Every finding on record at Ozark Rehabilitation & Health Care Center

Based on observation and interview, facility staff failed to maintain a clean, comfortable, homelike environment when staff failed to maintain the interior of building. Facility staff failed to remove trash from the exterior and maintain the exterior of the premises. The facility census was 40. 1. Observation on 05/12/25 between 12:00 P.M and 12:45 P.M., showed: -The bathroom door in resident room [ROOM NUMBER] contained a dark brown patch on the lighter stained door, and a marred area at the top with a layer of plywood dug out; -The bathroom door in resident room [ROOM NUMBER] patched with a dark brown patch in the middle of the lighter stained door; -The bathroom door in resident room [ROOM NUMBER] had a hole near the middle of the door; -The hallway ceiling tile near resident rooms #23 and #26 had yellow-brown stains; -The bathroom door frame in resident room [ROOM NUMBER] was marred near the floor; -The bathroom door frame in resident room [ROOM NUMBER] was marred, near the floor, and the door had a layer of plywood missing near the top of the door; -The door to resident room [ROOM NUMBER] contained portions of the door with a bleached-out appearance, and the bathroom door had a marred area under the door handle. Observations on 05/13/25 during the Life Safety Code tour, showed: -The hall one shower room contained square openings in the tile around both water faucets and the water outlet where the shower hose was attached. Observation showed the wall cavity was visible around the faucets and the shower hose attachment; -The floor drain in the hall one shower room had a missing tile and the drain was depressed below the tile surface which created a sharp edge. The black non-slip floor surface material was torn and in disrepair; -The floor of the hall one shower room was missing three tiles where the assist bars were installed near the commode; -The area near the floor drain in the hall two shower was missing a piece of tile; -The lower wall of the hall two shower was missing two tiles; -The hall two shower was missing two baseboard tiles and one tile was not attached and leaned against the shower wall; -The hall two shower wall was missing a tile near the hot water faucet. The wall cavity was visible where the tile was missing; -The floor in front of the commode in the hall two shower room contained two round holes which contained an accumulation of dirt and debris. There was one floor tile missing behind the commode; -A hole in the bathroom door of resident room [ROOM NUMBER]. During an interview on 05/15/25 at 1:41 P.M., the resident of room [ROOM NUMBER] said he/she wished the facility was kept up as well as the other facility where he/she lived. During an interview on 05/14/25 at 11:10 A.M., the maintenance director said he/she was responsible for facility repairs and facility grounds. The maintenance director said he/she was aware the building still had work to be done. The maintenance director said he/she tried to make repairs as issues were identified but the building was old and required a lot of work. The maintenance director said he/she was aware of the shower room issues but had not had time to make the repairs. 2. Observation on 05/13/25 at 12:50 P.M., showed the area outside the basement garage door contained more than 20 wood pallets, two mattresses, three tires, a charcoal grill, a garden hose and a soda vending machine. During an interview on 05/14/25 at 11:10 A.M., the maintenance director said the soda machine was removed from the building because it took up too much space. The maintenance director said the pallets were used to deliver facility supplies and he/she was not sure where some of the other items came from. The maintenance director said he/she thought the administrator was working on getting a dumpster to clear the area. 3. Observation on 05/13/25 at 1:15 P.M., showed multiple sections of the wood exterior of the facility at the end of resident hall two were rotted, broken and warped which exposed the wooden framework beneath to the elements. During an interview on 05/14/25 at 11:10 A.M., the maintenance director said some of the wood exterior was repaired last year but he/she did not realize the end of hall two also needed work. During an interview on 05/14/25 at 2:15 P.M., the administrator said maintenance was responsible for repairs in the building as well as the grounds around the building. The administrator said maintenance staff were making repairs but had not been able to get all repairs completed. The administrator said he/she did not know how long the pallets and other materials were outside the facility. The administrator said he/she was working to get a dumpster to remove the materials, but facility management changed on the first of March, which set things back. The administrator said the exterior of the building was repaired last year and he/she thought everything was taken care of.

Based on observation, interview and record review, facility staff failed to change and store oxygen tubing for one resident (Resident #18 ) of two sampled residents; failed to to use appropriate hand hygiene infection control practices during perineal and catheter care, for four residents (Resident's #12, #14, #24, and #37) of five sampled residents; failed to follow Enhanced Barrier Precautions (EBP), (the wearing of gown and gloves during high contact patient care activities to prevent the spread of multi-resistant organisms), for two residents (Resident #12 and #24) of five sampled residents. The facility census was 40. 1. Review of the facility's Hand Hygiene policy, revised 12/07/18, showed staff are directed to wash hands, as hand washing promptly and thoroughly after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions. If soap and water are not available, use alcohol gel/rub to clean hands. Review of the facility's Catheter Care policy, reviewed 03/15/23, showed staff are directed to remove gloves and wash hands after cleaning the perineal area and catheter tubing, and before repositioning the resident. Review of the facility's EBP policy, revised 07/13/23, showed EBP should be used when contact precautions do not apply for residents with open wounds that require a dressing change and indwelling medical devices. EBP requires the use of a gown and gloves during high contact resident care activities that provide opportunities for the transfer of multi-resistant drug organisms (MDRO's). High contact care activities include transfers, hygiene, changing briefs or toileting, caring for medical devices (i.e. urinary catheters, tracheostomies). Review of facility Dressing Change policy, revised 07/2007, instructs staff to discard all equipment in appropriate container after dressing change, then wash hands. 2. Review of resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/20/25, showed staff assessed the resident with an indwelling urinary catheter and always incontinent of bowel. Review of residents Care plan, dated 11/12/24, showed it did not contain documentation of the resident having a catheter. Review of residents hospice care plan, revised 5/12/25, showed the resident had a catheter. Review of residents Physician Order Sheets (POS) on 05/14/25 at 11:28 A.M. showed an order for Urinary Catheter. Observation on 05/13/25 at 03:16 P.M. showed an EBP sign on the door of the resident's room. Certified Nurse Assistant (CNA) F and Licensed Practical nurse (LPN) G entered the resident's room and provided perineal care without a gown. Observation on 05/13/25 at 03:25 P.M. showed CNA F and LPN G performed catheter care. CNA F washed his/her hands and put on gloves. He/She cleaned the resident's labia and catheter tubing he/she wiped top to bottom and replaced the resident's briefs. CNA F did not remove his/her soiled gloves or sanitize hands before he/she touched the clean brief. Observation on 05/13/25 at 03:40 P.M. showed CNA F and LPN G did not wash their hands before they exited the resident's room. During an interview on 05/13/25 at 03:50 P.M., CNA F and LPN G said they forgot to wear a gown during care. LPN G said the purpose of EBP is to prevent the spread of infection. During an interview on 5/15/25 at 03:30 P.M. Infection Preventionist (IP) said gown and gloves should be worn when staff perform care on residents with EBP. Staff received training on these precautions. 4. Review of Resident #14's admission MDS, dated 02/06025 showed staff assessed the resident as follows: -Cognitively Intact; -Dependent on staff for toileting; -Required partial to moderate assist for bed mobility; -Frequently incontinent of bowel and bladder. During an observation on 05/14/25 at 10:13 A.M. CNA D and CNA E provided incontinence care to the resident then removed and discarded PPE and did not wash their hands before exiting the resident's room. During an interview on 05/14/25 at 11:00 A.M. CNA D said hands should be washed before leaving a resident's room and he/she did not realize it was not done after cleaning up this resident. During an interview on 5/15/25 at 03:30 P.M., IP said hand hygiene should be done before exiting a resident's room if staff have provided care to the resident. Staff have received training on hand hygiene. 6. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Dependent on staff for bed mobility, transfers, and toileting hygiene; -Always incontinent of bowel and bowel. Observation on 05/12/25 3:20 P.M., showed CMT B wiped resident's perineal area, CNA C placed a clean brief under the resident's left side, and CMT B continued to wear the same soiled gloves and pulled the clean brief under resident's right side. CMT B and CNA C used the mechanical lift to move the resident from the bed to the chair, adjusted the resident, and exited the room. CMT B and CNA C did not wash their hands before exiting the resident's room. Observation on 05/12/25 at 2:25 P.M., showed CMT B and CNA C entered the resident's room with a sign to direct staff for EBP prior to performing peri-care. CMT B and CNA C did not put on gowns before performing the peri-care. During an interview on 05/12/25 at 3:40 P.M., CNA C said he/she thought the EBP sign on the door was outdated. CNA C said he/she would have to ask the charge nurse or the DON if it was outdated to be sure. 8. Review of resident #37's admission MDS, dated [DATE], showed staff assessed the resident as follows: -cognitively intact; -Frequently incontinent of bowel and bladder; -Diagnosis of Stage 3 pressure ulcer (severe wounds that cause damage to the deeper layers of the skin). Review of care plan, revised 05/14/25, showed staff assessed the resident as follows: -Dependent on staff for all care; -Incontinent of bowel and bladder; -Has pressure ulcers, Stage 3. Observation on 05/14/25 at 10:12 A.M. showed the resident's room had an EBP sign. CNA D and CNA E performed perineal care for the resident and left the room without washing their hands. During an Interview on 05/14/25 at 10:13 A.M., CNA E said he/she should have washed his/her hands before he/she left the resident's room to prevent cross contamination. During an Interview on 05/14/25 at 10:15 A.M. LPN G said hand hygiene should be performed when leaving a resident's room. During an interview on 05/14/25 at 11:00 A.M. CNA D said he/she did not realize he/she did not wash his/her hands before he/she left the resident's room. During an interview on 5/15/25 at 03:30 P.M., the IP said hand hygiene should be performed after providing care and before leaving a resident's room. Staff have received training on hand hygiene.

Based on observation, interview, and record review, facility staff failed to ensure two residents (Resident #18 and #37) had orders for oxygen and failed to ensure oxygen tubing was dated per facility policy. The facility census was 40. 1. Review of the facility's policy titled, Oxygen Therapy, March 2019, showed staff are directed to: -Verify the physician's order; -Adjust the delivery rate per the physician's order; -Change oxygen tubing/mask/cannuala and/or tracheostomy mask weekly; -Date tubing changes. 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/18/25, showed staff assessed the resident as: -admitted on [DATE]; -Cognitively intact; -Dependent on staff for upper body dressing and personal hygiene; -Required oxygen. Review of the resident's Care Plan, dated 04/14/25, showed the plan did not contain direction for staff in regard to the resident's oxygen use. Review of the resident's Nursing admission Assessment, dated 04/07/25, showed staff assessed the resident used oxygen at two Liters Per Minute (LPM) via nasal cannual at night. Review of the resident's Physician's Order Sheet (POS), dated May 2025, showed the record did not contain orders for oxygen or oxygen tubing maintenance. Observation on 05/12/25 at 12:35 P.M., showed the resident's oxygen tubing in the resident's room undated. Observation on 05/13/25 at 11:20 A.M., showed the resident's oxygen tubing in the resident's room undated. Observation on 05/15/25 at 1:41 P.M., showed the resident's oxygen tubing in the resident's room undated. During an interview on 05/15/25 at 1:41 P.M., the resident said he/she uses oxygen every night. The resident said he/she could not recall if staff had changed his/her oxygen tubing since he/she was admitted . 3. Review of resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident required oxygen. Review of the resident's care plan, dated 05/14/25, showed oxygen at two liters via nasal cannula. Review of the resident's POS, dated May 2025, showed the order did not specifify the oxygen flow rate. Observation on 05/14/25 at 09:00 A.M. showed the resident wore oxygen at two LPM. During an interview on 05/12/25 at 11:45 A.M. the resident said he/she uses oxygen continuously, but the nasal cannula falls off while he/she sleeps. He/She did not know the oxygen flow rate. During an interview on 05/13/25 at 11:30 A.M., Licensed Practical Nurse (LPN) G said he/she did not realize the resident's oxygen order did not include the flow rate. He/She said it is the responsibility of the nurse's to make sure orders are correct. During an interview on 05/14/25 at 3:10 P.M., the Director of Nursing (DON) said all oxygen orders should include the flow rate, and did not know how it was missed on this resident. During an interview on 05/14/25 at 3:30 P.M the administrator said oxygen orders should include the flow rate. It is the nurse's responsibility to ensure orders are transcribed correctly. If something is missing, the physician should be contacted for clarification.

