Every finding on record at Point Lookout Nursing & Rehab

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Residents #9, #80, #38, and #85). The facility census was 87. Review showed the facility did not have a policy pertaining to the frequency and provision of showers per residents' preferences. 1. Review of Resident #9's face sheet (gives basic profile information), showed the following:-admitted to the facility on [DATE];-Diagnoses included anxiety disorder, yeast infection of genital areas (fungal infection), urinary tract infection (UTI), dementia, reduced mobility, depression, Rheumatoid arthritis (long term disease where body's immune system mistakenly attacks the lining of the joints) and generalized arthritis (inflammation in one or more joints, causing pain, swelling, and stiffness), and high blood pressure. Review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, completed by facility staff, dated 07/24/26, showed the following:-Mild cognitive impairment;-Preferences: very important to choose between tub bath, shower, bed bath, or sponge bath;-Required supervision/touch assistance for tub/shower transfers and showers/bathing;-Independent for toileting/hygiene, personal hygiene, and dressing. Review of the resident's care plan, last updated 07/15/26, showed the following:-At risk for dementia: respect the resident's right to make decisions;-At risk for skin breakdown: provide incontinent care with each incontinent episode; weekly skin assessment by licensed nurse;-Required 1-2 person assistance with activities of daily living (ADLs).-Staff did not document information pertaining to showers/bathing. Review of the resident's shower sheets for July and August 2026 showed the following:-On 07/07/26. the resident refused a shower due to not feeling well, fingernails/toenails were clipped;-On 07/28/26: received a shower, fingernails/toenails clipped;-On 08/08/26: self shower.-Staff did not document any other showers/bathing during July or August 2026. During an interview on 08/24/26, at 2:43 P.M., Resident #9 said this was his/her fourth week without a shower. He/she would really feel dirty if he/she didn't give him/herself sink baths and wash his/her own hair in the sink; he/she would prefer showers. 2. Review of Resident #80's face sheet showed the following:-admitted to the facility on [DATE];-Diagnoses included osteoarthritis (common form of joint disease, protective cartilage that cushions ends of bone wears away over time), elbow and other body pain, seborrheic dermatitis (chronic skin condition that caused scaly, itchy, and red patches on oily areas of the body, such as the scalp, face, and chest), sebaceous cyst (noncancerous lump beneath the skin caused by a hair follicle or skin duct blockage or damage), multiple malfunctioning nerves, overactive bladder, and depression. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Mild cognitive deficit;-Upper extremity impairment to one side;-Lower extremity impairment to both sides;-Used either walker or wheelchair for mobility;-Required partial/moderate assist for showers/bathing;-Required supervision/touch assistance for toileting and dressing. Review of the resident's care plan, last reviewed 06/10/26, showed the following:-At risk for cognitive loss/dementia: monitor for signs and symptoms of pain, provide positive experiences with little or no stress demands;-At risk for skin breakdown: provide incontinent care with each incontinent episode, use absorbent, skin friendly pads/briefs to maintain personal hygiene and dignity, use moisture barrier product to peri area; weekly skin assessment by licensed nurse;-Let resident choose the things they can and continue to make decisions for themselves as long as able; involve resident in own plan of care.-Staff did not document information pertaining to showers/bathing. Review of the resident's shower sheets for the months of July and August 2026 showed the following:-On 07/08/26: resident received a shower, fingernails/toenails clipped, and shaved him/herself;-On 08/10/26: resident received a shower, no skin impairment, no need for shaving.-Staff did not document any other showers/bathing given in July or August 2026. During an interview on 08/26/26, at 9:35 A.M., Resident #80 said he/she would like to have at least one shower per week, but this had not been happening. The facility only had one designated shower aide, and there weren't enough staff to assist with more showers. The lack of showers made him/her feel like he/she was not very clean. 3. Review of Resident #38's face sheet, showed the following:-admitted to the facility on [DATE];-Diagnoses included atherosclerotic heart disease of coronary artery without angina pectoris (plaque containing cholesterol and lipids that build up on the artery walls that limits blood flow with no chest pain), generalized muscle weakness, need for assistance with personal care, Parkinson's disease (brain disorder causing unintended or uncontrolled movements). Review of the resident's annual MDS, dated [DATE], showed the following:-Cognitively intact;-Slurred or mumbled words. Usually understood with difficulty communicating some words or finishing thoughts;-Preferences: very important for resident to choose between a tub bath shower, bed bath, or sponge bath; -Dependent on staff for showering, toileting hygiene, personal hygiene, and dressing. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Usually understood with difficulty communicating some words or finishing thoughts;-Dependent on staff for showering, toileting hygiene, personal hygiene, and dressing. Review of the resident's care plan last reviewed/revised on 07/08/26, showed the following:-Let the resident make decisions for him/herself as long as able;-At risk for pressure ulcer/injury. Provide incontinence care after each incontinent episode. Keep clean and dry as possible; -Required one to two person(s) assistance with activities of daily living (ADLs);-Psychosocial well-being: allow resident to choose options;-No preference or showering information included in the care plan. Review of the resident's showers sheets for July and August 2026 showed the following:-On 07/01/26: received a shower, facial hair removed, and fingernails/toenails clipped;-On 07/29/26: received a shower;-On 08/12/26: received a shower; -On 08/19/26: received a shower and a bed bath;-Staff did not document any other showers/bathing during July or August 2026. During an interview on 08/24/26, at 7:31 P.M., Resident #38 said the following:-He/She would like to have at least two showers per week;-He/She has gone as long as one month without a shower;-He/She last had a shower about one week ago. During an interview on 08/24/26, at 8:07 P.M., Resident #38's family member said the following:-He/she expects the resident to be given at least two showers per week;-The resident had gone about one month without a shower recently because there was only one shower aide;-The resident may get about one shower per week;-It was important to Resident #38 to be clean and well groomed;-The family member comes every night to help the resident brush his/her teeth, brush hair, and wash his/her face and hands. He/she said the above grooming might not get done if he/she did not help. During an interview on 8/28/26, at 12:59 P.M., CNA O said Resident #38 had complained to the CNA about not getting a shower when he/she wanted. 4. Review of Resident #85's face sheet showed the following:-admission date of 08/28/25;-Diagnoses included chronic obstructive pulmonary disease (COPD – lung disease) and diabetes mellitus (DM – metabolic disorder). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-No behavior symptoms or rejection of care;-Required substantial staff assistance for showers and toileting;-Required moderate staff assistance with transfers. Review of the resident's care plan, dated 08/28/25, showed the resident required staff assistance to complete activities of daily living (ADL – essential routine self-care tasks such as bathing, dressing, transferring, and toileting) related to limited mobility. Review of the resident's July 2026 shower sheets showed the following:-On 07/06/26, the resident received a shower;-On 07/24/26, the resident received a shower. Review of the resident's July 2026 progress notes showed no documentation related to showers or bathing. Review of the resident's August 2026 shower sheets showed the following:-On 08/05/26, the resident received a shower;-On 08/18/26, the resident received a shower. Review of the resident's August 2026 progress notes showed no documentation related to showers or bathing. During an observation and interview on 08/24/26, at 6:21 P.M., showed the resident sat in a wheelchair with hair pulled back out of his/her face in a rubber band. The resident said he/she gets one bath a week, but the facility is supposed to provide two. He/she had not received a shower in over a week but should be getting one today. During an observation and interview on 08/25/26, at 9:44 A.M., showed the resident in bed with hair pulled back out of face with rubber band. The resident said he/she dd not receive a shower yesterday. He/she hoped to receive one today. During an interview on 08/26/26, at 9:38 A.M., the resident said he/she would really like a shower. He/he has an appointment with the physician on Friday and would like a shower before then. He/she keeps his/her hair pulled back all the time back because it is greasy. He/she tries to wash the best he/she can in the restroom. During an observation and interview on 08/27/26, at 8:51 A.M., showed the resident sat in his/her room in a wheelchair with hair pulled back. The resident reported he/she still had not gotten a shower. During an interview on 08/27/26, at 9:42 A.M., Certified Nursing Assistant (CNA) T said the following:-Aides are responsible for showers on the 400 and 500 units;-Resident #85 did not refuse showers when offered. During an interview on 08/27/26, at 10:57 A.M., CNA E said the following:-The aide on the 500 hall is responsible for providing resident showers;-They have a shower aide at times that provides showers;-Resident # 85 enjoyed his/her showers. During an interview on 08/27/26, at 1:00 P.M., Licensed Practical Nurse (LPN) M said Resident # 85 should be receiving showers on Monday and Thursday during the day shift. The resident never refused showers and is probably not getting them due to staffing. 5. During an interview on 08/28/26, at 10:13 A.M., Nurse Assistant (NA) P said the following:-Residents receive showers as much as the staff can;-Residents receive one shower a week;-Hospice residents receive two showers a week. 6. During an interview on 08/27/26, at 9:30 A.M., CNA S said the following:-He/she is the shower aide when he/she is not pulled to the floor to work;-He/she provides showers for the 100, 200, and 300 halls;-The 400 and 500 halls do not have a shower aide so the aides assigned to those halls for overall care/supervision complete them;-Residents should be receiving two showers a week;-The resident showers are given on Monday and Thursday, Tuesday and Friday, and Wednesday and Saturday;-He/she is off on Saturdays, so no showers are completed on that day;-Residents are not getting showers twice a week;-Some families have complained about residents not getting showers. 7. During an interview on 08/27/26, at 9:42 A.M., CNA T said the following: -Shower days are scheduled based on resident room number;-Residents should receive two showers a week;-Residents are not receiving two showers a week unless they are on hospice;-Aides complete shower sheets and place them in a shower book when complete. 8. During an interview on 08/27/26, at 10:57 A.M., CNA E said the following:-Residents should be receiving two showers a week;-The residents will get one shower a week on a good week;-There is a shower book with a schedule and shower sheets in it;-The aides are supposed to look in the shower book to see who has a shower scheduled that day;-The residents are not getting showers. 9. During an interview on 08/28/26, at 12:59 P.M., CNA O said the following:-Each resident should get at least two showers per week;-If a resident was on hospice, he/she would get two showers per week from hospice staff. Facility staff did not have enough time to give residents on hospice any showers;-There was one shower aide for the facility;-Most of the time the shower aide would be pulled from shower duty to work as a CNA on the floor;-It had been about one month since some of the residents had a shower. Some residents get a shower once a week. The residents that required two people for transfers were showered less;-CNA told charge nurses and administration several times that residents were not getting showers. -In the last three months, many residents have complained to the CNA about not getting showers when they wanted. 10. During an interview on 08/28/26, at 2:41 P.M., Licensed Practical Nurse (LPN) N said the following:-Some residents did not get showers at least twice a week or when they would prefer;-Many residents have told the LPN they wanted more showers.-The LPN gave three residents showers the shift before;-There are new staff hired all the time, but most staff quit when they realize how hard they have to work. 11. During an interview on 08/27/26, at 1:00 P.M., LPN M said the following:-Residents should have two showers per week;-Residents on hospice should be getting four showers a week;-The staff try to get the showers done but it is not always possible;-The residents do not get two showers a week. 12. During an interview on 8/27/26, at 1:30 P.M., LPN G said the following:-The shower aide provides resident showers but sometimes the aides on the floor will help out;-The residents should have two showers per week;-Residents on hospice should receive four showers weekly;-Aides will complete a shower sheet after the shower and give it to the nurse;-The nurse will review the shower sheet for any skin issues and documents if needed. 13. During interviews on 08/28/26, at 8:48 A.M. and 1:00 P.M., the Assistant Director of Nursing (ADON) said the following:-Residents should be receiving two showers a week;-The facility had a shower aide, but he/she had been pulled to the floor recently;-All the staff chip in to provide resident showers;-The residents are not getting two showers a week due to staffing.-The facility did not have a specific policy regarding shower/bathing frequency. -They tried to provide each resident with two showers per week, with a minimum of one per week. -Staff don't always document bed baths when given. 14. During interviews on 08/28/26, at 10:32 A.M. and 2:36 P.M., the Director of Nursing (DON) said the following:-Residents are scheduled for two showers weekly;-Staff should ensure the residents get at least one shower per week;-It has been a challenge to accomplish all resident showers due to staffing.-They did not have a specific policy on the frequency of showers. -The staff would try to accommodate requests for more frequent showers/bathing. 15. During an interview on 08/28/26, at 3:28 P.M., the Administrator said the following:-Residents should get two showers per week and are scheduled for that frequency. -At a very minimum, they should get one each week. -Staffing had been an issue, so the showers might not be getting done as often. -A designated bath aide gives showers for the residents on 100, 200, and 300 halls; -The Certified Nursing Assistants (CNAs) do the showers on the 400 and 500 halls. -The special care unit (SCU) has its own spa bathroom for showers. -The facility staff should offer all residents two showers per week, even if the resident also receives showers given by hospice staff. -Staff should document showers/bathing. 16. During an interview on 08/28/26, at 8:42 A.M., the Medical Director said residents should get showers or baths at least two times per week for their comfort and hygiene. Complaint #3153006

Based on observation, interview, and record review, the facility failed to ensure food was prepared and stored under sanitary conditions when potentially hazardous food was not thawed using sanitary methods; when staff failed to check the temperature of potentially hazardous and food was not kept at the proper temperature on the steam table; and when dietary staff failed serve food under sanitary conditions when dietary staff touched ready-to-eat food items with bare hands. This had the potential to affect all staff and residents in the facility. The facility census was 85.1.Review of the facility's policy titled, General Requirements of Basic Hazard Analysis (HAACP), dated 2005, showed the following:-All potentially hazardous foods should be kept at safe temperatures, 41 degrees Fahrenheit (F) of below for refrigerated items, or 0 degrees F of below for frozen items-Potentially hazardous foods have historically been involved in foodborne illness outbreaks. Some examples of potentially hazardous foods are eggs, milk, fish, poultry, and meat;-Potentially Hazardous frozen foods should be thawed under refrigeration so that the temperature of the food does not exceed 41 degrees F; under potable running water at a temperature of 70 degrees F or below, with sufficient water in velocity to agitate and float off loose food particles; in a microwave oven only when the food will be immediately transferred to conventional cooking facilities as part pf a continuous cooking process; or as part of the conventional cooking process. Review of the 2013 Missouri Food Code showed the following:-Potentially hazardous food shall be thawed, under refrigeration that maintains the food temperature at 41 degrees F or less or completely submerged under running water at a water temperature of 70 degrees F or below, with sufficient water velocity to agitate and float off loose particles in an overflow, for a period of time that does not allow thawed portions of ready-to-eat food to rise above 41 degrees F, or a period of time that does not allow thawed portions of a raw animal food requiring cooking as specified under to be above 41 degrees F, for more than four hours including: the time the food is exposed to the running water and the time needed for preparation for cooking, or the time it takes under refrigeration to lower the food temperature to 41 degrees F;-As part of a cooking process if the food that is frozen is thawed in a microwave oven and immediately transferred to conventional cooking equipment, with no interruption in the process. Review of facility's personnel records showed a counseling notice for [NAME] A, dated 11/19/25, for improper food handling. [NAME] A agreed with the violation. During an interview on 11/20/25, at 11:59 A.M., the Registered Dietician (RD) said the following:-There have been issues in the kitchen due to the previous Dietary Manager (DM) that discontinued working at the facility as of 11/19/25;-He/she was made aware by the Administrator that food had been improperly thawed by the kitchen staff recently;-Cook A left frozen raw hamburger out all night long and then fed it to residents the next day;-Cook A was written up by the Administrator;-Raw meat should be thawed on the meat rack in the refrigerator. During an interview on 11/20/25, at 12:20 P.M., [NAME] A said the following:-Raw meat was supposed to left in the refrigerator on the meat rack for a few days to thaw;-On 11/17/25 or 11/18/25, he/she pulled out two blocks of raw hamburger from the freezer and put them on the meat rack in the refrigerator. Somebody put one of the blocks of hamburger back in the freezer;-The meat was frozen solid that he/she needed to make the meal for 11/19/25. On 11/18/25 around 2:00 P.M., he/she pulled out the frozen raw hamburger from the freezer and it was left out all night on the counter;-The next day, the prior DM said he/she checked the temperature and said it was okay to use. He/she was not sure what the temperature was or how she checked it, but the meat was thawed;-He/she used the meat to make the sloppy joes for the residents. During an interview on 11/20/25, at 12:38 P.M., the Activities Director said the following:-He/she was not the DM but was helping until the facility got a new one hired;-He/she heard that raw hamburger was left out all night;-The previous DM pushed together a roll of hamburger and checked the temperature. He/she said it was below forty and told [NAME] A it was okay to feed to residents;-Cook A used the meat to cook the meal for the residents;-The meat should have been thrown away because it was not thawed properly and could make people sick;-The meat should have been placed in the refrigerator on the meat rack to thaw. Food should not be thawed at room temperature. During an interview on 11/20/25, at 12:53 P.M., Dietary Aide (DA) B said the following:-Raw meat should not be left out at room temperature to thaw;-Frozen meat should be placed in the refrigerator on the meat rack on the bottom to thaw. During an interview on 11/20/25, at 1:03 P.M., DA C said raw meat should be placed on the meat rack to thaw. Meat should not be thawed at room temperature.During an interview on 11/20/25, at 4:51 P.M., the Director of Nursing (DON) said he/she does not manage the kitchen, but he/she knew that meat should not be left out at room temperature overnight. If meat was left out overnight, it should be thrown away and not given to residents. During an interview on 11/20/2,5 at 2:21 P.M., the Administrator said the following:-He/she was made aware that DA A had left raw hamburger out all night to thaw and then it was used to make a meal for the residents the next day;-The meat should have been thrown out because it was not thawed properly;-Frozen meat should be placed on the meat rack in the refrigerator to thaw;-He/she let the RD know so that he/she could start education;-Cook A and the previous DM had disciplinary action taken. 2. Review of the facility's policy titled, Dining Services, dated 2011, showed the following:-The Dietary Manager or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled;-Follow these guidelines regarding food temperatures;-Keep the temperature of hot foods no less than 140 degrees F during meal service;-Hot food should be at least 120 degrees F when served to the resident;-Keep the temperature of potentially hazardous cold foods no greater than 40 degrees F. Prepare cold items a day in advance when possible. Place items in freezer 45 minutes before serving and use ice baths when needed;-Do not cook or heat food in the steam table because it fosters bacteriological growth and is detrimental to product quality. Heat food to the proper temperature by direct heat (using a stove, oven, steamer, etc.) and then transfer food to the preheated steam table no more than 30 minutes before meal service.-Place cold menu items such as ham salad and egg salad in the steam table over an ice bath with the well of the steal table turned off;-To ensure adequate temperatures, proper-holding techniques should be used. The following are examples of proper holding techniques;-Plate lowerators are functioning and turned on prior to the meal service according to manufacturer's direction;-Lowerators are not over-filled so that all items are being heated;-Food is not placed in the steam table more than 30 minutes before meal service;-Food is not held in warm ovens more than 30 minutes before meal service. It is recommended that food not be held on the steam table for longer than two hours;-Potentially hazardous foods are not held at ro0m temperature during meal service. Review of the facility's policy titled, General Requirements of Basic Hazard Analysis (HAACP), dated 2005, showed the following:-Proper Hot Holding: All foods kept in a hot holding unit steamtable, [NAME]-[NAME], soup warmer, etc. must be kept at 140 degrees F or higher and hot holding equipment should not be used to reheat foods. The purpose of hot holding equipment is to hold the foods at a temperature of 140 degrees F or higher, not to heat the foods,-Internal temperature of food should be checked every two hours to ensure temperature is kept above 140 degrees F;-Do not mix foods being held in hot holding equipment with freshly prepared foods. Review of the facility kitchen's temperature logs, showed the following:-On 11/01/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch, and did not document any food temperatures for dinner;-On 11/02/25, staff did not document any food temperatures for breakfast, lunch or dinner;-On 11/03/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch; -On 11/04/25, staff documented initial cooking temperatures but no holding temperatures for lunch and breakfast; -On 11/05/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch; -On 11/06/25, staff did not document food temperatures for breakfast, lunch or dinner;-On 11/07/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch; -On 11/08/25, staff documented initial cooking temperatures but no holding temperatures for breakfast, lunch, and dinner; -On 11/09/25, staff did not document food temperatures for breakfast or lunch;-On 11/10/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch; -On 11/11/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch; -On 11/12/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch; -On 11/13/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch, and did not document food temperatures for dinner; -On 11/14/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch, and did not document food temperatures for dinner; -On 11/15/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch, and did not document food temperatures for dinner; -On 11/16/25, staff did not document food temperatures for breakfast and lunch;-On 11/17/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch, and did not document food temperatures for dinner; -On 11/18/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch; -On 11/19/25, staff documented initial cooking temperatures but no holding temperatures for breakfast and lunch. Review of the facility kitchen's temperature logs, dated 11/20/25, showed the following:-For breakfast, staff document initial cooking temperatures but no holding temperatures;-For lunch, staff documented initial cooking temperatures but no holding temperatures;-For dinner staff documented initial holding temperatures for meat of 125 degrees F, meat substitute of 120 degrees F, starch of 110 degrees F, starch substitute of 110 degrees F, and vegetable of 120 degrees F,-For dinner mid meal holding temperatures staff documented meat at 125 degrees F, meat substitute at 120 degrees F, starch at 110 degrees F, starch substitute at 110 degrees F, and vegetable at 120 F;-For dinner end meal holding staff documented the meat at 125 degrees F, meat substitute at 120 degrees F, starch at 115 degrees F, starch substitute at 115 degrees F, and vegetable at 115F. Observations of the kitchen on 11/20/25, at 5:11 P.M., showed the following:-At 4:15 P.M., [NAME] E checked the temperature of meat riblets on the steam table which were 135 degrees F;-At 5:18 P.M., [NAME] E checked the temperature of items on the steam table. The tater tots were 125 degrees F, mixed vegetables were 160 degrees F, pureed bread was 125 degrees F, pureed vegetables were 100 degrees F, puree meat was 105 degrees F, mechanical soft meat was 111 degrees F, mashed potatoes were 145 degrees F, tomato soup 120 degrees F, and creamed corn 105 degrees F;-The cook did not reheat or recheck temperatures for any of the food items on the steam table;-At 5:22 P.M., [NAME] E took cooked hamburger patties out of the oven and placed them on the steam table. [NAME] E did not check the temperature of the hamburger patties;-At 5:38 P.M., [NAME] E began serving the food from the steam table;-At 6:30 P.M., the last plate was served from the steam table. During an interview on 11/20/25, at 6:30 P.M., [NAME] E said the following:-The food on the steam table should be kept at 135 degrees F during the meal service;-He/she does not warm up food if it is not at or above 135 degrees F because he/she believed the steam table would warm it up;-He/she did not recheck the temperatures of the food on the steam table after initial check;-He/she writes down temperatures in the log. During an interview on 11/20/25, at 11:59 A.M., the RD said the following:-He/she expected for the dietary staff to check the temperatures of food to make sure it was at a safe temperature and then check it again on the steam table;-Staff should document the temperatures in the log.During an interview on 11/20/25, at 12:20 P.M., [NAME] A said the following:-He/she checked food temperatures prior to putting them on the steam table to ensure the items get to the correct temperatures. He/she puts those temperatures on the logs;-He/she then checks the items on the steam table prior to serve out but he/she does not write it on the log;-He/she was not sure what the temperatures should be on the steam table, but he/she makes sure they around 130 degrees F;-The temperatures should be written in the log. During an interview on 11/20/25, at 12:38 P.M., the Activities Director said the following:-The staff should check food after the initial cooking to ensure it is hot enough and then again at the beginning of serve out and around the middle to ensure the food is staying around 135 to 140 degrees F. During an interview on 11/20/25, at 12:53 P.M., Dietary Aide (DA) B said the staff check the temperature of the food prior to and during serve out. He/she sees them doing it. During an interview on 11/20/25, at 1:03 P.M., DA C said the cooks check the temperatures of the food after cooking and while on the steam table. He/she was not sure what the temperatures should be. Temperatures are written in a log.During an interview on 11/20/25, at 4:51 P.M., the DON said the dietary staff must check the temperature of foods after cooking. The staff have a temperature log that it should be written on. During an interview on 11/20/25, at 2:21 P.M., the Administrator said the cook should check the temperatures of the food prior to putting it on the steam table and then again when it is on the steam table to ensure the food is cooked and kept at the recommended temperatures. 3. Review of the facility's policy titled, Glove Use, dated 04/2011, showed the following:-To ensure safe and proper food handling during food preparation and service. The food code states that food items should not be handled with bare hands;-Utensils or tongs should be used to serve or handle foods, both raw and cooked, whenever possible;-When serving, preference is not to use gloves unless only one task is being performed;-When preparing or handling food items such as meatloaf or raw chicken, gloves should be worn;-Hand washing per guidelines should occur between each task;-Gloves should be worn if handling food is necessary. Extra caution should be taken when multiple tasks are being completed;-Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines. Review of the 2013 Missouri Food Code showed except when washing fruits and vegetables as specified under S 3-302.15, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. Food employees shall minimize bare hand and arm contact with exposed food that is not in a ready-to-eat form. Observations of the kitchen on 11/20/25, at 5:11 P.M., showed the following:-Cook E picked up at least 24 hamburger buns with his/her bare hands and placed them on the residents' plates;-At 5:50 P.M., [NAME] E picked up a hamburger patty and touched it with his/her bare hands to tear it up/hold in place on a plate while cutting it up with a knife for a resident;-At 6:06 P.M., [NAME] E touched cheese slices and bread with his/her bare hands to make two grilled cheese sandwiches. During an interview on 11/20/25, at 6:30 P.M., [NAME] E said the following:-He/she was told not to wear gloves if he/she was touching resident food, but instead uses his/her bare hands;-He/she was not sure who told him/her that. During an interview on 11/20/25, at 6:40 P.M., the DON and Administrator said staff should not use bare hands to handle resident food. They should use tongs or apply gloves. 2673799

