Every finding on record at River Crossing Rehab and Healthcare Center

Based on observation, interview and record review, the facility failed to prepare and serve food at a safe and appetizing temperature to conserve the flavor of the food items. The facility census was 90.Review of the facility policy for Food Temperatures with a revision date of 10/24/22 showed:-The purpose of this policy is to provide the dietary department with guidelines for food preparation and service temperatures. Foods prepared and served in the facility will be served at proper temperature to ensure food safety;-Acceptable serving temperatures are: meats, entrees greater than 135 degrees; vegetables greater than 135 degrees; potatoes, pasta greater than 135 degrees;-If temperatures do not meet the required serving temperatures, reheat the product;-Do not put food on the tray line until 30 minutes to 45 minutes prior to meal service;-Heat hot plates. A pellet underline may also be used to maintain temperature. During an interview on 08/19/26 at 10:40 A.M., Resident #13 said he/she eats meals in his/her room on the 200 hall, the food is usually not hot when his/her meal is served. During an interview on 08/19/26 at 12:15 P.M., Resident #8 said he/she eats all meals in his/her room on the 400 hall, the food is not hot when the staff deliver the meal tray. During an interview on 08/19/26 at 2:17 P.M., Resident #11 said he/she eats all meals in his/her room on the 300 hall, the food was not hot when the staff deliver the meal tray today. Observation on 08/20/26 at 12:05 P.M., showed:-Dietary staff wheeled a metal cart with several meal trays to the 200 hall;-The cart was covered with a clear plastic cover, the cart contained several trays with a plastic plate on a pellet covered with an insulated cover;-The meal consisted of a breaded chicken patty that was deep fried, peas and carrots and wild rice. Observation on 08/20/26 at 12:15 P.M., showed all the residents' meal trays were served from the cart on the 200 hall. The food on the sample tray temperature was tested and the breaded fried chicken patty measured 110 degrees. During an interview on 08/20/26 at 1:30 P.M., the Dietary Manager said:-The food temperature is checked when the food is put on the steam table. The temperature is usually above 160 degrees on the steam table. Then the double doors are opened for the meal service to the main dining room and temperature of the food on the steam table will drop. The steam table has been checked and there is nothing wrong with the steam table. The food is placed on plates that have the insulated covers, he/she does not know why the food temperature is below the recommended temperature. The food should be at least 135 degrees when served. During an interview on 08/20/26 at 3:00 P.M., the Administrator said he would expect the food to be at least 135 degrees when served. 2624035, 2796452, 3171670

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The RN working on the hall was serving as the acting Director of Nursing (DON). This deficiency had the potential to affect all residents. The census was 87. Review of the nursing schedules provided by the facility, dated 12/30/24 through 1/23/25, showed: -On 1/3, 1/4, 1/5, 1/6, 1/8, 1/12, 1/13, 1/20 and 1/22, there was no RN; -On 12/31/24, 1/1, 1 /2, 1/7, 1/9, 1/10, 1/11, 1/14, 1/16, 1/17, 1/18, 1/21 and 1/23/25 the only RN scheduled was the DON. During interviews on 1/22/25 at 3:30 P.M. and at 4:13 P.M., the Administrator said the facility missed having RN coverage for four out of 30 days. The facility had posted an ad for an RN. The facility said the RN who was on the schedule was the DON. During an interview on 1/23/25 at 1:00 P.M., the DON said she was an RN. She had been training with the Regional Nurse since September for the acting DON position. She had been working on the floor because the facility was very short on nurses. They needed to do something about that, and they were trying hard. The Assistant Director of Nursing (ADON), was an Licensed Practical Nurse (LPN), assumed the DON responsibilities many days because that was what he preferred, and she preferred to work the floor. The DON said she usually worked on Tuesdays, Thursdays and Fridays. She had just started picking up some weekends, but she was reachable by phone. She had been coming in more often just to fill in. There were some days when there was no RN coverage, but the other staff were very competent. During an interview on 1/24/25 at 3:56 P.M., the Administrator said she expected for the facility to have an RN on duty for 8 hours daily. MO00246742

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to label, date and cover food. The facility also failed to ensure kitchen equipment and the floor was kept clean during three of four days of observation, in addition to ensuring that staff followed sanitary conditions when staff used their bare hands to clean out a mixing bowl and failed to ensure the mixing bowl was properly clean before preparing the next pureed dish. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 87. 1. Observation on 1/21/25 at 9:35 A.M., 1/22/25 at 4:06 P.M., and 1/23/25 at 11:38 A.M. of the kitchen, showed the following: -Dry storage room: -A bag of chocolate chips wrapped in plastic and without a date; -A bag of tortilla chips wrapped in plastic and without a date; -A bag of crispy onions wrapped in plastic and without a date; -A bag of powder sugar wrapped in plastic and without a date; -A bag of bow noodles wrapped in plastic and without a date; -A bag of croutons wrapped in plastic open, not closed and exposed to air and without a date. -Freezer: -Three door stand alone: -A plastic bag contained chicken patties without a date; -A blue plastic bag contained an unidentified frozen meat item without a date. 2. Observation on 1/21/25 at 9:35 A.M. and 1/22/25 at 4:06 P.M., of the two-door stand-alone freezer, showed a box contained a bag of biscuit dough which was open and exposed to air. 3. Observation on 1/22/25 at 4:06 P.M. a and 1/23/25 at 11:38 A.M. of the three-door stand-alone freezer, showed a plastic bag contained chicken nuggets without a date. 4. Observation on 1/21/25 at 9:35 A.M. and 1/22/25 at 4:06 P.M., of the kitchen, showed the following: -The stove: -Heavy caked-on stains on the stove burners; -Heavy caked-on stains along the front of the stove; -The deep fryer: -Heavy caked-on stains along the front; -Old grease in the fryer. -Heavy caked on grease and batter along the inside of the fryer. 5. Observation on 1/21/25 at 9:35 A.M. and 1/22/25 at 4:06 P.M., of the kitchen floor, showed following: -The floor dirty with debris on the floor; -The floor dirty with debris and food in between the stove and the fryer; -The floor stained in front of the stove and in between the stove and the fryer. 6. Observation on 1/23/24 of the kitchen, showed the following: -At 11:14 A.M., Dietary [NAME] (DC) I pureed chicken. After he/she pureed the chicken, he/she rinsed out the blending bowl with plain water. He/She did not clean the blending lid used during the chicken puree. He/She then proceeded to place the contents for the carrot puree in the blending bowl and blended the contents. There was chicken puree residue still in the blending bowl along the insides of the bowl as well as inside the lid; -At 4:05 P.M., DC J pureed creamed bean soup. After he/she pureed the soup, he/she rinsed out the blending bowl and the lid with plain water. He/She then used his/her bare right hand to wipe out the inside of the bowl. DC J then grabbed the blending bowl with his/her fingers inside the bowl and placed the blending bowl on the base. He/She then proceeded to place the contents for the cornbread puree in the bowl and blended the contents. There was still soup puree residue in the blending bowl along the inside of the bowl. 7. During an interview on 1/24/25 at 1:58 P.M., the Dietary Manager (DM) said the deep fryers are cleaned one time a month. She believes in all hands-on deck approach. She just recently started this and has already seen an improvement. On Wednesday, everyone comes in and they deep clean the stove and ovens. The cooks clean the grease trays daily and wipe down the equipment to try to keep everything clean. Staff are to clean with a degreaser. They empty the grease in the deep fryer every three weeks or after they fry fish. The DM has seen the sides of the equipment and said it looked bad. Her expectation is for equipment to be clean and grease traps emptied. The deep fryer is cleaned every three weeks. The oven has caked on stuff. The DM was aware of it and said she was in the process of taking care of it. The cooks are responsible for cleaning their equipment. The DM's expectations are for the floors and all the equipment to be clean and for everything to work properly. It was her expectation that all sanitary practices should be followed while preparing and cooking food. It was also her expectation that all food should be properly labeled, dated, and stored. It is the responsibility of her cook to ensure that all food is labeled, dated, and properly stored.

