23 and 09/25/23. Observation showed Resident #1 and #2 did not have a face mask on. The door to the residents room was open. During a telephone interview on 10/05/23 at 12:10 P.M., Resident #2's relative said he/she expected staff to move a resident who tested positive for COVID-19 out of a room of someone who tested negative. 2. Review of Resident #3's COVID test results form, dated 09/19/23, showed a positive result. Review of Resident #4's COVID test results form, dated 09/19/23, showed a negative result. Review of the resident's COVID test results form, dated 9/25/23, showed a positive result. Review of Resident #5's COVID test results form, dated 09/19/23, showed a negative result. Review of the resident's COVID test results form, dated 9/25/23, showed a positive result. Review of Resident #6's COVID test results form, dated 09/19/23, showed a negative result. Review of the resident's COVID test results form, dated 9/25/23, showed a negative result. Observation on 10/02/23 at 8:37 A.M., showed Resident #3, who tested positive for COVID on 09/19/23 and Resident #4, and Resident #5 who tested positive for COVID on 09/25/23 occupied in the same room with Resident #6 who tested negative for COVID on 09/19/23, and 09/25/23. Observation showed Resident #3, Resident #4, Resident #5 and #6 did not have a face mask on. Observation showed the residents' door did not have a sign on the door. Observation showed Resident #3 had a cough and shortness of breath. Observation on 10/02/23 at 5:30 P.M., showed Resident #6 in the main dining room as he/she sat at a table with three other residents without a mask. During a telephone interview on 10/05/23 at 1:10 P.M., Resident #6's relative said he/she was never notified by the facility they had a COVID outbreak, but that he/she would have expected staff to move a resident who tested positive for COVID-19 out of a room of someone who tested negative. 5. Review of Resident #8's COVID test results form, dated 09/25/23, showed a positive result. Review of Resident #7's COVID test results form, dated 09/19/23, showed a negative result. Review of the resident's COVID test results form, dated 9/25/23, showed a negative result. Observation on 10/02/23 at 8:42 A.M., showed Resident #8 who tested positive for COVID on 09/25/23 in a room with Resident #7 who tested negative for COVID on 09/19/23, and 09/25/23. Observation showed Resident #7 and #8 did not have a face mask on. Observation showed Resident #8 had a productive cough. Observation on 10/02/23 at 5:45 P.M., showed Resident #7 in the hallway near the dining room without a mask on. 6. During an interview on 10/02/23 at 09:15 A.M., the Director of Nurses (DON) said they were advised not to move any of the residents who tested positive for COVID by the administrator. He/She said there was no reason given other than he/she did not want to move them. He/She said they did not ask residents who were negative if they would like to move because they were instructed not to move residents. During an interview on 10/02/23 at 9:48 A.M., Certified Medication Technician (CMT) A said he/she is one of the staff members responsible to handle COVID and is the one who does all the tests. He/She said they chose not to move the residents because most of them did not feel sick so they were allowed to move about the facility as they chose and they did not wear masks. He/She said they did not ask residents who were negative if they would like to move because they were instructed not to move residents. During an interview on 10/02/23 at 10:35 A.M., the Minimum Data Set (MDS) Coordinator said they were in contact with their corporate office who sent them a copy of their updated policy from May 23 which said if residents weren't symptomatic then they did not have to quarantine so that is why they did not move any of the residents. During an interview on 10/02/23 at 10:50 A.M., the administrator said he/she and the nursing staff decided not to move residents when they had positive results because it was more detrimental to them to move then rather to not move them. He/She said over the past three to four years he/she has been in homes and to move them has increased the spread of the disease rather than to decrease it. He/She said he/she felt their psychosocial risk were more at risk by moving them. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00224755

Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #2) remained free from physical abuse, when another resident (Resident #1) hit the resident on the head with a metal object. The facility staff also failed to communicate to oncoming staff Resident #1 showed signs of agitation prior to incident. The facility census was 70. Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 2/1/23, showed: -Abuse, Neglect, Misappropriation of Patient Property and Exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor of any other individual in this center. The patient has the right to be free from abuse, neglect, misappropriation of patient property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patients medical symptoms. -Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Includes: verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Physical abuse: includes hitting, slapping, pinching and kicking. -Mental abuse: Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Review of the facility's internal investigation report, dated 2/8/23, showed staff documented Resident #2 headed to or from the bathroom and got too close to Resident #1. Resident #1 grabbed reachers and started to hit Resident #2. Staff separated the residents. Staff sent Resident #2 sent to the emergency room . Staff held an emergency meeting on 2/9/23 and issued an emergency discharge notice to Resident #1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/5/22, showed facility staff assessed the resident as follows: -Cognitively impaired; -No behaviors; -Diagnoses including Alzheimer's disease, Dementia and impulse disorder; -Wheelchair and walker use for mobility. Review of the resident's plan of care, dated 1/06/22, showed staff assessed the resident with potential for alteration in mood/behaviors, at risk for complications due to diagnoses of Impulse disorder, Alzheimer's, Depression, history of physically and verbally aggressive behavior towards staff and other residents. Staff were directed to approach resident in a calm, friendly manner, monitor effects and effectiveness of medications and side effects, to notify the physician with mood changes or behaviors, removed from any situations that could escalate behaviors, be direct and prompt when telling the resident his/her behaviors are inappropriate and calmly reassure resident. Review of Resident #1's nurse's notes showed staff documented: -On 2/8/23 at 8:40 P.M., Staff heard a loud commotion coming from the resident's room. Staff entered the resident's dark room to see the resident hitting his/her roommate over the head several times with two metal grabbers. Staff intervened and removed the grabbers. Staff removed the resident's roommate from the room. Resident #1 reported, He/She jumped on my outfit, pointing to the wheelchair, and I told him/her to quit it. My clothes fell on the ground. The resident said his/her roommate did not listen to him/her and they started fighting. He/She said his/her roommate knocked his/her things off the table so Resident #1 took his/her forks (pointing to the metal grabbers) and wrapped them around his/her neck. -On 2/9/23 at 10:20 A.M., The Director of Nursing (DON) documented an entry for 02/08/23. The DON documented Resident #1 became violent towards his/her roommate, striking him/her on his/her head causing lacerations that required an emergency room visit for evaluation and treatment. Review showed staff documented this was not the first time Resident #1 had behaviors that were violent. -On 2/9/23 at 10:25 A.M., staff documented they issued an emergency discharge notice to Resident #1 due to continuous resident-to-resident incidents. Review of Resident #2's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severely cognitively impaired; -No behaviors; -Diagnosis of Dementia; -Independent with mobility. Review of the resident's plan of care, dated 1/17/23, showed staff documented the resident had a diagnoses of dementia with periods of confusion. Staff were directed to approach at a different time when resident does not comply, ask how to make the resident more comfortable, assess behaviors and try to determine cause, assess for stressors in the environment, assess if patients anxiety is in response to fear, helplessness, or disruptions or changes in life, be direct and prompt when telling the resident a behavior is inappropriate, explain all procedures beforehand, observe for signs of increasing hostility, restrict harmful physical action in a cautious, non-harmful manner and monitor for increased confusion or agitation. Review of the resident's nurses notes, dated 02/08/23, showed staff documented staff heard a loud commotion coming from the resident's room. Staff entered the room to see Resident #1 hitting Resident #2 over the head several times with two metal grabbers. Staff intervened, removed the grabbers, and removed Resident #2 from the room. Staff cleaned Resident #2's head wounds and applied a pressure dressing. The resident said, He/She just started [NAME] on me and he/she did not know why. Staff documented they assessed bruising on his/her left thumb, left 3rd finger, and right thumb as well as several small cuts on the top of his/her head. Staff notified the resident's physician and the Director of Nursing (DON). Review of the resident's nurses notes, dated 2/9/23, showed staff documented the resident returned from the emergency room at 10:45 P.M. Stable condition and verbally alert and responsive. Vital signs stable and afebrile. Had small bandages to areas on head. No active bleeding at this time. Able to transfer into bed with one assist and has been resting without distress to present. No chief complaint of pain or discomfort voiced. At hospital negative for any abnormal findings. Review of Resident #2's hospital records, dated 2/8/23, showed the resident recieved steri strips to the head and CT negative for abnormal findings. Review of the resident's nurses notes, dated 2/11/23, showed staff documented the resident was content and laying in bed. The resident chief complaint is his/her head being slightly sore while the