Based on record review and interview, the facility failed to make individual financial record available to the resident or resident representative through quarterly statements and upon request when facility staff failed to provide 5 residents (Resident #1, #2, #3, #4, and #5) or their responsible party with reconciled quarterly resident trust fund statements. The facility census was 88.Review of the facility's policy titled, Guidelines for Maintaining the Resident Trust Fund Account, revised on 08/04/22, showed the following:-The facility will establish and maintain a system that assures full, complete and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf;-A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf;-The electronic accounting system is to be used to record resident trust deposits, disbursements, distribute interest and print quarterly statements;-The resident or responsible party will receive a copy of the resident's trust statement showing all transactions to resident's trust fund account on a quarterly basis;-This will be done each month in January, April, July and October by the 15th of the month.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 02/03/21;-Diagnosis of dementia (a disease that causes a loss of memory, language, problem solving and other thinking abilities that interfere with daily life), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), and physical debility;-Resident was his/her own responsible party.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 05/01/25, showed the following:-Resident unable to complete a brief interview for mental status;-Resident had a short- and long-term memory problem;-Resident had poor decision making for tasks of daily life and required cues or supervision.Review of the resident's care plan, revised 05/07/25, showed the following:-Resident had difficulty making self-understood;-Staff should ask resident questions requiring one-to-two-word answers;-Staff should anticipate needs as resident unable to communicate;-Resident had impaired decision making related to cognitive decline and dementia.During an interview on 06/25/25, at 10:00 A.M., the resident said he/she did not know how much money he/she had and did not receive any account statements from the facility.Review showed the facility could not provide reconciled quarterly statements for the resident's funds. 2. Review of Resident #2's face sheet showed the following:-admission date of 09/06/2018;-Diagnosis of severe depression with psychotic symptoms, schizoaffective disorder (mental health condition with symptoms of schizophrenia (mental health condition that affects how people think, feel, and behave) and mood disorders).-Had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's Care Plan, revised 06/04/25, showed the following:-Resident had schizoaffective disorder;-Staff should maintain a calm environment and approach to resident;-Resident had difficulty focusing attention at times.During interviews on 06/25/25, at 2:00 P.M., and on 07/01/25, at 1:45 P.M., the resident said he/she had never received a paper statement of how much money was in his/her account During an interview on 07/03/25, at 10:22 A.M., the resident's power of attorney (POA) for finance said the facility did not send financial statements.Review showed the facility could not provide reconciled quarterly statements for the resident's funds.3. Review of Resident #3's face sheet showed the following:-admission date of 09/26/24;-Diagnoses included dementia and depression;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident unable to complete a brief interview for mental status;-Resident had a short- and long-term memory problem;-Resident had severely impaired decision-making ability;-Resident was inattentive and had disorganized thinking.Review of the resident's Care Plan, revised 05/09/25, showed the following:-Resident had behavioral symptoms towards others;-Staff should maintain a calm environment and approach to resident;-Avoid over stimulating the resident.;-Staff should monitor for fluctuating state of disorientation and decreased environmental awareness;-Resident resides in the memory care unit due to cognitive loss, dementia, and exit seeking.During an interview on 07/08/25, at 11:48 A.M., the resident's POA said he/she was responsible for the resident's financial affairs. He/she had not received any quarterly statements related to money in the trust.Review showed the facility could not provide reconciled quarterly statements for the resident's funds.4. Review of Resident #4's face sheet showed the following:-admission date of 07/23/24;-Diagnosis of depression, dementia, and anxiety disorder;-Had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's Care Plan, revised 05/07/25, showed the following:-Resident had verbal behavioral symptoms directed toward others;-Staff should maintain a calm and reassuring approach to resident;-Staff should monitor resident for states of disorientation.During an interview on 07/09/25, at 12:29 P.M., the resident's POA said he/she was responsible for the resident's financial matters. He/she did not receive quarterly statements from the facility. Review showed the facility could not provide reconciled quarterly statements for the resident's funds.5. Review of Resident #5's face sheet showed the following:-admission date of 06/13/14;-Diagnoses included schizoaffective disorder, delusional disorder, depression, and generalized anxiety. dementia, and anxiety disorder;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident unable to complete a brief interview for mental status;-Resident had short- and long-term memory problems with delusions.Review of the resident's Care Plan, revised 05/21/25, showed the following:-Resident had socially inappropriate behavior;-Resident was pleasantly confused and often asked about parents.Review showed the facility could not provide reconciled quarterly statements for the resident's funds.6. During an interview on 06/25/25, at 12:55 P.M. the Corporate Financial Consultant said resident statements should be sent quarterly with a form for the resident or responsible party to sign and return.During interviews on 07/01/25, at 9:23 A.M. and 1:00 P.M., the new BOM said the following:-He/she had been unable to find many records in the BOM office since starting the job last week;-He/she found no resident funds records for months at a time;-Resident trust quarterly statements should be mailed with a letter to be signed by the resident or representative;-He/she was unable to find any letters or quarterly statements.MO00255783

Based on interview and record review, the facility failed to protect the right of all residents to be free from misappropriation when resident personal funds of five residents (Resident #1, #2, #3, #4, and # 5) were used to make multiple unauthorized purchases. A sample of residents was reviewed in a facility with a census of 88.Review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, dated November 2017, showed the following:-Each resident will be free from verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion;-Residents will be protected from abuse, neglect, and harm while at the facility. Review of the facility's policy titled, Guidelines for Maintaining the Resident Trust Fund Account, revised on 08/04/22, showed the following:-This facility will establish and maintain a system that assures full, complete and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf;-A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf;-The electronic accounting system is to be used to record resident trust deposits, disbursements, distribute interest, and print quarterly statements;-Disbursements from the resident's trust account will not be made without a signed Resident Trust Disbursement/Check request from the resident or the resident's legal representative;-The Administrator and the BOM shall be the signatories to any check written on the resident trust account. However, if either, the Administrator or the BOM are unavailable, the Social Service Designee (SSD) shall be an authorized signatory.-The facility will send a copy of the signed check to system services to be kept on file with the check approval. If the disbursement falls under the one of the items listed on agreement concerning management of personal funds, a copy of the signed agreement will take the place of a resident trust disbursement/check request.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 02/03/21;-Diagnoses included dementia (a disease that causes a loss of memory, language, problem solving and other thinking abilities that interfere with daily life), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), and physical debility.-Resident was his/her own responsible party.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 05/01/25, showed the following:-Resident had a short- and long-term memory problem;-Resident had poor decision making for tasks of daily life and required cues or supervision.Review of the resident's care plan, revised 05/07/25, showed the following:-Resident had difficulty making self-understood;-Staff should ask resident questions requiring one-to-two-word answers;-Staff should anticipate needs as resident unable to communicate;-Resident had impaired decision making related to cognitive decline and dementia.Review of the resident's bank statement, dated 06/06/25 showed the following charges on the bank card:-A charge, dated 05/14/25, to TJ [NAME] for $47.72;-A charge, dated 05/14/25, to, Mama Jeans Market for $106.88;-A charge, dated 05/14/25 to [NAME] for $141.06;-A charge, dated 05/14/25, to Coach for $239.48;-A charge, dated 05/27/25, to Wal-Mart Supercenter for $106.55;-A charge, dated 05/30/25, to Mama Jeans Market for $33.07;-A charge, dated 06/02/25, to [NAME] Pro Store for $171.03;-A charge, dated 06/05/25, to TJ [NAME] for $67.36.Review of a facility investigation, dated 06/18/25, showed the following:-On 06/13/25, at 8:03 A.M., the Social Service Director (SSD) opened a resident bank statement and observed eight suspicious charges and notified the Administrator;-The resident had not been out of the facility in the past few years and was not in procession of any of the items on the bank statement;-The BOM and resident family member reported no knowledge of anyone accessing the bank account;-The police department had been notified and began an investigation;-On 06/16/25, the Administrator and the Director of Nursing (DON) reported to the police department to view a video of the BOM using the resident bank card at a local Walmart; -The Administrator and Director of Nursing (DON) identified the BOM of the facility in the video using the bank card. The video footage showed BOM using the resident's bank card for a purchase at Walmart on 05/27/25 for $106.55;-The Administrator and a police officer then returned to the facility and suspended the BOM;-Misappropriation of the resident's bank funds had occurred.During an interview on 06/25/25, at 9:20 A.M., the Administrator said the following:-The SSD accidentally opened the resident's mail and noticed several suspicious charges;-SSD knew resident had not left the facility to go shopping and thought the account had been hacked;-The SSD notified the Administrator and an investigation was started;-The Administrator contacted the bank and a hold was placed on the card;-The resident's family member was called and reported he/she had not been to the facility in two years and did not have access to accounts;-Administrator contacted the police and filed a report;-The police department contacted him/her, and a video was viewed of the BOM using the resident's bank card to make an unauthorized Walmart purchase;-The facility had began reviewing resident accounts and had noted other unauthorized charges.During an interview on 06/25/25, at 10:00 A.M., the resident said the following:-He/she never leaves the facility;-He/he had not been to Wal-mart or TJ [NAME] and had not requested anyone at the facility buy anything.2. Review of Resident #2's face sheet showed the following:-admission date of 09/06/18;-Diagnoses included severe depression with psychotic symptoms, and schizoaffective disorder (mental health condition with symptoms of schizophrenia (mental health condition that affects how people think, feel, and behave) and mood disorders).-The resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's care plan, revised 06/04/25, showed the following:-Staff should maintain a calm environment and approach to resident;-Resident had difficulty focusing attention at times.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/11/25, showed an amount of $190.00 withdrawn for the resident with the following receipts attached:-A receipt, dated 11/04/24 at 3:46 P.M., for Hobby Lobby with a total of $178.11;-A resident cash withdrawal for spending of $11.89.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/08/25, showed an amount of $125.35 withdrawn for the resident with the following receipts attached:-A receipt, dated 02/19/25 at 12:49 P.M., for Target with a total of $43.50;-A receipt, undated, for Books-A-Million with a total of $31.85;-A resident cash withdrawal for spending of $50.00.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/12/25, showed an amount of $425.85 withdrawn for the resident with a receipt dated 05/11/25 at 7:41 P.M. for Target with a total of $425.85 attached.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/19/25, showed an amount of $92.08 withdrawn for the resident with the following receipts attached:-A receipt, dated 05/15/25 at 11:55 A.M., for Walgreens with a total of $13.70;-A receipt, dated 05/16/25 at 3:18 P.M., for Dollar General with a total of $53.67;-A receipt, dated 05/16/25 at 6:59 P.M., for Chick fil A with a total of $24.71.Review of a Cash Box Withdrawal and Reconciliation Report, dated 06/03/25, showed an amount of $150.00 withdrawn for the resident with the following receipts attached:-A receipt, dated 05/28/25 at 5:33 P.M., for Ross Dress for Less with a total of $30.72;-A receipt, undated, for Books-A-Million with a total of $19.76;-A receipt, dated 05/29/25 at 8:47 A.M., for Dollar Tree with a total of $33.86;-A receipt, undated, for Hobby Lobby with a total of $26.40;-A receipt, dated 05/20/25 at an unknown time, for Walgreens with a total of $16.53;-A resident cash withdrawal for spending of $22.73.During interviews on 06/25/25, at 2:00 P.M., and on 07/01/25, at 1:45 P.M., the resident said the following:-The facility holds his/her money, and he/she liked to get $50 out per week to go to the beauty shop;-He/she is worried if he/she had too much money it would be stolen;-He/she did not leave the facility and his/her family brings in what he/she needs;-The SSD helped with ordering clothes from a catalog one time;-It is hard to get money from the BOM and he/she had to go back several times;-The BOM said that he/she was too busy to give the money out at times;-He/she had not requested staff purchase items from target, chick fil a, or TJ [NAME].During an interview on 07/03/25, at 10:22 A.M., The resident's power of attorney (POA) for finance said the facility notified him/her of the purchase of clothes from a catalog and a mattress only. He/she was not aware of any other charges. 3. Review of Resident #3's face sheet showed the following:-admission date of 09/26/24;-Diagnoses included dementia and depression;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the following:;-Resident had a short- and long-term memory problem;-Resident had severely impaired decision-making ability;-Resident was inattentive and had disorganized thinking.Review of the resident's care plan, revised 05/09/25, showed the following:-Resident had behavioral symptoms towards others;-Staff should maintain a calm environment and approach to resident;-Avoid over stimulating the resident.;-Staff should monitor for fluctuating state of disorientation and decreased environmental awareness;-Resident resides in the memory care unit due to cognitive loss, dementia, and exit seeking.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/08/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/19/25, showed an amount of $112.03 withdrawn for the resident with the following receipts attached:-A receipt, dated 05/18/25 at 12:41 P.M., for Old Navy with a total of $50.42;-A receipt, dated 05/18/25 at 12:06 P.M., for Lululemon with a total of $41.93;-A receipt, dated 05/17/25 at 1:37 P.M., for Adidas with a total of $19.68.During an interview on 07/01/25, at 11:31 A.M., the resident said the following:-He/she did not go shopping, but his/her family brings things in;-He/she had never ordered anything from Lululemon, Old Navy, or Adidas;-He/she had no idea what Lululemon was;-He/she had never requested money from any account at the facility.During an interview on 07/08/25, at 11:48 A.M., the resident's POA said the following:-He/she was responsible for resident's financial affairs; -The resident had an account at the facility that is to be used for beauty services only;-The facility pays for beauty services directly out of the trust money;-He/she had advised the facility that the resident was not allowed to access funds for any other reason;-The resident gives her a list of items he/he needs and the POA purchased them for him/her;-He/she was not aware the facility was able to shop for the resident;-He/she had not been notified of any shopping trips for the resident;-The resident was unable to make any financial decisions.During an interview on 07/01/25, at 11:40 A.M., Certified Nurse Assistant (CNA) B said residents that reside on the memory care unit do not request money for the BOM. The staff will communicate to the social worker if a resident needs something. The residents do not leave the unit.4. Review of Resident #4's face sheet showed the following:-admission date of 07/23/24;-Diagnoses included depression, dementia, and anxiety disorder;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's care plan, revised 05/07/25, showed the following:-Resident had verbal behavioral symptoms directed toward others;-Staff should maintain a calm and reassuring approach to resident;-Staff should monitor resident for states of disorientation.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/10/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/13/25, showed an amount of $148.38 withdrawn for the resident for shopping with an undated Walmart receipt for $148.38.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/24/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/25/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/08/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/13/25, showed an amount of $198.76 withdrawn for the resident with the following receipts attached:-A receipt, dated 05/13/25 at 11:29 A.M., for Target with a total of $15.38;-A receipt, dated 05/09/25 at 11:39 A.M., for TJ [NAME] with a total of $183.38.During an interview on 07/01/25, at 11:50 A.M., the resident said the following:-His/her money goes directly to the bank and he/she does not know much about it;-His/her family member provided whatever he/she needed;-He/she had never withdrawn any money from the business office;-He/she did not have anyone from the facility do any shopping for him/her.During an interview on 07/09/25, at 12:29 P.M., the resident's POA said the following:-He/she was responsible for resident's financial matters;-The resident is unaware that he/she is able to take any money out of the resident trust;-The resident had never taken any money out of the trust;-He/she had spoken with the resident and was advised the facility had never shopped for him/her.5. Review of Resident #5's face sheet showed the following:-admission date of 06/13/14;-Diagnoses included schizoaffective disorder, delusional disorder, depression, and generalized anxiety;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident unable to complete a brief interview for mental status;-Resident had short- and long-term memory problems with delusions.Review of the resident's care plan, revised 05/21/25, showed the following:-Resident had socially inappropriate behavior;-Resident was pleasantly confused and often asked about parents.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/13/25, showed an amount of $75.14 withdrawn for the resident with the following receipts attached:-A receipt, undated, for Books-A-Million with a total of $5.46;-A receipt, undated, for Books-A-Million with a total of $38.53;-A receipt, dated 02/07/25 at 3:44 P.M., for Natures Wonders with a total of $30.61.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/15/25, showed an amount of $100.00 withdrawn for the resident with a receipt dated 02/13/25, at 4:20 P.M., for an amount of 96.64 to TJ [NAME] and $3.36 spending money for resident.Review of a Cash Box Withdrawal and Reconciliation Report ,dated 03/04/25, showed an amount of $80.00 withdrawn for the resident with a receipt, dated 03/03/25 at 11:30 A.M., for Dollar Tree with a total of $72.48 attached.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/05/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/07/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/11/25, showed an amount of $68.51 withdrawn for the resident with the following receipts attached:-A receipt, dated 03/08/25 at 3:08 P.M., for Books-A-Million with a total of $21.73;-A receipt, dated 03/08/25 at 3:09 P.M., for Books-A-Million with a total of $5.83;-A receipt, dated 03/09/25 at 2:03 P.M., for Target with a total of $40.95.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/13/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/18/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 04/11/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 04/25/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/08/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/02/25, showed an amount of $140.00 withdrawn for the resident signed by the resident with the following receipts attached:-A receipt, dated 04/18/25 at 11:25 A.M., for Dollar Tree with a total of $13.43;-A receipt, dated 04/30/25 at 11:26 A.M., for TJ [NAME] with a total of $91.12;-A resident cash withdrawal for spending of $35.45.During an interview on 07/01/25, at 11:05 A.M., the resident said he/she was unsure where his/her money was held. He/she does not need any money but would need to call his/her mom and dad to ask.6. During an interview on 06/25/25, at 12:55 P.M. the Corporate Financial Consultant said the following:-Residents are allowed to obtain $50.00 daily from the cash box;-Residents contact the BOM for money and then signs the Cash Box Withdrawal Form indicating the money was received;-Resident shopping is done by providing an estimate of the cost and verifying the money is available in account;-The resident signs the Cash Withdrawal Form and the receipt after shopping is completed;-The Cash Withdrawal Form and receipts are sent daily to the corporate specialist and reconciled.During an interview on 06/25/25, at 1:35 P.M., Licensed Pracitical Nurse (LPN) A said the following:-He/she would contact the BOM or SSD if a resident needed something;-Some residents have money on an account at the facility and some have family that provide items;-He/she did not receive any receipts for purchases and was unsure if the residents received one;-He/she thought there should be a receipt to account for the money spent;-It is misappropriation to use resident money for personal use. He/she would consider it stealing.During an interview on 06/26/25, at 1:45 P.M., the SSD said the following:-He/she noted suspicious charges on the resident's bank account statement and notified the Administrator;-The assistant SSD does the Walmart shopping for the residents;-The SSD will go to the BOM with the resident requested list and will do a guesstimate of charges for Walmart purchases;-He/she puts the money in separate envelopes for shopping;-The change and receipt are returned to envelope after shopping;-The resident and SSD or ASSD will sign the receipt and returns it to the business office.During an interview on 06/25/25, at 2:25 P.M., CNA C said misappropriation is a type of abuse. He/she would report abuse to the nurse as soon as possible. Financial abuse would be if someone used a resident's money or bank card. He/she would consider that stealing from residents.During an interview on 06/25/25, at 3:05 P.M., LPN D said he/she would report financial abuse to the DON immediately. It would be stealing to use a resident's money to buy something for personal use.During an interview on 07/01/25, at 12:55 P.M., CNA E said misappropriation is abuse and should be reported to the nurse immediately. It is not ok to use resident bank cards or funds to buy things for yourself. It would be stealing.During an interview on 07/01/25, at 1:20 P.M., CNA G said it was not ok to use resident money for anything unless it was for the resident. It would be stealing, and he/she would immediately report it.During an interview on 07/01/25, at 1:25 P.M., LPN F said misappropriation or stealing should be reported to the administration immediately. It would be stealing to use a resident's money for your own personal items.During an interview on 07/01/25, at 1:40 P.M, the DON said the following:-He/she and the Administrator went to the police department to identify the BOM was using a resident's bank card;-It is not ok to use resident funds to buy items for yourself. It would be abuse;-It is considered stealing or misappropriation to use resident funds for yourself and should be reported immediately.During interviews on 07/01/25, at 8:45 A.M. and 2:05 P.M., the Administrator said the following:-The Maintenance Director was identified as signing for resident funds;-The BOM and Maintenance Director would go to the bank together to cash checks for resident funds;-It is inappropriate and stealing to use resident funds for yourself;-It is the duty of the facility to ensure residents are protected from abuse;-Corporate and the facility are reviewing resident fund records;-Most residents interviewed have reported the signatures on cash box forms are not theirs;-The signatures are forged and appear to be cut and pasted on to the receipts.MO00255783

Based on observation, interview, and record review, the facility failed maintain a clean and comfortable environment when the facility staff failed to maintain all light fixtures, walls, floors, sinks, and ceilings in in the dining and kitchen areas clean and free of debris. The facility census was 93. Record review of the facility policy, Nutrition and Dining Services Manual, Section 10, dated April 2011, showed the following: -Specify days the cleaning schedule will be done; -Specify who is responsible to do the cleaning by shift and position; -Post the schedule prior to the beginning of each week; -The employee will initial in the column under the day the task is completed. 1. Observation on 10/21/24, at 10:00 A.M., of the main dining room showed the a light fixture above the serving counter covered in cobwebs. Observation on 10/21/24, at 10:05 A.M., of the kitchen showed the following: -The handwashing station not clean. Splash-marks remained from soap that looked like dried bubbles on the wall behind the sink. Debris, including hair and dirt, was located in and around the sink. -The floor was sticky; -The floor near the stove and food prep area was greasy. -The floor behind the ice machine was dirty with a bright red substance. -The area above the walk-in refrigerator and freezer, had metal strips going to the ceiling and filters that were covered with cobwebs and a lint/grease mixture that moved with the airflow. Observation on 10/23/24, at 11:30 A.M., of the kitchen showed the following: -The handwashing station was not clean with dirt and grease marks present; -The floor behind the ice machine had a bright red substance present; -The area above the walk-in refrigerator and freezer, had metal strips going to the ceiling and filters that were covered with cobwebs and a lint/grease mixture that moved with the airflow. Observation on 10/24/24, at 9:25 A.M., of the kitchen showed the following: -The handwashing station was not clean with dirt and grease marks present; -The floor behind the ice machine had a bright red substance present; -The area above the walk-in refrigerator and freezer, had metal strips going to the ceiling and filters that were covered with cobwebs and a lint/grease mixture that moved with the airflow. During an interview on 10/24/24, at 9:40 A.M., [NAME] D said the following: -All staff take turns cleaning different areas of the kitchen; -Staff does follow a cleaning schedule; -It has been a while since he/she had seen anyone clean above the walk-in units. He/she had noticed that it is not very clean up there. During an interview on 10/24/24, at 9:40 A.M., Dietary Aide B said the following: -Everyone has their own areas where they are supposed to be cleaning; -The Dietary Manager makes a cleaning schedule and they follow it each week; -Night shift is who cleans the baseboards and floors; -Maintenance should be cleaning above the walk-ins; -He/she will clean his/her own station and then everyone pitches in, where needed. During an interview on 10/24/24, at 9:40 A.M., [NAME] C said the following: -He/she will clean his/her own station where he/she is working from; -This is done everyday; -Sometimes the kitchen staff will meet in the evenings or at a different times and work together to deep clean. During an interview on 10/24/24, at 9:40 A.M., Dietary Aide E said the following: -There is a cleaning schedule that they all follow when working the kitchen; -Sometimes staff will stay in their own areas to clean or sometimes do whatever is needed; -He/she knows the kitchen is not as clean as it should be. During an interview on 10/24/24, at 9:40 A.M., the Dietary Manager said the following: -He/she would expect staff to be washing the base boards and sweeping and mopping the floor; -There should not be debris or dirt in or around the hand washing station. It should be sanitized; -He/she was unaware of the floor behind the ice machine not being cleaned. During an interview on 10/24/24, at 3:50 P.M., the Administrator said the areas in the kitchen should be clean and maintained that way.

Based on observation, interview, and record review, the facility failed keep food safe from potential contamination or bacterial growth at all times when staff failed to air dry dishese before storage. The facility census was 93. 1. Record review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Record review of the facility's policy, Nutrition and Dining Services Manual, Section 8, dated April 2011, showed the following: -Items are to be air dried; -No moisture can be found on any stacked item. Observations on 10/21/24, at 10:05 A.M., showed the following: -Forty-seven tall, plastic drinking glasses, upside down, flat on a tray, still wet on the inside. The storage of the glasses prevent air movement that would allow the glasses to dry; -Forty plastic coffee cups, upside down, flat on a tray, still wet on the inside. The storage of the glasses prevent air movement that would allow the cups to dry. Observation on 10/23/24, at 11:30 A.M., showed the following: -Seventy-one glass plates, stacked on top on each other, trapping water between them; -Five plastic, adaptive plates, stacked on top on each other, trapping water between them; -Four metal bins for the steam table, upside down, stacked, still wet, trapping water between them. Observation on 10/24/24, at 9:25 A.M., showed thrity-two plastic plate covers, wet and stacked, with water still dripping from in-between. During an interview on 10/24/24, at 9:40 A.M., [NAME] D said he/she was not aware that dishes could not be stacked while still wet. During an interview on 10/24/24, at 9:50 A.M., Dietary Aide B said he/she was not aware that the dishes were being stacked up before being completely dry. During an interview on 10/24/24, at 10:05 A.M., [NAME] C, said he/she was aware that dishes cannot be stacked, while still wet, but was not aware that this was happening; During an interview on 10/24/24, at 10:15 A.M., Dietary Aide E said he/she knew to never stack dishes while still wet and would have said something if realized this was happening. During an interview on 10/24/24, at 10:30 A.M., the Dietary Manager said the following: -He/she said they had not been aware that the dishes were being stacked wet; -He/she is going to order some dry racks to help with this issue. During an interview on 10/24/24, at 2:45 P.M., the Administrator, said he/she would expect staff to follow policy and allow dishes time to air dry before putting them away.

Based on interview and record review, the facility failed to ensure the staff member employed as the Dietary Manager had the required certifications, education, or experience to meet the regulatory requirements. The facility census was 93. Review of the facility policy titled, Dietary Manager, dated 01/01/98, showed the following: -Minimum qualifications of high school diploma or GED equivalent; -Two years of experience in a supervisory capacity in related field; -Certified Dietary Manager. 1. During an interview on 10/21/24, at 10:05 A.M., the Dietary Manager said the following: -He/she had only been the manager for two years and had been a CNA/CMT previously; -He/she was not certified; -He/she was given a voucher to take a test, but that was four or so, administrators ago. He/she was not sure what happened to it; The administrator was supposed to let him/her know when he/she would get certified, but he/she had not heard anything. Review of facility records showed the facility did not provide documentation the Dietary Manager being certified as a dietary manager, food service manager, or any similar certification, or other education or experience that met the regulatory requirements. During an interview on 10/24/24, at 11:35 A.M., the Administrator said the following: -He/she was unsure why the Dietary Manager didn't get certified except the Dietary Manager told him that several administrators before him/her had arranged for them to take a test, but they did not have the chance; -The Dietary Manager did get ready to test, that was arranged by a prior administrator, but ended up not going; -He/she was not sure as to why the Dietary Manager did not take the test; -He/she has spoken with the regional manager and they are going to set up the test to get it taken care of.

