Every finding on record at Ozarks Methodist Manor, The

Based on interviews and record review, the facility failed to ensure allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff witnessed possible abuse involving one resident (Resident #1) and failed to report the allegation in a timely fashion. The facility census was 59.Review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, undated, showed the following:-It is the policy of the facility that each resident will be free from abuse;-Abuse can include verbal, mental, sexual, or physical abuse;-All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source will be reported immediately, but no later than two hours (abuse) and 24 hours (non-abuse);-All facility employees are mandated reporters;1. Review of Resident #1 face sheet (admission data) showed the following:-admission date 10/09/23;-Diagnoses include Alzheimer's disease (neurological disease affection memory and cognition). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/30/25, showed the following:-Cognitively impaired;-Resident had verbal and physical behaviors.Review of the resident's current care plan, revised on 12/31/25, showed the following:-The resident had potential to be physically aggressive;-Staff should monitor and report signs and symptoms of resident posing danger;-Resident was resistive to care;-Staff should allow resident to make own decisions, encourage participation, and give clear explanation of care;-If resident resisted care, staff should leave and return five to ten minutes later and try again.Review of a witness statement dated 01/25/26, at 8:28 P.M., showed Certified Nurse Aide (CAN) B documented that the day before he/she and Certified Medication Tech (CMT) C took the resident to the bathroom. The resident became combative when staff were trying to change him/her. The resident bent CMT C's finger back and CMT C did the same back to the resident. CMT said you like that. Review of a witness statement dated 01/27/26, at 5:15 P.M., showed CNA B documented after the incident (on 1/24/26) he/she mentioned it to CNA D while on his/her lunch break. CNA D stated she should report it to LPN A to get the situation addressed. CNA B reported the incident to LPN A when he/she returned to work the following day.Review of the resident's progress note dated 01/25/26, at 8:30 P.M., showed Licensed Practical Nurse (LPN) A documented a CNA reported to him/her that another CNA thought he/she may have witnessed abuse to the resident last night on 01/24/26. Staff assessed the resident for injuries and notified the Director of Nursing (DON), who notified the Administrator. Staff placed call to power-of-attorney (POA) and to on-call physician. Staff notified county sheriff who came to facility and took statements from the CNA and CMT on duty at the time of the alleged abuse. Review of DHSS records showed the facility reported the allegation of possible abuse on 01/25/26, at 9:46 P.M. (The day following staff stated they witnessed the potential abuse.)Review of a witness statement dated 01/25/26, no time given, showed CNA D documented that CNA B came to him/her the prior night and said he/she thought he/she witnessed abuse. CNA D asked what happened and CNA B told him/her the resident bent CMT C finger backwards and then CMT C bent the resident's fingers backwards stating, how does that feel?During an interview on 01/30/26, at 8:15 P.M., CNA B said the following:-He/she should of reported the incident when it happened and was not sure why he/she did not;-He/she told CNA D about the incident on his/her lunch break and was told by CNA D to report it;-He/she went home after his/her shift and reported it the next day during his/her shift.During an interview on 01/30/26, at 10:17 A.M., CMT E said the following: -He/she was not aware of and had not received any complaints or allegations of abuse;-He/she would report any and all allegations of abuse to the charge nurse immediately.During an interview on 01/30/26, at 10:45 A.M., LPN F said the following:-Abuse can be any verbal, physical, or neglect that causes harm to a resident;-He/she would report an allegation of abuse immediately to the Director of Nursing (DON) and Administrator;-He/she expected his/her staff to report any allegations to them immediately;-He/she had not heard of or received any reports of abuse while working at the facility.During an interview on 01/30/26, at 11:00 A.M., CMT G said the following:-Any allegation of abuse should be reported to the charge nurse right away;-Any suspected abuse should be reported right away;-The facility had two hours to report allegations to the state;-He/she had not seen and was not aware of any abuse in the facility.During an interview on 01/30/26, at 12:35 P.M., the DON said the following:-He/she did not know why CNA B waited to report the incident;-He/she expected all staff to report allegations of abuse immediately.During an interview on 01/30/26, at 2:28 P.M., CNA H said the following:-All allegations of abuse should be reported to the nurse right away;-Staff should report allegations even if they are unsure so the nurse can investigate.During an interview on 1/30/26, at 2:35 P.M., Registered Nurse (RN) I said the following:-He/she expected all staff to report allegations of abuse to them immediately;-Reporting immediately was important so he/she could start the investigation and keep the resident safe by separating them from the alleged staff.During an interview on 01/30/26, at 4:00 P.M., the Administrator said he/she expected all staff to report allegations of abuse immediately.Complaint #2725411

Based on observation, interview, and record review, the facility staff failed to ensure residents were free from misappropriation when one resident (Resident #1) had $40 taken from his/her wallet in his/her room at the facility without the resident's knowledge or consent. The facility had a census of 60. Review of the facility policy titled, Abuse Prevention Policy/Elder Justice Act, revised 01/16/19, showed misappropriation of resident property included the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of the resident's belongings, or money without the resident's consent. 1. Review of Resident #1's face sheet (basic information sheet) showed the following: -admission date of 09/18/18; -Diagnoses included mild cognitive impairment, general anxiety disorder (excessive worry and fear that interfere with daily life), major depressive disorder (persistent sadness, loss of interest in activities, and other symptoms that affect daily life), traumatic brain injury, presence of a pacemaker, repeated falls, and pain. Review of the resident's Minimum Data Set (MDS -a federally mandated assessment tool completed by facility staff), dated 03/25/25, showed the resident had moderate cognitive impairment. Review of the resident's current care plan on 04/30/25, showed the following information: -Care plan focuses included knowledge deficit, impaired physical mobility, falls, mood issues, anxiety, activities of daily living self-care deficits, and impaired communication; -Staff did not care plan regarding concerns for maintaining his/her money. Review of the facility's follow-up investigation report, dated 04/30/25, showed the following: -The resident's guardian reported he/she believed Certified Nursing Assistant (CNA) A may have taken $40 from the resident; -The resident said he/she thought his/her family member had taken the money; -Statements were provided by staff regarding the missing money; -The money could not be located; -Facility investigation was unable to determine what occurred with the resident's money. Review of a second facility follow-up investigation report, dated 05/02/25, showed the following: -The resident was interviewed on 04/28/25, following receipt of an allegation of theft from the resident's guardian; -The resident's guardian alleged CNA A had taken the resident's money; -The resident said his/her family member took the money; -The allegation of possible theft was reported to the Ombudsman and local police department; -The facility investigation was unable to determine what occurred with the resident's money. Review of the resident's fund receipts records showed on 04/25/25, the resident received $40 in cash from his/her resident account and signed he/she received the funds. Review of the resident's nursing notes showed the following: -On 04/26/25, at 3:30 A.M., staff documented the resident fell in his/her room with a laceration noted above the right eye. The resident was sent to the hospital on [DATE], at 3:50 A.M.; -On 04/26/25, at 5:21 P.M., staff documented the resident returned from the hospital accompanied by his/her legal guardian. During an interview on 04/30/25, at 2:48 P.M., the resident said the following: -He/She received $40 in cash from facility staff one week ago on Thursday or Friday; -He/She typically received $40 in cash each week or so on Thursday or Friday and gave it to his/her family member when they visited during the same week; -He/She gave the money to his/her family member to get personal supplies and for outings they complete together regularly; -His/Her family member maintained a separate wallet for money he/she gave them; -He/She kept money received from the facility staff in his/her personal wallet and wrapped in a bandana until he/she gave the money to his/her family member; -He/She usually kept his/her wallet on his/her person; -The last $40 he/she received disappeared from his/her wallet before he/she could give to his/her family member; -He/She just returned from the hospital following a fall requiring stitches; -He/She received the money before going to the hospital; -He/She had his/her wallet with him/her while at the hospital; -He/She could not recall when the money disappeared; -He/She did not see anyone take money from his/her wallet. Review of CNA A written statement, dated 04/26/25, showed the following: -He/She changed the resident when he/she returned to the facility on [DATE], at 5:10 P.M.; -The resident pulled money (unknown amount) from his/her wallet and said it needed to be given to his/her family member; -He/She told the resident to put the money back in his/her wallet so it would not get lost; -He/She took the resident to the dining room to eat; -The resident had his/her wallet in his/her lap while eating in the dining room; -He/She took the resident to the bathroom in his/her room after the resident finished eating; -He/She set the resident's wallet and tea glass on his/her table before taking him/her to the bathroom; -He/She went back to the dining room while the resident was using the bathroom; -He/She returned to the resident's room at 6:15 P.M. to assist; -CNA C was in the bathroom assisting the resident; -He/She told CNA C he/she was leaving the facility to take care of a personal situation; -At 6:35 P.M., Licensed Practical Nurse (LPN) D called him/her requesting he/she return to the facility regarding a situation at the facility; -He/She returned to the facility at 6:51 P.M., and reported to LPN D. During an interview on 04/30/25, at 12:24 P.M., CNA A said the following: -He/She worked on 04/26/25 when the resident returned from the hospital; -The resident returned around 5:30 P.M. accompanied by his/her guardian; -The resident returned in his/her hospital gown; -He/She took the resident to his/her room accompanied by the resident's guardian to change the resident into normal clothes; -He/She retrieved the resident's wallet from his/her jeans in his/her hospital bag per the resident's request and handed the wallet to the resident; -The resident opened the wallet and pulled out money; -He/She did not see how much money the resident pulled out of his/her wallet; -The resident placed the money back inside his/her wallet; -He/She placed the resident's wallet on his/her recliner side table and assisted the resident to the bathroom; -He/She left the room after assisting the resident to the toilet to give the resident privacy and went to the dining room; -At 6:15 P.M., he/she went to the resident's room and CNA C was assisting the resident in the bathroom; -He/She told CNA C he/she needed to leave the facility for lunch to take care of a personal matter; -While he/she was gone he/she received a phone call from Licensed Practical Nurse (LPN) D asking where he/she had gone; -LPN D told him/her to report to the nurses' station immediately and said there was a report of missing resident money; -He/She did not see anyone take any money from any resident; -Multiple staff interacted with the resident and were in and out of his/her room following his/her return from the hospital; -He/She does not know what occurred with the resident's money. Review of CNA C's written statement, not dated, showed the following: -On 04/26/25, at 4:45 P.M., he/she was in the dining room assisting with passing drinks to residents for the dinner meal; -At 6:35 P.M., he/she was informed the resident was missing an unknown amount of money; -He/She was in the resident's room between 5:50 P.M. and 6:00 P.M., while the resident's family member was in the room; -He/She assisted the resident to the bathroom and left following assisting the resident. During an interview on 04/30/25, at 2:04 P.M., CNA C said the following: -He/She worked on 04/26/25 when the resident's money went missing; -The resident had returned from the hospital between 5:10 P.M. and 5:30 P.M.; -He/She didn't realize the resident had returned from the hospital until he/she observed him/her in the dining room for dinner; -He/She observed the resident's family member in the resident's room with the resident following dinner; -The family member was sitting on the resident's bed; -He/She did not see any money sitting out in the resident's room and did not recall seeing his/her wallet; -Nursing staff interviewed CNA's during the shift regarding a report of $40 missing from the resident; -He/She did not see anyone take any money from the resident or his/her room; -The resident usually kept his/her wallet on his/her person or wrapped in a pair of jeans next to his/her bed. Review of LPN D's written statement, dated 04/26/25, showed the following: -The resident returned from the hospital on [DATE], at 5:10 P.M., accompanied by his/her guardian; -LPN D, CNA A, and the resident's guardian assisted the resident to his/her room; -CNA A assisted the resident with changing his/her clothing; -The resident's wallet had been removed from the hospital bag by CNA A; -LPN D left the room to monitor the dining service; -At 5:45 P.M., the resident's family member arrived and reported the resident's wallet had no money inside; -The family member reported he/she had called the guardian; -LPN D spoke with the guardian by phone at 6:10 P.M.; -The guardian reported the resident had $40 in his/her wallet when he/she left the facility at 5:25 P.M.; -The guardian reported the resident removed the cash from his/her wallet, looked at it, and placed it back in his/her wallet; -The guardian said he/she told the resident his/her family member would by arriving at any time to get the money to buy what he/she needed; -He/She called all staff to the nurses desk at 6:30 P.M., to gather statements. During an interview on 04/30/25, at 3:17 P.M., Licensed Practical Nurse (LPN) D said the following: -He/She was the charge nurse working on 04/26/25 when the missing money of the resident was reported; -The resident returned from the hospital on [DATE] around 5:10 P.M.; -He/She observed the resident with his/her guardian and CNA A when the resident returned to the facility; -CNA A was assisting the resident to his/her room to change the resident into regular clothing; -The resident's clothing and wallet were in a hospital bag upon his/her return; -He/She observed the resident open his/her wallet while in his/her room and pull out $40 in cash consisting of one $20 bill and two $10 bills; -The resident put the cash back in his/her wallet and handed the wallet to CNA A; -CNA A took the wallet and placed it on the resident's recliner side table; -The resident's guardian was present when this occurred; -He/She left the area while the guardian and CNA were in the room with the resident; -Around 5:40 P.M., the resident's family member came to the facility to visit the resident; -Immediately after his/her arrival the family member came to him/her and reported $40 was gone from the resident's wallet; -The family member said he/she had told the guardian who had already left the facility; -He/She did not see anyone take the money from the resident's wallet; -He/She searched the resident's room with the family member immediately and was unable to find the $40; -He/She spoke with multiple staff but was unable to determine what happened to the money. During an interview on 04/30/25, at 1:31 P.M., CNA B said the following: -He/She was working on 04/26/25 when the resident's money was reported missing; -He/She was working in the dining room when the resident returned to the facility; -He/She observed several people including staff and others he/she did not know interacting with the resident when he/she returned to the facility; -He/She did not see anyone take anything from the resident's room or in the resident's room unattended; -Allegations or witnessed misappropriation was to be reported immediately to the charge nurse or administration. During an interview on 04/30/25, at 1:50 P.M., the Social Services Director (SSD) said the following: -On the following Monday (04/28/25) the Director of Nursing (DON) reviewed statements gathered related to the missing money; -He/She called the guardian and got a statement related to the incident; -The guardian told him/her the resident had $40 when he/she returned from the hospital; -A CNA set the wallet on the resident's bedside table with the money; -Approximately 5 minutes later the resident's family member came and the money was gone; -He/she spoke to the resident after talking to the guardian; -The resident did not mention anything about missing money; -The room was searched, and the money was not located; -He/She did not know specifics of the investigation; -He/She gives the resident $40 every week from the business office; -The resident signs for the money and the receipt is given back to the business office; -The resident is particular with his/her belongings and keeps his wallet on his/her bed stuffed in a pillow; -He/She would report any allegation of misappropriation to the Administrator and DON. During an interview on 04/30/25, at 2:58 P.M., the resident's family member said the following: -He/She arrived at the facility on 04/26/25 shortly after 5:30 P.M., once the resident had returned to the facility from the hospital; -The guardian had already left the facility when he/she arrived; -The resident opened his/her wallet when he/she arrived to give him/her $40 and no money was found in the resident's wallet; -The wallet was at the resident's bedside table; -He/she immediately called the guardian about the missing money; -The guardian told him/her the resident had $40 to give him/her consisting of one $20 and two $10's the resident showed the guardian and put back in his/her wallet; -He/She did not know the length of time between the guardian leaving and his/her arrival to the facility; -The resident gives him/her $40 in cash every Friday for personal items and outings they have that day/weekend; -He/She puts the money in a billfold specifically for the resident and provides receipts of money spent to the guardian; -He/She did not see anyone take the money from the room or wallet. Review of an emailed statement, dated 04/28/25, from the resident's guardian to the SSD showed the following: -On 04/26/25, at 5:21 P.M., he/she arrived at the facility along with the resident who returned via transport van; -He/She followed the resident to his/her room along with a facility aide; -The residents belongings from the hospital were in a bag he/she received from the driver on facility arrival; -He/She opened the resident's bag and removed the resident's wallet from his/her pants pocket; -He/She told the resident to give the money to his/her family member when he/she arrived for shopping for the resident; -The resident opened the wallet, and he/she observed one $20 and two $10's in the wallet; -The resident closed the wallet, and the CNA took the wallet from the resident and threw it on the table near the resident's recliner; -He/She visited with the resident and then left the facility at 6:10 P.M.; -At 6:18 P.M., the resident's family member called stating he/she had been at the facility for approximately five minutes; -The family member said when the resident got his/her wallet to give him/her the money it was missing from the wallet; -He/She told the family member the aide had thrown the wallet on the table near the recliner; -The family member said the wallet was in the same location when the resident grabbed his/her wallet; -He/She had the family member ask the resident if anyone had been in the room from the time, he/she left to when the family member arrived other than the CNA. The resident told the family member, no.; -He/She reported the allegation to LPN D at 6:21 P.M. During an interview on 04/30/25, at 3:56 P.M., the DON said the following: -The investigation was ongoing, but no one had been identified as taking the money; -The resident got $40 in cash every week to go on outings with his/her family member; -The guardian left that night at 6:10 P.M., and the family called to report the money missing to the guardian at 6:18 P.M.; -He/She did not know what happened to the money; -Allegations of misappropriation are to be reported immediately to administration; -Resident money and belongings should be accounted for. During an interview on 04/30/25, at 3:50 P.M., the Administrator said the following: -The missing money of the resident was still under investigation; -The investigation had not been able to identify what may have happened to the money; -The resident received $40 weekly and gives to his/her family member; -The resident's funds were to be made available to the residents and be accounted for. MO00253418