Based on interview and record review, the facility staff failed to document collaboration of care with hospice providers for development and implementation of a coordinated plan of care, communication between the facility and hospice providers and did not have physician orders for hospice for two residents (Resident #27 and #36) of three residents. The facility census was 40. 1. Review of facility Hospice Services policy, undated, showed the facility provides continuity of care to provide residents who are terminally ill with the opportunity to receive comprehensive, interdiscipinary care that recognizes the spirtiual needs, and to assist residents, family members and friends to live as fully and completely as possible with meaing and diginity. An interdisciplinary care plan which integrates the care and services provided by the faciity and the hospice provider including. Communication and/or coordination of participants and agencies providing aspects of palliative care. Hospice providers and this facility exchange information from the respective care plan, assessment updates, and resident and family conferences to asssure provision of changing necessary care and services. The facility will coordinate care planning with the hospice provider including all services and supplies provided by the hospice provider including nursing and nursing aid services, social services, chapaincy services, durable medical equipment, medictions and grief support to family members. Facility will observe, record and report to appropriate Hospice personnel, the patient's response to treatment and any changes in the patient's conditon, which migh require modificaton of the Plan of Care Review of the facility's hospice agreement, dated 04/28/20, showed the facility will observe, record and report to appropriate hospice personnel the patient's response to treatment and will immediately notify hospice if a significant change in the patient's physical status occurs. Facility records shall specifically include a record of all hospice care to the hospice patient by the faciilty and all events regarding care of the Hospice patient that occurred at the facility. 2. Review of Resident's #27's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/01/24, showed the resident on hospice and has a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 05/13/25, showed the resident listed received hospice services. Review of the resident's Physician Order Sheet (POS), dated May 2025 showed the POS did not contain a physician order for hospice care. Review of the resident's progress notes, dated March 2025, showed an MDS note the resident to receive hospice services. The record did not contain documentation of hospice staff visits. Review of the resident's progress notes, from April 2025-May 2025, showed the record did not contain documentation of hospice staff visits. Review of the resident's medical record, dated May 2025, showed the record did not contain documentation hospice staff visits. 3. Review of Resident's #36's Quarterly MDS, dated [DATE], showed staff documented the resident received hospice and has a condition or disease that may result in a life expectancy of less than six months. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed the POS did not have a physician order for hospice care. 4. During an interview on 05/14/25 at 09:46 A.M., LPN G said he/she was unable to locate an order for hospice. He/She stated hospice does not document progress notes after visits with residents. A verbal report is recieved. Nurses don't usually document the verbal report. He/She said hospice is notified when the resident has a change of status or significant event. During an interview on 5/14/25 at 11:10 A.M., the DON said hospice service providers do not provide notes of care or assessments during their visit. The nurses receive a verbal report when there is something relevant to report. To his/her knowledge, those conversations are not documented. He/She said there should be an order when hospice services are being provided. During an interview on 5/15/25 at 3:30 P.M., the Adminstrator said an order is expected for residents on hospice care; and service should be communicated between facility and hospice provider.

Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the resident census, and the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility census was 40. 1. Review of the facility's policies did not contain a policy for posting required nurse staffing information. 2. Observation on 05/12/25 at 12:43 P.M., showed the nurse staff posting did not include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care per shift. Observation on 05/13/25 at 11:45 A.M., showed the nurse staff posting did not include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care per shift. Observation on 05/14/25 at 02:37 P.M., showed the nurse staff posting did not include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care per shift. Observation on 05/15/25 at 10:45 A.M., showed the nurse staff posting did not include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care per shift. During an interview on 05/15/25 at 11:30 A.M., LPN A said the charge nurse fills out the nurse staff posting sheet. During an interview on 05/15/25 at 3:10 P.M., the Director of Nursing (DON) said the charge nurse is responsible to fill out the posting sheet. During an interview on 5/14/25 at 3:30 P.M., the administrator said the charge nurses fills the nurse staffing sheet out and put on different assignments, and the posting has the census, but generally is an estimate. Staff in the business office make corrections and keeps the staffing sheets for at least a year.

Based on interview and record review, facility staff failed to properly stretch one resident (Resident #1) leg for range of motion, in a safe manner which resulted in an injury to his/her leg that required surgical intervention. The facility census was 40. 1. Review of the Restorative Program - range of motion policy, revised 02/03/22, showed the policy is to provide the resident with limited range of motion appropriate treatment and services to increase or prevent further decrease in range of motion. Staff are instructed to provide resident with repetitions as per residents tolerance and care plan and never continue past the point of resistance or pain. 2. Review of Resident #1's Annual minimum data set (MDS) a federally mandated assessment tool, dated 09/17/24, showed staff assessed the resident as follows: -Cognitively intact; -Totally dependent with two plus staff to assist; -Incomplete quadriplegic (weakness or partial paralysis but has some sensation); -Wheelchair for mobility. Review of the physician order sheet, dated 6/21/24, showed the resident may participate in restorative program as tolerated. Review of the nurse's notes, dated 10/11/24 at 10:50 P.M., showed staff documented a loud pop from the resident's right knee while staff performed leg stretches and repositioning. The resident stated he/she had pain in the knee, rated a ten out of ten. Range of motion was painful and patella (kneecap) easily malleable (out of shape without breaking) and painful. Sent to local hospital. Review of the resident's x-ray, dated 10/11/24, showed the resident with a spiral fracture of the right femur. Review of the resident's plan of care, dated 10/18/24, showed staff assessed the resident with alteration in musculoskeletal impairment due to femur fracture and provide therapies as ordered. During an interview on 10/23/24 at 11:14 A.M., the resident said the aides are responsible to stretch his/her legs. He/She said the new Certified Nursing Assistant (CNA) A, said he/she had the perfect stretch to help his/her legs that was not a routine stretch. When CNA A and CNA B performed the stretch something in his/her leg snapped and he/she knew something was wrong immediately. The nurse came to assess him/her and sent him/her to local hospital where a spiral fracture was found in his/her right leg and he/she had surgery. During an interview on 10/23/24 at 11:33 A.M., the administrator said the stretch was not a routine stretch for the patient, but it was an accident, he/she said he/she expects the assigned stretches to be done and only therapy should introduce new stretches. During an interview on 10/23/24 at 12:28 P.M., CNA A said he/she taught the resident a new stretch because he/she had done it when he/she played sports. CNA A said he/she placed the resident's leg over his/her opposite knee and pushed towards his/her chest. He/She said it was an accident and he/she was trying to help the resident, the resident did not seem in pain at first after the pop, but then his/her knee cap was hurting. The resident was then sent to the local hospital. During an interview on 10/23/24 at 1:08 P.M., CNA B said he/she and CNA A stretched the resident's legs upon request. CNA A introduced a new stretch where they placed his/her leg over his opposite knee and pushed towards his/her chest. He/She said there was a pop in the residents leg. He/She did not know why CNA A changed the residents stretches from his/her normal routine. He/She said he/she immediately went and had the nurse assess the resident and he/she sent him/her to the hospital. During an interview on 11/21/24 at 3:12 P.M., the Director of Nursing (DON) said passive range of motion (ROM) is staff assisting the residents to move any joints. Staff have a list of movements and what they mean and they are not supposed to take anyone pass resistance or pain. He/She said he/she does not know why staff would introduce a stretch that was pass resistance and inflicted pain or injury. Staff recieve training in biweekly staff meetings on multiple topics and ROM is taught several times a year and information is in the Activities Daily Living (ADL) that is available to all staff at all times. MO00243950

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Resident #2 touched Resident #1's chest inappropriately. The facility census was 40. 1. Review of the facility's Abuse Prevention Program, undated, showed the facility affirms the right of their residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents. Review showed: -Abuse is defined as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility; - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish; -Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 3/25/24, showed staff assessed the resident as cognitively intact. Review of the resident's plan of care, updated 5/01/23, showed staff were directed to provide the resident with privacy and dignity. Review of the facility investigation, dated 6/26/24, showed staff documented a staff member reported Resident #2 sat in a chair in the lobby and Resident #1 sat in a chair next to him/her. Resident #2 then reached over and grabbed Resident #1's chest and in turn Resident #1 closed fisted struck Resident #2 in the chest. Review of the resident's nurse's notes, dated 6/26/24, showed staff documented Resident #2 grabbed Resident #1's chest and Resident #1 punched Resident #2. Staff documented the resident said he/she is ok, but pissed off about it. During an interview on 6/27/24 at 12:45 P.M., Resident #1 said Resident #2 pressed up on my chest, and I smacked him/her. He/She said Resident #2 knew what he/she was doing. The resident said he/she did not like it, when Resident #2 touched his/her chest inappropriately. 2. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident with cognitive impairment, physical and verbal behaviors directed at others, and other behaviors not directed at others. Review of the residents hospital records, dated 1/11/24, showed the physician documented the resident has, continued to have sexual behaviors and inappropriate comments, although managed better with current medications. Review of hospital records, dated 3/21/24, showed the physician documented the resident has become more aggressive, and the facility licensed staff are, concerned that he/she does force things on his/her spouse, who he/she shares a room with. The physician documented the resident is easily aggravated, with abnormal sexual behavior. Review of the resident's plan of care, updated 6/27/24, showed staff were directed as follows: -09/29/22 (revised 5/14/24)- Resident is known/has history of displaying inappropriate behavior. Specific behavior exhibited making inappropriate comments or making physical contact with staff or residents. Related diagnosis/condition Schizophrenia, Delirium (a serious change in mental abilities), personal history of other mental and behavioral conditions, altered mental state; -09/29/22- During episodes of inappropriate behavior, remove to a quiet environment; -09/29/22- Help resident understand why behavior is inappropriate/disruptive and the impact is has on personal well-being of others; -Initiate 15 minute checks for 72 hours; -Provide redirection/cueing as tolerated. Review of the resident's Physician's Order Sheets, dated 6/01/24 to 6/30/24, showed the following orders: -12/14/23- Estradiol (a hormone) one milligram (mg) one tablet daily for sexual behaviors, discontinued 6/21/24; -02/28/24- Progesterone (a steroid hormone) one capsule daily for sexual behaviors, discontinued 6/21/24; -03/01/24- Fluoxetine (an antidepressant) 40 mg two capsules once daily for depression with sexual behaviors, discontinued 6/21/24; -03/18/24- Naltrexone (an opioid analgesic) 50 mg one tablet daily for sexual behaviors; Review of the resident's nurse's notes, dated 6/26/24, showed staff documented the resident had abnormal behavior with another resident. Review of the resident's social service notes, dated 6/26/24, showed staff documented the resident grabbed a resident's breast. During an interview on 6/27/24 at 12:50P.M., Resident #3 said he/she saw Resident #2 grab Resident #1's chest. During an interview on 6/27/24 at 2:00 P.M., the Social Service Director (SSD) said he/she heard other people witnessed Resident #2 grab Resident #1's chest. He/She said staff are directed to redirect Resident #2 if the resident makes inappropriate comments. During an interview on 6/27/24 at 2:12 P.M., the Activities Director (AD) said he/she saw Resident #2 grab Resident #1's chest as he/she came out of the administrator's office. He/She said he/she reported the incident immediately to the administrator. During an interview on 6/27/24 at 2:55 P.M., the administrator said Resident #2 has a history of making inappropriate comments to female staff. He/She said Resident #1 has sat next to Resident #2 in the lobby of the facility on previous occasions, and did not have any issues. MO00238191