42247 Based on interview and record review, the facility failed to ensure residents who received dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys are not working properly) services had written communication with the dialysis center. The facility identified seven residents who received dialysis services. Three residents were sampled (Resident #32, #58 and #60), and issues were found with all three residents. The sample was 19. The census was 87. Review of the facility's Dialysis Care policy, dated 10/24/22, showed: -Policy: The facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing all non-dialysis needs of the resident including during the time period when the resident was receiving dialysis; -The nursing staff, dialysis provider staff, and the attending physician (dialysis staff) will collaborate on a regular basis concerning the resident's care as follows: -Nursing staff will communicate pertinent information in writing to dialysis staff which may include: -Any medication changes; -Any recent changes in condition; -The resident's tolerance of dialysis procedures; -The dialysis provider will communicate in writing to the facility: -The resident's current vital signs (blood pressure, pulse, respirations, and temperature); -Pre and post weight; and -Any problems encountered while the resident was at the dialysis provider; -Nursing staff may use NP-225-Form A- Nurse Dialysis communication record to convey information to the dialysis provider. Review of the facility's Nurse Dialysis Communication Record (NP-225 Form A), revised 10/24/22, showed: -Note: nursing facility/dialysis treatment sheet to be filled out prior to dialysis treatment. (Attach medication administration records (MAR) and new orders to this form. Dialysis center to complete lower half of the form at the end of treatment and send back to skilled nursing facility (SNF); -Information for the facility to prepare: -Residents name and date; -Fasting blood sugar and time. The insulin dose; -Last medications given and times; -Vital signs and pain scale; -Bruit (an abnormal sound that indicates turbulent blood flow through a narrowed artery or vascular channel) pulse and location; -Access site: note if redness, swelling or drainage; -Changes noted in the last 24-48 hours: falls/trauma; shortness of breath; nausea; vomiting; diarrhea; vertigo (dizziness), edema-specify location; antibiotic; behavioral; lung sounds; other changes in the last 24-48 hours (new meds, orders); -Nurse signature and date; -Dialysis center to complete and return with resident: -Dialysis center name, address and primary nurse; -Access site: redness, swelling or drainage; -Diet change; -Lab result to send first week of each month; -Pre-dialysis weight, vital signs, and pain scale; -Post dialysis weight, vital signs, and pain scale; -Other orders/changes today; -Special instructions/progress notes; -Post dialysis monitoring: -Vital signs every shift for 24 hours and bruit check every four hours for 24 hours; -Time returned to the unit. 1. Review of Resident #32's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 12/26/24, showed: -admitted on [DATE]; -Cognitively intact; -Impairment on one side of both upper and lower extremities; -Diagnoses included anemia, heart disease, high blood pressure, end-stage kidney disease (ESRD, chronic irreversible kidney failure), diabetes, high cholesterol, stroke, hemiplegia, or hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and depression; -On dialysis. Review of the resident's electronic record showed orders for dialysis on Mondays, Wednesdays, and Fridays. During an interview on 1/21/25 at 9:38 A.M., the resident said he/she received dialysis treatment three times a week. The facility provided transportation. During an interview on 1/24/25 at 2:35 P.M., the resident said no paperwork was provided by the facility for the dialysis center. There was not any type of communication paperwork or forms he/she had to take back and forth. He/She said the dialysis center checked the vital signs and weight but not the facility. He/She did not notice the driver carrying any paperwork related to his/her dialysis treatment. 2. Review of Resident #58's admission MDS, dated [DATE], showed: -admitted to the facility on [DATE]; -Cognitively intact; -Special treatment: Dialysis; -Diagnoses included end stage renal disease, heart failure, and high blood pressure, diabetes, anxiety disorder, and maniac depression. Review of the resident's electronic undated care plan, in use during the survey, showed: -Focus: Resident needs hemodialysis (dialysis) related to end stage renal failure; -Goal: the resident will remain free from discomfort or further complications related to renal disease. He/She will have no signs or symptoms from complications from hemodialysis. He/She will adequate fluid balance as evidence by (AEB) good skin turgor pink and moist mucous membranes, and sufficient fluid intake ; -Interventions: Communicate and collaborate with dialysis center regarding weights, medication, diet, and lab results. Dialysis three times a week on Tuesdays, Thursdays, and Saturdays at 9:00 A.M. Review of the resident's physician order sheet (POS), dated January 2025, showed: -An order for: dialysis on Mondays, Wednesdays, and Fridays with a pickup time at 5:00 A.M., start date 12/6/24. Review of the resident's medical record, showed no documentation the resident was assessed before and/or after dialysis. During an interview on 1/21/25 4:09 P.M., the resident said he/she received dialysis on Mondays, Wednesdays, and Fridays. 3. Review of Resident #60's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: anemia (low red blood count), high blood pressure, diabetes, stroke and depression; -Special treatment: dialysis. Review of the order summary report dated 1/22/25, showed an order for dialysis on Monday, Wednesday, and Friday. Review of the medical record, dated 1/1/25 through 1/22/25, showed no dialysis communication records. During an interview on 1/24/25 at 8:42 A.M., the resident said he/she received dialysis treatment on Mondays, Wednesdays, and Fridays. The resident, nor did the driver, took any paperwork back and forth to his/her dialysis appointments. He/She said the facility did not check his/her vital signs. The dialysis center weighed him/her and checked his/her temperature. 4. During an interview on 1/23/25 at 1:00 P.M., the Director of Nursing (DON) said the nurse should check the residents for bruit and thrill, check the dressing site to be sure it is clean and intact. She believed the facility had a dialysis communication form. Staff needed in-service to implement the form. Currently, the facility did not have a dialysis communication form. The dialysis centers were so good with doing the residents' weights and vital signs. The facility was aware of the residents' vital signs and a lot of things on the dialysis form. The information was just not technically on the communication form. When a resident went out for dialysis, the nurse would document the resident had dialysis, did well, returned with no signs and symptoms, ate dinner and things like that. This should be documented in the progress notes. 5. During an interview on 1/24/25 at approximately 2:00 P.M., the DON said the facility did not use the dialysis communication forms. 6. During an interview on 1/24/25 at 3:56 P.M., the Administrator said there should be communication between the facility and dialysis. 45083