Based on observation, interview, and record review, the facility failed to identify weight loss and poor intake and failed to implement interventions to aid in the prevention of weight loss for one resident (Resident #14) who had severe weight loss of 9.60% in one month and for one resident (Resident #228) who had weight loss of 19.38% in five months. Three residents were reviewed for weight loss in a facility with a census of 58. Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, revised 09/17, showed staff should report significant weight loss, abrupt change in appetite and food intake to the physician. Review of the facility policy titled Nutrition Assessment, revised 10/17, showed the Registered Dietitian (RD), in conjunction with nursing staff and other healthcare practitioners, would conduct a nutritional assessment for each resident as indicated by a change in condition that places the resident at risk for nutritional impairment. Review of the facility's Weight Assessment and Intervention policy, revised [DATE], showed the following: -Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Verbal notification must be confirmed in writing. The dietician will respond within 24 hours of receipt of written notification. -The dietician will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant; 3 months - 7.5% weight loss is significant; 6 months - 10% is significant. -Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the dietician, the consultant pharmacist, and the resident or resident's legal surrogate. -Individualized care plans shall address, to the extent possible: the identified causes of impaired nutrition, the resident's personal preferences, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. 1. Review of Resident #14's Admission Record, located under the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included vascular dementia, major depressive disorder, anxiety disorder, and unspecified protein-calorie malnutrition, anorexia, and diarrhea. Review of the resident's Care Plan, updated on 08/26/24, and located under the Care Plan tab of the EMR, showed the following: -Resident will consume 75% of ordered diet each day; -Educate resident/representative regarding nutritional needs and requirements; -Modify diet as appropriate according to resident tolerance and preference. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 11/09/24, and located under the MDS tab of the EMR, showed the following: -Resident had severe cognitive impairment; -The resident weighed 125 pounds (lbs.) and had no weight loss. Review of the resident's Weights, located under the Weights & Vitals tab of the EMR, showed the following: -Resident's weight on 11/22/24 was 144.4 lbs; -Resident's weight on 12/17/24 was 135.6 lbs. (This represents a 9.60% weight loss in less than a month.) Review of the resident's EMR Progress Notes showed staff did not document the RD was notified of the weight loss. Review of the resident's intakes, dated 11/25/24 to 01/07/25, located under the Tasks tab of the EMR, showed the resident was eating 20% or less or refusing meals two to three times a day. Review of the resident's EMR Progress Notes showed staff did not document the RD was notified of the reduced meal intake. Review of the resident's Progress Notes, located under the Progress Notes tab of the EMR, dated 01/14/24 to 01/09/25, showed do documented physician notes addressing the weight loss and no nutritional assessment addressing the weight loss. Review of the resident's Behavior Note, dated 01/06/25, and located under the Progress Notes tab of the EMR, showed the resident refused to eat breakfast this morning, Staff that is in the dining room state that it has been weeks since he/she ate just more than 20% at a meal. Observations on 01/06/25, at 5:40 P.M., and on 01/07/25, showed the resident sat at the table in the dining room with his/her eyes closed. The resident would occasionally take a drink of his/her fluids. Staff were observed helping the resident take a few bites of his/her meal. The resident would ask staff to remove him/her from the dining room before the meal was over. During an interview on 01/08/25, at 10:58 A.M., the Dietary Manager (DM) said she would notify the Assistant Director of Nursing (ADON) or Director of Nursing (DON) of any weight loss or change of condition unless the RD was coming in. She was not aware of any weight meetings and changes to the care plan would be discussed during care plan meetings. During an interview on 01/09/25, at 10:10 A.M., Certified Nursing Assistant (CNA)1 said he/she recorded all the intakes in the EMR and reported to nursing if a resident was not eating well. During an interview on 01/09/25, at 10:15 A.M., Restorative Nursing Aide (RNA) 1 said he/she did all the monthly weights and gives them to the Director of Nursing (DON) to record into the EMR. He/she will report any weight changes to the DON who will take care of it. During an interview on 01/09/25, at 11:31 A.M., the RD said she was not aware of the resident's intakes and was not notified of the resident's weight loss. She did not review the resident's EMR and she did not know if any intervention for weight loss had been put in place. If there were any interventions they would be documented in the Nutritional Risk Assessment. She would expect to be notified of poor intakes and weight loss. She does yearly assessments, but is behind. She has input on the care plan, but does not document on the care plan. She does not review the care plans of the residents. During an interview on 01/09/25, at 2:32 P.M., the Assistant DON (ADON) said she would expect the care plans to reflect weight loss and that dietary would be reviewing the care plans. During an interview on 01/09/25, at 4:38 P.M., the DON said when she is notified about weight loss, she would add the resident to weight meetings and then ask the physician for a supplement and review. The DON stated that the RD was given a weight list every time she came in. 2. Review of Resident #228's Admission Record, located in the Profile tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included hypertensive (high blood pressure) heart disease, diabetes, and myocardial infarction (heart attack). Review of the resident's Order Summary Report, located in the Orders tab of the EMR, showed the resident's diet was upgraded from mechanical soft to regular texture on 11/07/22. Review of the resident's Mini Nutritional Assessment, dated 02/01/23, and located in the Assmnts tab of the EMR, showed the following: -Resident had no weight loss; -Resident scored in the normal nutritional status range. Review of the resident's Care Plan, located in the Care Plan tab of the EMR, showed the following: -On 03/07/24, and reviewed 03/13/24, the resident had potential nutritional problem; -Assist the resident with developing a support system to aid in weight loss efforts; -Invite the resident to activities that promote additional intake; -Monitor/record/report to medical doctor as needed for signs/symptoms of malnutrition; -Significant weight loss; -The resident needs a calm quiet setting at meal times with adequate eating time; -The resident preferred to sit at table in dining room by his/her friends. Review of the resident's weights, located in the Wts/Vitals tab of the EMR, showed the following: -A weight of 141.4 lbs on 07/23/24; -A weight of 133.4 lbs on 08/06/24. (A weight loss of a 5.7 percent in less than a month.) Review of the resident's annual MDS, with an ARD of 08/12/24, located in the MDS tab of the EMR, showed the following: -Resident had was cognitively intact; -Resident received set up or clean-up assistance with eating; -Resident had a weight loss of five percent or more in the last month or loss of 10 percent or more in the last six months; -Resident not on a prescribed weight-loss regimen; -Resident's weight was 133 lbs. Review of the resident's CAA (Care Area Assessment) Worksheet, dated 08/12/24, and located in the MDS tab of the EMR, showed nutrition status was to be addressed on the Care Plan. No referral to another discipline was warranted, according to the CAA. Review of resident's weights located in the Wts/Vitals tab of the EMR showed the following: -On 09/10/24, the resident had a five percent weight loss in a month from 08/17/24 (133.4 lbs) to 09/10/24 (125.8 lbs). -On 10/07/24, the resident weighed 125.4 lbs. Review of the resident's EMR Progress Notes showed staff did not document that the RD was notified of the weight loss. Review of resident's nurse practitioner (NP) progress note, dated 10/22/24, located in the Misc tab of the EMR, showed the NP reviewed the resident's weights over the past 90 days and noted no significant weight changes. Review of the resident's quarterly MDS, with an ARD of 11/12/24, located in the MDS tab of the EMR, showed the following: -The resident had moderate cognitive impairment; -The resident received supervision or touching assistance for eating; -The resident had a weight loss of five percent or more in the last month or loss of 10 percent or more in the last six months; -The resident was not on a prescribed weight-loss regimen; -The resident weighed 125 lbs. Review of the resident's Care Plan, located in the Care Plan tab of the EMR, showed staff did not make updates regarding the resident's nutritional status from 03/13/24 until 11/14/24. On 11/14/24, a focus area of the resident had unplanned/unexpected weight loss related to poor food intake was added. Interventions included if weight decline persists, contact physician and dietician immediately and monitor and evaluate any weight loss. Staff to determine percentage lost and follow facility protocol for weight loss. Review of the resident's EMR Progress Notes showed staff did not document the RD was made aware of the weight loss. Review of the resident's Social Services Note, dated 11/20/24, and located in the Prog Notes tab of the EMR, showed the resident was admitted to hospice services. Review of the resident's Wts/Vitals tab of the EMR revealed the resident weighed 114 lbs on 12/16/24. Review of the resident's Order Summary Report, located in the Orders tab of the EMR, showed an order, dated 12/19/24, by hospice, for Med Pass 2.0+ (a supplement used for additional calories). Review of the Assmnts tab of resident's EMR showed no nutritional assessments or progress notes by the RD following the 02/02/23 Mini Nutritional Assessment Screening. During an interview on 01/07/25, at 10:23 A.M., the resident reported not having much of an appetite. During an observation on 01/08/25, at 12:30 P.M., the resident was observed slowly feeding him/herself lunch in the dining room. During an interview on 01/09/25, at 10:10 A.M., CNA 1 said RNA 1 weighed the residents and wrote down their intakes at meals for the CNAs to record. If RNA 1 was not working, the CNAs monitored the meal intakes. If a resident was not eating well or had a weight loss, CNA 1 reported it to the nurse. During an interview on 01/09/25, at 10:15 A.M., RNA 1 said she did the monthly weights and recorded them on a paper, which she gave to the DON. She was unaware of any intervention which occurred due to the resident's weight loss. During an interview on 01/09/25, at 11:05 A.M., the RD said she was in the facility twice a month. The RD did a nutritional assessment on admission and then after a period of time, which the RD tried to keep to within a year. She reviewed weights by running a report from the EMR and checked in with the nurses regarding any concerns. The RD expected to be notified of weight loss when she was in the facility and stated she was available by phone, which was probably better than waiting two weeks for her next time in the facility. She had not been aware of the resident's weight loss, which started in August 2024 until December 2024. The RD only had weights of 133 lbs in August 2024 and then 129 lbs in November 2024. The RD was unaware of any dietary interventions prior to December 2024. During an interview on 01/09/25, at 11:59 A.M., LPN 2 said he/she seldom had anything relayed to him/her regarding weights. RNA 1 weighed residents, and the DON entered the weights into the EMR. When the provider saw the weights, the provider may give orders. Occasionally, the RD asked questions or made recommendations. During an interview on 01/09/25, at 2:32 PM, the ADON/MDS Coordinator (MDSC) reported a lack of consistency with getting care plans in place. There have been a lot of missing items on care plans. Staff discuss weight loss at care conferences, and dietary can update them as well then. The MDSC stated a care plan was to reflect significant weight loss shortly after it occurred. During an interview on 01/09/25, at 4:55 P.M., the DON said she entered weights into the EMR. The DON ran a report to see the residents with weight loss and gain. Those residents were added to the risk meeting. The DON checked current orders and asked for supplement orders or medication review. The DON expected the dietician to be aware of weight loss. A weight report was provided during the RD's visits and EMR access was available.

Based on interviews and record review, the facility failed to consistently use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week between 07/04/24 and 12/30/24. This deficient practice had the potential to affect all 58 residents residing in the facility. 1. Review of the facility's Staffing Sheets, provided by the Human Resources Director (HR Director), dated 07/04/24 through 12/30/24, showed there was no RN coverage on the following dates: -On 07/04/24; -On 07/06/24; -On 07/07/24; -On 07/31/24; -On 08/01/24; -On 09/02/24; -On 12/23/24; -On 12/30/24. During an interview on 01/09/25, at 11:30 A.M., Central Supply (CS) and the HR Director confirmed that the facility had more licensed practical nurses than registered nurses and that there were days that the facility had not been able to schedule a registered nurse to work at the facility for at least eight hours a day. During an interview on 01/09/25, at 5:22 P.M., the Director of Nursing confirmed that there had been RN coverage issues, and that the facility was struggling to get full eight-hour RN coverage daily. During an interview on 01/09/25, at 11:47 A.M., the Administrator confirmed that there were days that the facility had not been able to have a registered nurse work for at least eight consecutive hours a day, seven days a week.

Based on interview and record review, the facility failed to ensure the Dietary Manger met the required training, certification, and/or experience This deficient practice had the potential to affect all 58 residents who received meals in the facility. Review of the facility's Director of Food and Beverage Services, updated 07/14, showed the position required certification as required by state regulations. 1. During an interview on 01/06/24, at 2:37 P.M., the Dietary Manager (DM) said she had been employed at the facility for two years. She was not certified and did not have any Serv-Safe courses. She had been enrolled in classes since 2023, but had not been able to complete the courses. During an interview on 01/09/24, at 11:31 A.M., the Registered Dietitian (RD) said she was aware the DM was not certified. She is in the facility two days a month for approximately 16 hours and spends most of her time precepting the DM in her courses, but she has had a hard time finishing them.

Based on record review and interview, the facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP) and update their program, as necessary, including revision of the IPCP as national standards changed. The failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use for all 58 facility residents. Review of the facility policy titled Infectious Disease Threat Communications Plan, revised April 2019, showed The Infectious Disease Threat Communications Plan was reviewed and updated at least annually. 1. Review of a binder provided by the facility titled Infection Prevention showed the following: -The binder appeared disorganized and had policy pages out of order or missing pages. The content of one page did not match the content of the following page. -The binder included a policy titled COVID-19 Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes Centers for Disease Control and Prevention (CDC) guidelines dated [DATE]. -Another policy titled Coronavirus Disease (COVID-19) Prevention and Control was dated March 2020. -The binder included a copy of a document titled F-Tag Help F880 that was not dated and did not specify how often the IPCP was to be reviewed. During an interview on 01/09/25, at 4:36 P.M., the Infection Preventionist stated the IPCP policies had not been reviewed since June when the Infection Preventionist was hired. During an interview on 01/09/25, at 6:10 P.M., the Administrator was unsure when the IPCP was last reviewed and did not have written documentation. The Administrator said the policies were reviewed during a QAPI (quality assurance) meeting, but was not sure. The Administrator was unable to provide documentation as to when the IPCP was last reviewed.

Based on observations, interviews, and record review, the facility failed to ensure a clean homelike environment for all residents when the bathroom exhaust fan vents of seven residents (Resident #281, #280, #76, #5, #279, #22, and #11) were kept clean. Review of the facility policy titled, Job Duties, Housekeeper (South Hall), dated 10/22/24, showed weekly duties included to dust all vents in rooms and bathrooms. 1. Observation on 01/06/25, at 3:10 P.M., showed the exhaust vent in the shared bathroom of Resident #281, Resident #280, and Resident #76 was covered in a layer of fuzzy, gray dust, dirt, and debris. Observation on 01/06/25, at 3:28 P.M., showed the exhaust vent in the shared bathroom of Resident #5, Resident #279, and Resident #22 was covered in a layer of fuzzy, gray dust, dirt, and debris. Observation on 01/06/25, at 4:38 P.M., the exhaust vent in the private bathroom of Resident #11 was covered in a layer of stringy cobweb-like fibers and fuzzy gray dirt, dust, and debris. During concurrent observations and interviews on 01/09/25, beginning at 1:43 PM, the Environmental Services/Plant Director (ESD) and Environmental Services/Plant Assistant (ESA) both confirmed the bathroom vents for Resident #281, Resident #280, Resident #76, Resident #5, Resident #279, Resident #22, and Resident #11 were covered in a layer of cobwebs, dust, dirt, and debris and stated the vents needed to be vacuumed. The ESD stated the vents were last cleaned about two months ago. The ESA stated the vents were to be vacuumed on a quarterly basis, though the vents were inspected for proper functioning weekly.