nurse applied the antibiotic ointment to the small abrasions on his/her head. Review of the resident's nurses notes, dated 2/12/23 staff documented the nurse was asked to go to the residents room due to resident being upset about being hit by former roommate. Staff entered resident room and resident was in wheelchair. Roommate in bed. Resident didn't recognize that roommate was a different person. Staff explained to resident that resident was safe and he/she had a new roommate and the new roommate would not hurt him/her. Resident stated, So you will be my guard! Resident laughed, was assisted back to bed and slept through the night. Observation on 2/22/23 at 10:55 A./M., showed Resident #2 in bed with lacerations on his/her head and bruising on his/her face, arms, and hands. During an interview on 2/22/23 at 8:52 A.M., the DON said this was not Resident #1's first combative episode. They sent Resident #2 to the emergency room with three lacerations on his/her head. During an interview on 2/22/23 at 10:05 A.M., Resident #1's Durable Power of Attorney (DPOA) said the resident has a tendency to be combative, especially at night, and believed this could be part of his/her Post Traumatic Stress Disorder (PTSD). During an interview on 2/22/23 at 10:43 A.M., Certified Nursing Assistant (CNA) A said Resident #1 was grumpy and very combative at times. The evening of the altercation he/she said he/she could tell Resident #1 was agitated, but it was shift change and he/she left. He/She said after the incident Resident #2 was confused about the lacerations to his/her head, the resident got a new roommate and he/she was very scared of new roommate, because of past roommate Resident #1. During an interview on 2/22/23 at 10:49 A.M., Registered Nurse (RN) C said Resident #1 was on Seroquel (an antipsychotic used to treat schizophrenia, bipolar disorder and depression) and Sertraline (a serotonin reuptake inhibitor used to treat depression, obsessive-compulsive disorder (OCD), PTSD, social anxiety disorder, and panic disorder) to help combat behaviors along with psych charting. He/She said the staff just monitored the resident, but was unsure of his/her triggers. He/She said Resident #2 was confused and scared after the incident occured. During an interview on 2/22/23 at 11:02 A.M., Certified Medication Technician (CMT) B said he/she did not work during the incident. He/She said Resident #1 could be combative, but was not aware of what interventions were in place. During an interview on 2/22/23 at 12:08 P.M., the Administrator said Resident #1 had previous altercations. He did not know what interventions were in place for Resident #1's combative behavior. During an interview on 2/28/23 at 6:36 A.M., Licensed Practical Nurse (LPN) F said CMT G said he/she heard commotion and went into the residents' room to find Resident #1 beating Resident #2 in the head with his/her metal grabbers. He/She sent Resident #2 to the hospital for treatment and evaluation for his/her head wounds. He/She did not personally have problems with Resident #1 being aggressive or combative, but knew he/she had a reputation of that when his/her spouse was alive, hitting other residents and staff to the point of requiring a haldol injection. Resident #1's triggers were the dark, not hearing/understanding and getting out of routine. Resident #1 needed to be approached in a gentle manner to not startle him/her. He/She said no one at shift change relayed to him/her that Resident #1 showed signs of combative behavior or aggression and that was something he/she would expect to know. During an interview on 2/28/23 at 9:56 A.M., CMT G said he/she heard commotion in Resident #1 and Resident #2's room, he/she walked into the room and witnessed Resident #1 hitting Resident #2 in the head with his/her metal grabbers and he/she stopped it. Resident #2 was bleeding from the head profusely and sent to the hospital for evaluation and treatment. He/She said he/she has never seen Resident #1 be physically combative but knew he/she had a history of being aggressive. He/She said no staff alerted him/her to Resident #1 showing aggressive behaviors and he/she was not sure of what interventions were in place to watch or prevent aggressive combative behavior. MO00213782

Based on observation, interview, and record review, facility staff failed to ensure the resident environment remains as free of accident hazards as is possible, when staff failed to maintain the hot water temperature of plumbing fixtures accessible to residents on corridors A and B in a manner to prevent serious [CONDITION(S)] or scalding in a short amount of time. Additionally, facility staff failed to ensure razors and hazardous chemicals were stored in a safe manner, and failed to lock an unattended treatment cart. Facility staff also failed to propel four residents (Residents #14, #30, #57 and #59) in wheelchairs in a manner to prevent accidents. The facility census was 68. The administrator was notified on 09/20/22 at 12:45 P.M. of an Immediate Jeopardy (IJ) which began on 09/19/22. The IJ was removed on 09/20/22, as confirmed by surveyor onsite verification. 