Based on observation and interview, the facility failed to follow recipes for three of four pureed meals observed to ensure that the desired consistency was achieved for nine residents on pureed diets. In addition, the facility failed to ensure food at time of service measured at least 120 degrees Fahrenheit (F) for hot food, and the cold food measured under 41 degrees F and to ensure that food was palatable. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 87. 1. Observation on 1/23/25 at 11:14 A.M., showed Dietary [NAME] (DC) I prepared pureed chicken. He/She placed an unmeasured amount of the chicken from a white plastic container into the blender and started the blender. He/She thought it may have been about 8 ounces in the container but to be on the safe side he/she said it may have been 12 ounces. He/She then poured an unmeasured amount of broth into the blender. DC I said the broth will stretch it so he/she will let the blender run. He/She pureed the items for approximately one minute. DC I took the lid off the blender and said that may be enough. He/She looked at it and started the blender again. DC I said he/she would add salt and pepper to taste. He/She then added an unmeasured amount of chicken broth in the mixture and continued to add an unmeasured amount as the chicken pureed. DC I said the pureed chicken would be enough because the mixture was all the way at the top. DC I just didn't want it to run out. DC I had stopped the blender after about approximately one minute and thirty seconds. He/She stopped the blender and said if he/she needed to add bread then he/she would. DC I pureed the chicken for another thirty seconds. He/She looked at the mixture and said it was still a little coarse so pureed it for approximately another two minutes. DC I stopped the blender and added an unmeasured amount of Mrs. Dash seasoning and pepper to the mixture and then pureed the chicken for approximately an additional forty-five seconds. He/She then tasted the pureed chicken and said it was great. The consistency was smooth with a small slight coarseness. Review of the pureed baked chicken recipe, showed the following for twelve servings: -Remove the number of pureed portions required from the regular recipe (3 oz per serving) (weigh meat only, do not include cooking juices or gravy); -Add to food processor and process to fine consistency; -Prepare broth by dissolving soup base in boiling water; -If thickener is needed, combine hot broth and thickener. Gradually add to meat while processing. All liquid may not be required; -Scrape down sides of the processor and process for thirty seconds. 2. Observation on 1/23/25 at 4:05 P.M., showed the DC J prepared pureed creamed bean soup. He/She said he/she had nine purees but will prepare for ten. DC J placed ten (10) ounce scoops of the cream bean soup in the blender. DC J pureed the soup for one minute. He/She stopped and looked at the mixture and then blended for an additional minute and thirty seconds. The consistency was a thin and soupy texture. DC J said the soup should be a little thicker but it was going to thicken up. Review of the pureed bean soup with ham recipe, showed the following for ten servings: -Measure the number of pureed portions required from the regular recipe; -Drain liquid from the soup ingredients and reserve; -Add soup ingredients to food processor and process to fine consistency; -Scrape down sides of the processor and process for thirty seconds; -Add reserve liquid and process until smooth. 3. Observation on 1/23/25 at 4:15 P.M., showed DC J prepared pureed cornbread. He/She cut ten squares of unmeasured cornbread and placed them inside the blender. He/She then placed an unmeasured amount of chicken base inside the blender along with one pint of milk. DC J pureed the items for approximately one minute. The consistency was a thick doughy, pasty texture. Review of the pureed cornbread recipe, showed the following for ten servings: -Remove the number of pureed portions required from the regular recipe after prepared; -Add to food processor and process to fine consistency; -Combine milk and thickener and gradually add to cornbread while processing; -Scrape down sides of the processor and process for thirty seconds; -Chill to serving temperature; -The recipe did not specify how much milk should be combined. During an interview on 1/24/25 at 1:58 P.M., the Dietary Manager (DM) said she would not expect the cornbread to be thick and pasty. The DM expected staff to follow recipes and use accurate measurements due to nutritional values as well as some residents may have swallowing problems or issues with their stomachs. The DM said pureed foods should be appealing and palatable. 5. Review of the email dated 1/24/25 at 3:38 P.M., received from a local nutrition specialist company regarding purees, addressed to Registered Dietician (RD) O showed: -The expectation is that the standardized recipes are followed for all pureed items to ensure appropriate/desired consistencies are achieved; 6. Review of the facility's Food Temperature policy, dated 10/24/22, showed: -Policy: foods prepared and served in the facility will be served at proper temperatures to ensure food safety; -Measuring food temperatures: -Take the temperature of each pan of product before serving; -Acceptable serving temperatures: -Cereal, gravy, temperature required (F degree) 135 F; -Casseroles, meat entrees; potatoes, pasta; soup; vegetables, the temperature required was greater than 135 F; -Milk, juice, temperature required was less than 41 F; -If temperature do not meet the required serving temperatures listed above, reheat the product or chill the product to the proper temperature; -If temperature are not at acceptable levels and cannot be corrected in time for meal service, an appropriate menu substitution should be implemented; -Do not put food on the tray line until 30 minutes prior to meal service; -Cold food may be put in the freezer 30 to 45 minutes prior to meal service to obtain serving temperature; -Bring only one tray at a time out to the tray line. Place on ice. Ice down all cold foods on tray line; -Heat hot plates. A pellet underline may also be used to maintain temperature. 7. Review of the facility's Resident Council Meetings, showed: -On 10/24/24: hall trays arriving cold (has this improved): 12 residents stated it had not improved. They did state that this is not dietary's fault as the dining room residents witnessed meals coming out hot and quickly. They state it's dependent on how long it takes the Certified Nurse Aides (CNA) to pass out hall trays. As residents on the end of the hall tend to get their food last; -On 11/21/24: hall trays arriving cold (has this improved): 12 residents stated it had not improved. They did state that this is not dietary's fault as the dining room residents witnessed meals coming out hot and quickly. They state it's dependent on how long it takes the CNAs to pass out hall trays. As residents on the end of the hall tend to get their food last. 8. During the Resident Council Meeting on 1/22/25 at 11:00 A.M., the residents said in the main dining room, the food was served quickly and was usually warm. The hall trays were served cold. This happened for all three meals. Sometimes the food will sit on the trays for 15 minutes, while five to six staff members are at the desk. 9. Review of Resident #60's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/25/24, showed: -Cognitively intact; -Diagnoses included stroke, high blood pressure, diabetes and gastroesophageal reflux disease (GERD). During an interview on 1/21/25 at 2:39 P.M., the resident said the food was cold and it did not matter if he/she ate in the dining room or in his/her room. 10. Review of Resident #11's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included heart failure, high blood pressure, diabetes and dementia. During an interview on 1/21/25 at 2:54 P.M., the resident said he/she ate in his/her room. He/She did not like the food and sometimes the food was served cold. 11. Observation on 1/22/25 at 12:45 P.M., showed a metal cart with open sides, arrived on the 300-400 hall dining room. Staff removed the plastic that