Based on record review and interviews, the facility failed to ensure completed Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) assessments were sent to the Centers for Medicare and Medicaid Services (CMS) system with required time frames days after completion for four residents (Resident #11, #19, #15, and #1) out 21 sampled residents reviewed for MDS transmission. Review of the facility's policy titled Nursing Services Policy and Procedure Manual for Long-Term Care - Assessments and Care Planning, dated July 2017, showed it did not address transmission of MDS data to the CMS system. Review of the CMS 2024 Resident Assessment Instrument (RAI) Manual, accessed at https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf on 01/09/24, showed the following: -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). The encoding requirements are as follows: -For a comprehensive assessment (Admission, Annual, Significant Change in Status, and Significant Correction to Prior Comprehensive), encoding must occur within 7 days after the Care Plan Completion Date; -For a quarterly, significant correction to prior quarterly, discharge, or PPS assessment, encoding must occur within 7 days after the MDS Completion Date; -For a tracking record, encoding should occur within 7 days of the event date; -Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements; -Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. -Tracking Information Transmission: For entry and death in facility tracking records, information must be transmitted within 14 days of the event date. 1. Review of Resident 11's Admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included dementia, post-traumatic stress disorder (PTSD), anxiety disorder, insomnia, and depression. Review of the resident's MDS tab of the EMR showed the most recent assessment that had been transmitted was a quarterly MDS with an Assessment Reference Date (ARD) of 07/18/24. Subsequent assessments, an annual MDS with an ARD of 08/26/24 and a quarterly MDS dated [DATE], were completed in the facility, but were not transmitted. 2. Review of Resident #19's Admission Record, located under the Profile tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included vascular dementia and fracture of right lower leg. Review of the resident's MDS tab of the EMR showed the resident's quarterly MDS, with an ARD of 11/08/24, was completed but not submitted. 3. Review of Resident #15's Admission Record, located in the Profile tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses that included depression, anxiety, and dementia. Review of the resident's MDS tab of the EMR showed the most recent assessment that had been transmitted was an annual MDS with an ARD of 08/08/24. A subsequent assessment, a quarterly MDS with an ARD of 11/08/24, was completed in the facility, but was not transmitted. 4. Review of Resident #1's Admission Record, located under the Profile tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move, balance, and maintain posture), paraplegia (the inability to voluntarily move the lower parts of the body), anxiety disorder, major depressive disorder, and muscle wasting. Review of the resident's annual MDS, with an ARD of 11/09/24 and located under the MDS tab of the EMR, showed the assessment was signed as completed on 11/14/24 and not submitted. 5. During an interview on 01/09/25, at 2:53 P.M., the Assistant Director of Nursing/MDS Coordinator (ADON/MDSC) said she was responsible for completion of the MDS; however, the DON was responsible for signing and transmitting the assessment. She would tell the Director of Nursing (DON) which assessments needed to be transmitted, as she was under the impression that comprehensive (initial, annual, or significant change) or quarterly assessments should not be submitted to prevent unauthorized access to residents' protected health information. She was not aware all completed assessments needed to be transmitted. 6. During an on 01/09/25, at 4:40 P.M., the DON said she was responsible for signing and transmitting MDS assessments and the ADON/MDSC would tell her which assessments needed to be transmitted. The DON stated her understanding was that only entry, prospective payment system (PPS), and discharge assessments needed to be transmitted and she was not aware of the requirement to transmit initial, annual, or significant change assessments.

Based on observation, interviews, and record review, the facility failed to develop a comprehensive care plan directing measurable goals and interventions for three residents (Resident #231, #11, and #10) of a total sample of 21 residents. 1. Review of the facility's Behavioral Assessment, Intervention and Monitoring policy, revised March 2019, showed the care plan will incorporate findings from the comprehensive assessment and Pre-Admission Screening and Resident Review (PASARR) Level II determinations (as appropriate), and be consistent with current standards of practice. Review of Resident #231's Admission Record, located in the Profile tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included paranoid schizophrenia (a type of schizophrenia accompanied by paranoia. Delusions and hallucinations are the two symptoms), bipolar (a mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration), major depressive disorder, intellectual disability, and anxiety. Review of the resident's PASARR/ID (Pre-Admission Screening and Resident Review/Intellectual Disability] Client Data/Determination Sheet), located in the Misc tab of the EMR, dated 10/21/19, showed the following: -The resident met the federal definition of Intellectual Disability/Related Condition (ID/RC), but did not require specialized services; -Please incorporate the lesser intensity services into the resident's care plan; -Recommended services included physical therapy, crisis intervention, drug therapy and monitoring of drug therapy, structured socialization activities, development and maintenance of daily living skills, development of personal support networks, physician services, and medically related social services. -Diagnoses included schizophrenia and major depressive disorder. Review of the resident's quarterly MDS, with an ARD of 12/30/24, located in the MDS tab of the EMR, showed the following: -The resident had moderately impaired cognition; -Diagnoses included schizophrenia and bipolar disorder; -The resident received antipsychotic medication. Review of the resident's Care Plan, located in the Care Plan tab of the EMR, showed staff did not care plan related to the resident's diagnoses of schizophrenia, bipolar, or intellectual disability diagnoses or the resident receiving antipsychotic medication. During an interview on 01/09/25, at 1:18 P.M., the Social Services Director (SSD) said schizophrenia, bipolar, and intellectual disability diagnoses should be on the care plan as well as antipsychotics with side effects and behaviors to monitor. During an interview on 01/09/25, at 2:32 P.M., the MDS Coordinator (MDSC) said she had spoken to the SSD about the resident. Schizophrenia, bipolar, and intellectual disability diagnoses should be on the care plan as well as antipsychotics with side effects and behaviors to monitor. During an interview on 01/09/25, at 4:55 P.M., the Director of Nursing (DON) expected medical diagnoses of intellectual disability, schizophrenia, and bipolar disorder treated with antipsychotic medications to be care planned, to include the medication side effects. 2. Review of Resident #11's Admission Record located in the Profile tab of the EMR showed the following: -admitted [DATE]; -Diagnoses included dementia, basal cell carcinoma (cancer) of skin, benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms, and neuromuscular dysfunction of bladder. Review of the resident's quarterly MDS, found under the MDS tab with an ARD of 11/26/24, showed the following: -Resident had severely impaired cognition; -Resident had open lesions (e.g., cancer lesions) of the skin and received ointments/topical medications; -Resident used an indwelling urinary catheter (a tube that is inserted into your bladder, allowing your urine to drain freely). Observations on 01/06/25, at 5:26 P.M., on 01/07/25, at 11:49 A.M., on 01/08/25, at 12:00 P.M., and 01/09/25 at 8:36 A.M., in the Memory Care unit dining room, showed the resident had a large, brownish-reddish scabbed area on the left side of his/her chin and had an indwelling urinary catheter with a privacy bag covering the urine collection bag. Review of the resident's Orders tab of the EMR, showed the following: -An order, dated 08/15/22, to empty the catheter bag every eight hours and as needed, and provide catheter care every shift with soap and water or wipes; -An order, dated 10/29/24, to insert and maintain an indwelling urinary catheter Review of the resident's most recent Weekly Skin Check, located in the Progress Notes tab of the EMR and dated 12/27/24, showed the following: -Skin issue has been evaluated on chin; -Mole/Lesion progress stalled; -Previously improving wound characteristics plateaued; -Wound acquired in-house. It is unknown how long the wound has been present; -Moisture barrier. Review of resident's care plan showed the following: -Staff did not care plan regarding the resident's skin lesion or the need to apply moisture barrier to the area; -Staff did not care plan interventions related to the resident's catheter. During an interview on 01/09/25, at 2:32 P.M., the ADON/MDSC said she was aware most residents' Care Plans were lacking information and was trying to work on updating the Care Plans in the building this week. The MDSC acknowledged information about the resident's skin lesion was missing from his Care Plan and she would expect the issue to be included on the Care Plan with pertinent approaches to monitor the area and notify the physician of any changes. 3. Review of Resident #10's Admission Record, located under the Profile tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses that included heart failure and acute kidney failure. Review of the resident's physician orders, dated 12/18/24, showed physician order for admission to hospice. Review of the resident's significant change in status MDS, with an ARD of 12/23/24, and located under the MDS tab of the EMR, showed the following: -The resident was cognitively intact; -The resident was receiving hospice care. Review of the resident's Care Plan, dated 10/06/24, and located under the Care Plan tab of the EMR, showed staff did not care plan related to receipt of hospice services. During an interview on 01/09/25, at 2:32 P.M., the Assistant Director of Nursing (ADON) said there had been a lack of consistency in getting care plans in place and that there had been a lot of missing areas on care plans. The ADON stated that she would expect hospice services to be included in the care plan with the facilities responsibilities and interventions.

Based on observation, interviews, record review, and policy review, the facility failed to develop a comprehensive care plan directing measurable goals and interventions for six residents (Resident (R) 19, R228, R231, R11, R10, and R14) of a total sample of 21 residents. This failure placed residents at risk for unmet care needs and the inability to meet their maximum practicable level of functioning. Findings include: 3. Review of R231's Admission Record located in the Profile tab of the EMR revealed the resident was admitted to the facility on [DATE] and had diagnoses that included paranoid schizophrenia, bipolar, major depressive disorder, intellectual disability, and anxiety. Review of R231's PASRR/ID [Pre-Admission Screening and Resident Review/Intellectual Disability] Client Data/Determination Sheet located in the Misc tab of the EMR, and dated 10/21/19, revealed R231 met the federal definition of Intellectual Disability/Related Condition (ID/RC) but did not require specialized services. Please incorporate the lesser intensity services into the resident's care plan. Recommended services included: physical therapy, crisis intervention, drug therapy and monitoring of drug therapy, structured socialization activities, development and maintenance of daily living skills, development of personal support networks, physician services, and medically related social services. Diagnoses included schizophrenia and major depressive disorder. Review of R231's quarterly MDS with an ARD of 12/30/24, located in the MDS tab of the EMR, revealed she scored a nine out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. Diagnoses included schizophrenia and bipolar disorder, and the resident received antipsychotic medication. Review of R228's Care Plan located in the Care Plan tab of the EMR revealed no documentation of schizophrenia, bipolar, or intellectual disability diagnoses, no documentation of a level II PASRR with recommendations, and no documentation of resident receiving antipsychotic medication. During an interview on 1/09/25 at 1:18 PM, the Social Services Director (SSD) stated schizophrenia, bipolar, and intellectual disability diagnoses should be on the care plan as well as antipsychotics with side effects and behaviors to monitor. During an interview on 01/09/25 at 2:32 PM, the MDSC reported she had spoken to the SSD about R231. The MDSC stated schizophrenia, bipolar, and intellectual disability diagnoses should be on the care plan as well as antipsychotics with side effects and behaviors to monitor. I'm not sure if that's one [Care Plan] I've scoured yet. I still have a list I'm working on. During an interview on 01/09/25 at 4:55 PM, the DON reported she expected medical diagnoses of intellectual disability, schizophrenia, and bipolar disorder, treated with antipsychotic medications to be care planned, to include the medication side effects. Review of the facility's Behavioral Assessment, Intervention and Monitoring policy, revised March 2019, revealed The care plan will incorporate findings from the comprehensive assessment and PASARR Level II determinations (as appropriate), and be consistent with current standards of practice. 4.Review of R11's undated Admission Record located in the Profile tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including dementia, basal cell carcinoma of skin, benign prostatic hyperplasia with lower urinary tract symptoms, and neuromuscular dysfunction of bladder. Review of R11's quarterly MDS, found under the MDS tab with an ARD of 11/26/24, revealed he scored five out of 15 on the BIMS, indicating severely impaired cognition. He had open lesions (e.g., cancer lesions) of the skin and received ointments/topical medications. He used an indwelling urinary catheter. a. During observations on 01/06/25 at 5:26 PM, 01/07/25 at 11:49 AM, 01/08/25 at 12:00 PM, and 01/09/25 at 8:36 AM in the Memory Care unit dining room, R11 had a large, brownish-reddish scabbed area on the left side of his chin. Review of R11's most recent Weekly Skin Check, located in the Progress Notes tab of the EMR and dated 12/27/24, revealed, Skin issue has been evaluated. Location: Chin. Laterality / Orientation: Left . Other skin issue description: Mole/Lesion Progress: Stalled: previously improving wound characteristics plateaued. Wound acquired in-house. It is unknown how long the wound has been present. Painful: No. Additional care: Moisture barrier. Review of R11's EMR revealed there was no Care Plan addressing his skin lesion or the need to apply moisture barrier to the area. During a telephone interview on 01/09/25 at 2:32 PM, the ADON/MDSC stated she was aware most residents' Care Plans were lacking information and was trying to work on updating the Care Plans in the building this week. The MDSC acknowledged information about R11's skin lesion was missing from his Care Plan and stated she would expect the issue to be included on the Care Plan with pertinent approaches to monitor the area and notify the physician of any changes. b. During observations on 01/06/25 at 5:26 PM, 01/07/25 at 11:49 AM, 01/08/25 at 12:00 PM, and 01/09/25 at 8:36 AM in the Memory Care unit dining room, R11 had an indwelling urinary catheter with a privacy bag covering the urine collection bag. Review of R11's Orders tab of the EMR revealed an order, dated 10/29/24, to insert and maintain an indwelling urinary catheter, size 16 French and 10 cubic centimeter (cc) balloon. Additional orders, dated 08/15/22, instructed staff to empty the catheter bag every eight hours and as needed, and provide catheter care every shift with soap and water or wipes. Review of R11's Care Plan, located under the Care Plan tab of the EMR and dated 07/17/24, revealed, The resident has Indwelling Catheter: Terminal condition/BPH [benign prostatic hyperplasia]. The goals were, The resident will be/remain free from catheter-related trauma through review date and The resident will show no s/sx [signs or symptoms] of urinary infection through review date. There were no interventions included on the Care Plan. 5.Review of R10's Admission Record, located under the Profile tab of the EMR, revealed R10 was admitted to the facility on [DATE] with diagnoses that included heart failure, and acute kidney failure. A review of the physician orders dated 12/18/24 revealed a physician order for admission to Hospice on 12/18/24. Review of R10's significant change in status MDS, with an ARD of 12/23/24 and located under the MDS tab of the EMR, revealed R10 scored 14 out of 15 on the BIMS, which indicated R10 was cognitively intact. It was recorded that R10 was receiving Hospice Care. Review of R10's Care Plan, dated 10/06/24 and located under the Care Plan tab of the EMR, revealed there was no care plan for Hospice Care developed. In an interview on 01/09/25 at 2:32 PM the Assistant Director of Nursing (ADON) stated that there had been a lack of consistency in getting care plans in place and that there had been a lot of missing areas on care plans. The ADON stated that she would expect Hospice to be included in the care plan with the facilities responsibilities and interventions.

Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity/respect at all times when staff failed to serve residents sitting at the same table consecutively during meal service resulting in one resident (Resident #233) sitting without a meal while tablemates ate. Review of the facility's policy titled Dining Room Dignity Service Policy, undated, showed meals would be provided to all residents sitting at the table at the same time. 1. Observation of a meal on 01/06/24, at 5:25 P.M., showed four residents sat at the same table. Three of the residents were served their meal at 5:25 P.M The fourth resident, Resident #233, was not served his/her meal. Staff served the surrounding tables their meals without noticing the resident did not have a meal. The resident was observed raising his/her hand to get staff's attention. No staff responded to the resident's raised hand. The staff noticed the resident's raised hand at 5:43 P.M., and served him/her a meal. During an interview on 01/06/24, at 5:43 P.M., the resident said he/she did not know why he/she did not get his/her meal and thought they forgot him/her. The resident said he/she was hungry and just wanted to eat. 2. Observation of a meal on 01/07/24, from 12:15 P.M. to 12:29 P.M., the resident was observed sitting at the table with three other residents. The three residents were served their meals at 12:22 P.M. Resident #233 was not served his/her meal. The surrounding tables were served their meals while the resident sat at his/her table without a meal. At 12:30 P.M. a staff member walked by the resident and noticed he/she did not have a meal. The resident was served her meal at 12:30 P.M. 3. During an interview on 01/08/24, at 11:59 A.M., the Dietary Manager (DM) said she was responsible for the service and the staff serving the meals in the dining room. She was not aware of any dining room protocols and did not know residents sitting at a table together were not being served their meals at the same time. The DM said that it would be frustrating to sit and watch other residents eat while not having a meal. The DM said that there was no training for staff serving meals.

Based on interview and record review, the facility failed to complete a significant change assessment within 14 days of the significant change when facility staff did not complete the assessment for one resident (Resident #228) after being admitted to hospice services. A sample of 21 residents were reviewed. Review of the facility's Resident Assessment Instrument policy, revised September 2010, showed the assessment coordinator is responsible for ensuring that the interdisciplinary assessment team conduct timely resident assessments and reviews when there has been a significant change in the resident's condition. 1. Review of Resident #228's Admission Record, located in the Profile tab of the Electronic Medical Record (EMR) showed the following: -admitted [DATE]; -Diagnoses included hypertensive (high blood pressure) heart disease, diabetes, and myocardial infarction (heart attack). Review of the resident's Census tab showed there resident began on hospice care on 11/20/24. Review of the resident's Social Services Note, dated 11/20/24, and located in the Prog Notes tab of the EMR, showed the resident was admitted to hospice services. Review of the resident's MDS tab showed a quarterly MDS assessment, with an ARD date of 11/12/24, was completed. Staff did not complete any further MDS assessment was done after 11/12/24. During an interview on 01/09/25, at 2:32 P.M., the MDS Coordinator (MDSC) reported she did not recall the resident changing to hospice care. A significant change MDS was to be completed when the resident started hospice care. During an interview on 01/09/25, at 4:55 P.M., the Director of Nursing (DON) said she expected completion of a significant change MDS within 14 days of a resident changing to hospice care.