Based on interview and record review, facility staff failed to meet professional standards when staff failed to document they administered medications and failed to document the reason they did not administer the medications for two residents (Resident #1 and #2) out of four sampled residents. The facility census was 43. 1. Review of the facility's Medication Administration policy, revised 11/18/17, showed: -Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts; -The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given; -After a drug is given, record the date, time, name of drug, dose and route on the residents individual medication administration record (MAR); -Document any medications not administered for any reason by circling initials and documenting on the back of the MAR the date, time, medication, dosage, reason for omission and initials. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/26/24, showed staff assessed the resident with severe cognitive impairment and short and long term memory problems. Review of the resident's Physician Order Sheets (POS), dated 05/01/24 to 05/31/24, showed the resident's physician directed staff to provide the resident with: -Furosemide (a diuretic used to treat fluid retention) 40 milligrams (mg) of twice a day; -Quetiapine (an antipsychotic used to treat schizophrenia and major depressive disorder) 25 mg twice a day; -Tramadol (an opioid pain reliever) 50 mg three times a day; -Melatonin five mg at hours of sleep. Review of the resident's MAR, dated 05/08/23, showed staff did not document they administered the resident's furosemide, tramadol, quetiapine and melatonin as directed by his/her physician. Review showed staff did not document why they did not administer the medications. 3. Review of the resident 2's quarterly MDS dated [DATE], showed staff assessed the resident as follows: -Intact cognition; -Diagnoses of cerebral palsy, quadriplegia, depression, major depressive disorder, low back pain, epilepsy, nightmare disorder, and muscle spasm of the back; -had a scheduled pain medication regimen and frequent pain; -took antidepressant and opioid medications. Review of the resident's POS, dated 06/01/24 through 06/30/24, showed the resident's physician directed staff to provide the resident with: -Melatonin 10 mg daily; -Baclofen (a muscle relaxer) 20 mg four times a day; -Hydrocodone/acetaminophen (a narcotic pain reliever) 10/325 mg four times a day. Review of the resident's MAR, dated 06/01/24, showed staff did not document they administered the resident's scheduled melatonin, hydrocodone/acetaminophen and baclofen as directed by the physician. Review showed staff did not document why they did not administer the medications. During an interview on 06/04/24 at 4:45 P.M., Resident #2 said on the night of 06/01/24, Certified Medication Technician (CMT) A administered his/her medications very late and he/she did not believe the CMT gave him/her all of his/her medications. The resident said he/she had less pills in the cup than usual and knew that the CMT did not include his/her baclofen. The resident said the CMT also did not administer his/her P.M. dose of baclofen earlier that day which caused him/her to be in a lot of pain from his/her muscle spasms that night. The resident said he/she told the CMT that he/she did not get all of his/her medications and the CMT did not believe him/her and said that he/she gave him/her all the medications he/she had ordered. During an interview on 06/10/24 at 1:52 P.M., CMT A said he/she worked the evening shift on 06/01/24 and administered medications during his/her shift. The CMT said he/she worked at the facility through a staffing agency and that was his/her first night passing medications at the facility. The CMT said he/she had to pass medications to more residents than he/she was used to and while he/she did run late with the medication pass, he/she made sure that all residents had their medications as ordered. The CMT said medications should be documented as administered on the MAR at the time they are administered and if they are not documented it is considered an error. The CMT said he/she did not realize that he/she did not document that he/she administered all of Resident #2's medications. 4. During an interview on 06/10/24 at 2:44 P.M., the Director of Nursing (DON) said staff should document all medications administered on the MAR at the time of administration. The DON said failure to documented the administration of medication is a medication error and he/she did not know about the medications that were not documented as administered for Residents #1 and #2. During an interview on 06/10/24 at 3:12 P.M., the administrator said staff should document all medications administered on the MAR at the time of administration and staff are trained on this requirement. The administrator said failure to document the administration of medication is a medication error he/she did not know about the medications that were not documented as administered for Residents #1 and #2. MO00237011

Based on interview and record review, the facility staff failed to ensure three Nurse Aide's ((NA) NA L, NA M and NA N) completed the nurse aide training program within four months of his/her employment in the facility. The census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of Certified Nurse Aide (CNA) training report showed NA L's hire date as 11/24/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 2/29/24 at 11:56 A.M., the Director on Nursing (DON) said NA L has not started the nurse aide training program yet. 3. Review of the CNA training report showed NA M's hire date as 1/16/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 2/29/24 at 11:56 A.M., the DON said he/she is not sure if NA M has started the nurse aide program yet. 4. Review of the CNA training report showed NA N's hire date as 6/27/23Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 2/29/24 at 11:56 A.M., the DON said NA N has done the program but has not passed the test to become a certified nurse aide. 5. During an interview on 02/28/24 10:43 A.M., the DON said there has been a lag in gettting the NA Certification completed, he/she said he/she is aware this needed to be completed within the four months, but with COVID changes and waivers offered, I just haven't kept up on the changes. During an interview on 02/29/24 at 4:45 P.M., the Administrator said NA's were required to be certified after four months. He/She said there were issues attempting to get the NA's certified, including issues with payment and class times, which is why they were not certified in the time frame. He/She said they are working on resolving the issue.

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, dated July 2023, showed the facility did not have an RN in the building the following dates: -Tuesday 07/01/23; -Thursday 07/13/23; -Thursday 07/20/23; -Monday 07/24/23; -Thursday 07/27/23; -Saturday 07/28/23. 3. Review of the facility's RN staff schedule, dated August 2023, showed the facility did not have an RN in the building the following dates: -Tuesday 08/01/23; -Thursday 08/03/23; -Saturday 08/05/23; -Tuesday 08/08/23; -Saturday 08/12/23; -Tuesday 08/15/23; -Thursday 08/17/23; -Saturday 08/19/23; -Tuesday 08/22/23; -Thursday 08/24/23; -Saturday 08/26/23; -Tuesday 08/29/23. 4. Review of the facility's RN staff schedule, dated September 2023, showed the facility did not have an RN in the building the following dates: -Saturday 09/02/23; -Tuesday 09/05/23; -Thursday 09/07/23; -Sunday 09/10/23; -Thursday 09/14/23; -Monday 09/18/23; -Tuesday 09/23/23; -Tuesday 09/26/23; -Thursday 09/28/23; -Saturday 09/30/23. 5. Review of the facility's RN staff schedule, dated October 2023, showed the facility did not have an RN in the building the following dates: -Sunday 10/01/23; -Monday 10/02/23; -Tuesday 10/03/23; -Thursday 10/05/23; -Saturday 10/07/23; -Sunday 10/08/23; -Monday 10/09/23; -Tuesday 10/10/23; -Saturday 10/14/23; -Tuesday 10/17/23; -Saturday 10/21/23; -Sunday 10/22/23; -Monday 10/23/23; -Tuesday 10/24/23; -Monday 10/30/23; -Tuesday 10/31/23. 6. Review of the facility's RN staff schedule, dated November 2023, showed the facility did not have an RN in the building the following dates: -Sunday 11/05/23; -Thursday 11/08/23; -Saturday 11/11/23; -Monday 11/13/23; -Thursday 11/16/23; -Sunday 11/19/23; -Monday 11/20/23; -Tuesday 11/21/23; -Thursday 11/23/23; -Monday 11/27/23; -Thursday 11/30/23; 7. Review of the facility's RN staff schedule, dated December 2023, showed the facility did not have an RN in the building the following dates: -Saturday 12/02/23; -Monday 12/04/23; -Tuesday 12/05/23; -Thursday 12/07/23; -Saturday 12/09/23; -Saturday 12/16/23; -Sunday 12/17/23; -Saturday 12/23/23; -Saturday 12/30/23; -Sunday 12/31/23. 8. Review of the facility's RN staff schedule, dated January 2024, showed the facility did not have an RN in the building the following dates: -Monday 01/01/24; -Saturday 01/13/24; -Monday 01/15/24; -Sunday 01/21/24; -Saturday 01/27/24; -Monday 01/29/24; -Tuesday 01/20/24. 9. Review of the facility's RN staff schedule, dated February 2023 showed the facility did not have an RN in the building the following dates: -Thursday 02/01/24; -Saturday 02/03/24; -Sunday 02/04/24; -Monday 02/05/24; -Tuesday 02/06/24; -Thursday 02/08/24; -Saturday 02/10/24; - Sunday 02/11/24; -Monday 02/12/24; -Tuesday 02/13/24; -Saturday 02/17/24; -Sunday 02/18/24; -Monday 02/19/24; -Tuesday 02/20/24. 10. During an interview on 02/28/24 at 11:13 A.M., the Director of Nursing (DON) said there might be a day without RN coverage, I wont lie but I try hard to make sure there is not a day without RN coverage, I work 7 days a week sometimes. The DON said they have ads out but have not been able to hire RN's, she said it's just her and two other RN's that each work only one or two days a week because they have other jobs. The DON said, I just don't have the RN staff for the coverage. During an interview on 02/29/24 at 5:51 P.M., the administrator said she was not aware the facility was not meeting the RN coverage expectation.