covered the cart and passed out the trays to the residents in the dining room. At 12:47 P.M., staff delivered the trays to the residents on the 400 halls. At 12:53 P.M., the last room tray was delivered. A test tray was removed from the cart and tested . The temperature (T) of the food was: Chicken Parmesan [NAME] 109.2 degrees F, garlic buttered vegetables 105.8 degrees F, and the garlic bread 90.5 F. 12. Observation on 1/23/25 at 8:54 A.M., showed a metal cart with open sides, arrived on the 300-400 hall dining room. Staff passed out the trays to the residents in the dining room. At 8:56 A.M., staff delivered trays to the residents on the 400 halls. At 9:08 A.M., the last room tray was delivered. A test tray was removed, and the T was taken. The biscuits and gravy were 102.5 degrees F, the orange juice cup was 67.1 degrees F, and the carton of milk was 66.6 degrees F. 13. Review of Resident #62's quarterly MDS dated , 1/3/2025, showed: -Cognitively intact; -No psychosis behaviors; -Diagnoses included heart disease, high blood pressure, kidney disease, diabetes, depression and asthma. Review of the resident's diet order, showed regular diet, regular texture and regular consistency. During an interview on 1/21/25 at 12:09 P.M., the resident said, the food sucks here. The food was usually cold and did not taste appetizing. The resident's parent visits up to three times a week and brings food so he/she can eat decent food at times. During an interview on 1/23/25 at 9:30 A.M., the resident had not eaten breakfast and said he/she did not want to eat breakfast because it was not good anyway. 14. During an interview on 1/24/25 at 3:56 P.M., the Administrator said she expected hot foods to be served hot and cold foods to be served cold. 42247 45083

Based on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity and respect for one sampled resident (Resident #22) after Housekeeper E dismissed the resident when he/she was trying to talk to him/her. Housekeeper E told the resident he/she did not speak the resident's language. In addition, the facility failed to follow their policy and ensure residents could participate in their treatment in a language they understood. The sample size was 19. The census was 87. Review of the facility's Resident's Rights policy, revised 5/1/23 showed: -Purpose: To promote and protect the rights of all residents at the facility; -Policy: -All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy; -The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance and enhancement of his or her quality of life, recognizing each resident's individuality; -The facility will protect and promote the rights of the resident and provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source; -The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. -Procedure: -State and federal laws guarantee certain basic rights to all residents of the facility. These rights include, but are not limited to, a resident's right to: -Be informed about what rights and responsibilities they have; -Be fully informed and participate in their treatment in a language that they, can understand. Review of Resident #22's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/9/24, showed: -Rarely/never understood; -Rarely/never understands; -Speech Clarity: Unclear words- slurred or mumbled words; -Race: Vietnamese; -Language: -Preferred language: Cantonese; -Diagnoses included atrial fibrillation (A-Fib, irregular heart rhythm), hypertension (high blood pressure), diabetes mellitus (DM, metabolic disease), hyperlipidemia (high cholesterol), Alzheimer's Disease (dementia), and stroke (CVA). Review of the resident's electronic care plan, undated, and in use during the survey, showed: -Focus: resident has a communication problem related to aphasic (unable to speak, write, or understand speech or writing because of damage to the brain) due to CVA. He/She is also in need of an interpreter as he/she speaks Cantonese; -Goal: He/she will be able to make basic needs known; -Interventions: Anticipate and meet needs. Be conscious of resident's position when in groups, activities, dining room to promote proper communication with others. Observation on 1/23/25 at 2:25 P.M., showed the resident sat in his/her wheelchair, in the dining room on the 300/400 hall across from the nurse's station. The resident motioned for Housekeeper E to come to him/her. He/She was trying to communicate something to Housekeeper E. At that time, Housekeeper E shrugged his/her shoulders and said he/she didn't speak the resident's language and kept walking. Certified Nurse Assistants (CNA) G and CNA H giggled at that time. Housekeeper E did not attempt to stop and see what the resident needed when the resident tried to talk to him/her. During interviews with CNA G and CNA H on 1/23/25 at 2:21 P.M., both said they were familiar with the resident and have worked with him/her. Neither CNA were assigned to the resident that day. CNA G said the resident communicates via pointing and motioning towards things (using hand gestures). The resident does not understand staff, but his/her family member went to the facility three times a day and was pretty good about saying/translating what the resident didn't understand. The family member was also pretty good about saying what the resident wanted and/or needed. The resident had been at the facility for a couple of months. Both CNA G and CNA H said they would not know how the resident would communicate to staff if the resident was in pain. CNA G said yeah that would be kind of hard. During an interview on 1/24/25 at 3:30 P.M., Licensed Practical Nurse (LPN) C said if a resident did not speak English, he/she would use a translator or use Google translator to communicate with the resident. Residents should be treated with dignity and respect. During an interview on 1/24/25 at 3:33 P.M., Certified Medication Technician (CMT) D said if a resident did not speak English, he/she would ask the resident simple questions like are you thirsty or if they wanted to go to the bathroom. The CMT said he/she could also call the power of attorney/resident representative to help translate. Residents should be treated with dignity and respect. During an interview on 1/24/25 at 3:56 P.M., the Administrator said residents should be treated with dignity and respect. During an interview on 1/29/25 at 11:13 A.M., the Assistant Director of Nursing (ADON) said typically when he communicated with the resident, he/she had been able to answer yes or no questions with a nod of the head or with hand gestures. This was pretty much universal. Staff knew the resident's dementia had progressed, so they were implementing a communication board and things of that nature. There was not a communication board in place for nursing staff prior to or during the survey. The reason a communication board was not used was because up until recently, the resident was able to answer yes or no questions or with a head nod or hand gestures. Often times, if the resident needed peri care he/she would point to the front of his/her private area. With this particular staff person involved, he did not think the situation could have been avoided because this was Housekeeper E's first time working in long term care. The ADON thought Housekeeper E just wasn't knowledgeable on what to do in this situation. The encounter between the resident and Housekeeper E was absolutely not dignified. Ultimately it was the ADON's responsibility to ensure that there were means of communicating put in place for residents. Before the facility admits residents, they would want to make sure a means of communication was in place. With this particular resident, he/she was able to communicate. The resident's family said they were even having a hard time communicating with the resident in his/her native language.