Based on observation, interview, and record review, the facility failed to provide pressure ulcer care per standards of practice when staff failed to document full and accurate assessments of a pressure ulcer and failed to care plan the pressure ulcer and interventions in place to prevent and/or treat pressure ulcers for one resident (Resident # 19), for three residents reviewed for pressure ulcers, in a total sample of 21 residents reviewed. Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy, revised April 2018, showed the following: -During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with complicated, extensive, or poorly-healing wounds. -The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. -Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. Review of the facility's Pressure Ulcer/Injury Risk Assessment policy, revised July 2017, showed the following: -Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. -The interventions must be based on current, recognized standards of care. The effects of the interventions must be evaluated. -The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. 1. Review of Resident #19's Admission Record, located under the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included vascular dementia and a healed fracture of right lower leg. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 05/08/24 and located under the MDS tab of the EMR, showed the following: -Resident had no pressure ulcer/injury; -Resident had a pressure reducing device for chair and bed, and was not on a turning/repositioning program. -Resident had functional limitation in range of motion on one lower extremity; -Resident needed partial/moderate assistance with transfers and mobility except for rolling side-to-side, which was done with supervision; -Resident had moderate cognitive impairment. Review of the resident's Braden Scale for Predicting Pressure Sore Risk, dated 05/13/24, and located in the Assmnts (Assessments) tab of the EMR, showed staff assessed the resident as a score of 18 (which indicated at risk for pressure ulcer development). Review of the resident's Care Plan, located under the Care Plan tab of the EMR, showed the following: -A focus area, initiated on 05/17/24, identified the resident's risk for pressure ulcer development related to immobility; -Care plan interventions included following facility policies/protocols for the prevention/treatment of skin breakdown, encourage small frequent position changes, turn/reposition at least every two to three hours, and pressure relieving/reducing device on bed/chair. Review of the resident's Braden Scale for Predicting Pressure Sore Risk, dated 05/20/24, and located in the Assmnts tab of the EMR, showed staff assessed the resident as a score of 14 (moderate risk for pressure ulcer development). Review of the resident's Skin Only Evaluation, dated 06/10/24, and located in the Assmnts tab of the EMR, showed no skin issues. Review of the resident's Braden Scale for Predicting Pressure Sore Risk, dated 06/11/24, and located in the Assmnts tab of the EMR, showed staff assessed the resident with a score of 11 (high risk for pressure ulcer development). Review of the resident's Skin/Wound Note, dated 06/15/24, and located under the Prog Notes tab of the EMR, showed resident noted to have an open area on his/her posterior right heel measuring 2.5 centimeters (cm) wide x 1.8 cm length with new order (treatment) until resolved. Review of the resident's Orders in the EMR showed a physician's order, dated 06/15/24, to cleanse area with wound cleanser and skin prep periwound. Apply fibracol to wound bed and cover with foam border dressing every day until resolved. Review of the resident's Skin Only Evaluation, dated 06/17/24, and located in the Assmnts tab of the EMR, showed a right heel pressure ulcer/injury without description or measurement other than painful. Clinical suggestions check-marked included: advise resident to frequently shift weight and raise buttocks while sitting in chair, evaluate for pain and discomfort, perform dressing changes/treatments as ordered, move resident at least every two hours, and administer PRN (as needed) medication per order. Review of the resident's care plan showed staff did not update the care plan with the new pressure ulcer or any new interventions related to the pressure ulcer. Review of the resident's Order Note, dated 06/21/24, and located under the Prog Notes tab of the EMR, showed new orders for wound care provider to eval and treat for right heel ulcer. Review of the resident's Skin Only Evaluation, dated 06/25/24, and located in the Assmnts tab of the EMR, showed a right heel pressure ulcer/injury without description or measurement other than painful. Clinical suggestions check-marked included: advise resident to frequently shift weight and raise buttocks while sitting in chair, evaluate for pain and discomfort, perform dressing changes/treatments as ordered, move resident at least every two hours, and administer PRN medication per order. Review of the resident's wound care provider's Visit Summary Report, dated 07/01/24 and provided by the facility, showed the wound care provider rounded with a facility nurse, who reported the wound was first observed approximately two weeks prior as a result of the resident's foot resting on wheelchair pedals. The first assessment by the wound care provider was 07/01/24. The wound care provider included instructions of educated nurse on updated treatment plan of frequent elevation of lower extremities, use of Podus boots (boots used to reduce pressure), and floating heels while in bed to offload pressure. Nurse reported resident was non-ambulatory since fracturing his/her right tibia about seven months prior to his/her admission to the facility, was wheelchair bound, and transferred with a hoyer lift (mechanical lift). The wound measured 2.6 cm x 1.2 cm x 0.1 cm and was a Stage 3 (full thickness tissue loss) pressure ulcer. Review of the resident's Orders showed an order from the wound care provider, dated 07/01/24, to cleanse wound with hypochlorous acid, protect peri-wound with skin protectant, apply Santyl to the wound bed and calcium alginate to wound base, and cover with super absorbent dressing. Review of the resident's care plan showed staff did not update the care plan with the new pressure ulcer or any new interventions related to the pressure ulcer. Review of the resident's wound care provider note, dated 07/08/24, located in the Misc tab of the EMR, showed resident found sitting in wheelchair with Podus boots on. He/She continued to spend a large part of the day sitting in wheelchair with legs dependent. Recommended getting new foot pedals that will allow patient to elevate lower extremities. Nurse stated he/she would check with physical therapy if available. Right heel wound with increased depth. Review of the resident's care plan showed staff did not update the care plan with the new pressure ulcer or any new interventions related to the pressure ulcer. Review of the resident's wound care provider Visit Summary Report, dated 07/15/24 and provided by the facility, showed resident found sitting in recliner. Legs elevated and Podus boots on. Right heel wound greatly deteriorated with larger measurements. New malodorous drainage noted. Debridement performed and tissue sample taken for culture. Reinformed teaching on floating heels while in bed to offload pressure and prevent further skin breakdown. Did note that no modifications made to foot pedals on wheelchair. Nurse stated she would discuss with physical therapy. The wound measured 2.9 cm x 1.4 cm x 0.3 cm. Review of the resident's care plan showed staff did not update the care plan with the new pressure ulcer or any new interventions related to the pressure ulcer. Review of the resident's Wound Care Notes, dated 07/22/24 and located in the Misc tab of the EMR, showed culture results reviewd from 07/17/24. Nurse stated he/she will forward the culture results to PCP (primary care provider) and get antibiotics started. Review of the resident's wound care provider Visit Summary Report, dated 07/29/24 and provided by the facility, showed facility nurse said physical therapy discussed modifying pedals on wheelchair, but orthopedic doctor said resident should not elevate as it will contribute to foot drop. Discussed with nurse that resident would benefit from Broda chair (reclining padded wheelchair), and he/she stated he/she would bring up at the next meeting. Review of Wound Care Notes, dated 08/05/24 and located in the Misc tab of the EMR, showed the nurse reported resident not eligible for Broda chair at this time. Resident found sitting in wheelchair with Podus boots on. Muscle rigidity and limited range of motion result in lower extremities to be extended and unable to effectively use foot pedals. Feet in direct contact with floor. Right heel wound deteriorated. Depth increased and more slough (non-viable tissue) to wound bed. Maceration (irritation) and bruising evident to peri site. Nurse did note that facility staff attempt to encourage resident to elevate in bed, however, resident refused and will shout out if not in wheelchair. Review of the resident's wound care provider Visit Summary Report, dated 08/12/24 and provided by the facility, showed nurse reported Broda chair had been approved and should be arriving at facility later that week. Review of the resident's wound care provider Visit Summary Report, dated 08/19/24 and provided by the facility, showed the resident found sitting in bed with Podus boots on. Right heel wound drastically deteriorated with new exposed bone and tendon. The nurse reported that resident spends majority of day sitting in wheelchair with legs in extended position, resulting in almost constant pressure to wound site against floor. A new geri chair (reclining padded wheelchair) had been ordered but awaiting delivery. Due to resident's behaviors it had been difficult to follow plan of care. The pressure ulcer's staging was downgraded to Stage 4 (full thickness tissue loss with palpable or exposed bone, tendon, or muscle). Review of the resident's wound care provider Visit Summary Report, dated 08/19/24 and provided by the facility, showed the nurse said they got the resident a new recliner in his/her room which allowed him/her to effectively elevate lower extremities. Resident is up to wheelchair for meals only, then in bed or recliner. Still awaiting delivery of new geri chair. Review of the resident's wound care provider Visit Summary Report, dated 08/19/24 and provided by the facility, showed received new geri chair last week. Review of the resident's Order Recap Report, dated 06/15/24 to 12/10/24, located in the Orders tab of the EMR, showed the following: -An order, dated 09/18/24, to change from weight bearing as tolerated to the right lower extremity to non-weight bearing; -An order, dated 12/03/24, to float heels at all times off of the bed and footrest of Broda chair. Review of the resident's Care Plan, located under the Care Plan tab of the EMR, showed a focus area was initiated on 12/10/24 which identified the resident's right heel pressure ulcer. Interventions initiated 12/10/24 included: heels to be floated at all times while in bed; follow doctor orders for weight bearing status; and bunny boots to be worn at all times when in bed. (No focus area for the right heel pressure ulcer nor interventions were added to the Care Plan prior to 12/10/24. The Care Plan did not mention the Broda chair or elevating the resident's legs.) During an observation on 01/07/25 at 11:26 A.M., the resident sat in a Broda wheelchair with feet in socks, heels resting on a pillow at the base of the chair During an interview on 01/09/25, at 11:59 A.M., Licensed Practical Nurse (LPN) 2 said the resident had orders to float her heels in bed. The resident had completed weight-bearing transfers with the assistance of two staff, but then changed to a hoyer lift after developing the pressure ulcer to his/her heel. During an interview on 01/09/25, at 2:05 P.M., LPN 1 said she rounded with the wound care provider for certain residents, which included the resident. The resident used the Broda chair because of comfort and safety, not due to the pressure ulcer. The resident would not bend her right leg. During an interview on 01/09/25, at 2:32 P.M., the Assistant Director of Nursing/MDS Coordinator (ADON/MDSC) said there had been a lack of consistency with getting Care Plans in place. The MDSC was trying to get them caught up. As soon as the pressure ulcer was identified, it should have been added to the Care Plan. During an interview on 01/09/25, at 4:55 P.M., the Director of Nursing (DON) said when a resident developed a pressure ulcer, she expected intervention to be put in place and documented in the EMR. The DON reported that when the resident's foot pedal was an issue, a pressure relieving boot was placed that the wound care provider had suggested. Per the DON, after a couple of weeks, the boot was making it worse, so the resident started using the Broda chair.

Based on interviews and record review, the facility failed to ensure residents' medical records were complete and accurately documented when the facility failed to ensure physician progress notes were documented and available for review in the electronic medical record (EMR) for one resident (Resident #133), reviewed out of a total sample of 21 residents. 1. Review of Resident #133's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included atherosclerotic heart disease (thickening or hardening of the arteries), chronic obstructive pulmonary disease (COPD - a condition caused by damage to the airways or other parts of the lung), low-tension glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), and osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 12/25/24, showed the resident had a was severely cognitive impaired. Review of the resident's Progress Notes tab of the EMR showed no documentation of the physician progress notes. Review of the resident's Miscellaneous tab of the EMR showed no documentation of the physician progress notes. Review of the resident's EMR showed there was no documentation of the physician progress notes accessible during the survey review dates without the physician submitting photos of his laptop, as noted in the Administrator interview below. During an interview on 01/08/25, at 11:25 A.M., Social Service Director (SSD) said the physician progress notes should be documented under the Miscellaneous tab in the EMR for the facility residents. She could not recall how long physician progress notes had not been consistently placed into resident records. She confirmed the physician progress notes could not be found in the EMR for the resident. During an interview on 01/09/25, at 5:22 P.M., the Director of Nursing confirmed that the facility had been having a hard time getting the physician progress notes from the physician's dictating company. She confirmed the resident records were not complete without the physician progress notes. During an interview on 01/09/25, at 9:28 A.M., the Administrator confirmed that the facility had been having a problem with getting the dictated physician progress notes and having them placed into the resident records. The Administrator was not aware of how long this had been a concern. The Administrator provided physician progress notes for the resident, which were photo images of the physician's laptop screen, and not documentation that had been available in the EMR.

Based on record review and interviews, the facility failed to conduct ongoing review for antibiotic stewardship for one resident (Resident #15), of three residents reviewed for antibiotic stewardship, who received multiple antibiotics over multiple months. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, showed the following: -All clinical infections treated with antibiotics will undergo review by the infection preventionist (IP), or designee; -The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics; -All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include resident name and medical record number; unit and room number; date symptoms appeared; name of antibiotic (see approved surveillance list); start date of antibiotics; pathogen identified (see approved surveillance list); site of infection; date of culture; stop date; total days of therapy; outcome; and adverse events. Review of the facility's policy titled, Antibiotic Stewardship - Staff and Clinician Training and Roles, revised December 2016, showed the Director of Nursing (DON) and will receive initial orientation and ongoing training on how to use surveillance tools to monitor infections rates, antibiotic usage patterns and outcomes. 1. Review of Resident #15's Admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included acute vaginitis (a condition that causes vaginal irritation, discharge, odor, swelling, itching, or pain) and urinary tract infection (UTI). Review of the resident's Order Summary Report, Medication Administration Records (MAR), and Treatment Administration Record (TAR), located in the Orders tab of the EMR, showed the following antibiotics were ordered and administered in August 2024, September 2024, November 2024, and December 2024: -On 08/16/24, cefuroxime oral tablet was ordered for UTI and administered for seven days as ordered; -On 09/05/24, ceftriaxone sodium injection was ordered for infection and administered one time as ordered; -On 09/06/24, cefuroxime oral tablet was ordered for sinus infection and administered for 10 days as ordered; -On 11/24/24, Macrobid oral capsule was ordered for vaginitis and administered one time as ordered; -On 11/24/24, Macrobid oral capsule was ordered for vaginitis and administered for five days as ordered; -On 12/03/24, Diflucan oral tablet was ordered for vaginal yeast/itching and administered one time as ordered; -On 12/11/24, ciprofloxacin oral tablet was ordered for UTI and administered for two days then changed to Augmentin on 12/13/24; -On 12/13/24, Augmentin oral suspension was ordered for UTI and administered for five days as ordered; Review of the resident's Laboratory Report, located in the Misc tab of the EMR, showed a culture and sensitivity lab result, dated 12/13/24, that showed the organism causing the infection was resistant to ciprofloxacin and susceptible to amoxicillin & pot clavulanate. Review of the facility's Infection Control Line Listing, located in the Infection Control binder. showed the resident was not listed on the log for antibiotic stewardship review dated August 2024, September 2024, November 2024, and December 2024. The Infection Control Line Listing log sheets were incomplete with missing information for resident room numbers, dates of labs/pathogen, date/Symptoms, and predisposing factors. During an interview on 01/09/25, at 4:36 P.M., the Director of Nursing (DON), who also served as the IP, said antibiotic stewardship was done by her and logged in the Infection Control binder. When asked about what protocols were followed, the DON said the residents were watched for signs and symptoms, labs ordered, and discussed with the provider. The DON said staff follow what the doctor gives us. The DON said the McGeer criteria (tool designed to support facility healthcare-associated infection surveillance) was followed for signs and symptoms. For documentation, a progress note was written on each resident. The DON said there was no policy that she was aware of for following the McGeer criteria or protocols to follow for reviewing antibiotic stewardship. Every resident that was prescribed an antibiotic should be on the log. The resident should have been on the log. During an interview on 01/09/25, at 6:10 P.M., the Administrator said the DON was responsible for the antibiotic stewardship program. The Administrator said that guidelines were to be followed for appropriate ordering of antibiotics.

Based on observation and interview, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 58 current residents. 1. Observations throughout the facility, on 01/06/25 through 01/09/25, showed the Daily Nursing Roster was posted in the facility at the North Hall Nurse Station on 01/06/25, at 2:00 P.M.; on 01/07/25, at 9:50 A.M.; on 01/08/25, at 5:00 P.M.; and on 01/09/25, at 11:25 A.M., without ensuring all information was documented. The daily postings failed to document the daily resident census, whether or not the nurse was a Licensed Practical Nurse (LPN) or Registered Nurse (RN), or the actual hours worked by the staff. During an interview on 01/09/25, at 11:30 AM, Central Supply (CS) and the Human Resources (HR)Director confirmed that they were not aware that the daily nurse postings required the resident census and/or the need to identify the licensing of the nurse. They said the Director of Nursing (DON) was the one responsible for posting them daily. During an interview on 01/09/25, at 5:22 P.M., the DON said she was not aware that the daily nurse posting forms did not have all the documentation required. During an interview on 01/09/25, at 11:47 A.M., the Administrator said he was not familiar with the requirements of the daily nurse postings.