1. Review of the facility's Water Temperature Policy, undated, showed the policy directed staff to check water temperatures in the kitchen, maintenance room, housekeeping room, central supply room and at least two rooms per hall once weekly and record the temperatures in the water temperature binder. Review showed the policy directed staff to adjust the water temperature accordingly if the water temperature measured outside the range of 105 to 120 degrees Fahrenheit (dF). Review of the facility's Weekly Domestic Hot Water Temperature Check log dated 09/05/22, showed the maintenance director documented: -Tank Location Building Area Supplied Supply Temperature dF *Housekeeping Laundry 120 D Wing NA C Wing 120 *Central Supply A&B Wing 120 *Maintenance Office Kitchen 120 Domestic 120 Review showed the record did not contain documentation of the water temperature in two rooms per hall as directed by the facility policy. Review of the facility's Weekly Domestic Hot Water Temperature Check log dated 09/12/22, showed the maintenance director documented: -Tank Location Building Area Supplied Supply Temperature dF *Housekeeping Laundry 115 D Wing NA C Wing 115 *Central Supply A&B Wing 120 *Maintenance Office Kitchen 120 Domestic 120 Review showed the record did not contain documentation of the water temperature in two rooms per hall as directed by the facility policy. Review of Resident #12's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 06/08/22, showed staff documented the resident's score for the Brief Interview for Mental Status (BIMS), a screening tool used to detect cognitive impairment, as 00 (severe impairment). Review of Resident #17's MDS, dated [DATE], showed staff documented the resident's diagnoses included diabetes mellitus and the resident's score for the BIMS as 11 (moderately impaired). Review of Resident #46's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease and dementia and the resident's score for the BIMS as 12 (moderately impaired). Observation on 09/19/22 at 12:10 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #12, #17 and #46 measured 147.7 dF when tested for two minutes with a calibrated metal stem-type thermometer. During an interview on 09/19/20 at 4:13 P.M., the Director of Nursing (DON) said Resident #12 is alert, but non-verbal so his/her cognitive orientation is difficult to determine. The DON said if the resident got in extremely hot water without staff supervision the resident would not react and pull his/herself out of the water. The DON said Resident #17 is alert and oriented, but he/she would not react if his/her feet were in extremely hot water due to sensation loss from diabetes. The DON said the resident uses an electric wheelchair and is able to operate the wheelchair independently. The DON also said Resident #46 is alert to person and place, but not time. The DON said the resident is able to propel himself/herself in a wheelchair for short distances, and would be able to propel him/herself into bathroom. Review of Resident #19's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease and dementia. Staff documented the resident would not be able to complete a BIMS as the resident was rarely/never understood. Staff assessed the resident with memory problems for both short term and long term memory and had severely impaired cognitive skills for daily decision making. Staff assessed the resident with inattention and disorganized thinking behaviors. Review of Resident #316's MDS, dated [DATE], showed staff documented the resident's diagnoses included diabetes mellitus and dementia and the resident's score for the BIMS as 00 (severe impairment). Observation on 09/19/22 at 12:17 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #19 and #316 measured 145.2 dF when tested for two minutes with a calibrated metal stem-type thermometer. During an interview on 09/19/22 4:18 P.M., the DON said Resident #19 is alert, but only oriented to himself/herself. The DON said the resident does ambulate independently and wanders throughout the facility. The DON also said Resident #316 is alert to only himself/herself and able to ambulate independently at times depending on the time of day and his/her mood. Review of Resident #26's MDS, dated [DATE], showed staff documented the resident's diagnoses included [CONDITION(S)] accident (stroke) and a [CONDITION(S)]. The staff documented the resident's score for the BIMS as 05 (severe impairment). Review of Resident #315's physician orders, dated September 2022, showed the resident's diagnoses included dementia. Continued review of the resident's medical records showed the records did not contain documentation of an assessment of the resident's cognition. Observation on 09/19/22 at 12:26 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #26 and #315 measured 146.5 dF when tested for two minutes with a calibrated metal stem-type thermometer. During an interview on 09/19/22 4:21 P.M., the DON said #26 is alert to himself/herself, time and sometimes place, but needs redirection/reorientation at times. The DON said the resident ambulates independently with with a wheeled walker. The DON said he/she did not know much about Resident #315 since he/she was admitted a week ago while he/she was away, but the resident ambulates independently with a wheeled walker. The DON said he/she