Based on interview and record review, the facility failed to follow their policy and accepted professional standards and practices for complete and thorough documentation, when staff failed to follow-up and document appropriately when one resident experienced a change of condition (Resident #82). The sample was 19. The census was 87. Review of the facility's Change of Condition Notification policy, revised on [DATE], showed: -Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner; -Documentation: A Licensed Nurse will document the following; -Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes; - The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received; -The time the family/responsible person was contacted; - Update the Care Plan to reflect the resident's current status; -The incident and brief details in the 24-Hour Report; -lf the resident is transferred to an acute care hospital, complete an inter-facility transfer form; -Complete an incident report per Facility policy; -A Licensed Nurse will communicate any changes in required interventions to the Interdisciplinary Team (IDT) members involved in the resident's care; -A Licensed Nurse will document each shift for at least seventy-two (72) hours; -Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-Hour Report. Review of Resident #82's entry Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated [DATE], showed: -admitted [DATE]; -Entered from short-term general hospital; -All other sections left blank. Review of the resident's electronic health records (EHR), showed diagnoses included acute respiratory failure with hypoxia (a condition where the lungs are unable to adequately provide oxygen to the body, resulting in a deficiency of oxygen in the blood), generalized muscle weakness, abnormal posture, cognitive communication deficit, dysphagia (difficulty swallowing) and protein-calorie malnutrition. Review of the progress notes dated [DATE] at 10:04 P.M., showed: -Contacted MD (physician) related to resident's status, noticed resident's mouth had an increased droop and appears to have increased drowsiness. During assessment, resident denied pain or wanting to go to the hospital. Vitals stable but pulse is elevated, sweat noted on his/her nose. Vitals recorded in chart and sister and brother notified of resident's current status. Sister said to just leave her since he/she is responding. Sister stated she was told there was nothing else could be done for the resident. Resident appears to be resting in bed, HOB (head of bed) elevated with call light in reach. MD will see the resident in the morning during visit to the facility. Will continue to monitor for any other changes; -On [DATE] at 6:07 A.M., documentation showed the resident passed away in his/her bed on [DATE]; -No follow-up notes regarding the resident's change of condition that was observed on [DATE]. During an interview on [DATE] at 4:45 P.M., Licensed Practical Nurse (LPN) F said during evening medication administration, he/she observed the resident with facial drooping and disfigured mouth. LPN F called and notified the physician and was advised to call the family on what they wanted to do. LPN F said the resident's sister or responsible party said to keep the resident in the facility as long as he/she remained responsive. LPN F reported his/her observations to the oncoming shift nurse. During an interview on [DATE] at 1:09 P.M., the acting Director of Nursing (DON) said she would expect the staff to notify the physician and family of any changes of condition, and document properly. She would follow up, assess, and document observations after receiving a report from a previous shift's nurse of a resident's change of condition. She said they also utilize an SBAR (Situation, Background, Assessment, Recommendation) sheet. During an interview on [DATE] at 9:55 A.M., the physician/medical director said when he receives calls from facility for resident concerns, he would normally send the resident out to the hospital for further evaluation, however, he also wanted to have the family involved in the decision-making. He said the family decided to have Resident #82 to stay in the facility. He saw the resident on [DATE], with a stable condition and no changes of condition observed. He did not see the resident on [DATE]. He expected the staff to follow-up and document appropriately. During interviews on [DATE] at 12:26 P.M. and on [DATE] at 3:24 P.M., the Assistant Director of Nursing (ADON) said he recalled the resident was very sick, and the sister was very involved with the resident's care. The resident was hospitalized for quite some time and the condition had not improved. The resident had declined upon returning to the facility following hospitalization in [DATE]. The ADON said the sister wanted to cancel follow-up appointments and considered hospice care. The ADON was notified that the resident was found unresponsive and was coded on the early morning of [DATE]. The ADON said the staff performed CPR (cardiopulmonary resuscitation, is an emergency lifesaving procedure performed when the heart stops beating) and called 911 when the resident was found unresponsive. The resident expired that morning. The ADON expected the staff to follow-up and document appropriately after receiving a report of the resident's change of condition. During an interview on [DATE] at 12:45 P.M., the ADON verified that there was no follow-up documentation, nurses' notes, physician's notes, or SBAR sheets regarding the resident's change of condition. He said he spoke with the physician and was notified that no further interventions were provided due to the family's decision. During an interview on [DATE] at 3:55 P.M., the Administrator said she expected the staff to complete the documentation on any residents' change of condition.