Based on interview and record review, the facility failed to maintain an effective infection prevention and control program when staff failed to read administered tuberculosis (TB - a disease caused by germs that are spread from person to person through the air) skin tests in a timely fashion, per standards of practice, for three employees (Dietary Aide (DA) A, Licensed Practical Nurse (LPN) B, and Certified Nurse Aide (CNA) C. Facility had a census of 93. Review of the facility policy titled, Tuberculosis Control, not dated, showed the following: -Provide a tuberculin skin test to all employees during pre-employment procedures unless a previous reaction greater than 10 millimeters is documented; -An initial two step tuberculin skin test will be given; -If the result of first tuberculin skin test is negative (a negative tuberculin skin test is any measurement between zero to nine millimeters), give the second tuberculin skin test ten days later; -The tuberculin skin test is to be read 48 to 72 hours after administered. Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities and State Correctional Centers showed the following: -All new long-term care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD (a skin test to test for TB) two-step tuberculin test within one month prior to starting employment in the facility. -If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. -It is the responsibility of each facility to maintain a documentation of each employee ' s and volunteer ' s tuberculin status. -All skin test results are to be documented in mm of induration. 1. Review of DA A's Staff Immunization Records showed the following: -Hire date of 05/06/24; -Second-step of the two-step TB test administered on 05/21/24. Staff read the test as negative on 05/22/24 (one day after administered). 2. Review of LPN B's Staff Immunization Records showed the following: -Hire date of 08/13/24; -Second-step of the two-step TB test administered on 08/27/24. Staff read the test as negative on 08/31/24 (4 days after administered). 3. Review of CNA C's Staff Immunization Records showed the following: -Hire date of 09/09/24; -First step of the two-step first TB test administered on 09/09/24. Staff read the test as negative 09/13/24 (4 days after administered). 4. During an interview on 10/23/24, at 3:19 P.M., the Assistant Director of Nursing (ADON) said the following: -TB skin tests should be read within 2 to 3 days and not sooner than 2 days; -TB skin tests should be repeated if read more than 3 days; -He/she expected staff to read and notify Human Resources (HR) when first test has been completed and set up for next screening. 5. During an interview on 10/24/24, at 1:32 P.M., the Human Resources (HR) Manager said the following: -He/she tracked employee TB skin test completion and scheduled them for any additional testing needed; -The TB skin test placed at orientation and read two days later by orientation staff or by facility staff; -Nursing reads the test and documents the results. He/she gives the form to set two week return for second TB skin test placed and read; -HR does not read TB skin test. He/she only sets up employees for completion of the testing requirements. 6. During an interview on 10/24/24, at 1:45 P.M., the Director of Nursing (DON) said the following: -The facility nurses place and read TB tests; -New employees have a TB skin test placed at orientation and are expected to return to the facility for reading in 48 hours; -If unable to return in 48 hours, they would have the employee take picture and send to her or have employee repeat test if could not return within 72 hours; -Employee should return in 2 weeks for another TB test; -The HR office monitors timeframes and reports to nursing staff if not TB test screening is not completed correctly. 7. During an interview on 10/24/24, at 2:25 P.M., the Administrator said the following: -He expected staff to read TB skin test results within appropriate times; -HR is responsible to schedule new employee TB test; -Staff go through the DON to get tests done; -Staff have first TB test read before working floor. 33187

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two resident (Resident #39 and #85) who remained in the facility after discharge from Medicare Part A services. The facility census was 93. Review of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024), undated, provided as the facility's policy, showed the following: -The SNF ABN provided information to the patient so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNF's must use the SNF ABN when applicable for SNF prospective payment system services (Medicare Part A); -It is important to note that the SNF ABN, CMS-10055, is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare, SNF's will continue to use the ABN form CMS-R-131 when applicable for Medicare Part B items and services. 1. Review of Resident #'39's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services started on 07/25/24; -Last covered day of Medicare Part A services on 08/10/24; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -The facility did not provide the resident or his/her legal representative the SNF ABN form CMS-10055 or alternative denial letter. During an interview on 10/24/24, at 12:08 P.M., the Business Office Manager (BOM) said the resident used 17 days and had 83 days left of insurance coverage. 2. Record review of Resident #85's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services episode start date on 05/29/24; -Last covered day of Part A services as 06/14/24; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -The facility did not provide the resident or his/her legal representative the SNF ABN form CMS-10055 or alternative denial letter. During an interview on 10/24/24 at 12:08 P.M., the BOM said the resident used 17 days and had 83 days left of insurance coverage. 3. During an interview on 10/23/24, at 3:40 P.M. the Social Service Director (SSD) said the following: -She gives notices of medicare non-coverage (NOMNC) forms to residents; -The insurance company sends the NOMNC forms to the facility which she prints off and gives to the resident and/or responsible party; -She explains the last covered day and the payer source will be private pay the next day with additional charges for therapy; -She did not give the ABN forms to the residents; -She did not know to give ABN forms to residents. 4. During an interview on 10/24/24, at 12:08 P.M., the BOM said the following: -She explains to residents upon admission of what insurance pays for; -Residents have a right to appeal discharge from therapy; -The insurance company sends NOMNC forms to the corporate staff who send to the facility; -The SSD gives the NOMNC to the residents and/or responsible party; -She did not know staff did not give the ABN forms to the resident and/or responsible party; -The ABN form informs residents and/or responsible parties of insurance not covering the therapy and the right to appeal; -Both of the residents are on managed care and she did not know if the ABN should be given. 5. During an interview on 10/24/24, at 1:34 P.M., the Administrator said the following: -The corporate office sends the facility with the NOMNC forms; -The SSD gives the NOMNC forms to the resident and/or responsible party; -The facility did not issue ABN notices to the residents who were discharged from therapy and had remaining days.

Based on interview, and record review, the facility failed to provide services per standards of practice when staff failed to provide ordered restorative nursing services for three residents (Resident #6, #7, and #8) and failed to care plan restorative services for one resident (Resident #7) out of four sampled residents. The facility census was 83. Review of the facility's Restorative Nursing Manual, undated, showed the following: -The Restorative Nursing Program (RNP) is an integral part of maximizing the daily restorative care process for the residents; -The RNP is a part of the logical step-down process in resident care; -A pro-active approach is necessary to prevent future negative outcomes; -It is the purpose of this facility to see that each resident receives, and the facility provides, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident in the facility. The objective of the RNP program is to provide restorative care necessary to meet the needs of all residents to enable them to achieve the standard of care as described by OBRA (Omnibus Budget Reconciliation Act) 1987; -Restorative services are to be made available per residents' assessed needs; -A mechanism for monitoring and on-going evaluation of the RNP programs must be established. 1. Review of Resident #6's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by staff), dated 01/22/24, showed the following: -Severe cognitive impairment; -Dependent on staff for transfers. Review of the resident's care plan, last revised on 01/31/24, showed the following: -Limited in ability to self-transfer related to hemiplegia and hemiparesis; -Follow physical therapy (PT) and occupational therapy (OT) recommendations. Review of the resident's current Physician Order Sheet (POS) showed the following: -An order, dated 02/01/24, for restorative aide (RA) to see resident two to five times weekly for 90 days to address passive range of motion (PROM - the range of motion that is achieved when an outside force (such as a therapist) exclusively causes movement of a joint) of left upper extremity (LUE) to maintain joint integrity for upper body (UB) dressing and hygiene. Please complete range of motion (ROM) to LUE, all joints, and apply resting hand splint for prolonged stretch to fingers; -An order, dated 02/12/24, for PT evaluation and treat as indicated. Review of the facility's Restorative Therapy Logbook and the resident's electronic medical record (EMR), dated February 2024, showed the following: -Staff document restorative therapy of ROM to LUE provided to the resident on four days (02/20/24, 02/21/24, 02/22/24, and 02/29/24); -Staff documented restorative therapy of applying resting hand splint on four days (02/20/24, 02/12/24, 02/22/24, and 02/29/24); -Staff documented being pulled to the floor on ten days (02/11/24, 02/14/24, 02/15/24, 02/18/24, 02/19/24, 02/23/24, 02/24/24, 02/25/24, 02/26/24, and 02/28/24); -Staff did not document any resident refusals. Review of the resident's current Physician Order Sheet (POS) showed the following: -An order, dated 03/28/24, for discharge from PT services and continue with restorative aide program two to five times weekly for 90 days for transfer training and static standing. Promote sit to stand transfers with hemi-walker and left ankle foot orthotic (LAFO), verbal cues for proper hand placements, maintain standing for two minutes, and perform sit to stand three to five repetitions. Review of the facility's Restorative Therapy Logbook and the resident's EMR, dated March 2024, showed the following: -Staff documented restorative therapy of ROM to LUE provided to the resident on ten days (03/03/24, 03/04/24, 03/05/24, 03/10/24, 03/11/24, 03/12/24, 03/13/24, 03/14/24, 03/18/24, and 03/25/24); -Staff documented restorative therapy of applying resting hand splint to resident on ten days (03/03/24, 03/04/24, 03/05/24, 03/10/24, 03/11/24, 03/12/24, 03/13/24, 03/14/24, 03/18/24, and 03/25/24); -Staff did not document restorative therapy regarding transfer training and static standing; -Staff did not document any residents refusals or being pulled to the floor on any dates. Review of the facility's Restorative Therapy Logbook and the resident's EMR, dated 04/01/24 to 04/09/24, showed the following: -Staff documented restorative therapy of ROM to LUE provided to the resident on two days (04/02/24 and 04/03/24); -Staff documented restorative therapy of applying resting hand splint to resident on two days (04/02/24 and 0403/24); -Staff did not document restorative therapy regarding transfer training and static standing; -Staff did not document any residents refusals or being pulled to the floor on any dates. 2. Review of Resident #7's face sheet showed the following: -admitted [DATE]; -Diagnoses included muscle weakness, and history of falls. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent on staff for most activities of daily (ADLs - dressing, grooming, bathing, eating, and toileting). Review of the resident's March 2024 POS showed the following: -An order, dated 03/19/24, for restorative services two to three times weekly for 90 days for transfers, bed mobility, and left knee hamstring stretching. Review of the resident's care plan, last revised 03/20/24, showed staff did not care plan related to ADL's or therapy services. Review of the facility's Restorative Therapy Logbook and the resident's EMR, dated February 2024, showed the following: -Staff documented restorative therapy of hamstring stretch on one day (02/28/24); -Staff documented restorative therapy of stand/pivot on one day (02/28/24); -Staff documented pulled to the floor on two dates (02/25/24 and 02/26/24); -Staff did not document any resident refusals. 3. Review of Resident #9's face sheet showed the following: -admitted [DATE]; -Diagnoses included hemiplagia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. Review of the resident's quarterly MDS, last revised 01/29/24, showed the following: -Severe cognitive impairment; -Dependent on staff with ADLs with the exception of set up for eating. Review of the resident's care plan, last revised 01/31/24, showed the following: -Resident received therapy services related to transfers and toileting; -Will participate in therapy. Review of the resident's current POS, showed an order, dated 02/21/24, for restorative therapy program two to five times weekly for 90 days for bed mobility and both lower extremities (BLE) strengthening. Review of the facility's Restorative Therapy Logbook and the resident's EMR, dated February 2024, showed the following: -Staff documented bed mobility restorative therapy provided on one day (02/29/24); -Staff documented BLE strengthening restorative therapy provided on one day (02/29/24); -Staff documented pulled to the floor on three days (02/25/24, 02/26/24, and 02/28/24); -Staff did not document any resident refusals. 4. During an interview on 04/04/24, at 3:14 P.M., the Director of Rehabilitation said the following: -He/she writes up a restorative therapy plans for residents coming off of skilled therapy and gives the to Restorative Aide (RA) E to complete with the resident and completes a general order for the physician to sign; -He/she does not oversee restorative therapy services. 5. During an interview on 04/05/24, at 11:46 A.M., RA C said the following: -He/she helps out with restorative therapy when not providing transportation for residents at the facility; -RA E tells him what the residents require restorative services; -He/she documents completing restorative services residents in the EMR and does not document in the restorative logbook. 6. During an interview on 04/05/24, at 12:27 A.M., RA E said the following: -Therapy writes an order for restorative therapy, which may include physical or occupational therapy, type of exercise, how many times per week, and the duration; -He/she tries to focus restorative therapy with residents on 100/200/300 halls at the beginning of the day and then 400/500 after, but the schedule is fluid; -He/she documents RA sessions in the restorative log and in the EMR; -He/she documents resident refusals in the restorative log as an R and ill residents as S; -He/she puts an X on the restorative log when she is pulled from restorative therapy to work the floor. 7. During an interview on 04/05/24, at 2:26 P.M., Licensed Practical Nurse (LPN) F said the following: -Residents usually receive restorative therapy following skilled therapy services; -The physician can order restorative therapy, but skilled therapy completes the evaluation; -Restorative aides are pulled to work the floor when staff members call in for their shift; -He/she does not know how often this happens, but it seems to occur in spurts. 8. During an interview on 04/05/24, at 2:43 P.M., LPN D said the RA is pulled from restorative therapy to work the floor when staff members call in for their shift and doesn't always get restorative therapy completed. 9. During an interview on 04/05/24, at 4:36 P.M., the Assistant Director of Nursing (ADON), Director of Nursing (DON) and the Administrator said the following: -When a resident completed a skilled therapy treatment plan, therapy orders restorative therapy, completes an evaluation and sends the information to RA E; -RA E documents restorative therapy sessions in the restorative logbook and in the EMR. RA C documents in the EMR; -RA E gets pulled to the floor; -RA C picks up some slack with restorative therapy, but he/she works four days per week and provides transportation for the residents; -If RA E is pulled to the floor and RA C is providing transportation, restorative therapy is not completed. MO00234013

Based on observation, interview, and record review, the facility failed to ensure food was served at a temperatures that were palatable and appetizing for five residents (Resident #1, #2, #3, #4, and #5) who often ate in their rooms. The facility census was 83. Review of the facility policy titled, Food Temperatures, dated April 2011, showed the following: -Hot food should be at least 120 degrees Fahrenheit (F) when served to residents; -A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels; -Plate lowerators are functioning and turned on prior to the meal service according to manufacturer's direction; -Lowerators are not over-filled so that all items are being heated; -Food is not placed in the steam table more than 30 minutes before meal service; -Food is not held in warm ovens more than 30 minutes before meal service It is recommended that food not be hold on the steam table for longer than two hours. 1. Observation on 04/04/24, at 12:12 P.M., showed the following: -A test tray was requested and received from the insulated food cart on 500 hall at the end of the meal service; -The meal included country fried steak, cream gravy, mashed potatoes, breaded okra, and cherry pie; -Temperatures were taken of the items served hot; -The country fried steak measured 111 degrees F, the mashed potatoes measured 114 degrees F, and the breaded okra measured 95 degrees F. 2. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 12/28/23, showed the following: -admitted [DATE]; -Moderate cognitive impairment; -Regular diet; -Setup assistance with eating. During an interview on 04/04/24, at 10:18 A.M., the resident said the following: -Staff often serve lukewarm food; -Staff will reheat food if requested. 3. Review of the Resident #2's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact; -Regular diet; -Setup assistance with eating. During an interview on 04/04/24, at 10:35 A.M., the resident said the following: -He/she eats meals in his/her room; -The meals are usually not warm by the time staff bring the meal to his/her room; -Staff will reheat the food upon request. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Mechanically altered diet; -Setup assistance with eating. During an interview on 04/04/24, at 12:47 P.M., the resident said the following: -He/she eats most meals in his/her room; -Most of the time, staff serve the food at temperatures not warm enough, including today; -The resident described the food temperature as not cold, but uncomfortable; -He/she has never asked staff to reheat the meal. 5. Review of the Resident #4's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Severely cognitively impaired; -Mechanically altered and therapeutic diet; -Setup assistance with eating. During an interview on 04/05/24, at 11:23 A.M., the resident said the following: -He/she eats meals in the dining room; -Meals are not always warm enough, but staff will reheat or get a new plate for the resident. 6. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact; -Regular diet; -Setup assistance with eating. During an interview on 04/05/24, at 11:35 A.M., the resident said the following: -The resident eats meals in his/her room; -Staff often serve lukewarm meals; -Staff served the resident a cold hamburger recently; -Staff will reheat meals when resident requests; -The food temperatures have been an ongoing issue. 7. During an interview on 04/04/24, at 2:35 P.M., Certified Nurse Assistant (CNA) A said the following: -Residents complain quite often that food is served too cold; -He/she offers to reheat the meals using the microwave in the therapy room. 8. During an interview on 04/04/24, at 3:22 P.M., CNA B said the following: -He/she passes hall meals in the evenings and residents often complain about the temperatures not being hot enough; -He/she offers to reheat the meal in the microwave in the therapy room if a resident complains. 9. During an interview on 04/05/24, at 1:32 P.M., the Dietary [NAME] G said the following: -Staff obtain temperatures of food on the steam table during before every meal service and document on the log; -Meat temperatures should be 175 degrees F and vegetable temperatures should be 190 degrees F on the steam table; -Food temperatures should be holding at 145 degrees F when served to residents; -Staff serve meals to the residents in the dining room first; -Staff pass 400/500 hall trays last; -The food is hot when it leaves the kitchen, but aides do not get the meals passed quickly enough; -He/she is aware there have been complaints regarding food temperatures; -If food temperatures are not acceptable for a resident, staff will replace with a new plate, offer an alternative, or reheat the meal in the therapy room microwave. 10. During an interview on 04/05/24, at 1:41 P.M., the Dietary Manager said the following: -Staff obtain temperatures of foods on the steam table right before serve out of meals; -Acceptable food temperatures on the steam table should be between 135 to 160 degrees F, and serve out to tables should be 135 degrees F; -The temperatures are documented for each meal in a log; -Meals for the 500 hall are loaded onto an insulated food cart and are the last to be delivered during meal service; -The test tray temperatures taken on 04/04/24 were not acceptable; -If food temperatures are not acceptable for a resident, staff will replace with a new plate, offer an alternative, or reheat the meal in the therapy room microwave. 11. During an interview on 04/05/24, at 2:43 P.M., License Practical nurse (LPN) D said the following: -Residents often complain about the temperature of food trays on all of the halls; -Meals are served to 500 hall from an insulated food cart; -Staff will reheat meals in the therapy room microwave for residents. 12. During an interview on 04/05/24, at 4:36 P.M., the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator said the following: -Staff should obtain temperatures of all food items on the steam table prior to serve out of meal and document in the log; -There are two serve out areas with steam tables one for the dining room and 100/200/300 halls and one for 400/500 halls; -While staff serve the dining room and 100/200/300 halls, other staff are loading the insulated food carts for 400 and 500 halls with 400 hall trays passed first; -If a resident complains about the temperature of the food, staff should preferably obtain a fresh plate for the resident, offer an alternative, or reheat the meal in the microwave and obtain a temperature before serving; -The test tray temperatures from 04/04/24 were not acceptable. MO00234013

Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Certified Nurse Aide (CNA) A) provided cares to three residents (Residents #1, #2, and #3) in an unrespectful and undignified manner when the CNA rushed residents, raised his/her voice at residents, and spoke in a disrespectful tone of voice when answering the residents' call lights. The facility census was 89. Review of the facility policy Resident Rights, undated, showed each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 1. Review of Resident #1's face sheet (document with admission information) showed the following: -admitted [DATE]; -Diagnoses included dementia (brain damaged by injury or disease which involves progressive impairments in memory, thinking, and behavior which negatively impacts a person's ability to function and carry out every day activities) without behavioral disturbance, anxiety (a feeling of worry, nervousness, or unease), fracture of upper left femur (leg), Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), cerebral infarction (stroke), osteoarthritis (degeneration of joint cartilage and underlying bone which causes pain and stiffness, especially in hip, knee, and thumb joints), renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), urine retention, pain, weakness, adult failure to thrive (a syndrome of weight loss, decreased appetite, and poor nutrition and inactivity), visual hallucinations (seeing images when there is nothing in the environment to account for it), anemia, and urinary tract infection (bladder infection). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/23/24, showed the following: -Moderately impaired cognition; -No behaviors observed and no hallucinations; -Partial to moderate staff assistance to roll left to right in bed; -Substantial/maximal assistance where helper does more than half the effort for toileting; -Substantial/additional assistance where helper does more than half the effort for resident's personal hygiene; -Occasional urinary and bowel incontinence. Review of the resident's care plan, dated 12/8/23 and updated 01/17/24, showed the following: -An alteration musculoskeletal status related to recent left hip fracture; -Staff to anticipate and meet needs; be sure call light is within reach and respond promptly to all requests for assistance; and give analgesics as ordered by the physician; -History of visual hallucinations; -Staff to maintain a calm environment and a calm, slow, understandable approach to the resident; -History of cerebral infarction (stroke) affecting cognition; -Staff to adjust tonal quality and speak distinctly; face the resident when speaking to resident; obtain resident's attention before speaking; and provide quiet, non-hurried environment, free of distractions for conversation; -Do not rush resident; -Resident requires one person assistance. During an observation and interview on 02/02/24, at 11:35 A.M., the resident said on consecutive nights, when he/she put on his/her call light, CNA A would come into the room, not knowing what he/she needed, and would yell at him/her, What do you want now? I can't keep coming all night. This happened every night CNA A came to his/her room. This happened when he/she was in another room too. CNA A grabbed his/her arms to move him/her. He/she was a two person assist to toilet and CNA A scared him/her. The staff were to come in, roll him/her, and put a diaper on him/her, and roll him/her to the other side. If done properly, it would not hurt. He/she has to toilet frequently and is on medicine for a urinary tract infection and swelling. He/she had to go to the bathroom every one and one-half hours and it irritated CNA A. He/she did talk to Licensed Practical Nurse (LPN) C, the night charge nurse, who went and talked to the Director of Nursing (DON) and said there were other residents who complained about CNA A. CNA A was unnecessarily rough and he/she was fearful. During an interview on 02/02/24, at 2:39 P.M., LPN C said it had been a busy night the night the resident had complained and asked to speak to him/her about something. The resident said CNA A was rough with him/her, yelled at him/her, and he/she did not want the aide to work with him/her. The resident said he/she didn't want to use the call light at night because when he/she did CNA A yelled at him/her during cares and was rough with him/her. LPN C did notify the DON about this. He/she said CNA A was a loud flamboyant person, talked loud, and even a whisper was loud. During an interview on 02/02/24, at 1:44 P.M., CNA A said he/she was good friends with the resident even before his/her fall when on another hall. The resident had been extra needy with the call light to get up to go to the bathroom and wanted covered up. He/she was going back and forth and then changed him/her. The resident apologized to him/her about using the call light frequently that night. Before he/she changed him/her, the resident was sitting up in bed and asked to lie down. CNA A said, You ready? Let me get your legs. One, two, three and when he/she moved the resident's legs up and over on the bed, the resident complained of his/her legs hurting. This was at approximately 2:00 A.M. to 3:00 A.M. CNA A covered the resident and left the room. Immediately, the resident turned on the call light and said he/she was wet. There were three other rooms with call lights on before the resident's call light went on. His/her call light had been going off a lot that night. CNA A was not to use a gait belt on (transfer belt placed around the resident's waist) the resident or to transfer him/her to take to the toilet since the resident was not weight bearing due to the fracture. He/she went to change the resident, pulled down the brief, counted one, two, three and rolled him/her to the side where the window was. The resident cried out, Ow, oh God, you are hurting me! when rolled to the left side, the resident said, Why are you so aggressive? CNA A said, I have to roll the resident. I don't allow the residents to grab my hand, but allow them to grab my forearm to turn them in bed. The resident thought he/she was mad at him/her. He/she was not rough but only when roll and move residents, they all say staff were being too rough to them. They are fragile and hurt with any type of movement. During an interview on 02/02/24, at 2:17 P.M., CNA E said he/she had worked with CNA A before and CNA A told him/her that the resident had told CNA A that he/she was rough with him/her and CNA A went to get LPN C. Resident #1 told LPN C that CNA A was rough with his/her words, but did not say what was said. CNA A talks loud. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included vesicointestinal fistula (an abnormal connection between the bladder and the bowel), urinary tract infection, Type 2 diabetes mellitus, atrial fibrillation (abnormal heart rhythm), obesity, depression, mild cognitive impairment, left shoulder osteoarthritis, right hip bursitis (painful swelling in joint), anxiety, pneumonia (upper respiratory infection), urine retention, anemia, and shortness of breath. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was interviewable; -Partial/moderate staff assistance to roll left and right in bed. Review of the resident's care plan, dated 01/05/24, showed the following: -Required assistance with ADL's (activities of daily living) related to disease process and general fatigue/weakness; -Staff to not rush resident who requires substantial assistance; -Staff to keep call light within reach; -Difficulty communicating with others related to hearing impairment; -Staff to be extremely patient, face the resident when speaking, provide quiet, non-hurried environment, free of background noises and distractions, repeat phrases as needed and rephrase if needed, and speak clearly and adjust tone as needed; During observation and interview on 02/02/24, at 9:49 A.M., the resident who was in bed, said he/she has pain in his/her left hip now and sometimes Tylenol helps the pain and sometimes it did not. The resident had a Foley catheter (a flexible tube inserted into the bladder to drain urine). He/she said once or twice on the night shift, one gal was rough with him/her. He/she told CNA A to be gentle with him/her and with his/her left leg to roll him/her to the right side. CNA A was moving him/her quickly to roll over. CNA A got his/her body on top of him/her and tried to hold him/her and felt his/her elbow dig into his/her left hip. CNA A was trying to hold him/her over so he/she wouldn't flip back over. CNA A pulled the blanket over him/her, but did not make sure the call light was in reach. CNA A's whole attitude was like, What do you want? CNA A had no patience and never apologized to him/her. A couple of times this aide was rough and he/she did not report this to anyone. During an interview on 02/02/24, at 2:39 P.M., LPN C said the resident had complained to him/her about CNA A. The resident said CNA A almost acted like he/she did not want to be there at the facility. He/she did things rapidly and he/she had no bedside manners but just wanted to get done and out of the resident's room. LPN C said the aide goes in and out of rooms quickly. 3. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included fracture of right femur (the longest and strongest thigh bone), fracture of upper humerus (bone from the shoulder to the elbow), anxiety, acute kidney failure (condition in which the kidneys suddenly can't filter waste from the blood), depression, osteoporosis, and insomnia (persistent problem falling and staying asleep). Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was interviewable; -Partial/moderate staff assistance to roll left and right (in bed); -Substantial/maximal assistance where the helper does more than half the effort to assist the resident from lying to sitting on side of bed and sit to stand to transfer; -Occasionally incontinent of urine. Review of the resident's care plan, dated 01/26/24, showed the following: -May have difficulty in communication related to hearing loss; -Staff to face resident when speaking and repeat phrases as needed and rephrase if necessary; -Staff to speak clearly and adjust tone as needed; -Required assistance with ADL's related to recent fractures, non-weight bearing status, weakness, and pain; -Staff to not rush resident; -Resident required two person assistance; -The resident has functional/urgency bladder incontinence; -The resident used disposable briefs; -Staff to change when wet or soiled and as needed. During observation and interview on 02/02/24, at 3:46 P.M., the resident, who was in his/her room, said there were a couple of incidents at night that he/she had not appreciated. One night, he/she needed the bed pan and a clean incontinence brief to put on. The girl (CNA) got out of shape! He/she was scooted down too far in bed and the aide said, What do you want? and asked the same question twice to the resident even after he/she requested some Tylenol twice. She was real nasty that night! About three to four nights ago, CNA A didn't want to assist him/her in bed and he/she had to occasionally wait to go to the toilet. 4. During an interview on 02/02/24, at 12:47 P.M., CNA D said the resident reported to him/her on 02/01/24, about 7:00 A.M., when they went to get the resident up, that CNA A would not listen to him/her, grabbed his/her left arm, and would not change him/her because he/she was wet. CNA A would not take the resident to the bathroom. CNA D said the resident was soaking wet with urine. He/she went to get the night charge nurse, LPN C, and the resident said to them that CNA A over talks him/her, was loud, does not listen to him/her, and snaps, What do you need?. CNA A was very short with him/her. During an interview on 02/02/24, at 2:45 P.M., CNA F said he/she worked nights with CNA A and he/she gets in a little bit of hurry when he/she worked side-by-side with CNA A. He/she had to tell CNA A to slow down before. During an interview on 02/02/24, at 2:39 P.M., LPN C said CNA A was a loud flamboyant person, talked loud, and even a whisper was loud. During an interview on 02/07/24, at 1:30 P.M., CNA H said staff were to treat with dignity and respect by not moving fast when doing cares for them and let them know what you were going to do like turn them to the wall. They were to explain to them and get assistance from other staff if need to pull them up in bed and/or turn them. During an interview on 02/07/24, at 1:36 P.M., Certified Medication Technician (CMT) I said dignity and respect was when staff go into a resident's room, they were to be positive, have a smile since this was their house. Staff can't be aggressive, negative, and yell at them. They should do personal cares slowly because a resident can be sore and in pain. During interviews on 02/07/24, at 11:55 A.M. and 1:24 P.M., LPN G said if a resident told him/her that staff person was rough with him/her, he/she would ask them to describe what rough meant. Staff were to treat someone like they deserve to be treated with dignity and respect. Staff were to go slow when turning residents, and respect their wants and needs. They were not to be rough in speech, not yelling, but be respectful. During an interview on 02/07/24, at 1:50 P.M., Registered Nurse (RN) J said staff were to treat the residents like a good family member, and speak respectfully. Staff were not to yell but may have to speak louder so they can hear. Staff were to be gentle with cares and listen to the resident, and make them comfortable. During interviews on 02/02/24, at 4:08 P.M., and on 02/07/24, at 1:55 P.M., the DON said she expected staff to treat people the way they wanted to be treated. It was how you spoke, asked, and responded to a resident to provide for their needs and make them comfortable. Respect them as a human being. During interviews on 02/02/24, at 9:07 A.M., and 4:25 P.M., and on 02/07/24, at 9:10 A.M., the Administrator said he interviewed CNA A who said he/she never grabbed anyone's arm. CNA A is a little person and he/she does roll residents during cares. He said CNA A told him that he/she tells the resident, One, two, three. And then rolls them over. CNA A was bubbly and his/her voice was loud. LPN C said that CNA A sings and was loud and would go into a resident's room and turn on their light. The Administrator said he had talked to CNA A about leaving the light off until he/she asked the resident if it was okay to turn on the light (in the night). CNA A has an excited startling voice. He had talked to CNA A about complaints of not finishing duties in rooms and would just leave the room. A few other residents had requested for CNA A not to take care of them. Staff were to treat everyone as family and speak respectfully. The look, facial expressions, tone of voice can be disrespectful. Talk to the residents as a human being, to [NAME] and love them and to make them feel safe. MO00230640