Please refer to Event ID 25WV12, exit date 07/12/23, for citation details. This deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated 5/18/23. Based on interview and record review, the facility failed to report an allegation of abuse immediately to facility management and to the state licensing agency (DHSS - Department of Health and Senior Services) within the required two hour time frame when a staff member (Housekeeper (HK) A) overheard one resident (Resident #1) be threatened and cursed at by one staff (Certified Nurse Aide (CNA) B). A sample of five residents was selected in a facility with a census of 61. MO00221215

Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services when the dietitian was not employed full-time by the facility. The facility census was 59. Review of the facility's policy titled Director of Food and Beverage Services, revised 07/2014, showed the following: -The Director of Food and Beverage Services is responsible for the overall effective dietary services; selecting, training and supervision all dietary services personnel; procuring supplies and equipment; assisting with budget preparation and operating within budgetary guidelines. (The policy did not address the requirements of being a Certified Dietary Manager, Certified in Food Services Manager, or education/training related to service management or hospitality.) 1. During an interview on 05/15/23, at 9:00 A.M., the Dietary Manager (DM) said the following: -He/she was not a Certified Dietary Manager and not enrolled in a training/certification course; -He/she was not a Certified Food Services Manager and did not have an associate's degree or higher in food service management or hospitality; -He/she started working in the kitchen as a cook on 11/2022 and took the DM position in 03/2023; -He/she had twenty-five years in food service management, but none of those years were in a skilled nursing facility; -A Registered Dietitian came to the facility twice monthly. Review of the DM's personnel file showed no completed Certified Dietary Manager course, Certified Food Services Manager, or higher education related to food service management or hospitality. During an interview on 05/17/23, at 3:42 P.M., the Administrator said the following: -The DM started his/her position in 03/2023 and had no prior employment as a DM in a skilled nursing facility; -The DM was not a Certified Dietary Manager and was not enrolled a course at this time; -The DM was not a Certified Food Services Manager and did not have an associate's degree or higher in food service management or hospitality.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to ensure foods were held at an appropriate temperature to inhibit the growth of pathogens that can cause foodborne illness; staff failed to discard dented cans when staff stored dented cans on the shelves along with cans of food staff used to prepare resident food; staff failed to discard expired food stored on the shelves along with food used to prepare resident food; staff failed to clean the floor in the dry storage rooms, dishwashing and food preparation area, refrigerators and freezers that stored food used to prepare resident food; staff failed to wear hairnets appropriately while preparing resident's food; staff failed to use proper hand washing and glove use while preparing residents food; and staff failed to regularly test the sanitation levels of the dishwashing machines. The facility census was 59. 1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Except during preparation, cooking, or cooling, time/temperature control for safety food shall be maintained at 41 degress F or less. Review of the facility's policy titled Holding Time and Temperature Log, undated, showed the following: -Cold holding temperatures should stay below 40.0 degrees Fahrenheit (F); -Just like hot foods, pathogens in cold foods can reach dangerous levels if the food stays in the temperature danger zone too long. To keep them safe, make sure the cold holding tables, freezers, and refrigeration units keep cold-held foods at 34 to 40.0 degrees F or colder; -Check the temperature of held food. Don't rely on the thermometers on the holding units alone. In order to prevent foodborne illness, staff should check the internal temperature of hot and cold-held food periodically to make sure it stays out of the danger zone; -For hot foods, use a handheld food thermometer to double-check food temperatures. Staff should also check cold foods for any signs that they may be thawing or melting; -Use the Holding Time and Temperature Log to record hot and cold holding temperatures. Seeing the log will remind staff to double-check the temperatures and allow the manager on duty to verify that food is not being held at unsafe temperatures. Review of the facility's salad bar temperature log showed the following: -Temperature should be between 34 to 40 degrees F; -The log for ,d+[DATE] showed no temperatures for [DATE]. No log provided for [DATE] through [DATE]; -No log provided for ,d+[DATE]. Observation on [DATE], at 11:47 showed the following: -Dietary Aide (DA) N checked the temperature of the cold food on the serving line; -Temperatures were as follows: pureed coleslaw 43.3 degrees F, coleslaw 42.6 degrees F in one pan and 41.5 degrees F in another pan, and potato salad 51.6 degrees F in one pan and 51.3 degrees F in another pan. Observation on [DATE], at approximately 12:20 P.M. showed DA N dished up six coleslaw, two potato salad, and two pureed coleslaw that staff served to residents. During an interview on [DATE], at 12:08 P.M., DA M said he/she did not know what temperature cold food should hold at because he/she only worked on the hot food side of service. During an interview on [DATE], at 12:13 P.M., DA N said cold food should hold somewhere around 30 degrees F. During an interview on [DATE], at 12:27 P.M., DA O said the following: -Staff should hold cold food at 40 degrees F or below; -If staff served cold food above this temperature above 40 degrees F, the food could be spoiled and residents could become ill; -No residents had been ill to his/her knowledge; -If cold food temped above 40 degrees F, staff should dump it out and get new cold food; -The temperatures of the coleslaw and the potato salad were not appropriate. During an interview on [DATE], at 7:54 A.M., DA J said the following: -Staff should hold cold food at 30 degrees F; -Staff should not serve potato salad above 51 degrees F and coleslaw above 41 degrees F because they contained dairy products and this could make the residents sick; -If he/she took temperatures of cold food and it was out of range, she/she did not serve it and reported this to his/her supervisor. During an interview on [DATE], at 8:29 A.M., Cook K said the following: -Cold food was held between 35 to 38 degrees F or below; -He/she did not know who took temperatures at the serving line; -Staff should not serve potato salad with temperature above 51 degrees F or coleslaw with temperature above 41 degree F because they contained mayonnaise that could turn bad and make the residents sick. During an interview on [DATE], at 9:28 A.M., [NAME] L said the following: -Cold food was held below 40 degrees F; -If cold food temperatures were above 40 degrees F, bacteria could grow and residents could become ill; -The DA that served on the service line were responsible for taking temperatures of the cold food and document in the temperature log; -Staff should not serve potato salad with temperatures above 51 degrees F or coleslaw with temperatures above 41 degrees F due to possible bacteria growth and could cause residents to get ill; -If temperatures were not appropriate, the DA should pull the cold food and not serve it; -The DM was responsible to ensure the DA know the correct temperatures to hold cold food and check the temperature logs. During an interview on [DATE], at 8:52 A.M., the Assistant DM said the following: -Cold food was held at 34 to 40 degrees F; -If cold food temperatures were not at 40 degrees F or below, staff should not serve them; -Staff should not serve coleslaw with temperatures above 41 degrees F and potato salad with temperatures above 51 degrees F. These could have bacteria growth and cause resident to become ill; -Staff who served on the serving line were responsible to take temperatures of cold food and document in the temperature log; -If staff noticed cold food temperatures were not 40 degrees F or below, they should place the cold food in an ice bath or in the refrigerator to bring the temperature down; -He/she and the DM were responsible to ensure staff who served cold food knew the appropriate temperatures for cold food and document in the temperature log. He/she and the DM should check the temperature logs daily. During interviews on [DATE], at 9:52 A.M. and 12:30 P.M., the DM said the following: -Holding temperatures for cold food was 40 degrees F or below; -If cold food not 40 degrees F or below, staff should not serve it; -Staff took temperatures of the food in the kitchen and then the DA's who worked the serving line took the temperatures before they served the food; -If staff noticed potato salad temperatures were above 51 degrees F and coleslaw temperature were above 41 degrees F they should not serve them. These temperatures would be in the danger zone; -He/she was responsible to ensure staff knew what the danger zone temperatures were and to check the temperature logs; -He/she did not have any cold food temperature logs past [DATE]. 2. Review of the FDA 2013 Food Code showed the following: -Rusted and pitted or dented cans may present a serious potential hazard; -Products that are held for credit, redemption, or return to the distributor, such as damaged, spoiled, or recalled products, shall be segregated and held in designated areas that are separated from food. Review of the facility's undated policy titled Dented Can Policy showed the following: -All dented cans are to be stored on the cart in the break room and reported to management. Management will in turn report it to the food service representative. They need to be stored away from all other food and not be used as this can cause a senior to become ill. Observations on [DATE], at 8:52 A.M., [DATE], at 7:50 A.M., and on [DATE], at 7:39 A.M. and 8:17 A.M., showed the following: -One 112 ounce (oz.) can banana pudding dented on the can storage rack in the dry storage of the health care kitchen; -Two 6 pound (lb.) 9 oz. dented cans of diced pears, two 6 lb. 10 oz. dented cans mandarin orange segments, two 6 lb. 8 oz. dented cans of yellow cling sliced peaches, one 51 oz. dented can of tomato paste, one 52 oz. dented can of bean and uncured bacon soup, and one 50 oz. dented can of cream of chicken soup on can storage rack in the dry storage of the cooking kitchen. During an interview on [DATE], at 7:54 A.M., DA J said the following: -He/she did not know where he/she put dented cans; -All kitchen staff were responsible for checking for dented cans; -If he/she saw a dented can, he/she took it off the shelf and put it in the DM's office; -If staff used a dented can, it could have a hole in it and make the residents sick. During an interview on [DATE], at 8:29 A.M., Cook K said the following: -Staff should send dented cans back to the supplier; -Staff should not store dented cans on the can storage rack with undented cans; -If dented cans stored with undented cans, staff may use the dented can and cause the residents to get sick; -All staff that stock the cans should check for dented cans. During an interview on [DATE], at 9:28 A.M., [NAME] L said the following: -Staff stored dented cans on the top shelves of the can storage racks in the cooking kitchen, but did not know where they stored them in the health care kitchen; -Staff should not store dented cans with undented cans because staff could use them and residents could become ill; -The DM and whoever stocks the cans was responsible to check for dented cans. During an interview on [DATE], at 8:53 A.M., the Assistant DM said the following: -The health care kitchen should not have dented cans and if staff saw a dented can they should bring it to the cooking kitchen to be placed with the other dented cans; -Staff stored dented cans on the top shelves of the can storage rack in the cooking kitchen; -Staff should not store dented cans on the same shelves used to store undented cans because they could potentially use the dented can and these could contain bacteria and cause the residents to get sick; -Staff that stock the cans, him/her and the DM should check for dented cans; -If staff found dented cans they should tell him/her or the DM and he/she or the DM contacted the supplier to inform them; -The DM was responsible to ensure staff checked for dented cans. During an interview on [DATE], at 9:53 A.M., the DM said the following: -Staff stored dented cans on the top of the can storage rack in the cooking kitchen and returned them to the supplier. The health care kitchen did not have a dented can storage area; -Staff should not store dented cans with undented cans because they could use the dented can and residents could become sick; -He/she was responsible for checking for dented cans. During an interview on [DATE], at 9:44 A.M., the Administrator said the following: -Staff should set dented cans aside away from other food to picked up and not used; -Staff should not store dented cans on the same rack as undented cans because there was a potential for staff to use the dented cans; -The DM was responsible for ensuring dented cans were not stored with undented cans. 3. Observations on [DATE], at 8:52 A.M., [DATE] at 7:50 A.M., and [DATE] at 7:39 A.M. and 8:17 A.M., showed the following: -In the dry storage area in the health care kitchen, one can of sweetened condensed milk, dated best before ,d+[DATE], on the shelf on the west wall and four 46 oz. containers of thickened lemon flavored water, dated use by [DATE], on the shelf on the north wall; -In the dry storage area in the cooking kitchen, four one gallon containers of raspberry vinaigrette, dated [DATE], on the shelf on the west wall. During an interview on [DATE], at 7:54 A.M., DA J said the following: -Staff should pull out of date food off the shelf, tell the DM, throw it away, and write it down; -Staff should not store out of date food on the shelves; -The dry storage should not have the can of sweetened condensed milk, dated best by ,d+[DATE], or container of thickened water, dated [DATE], on the shelves. Staff should discard these items. During an interview on [DATE], at 8:29 A.M., Cook K said the following: -Staff should check for expired foods weekly through ordering and rotation of food when stocking shelves when they received an order; -Every staff who handled food should check for expired items; -Expired raspberry vinaigrette, thickened water, or sweetened condensed milk should not be on the shelves because staff could serve these items and residents could get sick; -If he/she saw these items, he/she discarded them and let the DM know. During an interview on [DATE], at 9:28 A.M., [NAME] L said the following: -Staff should remove expired food items from the shelves and throw them out because staff could use them and cause residents to get ill; -The dry storage areas should not contain expired raspberry vinaigrette, thickened water, or sweetened condensed milk in them. If he/she saw this, he/she pulled the item off the shelf, discarded it and let the DM know; -The DM was responsible to check for expired foods. During an interview on [DATE], at 8:53 A.M., the Assistant DM said the following: -Staff who used food products or stocked food from the order should check for expired food; -Expired food should not be on the shelves in the dry storage areas because staff could use them and residents could become ill; -The dry storage areas should not have expired raspberry vinaigrette, thickened water, or sweetened condensed milk in them. If he/she saw this, he/she removed the item and threw it away and reported this to the DM. During an interview on [DATE], at 9:53 A.M., the DM said the following: -He/she was responsible for checking for expired food; -He/she checked for expired foods when he/she put the grocery order away; -The dry storage rooms should not have expired food on the shelves because staff could use these items and the residents could become ill. During an interview on [DATE], at 9:44 A.M., the Administrator said the following: -Staff should remove expired food when discovered and checked weekly when food orders are placed; -If staff found expired food, they should remove from the shelf and separated from the other food; -The DM was responsible for checking for expired foods. 4. Review of the FDA 2013 Food Code showed the following: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the facility's Dietary Aide Cleaning Job List showed the following: -At 6:30 (did not specify A.M. or P.M.) one aide to clear off dishes from tables and sanitize the tables; -When done, bring to kitchen for the other aide to wash; -Then get the broom, a clean mop head on a mop handle, and clean mop water; -Go to the dining room and sweep and mop; -Wipe the counter tops and clear off the bakers racks of all trash, bags and boxes; -Check the steam table to make sure it is wiped down completely and there is nothing left. Review of the facility's Cleaning Check Off List, dated ,d+[DATE], for all employees for the cooking kitchen showed tasks included dish room maintenance weekly, floor cleaning nightly, refrigerator and freezer cleaning two times a week, shelves and other surfaces clean weekly, and ice machine daily. Review of the facility's Cleaning Check Off List, dated ,d+[DATE], for the healthcare kitchen showed tasks included cabinet maintenance each shift, dish room maintenance weekly, floor cleaning nightly, refrigerator and freezer cleaning two times a week, shelves and other surfaces clean weekly, and ice machine daily. Observation on [DATE], at 8:52 A.M., [DATE], at 7:50 A.M., and on [DATE], at 7:39 A.M. and 8:17 A.M., showed the following: -The two door stainless steel refrigerator in the health care kitchen that contained milk and cottage cheese had white, brown, and black dried particles all over the bottom of the inside of the refrigerator and what appeared to be dried milk spillage on the left front corner of the inside of the refrigerator approximately 3 inches by 3 inches in size; -The two door stainless steel freezer in the health care kitchen that contained frozen shakes and juices had brown dried particles in the bottom of the inside of the refrigerator and a brownish in color dried spillage on the front inside edge on the right side; -The hand washing sink in the health care kitchen had brownish black substance in the bottom, sides, and edge of the sink; -The floor in the dry storage area of the health care kitchen felt sticky throughout the room; -A stack of eleven Styrofoam cups laid on the floor underneath a rolling stainless steel cart in the middle of the dishwashing area of the health care kitchen; -A black grease trap under the three vat sink in the health care kitchen appeared to have a brownish gray substance on top with a large puddle of water on the floor on top and in front of it next to the floor drain; -The floors throughout the health care kitchen had dried on debris in several areas; -Refrigerator #1 in the health care kitchen that contained food for the residents had a yellowish orange and red dried on debris in the bottom inside the refrigerator and inside the shelves on the doors; -Refrigerator #2 in the health care kitchen that contained food for the residents had red and yellow dried on debris in the bottom inside under the drawers of the refrigerator; -The dry storage area floors of the cooking kitchen had what appeared to be a rust colored substance under the racks and the cracks between the tiles had a blackish brown substance from the entry to the dry storage across the room to the west side; -The ice machine in the cooking kitchen had what appeared to be a grayish substance on the white shroud inside the machine and the floors around the ice machine between the walls and the ice machine approximately 2.5 feet on the left side and 2.5 feet on the back side had a brownish gray substance; -Between appliances on the cooking and baking sides of the cooking kitchen had food debris, three tater tots, a plastic bag and brown, black and white caked on debris approximately 22 foot in length and 2 to 3 inches wide. During an interview on [DATE], at 7:54 A.M., DA J said the following: -He/she did not know about a cleaning schedule; -He/she swept and mopped the kitchen floors at the end of his/her shift; -All kitchen staff were responsible for cleaning the kitchens; -He/she did not who was responsible for cleaning the freezers or refrigerators; -He/she cleaned the outside of the grease traps at the end of his/her shift or if he/she made a mess. During an interview on [DATE], at 8:29 A.M., Cook K said the following: -He/she did not know if the kitchen had a cleaning schedule; -The bakers and night crew were responsible for sweeping and mopping the floors; -There should not be a buildup of grease, old food, paper or debris on the floors anywhere; -He/she did not know the last time staff cleaned the floor between the baking and cooking areas but did not believe the floor should look that way; -All kitchen staff were responsible for cleaning. During an interview on [DATE], at 9:28 A.M., [NAME] L said the following: -Kitchen staff had a cleaning schedule and all kitchen staff were responsible for completing the tasks; -He/she swept and mopped his/her side of the kitchen and all kitchen staff were responsible for sweeping and mopping between the baking and cooking areas; -The area between the baking and cooking areas should not have all of that build up, it could attract pests and he/she did not believe the area had been cleaned in the year and a half he/she worked at the facility; -All kitchen staff were aware of how dirty the area between the baking and cooking areas was; -All kitchen staff were responsible for cleaning the freezers and refrigerators. They should not have any spillage dried on inside of them; -If he/she saw spillage in a refrigerator or freezer, he/she cleaned it up; -All kitchen staff were responsible for cleaning the ice machine. The ice machine should not have a grayish substance on the white shroud inside. This could be dust or lime and could cause residents to get ill; -The DM was responsible for ensuring the staff completed the cleaning of the kitchen. During an interview on [DATE], at 8:53 A.M., the Assistant DM said the following: -The kitchen staff had a cleaning schedule and a daily cleaning list; -All kitchen staff were responsible to complete cleaning of the kitchens; -Staff cleaned the floor between the baking and cooking areas three months ago. There should not be the buildup of grease, food or trash between these areas because it could be a fire hazard, attract pests and was unsanitary and all kitchen staff were responsible to complete this task; -The refrigerators and freezers should not have any dried debris in them and all staff were responsible for cleaning these; -If he/she noticed a spillage, he/she cleaned it up; -No specific kitchen staff was responsible for cleaning the ice machine, just whatever staff had time to complete this and evening shift had more time than day shift; -The ice machine should not have a grayish substance on the white shroud. This could be lime, dust or mold or mildew and could cause the residents to get ill; -The DM was responsible for ensuring staff completed the cleaning tasks in the kitchen. During interviews on [DATE], at 9:53 A.M. and 12:30 P.M., the DM said the following: -The kitchen had a cleaning schedule and some staff completed the tasks; -All kitchen staff were responsible for cleaning the kitchen; -Staff should clean the floors and if not would be unsanitary; -All staff were responsible for cleaning the floor between the cooking and baking sides of the kitchen; -The refrigerators and freezers should not have any particles or dried on substances inside; -The ice machine should not have a grayish substance on the white shroud inside. This could be bacteria and could cause residents to become ill; -He/she was responsible for ensuring staff cleaned the kitchen. During an interview on [DATE], at 2:27 P.M., the Director of Nursing said he/she expected staff to clean the kitchens. During an interview on [DATE], at 9:44 A.M., the Administrator said the following: -He/she expected kitchen staff to clean the kitchen constantly, clean as they work, clean refrigerators and freezers, wipe down spills and follow the kitchens cleaning schedule; -The floors should never have a buildup of debris and he/she expected kitchen staff to sweep and mop floors at least three times daily; -The kitchen staff should clean the ice machine weekly. He/she did not expect the ice machine to have a grayish substance on any part of the inside of the machine; -The DM was responsible for ensuring kitchen staff completed the cleaning of the kitchen. 5. Review of the FDA 2013 Food Code showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility's policy titled Hairnet Policy, undated, showed everyone entering the kitchen is required to wear a hairnet. If there is staff, a resident or a visitor they are to stand at the door and ring the doorbell or knock and they will be attended to at the door. They may not be allowed to enter without permission and a hairnet. All hair is to be under the hairnet. Any facial hair needs to be constrained by a beard net. Observations on [DATE], at 8:34 A.M. and 9:22 A.M. and on [DATE], at 8:29 A.M., showed Cook K wore a hair net covering the back and top of his/her hair and left his/her bangs hanging down on his/her forehead while he/she prepared food for the residents. During an interview on [DATE], at 7:54 A.M., DA J said the following: -Staff should wear hair nets covering all of their hair; -Staff should not wear a hair net with their bangs hanging out of the front of the hair net. He/she saw Cook K wear a hair net this way; -If he/she saw a staff member wear their hair net inappropriately, he/she either told the staff member or the DM. During an interview on [DATE], at 8:29 A.M., Cook K said the following: -Staff should wear hair nets with all hair inside; -His/her bangs should not hang out of the hairnet because hair could get in the food. During an interview on [DATE], at 9:28 A.M., [NAME] L said the following: -Staff should cover all of their hair with the hair net and should not leave their bangs hanging out; -If staff did not wear a hair net appropriately, their hair could get in the food; -The DM was responsible for ensuring all staff wear hair nets appropriately. During an interview on [DATE], at 8:53 A.M., the Assistant DM said the following: -Staff should wear hair nets covering all of their hair. Staff's bangs should not be out of the hair net; -If he/she saw a staff member's bangs hanging out of the hair net, he/she told the staff member to cover their bangs with the hair net; -If hair hung out of the hair net, hair could get in the resident's food; -The DM was responsible for ensuring all staff wore hair net's appropriately and all kitchen staff should keep an eye on each other as well. During an interview on [DATE], at 9:53 A.M., the DM said the following: -Staff should wear hair nets covering all of their hair including their bangs because their hair could get in the food; -He/she was responsible for ensuring all staff wear hair nets appropriately. During an interview on [DATE], at 9:44 A.M., the Administrator said the following: -He/she expected kitchen staff to wear hair nets appropriately and not leave their bangs hanging out of the hair net; -The DM was responsible for ensuring all staff wear hair nets appropriately. 6. Review of the FDA 2013 Food Code showed hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing. Even though bare hands should never contact exposed, ready-to-eat food, thorough handwashing is important in keeping gloves or other utensils from becoming vehicles for transferring microbes to the food. Review of the facility's policy titled Handwashing Policy, undated, showed the following: -When food handlers must wash their hands: before starting work; after using the restroom; before and after handling raw meat, poultry and seafood; after touching hair, face or body; after sneezing, coughing or using a tissue; after eating, drinking or smoking; after handling chemicals that might affect food safety; after taking out the garbage; after clearing tables or busing dirty dishes; after touching clothing or aprons; after leaving and returning to the kitchen/prep area; and after touching anything else such as dirty equipment, work surfaces or cloths; -Hands must be washed in a sink designated for handwashing. Never wash hands in sinks designated for food prep, dishwashing or utility services. Review of the facility's undated policy titled Glove Policy showed the following: -Single-use gloves can help keep food safe by creating a barrier between hands and food. They should be used when handling ready to eat food; -Wash hands before putting on gloves; -Select the correct glove size; -Hold gloves by the edge when putting them on. Avoid touching the glove as much as possible; -Once you have put the gloves on, check for rips or tears; -Never blow into gloves; -When to change gloves (ready to eat foods should not be handled with bare hands): as soon as they become dirty or torn; before beginning a different task; after interruption, such as taking a phone call; and after handling raw meat, seafood or poultry and before handling ready to eat food. Observation on [DATE], at 11:56 A.M., showed the following: -A DA, while wearing gloves, touched the underside of a trash can lid marked trash only, under side of a cart and handed another DA a pair of gloves; -DA M donned gloves without performing hand hygiene, touched several food containers and placed three pieces of pie on plates and covered them with saran wrap. He/she then grabbed a package of Styrofoam containers from under the serving area, dug through a bucket of utensils and dished up fruit salad into eleven bowls and salad into five bowls. He/she covered each bowl with aluminum foil and placed them on the cart that went to the Special Care Unit (a locked unit for residents with dementia). He/she then uncovered desserts and placed them on trays served to the main dining room. He/she removed his/her gloves and used hand sanitizer and left the dining room; -When DA M returned to the dining room with ice, he/she donned gloves without performing hand hygiene, scooped ice in a cup, poured lemonade into the cup and placed a straw in a cup. He/she took a sandwich out of a baggie and served the sandwich and lemonade to a resident. Observations on [DATE], at 8:34 A.M. and 9:22 A.M., showed the following: -Cook K donned gloves without performing hand hygiene and placed five cooked hamburger patties into a blender, blended them and poured them into a pan touching the blender and pan with his/her gloved hands; -He/she then placed three more cooked hamburger patties into the blender with the same gloves, blended them, added hot water and instant food thickener touching both containers with the same gloves, opened the blender and poured the mixture into a pan touching the pan and blender with the same gloves; -He/she covered both pans with aluminum foil and placed them into the oven with the same gloves; -He/she moved the dirty pan the hamburgers were in and the dirty blender to the stove top and grabbed the pan of baked beans and a clean blender, obtained a clean small pan and sprayed it with vegetable oil spray with the same gloves; -He/she scooped baked beans into the blender and blended them. While they blended, he/she touched the prep table with his/her right gloved hand and placed his/her left gloved hand over to top opening of the blender. He/she picked up the food thickener can three times and added it to the baked beans in the blender and then placed the lid on the can of the food thickener. He/she added hot water to the baked beans in the blender. He/she continued to blend the baked beans while touching the prep table with his/her right hand and placed his/her left hand over the top opening of the blender; -He/she put the blended baked beans into a pan wearing the same gloves; -He/she then scooped more baked beans into the blender with the same gloves on and placed the dirty pan of beans onto the stove top with the same gloves. He/she blended the beans while he/she touched the prep tabl[TRUNCATED]