45083 Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to change gloves and perform hand hygiene during wound care for one resident (Resident #75). In addition, the staff disconnected the catheter tubing from the drainage bag to untwist the tubing and reconnected the tubing without disinfecting the catheter tubing for one resident (Resident #236). Furthermore, the staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities with residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) for one resident (Residents #46). The sample was 19. The census was 87. Review of the facility's Infection Prevention and Control Program policy, revised on 10/24/22, showed its purpose is to ensure the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. Review of the facility's Hand Hygiene policy, revised on 10/24/22, showed: -Purpose: To ensure that all individuals use appropriate hand hygiene while at the facility; -Policy: The facility considers hand hygiene the primary means to prevent the spread of infections; -Hand hygiene is always the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand hygiene procedures. Review of the facility's Care of Catheter policy, dated 10/24/22, showed catheters (a sterile tube inserted into the bladder to drain urine) and drainage bags will be changed based on clinical indications such as infection, obstructions or when the closed system is compromised. Routine fixed internal changes of the indwelling catheter drainage bag is not recommended; -Aseptic technique (strict procedure to prevent the spread infection) must be used to change the drainage bag (a bag that collects urine from the catheter). The catheter tubing junction must be disinfected with alcohol or chlorhexidine sponge (antiseptic) prior to connecting the new drainage bag. Review of the facility's Standard and Enhanced Precautions policy, revised 4/1/24, showed: -Purpose: To ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents; -Policy: The facility will utilize current guidance from the Centers for Disease Control (CDC) and the Centers for Medicare & Medicaid Services (CMS) to determine the appropriate PPE to be utilized during the care of residents to minimize the risk of infection or spread of infection; -EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (such as urinary catheter, feeding tube, endotracheal (tube inserted through the mouth or nose) or tracheostomy tube (tube inserted through a surgically created opening in the neck), vascular catheters (flexible tube inserted into a vein to draw blood or deliver medication)) and wounds or presence of unhealed pressure ulcers; -For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: -Dressing; -Bathing/showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; -Wound care: any skin opening requiring a dressing. 1. Review of Resident #75's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/24, showed: -Cognitively intact; -Substantial or maximal assist to roll left and right mobility; -Dependent to transfer; -Diagnoses included anemia, high blood pressure, diabetes, dementia and malnutrition; -Two Stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) that were present upon admission; -One unstageable pressure ulcer (Slough (dead tissue) is present, the actual base and condition of the ulcer cannot be determined.) that was present upon admission. Review of the resident's Treatment Administration Record (TAR), dated 1/22/25, showed: -Vashe Wound Therapy External Solution (wound cleanser used to remove damaged tissue from chronic skin ulcers), apply to affected areas topically every day shift for wound care; -Santyl ointment 250 units per gram (used to remove damaged tissue from chronic skin ulcers), apply to affected areas per additional directions topically every day shift for wound care for 30 days. Observation on 1/23/25 at 7:47 A.M., showed Licensed Practical Nurse (LPN) B assisted LPN A with wound care while the resident lay in bed. LPN B lifted the resident's left leg, held the top foot and ankle to expose the heel with wound, while LPN A applied the treatments as ordered. After wound care was finished, LPN B did not remove his/her gloves and perform hand hygiene. He/She then covered the resident with sheets and with the resident's personal blanket with his/her gloved hands, while wearing the same gloves used during wound care. LPN B then touched the sides of the bed, used the bed remote to adjust the bed and prepared the resident to be repositioned after the resident requested to be pulled up. Two Certified Nurse Assistants (CNAs) entered the room to reposition the resident. 2. Review of Resident #236's medical record, showed: -Alert and oriented times four (person, place, time, and situation); -Diagnoses included obstructive and reflex uropathy (urinary tract condition that occurs when urine can't drain properly); benign prostatic hyperplasia (BPH, enlarged prostate) with lower tract symptoms (frequency, urgency, straining, weak stream, straining, and incomplete bladder emptying). Review of the progress notes, dated 1/21/25 at 9:39 A.M., showed his/her past medical history included: the resident was admitted (to the hospital) for urinary pain, pus coming out catheter and hypotensive (low blood pressure) and found to have urinary tract infection (UTI) and treated with antibiotic. Review of the order summary report, dated 1/22/25, showed: -A physician order for a suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) care every shift; -A physician order to change the catheter drainage bag as needed. Observation on 1/23/25 at 6:45 A.M., showed the resident lay in bed on his/her side. LPN A provided wound care, while LPN B held the resident in place. After they finished, LPN B assisted the resident by pulling up the resident's brief. The catheter tubing was twisted. LPN B disconnected the catheter tubing from the drainage bag to untwist the tubing and reconnected the tubing without disinfecting the catheter tubing junction with alcohol or a chlorhexidine sponge. 3. Review of Resident #46's annual MDS, dated [DATE], showed: -Cognitively intact; -Impairment to both upper and lower extremities on one side; -Dependent to chair/bed-to-chair transfer; -Diagnoses included stroke, anemia, heart failure, high blood pressure, diabetes and high cholesterol. Review of the facility's list of residents on EBP rooms for January 2025, showed Resident #46 as one of the 29 residents. He/She was placed on EBP due to ESBL (Extended-Spectrum Beta-Lactamase, an enzyme that makes bacteria resistant to certain antibiotics). Observation on 1/23/25 at 6:22 A.M., showed the resident lay in bed, and an EBP sign hung on the door which was visible to the hallway. Certified Nurses Aide (CNA) K and CNA L transferred the resident from bed to wheelchair. Neither CNA wore a gown. PPE supplies were hung on the resident's door. The resident had a facility gown on top and regular pants on the bottom half of his/her body. CNA L said morning care was provided while the resident was lying in bed. While in the wheelchair, CNA L removed the resident's gown and put the top shirt on then combed the resident's hair with no gown on. During an interview on 1/24/25 at 3:07 P.M., CNA M said gown, gloves and masks were to be worn during high contact care of the residents on EBP. He/She receives report from the nurse who identifies the residents on EBP. These residents had wounds, droplet (steps to prevent the spread of infections that are spread through respiratory droplets), and Foley catheter (a thin, flexible tube inserted into the bladder to drain urine) to be placed on EBP rooms. During an interview on 1/24/25 at 3:10 P.M., Registered Nurse (RN) N said EBP rooms were for residents who had wounds, lines, drains, such as Foleys. PPE supplies and door signs were placed in each room. The staff were expected to wear PPEs such as gowns and gloves in providing high-contact care to EBP residents. No PPEs were necessary if staff were to deliver meal trays only. 4. During an interview on 1/23/25 at 12:34 P.M., the Infection Control Preventionist (ICP) said the staff do not need to disconnect the catheter tubing for dressing and if they did, they need to clean the connection junction with alcohol before reconnecting it. Regarding EBP, the ICP said EBP rooms had supplies of PPEs and door signs were hung in each room. She said if the sign was placed by the doorknob, it was for the resident in the door bed, while if the sign was on the opposite side, it meant for the resident in the window bed. She said residents who had MDRO, tube feedings, Foley catheters and wounds were to be placed in EBP rooms. PPE were to be used when providing direct care and high-contact care to the residents on EBP. The staff would know which residents were on EBP through door signs and the monthly list placed in the nurses' stations. 5. During an interview on 1/23/25 at 1:00 P.M., the Director of Nursing (DON) said the catheter and drainage bag are a closed system and it did not need to be disconnected for dressing. If it was disconnected, the junction connection would need to be sanitized prior to reconnecting. The DON also expected staff to change gloves as needed and perform proper hand hygiene during care. The staff were expected to wear PPE while providing high-contact care to residents on EBP. 6. During an interview on 1/24/25 at 3:55 P.M., the Administrator said she expected staff to follow the facility's infection control policy and procedures.