did not know if the resident would be able to remove him/herself from extremely hot water. Review of Resident #6's MDS, dated [DATE], showed staff documented the resident's diagnoses included dementia and the resident's score for the BIMS as 05 (severe impairment). Review of Resident #42's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease and the resident's score for the BIMS as 01 (severe impairment). Observation on 09/19/22 at 12:32 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #6 and #42 measured 148.3 dF when tested for two minutes with a calibrated metal stem-type thermometer. During an interview on 09/19/22 4:31 P.M., the DON said Resident #6 is only alert to himself/herself at times and ambulates independently. The DON said Resident #42 is only alert to himself/herself and is able to propel him/herself in a wheelchair. Review of Resident #23's MDS, dated [DATE], showed staff documented the resident's diagnoses included diabetes mellitus and the resident's score for the BIMS as 05 (severe impairment). Review of Resident #65's physician orders, dated September 2022, showed the resident's diagnoses included unspecified dementia without behavioral disturbances. Review of Resident #317's MDS, dated [DATE], showed staff documented the resident's diagnoses included diabetes mellitus and the resident's score for the BIMS as 05 (severe impairment) Observation on 09/19/22 at 12:35 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #23, #65 and #317 measured 141.1 dF when tested for two minutes with a calibrated metal stem-type thermometer. During an interview on 09/19/22 at 4:26 P.M., the DON said Resident #23 is alert only to himself/herself and has limited mobility. If the resident got in extremely hot water without staff supervision, the resident would not be able to remove himself/herself from the water. The DON said Resident #65 is alert only to himself/herself at times and is able to propel him/herself independently in a wheelchair. The DON also said Resident #317 is alert only to himself/herself and is able to propel himself/herself in a wheelchair. He/she believed the resident would recognize extremely hot water, but he/she would not be able to remove himself/herself from the hot water. Review of Resident #7's MDS, dated [DATE], showed staff documented the resident's diagnoses included dementia and diabetes mellitus and the resident's score on the BIMS as 00 (severe impairment). Review of Resident #13's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease, dementia, stroke and diabetes mellitus. Further review showed staff documented the resident's score for the BIMS as 00 (severe impairment). Observation on 09/19/22 at 12:45 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #7 and 13 measured 147 dF when tested for two minutes with a calibrated metal stem-type thermometer. During an interview on 09/22/22 at 10:50 A.M., the DON said Resident #13 is alert only to him/herself and if he/she got in extremely hot water without staff supervision he/she would not be able to get him/herself out of the water. The DON said resident #7 is not oriented and non-verbal. He/she believed the resident would recognize if the water was too hot, because he/she does respond to physical stimuli, but if the resident got in extremely hot water he/she would not be able to get his/herself out of the water. Review of Resident #4's MDS, dated [DATE], showed staff documented the resident would not be able to complete a BIMS as the resident was rarely/never understood. Staff assessed the resident with memory problems for both short term and long term memory and had severely impaired cognitive skills for daily decision making. Staff assessed the resident with inattention, disorganized thought, and an altered level of consciousness. Review of Resident #14's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease. Staff documented the resident would not be able to complete a BIMS as the resident was rarely/never understood. Staff assessed the resident with memory problems for both short term and long term memory and had severely impaired cognitive skills for daily decision making. Review of Resident #22's MDS, dated [DATE], showed staff documented the resident's diagnoses included Alzheimer's Disease and dementia and the resident's score for the BIMS as 01 (severe impairment). Observation on 09/19/22 at 12:47 P.M., showed the temperature of the hot water in the sink of the shared bathroom for Residents #4, #14 and #22 measured 148.8 dF when tested for two minutes with a calibrated metal stem-type thermometer. During an interview on 09/22/22 at 10:50 A.M., the DON said Residents #4 and #14 are alert only to themselves and he/she believed the residents would recognize the water was too hot, but they would not easily be able to remove themselves from the water. The DON said Resident #22 is alert only to him/herself and he/she believed the resident would recognize if the water was too hot, but he/she would not be able to remove him/herself from the water at all. Observation on 09/19/22 at 1:18 P.M., of the thermometer for the two 108 gallon hot water heater holding tanks for corridors A and B, where the resident rooms were located, showed the temperature of the