Based on interview and record review, the facility failed to report an allegation of abuse immediately to management and to the State Survey Agency (Department of Health and Senior Services- DHSS) within the two-hour requirement when one resident (Resident #1) alleged abuse by a staff member. The facility census was 86. The Administrator and Director of Nursing (DON) were notified on 05/30/23 of the Past Non-Compliance which occurred on 05/29/23, at approximately 1:50 P.M. Facility staff notified Department of Health and Senior Services (DHSS) of the noncompliance, started an investigation, educated the staff member involved, began in-servicing of all facility staff as they began their shifts, and began monitoring charts and interviewing residents weekly to ensure no other incidents occur. The noncompliance was corrected on 5/30/2023. Review of the facility policy titled Investigation, undated, showed all allegations of abuse to be reported no later than two hours to the State Survey Agency, and if applicable, law enforcement. 1. Review of Resident #1's face sheet showed an admitted [DATE] and diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), chronic kidney disease stage 3 (moderate kidney damage), Type 2 diabetes (a chronic condition that affects the way the body processes sugar), and cardiomyopathy (a condition of the heart that makes it hard for the heart to deliver blood to the body). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), showed the resident was moderately cognitively impaired. Review of the resident's care plan, updated 05/29/23, showed the following: -Resident resists care; -He/she would not allow staff to change him/her when incontinent. Resident stated he/she would tell staff when they needed changed; -Resident is at risk for pain related to wound on coccyx (tailbone) and left arm. Review of the Social Services Director's (SSD) statement dated 05/28/23, at 5:00 P.M., showed the resident's next of kin reported to the SSD that a CNA B had shoved the resident and the resident had threatened to call the police. The resident had refused to let the CNA perform cares for the resident. (The SSD did not document reporting the allegation of possible abuse to management or DHSS.) Review of the resident's nursing notes dated 05/29/23, at 11:28 A.M., showed resident refused cares and threatened to call police on a certified nursing assistant (CNA). The resident would not let nurse perform treatment. Staff notified the next of kin and will attempt cares again in thirty minutes. Review of the resident's nursing notes dated 5/29/23, at 1:51 P.M., showed the resident had some behaviors that morning including refusing cares and treatments. Staff notified family members by telephone. Resident was fighting with CNA during brief change and threatening to call police for abuse. Nurse transferred resident to bed. Resident complained of pain to arm and resident accused nurse of abuse. Staff will continue to observe. (The staff did not document reporting the allegation of possible abuse to management or DHSS.) During an interview on 05/31/23, at 10:00 A.M., the resident said a couple days before, he/she fell asleep with his/her leg hanging off the bed and an aide came in, slung his/her leg back on the bed, and shoved him/her back in the bed. The aide then said, Great, now I have to change you. During an interview on 05/31/23, at 10:23 A.M., the SSD said she was working as a Certified Medication Technician on 05/29/23. She had been told that the resident was having some behaviors and was still needing to do some admission paperwork for the resident. She had gone to the office to find out what kind of behaviors the resident was having. She decided to wait for the resident's family member to come in before continuing the paperwork. When the family arrived, she went in with the family. She said the family said the resident had threatened to call the police because an aide was being rude, but never mentioned abuse and did not mention shoving. She would consider shoving abuse. Review of the Administrator's statement, dated 05/30/23, showed upon arriving to work, he looked at notes and found the section in the resident's chart with the resident stating to a CNA that he/she was going to call the police for abuse. After that progress note, he found a note of the resident telling Licensed Practical Nurse (LPN) A he/she was going to report him/her for abuse. After reviewing, the Administrator interviewed the resident who stated the CNA shoved him/her back against his/her bed to lay him/her down to be changed and hurt his/her arm in the process. The resident said the aide was being rough and that he/she was calling the police. The resident said he/she had called his/her next of kin who was coming to the facility to file a grievance. The Administrator said he would have to report it to the State Agency and asked who all he/she had told, and the resident stated his/her next of kin. The allegation was reported to the state on 05/30/23. Review of LPN A's witness statement dated 05/30/23, at 10:50 A.M., showed on 05/29/23, at approximately 11:00 A.M., CNA B walked up to him/her to report the resident was refusing to let the aide change his/her soiled brief. LPN A walked into the resident's room to talk to the resident about the importance of good hygiene. The resident stated I don't want anyone touching me. I am going to call the police for abuse. The nurse contacted family to report that resident was making false allegations and refusing cares. (The LPN did not document reporting the allegation of possible abuse to management or DHSS.) During an interview on 05/31/23, at 12:05 P.M., LPN A said on 05/29/23, he/she walked in the resident's room and the resident was slumped over in his/her wheelchair. The nurse asked if the resident wanted assistance and the resident said yes. The nurse assisted the resident to the bed. After the resident got to the bed, the resident said, You hurt me, you are hurting me. I am calling the police. The nurse left the room and later CNA B came to the nursing station and said the resident would not allow him/her to change his/her brief. The nurse went in and the resident said he/she didn't want anyone touching him/her. The nurse said he/she wasn't aware abuse allegations could be verbal. He/she thought they should just be reported if there were allegations of physical abuse. He/she thought the resident was just talking out of his/her head. The LPN said he/she did not report the allegation of abuse to management or DHSS. During an interview on 05/31/23, at 10:12 A.M., LPN C said if a resident says they are abused, staff make sure they are safe, let the Assistant Director of Nursing (ADON), Director of Nursing (DON), or Administrator know, contact the State Agency within two hours, and start the investigation. During an interview on 05/31/23, at 10:15 A.M., Certified Medication Technician (CMT) D said if a resident reports they are abused, staff should make sure the resident is safe, report to the charge nurse, report to the State Agency within two hours, and an investigation is started. During an interview on 05/31/23, at 10:18 A.M., LPN E said if a resident says they are abused, staff should remove them from the situation if possible, report to the State Agency within two hours, and begin the investigation. The resident should be assessed for injuries. During an interview on 05/31/23, at 12:15 P.M., the ADON, DON, and Administrator said if a resident makes an allegation of abuse, they expect staff to immediately make sure the resident is safe, let the charge nurse know, contact the ADON, DON, and Administrator. The ADON and DON are in charge of starting the investigation. They are always available. The charge nurses have access to the online reporting feature to report to the State Agency and are able to report the allegation within two hours if the management are not. They do expect the allegation to be reported within two hours. MO00219154

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination when food items were not dated or labeled after opening, or were left open and exposed to absorb ice crystals and odors and when staff failed to keep the kitchen free of an accumulation of grime and debris. This had the potential to affect all residents who ate food from the kitchen. The facility census was 83. Record review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, currently updated 3/4/23, showed the following: -Facility staff must ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated; -Food shall be stored in a safe manner (no open containers, without covers, spillage from one food item onto another, etc.) to prevent cross-contamination -Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. 1. Record review of the facility's policy titled Safe Food Handling, dated April 2011, showed the following information: -All food, including bulk items, should be tightly sealed with an identifying label and date; -The facility could not provide further policy regarding labeling items. Observation of the walk-in refrigerator on 3/13/2023 at 9:54 A.M., showed the following items were all undated and were not labeled: -Tall pitcher for liquid, half-full of juice; -Butter, approximately two sticks, in a plastic bowl; -Chicken salad sandwich, already made; -Chicken salad mixture, approximately enough for two sandwiches; -Ham cubes, in large plastic bag; -Ham slices, in two separate zip lock bags; -Bacon slices, in a large zip lock bag; -Bologna slices, in a large zip lock bag; -Cheese slices that have been separated into small bunches of approximately 10 slices each, and there are 8 packages in their own saran wrap (80 slices total). Observation of the walk-in refrigerator on 3/13/2023 at 10:00 A.M. , showed the following items were not properly closed and were exposed to the cold air, allowing for food to absorb odors and become stale: -Chicken salad sandwich, ready to eat, exposed and bread is hard; -Chicken salad mixture, dried out across the top; -28 small juice glasses, open and exposed inside the refrigerator; -4 small plastic bowls of applesauce with some cinnamon mixed in, -All of the items are exposed to the other items in the fridge. Observation of the walk-in freezer on 3/13/2023 at 10:05 A.M., showed the following: -One large box of biscuits were found to be open and exposed to the freezing air, showing ice crystals on all of the biscuits; -Potato wedges, no date/label and not closed correctly, and with ice crystals on them; -Six meat patties, the bag is open, exposed to the cold air, and have ice crystals on them. During an interview on 3/20/23 at 1:04 P.M., Dietary Aide M, said the following: -The dietary manager is the one who usually puts the food away; -All food needs to be labeled and dated; -If there are any leftovers, those should also be labeled and dated; -He/she will label/date any foods that he/she is personally in contact with or will ask; -Hasn't seen anything without a label, as far as he/she can remember; -Knows this should be done with all food, no matter what it is or where it's kept; -Hasn't seen any food left open in the freezer, but would throw out any that he/she saw. During an interview on 3/20/23 at 1:13 P.M., Dishwasher N, said the following: -He/she does not put any food away; -He/she mostly does dishes only; -He/she knows food needs to be labeled and dated correctly; -Food should never be left in the refrigerator or the freezer, opened and not labeled; -If food is exposed and open in the freezer and has ice crystals, he/she believes it should be thrown away. During an interview on 3/20/23 at 1:13 P.M., Evening Cook O said the following: -He/she always tries to label items in the dry food storage, refrigerator and the freezer; -He/she has seen that there are many items in the refrigerator and freezer that are not labeled and it is upsetting to him/her because he/she is tired of trying to keep up; -He/she is glad that state is here because it may make staff pay attention to what is not being done; -Any biscuits or any food items that are exposed to the freezer in an open container should be thrown away and never fed to residents; -He/she said the same is true with any items that have not been labeled; -If they make any desserts or pour juices, they should be covered up/wrapped appropriately and not just exposed to the open air, sitting out for anything to fall in them. During an interview on 3/20/23 at 1:13 P.M., Prep Cook P said the following: -He/she thinks the dietary manager is who usually labels and dates all new and incoming items; -Anything that is saved, for example, from today's lunch- should be labeled and dated before putting it away; -Everything must be covered up and that includes the biscuits or anything else in the freezer; -Food found opened and with ice crystals should be disposed of; -He/she said the entire freezer needs to be redone and gone through. During an interview on 3/20/23 at 3:20 P.M., both the administrator and the DON, said the following: -Both have already been informed of the condition of the kitchen and know there are some problems; -The dietary manager is fairly new and is still trying to figure things out; -The dietary manager is on vacation during this survey; -Both took notes of the concerns listed and said they did not realize items had been placed in the refrigerator uncovered or in the freezer exposed to the air and getting ice crystals on them; -There will be an in-service with the kitchen staff to ensure all labeling and storing food correctly to ensure it will be done the right way. 2. Record review of the Food and Drug Administration (FDA) 2013 Food Code showed nonfood-contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, or other debris. Record review showed a facility policy regarding cleaning nonfood surfaces was not provided. Record review of the kitchen cleaning schedule shows the following: -The schedule is broke down to six days a week, Monday through Saturday; -The chores are divided between the cook/prep/AM Aides/PM Aides; -The ice machine is listed for Mondays but none of the other areas of concern are listed on the cleaning schedule. Observation of the kitchen, on 3/13/2023, at 10:20 A.M., showed a dark, stringy, substance that is made up of dust, dirt, food residue and/or debris, collected with grease and hanging or collected on almost all kitchen surfaces, including: -Range Hood, back and sides had large amounts across the entire surface area; -Brace bars that are connected to the ceiling and are holding up the dishwasher; -The metal door that raises/lowers for serve-out, from the kitchen to the dining room; -Metal shelving that holds cooking utensils, metal lids and cutting boards; -The cooking range fire alarm on the east wall, near the kitchen door; - The substance lined the blades and the cage area of the fan in the kitchen. The staff had the fan running with the fan blowing air across the kitchen; -The substance covered the wall behind the ice machine; -The substance covered the filter on the upper left side of the ice machine; -A greasy, fuzzy substance covered all five ceiling vents in the kitchen. The debris moved back and forth as air blew through the air vents; -The substance coated all of the electrical conduits on the ceiling. Observation of the kitchen on 3/15/23, at 8:52 A.M., showed the no changes from the observation from 3/13/23. During an interview on 3/15/23, at 8:55 A.M., Cook Q, said the following: -There was a cleaning schedule (and grabbed it from the wall); -The kitchen staff did not really follow the cleaning schedule; -He/she did not know why it was not followed and said staff just clean up after themselves to keep the kitchen clean. During an interview on 3/20/23 at 1:04 P.M., Dietary Aide M, said the following: -Management expected him/her to clean and follow the cleaning schedule, but he/she just tried to clean up after himself/herself; -He/she thought the schedule should be followed daily, but is not sure how often it's followed currently; -He/she had cleaned off the front of the ice machine and pointed to the front of the machine; -When asked about the wall behind the ice machine, he/she states he/she was unsure who was scheduled to clean the walls, but said it looked like no one ever cleaned it; -When he/she looked at the fan and the ceiling vents, he/she said they needed to be scrubbed and said he/she thought maintenance completed that task; -He/she said that he/she couldn't believe how bad the build-up actually was, now that it had been pointed out to him/her. During an interview on 3/20/23 at 1:13 P.M., Dishwasher N, said the following: -He/she die not realize there was a separate cleaning schedule that staff was expected to follow; -He/she saw what was pointed out, he/she said he/she found it to be gross; -He/she said with what they are seeing, he/she would not eat from this kitchen; -He/she will work with the kitchen staff to get it cleaner and to make sure it's not covered in the grease and lint. During an interview on 3/20/23 at 1:13 P.M., Evening Cook O said the following: -He/she wished the dietary manager was there to hear the issues because the kitchen staff weren't doing a very good job of understanding what is important to keep a kitchen clean; -He/she used to be the dietary manager of this very kitchen, but any time he/she wanted to do something and it cost more than a few dollars, management would throw a fit and would not allow it; -He/she thought the newer management did not understand what requirements were necessary to keep the kitchen going; -He/she said they saw how grimy the kitchen had become, and it was dirty with grease/lint build-up; -He/she said there was no excuse, because someone should be cleaning all of these things on a regular basis; -He/she believed if it was up high or above their heads, then maintenance was tasked with the cleaning; -He/she feels the rest of the cleaning was up to the kitchen staff to complete; -He/she said the kitchen needed a deep cleaning, starting immediately. During an interview on 3/20/23 at 1:13 P.M., Prep cook P, said the following: -He/she thought maintenance should be doing the vents, braces and everything up high; -He/she did the wires that go up to the ceiling, as high as he/she could reach, stating these get greasy and flies get stuck to them; -He/she said the manager does assign a few chores, but did not think the kitchen staff really listened to him/her; -He/she said the manager was not doing those things either to maintain a clean kitchen. During an interview on 3/20/23 at 2:15 P.M., Transport R said the following: -Who does the cleaning of the ceiling vents and the areas above the walk-ins depends on who was the boss; he/she was never sure who's supposed to clean the upper areas of the kitchen; -He/she had always cleaned the grime from those areas when he/she was maintenance and would come in at night to deep clean; -He/she was unsure if anyone was doing anything towards cleaning the worst areas at this time; -He/she acknowledged the areas above the walk-ins were bad and the filters were dirty, because, if those broke it could put a serious strain on facility operations. During an interview on 3/20/23 at 3:50 P.M., the Maintenance Director, said the following: -He/she had not been in the kitchen for quite a while, but was aware that it could use a good cleaning; -He/she had not personally done anything in or to the kitchen for some time; -As far as he/she knew, the kitchen did their own cleaning; -Maintenance would help with the vents in the ceiling, if needed, but for the most part, he/she thought the kitchen staff cleaned their own vents; -He/she did not currently have a kitchen cleaning schedule; -Maintenance used to do maintenance work/cleaning in the kitchen; -He/she only goes in there as an as needed basis; -He/she did change the filters above the walk in refrigerator and freezer; -He/she did not have a schedule he/she follows for when to change the filters; -He/she did not record when he/she changed the filters; -He/she acknowledged that the filters have not been changed in a really long time and they currently needed to be replaced. During an interview on 3/20/23 at 3:20 P.M., the Administrator and the Director of Nursing (DON) said the following: -Both had already been informed of the condition of the kitchen and knew there were some problems; -The dietary manager (DM) was fairly new and was still trying to figure things out; -The DM was having a hard time getting staff to listen to her and do their assigned duties; -They would be working with both kitchen staff and maintenance to determine who would be cleaning what, to ensure the grime is removed from the kitchen; -A better, more thorough cleaning schedule may be made or they would come up with something to fix these issues.

Based on observation, record review and interview, the facility failed to to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene while completing medication administration for 7 residents (Residents #10, #23, #35, #51, #55, #66, and #69). The facility census was 83. 1. Record review of the facility policy, titled Medication Administration, dated 2/7/13, showed the following information: -Medications are given to benefit a resident's health as ordered by the physician; -Staff should bring the cart to the resident room; -Knock on the door before entering the room; -Introduce yourself, call resident by name, and check picture ID in the medication book; -Wash hands; -Read the label three times before administering the medication; -Administer medication; -Remain in the room while the resident takes the medication; -Return the medication cart to designated location when medication pass is completed. Record review of the facility undated policy, titled Hand Cleanser (Antiseptic), showed the following information: -To cleanse the hands between resident contacts during care and to prevent spread of infection; -Place the container of antiseptic solution on the medication cart; -Wash and dry hands thoroughly in preparation for resident care; -Administer medication or provide care to resident as indicated; -Apply recommended amount of antiseptic cleanser into the palm of the hand; -Rub hands briskly until cleanser has evaporated. Record review of the facility undated policy, titled Gloves, showed the following information: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances and/or persons with a rash. -Gloves must be changed between resident; -Change glove between contact with different residents or with different body sites of the same resident. Record review of the undated facility policy, titled Handwashing, showed the following: -To reduce the transmission of organisms; -Adjust water temperature to comfortably hot water; -Soap hands well, rub briskly, paying special attention to area between fingers; -Use brush to clean under nails as necessary; -Rinse, use paper towel to turn off water and dry hands. 2. Record review of the Resident #69's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: chronic pain syndrome, Type 2 diabetes mellitus, cough, and chronic kidney disease (progressive damage and loss of function in the kidneys). Observation on 3/17/23 at 11:23 A.M., showed Certified Medication Technician (CMT) W at the nurses' station preparing medications for Resident #69 at the medication cart. The CMT did not complete hand hygiene prior to preparing the medications. He/she prepared Gabapentin (nerve pain medication) 300 milligrams (mg), Mucus Relief (Guaifensin - cough expectorant) 400 mg, Methadone (strong pain medication) 5 mg, took the cup of medications and a cup of water to the resident's room. The CMT handed the water cup and medication cup to the resident. The resident took the medication and requested straws for his/her drink cups. The CMT returned to the nurse station and medication cart. He/she charted in the electronic medical record. He/she did not complete any hand hygiene. He/she opened the medication cart and put straws in paper wrapping into his/her pocket. -At 11:35 A.M., the CMT walked down the hall to Resident #69's room and put the straws from his/her pocket on to the resident's bedside table. He/she walked back toward the nurse station and unlocked the medication room to put supplies in the room. He/she then returned to the nurse station and used hand sanitizer. 3. Record review of the Resident #66's face sheet showed the following information: - admitted on [DATE]; -Diagnosis included: malignant neoplasm (cancer) of the lung, chronic obstructive pulmonary disease (COPD - condition involving constriction of the airways and difficulty or discomfort in breathing), and anxiety disorder. Observation on 3/17/23 at 11:28 A.M., showed CMT W prepare medications for Resident #66. The CMT did not complete hand hygiene prior to preparing medications. He/she removed the Morphine sulfate (narcotic pain medication) 20 mg/milliliters (ml) box from the locked narcotic box in the medication cart. The CMT left the nurses station, walked across the dining area to the locked medication room, opened the medication refrigerator, and removed the locked red box. The CMT removed the Lorazepam (antianxiety medication) 2 mg/ml box. He/she walked down the hall to the resident's room. After entering the room, he/she applied gloves without completing hand hygiene. The CMT administered Morphine 0.5 ml by syringe to the resident's mouth and put the syringe and medication bottle back in the box. The CMT administered Lorazepam 0.5 ml by dropper to the resident's mouth and returned the dropper and medication bottle to the medication box. He/she removed his/her gloves and threw the gloves in the trash. The CMT returned to the medication room and returned the medication to the locked box in the refrigerator. He/she returned to the medication cart and put the medication into the locked medication cart. He/she did not complete any hand hygiene. 4. Record review of the Resident #51's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: depressive episodes, anxiety disorder, cognitive communication disorder, and chronic pain. Observation on 3/17/23 at 11:32 A.M., showed CMT W began preparing Resident #51's medication. He/she prepared Buspirone 10 mg and took the medication cup and water into the dining room and handed the cup to the resident. After the resident took the medications the CMT returned to the medication cart and charted in the electronic medication record. He/she did not complete hand hygiene. 5. Record review of the Resident #35's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) with agitation, anxiety disorder, pain, and cerebrovascular disease (loss of blood flow to part of the brain, which damages brain tissue). Observation on 3/17/23 at 11:39 A.M., showed CMT W prepare medications for Resident #35. He/she opened the medication cart and prepared Lorazepam 0.5 mg and Acetaminophen (generic Tylenol) 325 mg, then crushed the medications together and mixed with yogurt. He/she took the medication cup and water into the secured unit. The CMT administered medication into the resident's mouth by spoon. He/she then handed the resident the water cup. He/she took the trash away from the resident and threw in trash can. He/she left the secured unit. The CMT returned to the nurse station and medication cart. The CMT did not complete hand hygiene. 6. Record review of the Resident #55's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: dementia without behavioral disturbance, generalized anxiety disorder, pain in throat, low back pain, and upper respiratory infection. Observation on 3/17/23 at 11:45 A.M., showed CMT W prepare medications for Resident #55. He/she did not complete hand hygiene and prepared Mucus relief 400 mg, Acetaminophen 500 mg, and Tramadol (pain medication) 50 mg. He/she crushed the medications and mixed it with yogurt. He/she went into the secured unit and and gave the resident the medication mixed with yogurt by mouth with a wooden spoon, and held the water cup to the resident's mouth to drink water. He/she then left the unit and returned to the med cart. He/she then used hand sanitizer. 7. Record review of Resident #10's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included Type 2 diabetes mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), and depression. Record review of the resident's physician order sheet (POS), current as of 3/17/2023, showed an order for Tizanidine (muscle relaxant) 2 mg tablets; one every six hours as needed. Observation on 3/17/2023, at 11:35 A.M., showed the following: -CMT A used hand sanitizer prior to dispensing medications for Resident #10; -CMT A opened the medication cart drawer, retrieved four cards of bubble packed pills, and placed them on top of the medication cart; -Holding the card of Tizanidine over a medication cup, the CMT punched out one pill. The pill did not land in the cup, but on the top surface of the cart; -CMT A applied gloves, picked up the pill and placed it in the medication cup; -CMT A took off the gloves and continued dispensing other scheduled medications into the medication cup. During an interview on 3/20/2023, at 10:35 A.M., Licensed Practical Nurse (LPN) E said if a pill dropped onto the surface of the medication cart, he/she would discard that pill and retrieve a new pill that wasn't contaminated. During an interview on 3/20/2023, at 1:54 P.M., CMT B said if a pill fell on the top of the medication cart, he/she would discard it and replace it; the dropped pill would be contaminated. 8. Record review of Resident #10's physician order sheet (POS), showed an order, dated 03/10/23, for staff to cleanse the right stump with Pure n Clean, cover with abdominal (ABD) pad and secure with kerlix (rolled gauze) and tape or surginet (elastic net bandage), daily and PRN (as needed) soilage. Observation on 3/14/23, at 11:44 A.M., showed LPN J pushed the supply cart to the doorway outside of Resident #10's room. The LPN gathered supplies including a clean towel, small trash bag, abdominal pad, a stack of gauze pads, tape and a bottle of wound cleanser. The LPN went into Resident #10's room. The LPN placed a clean towel on the resident's wheelchair and placed supplies on the towel. The LPN applied gloves without performing hand hygiene. He/she then sprayed a clean gauze pad with wound cleanser, and wiped the tape that was affixed to the resident's stump, lifting the tape and removing the bandage. The LPN placed the bandage and gauze pad in a trash bag. He/she removed his/her gloves and placed them in the trash bag. The LPN put on another pair of gloves, without washing or sanitizing hands. The LPN sprayed wound cleanser to the wound and patted it dry with a clean gauze pad. The LPN placed the gauze pad in the trash bag. The LPN then placed an abdominal pad to the wound and secured it with tape. The LPN said he/she needed more tape, left the room, went to the supply cart outside the room, moving a key lanyard with several keys attached, then removed his/her gloves. He/She did not perform hand hygiene. The LPN found a roll of tape and scissors inside the supply cart. He/she cut the tape with the scissors. The LPN then put on new gloves without performing hand hygiene, returned to the resident's room and placed additional tape to the bandage. The LPN dated and initialed the bandage, removed his/her gloves, and placed them in the trash bag. He/she gathered the trash bag, gathered all the remaining supplies and returned to the supply cart. The LPN then used hand sanitizer. During an interview on 03/20/23, at 1:00 P.M., LPN J said the nurse should wear gloves and perform hand hygiene before and after changing gloves and at the end of changing a dressing. During an interview on 03/20/23, at 3:40 P.M., the Director of Nursing (DON) said she expects staff to wash hands prior to starting wound care, at the end of wound care and prior to putting on gloves. The DON said gloves should be worn and changed between dirty and clean dressing change. He/she said staff should remove gloves before touching other things in the resident's room or on the supply cart. During an interview on 03/20/23, at 5:10 P.M., the interim administrator said staff should follow wound care policy, handwashing policy, glove policy and follow the physician orders. 9. Record review of Resident #23's face sheet (a brief resident profile) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included Type 2 diabetes mellitus, hyperglycemia (high blood glucose), chronic obstructive pulmonary disease (lung diseases making it difficult to breathe), and schizoaffective disorder (a condition of psychosis and mood disorder). Record review of the resident's physician order sheet (POS), current as of 03/20/23, showed the following orders: -An order, dated 09/29/22, check blood sugar before meals and at bedtime; -An order, dated 03/10/23, for Novolog U-100 Insulin aspart solution 100 unit/ml (unit of fluid volume); amount: 12 units with meals; subcutaneous (inject under the skin); hold if blood sugar is less than 150. Administer with meals: 7:00 A.M., 12:00 P.M., 5:00 P.M. -An order, dated 10/18/22, for Novolog U-100 Insulin aspart solution 100 unit/ml (unit of fluid volume); amount: Per Sliding Scale; -If blood sugar (BS) is less than 70, call physician; -If BS is 140 to 180, give 3 units of insulin; -If BS is 181 to 240, give 4 units of insulin; -If BS is 241 to 300, give 6 units of insulin; -If BS is 301 to 350, give 8 units of insulin; -If BS is 351 to 400, give 10 units of insulin; -If BS is 401 to 450, give 14 units of insulin; -If BS is 451 to 500, give 16 units of insulin; -If BS is greater than 501, call doctor; -Give subcutaneous (inject under the skin); -With meals: 6:00 A.M. - 8:00 A.M., 11:00 A.M. - 12:00 P.M., 4:30 P.M. - 6:00 P.M. Observation and interview on 03/14/23, at 12:40 P.M., showed LPN J go to Resident #23's room. LPN J sanitized his/her hands and said he/she was not able to check the resident's blood sugar prior to the meal. LPN J cleansed the resident's finger with an alcohol pad and performed the accu-check (blood sugar test) without wearing gloves. The resident's blood sugar reading on the glucometer was 423. LPN J sanitized his/her hands, left the resident's room, went to the medication room to get a new insulin pen. LPN J returned to the resident's room, without performing hand hygiene, applied gloves, opened the box of the new pen, removed the cap, and cleansed the area with an alcohol pad. The LPN applied a new needle to the pen. He/she then dialed the pen to 26 units, cleansed the resident's right upper arm with an alcohol pad, administered the dose. LPN J removed his/her gloves and did not perform hand hygiene. The nurse then pushed the medication cart down the hall to the nurse's station then sanitized his/her hands. 10. During an interview on 3/20/23, at 11:01 A.M., CNA L said staff should wash hands after meals, after restroom use. Hand sanitizer or hand washing should be done before and after every glove change, and hand hygiene should be done between dirty and clean process. During an interview on 3/20/23, at 11:30 A.M., CMT X said hand hygiene should be done between every resident and hands washed after the third resident during medication pass. If a pill lands on the top of the cart or on the floor, or anywhere but in the med cup, the pill should be discarded. During an interview on 3/20/23, at 11:40 A.M., LPN S said staff should wash their hands or use hand sanitizer every time entering and exiting a resident room. Staff should clean hands before touching anything in the resident room and should not touch anything with dirty hands or gloves. During an interview on 3/20/23, at 4:00 P.M., RN T said staff should clean hands before and after any resident interaction, including medications. Staff should discard any pill that fell on the medication cart or the floor. During an interview on 3/20/23, at 3:05 P.M., LPN E said staff should always wash or sanitize their hands before and after resident contact. During an interview on 03/20/23, at 12:40 P.M., Assistant Director of Nursing (ADON) said she expected staff to wash hands and put on gloves prior to performing accu-checks. During an interview on 03/20/23, at 3:40 P.M., DON said he/she expects staff to wash hands before and after performing accu-checks. Gloves should be worn during accu-checks. During an interview on 3/20/23, at 4:30 P.M., with the DON, ADON, Administrator, and corporate nurse. The DON said staff should not touch pills during medication administration and pills that are on the cart or the floor should be discarded and not given to a resident. During an interview on 03/20/23, at 5:10 P.M., Interim Administrator said he/she expects staff to use hand hygiene before, wear gloves while performing accu-checks, and hand hygiene should be done after. Staff should wash hands and wear gloves between accu-checks and insulin administration and between each resident. 41787 48187