Based on interview and record review, the facility failed to keep all residents safe from physical abuse by failing to educate nursing staff on the risk of resident-to-resident physical assault, failed to educate staff on immediate interventions to deescalate verbal altercations, and failed to provide adequate supervision for one resident (Resident #1). Resident #1 was cognitively intact when he/she willfully physically assaulted Resident #2 on 4/13/24. The nursing staff was not aware Resident #1 was a risk to physically assault other residents and did not immediately intervene when Resident #1 had a verbal altercation with Resident #2, which then escalated to the physical assault. Resident #1 was then given an immediate discharge due to the assault. The sample was five. The census was 90. Review of the facility's abuse prevention and prohibition program, updated, showed: -Purpose: To ensure the facility establishes, operationalizes and maintains an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has a zero-tolerance for abuse, neglect, mistreatment and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The facility is committed to protecting residents from abuse by anyone; -Covered individuals will be trained through orientation and on-going training sessions, no less than annually, on the following topics: Abuse prevention and appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse; -Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict; -Resident to resident altercation must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain. Review of Resident #1's care plan, undated, showed: -A problem, initiated on 7/18/23 and revised on 11/21/23, the resident was verbally aggressive related to poor impulse control. Interventions included: Investigate/monitor need for psychological/psychiatric support; Monitor behavior episodes, attempt to understand cause; When agitated, intervene before agitation escalates. Review of the facility's investigation, provided by the Administrator via email on 4/29/24 at 9:31 A.M., showed: -On 8/23/23, at 6:30 A.M., a video showed the resident wanted to go outside with other residents. Another resident told the resident it was too early to smoke. The resident called the other resident a son of a bitch accusing him/her of telling staff he/she was going outside to smoke. The other resident told Resident #1 he/she need to close his/her mouth talking about my momma and then pointed at the resident's face. Resident #1 called the other resident a son of a bitch and hit his/her hand. The other resident then slapped Resident #1's face; -The incident was investigated according to their abuse and neglect policy. Review of Resident #1's care plan, undated, showed: -A problem, initiated and revised on 11/22/23, the resident had potential to be physically aggressive and had poor impulse control. Interventions included: Investigate/monitor need for psychological/psychiatric support; Monitor behavior episodes, attempt to understand cause; When agitated, intervene before agitation escalates; Report to physician unexpected changes in behavioral status. Review of the resident's soft file, provided upon request, showed on 7/26/23 at 3:26 A.M., the resident went outside to smoke at 2:30 A.M. when told by staff there were smoking rules and he/she could not be outside at that time. The resident refused to come back into the building and told staff they could not tell him/her what to do, to fuck off and the nurse was not his/her boss. When the nurse told the resident the incident would get reported to the management, the resident said he/she did not give a fuck and they could not tell him/her what to do either. When the resident went back into his/her room, he/she yelled out of the door to the resident across the hall to turn down the fucking TV. Review of resident's progress notes, dated 7/14/23 through 4/23/24, showed: -The notes skip from 8/6/23 through 1/10/24; -On 1/12/24 at 7:12 P.M., (social services note) they met for a quarterly care plan meeting on 1/11/24, the resident was alert and oriented times four (to person, place, time and situation) and was able to make his/her needs known to nursing staff. The resident was cognitively intact. The resident had a history of loud outbursts towards staff with him/her cussing at them, no behaviors reported at this time; -On 1/25/24 at 8:23 P.M., (nurse's progress note) the resident had a verbal altercation with the Certified Medication Technician (CMT). Per the CMT, the resident rolled up to the CMT in his/her wheelchair, asking to have his/her Percocet (narcotic used for pain relief). The CMT explained the order was to give every six hours, as needed for pain, and it was too soon to give it to the resident, since the last administration. The resident got extremely upset and started cussing at the CMT. The CMT and the resident started going back and forth and the resident rolled off down the hall yelling and cursing. The Director of Nursing (DON) was contacted to report the incident and the resident was told the DON would speak to the resident personally regarding the incident. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/4/24, showed: -admitted on [DATE]; -Cognitively intact; -No behaviors noted; -Diagnoses included: seizures, vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage), Crohn's disease (intestinal disorder), diabetes mellitus and coronary artery disease. Review of Resident #1's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Cognitively intact; -Verbal behavioral symptoms directed towards others occurs every four to six days, but less than daily; -Rejection of care occurred every one to three days; -Diagnoses included anxiety, depression, cognitive communication deficit and schizoaffective disorder (chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). Review of Resident #1's progress notes, showed: -On 4/13/24 at 6:00 P.M., a late entry progress note showed, the resident had an incident with another resident and was given immediate discharge paperwork, the resident signed the paperwork and a copy was given to the resident. An ambulance transported the resident to a hospital for psychiatric evaluation and to find alternative placement. During an interview on 4/23/24 at 10:51 A.M., CMT A said: -He/She was passing medication to residents on 4/13/24 and was a witness to the resident physically assaulting Resident #2; -The resident and Resident #2's rooms were directly across from each other; -He/She had just given Resident #2 medication and had moved his/her cart down the hall, a short distance from the resident's room; -He/She saw the resident exiting his/her room, trying to wheel him/herself down the hall; -Resident #2 was sitting in his/her wheelchair, in front of his/her room, facing the resident. Resident #2 was blocking the resident from going down the hall; -He/She heard the resident loudly cussing at Resident #2 and telling him/her to move out of his/her way; -He/She told Resident #2 to back up his/her wheelchair and then turned back to his/her medication cart to pass out medications to other residents; -He/She thought Resident #2 would back his/her wheelchair into his/her room to let Resident #1 access to the hall; -He/She heard Resident #2 