water measured 129 dF. During an interview on 09/19/22 at 1:27 P.M., the Maintenance Director said he/she looks at the gauges on the water heaters and checks one room on each hall in addition to the kitchen, laundry and a common area weekly. He/she does not document the temperatures of the water tested from the plumbing fixtures on each hall, but they should not be greater than 125 dF. He/she had worked at the facility for two years and the previous maintenance director who trained him/her told him/her that 125 dF is the maximum hot water temperature allowed by regulations. Observation on 09/19/22 at 2:00 P.M., showed the temperature of the hot water from the shower head in the common shower room measured 146.5 dF. During an interview on 09/19/22 at 2:10 P.M., the administrator said he/she would expect staff to check the water temperatures in two to three rooms and common areas weekly. The administrator said staff should also document each temperature and area measured. The maximum water temperature allowed by regulation is 120 dF and he/she did not know the maintenance director did not know that. 2. Review of the facility's Hazardous Materials Policy, revised November of 2017, showed it did not contain direction for staff in regard to hazardous chemical storage. Review of the facility's Administration Procedures for All Medications Policy, dated 1/1/19, showed all medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/technician. Observation on 9/21/22 at 8:21 A.M., showed an unlocked and unattended treatment cart on C hallway. Observation on 9/21/22 at 8:29 A.M., showed an unlocked and unattended treatment cart on C hallway. Observation on 9/21/22 at 8:31 A.M., showed two staff members walked by the unlocked treatment cart on C hallway. Observation on 9/21/22 from 8:38 A.M. to 8:48 A.M., showed the unlocked and unattended treatment cart contained: -Five lancets (For blood sampling); -Two tubes of antifungal cream labeled, Contact poison control if ingested; -Two tubes of Biofreeze (Medication for muscle or joint pain); -Two containers of [MEDICATION(S)] powder (Treats fungal or yeast infections of the skin); -One bottle of [MEDICATION(S)] 3% (Antiseptic) labeled, Contact poison control if ingested; -One bottle of first aid antiseptic [MEDICATION(S)]-iodine solution 10% labeled, Contact poison control if ingested; -One tube of [MEDICATION(S)] ointment 2% (Ointment to treat skin bacteria) labeled, Contact poison control if ingested; -One tube of [MEDICATION(S)] (Ointment to treat skin bacteria) labeled, Contact poison control if ingested; -One tube of Calazinc Body Shield (Skin protectant) labeled, Contact poison control if ingested; and -Multiple packets of [MEDICATION(S)]-iodine 10% (Antiseptic) swabs labeled, Contact poison control if ingested. Observation on 9/21/22 at 8:50 A.M., showed ten staff members walked by the treatment cart as this surveyor documented it's contents. The DON locked the treatment cart. During an interview on 9/22/22 at 2:00 P.M., Certified Nurse Aide (CNA) C said if staff see an unlocked treatment cart, they should lock it and then notify the nurse. During an interview on 9/23/22 at 12:17 P.M., the DON said staff are expected to lock the treatment cart before they leave it. He/ She said, Anyone could get into it, and a confused resident could get something and lick it. 3. Observation on 9/20/22 at 8:39 A.M., showed the C hallway shower room unlocked and unattended with a hair dryer plugged in, a disposable razor on the sink, and a disposable razor in the shower. Further observation showed two unlocked and unattended cabinets that contained: -Mycolic disinfecting wipes labeled, Call poison control or doctor for treatment advice; -One container of Arrid extra dry labeled, Call poison control if ingested; and -One container of Right guard sport unscented labeled, Call poison control if ingested. -Two disposable razors. Observation on 9/21/22 at 8:26 A.M., showed the C hallway shower room unlocked and unattended with two unlocked and unattended cabinets that contained: -One container of Arrid extra dry labeled, Call poison control if ingested; and -One container Right guard sport unscented labeled, Call poison control if ingested. -Three disposable razors. During an interview on 9/22/22 at 2:00 P.M., CNA C said the housekeeping staff is responsible for cleaning the shower rooms. He/She said they are cleaned daily and checked for hazardous or dangerous items. He/She said the shower aides should dispose of the razors, but housekeeping is also responsible for disposing of them if found while cleaning. He/She said the shower room door should be locked at all times when not in use. He/She said all staff are responsible to ensure the shower rooms are locked. He/She said razors and other sharp items should be locked up, and out of reach of residents. He/She said chemicals should not be in shower rooms, but locked up in the medication room. He/She would remove razors from a resident's room, who is receives an anticoagulant, and inform the charge nurse. During an interview on 9/22/22 at 2:08 P.M., Licensed Practical Nurse (LPN) A and LPN B said staff are directed to lock the medication and treatment carts before they leave them. Both LPN A