Based on observation, record review, and interview, the facility failed to dispose of empty card board boxes in the kitchen area on the north hall to prevent the harboring of pests. The facility census was 59. Review showed the facility did not provide a policy related to cleaning or refuse disposal. 1. Observation on 05/15/23, at 8:52 A.M., showed in the kitchen area on the north hall, an empty box of oatmeal cream pies laid on the floor on the right side of the washing sink and behind the trash can. Observation on 05/16/23, at 7:50 A.M., showed the following: -One empty box with used gloves, cellophane, and pieces of cardboard laid on the floor in front of the hand washing sink; -Two empty oatmeal cream pie boxes laid on the floor on the right side of the hand washing sink behind the trash can. -In the dry storage area, two empty cardboard boxes laid on the floor in front of the wire shelving on the west side and eleven empty soda flats sat on the top shelf of the wire shelving on the west side. Observation on 05/17/23, at 7:39 A.M., showed the following: -In the dry storage area, three empty soda cardboard flats sat on the floor in front of the wire shelving on the west side, eleven empty soda cardboard flats sat on the top of the wire shelving on the west side, and one empty soda cardboard flat, one empty Coffee Mate creamer cardboard box, one empty cardboard tomato box with an open stack of crackers with one cracker inside and one empty cardboard honey bus box with several empty cardboard boxes inside sat on the floor next to the desk. During an interview on 05/17/23, at 7:54 A.M., Dietary Aide (DA) J said the following: -Staff should not leave empty cardboard boxes on floor or on shelves because they can harbor pests; -If he/she saw empty cardboard boxes on the floor or shelves, he/she cleaned them up and told coworkers not to leave them on the floor. He/she also told the Dietary Manager (DM). During an interview on 05/17/23, at 8:29 A.M., Cook K said the following: -Staff should not leave empty cardboard boxes on the floor or shelves because they could spread bacteria; -If he/she saw an empty cardboard box, he/she removed it. During an interview on 05/17/23, at 8:53 A.M., the Assistant DM said the following: -When he/she emptied a cardboard box, they should break it down and place it on a rack until they could take it out; -Staff should not leave empty boxes on the floor or shelves because they could harbor pests. During an interview on 05/17/23, at 9:28 A.M., [NAME] L said the following: -Staff should not leave empty cardboard boxes on the floor or shelves because they could harbor pests; -Staff should take empty cardboard boxes out when they emptied them; -The staff who emptied the cardboard box or any staff who saw an empty cardboard box was responsible for disposing it; -The Assistant DM and DM were responsible to ensure empty cardboard boxes were disposed of. During an interview on 05/17/23, at 9:52 A.M., the DM said the following: -Staff should not leave empty cardboard boxes on shelves or floors because they could harbor pests; -He/she was responsible to ensure staff disposed of empty cardboard boxes. During an interview on 05/18/23, at 8:15 A.M., the Environmental Services/Plant Director said kitchen staff should not leave cardboard boxes laying around. They should break them down and throw them in the trash because they can be a harbor for pests. During an interview on 05/18/23, at 9:44 A.M., the Administrator said the following: -He/she expected staff to discard empty cardboard boxes immediately into the trash because they could harbor insects and pests; -The DM was responsible to ensure staff disposed of empty cardboard boxes.