Based on observation, interview, and record review, the facility failed to ensure facility staff provided two residents (Residents #8 and #79), who were unable to complete their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene, including showers and nail care, out of a sample size of 23. The facility census was 83. Record review showed the facility did not have a policy available for showers. Record review of the facility provided undated policy, title Nails, Care of (Fingers and Toes), showed the following information: -Purpose to provide cleanliness, comfort, and prevent spread of infection; -The nursing assistant may perform nail care on the residents who are not at risk for complications of infection; -The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease; -Staff should prepare equipment; -Staff should soak the resident hands for five minutes in a basin of warm water; -Scrub nails gently with brush if necessary; -Put hands on a towel. Trim and clean nails and file smooth; -Discard water, clean equipment and wash your hands; -Obtain clean water and soak resident's feet; -Scrub nails gently with brush and remove from basin; -Put feet on clean towel. Trim and clean nails and file smooth; -Apply lotion to hands and feet. 1. Record review of Resident #8's face sheet showed the following: -admitted on [DATE]; -Diagnosis included: Chronic obstructive pulmonary disease (COPD - condition involving constriction of the airways and difficulty or discomfort in breathing), obsessive-compulsive disorder (personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control), chronic pain, congestive heart failure (CHF - chronic condition in which the heart does not pump blood as well as it should). Record review of the resident's physician order sheet, current as of 3/20/23, showed the following: -An order dated 3/8/22, Wound Care Plus to evaluate and treat for toenail care. Record review of the resident's medical record showed the following: -On 10/12/22, Wound Care Plus documented that foot care was completed. Staff used a dremmel (hand-held rotary tool) over the left first and second toe and toenail clipping completed of all toes on both feet. -Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 2/18/23, showed the following: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfer, toilet use; -Required extensive assistance of one staff for locomotion; -Required extensive assistance of one staff for dressing and personal hygiene; -Used a wheelchair for mobility. Record review of the resident's care plan, last reviewed 2/21/23, showed the following: -Resident required assistance with activities of daily living (ADL) related to weakness; -Staff should assist the resident as needed with ADL's; -Staff should not rush the resident; -Staff should document and report any decline in status to the physician. Record review of the resident's medical record showed the staff documented the following: -On 3/7/23, staff documented on the shower sheet that a bed bath was given and the resident refused to have his/her hair washed. Staff did not document any information about nail care; -On 2/28/23, staff documented on the shower sheet that a full bed bath was done. Staff did not document any information about nail care; -On 1/24/23, staff documented on the shower sheet that the resident requested a bed bath. Staff documented that fingernails/toenails were clipped; -On 1/9/23, staff documented on the shower sheet that the resident requested a bed bath. Staff documented that fingernails/toenails did not need to be cut. During observation and interview the following was noted: -On 3/14/23, at 10:52 A.M., the resident said that the aide that assisted him/her on Wednesday was very busy and doing two persons' job. He/she said that the aide massaged his/her left leg and foot and put cream on the dry skin. He/she said that the left toenails are thicker and require a special tool. He/she said someone had been coming in to cut toenails but not any longer. He/she said that his/her toenails and fingernails had not been trimmed for months. He/she said he/she would like to receive a bed bath three times per week. The resident said I smell and the deodorant the facility provides is not any good. The resident's fingernails appear jagged on the right hand and were approximately between one eighth and one quarter inch in length. The resident's left toenails appeared thick and yellow discolored and were approximately between one eighth and one quarter inch in length; -On 3/17/23, at 9:25 A.M., the resident said that his/her toenails had not been trimmed for about three months, he/she had been asking for staff to have someone work on his/her toes. His/her fingernails need trimmed as well but you have to find an aide that has time to trim fingernails. The resident's nails appeared approximately one quarter inch long and the right hand fingernails had jagged appearing edges. The resident's left toenails are thick and have yellow discoloration. The right foot great toenail was approximately one quarter inch long and remaining toenails were longer than the edge of the toe and curled downwards. The resident said he/she had not had a bath or shower for about two weeks and felt gross. He/she was able to get some deodorant to help with the smell; -On 3/20/23, at 10:30 A.M., the resident said he/she was scheduled for a bed bath the following day but the aide would not have time to cut his/her nails because he/she would have about ten baths to complete during the shift. 2. Record review of Resident #79's face sheet showed the following information: -admitted on [DATE]; -Diagnoses included: CHF, COPD, type 2 diabetes mellitus (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), generalized anxiety disorder. Record review of the resident's care plan, last reviewed on 3/20/23, showed the following: -Resident is at risk for decline in ADL's related to the progression of disease process; -Staff should not rush resident; -Staff should document and report any decline in status to the physician; -Resident requires one to two staff for assistance. Record review of the resident's medical record showed the staff documented the following: -On 1/4/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 1/12/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 1/19/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 1/23/23, staff documented on the shower sheet that shower was provided. Staff documented that the resident's fingernails were cut; -On 2/2/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 2/7/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 2/23/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 3/3/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Resident was independent with set up of one staff required for bed mobility, transfers, walking, locomotion, toilet use, personal hygiene; -Resident required one staff supervision, cueing, for dressing and eating. During observation and interview the following was noted: -3/13/23, at 12:43 P.M., the resident was seated in a recliner in his/her room and said that his/her fingernails need trimmed, it had been months since they had been trimmed. He/she said staff did not have time to trim his/her nails; -On 3/17/23, at 3:18 P.M., the resident was ambulating in the hall and showed his/her fingernails. The fingernails were approximately between one eighth and one quarter inch in length. The index finger on both fingers had jagged edges and nails appeared discolored. The resident said that staff had not had time to trim his/her nails. -On 3/20/23, at 11:05 A.M., the resident was near the nurse's desk ambulating in the hall and said his/her nails had not been trimmed. 3. During an interview on 3/20/23, at 11:01 A.M., Certified Nurse Aide (CNA) L said that there was not a scheduled shower aide and that staff on duty should check the list on the shower wall for resident's that are scheduled. He/she said that the aides should complete nail care during showers unless the resident has diabetes. The nurses should do the nail care for diabetic residents or a podiatrist occasionally comes into the facility to diabetic nail care. 4. During an interview on 3/20/23, at 11:40 A.M., Licensed Practical Nurse (LPN) S said the CNA's usually do resident nail care with showers but the nurses can also complete nail care. The nurses will complete nail care on diabetic residents. The facility also has Wound Care Plus that will come for one year on a quarterly basis for a resident with a physician order that has thick or fungus nails. Wound Care Plus has the proper equipment for those residents. 5. During an interview on 3/20/23, at 4:13 P.M., the Director of Nursing (DON) said nurses should ensure the aides provide showers to residents once per week at a minimum. The facility no longer has a designated shower aide. 6. During an interview on 3/20/23, 4:30 P.M., the administrator said that showers should be done twice per week and the facility is working on getting staff to document in the electronic medical record. The paper shower sheets are a tool for nurses to see showers are done and any skin concerns the aides document. Nail care should be done during showers by aides unless the resident is diabetic or on a blood thinner, then DON and Assistant Director of Nursing (ADON) do the nail care.

Based on observation, interview, and record review, the facility failed to obtain physician's orders for bed rail use for two residents (Resident #46 and #69); failed to complete a risk/benefit review and document alternatives attempted prior to bed rail use for two resident's (Resident # 23 and Resident #46); failed to obtain informed consent prior to the use side rails for two resident's (Resident #23 and Resident #46); failed to address the use bed rails in residents' care plans for two residents (Residents #12 and #46); failed to conduct an initial safety gap check for five residents (Residents #12, #23, #36, #46, and #69); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 83. Record review of the (undated) facility policy, titled Bed Rail Policy, showed the following: -Bed rails are adjustable metal or rigid plastic bars that attach to the bed; -They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. -The facility will ensure bed rail evaluations are performed on a regular basis; -Bed rail evaluations will include data collection analysis and determination of potential alternatives to bed rail use. 1. Record review of Resident #12's face sheet (gives basic profile information) showed the following: -admitted to the facility on [DATE]; -Diagnoses included left femur (hip) fracture, muscle weakness, right femur fracture, pain in right hip, history of Coronavirus infection, delusional disorder, anxiety, mild cognitive impairment, history of falling, cellulitis (inflammation of connecting tissue under the skin) of right lower leg, major depressive disorder, restless leg syndrome, and generalized osteoarthritis (degenerative joint disease). Record review of the resident's significant change Minimum Data Set (MDS; federally mandated comprehensive assessment tool completed by facility staff), dated 2/14/2023, showed the following: -Moderately impaired cognition; -Required extensive assistance of one person for bed mobility; -Required extensive assistance of two persons for transfers and toileting; -Frequently incontinent of bowel and bladder; -Wheelchair used for mobility. Record review conducted of the physician order sheet (POS) showed an order dated 3/10/2023: may have side rails for bed mobility, transfers and repositioning. Record review of the resident's electronic medical record (EMR) showed a documented risk informed consent by the responsible party for the use of bed side rails. Record review of the resident's care plan, last updated 2/14/2023, showed no information pertaining to the use of bed side rails. Observation on 3/17/2023, at 3:59 P.M., showed the resident sat in his/her wheelchair facing his/her television; the resident's eyes were closed and head tilted down. On the resident's bed, u-shaped grab bars were fastened to both sides of the bed. During an interview on 3/17/2023, at 4:20 P.M., MDS D gave the surveyor a copy of the resident's informed consent for the use of bed side rails, but said the safety gap measurements were not completed prior to the surveyor's document request. 2. Record review of Resident #46's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Alzheimer's disease, fracture of left femur (at the hip), pain in left hip, influenza, acute upper respiratory infection, cellulitis of left upper arm and both lower legs, polyneuropathy (disorder of multiple nerves throughout the body), repeated falls, restlessness and agitation, and generalized osteoarthritis. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance of one person for bed mobility and toileting needs; -Required extensive assistance of two persons for transfers; -Always incontinent of bowel and bladder; -Wheelchair used for mobility. Record review of the resident's POS, current as of 3/20/2023, showed no order pertaining to the use of bed side rails. Record review of the resident's EMR showed no documented pre-use assessment or informed consent for the use of bed side rails. Record review of the resident's care plan, last updated 2/8/2023, showed no information pertaining to the use of bed side rails. Observation on 3/14/2023, at 11:08 A.M., showed the resident lay in his/her bed. The resident was awake and moving his/her arms and legs. During an interview on 3/17/2023, at 4:47 P.M., MDS D said he/she was not made aware that the resident had side rails on his/her bed and had not completed a pre-use assessment or obtained informed consent for their use. MDS D said staff would need to contact the family to discuss side rail use and complete the safety gap measurement check. 48187 3. Record review of Resident #23's face sheet showed the following information: -admitted on [DATE]; -Diagnoses included Type 2 diabetes mellitus (high blood glucose), hyperglycemia (high blood glucose), chronic obstructive pulmonary disease (COPD-lung disease making it difficult to breathe), schizoaffective disorder (a condition of psychosis and mood disorder). Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with bed mobility and transfers; -Not steady but able to stabilize without human assistance when moving from seated to standing position. Record review of the resident's current care plan, last revised 03/15/23, showed the following information: -On 12/27/22, staff documented that the resident is at risk for decline in activities of daily living (ADLs) related to COPD; -On 12/27/22, staff documented the resident may use partial side rails to assist with bed mobility and to enable more independence when in bed. Record review of the POS showed an order, dated 03/19/23, indicating the resident may have grab bars to assist with bed mobility, transfers, and repositioning while in bed. Record review of the resident's EMR showed the following information: -Staff did not document informed consent for the use of the grab bars; -Staff did not document a pre-use risk evaluation/assessment for the use of the grab bars/side rails. -Staff did not document any gap measurements for the grab bars. Observation on 03/13/23, at 2:05 P.M., showed the resident had U shaped grab bars attached to both sides of his/her bed. During an interview on 03/12/23, at 2:05 P.M., the resident said he/she uses the grab bars to help reposition in bed. The grab bars have been on his/her bed since admission to the facility. During an interview on 03/20/23, at 2:40 P.M., Licensed Practical Nurse (LPN) E said the resident has had grab bars on his/her bed since admission. The resident uses them to reposition. Nursing completes the assessment during the admission process. It is documented in the observation section of the EMR for side rail assessments. Grab bars/side rails are discussed at the morning meetings. The nurse did not know for sure about the consent form or the physician order. He/she does not get the consent form. He/she does not do any gap measurements and did not know for sure who does that. He/she would assume the grab bars would be on the care plan. 41787 4. Record review of Resident #36's face sheet showed the following information: -admitted [DATE]; -Diagnoses included: Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), weakness, repeated falls, dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) without behavioral disturbance. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Extensive assistance of two staff required for bed mobility, transfers, dressing, toilet use, personal hygiene, and locomotion; -Frequently incontinent of bowel; -Had an indwelling catheter (catheter which is inserted into the bladder, via the urethra (duct by which urine is conveyed out of the body from the bladder) and remains in to drain urine); -Wheelchair used for mobility. Record review of the resident's care plan, last reviewed on 3/15/23, showed the following: -Resident has limited mobility or functional status and required use of supportive device for transfers and mobility while in bed; -Staff should explain the risks and benefits of using side rails to the resident and have resident sign consent. If the resident cannot sign consent, must obtain consent from his/her spouse; -Staff should keep physician and family informed of any changes; -Staff should obtain an order from the physician for device and obtain screening from therapy if needed; -Side rail assessment should be completed upon admission, quarterly and annually, or upon change of condition; -Staff should teach the resident safety measures and proper technique. Record review of the POS, current as of 3/20/23, showed the following: -An order dated 7/8/22, for side rail to left upper side of bed, at all times when in bed for repositioning, mobility, and transfers. Record review of the resident's EMR showed the following: -On 10/10/22, side rail consent risks and benefits discussed with spouse and signature obtained; -On 7/8/22, side rail verbal consent by the resident's spouse for left side rail only; -On 7/8/22, side rail measurements for the left side rail only; -On 10/4/21, side rail consent signed by resident's spouse. During observation the following was noted: -On 3/12/23, at 4:07 P.M., the resident was not in the room. The bed had bilateral half size side rails in the upright position. The right side rail had foam type covers. -On 3/13/23, at 12:43 P.M., the resident was seated in a Broda chair (type of wheelchair that provides supportive positioning through a combination of tilt, recline, adjustable leg rest angle, wings with shoulder bolsters and height adjustable arms) at nurses desk. The resident's room showed bilateral side rails in the up position in the resident room and floor mat propped against the wall; -On 3/15/23, 2:33 P.M., the resident was in a Broda chair at the nurses desk. The resident's room showed the bilateral side rails in the down position; -On 3/17/23, at 10:36 A.M., the resident was in a Broda chair at the nurses desk. Bilateral bed rails were in the up position on the resident's bed. During an interview on 3/17/2023, at 4:20 P.M., MDS D gave the surveyor a copy of the resident's informed consent for the use of bed side rails, but said the safety gap measurements were not completed on the right side rail prior to the surveyor's document request. 5. Record review of Resident #69's face sheet showed the following: -admitted on [DATE]; -Diagnoses included: Paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, chronic pain syndrome, chronic kidney disease stage 4. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Extensive assistance of two or more staff for bed mobility, transfers, locomotion, toilet use, personal hygiene; -Extensive assistance of one staff for dressing; -Supervision and set up help for eating; -Required use of a wheelchair for mobility. Record review of the resident's care plan, last reviewed 3/15/23, showed the following: -Resident was at risk for deterioration in bed mobility and injuries due to side rail usage; -Staff should discuss with the resident and family of risks and benefits with use of side rails and sign a consent form every 30 months; -Staff may use partial side rails to assist the resident with bed mobility and to enable more independence when in bed. Record review of the POS, current as of 3/20/23, showed the following: -No orders for side rails or grab bar. Record review of the resident's EMR showed the following: -On 10/27/22, side rail consent form with no signature noted; -On 2/07/2023, staff documented in the progress notes, spoke with the resident and discussed the usage of side rails or grab bars. Discussed the benefits: Bed mobility, transfers and repositioning while in bed. Discussed the risks are skin tears, bruising and bodily injury if he/she tried to climb over them. The resident stated understanding and signed the consent form. Staff should continue to observe for safety and follow plan of care. During observation and interview, the following was noted: -On 3/14/23, at 11:18 A.M., bilateral grab bars in the up position on the bed. The resident said he/she used them to assist staff when repositioning; -On 3/16/23, at 1:05 P.M., the resident rested in bed with eyes closed. The head of bed was elevated and the grab bars were in the upright position; -On 3/20/23, at 9:20 A.M., the resident was in bed with breakfast tray on the bedside table. The resident's grab bars were in the upright position. During an interview on 3/17/2023, at 4:20 P.M., MDS D gave the surveyor a copy of the resident's informed consent for the use of bed side rails, but said the safety gap measurements were not completed on the grab bars prior to the surveyor's document request. 6. During interviews on 3/17/23 at 11:45 A.M. and on 3/20/23 at 1:30 P.M., the Maintenance Director said he does the safety gap measurements for most newly installed side rails. He does not complete measurements on grab bars, he only does measurements on side rails when first installed. The nursing staff notify him when a resident needs side rails, and they have a physician order for installing them. He did not do any routine monitoring or scheduled periodic safety re-checks of side rails. 7. During an interview on 3/17/2023, at 2:30 P.M., MDS D said he/she was not aware until that day that grab bars were considered side rails. They were not previously doing the safety measurements on those, but asked the Maintenance department to do those that day. 8. During an interview on 3/20/23, at 11:40 A.M., LPN S said if a resident or family wanted side rails or grab bars, the nurses should investigate the reason for use, staff will complete a side rail assessment, and maintenance will get the rails onto the bed. Staff should review the risks and benefit consent with the resident or family. Hospice will be notified if it is a hospice resident. 9. During an interview on 3/20/23, at 1:40 P.M., MDS C said nursing gets an order for the use of side rails for positioning and mobility and tells MDS staff. The MDS staff does the pro/con risk assessment and gets consent signed or verbal approval given. Side rail use should be added to the resident's care plan. Side rails should only be used for bed mobility, positioning, and seizure precautions; not as a restraint to prevent falls. He/she said the side rails should have gap measurements when installed. 10. During an interview on 3/20/23, at 3:40 P.M. and at 4:13 P.M., the Director of Nursing (DON) said some residents request side rails or grab bars for positioning. The MDS coordinator makes sure everything is in place including the assessment, consent and added to the care plan prior to putting them on the bed. Maintenance puts the rails on the bed and does the gap measurement. The assessments are found in the Observation section of the electronic medical record (EMR) and he/she did not know for sure where the consent could be located. 11. During an interview on 3/20/23, at 4:30 P.M., with the DON, ADON, Administrator, and corporate nurse, the staff said side rails require evaluation and consent. MDS completes consent and maintenance should measure and install side rails. There are some specialty beds that require rental from another company. Side rails should be documented in the physicians' orders and care plans.