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 45. 1. Review of facility's In-service Training policy, dated 06/06, showed the Food Service Manager or Registered Dietician plans and/or conducts regularly scheduled in-service training and education to develop the skills and knowledge required for satisfactory job performance. The policy did not contain guidance related to the qualifications of the dietary manager. Review of the dietary manager's (DM) personnel record showed he/she hired to the DM position on 09/01/22. Review showed the record did not contain documentation of prior dietary experience or related education. Documentation showed a Certified Dietary Manager course enrollment on 10/27/22 but did not include documentation of progress or completion. During an interview on 02/26/24 at 1:29 P.M., the administrator said the dietary manager was on leave since 01/22/24. The administrator said the DM was not certified and he/she did not think the facility had a Certified Dietary Manager (CDM) on staff. The administrator said the dietary manager may have received kitchen related training, but he/she did not have any documentation of training. The administrator said he/she was responsible for ensuring the dietary manager was qualified. During an interview on 02/27/24 at 9:48 A.M., the activities director said he/she used to be the kitchen manager and he/she helped the kitchen staff by doing dietary orders and answering questions in the DM's absence. The activity director said he/she was not a CDM. The activity director said he/she had food safety training about three years ago but he/she did not know the level of training. The activity director said the DM was responsible for the kitchen and he/she did not know who was responsible in the DM's absence. During an interview on 02/27/24 at 2:43 P.M., the business office manager/acting administrator said the activities director used to be the facility's DM and he/she was unaware of other qualified staff.

Based on observation, interview, and record review, facility staff failed to ensure dietary staff had the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Facility staff failed to provide effective training to dietary staff related to handwashing. Facility staff also failed to provide effective training to dietary staff related to kitchen ware washing/sanitation. The facility census was 45. 1. Review of facility's In-service Training policy, dated 6/06, showed the Food Service Manager or Registered Dietician plans and/or conducts regularly scheduled in-service training and education to develop the skills and knowledge required for satisfactory job performance. Review of the facility's Hand Washing policy, revised 10/09, showed hand washing is to be done using soap and water for at least 20 seconds: -When hands are visibly soiled; -After contact with soiled or contaminated articles; -Before and after eating, drinking or handlind food; -After handling soiled equipment or utensils. Review showed the hand washing policy also directed food service employees to wash hands in a hand washing sink. They may not wash hands in a sink used for food preparation, ware washing or in a service sink used for disposing mop water or liquid waste. Review of Dishwasher W's training record showed a hire date of 11/08/23, as maintenance staff. Review showed the record did not contain documentation of training related to handwashing or operation and testing of the dish washing machine. Observation on 02/26/24 at 9:19 A.M., showed Dishwasher W precleaned soiled dishes with his/her bare hands, pulled a clean rack of wares out of the dish machine and did not wash his/her hands. Observation showed Dishwasher W completed the same sequence two additional times and did not wash his/her hands. Observation on 02/26/24 at 9:33 A.M., showed Dishwasher W precleaned soiled dishes, removed a clean rack of bowls from the dish machine and lifted each bowl to check for cleanliness. Dishwasher W did not wash his/her hands before touching the clean bowls. Observation on 02/26/24 at 9:38 A.M., showed Dishwasher W entered the kitchen and distributed clean wash cloths and oven mitts in the kitchen. Observation showed one clean wash cloth was set on a shelf directly above soiled dishes on the dirty side of the dish machine. Dishwasher W picked up soiled food processor parts, placed the parts on the dirty side of the dish machine, rinsed his/her hands in the three-part sink for five seconds and dried his/her hands with a cloth which set above dirty dishes. Dishwasher W removed clean plates from racks and placed the clean plates on a cart and did not wash his/her hands. Dishwasher W precleaned additional dirty dishes, advanced another clean rack from machine then lifted and inspected each bowl. Dishwasher W did not wash his/her hands before handling the clean bowls. During an interview on 02/26/24 at 9:48 A.M., Dishwasher W said he/she was hired as maintenance staff but was filling in as a dishwasher. Dishwasher W said he started working at the facility in November of 2023 and had worked in the kitchen for three or four days. Dishwasher W said he/she washed dishes and fixed resident drinks. Dishwasher W said he/she used the three part sink to rinse his/her hands for a few seconds and then dried his/her hands with a cloth. Dishwasher W said proper handwashing is when you use soap for about a minute. The Dishwasher said rinsing was not proper handwashing. Dishwasher W said he/she did not wash his/her hands because they did not appear dirty. Dishwasher W said the acting administrator trained him/her the first day but never talked about handwashing. During an interview on 02/26/24 at 1:29 P.M., the administrator said the dietary manager (DM) was responsible for training kitchen staff. The administrator said Dishwasher W just started picking up shifts in the kitchen and he/she did not know if Dishwasher W was trained on handwashing. 2. Review of the dish machine operational requirements label on the front of the dish machine showed the wash and rinse temperature: 120 degrees Fahrenheit (F) minimum. Observation on 02/26/24 at 9:36 A.M., showed the dish machine temperature at 106 degrees F during the wash cycle. Observation on 02/26/24 at 9:57 A.M., showed the dish machine reached a maximum temperature of 106 degrees F during a complete wash and rinse cycle. During an interview on 02/26/24 at 1:12 P.M., Dishwasher W said he/she had not told anyone about the dish machine not reaching the correct temperature because he/she did not have time yet. Dishwasher W said he/she never received training on proper operation and testing of the dish machine. Dishwasher W said the acting administrator trained him/her the first day but never talked about checking the dish machine chemical concentrations or operating temperatures. During an interview on 02/26/24 at 1:29 P.M., the administrator said the dietary manager (DM) was responsible for training kitchen staff. The administrator said Dishwasher W just started picking up shifts in the kitchen and he/she did not know if Dishwasher W was trained on the operation and testing of the dish machine. During an interview on 02/27/24 at 12:02 P.M., the acting administrator said Dishwasher W was filling in on a temporary basis and did not receive any training related to handwashing or the dish machine. The acting administrator said he/she decided to have Dishwasher W wash dishes because the facility was short staffed and needed somebody. The acting administrator said he/she gave Dishwasher W a crash course on drinks and diets but did not cover handwashing or dishwashing.