Based on observation, interview, and record review, the facility failed to assess one resident's (Resident #1) fall risk. The facility failed to identify risks or implement steps to minimize the identified risks associated with the use of an air mattress, to prevent the resident from falling out of bed, prior to implementing the air mattress. The resident fell off the air mattress and sustained a maxillary fracture, facial laceration, and multiple contusions. The facility did not document pressure assessment checks of the original air mattress or the air mattress currently in use by the resident. The facility failed to assess fall risk and failed to implement new interventions after falls for two residents (Resident #3 and #4) to prevent additional falls. The facility failed to implement new interventions after falls for one resident (Resident #5) to prevent additional falls. The facility failed to identify risks or implement steps to minimize identified risks associated with the use of an air mattress and failed to document pressure checks for the air mattresses in use for two residents (Resident #3 and #4). The facility failed to complete an assessment for the side rails in use by one Resident (Resident #5) and failed to intervene and follow-up to ensure safety devices were functioning properly in a sample selection of five residents with recent falls in a facility with a census of 67. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 7/27/12, showed the following information: -Severely cognitively impaired; -Total dependence on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -No falls since prior assessment; -No side rails or restraints used. Record review of the care plan, dated 1/24/12, and last reviewed on 7/18/12, showed the following information: -Total dependence on staff for turning and repositioning in bed; -Use pillows, pads, or wedges to reduce pressure on heels and pressure points. Turn and reposition resident; -On 9/6/12, staff added the new intervention of low loss air bed to the care plan. -On 9/6/12, staff implemented a new interim care plan for the problem of Stage II ulcer on coccyx. Staff provide routine position changes to prevent pressure. Staff to use a cushion in the chair and a specialty mattress on the bed. Record review of the nurses' notes, dated 9/7/12, at 4:30 A.M., showed staff discovered the resident on the floor lying face down in blood from an apparent cut above the left eye, a cut on his/her nose, and a cut on his/her cheek. The nurse documented he/she had just been to the resident's room. The resident had been laying on his/her right side on the air mattress with an extra long pillow behind the resident's back to prevent this type of occurrence from happening. The resident had a bruise to the right elbow and abrasions to the left knee. The nurse called the ambulance and then called the physician to leave a message. Record review of the nurses' notes, dated 9/7/12, at 8:40 A.M., showed the family member returned the nurses' call and asked if the facility would consider side rails. The nurse reminded the family member that side rails are considered a restraint. The family member said "maybe we could figure out a way for the resident to have them, even if the family member signed something". The nurse said the facility would get back to the family member after speaking to the Director of Nursing (DON). At 10:55 A.M., the nurse documented the resident was still at the hospital and the air mattress was removed from the bed. Staff ordered a replacement mattress from therapy support. The resident would be moved to bed two and placed on fall precautions. The nurse positioned the bed in low position and added a fall mat. At 11:50 A.M., the facility received report from the hospital the resident was returning to the facility. The nurse spoke to the family member and the family member requested hospice for the resident. At 3:00 P.M., the resident returned to the facility. The paramedics assisted the resident to transfer to the bed. The resident had an air mattress. The resident had injuries to his/her face. The resident's left eye was swollen. The resident could open his/her eye "a little". The resident had contusions above his/her eye that were a red/blue color with two scabbed areas and down the left cheek. The resident had multiple areas of bruising on his/her lips, both arms, left shoulder, and left outer knee. The resident's nose was swollen with blue bruising. Record review of the 72 Hour Event follow up, dated 9/7/12, showed the following information: -Resident placed on air mattress on 9/6/12. Resident rolled out of bed on 9/7/12, at 4:30 A.M.; -At 4:25 A.M., the registered nurse (RN) walked by and the resident was in bed; -At 4:30 A.M., the same nurse found the resident on the floor. Record review of the event report, dated 9/7/12, at 4:30 A.M., RN A documented the resident fell out of bed. The resident was placed on the air mattress on 9/6/12. The nurse found the resident on his/her stomach on the floor in a pool of blood around his/her face. The immediate comments and action documented by the nurse was this resident does not move. The air mattress must have malfunctioned as the resident was on his/her right side, facing the wall with a long pillow behind his/her back. The nurse walked by at 4:24 A.M. and the resident was in bed. The nurse walked by at 4:30 A.M. and the resident was on the floor. The investigation summary, dated 9/7/12, completed by the DON showed the air mattress was placed on the bed at noon on 9/6/12. This nurse (DON) went to the room and checked the bed. If a person was close to the edge, it would turn or shove the person to the side when it shifts or fills. The DON lay on the bed and if she was not exactly in the center of the bed, it rolled her to the edge. Record review of the care plan, showed the following information: -On 9/7/12, the DON added a new problem to the care plan of fall risk. At that time, the DON added the interventions of low bed, low loss air bed, mats on floor, and Gold Star Program with identifiers. Record review of the radiology reports, dated 9/7/12, showed the following information: -Anterior and lateral wall left maxillary sinus fractures; -Nondisplaced fracture of the left orbital floor; -Left forehead scalp hematoma. During interview on 9/18/12, at 8:22 A.M., the DON said the resident is now on a hospice air mattress with bolsters. The DON said the facility decided to put the resident on an air mattress and used one the facility had in the building. The air mattress was placed on the bed at noon during lunch on 9/6/12 and on 9/7/12, at 4:30 A.M., the resident fell from the bed. The resident was on it for less than 24 hours before the fall. The facility then took that air mattress off the bed and placed a standard pressure reduction mattress on the bed. The facility rented an air mattress and had it on the bed the same day after the resident fell . Then, the facility switched the resident to the hospice air mattress when the resident began hospice services. Resident #4 was the only other resident with an air mattress. Resident #4's mattress also had bolsters. Record review of the nurses' notes showed the following information: -On 9/10/12, at 2:40 P.M., the nurse called the family member for permission to have side rails up on both sides when the resident is in bed. The family member agreed. The nurse explained the rules and laws regarding the restraint. -On 9/10/12, at 6:00 P.M., the nurse obtained a new order for side rails up, when the resident is in bed, for safety. Record review of Resident #1's September 2012 treatment administration record (TAR) did not show documentation of monitoring air pressures for either air mattress. On 9/10/12, staff wrote an "FYI" (for your information) regarding siderails up on both sides, when in bed. Record review of the side rail assessment, dated 9/7/12, showed the resident scored negative 13. A score of 10 or less indicates a high risk for injury. Staff currently used quarter side rails on both sides. The facility determined to continue use at head of bed only. A score of 10 or below should have an interdisciplinary team (IDT) review due to side rail use risk. Staff to notify the DON. The nurse documented the resident in a low air loss bed with quarter side rails at head of bed added with family's consent. The nurse did not document notification of the DON or any follow-up with IDT. Record review of the September 2012 physician order [REDACTED]. -Order date of 2/3/10, for adaptive equipment included: concave mattress, bed against wall, mat on floor, bed pillow to position the resident; -The POS did not include orders for the side rail or air mattress. Record review of the telephone physician's orders [REDACTED]. -On 9/7/12, hospice per family request as of 9/7/12 for [DIAGNOSES REDACTED]. -On 9/10/12, side rails up when in bed for safety, both sides. Record review of the resident's medical record did not show a fall risk assessment, bed safety assessment, or side rail assessment. The medical record did not show any documentation regarding pressure check assessments of the air mattresses. Observation on 9/18/12, at 1:56 P.M., showed the resident lay in the second bed against the wall. The resident lay on his/her right side. The resident lay on an air mattress with four bolsters around the edges of the mattress. The resident had a long pillow behind his/her back. A floor mat lay on the floor by the bed. Observation on 9/19/12, at 2:14 P.M., showed the resident lay in bed, tilted to his/her right side. The resident had a pillow behind his/her back. The bed had half side rails up on both sides of the bed. Observation on 9/20/12, at 9:34 A.M., showed the resident lay in bed on his/her left side with half siderails up on both sides of the bed. A floor mat lay in the floor by the bed. During interview on 9/19/12, at 2:53 P.M., the DON said fall risk assessments should be done with every quarterly MDS assessment. During interview on 9/19/12, at 4:00 P.M., restorative nursing assistant (RNA) B said he/she put the original air mattress on the bed. He/she input the resident's weight on the box to adjust the pressure based on the resident's weight. The aide did not recommend this original air mattress for mobile people who can get in and out of bed by themselves because it is an older mattress. It does not adjust to weight very well; not as quickly. If a resident moves to one side of the bed, the other side blows up and fills up with more air. Regarding Resident #1, he/she does not move much, but can move self in bed some. The aide thought the mattress would be okay for him/her if staff centered the resident in the bed. The aide thought it would be fine that way. If a resident is not centered in the bed, the aide thought it was possible to throw the resident out of the bed. Also, if a resident moved very much, it could do the same thing. Resident #1 repositions self in the wheelchair. The resident "squirms" in the wheelchair. The aide said he/she was surprised the resident fell out of the bed. The aide thought the resident would be okay. The aide said he/she felt awful about it. The aide said there had been issues with that air mattress before with mobile residents. One resident would sit on the side of the bed and the air would fill up around him/her. The aide said no one had ever fallen out of the bed with that mattress except for Resident #1 in this recent incident. The resident used to have a concave mattress before the air mattress. The resident had that mattress because 4-5 years ago, the resident would climb out of bed. The aide said he/she did not complete an assessment for the air mattress. He/she did not know if anyone else completed an assessment or not. During interview on 9/19/12, at 1:08 P.M., the DON said the air bed was added to the resident's plan of care and care plan on 9/6/12 per the DON's decision. The wound nurse completed the interim care plan, dated 9/6/12, for the new pressure ulcer. The fall risk problem was added to the care plan after the fall on 9/7/12. The DON said no safety or risk assessment for the air mattress was completed for the resident. The DON said the resident never moves in bed and so she did not think it would be a problem. The next day, the DON lay on the air mattress and it almost threw the DON to the floor. The staff discussed the fall issue, but since the resident never moves, they did not think there was a problem. The DON thought the air mattress would be a temporary intervention. The staff did not document an assessment related to the air mattress. The DON said no fall risk assessment had been completed since the resident's admission to the facility, that the staff could find. The DON acknowledged the resident admitted to the facility in 1995. The DON said RNA B put the air mattress on the bed and set it up. The DON said you could tell if the mattress had the right pressure by looking. It seemed fine. If a resident was not exactly in the center, it pushed the resident towards the side the resident is headed towards. The DON said the resident was originally in the bed by the door when the fall occurred. It was placed lengthwise along the wall. After the fall, staff moved the resident to the second bed, which was also lengthwise along the wall when he/she came back from the hospital. The DON said before the fall, there were no floor mats or other interventions for fall prevention because the resident was not a fall risk. The resident had no falls for months that anyone could remember. After the fall, staff initiated the star identifier, low bed, and the floor mats. The facility obtained a physician's orders [REDACTED]. The DON said there was no documented assessment for the side rails ordered on [DATE]. The DON said staff check the pressure of the air mattress when putting the resident in bed or doing cares. That would not be documented anywhere. On 9/20/12, at 1:23 P.M., the administrator and DON said the facility owned the original air mattress used by Resident #1. During interview on 9/19/12, at 3:15 P.M., RN A said the resident's bed was along the wall and there were no floor mats or alarms on the resident. The night the resident fell was the first night, he/she had the air mattress. The air mattress was placed on 9/6/12. The nurse placed a long pillow behind the resident's back with the resident facing the wall so possibly it would not happen. The nurse said he/she had a feeling about it and put the pillow there just to keep the resident from rolling out of bed. The nurse wanted the resident to be safe and comfortable and did not want anything to happen to the resident. The nurse was not aware of any residents thrown off the air mattress before. During interview on 9/19/12, at 2:23 P.M., certified nursing assistant (CNA) C said regarding care of the air mattress, that if it turned off, then he/she would turn it back on. The aide said he/she did not do pressure checks on the mattress. He/she did not stick his/her hand under the mattress to check the pressure. The only thing he/she did with the bed was that if it got pushed against the wall where it dislodged the plug, he/she would turn it back on and put the plug back in. During interview on 9/20/12, at 9:40 A.M., licensed practical nurse (LPN) D, charge nurse for the special care unit, said the company comes and sets up the pressure for the air mattress. If it is a hospice resident and bed, hospice comes and checks the pressure. Hospice staff is at the facility 2-4 times a week. If an air mattress is not working correctly, the facility staff contact hospice and they contact the supply company. Resident #1 now has half siderails up on both sides routinely. The nurse said he/she was not here the day the original air mattress was set-up for the resident. During interview on 9/20/12, at 9:45 A.M., CNA E said another aide trained him/her how to position the resident on the air mattress. The other aide told him/her to make sure the resident was closer to the wall. The aide taught him/her how easily a resident could roll off it. The aide placed a pillow in front of the resident so if the resident moved, it would help the resident. The other aide knew the need to be careful with air mattresses. The aide said he/she was shocked when he/she heard the resident fell out of the bed. The resident does not move. Regarding the pressure of the air mattress, the aide said he/she makes sure it is appropriate every time the aide goes in to provide care. During interview on 9/20/12, at 9:54 A.M., CNA F said he/she was not involved with pressure checks for the air mattress. The pressure is usually set by hospice. The aides just hit the re-inflate button and it usually fixed the problem. The aides visually look and make sure the resident is not in a hole or anything, but they do not do any checks with their hand to check the pressure. RNA B may do pressure checks. He/she is the main restorative aide for the facility. Record review of the air mattress Select Air Max by ROHO, showed the following information regarding ROHO Product Information: -The decision to use side rails should be based upon applicable laws and regulations, and based on a case-by-case assessment by clinicians and/or caregivers actively involved in the patient's care, based upon each patient's individual condition and needs. Such an assessment may include, but not be limited to: the patient's physique, overall condition, level of confusion, or cognitive impairment, mobility (or lack thereof), history of falls, combativeness, attempts to get out of bed, uncontrolled body movement, and the patient's frustration when confined; -In the event a decision is made to use side rails, knowledgeable and properly trained care givers should ensure that any identified risks associated with the patient becoming entrapped in the side rails are identified and steps are taken to minimize such risks; -In the event a decision is made to not use side rails, knowledgeable and properly trained care givers should ensure that any identified risks associated with the patient falling out of bed are identified and steps are taken to minimize such risks; -When using the SelectAir mattress replacement or mattress overlay, make sure the product is properly inflated, such that the patient will be immersed in the mattress. Proper inflation offers the maximum therapeutic benefit to the patient and also reduces the risk of the patient inadvertently rolling off the product. Over-inflation increases the likelihood that a patient will roll off a mattress replacement or overlay. For these reasons, it is important that the product be set up by knowledgeable care givers properly trained in the use of this product. 2. Record review of Resident #3's July 2012 POS included the following adaptive equipment ordered 1/17/12 for the resident: -Concave mattress; -High back wheelchair and may use seatbelt; -Personal body alarm on in recliner; -Mat on floor; -Bed against wall; -Seat belt alarm in wheelchair; -High-low bed; -Half side rails times two at the top of bed. Record review of the nurses' notes, dated 7/21/12, showed the resident sleeps on an air mattress with scoops and a mat on the floor for safety. The resident's personal body alarm was in place. During interview on 9/20/12, at 1:23 P.M., the assistant Director of Nursing (ADON) said the resident began the air mattress on 7/22/12 per hospice information. Record review of the July 2012 TAR did not show any monitoring of the function and use of any floor mat, alarms, or seatbelt. Record review of the August 2012 POS included the ongoing adaptive equipment orders from 1/17/12. The POS did not show any new adaptive equipment orders. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Total dependence on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Frequently incontinent of bladder and bowel; -[DIAGNOSES REDACTED]. -The resident has not had any falls since admission/reentry or prior assessment; -Staff did not document the resident had any siderails or restraints. Record review of the care plan, dated 11/21/11, last reviewed on 8/8/12, showed the following information: -At risk for falls related to attempts to rise without assist. The resident had history of falls; -Call light in reach at all times. Remind resident not to rise without assistance; -Up in wheelchair daily. The resident has an alarming seat belt on wheelchair and personal body alarm in the bed and recliner; -Staff not to leave resident unattended in bathroom due to poor impulse attempts to rise without assist; -Bed in lowest position with wheels locked at all times; -Clear pathway to safety. Room to be free of clutter and debris; -Implement safety measures (keep path to bathroom clear and well-lit, select clothing that is easily removed for toileting, answer call light quickly); -The care plan did not address the use of side rails on the resident's bed. Record review of the resident's medical record did not show any fall risk assessments completed. During interview on 9/20/12, at 12:55 P.M., the ADON reviewed the resident's care plan and said it had been updated and reviewed on 8/8/12. If a resident had a new problem, the facility would add a separate interdisciplinary care plan page. Record review of the nurses' notes did show documentation of a fall on 8/22/12. Record review of the Event report, dated 8/22/12, at 8:45 P.M., showed no injury noted at this time. The floor mat was not in place. The event was an unattended alleged fall in the resident's room. The nurse counseled the aides on the need to always make sure the safety devices are in place, such as mat and alarm. The nurse determined the root cause of the fall was the mat was not replaced next to the bed after staff put the resident to bed. The investigation summary showed staff to utilize the mat when the resident is in the bed and in the chair. Record review of a statement, dated 8/22/12, showed an aide was walking down the hall and just happened to look into the resident's room and saw the resident laying on the floor. The aide yelled at one of the other aides and they got the nurse. Record review of the interdisciplinary team post fall assessment, dated 8/22/12, showed the current fall and injury prevention interventions in place included the following: -Self-releasing seat belt; -Floor mat; -Low bed; -Personal body alarm. The nurse documented the floor mat was not effective because it was not in place. The nurse documented staff need to utilize the mat for the recliner and the bed. The resident has poor safety awareness. The root cause of the fall was the resident has no realization of his/her limits on safety. The DON documented the new intervention as a result of the fall risk meeting was use mat at all times and personal body alarm at all times on the bed and the recliner. Record review of the nurses' notes showed the following information: -On 8/24/12, at 11:30 A.M., staff found the resident lying on the floor at the foot of the recliner on the floor mat. The resident sustained [REDACTED]. The nurse began neurological checks. The nurse left a message for the physician. Record review of the information requested from the facility did not include an event report or fall investigation for the fall on 8/24/12 at 11:30 A.M. The facility provided an investigation for an injury of unknown origin dated 8/24/12 at 11:00 A.M. Record review of the care plan did not show any updates or changes to the plan of care after the falls on 8/22/12 and 8/24/12. Record review of the August 2012 TAR did not show any monitoring of the function or use of floor mat, alarms, or seatbelt. The TAR did not show any new interventions initiated after the falls. Record review of the September 2012 POS included the ongoing adaptive equipment orders from 1/17/12. The POS did not show any new adaptive equipment orders. Record review of the September 2012 TAR did not show any monitoring of the functioning or use of the floor mat, alarm, or seatbelt. During interview on 9/18/12, at 12:25 P.M., the DON said she started working at the facility on 6/25/12. During interview on 9/18/12, at 1:30 P.M., the DON said the facility did not have any siderail or bed safety assessments because the facility does not have side rails. Observation on 9/18/12, at 1:42 P.M., showed the resident laying in bed on his/her right side facing the wall. The resident had an air mattress with four bolsters around the sides. A floor mat lay on the floor by the bed. The resident had a personal alarm attached to the resident. The alarm box lay on the bed. It was not attached to anything. Observation on 9/19/12, at 2:28 P.M., showed the resident lay in bed tilted to the right. The resident's air mattress had four bolsters around the sides. The siderails were in the down position. A floor mat lay on the floor by the bed. The resident had a personal alarm attached to the resident but the alarm box was not attached to anything. The mattress was a Select Air mattress. During interview on 9/19/12, at 2:34 P.M., the DON said the personal body alarm should be attached to something and not just laying on the bed. At that time, the DON fastened the alarm to the resident's pillow. During interview on 9/19/12, at 2:34 P.M., CNA H said the resident had an alarmed seatbelt that the resident could remove on command. The resident has had it at least since May 2012. That is when the aide began working at the facility. Observation showed the resident's wheelchair with the seat belt alarm on it. The aide said the resident would try to stand, but needs assistance. The aide said the only time the resident tried to climb out of bed is if he/she needed to use the bathroom or was wet. Observation on 9/20/12, at 8:03 A.M., showed the resident sat in the wheelchair in the room with the alarmed seatbelt fastened. On 9/20/12, at 8:17 A.M., the DON said the staff told her last week that the resident could release the seatbelt on command. The DON said she did not know the resident had the seatbelt until she saw him/her up in the hall last week. During observation on 9/20/12, at 8:29 A.M., CNA G asked the resident to remove the seatbelt and the resident did without difficulty. Another CNA said the resident could remove it any time he/she wanted and does remove it at times. During observation on 9/20/12, at 9:25 A.M., showed the resident lay in bed. The side rails were in a down position. Record review of the resident's medical record did not show documentation of any assessment of the safety of the air mattress for the resident, checking air pressure of the air mattress, or determination of use of side rails for the resident, with the air mattress. Record review of the Select Air mattress manufacturer recommendations provided upon request by the facility on 9/19/12, showed the following information: -Safety precautions included that when leaving a patient unattended to make sure the bed side rails are locked in the highest position. -Under the Manual Setup section, it cautions the bed rails should be locked in their highest position before proceeding. -Due to the different shapes and sizes of each patient, the settings recommended on the Comfort Level Chart are only a guideline. User judgment must be applied to properly adjust the comfort level to the setting that best suits the patient. -Inspect the patient to ensure that they are sunk into the mattress about 40-50 percent. If they are not, adjust the Comfort level using the comfort level softer and firmer buttons until the proper results are achieved. -Once the desired setting is found, check to see if there is adequate clearance between the patient and the bed frame. This is accomplished by the user placing their hand between the patient and the bed frame. There should be 3-4 inches of clearance and the patient should not be contacting the bed frame at any point. If there is not enough clearance, increase the comfort level setting to compensate. Record review of the manufacturer recommendations, received by the facility on 9/19/12, did not match visually what the resident's mattress set-up looked like. Upon further discussion with the facility regarding the apparent conflict, the facility provided the following additional information regarding the resident's bed set-up. Record review of the SelectProtect manufacturer recommendations provided by the facility on 9/27/12, showed the following information: -The SelectProtect safety enhancement system is intended to aid in the reduction of patient falls and increase bed-bound safety. It is intended to be used without bed side rails. the SelectProtect is designed to be integrated only with ROHO SelectAir low air loss mattress replacement systems. -Fall risk: Properly trained and knowledgeable care givers should determine whether to use pads, additional bolsters, alarms, high-low beds, or other positioning aides and safety devices that are available on the market to reduce the risk of entrapment or falls. Fall risk increases if patient is not properly immersed, if the mattress is over-inflated, or if the bed is in an upright position; -Do not use the SelectProtect with bed side rails. This contra-indication supersedes the references to bed side rails currently stated in the SelectAir Low Air mattress systems operations manual. Record review of the air mattress Select Air Max by ROHO, showed the following information regarding ROHO Product Information: -The decision to use side rails should be based upon applicable laws and regulations, and based on a case-by-case assessment by clinicians and/or caregivers actively involved in the patient's care, based upon each patient's individual condition and needs. Such an assessment may include, but not be limited to: the patient's physique, overall condition, level of confusion, or cognitive impairment, mobility (or lack thereof), history of falls, combativeness, attempts to get out of bed, uncontrolled body movement, and the patient's frustration when confined; -In the event a decision is made to use side rails, knowledgeable and properly trained care givers should ensure that any identified risks associated with the patient becoming entrapped in the side rails are identified and steps are taken to minimize such risks; -In the event a decision is made to not use side rails, knowledgeable and properly trained care givers should ensure that any identified risks associated with the patient falling out of bed are identified and steps are taken to minimize such risks; -When using the SelectAir mattress replacement or mattress overlay, make sure the product is properly inflated, such that the patient will be immersed in the mattress. Proper inflation offers the maximum therapeutic benefit to the patient and also reduces the risk of the patient inadvertently rolling off the product. Over-inflation increases the likelihood that a patient will roll off a mattress replacement or overlay. For these reasons, it is important that the product be set up by knowledgeable care givers properly trained in the use of this product. 3. Record review of Resident #5's side rail assessment, dated September 2011 showed the following information: -The resident scored a 9. A score of 10 or less indicated high risk for injury. Staff did not identify the current side rails used or what the plan for the side rails included. Record review of the resident's device use safety plan and authorization, dated 12/7/11, showed the following information: -The resident scored a minus 2 on the side rail assessment. A score of 10 or less indicates high risk for injury. The device type to be used was half side rails at the top of the bed, both sides. The resident had a mat on the floor and a pad alarm. Prior interventions attempted included