Based on interview and record review, the facility failed to give written information to the resident and/or resident's representative regarding the facility's bed hold policy for five residents (Residents #8, #12, #17, #69, and #83) who were transferred out to the hospital. The facility census was 83. Record review of the facility's Bed Hold Guidelines (undated), showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave; -If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. Signed authorization must be received within 24 hours of the discharge if it occurs during the week. Signed authorization must be received by the first business day following the discharge if it occurs on a weekend or holiday; -If the resident or resident representative does not choose to hold the bed, the bed will be released and any personal belongings must be picked up within three days; -Bed holds are strictly voluntary. If the bed is not held and is not available when the resident wants to be readmitted , the resident's name will be placed on a waiting list for the next available bed; -At the bottom of the guidelines page, the resident or responsible party are to indicate choice and sign/date to hold (at the defined daily rate) or not hold the bed. 1. Record review of Resident #12's face sheet (gives basic profile information) showed an admitted [DATE]. Record review of resident's nurses' notes showed the following information: -On 1/18/2023, at 1:09 P.M., the resident was in the shower room receiving a shower. After the shower was completed, the aide was transferring the resident to a wheelchair. The resident started slipping; the aide lowered the resident to the floor. Resident complained of mild pain to the right leg; no swelling or abnormal alignment noted. Resident did not hit his/her head. Resident was assisted back up into the wheelchair and propelled him/herself without any issues. Staff notified the physician and attempted to contact the responsible party with no answer at that time. Report was given to oncoming shift staff; -at 5:30 P.M., the resident was noted to have bleeding from skin tears to both feet; three toes on the left foot were black and blue. Resident said he/she hadn't hit his/her feet on anything, but had a fall earlier in the day and his/her feet went under him/her; the aide caught him/her. Resident expressed a pain level of 10/10 to the right leg and was unable to lift it at that time; the resident described pain from the knee up past the hip. The Nurse Practitioner, Director of Nursing, and nurse on call were notified; the resident was transferred to the hospital. Record review of the resident's electronic and paper medical records showed staff did not document notification to the resident or resident's responsible party in writing of the facility's Bed Hold Policy when the resident was transferred to the hospital on 1/18/2023. 41787 2. Record review of Resident #8's face sheet showed the following information: -admitted [DATE]; -Re-admitted [DATE]; -Diagnoses included: Chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), urinary tract infection (an infection in any part of the urinary system, includes the kidneys and bladder), congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), obsessive-compulsive disorder (personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others). Record review of the resident's discharge Minimum Data Sheet (MDS - a federally mandated assessment tool completed by facility staff), dated 10/4/2022 showed the resident discharged to the hospital with a return anticipated. Record review of the resident's entry MDS, dated [DATE], showed the resident was readmitted to the facility. Record review of the resident's medical record showed staff did not provide any documentation regarding the facility's bed hold policy to the resident or resident's representative at transfer to the hospital. Record review of the resident's progress notes, dated 12/16/2022, showed staff documented the following: -1:18 P.M., staff documented a phone call with physician regarding lab results of white blood cell (WBC - number of white cells in the blood, part of the immune system to fight of infections) count results at 22.9 (normal 4 to 11), physician ordered to send the resident to the emergency room for evaluation. Staff contacted the ambulance for transport. -At 1:21 P.M., staff notified the resident's family member by phone of the transfer to the hospital; -At 1:55 P.M., resident left the facility by ambulance; -At 11:24 P.M., staff documented the resident returned to the facility per ambulance at 6:15 P.M. He/she arrived by ambulance stretcher, was alert and talkative. The diagnosis was urinary tract infection (UTI). He/she received intravenous (IV) antibiotics in the emergency room and has a new order for Levaquin (antibiotic to treat infections caused by bacteria) 500 mg tablet, to take 1 tablet by mouth daily for the next 10 days. During an interview on 3/17/2023, at 9:24 A.M., Resident #8 said that he/she had not been provided any information about a bed hold policy when he/she was sent to the emergency room a few months ago but he/she returned to the same room. 3. Record review of Resident #17's face sheet showed the following information: -admitted to the facility on [DATE]; -Re-admitted [DATE]; -Diagnoses included: Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), chronic ischemic heart disease (heart problems caused by narrowed heart arteries that supply blood to the heart muscle), cognitive communication deficit, urinary tract infection. Record review of the resident's medical record showed staff documented the following information: -On 12/21/2022, at 7:09 P.M., nursing aide staff alerted the nurse staff that the resident had an episode during evening cares at 6:35 P.M., where he/she became flaccid (party of the body hanging loosely or limply) and incontinent of bladder (loss of bladder control). This was not normal for the resident. Upon entry into the room at 6:40 P.M., the vital signs showed blood pressure 148/78, pulse 68, oxygen saturation 98% on room air, and temperature of 96.8 degrees. The resident appeared diaphoretic (sweating heavily), however, was responding within normal limits to questions asked. Notified the on call provider and received orders to call the family to see if okay to send to the hospital for evaluation and treatment. Called resident's family and received approval to send the resident to the hospital. Notified the DON and the on call provider of approval to send for evaluation. The resident left via ambulance at 6:58 P.M., with face sheet and code status; -On 12/22/2022, at 5:27 A.M., the resident returned from the emergency room by ambulance. The resident arrived on the stretcher to his/her room at 4:00 A.M. Per documentation from emergency room the resident had a diagnosis of UTI. The resident was given intravenous (IV) fluids and antibiotics at the hospital. The resident had new orders for Keflex (antibiotic used to treat a variety of bacterial infections) 500 mg, 1 capsule every 8 hours for 7 days. The resident was assisted into his/her bed by the ambulance staff and facility staff. The resident's family member was made aware of the resident's return and diagnosis. Vital signs obtained upon arrival were blood pressure 133/69, pulse 68, temperature 98.1, and oxygen saturation of 94%; -On 03/07/2023, at 6:22 P.M., the nurse received a call from the laboratory at 5:55 P.M., in regards to a critical hemoglobin (Hgb - protein in red blood cells that carries oxygen) of 6.5 (normal range 12 to 17). The provider was called and gave the order to send the resident to the emergency room for a blood transfusion. Called the resident's family at 6:06 P.M. to update on the current situation. Notified the DON and the ambulance was called and the resident was transported to the emergency room at 6:15 P.M.; -On 03/08/2023, at 3:23 A.M., the resident returned to the facility at 3:05 A.M. from the emergency room . The resident arrived on a stretcher with two medical attendants. The resident was assisted into bed by the two attendants and facility staff. Vital signs included blood pressure 99/59, pulse 91, temperature 98.2 degrees and oxygen saturation 96% on room air.; -On 3/08/2023, at 6:44 A.M., staff called the provider to let him/her know the resident returned back to the facility, and notified the family of the resident's return. Record review of the resident's electronic and paper medical records showed staff did not document notification to the resident or resident's responsible party in writing of the bed hold policy related to the resident's transfer to the hospital on 12/21/2022 or 3/8/2023. Record review on 3/17/23 of the facility provided ombudsman Transfer Log Notice for the month of December 2022 and for the month of March 2023 showed Resident #17's name not listed on the transfer notice log to the ombudsman. SSD H wrote that resident did not stay overnight so a transfer notice was not sent to the responsible party. 4. Record review of Resident #69's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included: Atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), urinary tract infection, type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), chronic pain syndrome, chronic obstructive pulmonary disease, and chronic kidney disease (CKD - kidneys are damaged and cannot filter blood the way they should). Record review of the resident's progress notes showed staff documented the following information: -On 03/12/2023, at 1:06 P.M., the resident complained of not feeling well, the resident had wheezing in his/her lungs bilaterally, productive cough, oxygen saturation at 75%, and refusing to wear oxygen. The nurse had put oxygen on the resident multiple times and when the aide told the resident he/she needed to wear it the resident said he/she didn't have to and told the aide to shut up. The resident's eye balls were rolling in the back of his/her head and sweating. The on call provider was contacted and gave an order to send the resident to the emergency room for evaluation. The ambulance staff arrived and left the facility around 1:00 P.M.; -On 3/12/2023, at 5:30 P.M., the resident arrived back to the facility via ambulance services at 5:30 P.M., via stretcher. Report was called from the hospital and the only thing they could find wrong with the resident was that when he/she takes off the oxygen his/her oxygen saturation drops down shortly thereafter. The resident was alert and oriented upon arrival, no new orders were given by the hospital, will continue to observe. Record review of the resident's electronic and paper medical records showed staff did not document notification to the resident or resident's responsible party in writing of the bed hold policy related to the resident's transfer to the hospital on 3/12/2023. Record review, on 3/17/2023, of the facility provided Transfer Notice Log for the month of March 2023 showed Resident #69's name was not on March 2023 transfer notice log for 3/12/2023. Social Services Director (SSD) H wrote that the resident did not stay overnight so a transfer notice was not sent to the responsible party. 5. Record review of Resident #83's face sheet showed the following information: -admitted on [DATE]; -readmitted on [DATE]; -Diagnoses included: cerebral vascular accident (stroke), chronic kidney disease, type 2 diabetes, and dementia. Record review of the resident's medical record showed staff documented the following information: -On 11/29/2022, at 12:28 P.M., the resident was transferred to the hospital by ambulance; -On 12/02/2022, at 12:51 P.M., the resident returned to the facility. Record review of the resident's discharge MDS, dated [DATE], showed the resident discharged with return anticipated. Record review of the resident's entry MDS, dated [DATE], showed the resident's re-entry to the facility. 6. During an interview on 3/17/2023, at 9:50 A.M., Licensed Practical Nurse (LPN) G said when a resident is sent to the hospital, the nursing staff sends a face sheet with diagnosis, medication list, and any pertinent documentation such as lab results. The nursing staff notifies the resident's family by phone. The nursing staff does not send any written notice of hospital transfer or bed hold policy to the family but the facility does hold the bed for the resident. 7. During an interview on 3/17/2023, at 11:50 A.M., LPN J said when a resident is transferred to the emergency room the staff send a face sheet and medication sheet. The nurse calls the family with resident transfer status, he/she said he/she did not know about the bed hold policy information. 8. During an interview on 3/17/2023, at 11:52 A.M., the Director of Nursing (DON) said she would be completing in-services that day regarding the need to send bed hold guidelines to the resident's responsible party. She said the facility had not been sending bed hold notices. 9. During an interview on 3/17/2023, at 11:55 P.M., with SSD H and SSD I, the staff said they send a written hospital transfer notice the day after a resident is sent to the hospital. They enter the transfer to the Transfer Notice Log and the date the notice was mailed to the family. They then mail this log to the ombudsman on the first day of the following month. He/she puts a date at the top of the log when it was mailed to the ombudsman. SSD H said he/she had never seen the bed hold guidelines form that DON provided. SSD H said that he/she had not mailed a bed hold form to any family members. They do not keep a copy or proof of the mailed letters to family. SSD I said when a resident was sent to the emergency room and was not out of the facility overnight, the staff do not send a written transfer notice to the family and had not sent the bed hold information for any transfers. 10. During an interview on 3/20/2023, at 4:30 P.M., with the DON, ADON, Administrator, and Quality Assurance nurse, the DON said that when a resident was transferred to the hospital an emergency transfer notice is mailed to the family by the business office after admission to the hospital. The nursing staff verbally discussed bed hold information, and it was provided on resident admission to the facility. The bed hold notice had not been attached to the transfer notice when mailed.

Based on observation, interview, and record review, the facility failed to provide a clean and homelike environment when staff failed to replace/fix ceiling tiles damaged by a water leak for one resident (Resident #10), failed to repair damage on two residents' (Residents #8 and #72) bedroom walls, and failed to change ceiling tiles that were stained from water leaks in the resident hallways and dining rooms. The facility census was 83. The facility did not have a specific policy pertaining to the repair of walls or ceiling tiles. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), depression. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/12/23, showed the resident as cognitively intact. Observation on 03/13/23, at 10:07 A.M., showed a 1.5 foot (ft) x 2 ft area on the ceiling in Resident #10's room. The area was various shades of brown ring stains with a 4 inch by 4 inch area near the center of the stain, that bulged downward. During an interview on 03/13/23, at 10:07 A.M., Resident # 10 said he/she told the maintenance assistant last month about the discolored ceiling tile in his/her room. He/she told the resident he/she would change the ceiling tile out. He/she also told the resident that they have a bucket in the ceiling above the resident's room collecting water due to the roof leaking. The resident was concerned because he/she has paintings and other belongings that could get ruined due to the leaking roof and damaged tile. Every time the resident has mentioned it to maintenance, the maintenance staff says he will get it done. 31464 2. Record review of Resident #72's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). Observation on 3/17/2023, at 9:30 A.M., of the resident's room showed the following: -The mattress rested on the floor; on top were two pillows and a sheet left in disarray; -The walls to the head and side of the mattress were very marred; the paint was scraped off and the surface gouged. 3. Observation on 3/17/2023, at 3:55 P.M., in the main corridor leading toward the 200 resident hall, showed the following: -The ceiling above the left side smoke barrier door contained a large dinner plate sized black area, fuzzy in appearance. The black area faded outward to a rust color; approximately the size of a serving platter. 41787 4. Record review of Resident #8's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - chronic condition involving constriction of the airways and difficulty or discomfort in breathing), urinary tract infection (UTI - infection in part of the urinary system, including kidneys or bladder), and obsessive-compulsive disorder (disorder in which a person feels compelled to perform certain stereotyped actions repeatedly to alleviate persistent fears or intrusive thoughts). Observation on 3/14/23, at 11:05 A.M., of the resident's room showed the following: -The walls at the head of the resident's bed had a large area of approximately 10 by 10 inches of paint scraped off the wall and the surface was gouged. During an interview on 3/17/23, at 10:30 A.M., the resident said that his/her bed drifted into the wall at some point in the past. He/she was unsure if the staff were aware of the large area of damage on the wall. 5. Observation on 3/15/23, at 12:10 P.M., in the facility showed the following: -In the 500 hall, there were six ceiling tiles with brown ring stains varying in size from approximately 4 inches in diameter to approximately 12 inches in diameter; -In the 500 hall dining area, there were two air vents that had brown to black discoloration and paint chipped away from the vents, there was black fuzz appearance at the vent; -In the 500 hall dining area, there were ten ceiling tiles with brown to gray discoloration and varying sized of stained appearance from approximately 4 inches in diameter to covering over 50 percent of the ceiling tile; -In the 300 hall, there were two ceiling tiles near the skylight on ceiling with large brown wet stain appearance and discoloration, one tile of approximately 6 to 8 inches wide and the full length of the tile of approximately 20 inches with dark brown wet appearance and bowed downward out of the ceiling; -The 300 hall had eight ceiling tiles that were brown stained in appearance with varying sizes from approximately 4 inches to 10 inches in diameter; -The carpet in the 500 hall dining room, showed multiple red stains, such as Kool-Aid appearance stains, white stains and brown stains throughout the dining room carpet. The stains ranged from softball size to plate size. Observation on 3/17/23, at 3:39 P.M., in the main dining room showed the following: -Approximately 13 ceiling tiles with varying sized of brown and gray wet appearing stains throughout the dining room; -At the main entry to dining room, the first skylight had 2 tiles that were brown stained with approximate size of 10 inches in diameter; -Above the coffee and drink bar station there were two panels that covered the entire ceiling panel in dark brown stain appearance. 6. During an interview on 3/20/23, at 10:50 A.M., Housekeeping K, said that if he/she finds an environment concern when working, he/she will notify the housekeeping supervisor. If there is a dirty or stained carpet, he/she will notify the staff that cleans the carpet daily. And if finds damage to ceiling tiles, walls, or broken items, he/she will notify the maintenance staff. He/she had seen maintenance changing ceiling tiles in the past. 7. During an interview on 3/20/23, at 11:01 A.M., Certified Nurses Aide (CNA) L said that if he/she sees any stains, damage, or repairs needed, he/she will let the housekeeping supervisor or the maintenance department know. The housekeeping supervisor will notify maintenance. 8. During an interview on 3/20/23, at 1:30 P.M., the Maintenance Director said that there are currently new ceiling tiles on order. There are water leaks after every rain and they could change the tiles multiple times throughout the year. The ceiling tiles should be changed when soiled. The carpet stains are cleaned the best they can every day. The carpets look new compared to two years ago. 9. During an interview on 03/20/23, at 3:40 P.M., the Director of Nursing (DON) said she did not know of any water damage. Residents can report damage to herself, a nurse or maintenance. 10. During an interview on 3/20/23, at 4:30 P.M., the administrator said that every time it rains they would have to change ceiling tiles. The Corporate maintenance is aware and when they finish another job they will come fix the roof. She said they cannot get the red and white stains out of the carpet, it is from the thickened liquids, and they will be asking corporate if they can change the carpet to tile or flooring in order to manage spills better.

Based on observation, interview, and record review, the facility failed to promote resident self-determination when staff failed to provide routine baths or showers to one resident (Resident #10). The facility had a census of 83. The facility did not have a shower policy. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admitted on [DATE]; -Diagnoses included Type 2 Diabetes Mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), and depression. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/12/2023, showed the following: -Cognitively intact; -Independent with transfers; -Required physical help with part of bathing activity. Record review of the resident's current care plan, last revised 03/15/2023, showed the following: -Had an activities of daily living (ADLs - dressing, grooming, bathing, eating and toileting) deficit and required assistance with ADLs; -Resident at risk for decline in ADLs related to decreased functional status/rehabilitation potential; -Interventions included resident required 1-2 person(s) assistance; -Staff not to rush resident. Record review of the resident's Skin Monitoring: CNA Shower Review sheets showed the following: -Staff documented providing the resident one shower during the month of March 2023 (03/09/2023). -Staff did not document providing the resident any showers during the month of February 2023. -Staff documented providing the resident two showers during the month of January 2023 (01/04/2023, 01/18/2023). -Staff documented providing the resident three showers during the month of December 2023 (12/07/22, 12/14/22, 12/21/22). Observation on 03/13/23, at 10:14 A.M., showed the resident as clean and well groomed. During an interview on 03/13/23, at 10:14 A.M., the resident said he/she had a bath last Thursday (03/09/2023), but prior to that has not had a bath in one and a half months. The resident said his/her scheduled shower days are Mondays and Thursdays. The resident said he/she feels yucky when he/she does not get a bath. During an interview on 03/20/23, at 10:25 A.M., Certified Nurse Aide (CNA) R said showers are mostly given in the evenings. There is a shower schedule at the nurses' station. There is one aide on each hall. They provide all the care, including showers, toileting, everything. The facility no longer has a designated shower aide and there is not enough staff to get showers done. Typically, there are 2-3 showers scheduled per day that are supposed to be completed. Sometimes, he/she gets one shower completed, sometimes none. If a resident requests a shower, the aide tries to make time and give the shower to that resident. There is a shower record on the electronic medical record (EMR) under ADLs where the aide documents the shower given. If a resident refuses a shower, staff document it and have the resident sign the skin sheet (Skin Monitoring: CNA Shower Review sheet). The aide had not given any showers yet on this day, but did complete two showers the day before. The residents probably get one shower a week, but staff try to give two showers a week. During an interview on 03/20/23, at 11:00 A.M., Licensed Practical Nurse (LPN) J said he/she believes all residents get weekly baths. There is a shower schedule on the nurses' station desk. Showers are scheduled twice a week by room number. If a resident refuses a shower, the CNA will have the resident sign the skin sheet (Skin Monitoring: CNA Shower Review sheet) and the nurse signs it also. The LPN could not show or find documentation of any additional baths given to Resident #10. During an interview on 03/20/23, at 12:00 P.M., the social services assistant said he/she is able to view additional shower dates in the EMR. After looking in the EMR, he/she could not find any additional dates that staff assisted Resident #10 with showers. During an interview on 03/20/23, at 4:25 P.M., the MDS Coordinator said he/she adds the days the residents prefer baths to the care plan. All residents should receive two baths per week. However, due to staffing, that is not happening. No one has complained to him/her about not getting enough baths. During an interview on 03/20/23, at 12:40 P.M., the assistant director of nursing (ADON) said normally residents should receive showers twice per week. Resident #10 does not normally refuse showers so it is likely the resident went that long without a shower. The main documentation for showers is the skin observation form (Skin Monitoring: CNA Shower Review sheet). The ADON looked in the EMR regarding shower documentation for Resident #10. She noted two shower records, 1/19/2023 and 3/10/2023 for Resident #10. The ADON has had residents complain about not getting showers. Prior to Covid, the facility had a designated shower aide and now they do not have the staff to give baths routinely. If she hears complaints, staff try to get the resident to the shower. Sometimes, it is sporadic if they do not have a shower aide. The facility does not have enough staff to get showers completed. The facility is aware, they just do not have the staff. The facility used to have a designated shower aide, but now there is not enough staff to have a designated person. During an interview on 03/20/23, at 3:40 P.M., the director of nursing (DON) said that CNAs or certified medication technicians (CMTs) give showers. Some residents have missed showers. It is expected that one bath per week to be given as the bare minimum. The nurse should remind the aides and organize them to ensure that baths are given. If a resident requests a shower, the facility tries to get the staff to give the shower. The facility currently does not have a designated shower aide and the facility has enough trouble to keep enough aides just to work the floor (to provide basic activities of daily living). The facility is just trying to keep things going the best they can with what they have. Resident #10 has not complained to her about showers. During an interview on 03/20/23, at 5:10 P.M., the interim administrator said staff should follow the policy on baths when questioned regarding expectations of the facility regarding providing baths to residents.

Based on record review and interview the facility failed to identify, assess and notify the physician, for at least 33 hours, when one resident (Resident #15) had unusual swelling of his/her left ankle and new persistent signs and symptoms of pain including crying out and guarding of his/her ankle. After the physician was notified, X-rays showed the resident had a lower leg fracture. The total sample of residents reviewed was 21 residents. The facility had a census of 121. Record review of the facility's Nursing Guidelines Manual, dated March 2015, regarding Condition Change to include Observing, Recording and Reporting for resident injury showed the following: -Staff should monitor residents after all injuries or changes in physical or mental function. -Observe for swelling and discoloration and if present document size, site, amount and color; -Observe for pain; -The facility has identified unusual swelling as an incident that would warrant an investigation; -Staff should notify the physician of condition change, need for treatment orders and/or medication order changes; -When the nurse is unable to reach the attending physician or on call physician, call the facility medical director for emergency situations; -Staff should complete an incident report; -Staff should notify the resident's responsible party; -Staff should monitor the resident's condition frequently until stable. 1. Record review of Resident #15's face sheet showed staff admitted the resident to the facility on [DATE]. His/her [DIAGNOSES REDACTED]. Record review of the resident's care plan dated 4/04/14, and updated on 8/10/16, showed the following information: -The resident received hospice services; -Had impaired cognition due to dementia; -Had decreased mobility, strength and endurance; -Required half side rails to assist in repositioning, comfort and mobility; -Required extensive assist of one staff with dressing and other activities of daily living; -Required extensive assist of two staff and the use of a mechanical lift with transfers and toileting; -At risk for pain; -Staff to monitor and document any complaints of pain and any non-verbal signs of pain to include crying, guarding, moaning, restlessness, grimacing, diaphoresis (sweating) and withdrawal; -Administer medications as ordered for pain, monitor and document the effectiveness; -Follow-up with the physician. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 11/11/16, showed the following: -Brief interview for Mental Status (BIMS) assessment showed cognition was severely impaired; -No behaviors; -Required extensive assistance from staff for transfers, bed mobility, dressing, eating, and toileting; -Required total assistance from staff for hygiene and bathing; -Only able to stabilize with staff assistance when moving from a seated potion to a standing position, moving on and off the toilet and transferring from the bed to a chair or wheelchair; -He/she weighed 86 pounds. Record review of the resident's January 2017 physician's orders [REDACTED]. -Assess the resident's pain every shift; -[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) (a strong pain reliever), 10 milligrams (mg)/325 mg, every 4 hours as needed for pain. -[MEDICATION NAME] (a narcotic pain medication) 2.5 mg every 8 hours. Record review of the resident's nurses' note, dated 01/30/17, at 4:31 A.M., showed: -A nurse documented the resident was guarding his/her left ankle and complained of pain; -A nurse assessed the resident and found swelling to the resident's left ankle; -The resident's ankle had no visible no deformity, but range of motion was limited; -Staff administered as needed pain medication to the resident; -The nurse left a message for the physician; -The nurse would monitor the resident and continue to contact the physician; -The nurse did not document any follow-up that he/she ensured notification of the physician or the director of nursing (DON). Record review of the 24-hour nursing report, dated 1/30/17, showed the following; -The nurse who worked the night shift (10:00 P.M. to 6:00 A.M.), documented the resident complained of pain and had left ankle swelling. Staff left a message for the physician and documented in the physician book the resident may need an X-ray; -The day nurse (6:00 A.M. to 2:00 P.M.) did not document any information regarding the resident; -The nurse who worked the evening shift (2:00 P.M. to 10:00 P.M.) documented the resident had no complaints of pain; -Staff did not document any further attempts to notify the physician of the resident's new complaints of pain or swelling of his/her left ankle. Record review of the January 2017 Medication Administration Record (MAR) showed the following: -Assess the residents' pain every shift; -01/01/17-01/30/17, on all three shifts, staff documented a 0 indicating the resident had no pain; -On 1/30/17 a nurse initialed the MAR indicating he/she administered [MEDICATION NAME], to the resident. The nurse did not document on the back side of the MAR the date, time, medication, reason for administering and the follow-up results of the medication to ensure effectiveness; -On 01/31/17, the day and evening shift staff did not document assessing the residents pain (those sections of the MAR were left blank). During an observation on 2/3/17, at 10:35 A.M., the resident laid in bed with his/her right leg extended and his/her left leg pulled up close to him/her. The resident was very small and frail in stature. The resident was totally dependent on staff for all cares. The resident was alert with confusion. During an interview on 2/07/17 at 10:05 A.M., Licensed practical nurse (LPN) O said the following: -On 01/30/17 he/she worked the 10:00 P.M. to 6:00 A.M. shift and was the resident's nurse, but he/she did not work with the resident on a day-to-day basis; -LPN O documented at 4:31 A.M., Certified Nurse Aide (CNA) F told LPN O the resident was holding his/her left ankle and seemed to be in pain; -LPN O assessed the resident and found the resident's left ankle swollen. The resident was tearful at times, but that morning the resident's tears seemed to be more pain related. The resident was grimacing and holding his/her left leg which, as far as he/she knew, was not the resident's normal behavior; -LPN O administered as needed [MEDICATION NAME] to the resident for pain but was unaware he/she needed to document the time administered, reason for giving the pain medication, or the result to show whether the medication was effective on the back of the MAR; -The LPN O attempted to contact the physician but was unable to reach him, so he/she left a voicemail; -LPN O did not contact the DON to report the resident's change in condition. It was only swelling and he/she would only contact the DON if the resident had a visible break in the bone; -LPN O documented the concerns regarding the resident's left ankle in the 24-hour reporting book; -LPN O told LPN Q (the oncoming nurse) he/she was unable to reach the physician, but the resident had swelling and pain in his/her left ankle and may need an X-ray of his/her leg. Record review of the nurses' notes dated 1/31/17, at 1:38 P.M., a nurse documented the resident had swelling to his/her left lower ankle. He/she notified the physician and received orders for an X-ray of the resident's left lower ankle/foot. Record review of the X-ray report, dated 1/31/17, showed an acute (recent) spiral fracture (breaking of the bone, in which the bone has been twisted apart) of the resident's left lower leg. Record review of the resident's care plan, updated on 1/31/17, showed the following information: -Assess for any signs or symptoms of pain or discomfort to include crying, guarding and facial expression every shift and as needed; -Administer scheduled and as needed pain medications per physician orders; -X-ray per physician orders; -Fracture to left leg; -Boot to left lower extremity for support, report any signs or symptoms of complications to the physician. During a telephone interview on 2/6/17 at 3:00 P.M., CNA G said the following: -The resident required a mechanical lift and two staff for transfers; -The resident did not talk much and was confused; -If the resident was in pain, he/she would yell and grab the area that was hurting; -On 1/29/17 during the day shift, the resident was holding and guarding his/her left leg. This was not the resident's normal behavior, he/she did not normally guard or grab at his/her leg, this behavior was out of character; -The CNA G did not report this behavior to anyone; -CNA F, who was going off shift on 1/30/17, reported to CNA G the resident's leg was swollen and the resident was complaining of pain; -CNA G worked a double shift on 1/30/17 and the resident's leg was swollen and the resident was yelling out in pain; -CNA G told LPN O the resident's leg was swollen and he/she was yelling out in pain; -He/she was not sure if LPN O assessed the resident or if the LPN reported the change in the resident's condition to anyone else; -The resident continued on both shifts to guard his/her left leg and yell out in pain more when staff were repositioning or transferring the resident from wheelchair to bed or transferring the resident from bed to wheelchair; -He/she did not report the continued swelling or pain issues to the second shift nurse. During an interview on 2/07/17, at 9:20 A.M., CNA D said the following: -The resident was confused and required two staff and a mechanical lift for all transfers and extensive assistance from staff with all Activities of Daily Living (ADLs); -On the morning of 1/29/17, CNA F reported to him/her and CNA U that the resident was hurting and was grabbing at his/her left leg. The resident did not normally grab at his/her left leg. When staff transferred the resident, the resident cried out but the cries did not sound like his/her normal cries. The resident cried out, at times, like a habit or a little tic, but not normally in pain. These behaviors the resident exhibited were different, not the cries for attention, these were cries of hurting. CNA D reported to the charge nurse (could not remember what nurse) the resident was in pain but he/she was unsure if the nurse assessed the resident; -On 1/30/17 CNA G said he/she was told at shift change the resident left leg was swollen and the resident was still in pain. CNA D reported the resident's condition regarding the swelling and pain in the residents left leg to LPN Q. CNA D was not sure if LPN Q assessed the resident; LPN Q did not always listen to the CNAs concerns; -On 1/31/17, the resident's leg remained swollen and he/she was still in pain. Again, CNA D reported the resident's condition to the charge nurse (could not remember what nurse) because he/she did not think anything had been done. After CNA D went off shift, the DON called and asked him/her to return to the facility to write up a statement regarding the incident; -Prior to 1/29/17 the resident did not show any signs of pain. During an interview on 2/07/17 at 10:25 A.M., CNA U said the following: -He/she worked the 6:00 A.M. to 2:00 P.M. shift on 1/29/17. At change of shift (when CNA U came to work) an unknown CNA told him/her the resident had been holding his/her leg. The resident continued through CNA U's shift to hold his/her leg and looked like he/she was in pain; -CNA U reported to an unknown charge nurse on duty, but was not sure if the nurse ever assessed the resident. During an interview on 2/07/17 at 10:35 A.M., CNA F said the following: -He/she worked on 1/28/17 and 1/29/17, from 10:00 P.M. to 6:00 A.M., -The resident required two staff with a Hoyer lift for all transfers; -On 1/29/17, CNA F reported to the charge nurse (could not remember what nurse) the resident was holding his/her left leg. When going off shift, CNA F told CNA D the resident was holding his/her left leg and was hurting; -On the morning of 1/30/17, CNA F reported to LPN O the resident was holding his/her leg and was hurting. When going off shift, CNA F told CNA G the resident was holding his/her left leg and was hurting. On 1/30/17, LPN O assessed the resident; -The resident did not normally hold his/her leg or have pain issues; -It had been hard providing care for the resident due to his/her pain and him/her holding his/her leg. During an interview on 2/07/17 at 10:55 A.M., LPN P said the following: -The resident was not alert and oriented and was non-verbal. The resident required total assistance from staff with all cares; -LPN P worked a 16 hour shift on 1/28/17 from 6:00 A.M. to 10:00 P.M. The resident was his/her usual self and showed no signs of pain; -On 1/30/17 LPN Q informed LPN P the resident had some swelling and pain in his/her left leg and may need an X-ray. LPN Q said the physician had been notified; -LPN P said no CNAs had reported the resident was in pain or any change in condition on 1/30/17; -LPN P talked with the physician on 1/30/17 about another resident and if he/she had known LPN Q had not followed up with the physician regarding Resident #15's condition, he/she would have reported the concerns at that time; -On 1/31/17 the resident was holding his/her left leg close to him/her and showed signs of pain when staff tried to look at his/her leg. On 1/31/17 staff obtained an X-ray of the resident's left ankle which showed the resident had a fracture in his/her left leg. During an interview on 2/07/17 at 11:10 A.M., Registered nurse (RN) S (RN S was a hospice nurse not employed by the facility) said the following: -The resident had been on hospice for over a year. The resident was alert to self with confusion and was non-verbal. He/she required total assistance from staff with all cares; -The resident's left leg had been contracted (abnormal shortening of the muscle tissue and highly resistant to stretching) for some time. The resident did not have any pain issues. The resident had an order for [REDACTED]. -On 1/31/17, at approximately 12:30 P.M., RN S observed the resident and the resident showed no signs of pain. RN S was not aware the resident had an injury. During an interview on 2/07/17 at 11:50 A.M., a hospice aide said the following: -He/she was the hospice shower aide for the resident; -On 1/30/17, the resident had tubi-grip (a multi-purpose tubular bandage that provides comfortable and effective tissue support) on his/her left leg half way up the leg and half the foot. The tubi-grip was put on wrong; they were twisted and hard to remove. The residents left ankle/foot was swollen. The hospice aide had never seen the resident with tubi-grips on his/her legs; -He/she reported to this concern of the tubi-grips and the swollen ankle/foot to LPN Q. At the time he/she reported the information to LPN Q, the LPN was performing blood glucose monitoring on other residents. The LPN did not assess the resident at that time and said he/she would look at the resident later. Record review of the current physician's orders [REDACTED]. During an interview on 2/07/17 at 1:40 P.M., CNA E said the following: -He/she worked the 2:00 P.M. to 10:00 P.M. shift; -The resident required total assistance from staff with cares; -On 1/30/17 the resident's ankle was swollen and he/she was told X-ray would be in later. (The X-ray was not ordered until 1/31/17); -If any resident showed signs of pain or changes in condition he/she would report to the charge nurse. During an interview on 2/02/17 at 4:30 P.M., the resident's physician/medical director said: -The resident was not alert and oriented and required total assistance from staff with ADLs. The resident was unable to bear any weight on his/her legs and feet (staff had to transfer the resident with a mechanical lift); -He did not receive any missed calls or voicemails from the facility regarding the resident's change in condition until 1/31/17 when he ordered the X-ray and the results showed a fracture in the residents ankle; -The resident did not typically grab or guard his/her body parts, this would be a change in the resident's condition; -Staff should have notified the physician and the DON if there was a change in the resident's condition. During an interview on 2/07/17 at 2:50 P.M., the DON said the following: -Staff should report any change in a resident's condition to the physician, family, administrator and DON; -If staff could not reach the physician, they should ensure that the DON is aware of the resident's condition; -An injury of unknown origin should be reported to the physician and the DON immediately; -Staff should report any increased pain or swelling that is out of the ordinary to the physician and the DON; -Staff should document in the nurses' notes any changes in a resident's condition and that a full assessment was completed; -Staff should document when they administer as needed pain medication on the MAR and document the date, time, reason for giving the pain medication and the result showing whether the pain medication was effective on the back side of the MAR; -If a resident continued to have swelling and pain or change in condition, staff should continue to report to the next shift and/or report to the DON. #MO 772