and LPN B said chemicals and other potential hazardous items such as razors or scissors should be kept in a locked cabinet at all times when not in use so confused residents don't have access to them, and don't get hurt. During an interview on 9/22/22 at 2:32 P.M., CNA M said the shower aides should check the shower rooms throughout the day for razors, chemicals or any other potentially hazardous items. He/She said if razors or other sharps were left unattended, staff should put them in a sharps container. CNA M said the spa rooms should always be locked. During an interview on 9/23/22 at 12:17 A.M., the DON said it is the shower aides responsibility to ensure the shower rooms are locked. He/ She would not expect razors, chemicals, or anything that could be hazardous to be left out because it puts the residents at risk for opening something up and ingesting it. 4. Review of the facility's Wheelchair Use Policy, dated 2006, showed staff are directed to lower the foot rests of the wheelchair, and place resident's feet on the foot rests if used. Position the resident's feet and legs in good body alignment. 5. Review of Resident #14's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/11/22, showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from one staff member for locomotion on unit; -Required total dependence assistance from one staff member for locomotion off unit; -Used a wheelchair. Observation on 9/20/22 at 8:57 A.M., showed CNA D propelled the resident from the dining room to midway down B Hall without foot pedals on the wheelchair. The resident's left foot touched the floor. Observation on 9/20/22 at 9:01 A.M., showed CNA D propelled the resident down the hallway to his/her room without the use of foot pedals. Observation on 9/21/22 at 8:41 A.M., showed CNA T propelled the resident from the dining area to his/her room with foot pedals, but did not ensure the resident's feet were on the pedals. The resident's feet were behind the pedals, and his/her feet dragged on the floor when he/she was propelled out of he dining room. During an interview on 9/21/22 at 8:41 A.M., CNA T said he/she ensured the resident's feet were on the pedals before he/she propelled the resident. He/She didn't realize the resident's feet were not on the pedals and dragged on the floor. He/She said staff are directed to use foot pedals and ensure the resident's feet are on the foot pedals. 6. Review of Resident #30's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required assistance from on staff member for locomotion on and off unit; -Used a wheelchair. Observation on 9/21/22 at 8:16 A.M., showed the Business Office Manager (BOM) pulled the resident in a wheelchair from the dining room to the hallway without foot pedals. The resident's left toes dragged on the floor. Observation on 9/21/22 at 8:30 A.M., showed CNA U propelled the resident in his/her wheelchair with the resident's hands on the wheels while he/she was propelled. Observation on 9/19/22 at 1:46 P.M., showed Certified Medication Technician (CMT) V propelled the resident down the hallway to the dining room without foot pedals. 7. Review of Resident #57's Admission MDS, dated [DATE] showed staff assessed the resident as: -Cognitively Intact; -Required assistance from on staff member for locomotion on and off unit; -Used a wheelchair. Observation on 9/19/22 at 1:38 P.M., showed CMT W propelled the resident from the dining room to the resident's room without the use of foot pedals. 8. Review of Resident #59's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required limited assistance from one staff member for locomotion on unit; -Required extensive one person assistance from one staff member for locomotion off unit; -Used a wheelchair. Observation on 9/19/22 at 1:46 P.M., showed CMT V propelled the resident down the hall to the dining room without foot pedals. Observation on 9/19/22 at 4:12 P.M., showed an unidentified staff member propelled the resident from the television room to the activity room without the use of foot pedals. During an interview on 9/22/22 at 2:00 P.M., CNA C said staff are directed to make sure foot pedals are on and arms are inside the wheelchair. He/She had seen staff propel residents without foot pedals, but had not witnessed staff propel residents with their arms outside the chairs. During an interview on 9/22/22 at 2:08 P.M., LPN A and LPN B said staff are directed to elevate the resident's feet on pedals and ensure the resident's arms on the armrest arms or inside the wheelchair prior to propelling them. During an interview on 9/22/22 at 2:32 P.M., CNA M said staff are to ensure the resident has their arms inside the wheelchair and feet on the foot pedals before staff propel them. CNA M said if a resident refuses the foot pedals and wants to be propelled, staff should make sure the resident holds their feet up. During an interview on 9/23/22 at 12:17 P.M., the DON said the staff are directed no pedals, no push. He/she said staff should keep the residents arms on the armrests or within the armrests. Injuries such as broken bones and skin breakdown could occur if feet and hands are not addressed during wheelchair locomotion. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).