42815 45564 Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. The facility staff failed to maintain the kitchen floors and appliances in a clean manner to prevent the growth and harborage of bacteria. Facility staff failed to properly sanitize kitchen wares, food preparation surfaces and resident dining tables to prevent potential cross contamination. The facility staff failed to maintain the dining room ice machine in a clean and sanitary manner to prevent cross contamination and inhibit the growth water-borne pathogens. The facility census was 45. 1. Review of the facility policy Storage, Revised ,d+[DATE], showed kitchen staff are directed to: -Date items upon receipt; -Store left overs in covered, labeled and dated containers under refrigeration or frozen; -Clean up all debris dropped on the floor immediately; -Set aside dented cans and cans without labels in a designated area. These are not to be used. Review of the facility's Refrigerator and Freezer Storage policy, Revised ,d+[DATE], showed: -A designated dietary employee is to check, pull and throw away any potentially hazardous foods that have been in the refrigerator for seven days and staff are directed to; -Mark containers with the name of the item and the date the container was opened or the date of preparation; -Label refrigerated, potentially hazardous food prepared and held for more than 24 with the day/date by which the food shall be consumed or discarded. Observation on [DATE] at 9:50 A.M., showed the shelf by the entrance door contained: -An opened and undated bag of corn flakes; -A undated plastic container of crisped rice cereal; -A undated plastic container of corn flakes. Observation on [DATE] at 9:55 A.M., showed the dry goods pantry contained: -Three undated 16 ounce (oz) bags of whipped topping mix; -Three undated 16 oz bags of alfredo sauce mix; -An opened and undated bag of chocolate sandwich cookies; -An opened and undated bag of macaroni; -A dented 6 pound (lb) 9 oz can of sweet potatoes; -A dented 50 oz can of chicken noodle soup; -A dented 6 lb 6 oz can of tomatoes; -An undated box of individual saltine crackers; -An undated box with six packages of graham crackers; -Six undated 2.25 lb boxes of iodized salt; -Three undated 18 oz bags of lemonade soft drink mix; -Nine undated 18 oz bags of strawberry lemonade soft drink mix. Observation on [DATE] at 10:10 A.M., showed the freezer contained: -Two undated packages of rolls/hot dog buns; -An undated bag of meatballs; -A box of meat sat on top of a container of ice cream. Observation on [DATE] at 10:54 A.M., showed the refrigerator contained: -An undated plate of salad; -Two opened, unsealed and undated bags of cheddar cheese; -A bag of lettuce touched the side of the egg container; -An egg container sat on the second shelf with deli meats on the shelf below; -Several undated packages of deli meats. Observation on [DATE] 8:51 A.M., showed the shelf by the entrance door contained; -An undated container of crisped rice cereal; -A bin of corn flakes dated ,d+[DATE]; -An opened and undated bag of corn flakes; -An opened and undated bag of chex cereal. Observation on [DATE] at 8:56 A.M., showed the dry goods pantry contained: -Five dented cans of cream of chicken soup; -One dented can of diced tomatoes -One dented can of chicken noodle soup; -An opened and undated bag of crispy onions; -An opened, undated and unlabeled plastic zipper bag of white flakes; Observation on [DATE] at 9:03 A.M., showed the reach in freezer contained two opened and undated packs of hot dog buns and a bag of meatballs. During an interview on [DATE] at 11:01 A.M., Cook K said the kitchen supervisor is currently on medical leave and the Activity Director (AD) was filling in during the interim. He/She said the AD was responsible for dating items as soon as they are received and is responsible to remove dented cans and expired items from the inventory. He/She said if he/she found items without a date received, he/she would check the inventory sheet to see if it was ok to use, or needed to be discarded. He/She said the dented cans should be removed from inventory and sent back to the distributor. He/She said the staff who opened a food item, were responsible to seal and date the item. He/She said the eggs should not be stored above the deli meat and other items. During an interview on [DATE] at 10:10 A.M., Cook X said whoever worked on truck day put delivered food away. Cook X said dented cans should not be on shelves and he/she was not aware of any dented cans. Cook X said opened food items should be labeled and dated. 2. Review of the facility's policies showed facility staff did not provide policies in regards to kitchen cleanliness. Observation on [DATE] at 10:17 A.M., showed: -The front of the stove was covered with food splatters; -The floor by the stove and standing oven had a black and brown substance; -The front of the standing oven was covered with debris/food splatters; -The wall by the standing oven had large spatters of food; -The floor was dirty with debris and trash; -The trashcan by the back door did not contain a lid. During an interview on [DATE] at 11:01 A.M., Cook K said the floors and kitchen equipment should be cleaned daily. He/She did not know the last time the kitchen equipment was cleaned, but the floors were cleaned a couple of days ago. He/She said he/she did not know who was responsible to clean the kitchen walls. He/She said there was not enough staff to complete all the responsibilities in the kitchen. Observations of the kitchen on [DATE] from 8:50 A.M. through 10:00 A.M., showed: -The wall laminate near the hand washing sink was worn and exposed the wood substrate in multiple locations; -An accumulation of food particles on the front of the stove and oven; -An accumulation of dust and crumbs on a tray which set near the kitchen window and contained sixteen containers of food seasonings; -An accumulation of dust and grease on the wall and gas line next to the oven; -The wall next to the oven contained a broken light switch cover which exposed the light switch; -The wall next to the oven contained a wire shelf, which contained food colorings and extracts, which had an accumulation of dust and grease; -The area under the oven and stove littered with dirt and food debris; -The wall panels behind the dish washing machine contained multiple holes; -An accumulation of dust and grease on the ceiling in the dish washing area; -The ceiling in front of the oven contained flaking paint and a 32 inch long separation of plaster board panels. One panel drooped one inch below the other and exposed blown in insulation in the attic space; -The trash dumpster, which was located outside the kitchen exit, was not covered and was overflowing with trash which had spilled onto the surrounding ground. Observation on [DATE] at 9:31 A.M., showed the trash can near the rear door was not covered and was not in use. Observation on [DATE] at 10:56 A.M., showed the trash can near the rear door was not covered and was not in use. Observation on [DATE] at 1:21 P.M., showed the trash can near the rear door was not covered and was not in use. During an interview on [DATE] at 10:10 A.M., Cook X said all staff were responsible for kitchen cleaning. Cook X said the facility had cleaning lists but he/she was not sure where the lists were. During an interview on [DATE] at 1:24 P.M., Cook X said all kitchen staff were responsible for making sure trash cans were covered when not in use. 3. Review of the facility's policies showed facility staff did not provide policies in regards to kitchen equipment sanitiziation or maintenance. Observation on [DATE] at 10:58 A.M., showed a sign on the door between the dishwashing area and resident dining room which read Wash the tables with pots and pan detergent. Review of the pot and pan detergent instructions for use showed: -Scrap and pre-rinse surface food soils; -Sink #1 - wash in a solution of one ounce of detergent to four gallons of hot water; -Sink #2 - rinse with clean water -Sink #3 - sanitize with an approved sanitizer. Observation on [DATE] at 11:00 A.M., showed the three part sink did not contain kitchen wares sanitizer. Observation on [DATE] at 11:17 A.M., showed Cook X wiped a food preparation counter with a damp cloth which was in a sanitizer bucket. Observation showed Cook X refilled the sanitizer bucket with pot and pan detergent from the three part sink when he/she finished wiping the counter. Observation on [DATE] at 12:02 P.M., showed Cook X wiped a food preparation counter with a cloth from a sanitizer bucket which contained diluted pot and pan detergent. During an interview on [DATE] at 11:22 A.M., Cook X said he/she used pot and pan detergent to clean the prep counter and the resident dining tables. Cook X said the surfaces were not sanitized correctly by pot and pan detergent. Cook X said the only sanitizer available in the kitchen was connected to the dish washing machine. Cook X said he/she told the DM about the broken sanitizer dispenser in the three part sink. 4. Review of the facility's Ware-Washing - Dishmachine policy, dated [DATE], showed the wash temperature for low temperature dishmachines shall not be less than 120 degrees Fahrenheit (F) and the policy directed staff to record the temperatures on th Dischmachine Temperature/Sanitizer Log. Review of the dish machine operational requirements label on the front of the dish machine showed wash and rinse temperature: 120 degrees F minimum. Review of a General Operating Instructions sign, which was posted at eye level on the soiled side of the dish machine, showed the sign read, in part, Report to your supervisor if water temperature is less than 120 degrees or higher than 160 degrees. Observation on [DATE] at 9:36 A.M., showed the dish machine temperature at 106 degrees F during the wash cycle. Observation on [DATE] at 9:57 A.M., showed the dish machine reached a maximum temperature of 106 degrees F during a complete wash and rinse cycle. During an interview on [DATE] at 1:12 P.M., Dishwasher W said he/she never received training on proper operation and testing of the dish machine. Dishwasher W said the acting administrator trained him/her the first day but never talked about checking dish machine chemical concentrations or operating temperatures. Dishwasher W said he/she had not told anyone about the dish machine not reaching the correct temperature because he/she did not have time yet. 5. Review of the facility's Ice Machine Cleaning and Sanitizing Procedures policy, undated, showed the policy directed staff to clean the ice machines and bins with the specified cleaning solution and to change the water filters every six months. Review of the facility's Water Management Policy and Procedures, dated [DATE], showed Water systems and devices are to be inspected, cleaned, and maintained to reduce any risks of possible waterborne pathogens. Review showed the policy and procedures directed staff to inspect ice machines monthly and to clean and replace filters per manufacturers guidelines. Observation on [DATE] at 10:30 A.M., showed an excess build-up of white, brown and black debris on the exterior of the ice machine in the dining room and the ice machine's drain and water filtration cartridge. Observation showed the water filtration cartridge for the ice machine dated [DATE] and the cartridge's product label showed direction to change the cartridge every 12 months. Observation on [DATE] at 11:00 A.M., showed the dietary staff used the ice from the ice machine to prepare drinks for service to the residents at the lunch meal. During an interview on [DATE] at 11:02 A.M., the maintenance director said he/she was responsible for cleaning the ice machine filter. The maintenance director said he/she cleaned the filter last month by hosing it off and scrubbing the exterior with a green scouring pad. The maintenance director said he/she never changed the ice machine filter because he/she thought an outside vendor took care of the filter change. The maintenance director said he/she did not know which vendor changed the filter or when the filter was last changed. 6. During an interview on [DATE] at 1:29 P.M., the administrator said he/she was responsible for the kitchen in the absence of the DM. The administrator said the DM was responsible for kitchen cleanliness and ensuring sure staff have proper tools for jobs. The administrator said he/she was not aware of kitchen staff missing anything. The administrator said sanitizer from the three part sink dispenser should be used to wipe food prep counters and resident tables. The administrator said he/she was not aware kitchen staff used pot and pan detergent to wipe down surfaces because there was not sanitizer available. The administrator said maintenance staff were responsible for the area around the dumpster. The administrator said facility staff had a hard time getting the dumpster emptied by the trash vendor but he/she did not know why. During an interview on [DATE] at 9:48 A.M., the activities director (AD) said he/she started helping kitchen staff when the DM left for a temporary absence. The AD said he/she helped with diet orders and answered questions as needed. The AD said the DM was responsible for kitchen staff training, food prep and overall kitchen cleanliness and maintenance. The AD said he/she was not sure who was in charge of the kitchen in the DM's absence. The AD said more could be done to keep the kitchen clean. The AD said the hole in the ceiling had been there a while and he/she told the administrator about the hole. The AD said he/she told the DM and administrator about the broken sanitizer dispenser and missing sanitizer over a month ago. The AD said staff used the pot and pan detergent for wiping surfaces because it is all they had available. During an interview on [DATE] at 11:13 A.M., the maintenance director said he/she had been aware of the kitchen ceiling for a few weeks but did not know why he/she had not repaired the ceiling. The maintenance director said kitchen staff had not told him/her about the broken sanitizer dispenser. The maintenance director said he/she checked the dish machine temperatures and the temperatures varied from 100 to 120 degrees F. He/She said staff should not use the machine if the temperature is less than 120 degrees F. The maintenance director said he/she had not taken any action to correct the dish machine temperatures because he/she felt it was a given that staff would know not to use the machine. During an interview on [DATE] at 12:00 P.M., the acting administrator said he/she was not familiar with the kitchen ceiling in need of repairs or the dish machine not reaching the correct temperatures.

Based on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 45. 1. Review of he facility's policies showed staff did not provide a policy in regard to the qualifications of the Infection Preventionist. During an interview on 02/28/24 at 2:15 P.M., the Director of Nursing (DON) said he/she had mistaken a different Center for Medicare and Medicaid Services (CMS) course with the Infection Preventionist (IP) Course, so he/she was not certified as an IP. During an interview on 02/29/24 at 8:41 A.M., the Administrator said he/she was the Certified Infection Preventionist (IP) and the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator are his/her backup when he/she was on leave. He/She said the DON and MDS Coordinator were not certified IP's, even though they were directed to obtain their certification. He/She said he/she did not know they were not certified as IP's. He/She said he/she was not a nurse and did not have any medical or laboratory experience or degree, but did have a master degree in Health Care Management. He/She said he/she did not know the IP qualifications required certain types of degrees or diplomas to be qualified as an IP.

Based on interview and record review, facility staff failed to ensure three residents (Resident #14, #15 and #19) had appropriate access to their trust fund account which included evenings and weekends. The facility census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for availability of funds. 2. Review of Resident #14's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/18/23, showed staff assessed the resident as cognitively intact. During an interview on 02/26/24 at 3:30 P.M., the resident said we cannot get money on the weekends, you have to get it on Fridays if we want it for the weekend, or your're just out of luck and have to wait. 3. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as mildly cognitive impaired. During an interview on 02/26/24 at 10:28 A.M., the resident said he/she did not have access to his/her funds on the weekends 4. Review of Resident #19's Annual MDS, dated [DATE], showed staff assessed the resident as mildly cognitive impaired. During an interview on 02/29/24 at 11:06 A.M., the resident said we can't have money in the evenings or on the weekends. There is only one person who can get us money, we have to ask for it by 10:30 A.M. on Friday if we want it for the weekends. The resident said, It sucks not to be able to have money on weekends because what if I wanted to order a pizza, because I like to do that sometimes, or go to the store I just can't. 5. During an interview on 02/29/24 at 3:51 P.M., the Business Office Manager (BOM) said they do not keep petty cash at the facility. He/She said he/she or the administrator go to the bank to get money when requested by the resident. The BOM said there is no one in office in the evening or on weekends to get money for the residents. The BOM said he/she was not aware what the regulation says about residents' access to money. During an interview on 02/29/24 at 5:50 P.M., the administrator said she was not aware petty cash needed to be available for residents during non-banking hours.

Based on interview and record review, facility staff failed to document two residents (Resident #7 and #8) code status as Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR). The facility census was 45. 1. Review of the facility's policy titled, Advanced Directive, dated [DATE], showed each resident has the right to make their own decisions, and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. Review showed the facility shall take all steps necessary to comply with state and federal legislation relating to advanced directives. Review showed any decision made by the resident shall be indicated in the chart in the manner easily understood by all staff. Review showed it is the intent to implement the terms of the advanced directive placed in the resident's medical record in accord with appropriate direction of the Power of Attorney and resident's physician. If a resident communicates a revocation of an advance directive to an employee of this facility, that communication, constituting revocation, shall be noted in the resident's medical record and placed in a central file to avoid any misunderstanding. 2. Review of Resident #7's Physician Order Sheet (POS), dated February 2024, showed staff documented the resident as a Full Code status. Review of the resident's care plan, dated [DATE], showed a code status of DNR. Review of the resident's Care Conference Sheet, dated [DATE], showed a code status of Full Code. Review of the resident's medical record face sheet showed a code status of DNR. Review of the resident's annual social service review form , signed [DATE], with a code staus of DNR. 3. Review of Resident #8's POS, dated February 2024, showed staff documented the resident as a Full Code status. Review of the resident's medical record face sheet showed a code status of DNR. Review of the resident's transportable Physician Orders for Patient Preferences, dated [DATE], showed a code status of DNR. 4. During an interview on [DATE] at 1:28 P.M., Licensed Practical Nurse (LPN) Q said the code status should be the same on all forms. He/She said if the information was document differently in the resident's medical record. He/She would not know which code status is correct. During an interview on [DATE] at 9:41 A.M., the Administrator said he/she would expect the residents code status to be documented in the resident's charts. He/She said the information to should be the same would be the same in all areas of the medical record to avoid confusion and prevent the wrong directives. During an interview on [DATE] at 9:45 A.M., the Director of Nursing said staff were directed to have the resident and/or representative to complete a form with the resident's code status wishes and it would be signed off by the physician. He/She said the information was documented in the resident's medical chart by the nurse. He/She said the information should be the same in each area of the resident's medical records to ensure the resident's advance directive were followed. He/She said he/she would expect staff to follow physician orders. He/She said he/she checked the Physician Order Summary monthly to verify orders are correct in the resident's medical chart. He/She said the Minimum Data Set (MDS) Coordinator was responsible to verify the care plan reflect the information in the resident's medical chart. He/She said the MDS Coordinator has been on leave for a couple of weeks.