Based on observations, interviews, and record review, the facility failed to put interventions in place to ensure one resident (Resident #10) maintained adequate body weight. Staff did not provide adequate assistance and cueing with meals, did not follow the resident's nutritional orders, did not implement weight loss interventions identified in the resident's care plan, and did not maintain an accurate care plan to address the resident's risk for weight loss and impaired nutritional status. Resident #10 had a 12.6 pound loss, which represented 12.7 % of the the resident's body weight (a severe weight loss) in less than 30 days. The facility failed to maintain body weight of one resident (Resident #18) when staff did not appropriately assess, monitor, document and follow physician's orders [REDACTED]. The resident complained of a cough and was treated with an antibiotic. Resident #18 withdrew from social and dining activities and had a weight loss of 10 pounds or 8.2 % severe loss in less than 30 days. The facility failed to offer meal alternatives and implement dietitian recommendations for one resident (Resident #19), who had a severe weight loss of 29 lbs. or 14% in 10 weeks. The facility census was 110. 1. Record review of Resident #10's significant change Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 8/28/13, showed the following information: -Highly impaired hearing; -Severely impaired vision; -Severely impaired decision making; -Required oversight, encouragement or cueing for eating, setup help only; -Total dependence on staff for transfers, locomotion, dressing, toilet use, personal hygiene, and bathing. Record review of the readmission record dated 7/24/13, showed the resident had [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. -Offer a regular diet (ordered 2/24/11); -Offer double portions of desserts for extra calories (ordered 1/22/09); -Give health shakes with meals two times a day (ordered 4/22/12); -Give fortified mashed potatoes when on menu (ordered 3/4/13); -Give VHC (High calorie supplement) four times a day with medications (ordered 12/29/05). Record review of the Nutritional Risk Assessment completed by staff on 5/4/13, showed staff assessed the resident had increased risk of impaired nutritional status. Record review of the nutritional progress notes dated 5/24/13, and signed by the dietary manager, provided the following information: -Provide a regular fortified diet, offer a health shake two times a day, and double deserts; -Required meal set up and much encouragement; -Appetite fair; -Weight stable, yet below ideal body weight. Record review of the nutritional progress notes dated 8/22/13, and signed by the dietary manager, provided the following information: -Provide a regular diet, offer health shakes with meals, double desserts, and fortified mashed potatoes when available; -Required staff set up with meals and explanation of plate due to poor eyesight; -No teeth; -Appetite fair; -Weight fairly stable. Record review of the dietary consultation, performed by a registered dietitian (RD), dated 9/24/13, showed the following information: -The resident's weight at 83 pounds, down from 92 pounds last week; -The resident's weight fluctuated a bit; -Weight loss was a nutritional concern; -The resident had no teeth, and fed self; -Encourage and assist with meals, with a goal for 50% intake and stable weight. Record review of the care plan on 11/21/13, showed the following information: -Staff last updated the care plan on 5/29/13; -Required assistance with activities of daily living and fed self; -Diet per medical director's order, eats with occasional prompts and encouragement to finish meal; -Offer food preferences to avoid dislikes; -Offer substitutes for uneaten foods; -On 12/14/12, staff noted on the care plan the resident did not have orders for between meal nourishments; -Staff did not update the care plan to address the resident's need for assistance, encouragement, set up, and explanation of plate due to poor eyesight, during meal times. Staff did not update the care plan to address the resident's orders for health shakes with meals two times a day, double dessert portions, fortified mashed potatoes (when available), and high calorie/high protein supplements with medications four times a day. Record review of the medical record on 11/21/13 showed a care plan conference form dated 8/29/13, with the following dietary information discussed by staff: -Regular diet, with double portion desserts, health shakes with meals, and fortified mashed potatoes when available; -Resident with no teeth; -Staff did not document the resident's orders for high calorie supplements with medications four times a day; -Staff failed to update the resident's care plan with the information discussed during the 8/29/13 care plan conference in the folder located at the nurse's station, which remained dated 5/29/13. Record review of the weight variance report showed the following weights: -8/6/13: 90 pounds; -9/9/13: 90 pounds, 9/16/13: 92 pounds, 9/23/13: 83 pounds (9 pound loss. 9.7% severe weight loss in less than 30 days); -10/6/13: 91 pounds, 10/13/13: 85 pounds (6 pound loss. 6.5 % sever weight loss in less than 30 days), 10/20/13: 89 pounds, 10/27/13: 93 pounds; -11/6/13: 99 pounds, 11/13/13: 86.4 pounds (12.6 pound loss. 12.7 % severe weight loss in less than 30 days), 11/20/13: 89.6 pounds. Observations on 11/19/13 beginning at 11:30 A.M., showed the following: -The resident sat at a table in the secured unit dining room; -Staff brought and set up the lunch meal for the resident; -Staff did not provide the resident with a health shake or double desert; -From 11:30 A.M. to 11:50 A.M. the resident drank all of his/her water and ate no food; -From 11:50 A.M. to 11:58 A.M., the resident fell asleep at the dining room table; -At 11:58 A.M., a staff person woke the resident, and encouraged the resident to eat. The resident grabbed a cubed shaped piece of corn bread off his/her plate, and used his/her gums to nibble small pieces off the edge; -At 12:02 P.M., the resident fell asleep, staff woke the resident at 12:15 P.M.; -From 12:15 P.M. to 12:28 P.M., staff began feeding the resident without warming the food back up; -At 12:36 P.M., staff assisted the resident from the dining room. Record review of the meal intake record for the lunch meal on 11/19/13, showed staff documented the resident with 75% meal intake, and 360 cc's of fluid intake. Observations on 11/20/13 at 8:50 A.M., showed the resident in the secured unit dining room at a table with uneaten breakfast food in front of him/her, and no health shake. From 8:50 A.M. to 9:05 A.M., staff did not encourage or assist the resident with eating. At approximately 9:05 A.M., staff assisted the resident from the dining room. Staff did not offer the resident a substitute for the uneaten food. Record review of the meal intake record for the breakfast meal on 11/20/13, showed staff documented the resident with 10% food intake, and 0 fluid intake. Observations on 11/20/13 at 11:45 P.M., showed the resident in the secured unit dining room with lunch food in front of him/her. Staff did not provide the resident with a health shake or double desserts. From 11:45 A.M. to 12:10 P.M., the resident did not eat. At 12:10 P.M., staff encouraged the resident to eat, and the resident began picking at his/her food. From 12:10 P.M. to 12:30 P.M., the resident used his/her hands, picked up his/her chicken fried steak covered in gravy, and tore a piece off. The resident used his/her gums to chew on the piece of chicken fried steak, but he/she could not bite off a piece. At 12:30 P.M., staff assisted the resident from the dining room without providing any other encouragement to eat or offering a substitute for uneaten food. Record review of the meal intake record for the lunch meal on 11/20/13, showed staff documented the resident with 10% food intake, and 240 cc's of fluid intake. During an interview on 11/22/13 at 9:40 A.M., certified medication technician (CMT) P said it should be documented in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observations of the MAR indicated [REDACTED]. After reviewing the resident's physician's orders [REDACTED].M. and 12:00 P.M. Record review of the MARs for July, August, September and October of 2013, showed staff did not document administration of the health shakes with breakfast and lunch as ordered by the physician. During an interview on 11/22/13 at approximately 10:15 A.M., the dietary manager said the following about the resident: -The resident is a picky eater and fluctuates with intake; -Staff provide fortified mashed potatoes when available; -Staff provide double desserts with meals for increased intake; -Staff provide health shakes with breakfast and lunch; -The dietary manager said he/she brought the resident a health shake yesterday (11/21/13) when he/she noticed the resident did not get one with lunch, -When told the resident did not receive health shakes and double desserts with breakfast and lunch from 11/18/13 through 11/21/13, the dietary manager said she expected staff to provide the health shakes and double desserts as ordered by the resident's physician; -The dietary manager said he/she expected staff to provide cueing, encouragement, and offer substitutes to increase the resident's intake. During an interview on 11/26/13 at 10:10 A.M., CNA V said staff need to cue and encourage the resident to eat. CNA V said staff give ice cream at times when the resident will not eat. During an interview on 11/26/13 at 10:30 A.M., CNA W said the resident required set up and encouragement to eat. CNA W said staff offer the resident peanut butter and jelly sandwiches and ice cream at times when the resident will not eat. Observations on 11/27/13 at 8:20 A.M. showed the resident did not receive a health shake with lunch. During an interview on 11/27/13 at 8:35 A.M., Dietary Worker X said the facility ran out of health shakes, and they should be receiving a delivery of them later today. During an interview on 11/27/13 at 11:30 A.M., the DON said she expected staff to follow physician's orders [REDACTED]. Staff should have assisted and cued Resident #10 during the meals. The staff should report to the nurse if a resident was not eating or required increased assistance at meals. Staff should follow the orders and should have given Resident #10 the nutritional supplements. If the dietary department was out of a supplement, she expected them to notify nursing so they could supply a supplement to the resident. The DON said staff had not made her aware of Resident #10's weight loss. 2. Record review of Resident #18's medical record showed [DIAGNOSES REDACTED]. Record review of the progress note, dated 7/25/13, the physician documented the following information:-Chief complaint: He/she was seen at his/her request to evaluate a cough;-Resident stated he/she developed a cough that has gotten much worse over the last 2-3 days. His/her throat feels like he/she gets choked at times but it was due to having such a hard cough. -Impression: cough;-Plan: start antibiotics and get a chest x-ray just to make sure there are no infiltrates (abnormal substance that accumulates in the lungs. Can represent many things including pneumonia and other infections). Record review of the progress note, dated 8/19/13, the physician documented the following information:-Chief complaint: evaluation and management of resident's cough;-The resident does have some coughing at times;-Impression: cough but the physician had questioned if it was more of a dysphagia (swallowing trouble) cough; Record review of the website www.aslha.org American Speech Language Hearing Association showed the following information:-General signs of swallowing disorders may include:-Coughing during or right after eating or drinking;-Wet or gurgly-sounding voice during or after eating or drinking;-Extra effort or time needed to chew or swallow;-Food or liquid leaking from the mouth or getting stuck in the mouth;-Recurring pneumonia or chest congestion after eating;-Weight loss or dehydration from not being able to eat enough;-As a result, adults may have:-Poor nutrition or dehydration;-Risk of aspiration (food or liquid entering the airway), which can lead to pneumonia and [MEDICAL CONDITION];-Less enjoyment of eating or drinking;-Embarrassment or isolation in social situations involving eating. Record review of the August 2013 POS showed the physician wrote orders dated 8/19/13, for the following information:-Chest x-ray;-Speech therapy evaluation for swallowing and cough;-[MEDICATION NAME] (cough syrup) every 6 hours as needed. Record review of the chest x-ray, dated 8/20/13, showed chronic lung finding with developing right lower lobe infilitrates. Follow-up recommended. Record review of the nurse's notes showed the following information:-On 8/21/13, showed new orders for antibiotic twice a day for ten days related to pneumonia; -On 8/23/13, coarse lungs sounds, cough noted. Record review of the progress note, dated 8/26/13, the physician documented the following information:-Chief complaint: Resident had a recent chest x-ray that showed a right lower lobe infiltrate. The resident said he/she was still coughing despite being on an antibiotic.-Impression: Acute pneumonia and cough;-Plan: will add additional antibiotic for ten days. Record Review of the POS [REDACTED]. Record review of the progress note, dated 9/23/13, the physician noted the following information: -Resident did complain of some cough, does not appear to have infection at this time;-Plan: Get ST evaluation on the cough and get a chest x-ray in the morning. Record review of the nurse's notes, dated 9/24/13, showed an order for [REDACTED]. During an interview on 11/25/13 at 2:11 P.M., the assistant director of nursing (ADON) said she called the mobile x-ray. They only completed a chest x-ray on the resident on 8/20/13 and 11/23/13. The 9/24/13 x-ray was not completed. Record review of the medical record showed staff did not complete a ST evaluation as ordered on [DATE]. Record review of the weight record showed the following information:-Weight 10/18/13: 121.4 pounds. Record review of the nutritional progress notes dated 10/23/13, showed the dietary manager (DM) documented the resident could feed self and make any dietary changes known. Weight was up since admission. No chewing issues reported. Nutritional needs were being meet. Record review of the care plan dated 7/23/13, and reviewed on 10/24/13, showed the following information:-Resident alert and oriented x3;-Resident fed self;-Weigh monthly, monitor for significant weight changes; -Staff did not implement problems, goals and approaches to address the resident's cough. Record review of the weight record showed the following information:-Weight 11/6/13: 113.8 pounds (8 pound loss. 6.5% severe weight loss in less than 30 days). Record review of the nutritional progress notes showed the DM did not document any additional information after 10/24/13. The DM did not address the resident's severe weight loss. Record review of the care plan showed staff did not implement problems, goals and interventions to address the resident's severe weight loss. Record review of the nurse's notes showed the following information:-On 10/31/13, the resident started to choke on undigested food. He/she was able to bring the food up on his/her own. The resident's lungs were clear. After coughing a couple of times, he/she went back to eating. Staff did not document they notified the physician of the incident. During the initial tour of the facility on 11/18/13 at 10:15 A.M., the ADON said the resident was alert and oriented. The resident was interviewable. He/she was mostly independent with most care. The resident fed him/herself in the dining room. The ADON said the resident did not have any weight concerns. Record review of the physician's orders [REDACTED]. Record review of the nurses' notes showed the following information:-Between 10/31/13 to 11/22/13, staff did not document any additional information in the notes.-On 11/23/13, the nurse documented new orders for antibiotics, chest x-ray and speech evaluation. During observation and interview on 11/25/13, showed: -At 9:45 A.M., the resident sat in a chair in his/her room. The resident was short in stature and thin-framed. The resident said he/she had been coughing and just did not feel good. The restorative nurse aide (RNA) entered and told the resident it was time for exercise activity. The resident said he/she did not feel well and did not want to start coughing "out there". The RNA said the resident usually goes to the activities, and hardly ever misses one. As the resident talked, he/she had increased amounts of saliva present and would spit small amounts of saliva.-At 1:30 P.M., the resident sat in a chair in his/her room. The resident said he/she was still coughing and did not want to go to the dining room for lunch. He/she was "gonna miss Bingo too, just gets to coughing and gets embarrassed". Record review of the weight record showed the following information:-Weight 11/25/13: 111 pounds (10 pound loss. 8.2% severe weight loss in 30 days). During an interview on 11/25/13 at 2:05 P.M., the therapy program director said the following information:-When nursing staff received an order for [REDACTED]. She was not aware of the speech therapy evaluation orders. During an interview on 11/25/13 at 2:10 P.M., LPN P said the following information:-When staff received therapy orders, they would either tell the therapy department verbally or give them a note for the evaluation. -When staff received orders for an x-ray, they were to call the mobile x-ray service with the orders. Record review of the 11/23/13 chest x-ray showed the following information:-X-ray completed on 11/23/13,-Results showed no infiltrates.-RN B documented he/she notified the physician of the results on 11/25/13. During an interview on 11/25/13 at 2:20 P.M., the DON said the following:-When the nurse received new orders, they were to note the order on the POS, and in the notes;-If there was an order for [REDACTED]. During an interview on 11/25/13 at 2:50 P.M., the resident said he/she had been coughing for a while. He/she has to spit phlegm out in the trash can. The resident has coughing spells. Staff give him/her a cough medication, but he/she can only have it every so often. The resident had his/her friend bring in some cough drops. The resident said he/she had not been going to the dining room or activities as much because of the coughing spells. The resident said sometimes he/she had trouble swallowing food. The resident just had to chew his/her food slower and chew it up. As the resident talked, he/she had increased amounts of saliva present and he/she would spit small amounts of saliva. During an interview on 11/26/13 at 10:40 A.M., the speech language pathologist (SLP) said the following information:-Several months ago there was an order for [REDACTED]. But, she should have documented the evaluation.-She had not received any further speech evaluation requests from the nursing/dietary staff;-She was not aware the physician had continued to request the evaluation two additional times;-She was not aware of the resident's choking incident on 10/31/13;-She does have an order now for a speech evaluation to be completed. She started the evaluation today and saw the resident this morning;-The SLP said she had noticed the resident having increased saliva, and the resident could possibly be aspirating on his/her own saliva. During an interview on 11/27/13 at 9:00 A.M., the dietary manager (DM) said the following information:-The resident was not on the registered dietitician's (RD) list yesterday (11/26/13). The RD did not see the resident yesterday;-Last Friday (11/22/13) the DM witnessed the resident having a bad cough. The cough did not seem to prevent him/her from eating. The staff give the resident cough medication, which seemed to help;-The resident was able to voice his/her needs and preferences and did not need any staff assistance;-She was not aware of the resident having a choking incident on 10/31/13;-The departments heads used to discuss the resident's weights weekly but not as much anymore;-On admission, staff weight the resident weekly for four weeks then monthly;-If a resident had a weight concern, staff would add them to the weekly weights;-She was not aware of which staff weighed the resident. The medical record's staff gathered the residents weights and dispersed them to the department heads.-She was not aware the resident had a weight loss in the last 30 days. During an interview on 11/27/13 at 11:30 A.M., the DON said she did not know that staff had not notified therapy of the ordered speech evaluation and was not aware the resident had any weight loss concerns. 4. Record review of Resident #19's re-admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Required assistance for transfers, ambulation, toileting, and bathing; -Ate independently with no difficulty with chewing or swallowing. Record review of the resident's weight chart showed the following information: -On 8/30/2103 - 207 pounds (lbs.); -On 9/23/2013 - 200 lbs.; -On 10/04/2013 - 194 lbs.; -On 10/25/2013 - 189 lbs.; -On 11/13/2013 - 178 lbs. Record review of the nutritional risk assessment showed staff documented on 9/7/2013 the resident was on a regular diet, no supplements, no difficulty with chewing or swallowing, no adaptive devices required for eating, no mental impairment, no wounds present, mild [MEDICAL CONDITION] present, and no appetite stimulant required. Staff documented the total risk score for the assessment as "1" (score of 5 or more = increased risk). Staff did not document a nutritional risk assessment on any other date. Record review of the meal intake records showed staff documented the resident usually consumed 100% of his/her breakfast, 75% of his/her lunch, and did not eat at the evening meal (fluid intake only). Record review of a dietary consultant visitation note dated 9/24/2013 showed RD S documented a plan to continue to monitor weight, and recommended to add one chocolate shake daily for added calories (the resident agreed). Record review of the dietary card showed a regular diet. The resident did not like carrots and did not drink milk. Staff did not document any nutritional supplements on the dietary card. Record review of the MAR indicated [REDACTED]. Record review of the nurses' notes showed the following information: -On 11/12/2013 - Appetite and fluid intake good; -On 11/17/2013 - Appetite and fluid intake good; -On 11/19/2013 - Appetite and fluid intake good. -Staff did not document information pertaining to the resident's weight loss. During an interview on 11/26/2013 at 11:00 A.M., the resident said he/she did not want to eat the regularly served evening meals because of related stomach discomfort during the night. He/she said he could probably eat an alternative food, such as a bowl of cereal or something else bland and light, if staff offered it to him/her. The resident said staff had not discussed with him/her about not eating the evening meals, nor did staff offer him/her something different for the meals. During an interview on 11/27/13 at 11:30 A.M., the DON said she expected staff to check with residents on their food likes and dislikes. Staff should have offered the resident a different choice for his/her evening meals. 5. During an interview on 11/26/2013 at 12:17 P.M., RD T said two registered dietitians (RDs) from the consulting agency come to the facility for three eight-hour days each month. The RDs are given referral forms by the DM (dietary manager) for any resident who is of nutritional and/or weight loss/gain concern. The DM receives input from other staff who monitor residents' weights and nutritional status. The RD completes an assessment for each resident of concern, and documents a plan and recommendations on the visitation note. A copy of the visitation notes are given to the administrator, DON, and DM. If a recommendation requires a physician order, a separate copy is given to the physician. 6. During an interview on 11/27/13 at 11:30 A.M., the DON said the following: -Back in October, she did have concerns with the recording and accuracy of weights. She now has one aide that weighs the residents through the week and the aides on the weekends assist as needed;-She expected staff to weigh the resident's and report the gains and/or losses to the nurse. If the weight was really different than the previous weight, she expected staff to re-weigh the resident. -The interdisplinary team meets to discuss the residents with weight concerns following quarterly care plan meetings. The DM then submits the names to the RDs on a referral form. The ADON is responsible for obtaining physician orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure staff documented complete, accurate and consistent pressure ulcer assessments to include size, stage and a description of the pressure ulcers, failed to perform wound care using current infection control guidelines, failed to perform physician ordered treatments, and failed to complete the treatment as ordered for four residents (Resident #4, #5, #7 and #8). Staff failed to offer and/or attempt to reposition three residents (Resident #4, #5, and #7), which had the potential to cause further deterioration of the pressure ulcers in a sample of 19 residents. The facility had a census of 110. Pressure ulcer staging according to the U.S. Dept. of Health and Human Services Clinical Practice Guidelines #15: -Stage I pressure sore (a persistent area of skin redness without a break in the skin, that is nonblanchable) -Stage II pressure sore (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) -Stage III pressure sore (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to but not including the bone) -Stage IV pressure sore (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures) 1. Record review of Resident #7's Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 9/5/13, showed the following information:-Severely impaired cognitive decision-making;-Total dependence on staff for mobility;-Extensive staff assistance for transfers, toileting and personal hygiene;-Urinary catheter;-Occasionally incontinent of bowel;-Pressure relieving device for bed and chair;-Staff did not check the section for turning and positioning; -At risk for pressure ulcers;-Unhealed pressure ulcers;-One Stage III pressure ulcer;-Measured length 0.7 centimeters (cm) x width 0.3 cm x depth 0.9 cm Record review of the care plan conference form dated 9/5/13, showed staff did not address the resident's Stage III coccyx pressure ulcer. Record review of the resident's care plan dated 3/23/13 and last reviewed on 9/5/13, showed the following information: -Resident had very short term memory and periodic confusion; -Call light in reach at all times while in the room;-Stage III wound on coccyx;-Position change every two hours and as needed;-Two assist for all transfers;-Skin inspection weekly, monitor skin while in the shower and with care;-Use the wheelchair cushion for pressure reduction when resident is in the chair. Avoid shearing the resident's skin during positioning, transferring and turning;-Staff did not document any problems, goals or interventions of the resident's choice to remain up in the wheelchair for long periods, or any refusals of care and/or if any behaviors were present. Record review of the resident's initial wound assessment documentation, dated 9/13/13, showed the following information:-Stage III pressure ulcer, full thickness on the resident's coccyx (tailbone);-Acquired at the facility on 11/16/2011; -Measured length 1.0 cm x width 0.5 cm x depth of 1.5 cm. -Interventions: turn every two hours, keep skin clean and dry, airbed;-Risk factors: impaired mobility. Record review of the weekly wound report showed on 9/19/13, 9/26/13, and 10/3/13, the assistant director of nursing (ADON) documented the weekly assessment. The pressure ulcer remained approximately the same at 1.0 cm diameter x depth 1.4 cm; Record review of the progress note dated 11/5/13, the physician documented the resident had an area on the coccyx covered at this time, but continuing wound treatment. Recommendations through wound clinic. Continue current plan of care. Record review of the resident's weekly wound report showed the following information:-On 10/10/13, 10/17/13, and 10/24/13, the ADON documented the weekly assessment. The pressure ulcer remained approximately the same at 1.0 cm diameter x depth 1.4 cm;-On 10/31/13 and 11/7/13, the ADON documented the weekly assessment. The pressure ulcer measured length 0.9 cm x width 1.0 cm x depth 1.4 cm. The ADON did not document a description of the peri-wound, treatment and any special devices;-On 11/15/13, the ADON documented the weekly assessment. The pressure ulcer measured length 0.1 cm in diameter x depth 1.7 cm. During an interview on 11/18/13 at 10:40 A.M. and 2:00 P.M., the ADON said she was in charge of the wound tracking. The ADON said the wounds were measured every Thursday. She tried to look at the wounds weekly, complete the wound tracking and report the findings to the corporate office. Back in August, she noticed staff were having trouble finding out when a pressure ulcer developed, so she started tracking them. She started wound books for each of the halls. However, she had not seen the wounds in the last few weeks. (ADON documented the wound assessment and signed the weekly report for the last 9 weeks). Observation and interview on 11/19/13, showed the following information:-At 9:06 A.M., the resident sat in the wheelchair in his/her room. The resident sat on a pressure relieving device (PRD). The resident's call light was on the recliner behind the resident and not in the resident's reach;-At 9:12 A.M., 9:22 A.M., 9:32 A.M., and 9:42 A.M., the resident remained in the same position; -At 9:52 A.M., and 10:02 A.M., certified nurse assistant (CNA) F entered to assist the resident's roommate. CNA F did not offer and/or attempt to reposition the resident or place the call light within the resident's reach;-At 10:12 A.M., 10:22 A.M., 10:32 A.M., and 10:40 A.M., the resident remained in the same position. CNA G entered with linens for the resident's roommate. CNA G did not offer and/or attempt to reposition the resident or place the call light within the resident's reach;-At 10:50 A.M., 11:01 A.M., 11:15 A.M., 11:25 A.M., and 11:30 A.M., the resident remained in the same position and call light was not in reach;-At 11:35 A.M., the resident yelled out, "Hey, I need to go to the bathroom. Anyone there? Hey!" The resident propelled his/her self into the bathroom. The resident sat in the wheelchair in front of the toilet. The resident yelled out, "Anyone out there?" The surveyor stepped in the bathroom to check on the resident. The resident said he/she had already went to the bathroom and just needed toilet paper. The resident used toilet paper, reached down the front of his/her pants, wiped his/her front peri-area and left the toilet paper in the front of his/her attend; -At 11:40 A.M., CNA F and CNA G wheeled the resident to the dining room for lunch. -At 11:55 A.M., 12:10 P.M., 12:30 P.M., and 12:50 P.M., the resident remained in the same position in the wheelchair at the table in the dining room;-At 12:58 P.M., and 1:05 P.M., the resident sat in the wheelchair and the call light was not in reach;-At 1:08 P.M., a CNA wheeled the resident's roommate into the room, placed the roommate's call light in reach. The CNA did not offer and/or attempt to reposition the resident or place the call light within the resident's reach;-At 1:15 P.M., the resident remained in the same position;-At 1:30 P.M., CNA F entered the room, emptied the resident's urinary catheter drainage bag. CNA F did not offer and/or attempt to reposition the resident or place the call light within the resident's reach;-At 1:35 P.M., 1:45 P.M., 1:55 P.M., and 2:00 P.M., the resident remained in the same position. -At 2:10 P.M., day shift, CNA F and CNA G said they got the resident up this morning around 6:30 A.M. The resident was a two person assist. -Staff did not offer and/or attempt to reposition the resident for at least 7 and a half hours. The resident sat in a position that applied pressure to his/her Stage III coccyx pressure ulcer. During an interview on 11/19/13 at 2:15 P.M., evening shift, CNA J and CNA K said staff should toilet and reposition the resident every two hours. CNA F and CNA G did not report anything specific on the resident at shift report. They were not aware the resident had been up in the wheelchair all day. Staff should offer and/or attempt to get the resident to lay down. During an interview on 11/19/13 at 2:20 P.M., registered nurse (RN) B said he/she expected the aides to offer and/or attempt to reposition the resident every two hours. During an interview on 11/19/13 at 2:22 P.M., the Director of nursing said the resident was able to communicate his/her needs to the staff. Staff used a PRD in the resident's wheelchair. The resident had a Stage III pressure sore on his/her coccyx. The resident was two person assist. Staff should reposition the resident every two hours. The DON said she expected the staff to follow the care plan. Record review on 11/19/13, of the wound clinic physician's orders [REDACTED]. of [MEDICATION NAME] (dressing that kills bacteria, manages exudate, and debrides the wound bed) every day and as needed;-Wheelchair cushion;-Seat lifts or shift position in chair every 15 minutes. Record review of the November 2013 POS and treatment administration record (TAR) showed the following information:-Coccyx: -Cleanse wound with normal saline (the order did not instruct staff to irrigate the wound as ordered by the wound clinic physician);-Cleanse wound with mild soap and water with dressing changes;-[MEDICATION NAME] to peri-wound;-Pack with [MEDICATION NAME], cover with a thin layer of [MEDICATION NAME] every day and as needed;-On 11/12/13 and 11/18/13, evening staff did not initial they completed the coccyx dressing changes as ordered. Staff did not document on the back of the TAR the reason why they did not complete the dressing change. Observation and and interview on 11/19/13, at 2:25 P.M., showed the following information:-CNA J and CNA K assisted the resident into the bed, positioned the resident onto his/her left side, pulled down his/her pants and attends. -Registered Nurse (RN) H placed a pillowcase on the bedside table as a barrier and placed the wound care supplies on the pillow case. RN H did not wash his/her hands or use sanitizer and applied gloves;-RN H removed a bandage from the resident's lower leg, with the same gloves. RN H removed the dressing from the resident's coccyx. The dressing was dated 11/17/13. RN H confirmed the dressing was dated 11/17/13;-The soiled dressing was saturated with a bloody brown drainage. The pressure ulcer had a foul smell. The area was nickel-sized with visible depth. The peri-wound was pinkish-red with scarring present;-RN H used a cotton swab to measure the area. Measured length 1.0 cm x width 0.5 cm x depth 1.0 cm (11/15/13 measured 0.1 cm in diameter x depth 1.7 cm).-RN H removed his/her gloves and applied new gloves. RN H did not wash his/her hands or use sanitizer.-RN H cleansed the pressure ulcer with normal saline and gauze. RN H did not irrigate the wound and did not cleanse the pressure ulcer with mild soap and water as ordered;-RN H packed the pressure ulcer with the [MEDICATION NAME]. He/she did not sanitize his/her scissors (multi-use equipment used on other residents), cut a piece of the [MEDICATION NAME] and placed it over the [MEDICATION NAME] and covered the area with the [MEDICATION NAME].-RN H said he/she was the charge nurse on 11/18/13. He/she did not complete the resident's coccyx treatment as ordered. RN H said he/she reported to the night nurse of the treatment not being done. During an interview on 11/21/13 at 11:40 A.M., the administrator and DON said staff should complete the treatments as ordered, the pressure ulcer treatments should be a priorty. Record review of the weekly wound report dated 11/21/13, showed the ADON noted the following information: The pressure ulcer measured length 0.5 cm x width 0.9 x depth 1.2 cm. 2. Record review of Resident #5's medical record showed the facility admitted the resident on 8/6/13, with [DIAGNOSES REDACTED]. Record review of the interim care plan (completed on admission and updated by staff until the full comprehensive care plan was completed) dated 8/6/13, showed the following information: -Required assist with care; -Alert and oriented to person and place; -Pressure ulcers/wounds; -Incontinent of bowel; -Urinary catheter in place; -On 9/26/13, staff handwrote: wounds to bilateral heels. Treatment as ordered; -Staff did not document any further updates to the care plan. Record review of the 5 day medicare MDS dated [DATE], showed the following information: -Severely impaired cognitive decision-making skills; -Extensive staff assistance for mobility, transfers, toileting and personal hygiene;-Urinary catheter; -Incontinent of bowel; -Pressure ulcer risk; -Stage I pressure ulcer; -Pressure relieving device to bed and chair;-Staff did not check the area for turning and repositioning. Record review showed staff completed a 14 day Medicare MDS on 8/20/13 and a 30 day Medicare MDS on 9/13/13. Staff never completed a comprehensive care plan to address the resident's problems, goals and interventions. Record review of a care plan update dated 10/21/13, showed, in part, the following information: -Existing/risk for pressure ulcer; -Pressure relieving device in wheelchair; -Treatment as directed; -Turn every two hours. Record review of the wound clinic physician orders [REDACTED]. -Seat lifts or shift position in chair every 15 minutes: Buttock very red, please reposition; -Orders noted and signed on 10/30/13 by RN B. Record review of the nurses' notes between 10/29/13 to 11/10/13, showed staff did not document any additional information regarding the resident's left buttock pressure ulcer. Record review of the weekly skin assessment dated [DATE], showed the charge nurse documented the resident had an approximate 4 cm diameter sized Stage II "open sore" to the left buttock. The nurse washed the "sore" and applied ointment, but did not apply a dressing. Record review of the nurses' notes on 11/10/13 at 8:00 P.M., showed the charge nurse documented a Stage II wound to the left buttock. The nurse cleansed the wound and applied ointment, and turned the resident side to side. Staff did not document any further description of the pressure ulcer to include color of the wound bed, description of the peri-wound, odor and/or pain present, any drainage, and treatment in place. Staff did not document they notified the resident's physician and responsible party. Record Review of the POS [REDACTED]. Record review of the nurse's notes showed between 11/11/13 to 11/14/13, staff did not document any further information regarding the resident's left buttock pressure ulcer. Record review of the weekly wound report dated 11/15/13 (5 days after initially identified), showed RN B noted the following information: -Right buttock: (the area was on the left ischial) -RN B did not document a stage; -Measured length 1.7 cm x width 1.5 cm x depth 0.1 cm; -Wound bed pink; -Serosanginous drainage; -No odor; -Peri-wound pink. Record Review of the POS [REDACTED]. Record review of the nurses' notes showed the following information: -On 11/15/13, the charge nurse documented a new pressure ulcer to the left ischial area. (same charge nurse identified the same stage II pressure ulcer on 11/10/13). Treatment per standing order. -Between 11/16/13 to 11/17/13, staff did not document any further information regarding the resident's left buttock pressure ulcer. Record review of the November 2013 TAR showed the following information: -On 11/15/13, left sacral (staff refer to the area as buttock, ischial and sacral ulcer. Area located on ischial area) Stage II. -[MEDICATION NAME] every shift and as needed; -Day shift staff initialed they completed the treatment on 11/15/13, 11/16/13, 11/17/13 and 11/18/13; -Evening shift staff left the area blank from 11/15/13 to 11/17/13; -Night shift staff only initialed they completed the treatment on 11/16/13. Record review of the November 2013 POS showed RN B documented an order on 11/18/13, to cleanse the left ischial tuberosity with normal saline. Apply [MEDICATION NAME], cover with [MEDICATION NAME] secure with [MEDICATION NAME] every other day per physician at wound clinic. Record review of the nurses' notes between 11/18/13 to 11/20/13, staff did not document any further information regarding the resident's left buttock pressure ulcer. Observation on 11/19/13, showed the following information: -Between 11:30 A.M., to 1:00 P.M., the resident sat in the dining room in the wheelchair; -At 1:15 P.M., the resident sat in the wheelchair in his/her room; -At 1:30 P.M., 1:45 P.M., 2:00 P.M., and 2:30 P.M., the resident remained in the same position; -The resident sat in a position that applied pressure to his/her ischial tuberosity (know as the sitting bone. When sitting, the weight is frequently placed upon the ischial tuberosity. The gluteus maximus covers it in the upright position, but leaves it free in the seated position) for at least 3 hours. Observation and interview on 11/20/13, showed the following information: -At 9:09 A.M., the resident sat in dining room in the wheelchair; -At 9:16 A.M., a CNA wheeled the resident to his/her room; -At 9:21 A.M., 9:45 A.M., and 10:00 A.M., the resident remained in the same position; -Between 10:30 A.M., to 12:00 P.M., the resident sat in the wheelchair. The resident visited with family, attended a care plan meeting and his/her family member wheeled the resident to the dining room. During an interview on 11/20/13 at 12:20 P.M., RN B said the following information: -He/she completed the dressing change on the resident's ischial pressure ulcer before breakfast this morning and measured the area. The wound measured length 1.6 cm x width 1.7 cm x depth 0.6 cm; -The peri-wound measured 3.1 cm x 2.7 cm; -He/she said the pressure ulcer was found on 11/15/13 (notes showed staff identified the area on 11/10/13); -The area had yellow slough on the top edge of the wound; -He/she did not add the area of slough to the weekly wound report on 11/15/13; -He/she did not add the stage of the wound to the weekly wound report on 11/15/13; -RN B said on 11/15/13, he/she staged the ischial pressure ulcer as a Stage III (full thickness). Observation on 11/20/13, showed the following information: -At 12:22 P.M., day shift aide CNA I said he/she got the resident out of bed this morning before breakfast. CNA I said the day aide was going to lay the resident down after lunch. CNA I said the resident had pressure ulcers on his/her heel and coccyx. The dressing on the coccyx was coming off that morning. The charge nurse changed the dressing; -At 12:30 P.M., 12:45 P.M., and 1:00 P.M., the resident sat in the wheelchair in the dining room. During an interview and record review on 11/20/13 at 2:15 P.M., the ADON said the following information: -She reviewed the 11/10/13 weekly skin report and 11/15/13 weekly wound report. She said the ischial pressure ulcer appears to be a Stage II. RN B did not stage the ulcer on 11/15/13; -She had not seen the resident's pressure ulcers for several weeks; -DHSS surveyor reported to the ADON, RN B's findings of slough and him/her staging the area as a Stage III, as of 11/15/13; -The ADON said [MEDICATION NAME] was not an appropriate treatment for [REDACTED]. Observation and interview on 11/20/13, showed the following information: -At 3:35 P.M., the resident sat in the wheelchair in his/her room; -At 3:36 P.M., the evening shift aide CNA U said the resident was up in the wheelchair when they started their shift at 2:00 P.M. The resident is alert with confusion. -The resident told the aides he/she had been laying down all day. -CNA U said he/she did not recall the day aides telling him/her anything specific about the resident in shift report. CNA U said he/she had not been made aware the resident had been up all day; -At 3:38 P.M., DHSS surveyor reported to the DON, the resident had been up in the wheelchair for approximately 6 and one half hours. The surveyor requested to see the resident's coccyx pressure ulcer; -At 3:40 P.M., CNA U and CNA Z assisted the resident into the bed. The aides assisted the resident onto his/her right side, removed his/her pants, and the incontinent brief. The resident had a dressing on his/her left ischial tuberosity. -The resident sat in a position that applied pressure to his/her ischial tuberosity pressure ulcer for at least 6 and a half hours. Observation and interview on 11/20/13, showed the following information -At 3:44 P.M., RN B gathered the treatment supplies and entered the room. He/she washed his/her hands and applied gloves and removed the soiled dressing. The ischial pressure ulcer was the size of a quarter. The center of the wound was dark brownish-black leather-like appearance with yellow slough present. The peri-wound was bright red. RN B told the resident the pressure ulcer "looked worse than this morning". RN B said the pressure ulcer did not look like that this morning. The area was bleeding but was not black. RN B measured the dark area as 1.5 cm in diameter and the entire wound 3.5 cm x 4.0 cm. RN B said the area was unable to be staged at this point. RN B placed the [MEDICATION NAME] over the ulcer, then the [MEDICATION NAME] and covered it with the [MEDICATION NAME] (orders were to apply the [MEDICATION NAME] over the ulcer then the [MEDICATION NAME]). During an interview on 11/20/13 at 3:48 P.M., CNA Z said the day aides CNA I and CNA C told him/her the resident was the last one to lay down for the day. They wanted the evening aides to ask the resident if he/she wanted to lay down. CNA Z was not aware the resident had been up in the wheelchair all day. Record review of the nurses notes, POS, and TAR on 11/20/13 at 5:15 P.M., showed staff did not document the change in the resident's ischial pressure ulcer. Staff did not document they notified the physician of the change. During an interview on 11/20/13 at 5:20 P.M., the DON said the following: -She believed RN B had left for the day. She did not received any type of report on the resident. -The DON asked the evening shift charge nurses if they had received any report on the resident. Both nurses said no; -The surveyor reported to the DON, the change in the condition of the ischial pressure ulcer. The area was darker in color when observed on the second dressing change; -The DON said RN B should have documented in the nurses' notes and/or on the weekly wound report and the physician should have been notified of any changes. During observation and interview on 11/20/13 at 5:25 P.M., the DON telephoned RN B: -RN B had the clipboard with the measurements at home. He/she did not document in the nurses' notes or on the wound report prior to leaving; -RN B agreed he/she should have documented on the pressure ulcer, notified the physician for any recommendations, measured the area and reported the change to the evening shift nurse. -The DON said she would have the evening shift nurse measure the area and report the findings to the resident's physician. Record review of the weekly wound report on 11/21/13, showed the following information: -As of 11/21/13, RN B added the staging of the ischial area as a Stage III on the 11/15/13 assessment and changed the location from "R for right" to an "L for left" buttock' -On 11/20/13, the evening nurse noted: -Left ischial unstageable; -Measured length 1.5 cm by width 2.5 cm x depth 0.1 cm; -Wound bed with yellow slough. -Physician notified and orders received to continue the current treatment. Observation and interview on 11/21/13, showed the following information: -RN B said the resident had an appointment this morning at the wound clinic. The pressure ulcer was yellow this morning; -Staff assisted the resident to stand. RN B pulled down the resident's pants and removed the dressing. The area remained the size of a quarter to half dollar. The peri-wound was red. The wound bed was yellow with fiborous slough present in the wound bed; -RN B agreed the area was larger than the first time he/she saw it on 11/20/13 (prior to 9:00 A.M.) During an interview on 11/22/13 at 11:50 A.M., the resident's physician, who is the Medical director said he saw the resident's coccyx pressure ulcer this morning. The area was a Stage III. He felt like the area would heal up. He was not aware wound tracking was not getting done as it should. The weekly wound reports will now need to be signed by a physician weekly. 3. Record review of Resident #4's nurses' notes, showed the following information: -On 7/12/13, at 6:30 A.M., the nurse documented the resident had a 5-6 centimeter circular raised area to sacrum. The area was nontender, firm, and did not have any discoloration. The nurse did not document any notification to the physician regarding the area. -On 7/16/13, at 1:30 P.M., the nurse documented the physician saw the resident (four days later) and ordered a new treatment for [REDACTED]. Record review of the physician's progress note, dated 7/16/13, showed the physician saw the resident for a large hardened area in the coccyx region. The physician examined the resident and documented the coccyx region had a firm nodule, non-tender to palpation. The physician assessed the area as an atopic [MEDICAL CONDITION] with nodular mass in the coccyx region, non-tender. The physician's planned to apply [MEDICATION NAME] to the area twice a day. If the area did open, nursing staff should notify the physician. Record review of the physician's orders [REDACTED]. During interview on 11/21/13, at 12:53 P.M., the ADON said when the wound first came up, the physician was in the facility. Staff described the area as a "hockey puck under the skin" . It was hard and the "strangest-looking" thing. The physician assessed it as a [DIAGNOSES REDACTED]. The nurse thought staff notified the physician on 7/12/13. Staff did not know what they were dealing with at that point. The Director of Nursing (DON) said the resident does have a preference for the recliner. Until the pressure ulcer developed, the resident slept in the recliner. When the area came up, the facility had the family assist with encouraging the resident to be in bed more. The area opened up and it could have been caused by pressure. The DON said staff used the low air loss mattress the resident went to the wound clinic; they would have started using it the first week they saw the wound, approximately 7/16/13. During interview on 11/21/13, at 3:15 P.M., RN Y said when he/she first found the wound, it was white in the center with red around it. The red part had very thin-looking skin, almost transparent. It looked like it was about to break open. As it progressed, it developed a couple open areas in the thin skin areas. The nurse irrigated the top of the skin and the fluid went into the little holes. On 8/11/13, the nurse called the physician to get an order to pack it. The nurse said he/she did not know what to call it at that point. The transparent skin was mostly gone and you could see the wound bed to measure the depth. The nurse said he/she did not remember what kind of mattress the resident had at that time. The nurse was sure the resident had a cushion for the wheelchair, but did not remember any details about the cushion. Record review of the July 2013 POS showed a new order, dated 7/21/13, to cleanse the open area on the coccyx with normal saline, apply [MEDICATION NAME], and cover with [MEDICATION NAME] dressing daily and as needed until healed. Record review of the facility's quality assurance wound tracking (a document that is not part of the resident's medical record), showed the following information: -On 7/29/13, the resident's coccyx wound measured 2.5 centimeters (cm) x 3 cm x 0.2 depth with an onset date of 7/26/13. The tracking showed the resident acquired the wound in-house (at the facility) and did not have any exudate or tunneling. In the comments section, the staff documented the physician said it was a [DIAGNOSES REDACTED]. Staff documented the resident had an overlay mattress and gel cushion in the wheelchair. -On 8/5/13, the resident's coccyx wound measured 2.5 cm x 4 cm x 0.2 cm and was deteriorating. Staff documented the treatment consisted of cleansing with normal saline, apply [MEDICATION NAME], and cover with [MEDICATION NAME] daily. In the comments section, staff documented the physician said it was a [DIAGNOSES REDACTED]. Record review of the resident's medical record did not show any tracking or documentation regarding the coccyx ulcer from 7/12/13 through 8/9/13. Record review of Resident #4's annualMDS, dated [DATE], showed the following information: -Severely impaired cognition; -Required extensive assistance of staff for bed mobility and transfers; -Total dependence on staff for dressing, toilet use, and personal hygiene; -Occasional incontinence of bowel; -Frequent incontinence of bladder; -At risk for pressure ulcer development; -Staff assessed the resident as having one pressure ulcer of Stage I or higher and as having an open lesion other than ulcers, rashes, or cuts; -Staff did not document the measurements, the stage of the pressure ulcer, or the most severe tissue type in the pressure ulcer; -Staff documented the resident had an area of moisture associated skin damage (MASD); -The resident had pressure-relieving devices in place for the chair and bed. Record review of the care plan with start date of 8/8/13, showed the following information: -Toilet every two hours and as needed. The resident is sometimes incontinent of bowel and bladder; -The resident is at risk for impaired skin integrity related to lack of mobility and occasional incontinence; -Keep clean and dry as possible. Minimize skin exposure to moisture; -Use pressure reducing devices while in bed and/or while in chair; -Limit time the resident sits in a chair. Change position at least every two hours; -Provide incontinence care after each incontinent episode. Record review of the nurses' notes, showed the following information: -On 8/10/13, at 1:00 P.M., RN Y documented he/she cleansed the coccyx area with normal saline. The wound bed was yellow with dark areas with a strong odor (indicating possible signs of infection, slough, and possible necrotic tissue). At 1:20 P.M., RN Y irrigated the coccyx wound with normal saline. The wound bed measured 2.5 cm x 3.5 cm with a depth of 2.25 cm. The wound bed had yellow with black spots (indicating possible slough and necrotic tissue). The nurse packed the wound with [MEDICATION NAME] gauze and covered the wound with a dry dressing per the physician's new order. Record review of the August 2013 POS showed the following physician orders: -On 8/11/13, the physician ordered to clean the open wound on the coccyx with normal saline, pack the wound bed with [MEDICATION NAME], cover with the dressing daily and as needed until healed; -On 8/14/13, the physician discontinued the previous treatment to the sacral area (same area) and ordered to cleanse the area with normal saline, apply Santyl to the wound bed, pack with [MEDICATION NAME] packing strips, and cover with [MEDICATION NAME] dressing daily and as needed until healed. Record review of the nurses' notes, showed the following information: -On 8/15/13, at 9:30 A.M., a nurse spoke with the physician regarding the sacral wound. The nurse received a new order for a consult to the wound clinic, low air loss mattress, and a pain patch. (Record Review of the POS [REDACTED]. Record review of the care plan conference, dated 8/15/13, showed the resident had an open area on coccyx. Treatment order to cleanse with normal saline, [MEDICATION NAME], cover every day. Staff documented the physician orders [REDACTED]. Staff did not document any interventions re