Based on facility medical records, hospital medical records, observations, and interviews with resident, staff, family, facility physician/medical director and orthopedic surgeon the facility failed to safely transfer one resident (Resident #1). Staff assessed this resident required two staff to properly transfer this resident. One staff transferred the resident alone which resulted in a fracture of the resident's right glenoid (shoulder socket) cavity and neck of scapula (shoulder blade) and a right rotator cuff tear. The facility census was 70. 1. Record review of the facility "Event Management Program" dated 10/5/11, showed the following information: -It is policy to ensure a safe environment with the least restrictive measures, while promoting the highest possible level of independence and quality of life. All residents shall benefit from a safe environment and an individualized resident centered plan of care, based on assessment of risk factors; -An event or incident is anything that is outside of the normal expectation for resident activity or condition that results in an injury or may have the potential for injury; -The initial care plan for the resident will address interventions based on the Risk Assessment results, hospital discharge summary, physician's orders [REDACTED]. -Any new risk factors identified or new interventions implemented due to a change in condition or as a result of an event, will be documented in the care plan with the date of the new intervention; -Steps following an event/incident include documentation will include event report, the nurses' notes, and event investigation, review and update causative/risk factors and update care plan immediately with new interventions to prevent reoccurrence, notify physician and family of incident/event within 24 hours and within 2 hours if event resulted in injury, director of nurses(DON)/designee will review all event/incident reports within 24 business hours, IDT/risk team will review events within 48 hours to determine if initial intervention is working or to determine if there is a need for further intervention, and the Administrator and/or DON will be notified immediately of all events that may be as a result of or suspected of abuse/neglect. Based on their review of the event and additional investigation if needed, the appropriate state agency will be notified; -Event management required key components include there is a summary of each event with root cause and intervention to prevent reoccurrence in the clinical record, investigation of any event begins at the time of the event by the nurse in charge, written statements are obtained from witnesses to event and kept with the investigation, the care plan is updated with a new intervention at the time of the event to prevent reoccurrence. 2. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment tool required to be completed by facility staff, dated 1/27/12, showed the following information: -Admission to the facility on [DATE], from the hospital; -Staff assessed resident alert; -Making choices is important to the resident; -Resident assessed continent of bowel and bladder; -Resident had one fall since admission with no injury; -Staff assessed the resident two person total dependence with transfers and toilet use; -Staff assessed the resident not steady, only able to stabilize with human assistance; -Staff assessed the resident with impairment on one side of his/her lower extremity. Record review of the hospital discharge orders for the resident dated 1/14/12, showed the following information: -Resident with a right knee immobilizer; -Staff to remove staples and then steri-strip incisions on resident's right lower extremity on 1/24/12; -Resident is non weight bearing on his/her right lower extremity; -Staff to make follow-up appointment with resident's surgeon in 5 weeks. Record review of the "Initial Nursing Assessment" dated 1/14/12, for the resident showed the following information: -Staff assessed resident alert; -Staff assessed resident short and long term memory OK; -Staff assessed resident with modified independence cognitive skills; -Staff assessed resident two person assist with bed mobility, transfer, ambulation, and toileting; -Resident with a surgical wound on his/her right leg. Record review of the care plans for the resident showed the following information:-"Initial Care Plan" identified the resident as a two person transfer with a roller walker, non-weight bearing and a knee immobilizer on at all times. Staff documented on 1/29/12, the resident had a fall. Resident identified with a treatment of [REDACTED]. -"Interdisciplinary Care Plan" dated 1/23/12, documented the resident had a fall on 1/23/12. Staff identified the resident requiring two person assistance with a roller walker. Staff documented the resident is to have non slip socks or no skid shoes on when transferring. Staff identified the resident with a potential for falls due to non-weight bearing status on his/her right lower extremity at this time; -"Interdisciplinary Care Plan" dated 1/24/12, identified the resident had a skin tear to his/her right elbow area; -"Interdisciplinary Care Plan" dated 1/28/12, identified the resident with pain due to his/her right shoulder fracture. Resident non-weight bearing right arm/shoulder and using a right shoulder sling; -"Interdisciplinary Care Plan" dated 1/29/12, identified the resident at risk for injury during transfer. Approaches identified were therapy to evaluate for transfers, gait belt, non skid footwear, and two assist with all transfers; -"Interdisciplinary Care Plan" dated 2/9/12, identified the resident at risk for fracture due to the [DIAGNOSES REDACTED]. Record review of the nurses' notes of the resident showed the following information:-On 1/14/12, staff documented resident admitted to the facility after surgical repair of distal right femur fracture. Resident has a knee immobilizer that must stay on at all times. Resident is alert and orientated. Staff transferred the resident into bed with the assistance of three staff; -On 1/15/12 at 1:20 P.M., staff documented the resident as alert and orientated and he/she is able to express his/her needs and wants verbally; -On 1/17/12 at 7:15 P.M., staff documented the resident complained of right lower leg swelling, and the edema now at 4+. Staff notified the resident's surgeon and received an order to transfer the resident to the emergency room for an ultrasound to rule out a deep vein thrombosis. At 10:20 P.M., the facility medical director notified the facility the resident will be sent back to the facility on bed rest and a portable ultrasound scheduled to be done in the morning at the facility; -On 1/21/12, not in the daily skilled nurses' notes but documented on the nursing 72 hour following of an incident assessment form with no time of incident identified, staff documented in the comment of the initial assessment the resident is alert and orientated and reported he/she slid down onto the floor on his/her bottom when being transferred from the bedside commode to his/her bed. Resident denied any injury; -On 1/27/12 at 00:20 A.M., staff documented the resident is alert and orientated, pleasant and cooperative with staff. Resident has brace on his/her right lower leg. Resident requires the assistance of two for transfers and he/she uses a walker to assist with the transfers; -On 1/28/12 at 7:30 P.M., staff documented the resident was being transferred by two certified nurse aides (CNA) and felt a pop and resident had excruciating pain in his/her right shoulder. Humeral head palpated and found not to be in the joint. The facility medical director was contacted and the resident was sent to the emergency room for evaluation. At 10:30 P.M., the facility medical director reported to the facility the resident had a fracture and will have a sling. Staff documented the medical director feels the fracture is related to osteoporosis; -On the facility 72 hour follow up assessment report identified the incident occurred on 1/28/12 at 7:30 P.M. Report documented the resident was being transferred and heard a pop and he/she had pain in right shoulder; -On 1/30/12 at 7:10 A.M., staff documented resident with sling in place right arm and immobilizer to right leg. No bruising noted to resident's right shoulder or upper arm, resident with fluid filled area at top of his/her right arm/shoulder; -On 1/30/12 at 1:20 P.M., staff documented resident is transferred from wheelchair to bed using a slide board and the assistance of two staff; -On 2/2/12 at 7:10 A.M., staff documented the resident alert and orientated and with flat affect. Resident has a sling in place right arm and knee immobilizer in place to right leg. Resident is unable to propel self in wheelchair. Resident is assisted with all activities of daily living as needed and he/she is a two person transfer; -On 2/2/12 at 10:00 A.M., staff documented they spoke with resident's family regarding resident's flat affect and apparent depression. Family member said "well why wouldn't he/she be depressed with what all has happened". The family member does not want the medical director contacted regarding medication changes at this time; -On 2/3/12 at 7:30 A.M., staff documented resident up in wheelchair with sling to right arm and knee immobilizer to right leg. Resident is alert and oriented, pleasant and ready to go to an appointment with his/her surgeon; -On 2/9/12, staff document resident transferred to another skilled facility. Record review of the "Patient Transfer Form" regarding the resident's emergency room visit on 1/28/12, showed the following information: -[DIAGNOSES REDACTED]. -Additional pertinent information identified resident was being lifted and felt a pop and he/she is in severe pain right shoulder; -Dismissal instructions from the emergency room visit showed resident with shoulder fracture, arm/shoulder sling for four weeks, resident may need lift chair or Hoyer lift (mechanical lift), and staff are to call resident's surgeon for an appointment in seven to ten days. Record review of the preliminary radiology report from the emergency room visit on 1/28/12, showed the history identified the resident felt and heard pop while being moved at the nursing home and shoulder pain. The impression identified resident with right glenoid fracture and large right shoulder joint effusion (increased fluid). Record review of the resident's surgeon's report regarding the visit on 2/3/12, showed the resident with a closed fracture of his/her glenoid cavity and neck of scapula and a rotator cuff tear. During an interview on 2/10/12 at 9:10 A.M., the DON said he/she probably knew why the surveyor was in the facility and he/she would pull the investigations they had just completed on the resident. During an observation and interview on 2/10/12 at 10:10 A.M., the resident was up in his/her wheelchair in his/her room with his/her right leg elevated and right arm in a sling. The resident said he/she was moving out today to another facility. The resident said he/she did not want to get hurt again, so he was moving out. The resident said he/she wanted to go back home after receiving some therapy and was using both arms and doing good with the therapy until he/she received the injury to his/her right shoulder. He/She said the right shoulder fracture was a "big set back". The resident said now staff use a slide board for transfers and he/she wears a sling on right arm and brace on his/her right leg and he/she is non weight bearing on right leg. The resident said now he/she cannot use the walker. The resident said the shoulder fracture occurred in the shower room in the evening when one staff person got under his/her right arm and jerked him/her up. The resident said they were supposed to have two staff to transfer and it was only one. The resident said he/she "heard it pop". The resident said his/her surgeon had to drain fluid off the right shoulder when he/she saw it and the resident said the fluid is building up again on the right shoulder. The resident said most of the care was great, but on two occasions it was not good. He/She said the facility has a lot of staff turnover and they send in staff to assist he/she that do not know how to care for him/her and they don't have the two staff all the time. The resident said it occurred yesterday again when they sent in one staff to get him/her up in the morning. When asked about the other shower incident, the resident said it occurred when he/she was first there and it is forgotten after all the rest that has happened. The resident said "can't take a chance of being hurt again". During an interview on 2/10/12 at 11:00 A.M., the DON said the CNA was terminated for not following the facility policy and referring to the care plan which showed the resident was a two person transfer. The DON provided the statement written by the CNA. Record review of the facility shoulder injury investigation of the resident is dated 1/30/12, and shows the CNA was interviewed and he/she failed to review the care plan of the resident. The facility terminated CNA B. Record review of the statement written by CNA B on 1/28/12, regarding the resident showed the following information: -The resident was in the shower room and he/she helped the resident stand up to get in his/her chair. When the resident stood up we heard a pop. The resident seemed okay till we got back to his/her room and then he/she said the shoulder was hurting and he/she told the nurse; -CNA B was told the resident was a one or two assist by the aide he/she was working with. He/she had asked about it before hand because CNA B doesn't work that hall very often. Record review of the facility staffing sheets showed CNA B worked the evening shifts on Saturday 1/28/12, Sunday 1/29/12, and scheduled also for Monday 1/30/12. During an interview on 2/10/12 at 1:40 P.M., CNA A said the resident is a two person transfer. He/She worked the evening the resident received the shoulder injury. CNA A said he/she and CNA B were assigned to the resident's hall. CNA A said he/she heard CNA B was giving the resident a shower and saw him/her get the resident's walker. Then CNA A said he/she heard the resident crying in bad pain in his/her room. CNA A said CNA B did not ask for his/her help. During an interview on 2/10/12 at 3:15 P.M., the facility medical director and facility physician for the resident said he/she saw the resident in the emergency room the evening of the shoulder injury. The medical director said the resident told him/her that he/she asked the aide to use two staff and the aide didn't and the resident felt that caused the injury. He/She said the resident had a fracture. The medical director said after that the resident had a major problem with the therapy. The medical director said the resident has osteoporosis. During an interview on 2/10/12 at 4:45 P.M., the administrator said they immediately start an investigation when there is an incident/accident. The nurse updates the resident's care plan after the incident. Monday through Friday mornings they go over the incidents/accidents. The DON said the charge nurse got the statement from CNA B after the incident 1/28/12, when the aide did the transfer of the resident in the shower room alone. During an interview on 2/10/12 at 5:02 P.M., registered nurse (RN) D said he/she worked on 1/28/12 evening shift when the resident received the shoulder injury. RN D said he/she was called to the resident's room due to a pop being heard and the resident had excruciating pain in his/her shoulder. He/She said the shoulder felt out of place. RN D said by talking with the two aides, CNA A and CNA B later that evening he/she learned that CNA B did the transfer alone. RN D said CNA A knew the resident was a two person transfer and CNA B normally worked on another unit. RN D said he/she had CNA B write a statement and an incident/accident event was filled out. RN D said he/she notified the administrator and the DON. RN D said he/she called the DON again before the end of his/her shift and told the DON the resident was transferred by one aide and RN D told the DON he/she got a statement from CNA B. The incident/accident event report and statement were left in the DON's box before RN D left the facility that evening at 11:00 P.M. During an interview on 2/15/12 at 1:15 P.M., CNA B said he/she had been employed at the facility for five months and usually he/she worked on the evening shift in the unit of the facility. On 1/28/12, on the evening shift, he/she said he/she had not taken care of the resident before. CNA B said CNA A worked the hall with him/her. CNA B said CNA A told and showed CNA B how to one person transfer the resident that evening. CNA A took the resident by the right arm from bed to wheelchair. Then later about 7:00 P.M., CNA B took the resident for a shower. The resident transferred into the shower chair good and then when the resident stood up to get out of shower chair they heard a pop. CNA B said he/she did not use a gait belt in the transfers. CNA B said he/she had his/her arm under the resident's arm on the resident's weak side. He/She said the nurse gave him/her a paper to fill out for a statement of the incident. CNA B said the statement he/she completed on 1/28/12, was how the incident occurred. CNA B said the next evening (Sunday), he/she was assigned to work in the unit and was told to stay hidden and not to answer any questions from the resident's family. During an interview on 2/16/12 at 11:10 A.M., physical therapist (PT) H said the resident was doing well in therapy until the shoulder incident. Prior to the incident the resident had good use of his/her right arm, after the fracture the resident had to keep his/her arm in a sling and was not allowed to use it, he/she could not use a walker then. The resident was discouraged after the shoulder fracture. During an interview on 2/17/12 at 4:35 P.M., RN I said he/she worked the day shift on Sunday 1/29/12, and he/she was assigned to care for the resident. RN I said they were filling out the 72 hour report on the resident. He/She said a family member came in and wanted a copy of the incident report. RN I said he/she would have to call the DON. RN I called the DON and the DON told RN I to give the family member her cell number, but do not give the family member the incident report. RN I said the resident gave up after the shoulder fracture, it was a big set back for the resident. During an interview on 2/23/12 at 9:23 A.M., a family member said it's been awful for the resident. The shoulder fracture set the resident back. The family member said the resident's surgeon took two syringes of fluid out of his/her right shoulder when he/she saw the resident a few days after the injury. The resident was told he/she probably will need more surgery on his/her right shoulder after the fracture heals due to a pin being pulled out from prior surgery on the resident's right shoulder. During an interview on 2/24/12 at 12:05 P.M., RN E said he/she worked the night shift when the resident returned to the facility after his/her shoulder fracture. RN E said he/she was told staff had transferred the resident wrong and the resident's shoulder was messed up. During an interview on 2/24/12 at 2:20 P.M., the resident's orthopedic surgeon said something broke the resident's right shoulder socket and tore the tendon further. The X-ray shows one screw from a prior right shoulder surgery is in the soft tissue. The screw will need to come out and the resident may need a reverse total shoulder surgery. When asked if the resident had osteoporosis, the surgeon said there could be some. During an interview on 2/27/12 at 2:10 P.M., another family member said on Sunday 1/29/12, he/she tried to get information at the facility and also on the cell phone of the DON regarding the resident's injury. The DON would not give any information, only said that they would look into it. The resident and the family were concerned because one staff continued to try to transfer the resident after the shoulder injury and they were very concerned the resident would be treated worse if they said anymore about the staff. He/She said the resident had use of both arms when he/she entered the facility and the resident is still not able to use a walker due to the right shoulder injury. The resident has to be transferred with the use of a mechanical lift and he/she still cannot go home. Complaint # MO 527