Based on interview and record review, facility staff failed to give appropriate Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) for two resident (Resident # 12 and #45) of three sampled residents the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 45. 1. Review of the facility's policies showed staff did not provide a policy on SNFABN Notices. 2. Review of Resident #12's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form showed staff documented: -Medicare Part A Skilled Services started on 12/19/23; -Last covered day of Medicare Part A Skilled Services on 01/06/24; -The resident wanted to go home. Review of the resident's medical record showed the resident remained in the facility after the facility initiated his/her discharge from Medicare Part A services. Review showed the medical record did not contain documentation staff provided the resident or his/her legal representative the SNFABN. 3. Review of Resident #45 SNF Beneficiary Protection Notification Review form showed staff documented: -Medicare Part A Skilled Services started on 12/19/23; -Last covered day Medicare Part A Skilled Services on 12/31/23; -The replacement policy was terminated. Review of the resident's medical record showed the resident remained in the facility after the facility initiated his/her discharge from Medicare Part A Services. Review showed the medical record did not contain documentation staff provided the resident or his/her legal representative the SNFABN. 4. During an interview on 02/29/24 at 2:59 P.M., the Business Office Manager (BOM) said he/she did not complete the forms because he/she believed the insurance companies sent all the forms required to be in compliance with State and Federal regulations. During an interview on 02/29/24 at 4:45 P.M., the administrator said the BOM was responsible to complete the beneficiary notices. He/She said there was no system in place to audit to ensure the notices were given to the resident and/or their representative. He/She said he/she did not know the BOM was not completing all the necessary forms. During the interview on 02/29/24 at 4:46 PM., the Director of Nursing said he/she did not know the process for the beneficiary notices.

Based on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed maintain resident rooms, common areas, medical device equipment and the exterior of the building clean and in good repair. Facility census was 45. 1. Review of the facility's policy titled, Physical Plant and Environmental Policy and Guidelines, undated, showed staff were directed to do the following: -It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents; -A well maintained building and environment is also important for creating safe work surrounds across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so; -The building and grounds must be maintained in the best presentable state and must be done through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and National Fire Protection Association (NFPA) codes; -Maintenance/Approved contractors are responsible for: *Routine care and repairs to interior finishings, which includes ceilings, walls, floors and windows; *Resident care equipment; *Wheelchair and bed maintenance; *Maintain essential supplies and parts; -The facility Administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. 2. Observation on 02/25/24 at 11:48 A.M., showed the resident occupied room [ROOM NUMBER] with missing trim by the entrance door and the bathroom door with a small gouge. Observation showed the walls with black marks, nail holes, exposed screws and the corner of the outer closet with missing and chipped paint. Observation on 02/27/24 at 10:07 A.M., showed the resident occupied room [ROOM NUMBER] with missing trim by the entrance door and the bathroom door with a small gouge. Observation showed the walls with black marks, nail holes, exposed screws and the corner of the outer closet with missing and chipped paint. Observation on 02/28/24 at 10:53 A.M., showed the resident occupied room [ROOM NUMBER] with missing trim by the entrance door and the bathroom door with a small gouge. Observation showed the walls with black marks, nail holes, exposed screws and the corner of the outer closet with missing and chipped paint. Observation on 02/29/24 at 1:02 PM., showed the resident occupied room [ROOM NUMBER] with missing trim by the entrance door and the bathroom door with a small gouge. Observation showed the walls with black marks, nail holes, exposed screws and the corner of the outer closet with missing and chipped paint. 3. Observation on 02/25/24 at 12:58 P.M., showed the resident occupied room [ROOM NUMBER] did not have decor on the wall, exposed nails, and nail holes. The walls had missing and chipped paint. Observation on 02/27/24 at 10:12 A.M., showed the resident occupied room [ROOM NUMBER] did not have decor on the wall, exposed nails, and nail holes. The walls had missing and chipped paint. Observation on 02/28/24 at 10:56 A.M., showed the resident occupied room [ROOM NUMBER] did not have decor on the wall, exposed nails, and nail holes. The walls had missing and chipped paint. Observation on 02/29/24 at 1:02 P.M., showed the resident occupied room [ROOM NUMBER] did not have decor on the wall, exposed nails, and nail holes. The walls had missing and chipped paint. During an interview on 02/29/24 at 1:28 P.M., Licensed Practical Nurse (LPN) Q said residents are allowed to have personal items in their room. He/She said the resident in the occupied room [ROOM NUMBER], had a habit of removing items from the walls. During an interview on 02/29/24 at 4:45 P.M., the Administrator said the resident who occupied room [ROOM NUMBER], was a newer resident and he/she had not been down to the resident's room, so he/she did not know the resident did not have any decor on the walls. He/She said he/she did not feel like it was homelike if there was nothing on the walls. During an interview on 02/29/24 at 4:46 P.M., the Director of Nursing (DON) said he/she just noticed room [ROOM NUMBER] with nothing on the walls when he/she went down the hall looking for hazardous items. 4. Observation on 02/26/24 at 10:02 A.M., showed the resident occupied room [ROOM NUMBER] with gouges in the walls, wood wall trim and by the out corner of the closet. Observation showed the walls with black marks along the bottom, nail holes, exposed nails and missing and chipped paint. Observation showed missing and chipped paint on the entrance door. Observation on 02/27/24 at 9:57 A.M., showed the resident occupied room [ROOM NUMBER] with gouges in the walls, wood wall trim and by the out corner of the closet. Observation showed the walls with black marks along the bottom, nail holes, exposed nails and missing and chipped paint. Observation showed missing and chipped paint on the entrance door. Observation on 02/29/24 at 12:56 P.M., showed the resident occupied room [ROOM NUMBER] with gouges in the walls, wood wall trim and by the out corner of the closet. Observation showed the walls with black marks along the bottom, nail holes, exposed nails and missing and chipped paint. Observation showed missing and chipped paint on the entrance door. 5. During an interview on 02/29/24 at 11:49 A.M., Certified Nurse Aid (CNA) H said staff are directed to report environmental concerns to the Director of Nursing (DON). He/She said he/she had noticed the resident rooms and common areas in disrepair and had reported it to staff. During an interview on 02/29/24 at 1:07 P.M., the Maintenance Director said staff are directed to complete a maintenance form if they observe environmental issues. He/She said he/she did not always check the book and he/she did not have a reason he/she did not check. He/She said he/she did audit the rooms at least weekly. He/She said he/she did not always have the funding to make the repairs. During an interview on 02/29/24 at 1:28 P.M., LPN Q said staff are directed to report environmental or medical equipment concerns to the charge nurse, document in the maintenance book or verbally tell the maintenance department. He/She had not noticed concerns with resident rooms or medical equipment. During an interview on 02/29/24 at 4:45 P.M., the administrator said staff are directed to report maintenance issues to the charge nurse, maintenance department or DON or document in the maintenance log. He/She said the maintenance log was Monday through Friday. He/She said he/she did notice the resident rooms in disrepair. During an interview on 02/29/24 at 4:46 P.M., the DON said staff were directed document environmental concerns in the maintenance book or report directly to the maintenance department. He/She said the maintenance department checked the book Monday through Friday. 6. Observation on 02/25/24 at 1:02 P.M., showed hall two with a missing hand rails between room [ROOM NUMBER] and the electrical room and between room [ROOM NUMBER] and room [ROOM NUMBER]. Observation on 02/27/24 at 10:02 A.M., showed hall two with a missing hand rails between room [ROOM NUMBER] and the electrical room and between room [ROOM NUMBER] and room [ROOM NUMBER]. Observation on 02/28/24 at 8:51 A.M., showed hall two with a missing hand rails between room [ROOM NUMBER] and the electrical room and between room [ROOM NUMBER] and room [ROOM NUMBER]. During an interview on 02/28/24 at 8:51 A.M., the maintenance director said the hand rails were downstairs in the basement. The maintenance director said the hand rail by room [ROOM NUMBER] came off the previous week and the other hand rail came off about two weeks ago. The maintenance director said he/she had not reattached the hand rails because he/she did not have the brackets to secure them to the wall. The maintenance director said he/she thought he/she told the Business Office Manager (BOM) about the hand rails the previous week and the administrator the week before that. The maintenance director said he/she does not have the ability to purchase items needed to make repairs him/herself and those purchases have to be made by the administrator or corporate environmental director. The maintenance director said he/she did not know if anyone had ordered the part needed to restore the hand rails. During an interview on 02/28/24 at 2:00 P.M., the BOM, who was the acting administrator, said the maintenance director is responsible to maintain the facility hand rails and if they are not present, it has the potential for a resident to fall. The BOM said if anything in the facility needs repaired, he/she would expect the maintenance director to make repairs as soon as possible and if he/she needs things purchased to make repairs he/she is to notify the administrator and/or the corporate environmental director about what is needed. The BOM said he/she did not notice the missing hand rails on hall 2 and they had experienced problems with the corporate environmental director providing assistance as needed, so he/she did not know if the director or anyone else had done anything about the parts needed to restore the hand rails. 7. Review of the facility's policy titled, Wheelchair Skills, undated, showed staff were directed to do the following: -To provide skills needed for ambulation about facility per wheelchair in safe efficient manner; -Safety Precautions include wheelchair in proper working order; -Did not provide direction for staff of the protocol for a wheelchair found in disrepair. Observation on 02/25/24 at 11:48 A.M., showed Resident #31 the vinyl of the right armrest of his/her wheelchair was worn with cracks. Observation on 02/27/24 at 10:07 A.M., showed Resident #31 the vinyl of the right armrest of his/her wheelchair was worn with cracks. Observation on 02/29/24 at 1:02 PM., showed Resident #31 the vinyl of the right armrest of his/her wheelchair was worn with cracks. During an interview on 02/29/24 at 11:49 A.M., CNA H said he/she are directed to report wheelchairs in disrepair to the maintenance depart. He/She said he/she had noticed several wheelchairs with concerns and have reported to staff. He/She said if a wheelchair armrest is in poor condition, it could cause skin tears and wounds to the resident. During an interview on 02/29/24 at 1:28 P.M., LPN Q said staff are directed to report medical equipment concerns to the charge nurse, document in the maintenance book or verbally tell the maintenance department. He/She had not noticed concerns with resident rooms or medical equipment. He/She said there a concern of a resident sustaining a skin tear if the wheelchair armrest is in disrepair. During an interview on 02/29/24 at 4:45 P.M., the Administrator said staff are directed to report medical equipment to the charge nurse, maintenance department and DON or document in the maintenance log. He/She said the maintenance log was checked daily. He/She said staff should remove medical equipment in disrepair out of resident use. He/She said if a resident continued to use a wheelchair with a torn and/or worn armrest, there is the potential for skin tears and/or breakdown, or the spread of germs. During an interview on 02/29/24 at 4:46 P.M., the DON said staff were directed document environmental concerns in the maintenance book or report directly to the maintenance department. He/She said the maintenance department checked the book Monday through Friday. He/She said staff were directed to remove mechanical devices in disrepair and to put sheep's wool over it. He/She said if the wheelchair armrest were worn and/or torn, there was a concern for skin breakdown. 8. Reivew of the facility maintained window inspection records, dated January 2023 through January 2024, showed documentation of a window and screen inspection dated 10/17/23. Review showed the maintenance director documented the results of his/her inspection, but did not document the actions taken to repair the failed windows. Review showed the maintenance director documented.the windows in Resident #19's room and resident rooms [ROOM NUMBERS] failed the inspection due to the frame and window screen. Review of the window inspections, showed the records did not contain documentation of another inspection after 10/17/23. Observations on 02/27/24 during the Life Safety Code tour, showed: -The windows in resident rooms [ROOM NUMBER] did not contain window screens; -The window screen to the window in resident room [ROOM NUMBER] bowed out of the frame which created an opening between the screen and the window; -The window in resident occupied room [ROOM NUMBER] with an accumulation of dirt and debris; -The window in Resident #19's with an excessive accumulation of dirt and debris and the window did not contain a window screen. During an interview on 02/27/24 at 9:20 A.M., Resident #19 said he/she likes to look out his/her window, but he/she did not like to look out it now because it was so dirty. The resident said he/she had a bird feeder that he/she wanted to have put outside his/her window, but has not asked staff to put it up because he/she would not be able to see it through the window. During an interview on 02/28/24 at 12:25 P.M., the maintenance director said he/she is responsible to inspect the windows every few months to ensure they are clean and in good repair and have screens. The maintenance director said he/she spoke to the corporate environmental director about the missing window screen a while ago and a guy came out and gave a bid to fix them and the bid was approved, but nothing every happened after that. The maintenance director said he/she had not follow-up with anyone on the screens because that was all handled at the corporate level and now the facility recently underwent a management change, so he/she did not know how to follow-up on it now. The maintenance director said he/she is responsible to clean the outside of the windows and he/she just had not done so for a while. During an interview on 02/28/24 at 2:00 P.M., the BOM, who was the acting administrator said the maintenance director is responsible for the maintenance of the windows and to clean the windows from the outside, while housekeepers are responsible to clean the inside of the windows every three months. the BOM said the maintenance director told him/her that the corporate environmental director had approved the purchase and installation of new window screens, but no one ever came to do it or called to schedule for it to be done and now the facility is under new management. The BOM said he/she did not know about the dirty windows and there is a resident that enjoys looking out of the window while in their room, then staff should definitely ensure that resident's window is clean and in good repair. 9. Observations on 02/27/24 during the Life Safety Code tour, showed the multiple sections of the fascia board (material used to cover the joints between the top of a wall and projecting eaves) on the exterior of the facility rotted, broken and warped which expose the wooden framework beneath to the elements. During an interview on 02/27/24 at 12:00 P.M., the maintenance director said he/she was responsible for the maintenance of the facility and he/she knew about the issues with the fascia. The maintenance director said he/she does not have the ability to purchase items needed to make repairs him/herself and those purchases have to be made by the administrator or corporate environmental director. The maintenance director said he/she contacted the corporate environmental director who said he/she would handle it, but nothing ever came of it and now the facility had new management so he/she did not know what to do about getting it fixed. During an interview on 02/28/24 at 2:00 P.M., the BOM, who was the acting administrator, said the maintenance director is responsible to maintain the exterior of the facility. The BOM said if anything in the facility needs repaired, he/she would expect the maintenance director to make repairs as soon as possible and if he/she needs things purchased to make repairs he/she is to notify the administrator and/or the corporate environmental director about what is needed. The BOM said he/she did not know about the issues with the fascia and he/she did not know if the maintenance director had contacted the corporate environmental director to have it repaired and the facility now has new management.