Based on observation, interviews, and record review, the facility failed to follow physician orders [REDACTED]. The facility had a census of 110. 1. Record review of Resident #2's quarterly Minimum Data Set (MDS), a comprehensive assessment tool completed by facility staff, dated 10/22/13, showed: -Severely impaired cognition, but able to make some needs known; -[DIAGNOSES REDACTED]. -Dependent on staff for all transfers, mobility via wheelchair, and most activities of daily living (ADLs). Record review of the resident's physician order [REDACTED]. Record review of laboratory results dated [DATE], showed PT/INR (blood clotting time/ratio ranges) of 86.2 H (high result) and 7.7 CH (critically high result; 5.1 and greater is critical range). Record review of a resident's physician telephone order, dated 8/19/2013, showed to hold [MEDICATION NAME] for two days, then recheck PT/INR on Wednesday (8/21/2013). Record review of laboratory results completed for the resident showed no documentation regarding completion of a PT/INR on 8/21/2013. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of a physician telephone order. dated 8/22/2013, showed to transfer the resident to the ER for evaluation due to altered mental status and low blood glucose (sugar). Record review of a history and physical report from a hospital, dated 8/22/2013, showed: -[AGE] year old female; -Significant past medical history for dementia, [MEDICAL CONDITION], valvular [MEDICAL CONDITION] and clot history, on [MEDICATION NAME]; -Recently treated with antibiotics for urinary tract infection, subsequent worsening of mentation; -INR was supratherapeutic (very high) at 11.8; -Patient received vitamin K (to offset the [MEDICATION NAME] effects). During an interview on 11/22/13 at 1:38 P.M., the resident's physician said the following:-He did recall the resident's INR being very high and giving the order to hold the [MEDICATION NAME] for two days;-He was not aware the resident had toxic levels at the hospital;-When staff received an order for [REDACTED]. During an interview on 11/27/2013 at 11:35 A.M., the DON said it is the nurses' responsibility to follow through with all lab orders. Staff should not have given the dose of [MEDICATION NAME] on 8/21/2013 without obtaining the lab results and contacting the physician for orders.