Based on interview and record review, facility staff failed to screen six new employee (Dietary E, Dietary F, Dietary G, Certified nurse aide (CNA) H, Licensed Practical Nurse (LPN) I, and housekeeping J) out of ten new employees prior to employment to determine if any employees had a federal indicator with the Employee Disqualification List (EDL) and/or the Family Care Safety Registry (FCSR). Facility staff failed to develop a written policy to notify the Department of Health and Senior Services (DHSS) of any allegation of abuse within the required two hour timeframe. The facility census was 45. 1. Review of the Facility's Abuse Prevention Program Facility Policy, not dated, showed the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by conducting pre-employment screening of employees. Review showed: -The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. -This facility will not knowingly employ any staff convicted of any crimes listed in the Missouri Healthcare Worker Background Check Act (unless waivered under the provision of the Act), or with findings of abuse listed on the Missouri Nurse Aide Registry. Prior to a new employee starting a work schedule, this facility will file a Missouri State Police Healthcare Worker Background Check application on any individual being hired for a position. The facility policy and procedures for conducting a Healthcare Worker Background Check will be followed. 2. Review of Dietary E's personnel record showed: -Hire date of 7/12/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 3. Review of Dietary F's personnel record showed: -Hire date of 12/20/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 4. Review of Dietary G's personnel record showed: -Hire date of 11/24/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 5. Review of CNA H's personnel record showed: -Hire date of 12/12/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 6. Review of LPN I's personnel record showed: -Hire date of 8/09/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 7. Review of Housekeeping J's personnel record showed: -Hire date of 10/11/23; -Did not contain documentation the facility had completed an EDL or FCSR check prior his/her hire date. 8. During an interview on 02/29/24 at 3:00 P.M., the Business Office Manager (BOM) said he/she is responsible for making sure the EDLs are completed. He/She said they frequently have people not show up after they are hired. He/She said since they pay for the EDL's themselves and do not get reimburse when people do not show up for work, he/she has not been running them until they have already started. He/She said he/she lets them work the floor while they wait to come back. He/She said if it came back that they had abuse or neglect on their record he/she would then let them go. During an interview on 02/29/24 on 4:45 P.M., the Administrator said staff were directed to check the EDL prior to the start date. He/She said staff receive the EDL information immediately. He/She did not know the EDL's was not received in a timely manner. 9. Review of the facility's Abuse Prevention Program Facility Policy, updated, showed if, during the course of an incident investigation, the administrator or designee has determined that there is a reasonable cause to suspect mistreatment has occurred, the resident's representative and the department of public health shall be informed. Public Health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated. Review showed the facility's Abuse Prevention Program Facility Policy did not include the requirement to notify DHSS of any allegation of abuse within two hours. During an interview on 02/29/24 at 5:50 P.M., the administrator said she was not aware the facility policy did not have the required time frame for reporting to DHSS.

Based on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of resident transfers to the hospital for five sampled residents (Resident #14, #19, #24, #49, and #50). The facility census was 45. 1. Review of the facility's Transfer and Discharge Policy and Procedure, undated , showed the policy did not include direction for staff to notify the ombudsman of resident discharge or transfer. 2. Review of an email from the Regional Ombudsman Program Director, dated 02/22/24 at 1:42 P.M., showed did not send the Ombudsamn Director the monthly notifications of discharged or transferred residents. 3. Review of Resident #14's medical record, showed the resident transferred to the hospital on 12/24/23 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 4. Review of Resident #19's medical record, showed the resident transferred to the hospital on 01/13/24 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 5. Review of Resident #24's medical record showed the resident transferred to the hospital on 01/01/24 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 6. Review of Resident #49's medical record showed the resident discharged to home on 01/03/24. The medical record did not contain documentation staff notified the Ombudsman of the resident's discharge. 7. Review of Resident #50's medical record showed the resident transferred to the hospital on 12/19/23 and did not readmit to the facility. The medical record did not contain documentation staff notified the Ombudsman of the resident's discharge. 8. During an interview on 02/27/24 at 12:13 P.M., the Social Services Director (SSD) said he/she has not been sending the transfer or discharge information to the Ombudsman, as she was not aware this need to be done. During an interview on 02//29 at 5:50 P.M., the administrator said she was not aware tranfer and discharge information needed to be sent to the Ombudsman.

Based on observation, interview, and record review, facility staff failed to provide protective oversight for one resident (Resident #1) with cognitive impairment and a history of wandering, when on 12/13/2023 the resident exited the facility without staff knowledge and was found lying in the street, less than one mile away from the facility, in the early morning hours by a passerby, who notified the police and the emergency medical services (EMS). The outside air temperature was 31 degrees Fahrenheit (F). The resident was found in only a shirt and undergarments with his/her body temperature at 90.2 degrees F. The facility census was 48. The Administrator was notified on 12/13/23 at 6:30 P.M., of an Immediate Jeopardy (IJ) which began on 12/13/23. The IJ was removed on 12/15/23 as confirmed by surveyor onsite verification. Review of the facility's Missing Resident Policy, revised 8/13/14, showed it is the policy of the facility that reasonable precautions be taken to minimize the risks of resident elopement attempts. Reasonable precautions include, but are not limited to: door alarms, personal door alarm activation devices, staff intervention, staff education regarding response to door alarms, and individual resident interventions. It is also the policy of the facility to demand immediate response to door alarm activation and participation in search attempts in the event that the resident is deemed missing. Review of the facility's Door Alarm Policy, revised October 2002, showed it is the policy of the facility to ensure resident safety and security through the use of door alarms. Door alarms require immediate attention and response by facility staff to ensure the safety of all residents. Disengaging the alarm is not allowed until the reason for activation is determined. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument tool, dated 8/7/23, showed staff assessed the resident with severe cognitive deficit, had delusions, diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a condition characterized by progressive or persistent loss of intellectual function especially with impairment of memory). Review of the resident's plan of care, dated 2/17/2020, showed staff assessed the resident with impaired cognition, delusions, hallucinations, and poor decision making. Review showed the plan of care did not have interventions for wandering. Review of the resident's nurses notes, dated 12/13/23, showed staff documented the resident has had increased confusion, irritability, and elopement which started on 12/11/23. Review showed staff documented the resident eloped this morning and was located by the police. Review of the Emergency Medical Service (EMS) Report, dated 12/13/23 at 4:48 A.M., showed EMS dispatched to location by police dispatch for a person who had been found in the road cold and confused. Review showed primary impression of hypothermia (caused by prolonged exposures to very cold temperatures). The resident was approximately 200 yards from the facility. Review showed EMS learned the person was a resident at the nearby facility and they were not aware he/she was missing. Review showed the resident was in the middle of the roadway with pale skin, cold to touch and dry, and only in a t-shirt and underwear. Review showed the resident presented with significant hypothermia symptoms. The resident was assisted to standing and onto the stretcher, covered in multiple blankets and secured with safety belts. Review showed the resident's temperature assessed at 90.2 degrees (the average body temperature is 98.6 F), unable to assess blood pressure due to shivering and tense musculature. Orders transferred to local hospital and patient transported to hospital for evaluation and treatment. Review of the underground.com weather report application, dated, December 13th 2023 at 5:00 A.M., showed an outside temperature of 31 degrees Fahrenheit at zip code 65065 where the resident was found. Observation on 12/13/23 at 7:00 P.M., showed the resident was found 0.3 miles from the facility per trip meter in vehicle. During an interview on 12/13/23 at 11:32 A.M., the police officer said he/she was a mile from the facility when he/she received the call from dispatch there was a person in the road by the highway. He/She said when he/she got there the person was in a shirt and undergarments and was cold with an outside temperature of 34 degrees. The officer said he/she gave him/her a blanket and waited for EMS. When EMS arrived they took his/her temperature which was 90 degrees. The officer said he/she contacted the facility who reported to him/her they did not even know the resident was gone. Staff later admitted the doors were left unlocked when questioned. During an interview on 12/13/23 at 12:35 P.M., EMS said the police were first on the scene and he/she was next. The resident was found in his/her undergarments and a t-shift and was very cold with a temperature of 90 degrees with a blanket already placed on him/her by the officer on scene. He/She said. I am not certain how long it would take for the resident to drop that low in temperature, but I would say well over an hour at least. They got the resident in the ambulance wrapped him/her with blankets and a towel over his/her head to keep the heat in and took him/her directly to the hospital. During an interview on 12/13/23 at 11:00 A.M., the Administrator said he/she got a call this morning around 5:00 A.M., the police called the facility and reported they found the resident in the street and took him/her to the hospital. He/She said they are still investigating to determine how the resident got out, because the resident does not know the code to the front door. The administrator said they have been letting residents smoke out of the 100 Hall exit door so it is possible the door may not have been locked back, but they are really not sure at this time. During an interview on 12/13/23 at 12:30 P.M., Certified Medication Technician (CMT) A said the doors on the ends of the halls have been unlocked for the smokers for about two weeks due to the COVID outbreak. He/She said they were supposed to be locked, but that obviously didn't happen because that is the only way Resident #1 could have gotten out. He/She said the resident used to have a room down that hall and frequently wandered throughout the building. During an interview on 12/13/23 at 1:15 P.M., Certified Nursing Assistant (CNA) B said normally the doors were all locked, however for the past couple of weeks they have been unlocked because the COVID residents have been smoking out the 100 Hall door exit door. He/She said Resident #1 is a wanderer and is down the other hall frequently and has to be redirected. During an interview on 12/13/23 at 1:30 P.M., Registered Nurse (RN) C said the doors have been kept unlocked now for about two weeks to allow COVID residents to go out and smoke. He/She said Resident #1 is a wanderer and is always up and down the halls so it is very possible he/she went out one of the unlocked doors. During an interview on 12/13/23 at 1:38 P.M., Nurse Assistant (NA) D said he/she worked the night the resident eloped. He/She said the door on the 100 hall was unlocked and had been for about two weeks. NA D said they could not lock it, because they had no access to a key. NA D said it had been unlocked to allow residents who were COVID positive to go out and smoke. He/She said he/she never saw Resident #1 go down that hall, but did realize he/she was not in bed at approximately 3:00 A.M. or 3:30 A.M. and alerted the charge nurse. They began a room check and then the phone rang and the charge nurse reported the police reported the resident was found and taken to the hospital. During an interview on 12/13/23 at 3:00 P.M., NA E said he/she worked the night Resident #1 eloped and said he/she was alerted by NA D that he/she could not find Resident #1 as he/she was not in bed. NA E said he/she was unaware what time it was, but shortly after they did room to room checks and did not find the resident the phone rang and it was the police per the charge nurse they had found the resident and took him/her to the hospital. NA E said he/she immediately went to the door by the kitchen off 300 hall and the door opened, the key was in the box and no alarm sounded. He/She said NA D was on that hall so he/she would know when the resident was last seen. He/She did not know when the resident was last seen. NA E said the nurse would have the keys to the doors, so he/she would assume the nurse would be the one to check the alarms. During an interview on 12/13/23 at 6:30 P.M., Licensed Practical Nurse (LPN) F said he/she was the charge nurse that night and he/she had made rounds at midnight on all residents and Resident #1 was in bed. At 5:00 A.M. he/she said NA D reported he/she could not find the resident so they began to search for the resident room to room. LPN F said shortly after they started the search the phone rang and it was a police officer who said they found the resident on the road near the highway and they had taken him/her to the hospital. LPN F said he/she did not see the resident go out of the door, but figures he/she went out the 100 hall door, because it was unlocked and unalarmed because the smokers who were positive for COVID had been going out that door to smoke. He/She said there was a key on the key ring he/she had, but it was missing when he/she tried to lock it after the police officer called. All he/she had was a key to turn on the alarm so the door would just alarm when he/she attempted to lock it, so he/she was unable to lock and/or alarm the door. LPN F said typically the doors were locked, but recently with the outbreak of COVID the doors had been unlocked for the smokers so he/she did not know the doors would need to be checked prior to this incident. He/She said they typically checked on the resident every two hours when the aides did bed checks, but if the resident was in bed the aides usually left him/her to sleep, because if not he/she wandered. During an interview on 12/13/23 at 7:30 P.M., the Physician said he/she was the one who took care of the resident when he/she was brought into the emergency room . The resident arrived very cold and had apparently been found lying in the street outside his/her facility per EMS staff. The physician said in his/her professional opinion for the resident's temperature to be that low, he/she would have had to been outside between 2-3 hours, but that could vary with certain factors like if he/she was sweating and/or if the wind was blowing or not that night. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00228691, MO00228703

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to prevent the development and healing of one unstageable (full thickness tissue loss known but actual depth not stageable due to coverage of wound bed by eschar (dead tissue) pressure ulcer for one resident (Resident #2) of 13 sampled residents. The facility census was 49. 1. Review of the facility's preventative skin care policy, revised 10/2006, directs staff to provide preventative skin care through repositioning and careful washing, rinsing, drying and observation of the resident's skin condition to keep them clean, comfortable, well groomed and free from pressure ulcers. Further review of this policy directs staff to ensure proper fit of resident's wheelchairs, splints, braces, prosthesis, etc. 2. Review of the facility's decubitus care/pressure areas policy/procedure, revised 05/2007, directs licensed nursing staff to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. Further review of this policy/procedure shows licensed nursing staff are directed to: - Assess and document the pressure ulcer on the resident's Treatment Administration Record (TAR); - Notify the physician for treatment orders and initiate the physician order [REDACTED]. - Reevaluate the treatment for [REDACTED]. If no improvement is seen in this timeframe, contact the physician for a new treatment order. 3. Review of Resident #2's latest Minimum Data Set (MDS), a federally mandated assessment instrument, dated 06/25/11, showed staff assessed the resident as: - Short-term and long-term memory problem; - Moderately impaired cognitive skills for daily decision making; - Extensive assistance for bed mobility, transfer, dressing and toilet use; - Frequently incontinent of urine and bowel; - At risk of developing pressure ulcers; - Does not have one or more unhealed stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) or higher pressure ulcer. Review of the resident's care plan, dated 06/24/11, showed he/she has memory problems and occasional confusion. Further review showed the resident has declined physical status and requires assistance with all activities of daily living (for example, personal hygiene, dressing and transfers). Additionally, review showed staff are directed to report acute status changes to the resident's physician. Review of the resident's weekly skin assessments, dated September 9, 2011 thru September 25, 2011, showed licensed staff documented, " see wound book" or "see wound care." During an interview on 11/10/2011 at 3:00 P.M., the Director of Nursing (DON) said the wound book and wound care sheets are each resident's wound tracking sheets. The DON said he/she could not locate Resident #2's wound tracking sheets for the month of September. Review of the resident's TAR, dated September 2011, directed facility staff to treat the resident's left heel with [MEDICATION NAME] twice a day and to float (suspended to prevent any pressure against the skin) his/her heels at all times. Further review of the TAR showed facility staff documented the treatment started on 09/21/11 evening, and then from 09/22/11 through 09/30/11, facility staff documented the resident received this treatment twice a day. Review of the resident's physician's orders [REDACTED]./procedure. Review of the resident's nurse's notes, dated September 2011, showed licensed staff failed to document physician notification and any physician ordered treatment related to his/her left heel pressure ulcer per the facility's policy/procedure and the resident's care plan. Review of the resident's weekly wound tracking sheet, dated October 2011, showed staff documented "high Braden risk" (an instrument used by staff for predicting pressure sore risk). Further review of this sheet showed staff documented the resident acquired his/her left heel pressure ulcer at the facility on 09/21/11. Additional review of this sheet showed facility staff documented the following: - On 10/02/11, unstageable left heel pressure ulcer measured 2.7 centimeters (cm) long by 1.0 cm wide by 0.0 cm deep; - On 10/10/11, unstageable left heel pressure ulcer measured 1.0 cm long by 0.8 cm wide by 0.0 cm deep; - On 10/18/11, unstageable left heel pressure ulcer measured 1.5 cm long by 1.0 cm wide by 0.0 cm deep; - On 10/27/11, unstageable left heel pressure ulcer measured 2.0 cm long by 2.0 cm wide by 0.0 cm deep. Review of the resident's TAR, dated October 2011, showed staff did not provide any wound treatment to his/her left heel from 10/01/2011 through 10/26/2011. Further review of the resident's TAR showed a handwritten entry, dated 10/27/11, that directed facility staff to treat the resident's left heel daily with [MEDICATION NAME], and then cover with a foam dressing, secured with gauze. Review of the resident's POS, dated October 2011, showed facility staff did not have any wound treatment orders for his/her left heel pressure ulcer, until 10/27/11, which directed facility staff to use [MEDICATION NAME] spray to his/her left heel and cover with foam dressing, secured with gauze dressing daily. Review of the resident's Nurse's Notes, dated October 1, 2011 through October 26, 2011, showed licensed staff failed to document physician notification and any physician ordered treatment related to his/her left heel pressure ulcer per the facility's policy/procedure. Review of the resident's weekly wound tracking sheet, dated November 2011, showed staff documented "high Braden risk." Further review of this sheet showed staff documented the resident acquired his/her left heel pressure ulcer at the facility on 09/21/11. Additional review of this sheet showed facility staff documented the following: - On 11/03/11, unstageable left heel pressure ulcer measured 2.2 centimeters (cm) long by 2.2 cm wide by 0.0 cm deep; - On 11/07/11, unstageable left heel pressure ulcer measured 2.5 cm long by 2.2 cm wide by 0.0 cm deep. Observation on 11/09/11 at 8:26 A.M. showed LPN E provided the physician ordered treatment to the resident's left heel ulcer. Observation showed the resident's left heel with an approximate one inch diameter open ulcer. Further observation showed the ulcer contained black, necrotic (dead) tissue and a thin, open area of pink and red tissue surrounded its perimeter. During an interview on 11/10/2011 at 3:00 P.M., LPN E said the resident acquired the left heel pressure ulcer at the facility, because his/her shoes did not fit him/her. During an interview on 11/10/2011 at 3:00 P.M., the DON said licensed and certified staff are expected to follow the facility's preventative skin care policy. Additionally, the DON said licensed staff are expected to follow the facility's decubitus care/pressure areas policy/procedure. The DON said licensed staff are responsible to notify the resident's physician for wound treatment orders and initiate them on the resident ' s TAR.