cry out, turned from his/her medication cart and saw the resident leaning forward in his/her wheelchair, with his/her hands wrapped up in Resident #2's long hair, while hitting Resident #2's left side of his/her face with a closed fist; -CMT A yelled out to the resident to stop hitting Resident #2; -The resident continued to hit Resident #2, striking him/her across his/her face and on the top of his/her head; -Resident #2 was yelling at the resident and was trying to get the resident off of him/her by scratching at the resident's arms and chest; -CMT A intervened by physically trying to pry the resident's hands out of Resident #2's long hair, while telling the resident to stop hitting Resident #2; -After CMT A was able to get the resident's hands unwound from Resident #2's hair, he/she rolled Resident #2 back into his/her room; -He/She was aware the resident had a history of verbal aggression to other residents, often cursing them when he/she was angry; -He/She was not aware the resident had a history of physical altercations or was a risk to escalate from a verbal altercation to a physical altercation; -He/She was not aware of any interventions specific to the resident to help him/her calm down during a verbal altercation; -He/She expected to know if a resident had a history or was at risk of physically assaulting others so he/she would know what interventions to use to stop verbal altercations from escalating; -He/She expected the nurse on duty to inform him/her of any residents who were at risk of acting out physically towards staff or other residents; -He/She had access to resident care plans. During an interview on 4/23/24 at 11:44 A.M., Licensed Practical Nurse (LPN) B said: -He/She was the nurse manager over the resident's hall; -He/She would know if a resident had a history of physical or verbal aggression by looking at residents' care plans; -He/She was not aware of any residents on the halls he/she managed who had a history of verbal and/or physical aggression; -He/She was shocked when he/she heard the resident had physically assaulted Resident #2; -He/She had no knowledge of the resident exhibiting any behaviors, verbal or physical, with other residents; -He/She had no knowledge of the resident hitting another resident in the past; -He/She expected to know if any residents exhibited verbal or physical aggression towards staff or other residents so he/she could protect the resident from escalating to such behaviors and protect other residents; -He/She did not think the resident was unsafe around other residents before the incident occurred on 4/13/24. During an interview on 4/23/24 at 12:01 P.M., Resident #2, said: -He/She was in the hallway and had asked Resident #1 for assistance to move out of a doorway; -Resident #1 all of a sudden grabbed him/her around his/her neck, puling down his/her head and started to hit him/her on the top of his/her head and across his/her face; -He/She tried to defend him/herself by trying to push Resident #1 off of him/her and scratching at Resident #1's chest; -Resident #1 kept hitting the left side of his/her face, around his/her left eye and temple; -His/Her left side of his/her face no longer hurt, but it felt a little numb; -He/She could not remember if any staff helped him/her get Resident #1 from hitting him/her. Everything was now a blur to him/her; -He/She was shocked Resident #1 had physically assaulted him/her. Observation on 4/23/24 at 12:10 P.M., showed Resident #2 sitting in his/her wheelchair, with his/her long hair pinned up in the back of his/her head, well groomed and able to propel him/herself. The resident did not have any bruising or discoloration to his/her face. During an interview on 4/23/24 at 12:13 P.M., Certified Nursing Assistant (CNA) C said: -He/She regularly worked on the resident's hall; -He/She would know if a resident was verbally aggressive or physically aggressive based on how the resident was acting; -He/She would know if a resident had a history of verbal and/or physical aggression if he/she was required to chart on their behaviors; -He/She knew the resident had a history of verbal aggression as the resident often yelled and cussed at staff when he/she did not get the medication when he/she wanted it; -He/She knew the resident was verbally aggressive to another resident a few months ago, yelling at the other resident to get out of his/her way; -He/She expected the nurse or nurse manager to inform him/her if a resident had a history of physical assaults or was at risk of physically assaulting others and to instruct him/her on what interventions to use to avoid such behaviors; -He/She was not aware the resident had a history and was at risk of physical aggression; -He/She had access to residents' care plans. During an interview on 4/23/24 at 1:20 P.M., the Administrator and DON said: -They expected nursing staff to have knowledge of and to follow facility policies; -They expected nursing staff to have knowledge of and to follow resident care plans; -On 4/13/24, the resident was talking to his/her family member on the phone and had a distressing conversation with them. He/She was trying to go out of his/her room to go and smoke when Resident #2 was in his/her way. That is when the resident physically attacked Resident #2; -The resident had a history of verbal aggression towards other residents, calling them racial slurs and cursing at them; -The resident had a history of verbal aggression towards staff, cussing at them and using racial slurs when he/she did not get his/her way in regards to getting pain medication outside of the administration orders and when not able to smoke when outside of the scheduled smoke breaks; -There were a few times when the Administrator and the DON were able to intervene when the resident was verbally abusive to other residents, to prevent him/her from escalating to physical violence; -The Administrator and the DON were able to calm the resident down when he/she almost became physically aggressive with them on several occasions; -The Administrator and the DON were concerned the other residents would not have the capacity to calm the resident down when he/she was verbally aggressive towards them to avoid the resident becoming physically aggressive; -The resident was given an immediate discharge due to his/her history of being on the verge of physical aggression towards others, his/her history of verbal aggression to others, and because he/she was considered a danger towards weaker residents as he/she was very mobile in his/he wheelchair. Review of the resident's medical record, on 4/23/24, showed: -There was no documentation of any incidents of the resident acting verbally aggressive, cussing and using racial slurs against other residents; -There was no documentation of any incidents of the resident acting verbally aggressive towards the Administrator or DON. During an interview on 4/25/24 at 1:34 P.M., the Social Service Director (SSD), said: -The resident had a history of outbursts with staff when he/she didn't get pain medication, when it wasn't time for administration. The resident would yell and holler, but never anything physical; -He met with the resident and gave him/her psychosocial counseling after altercations with staff or residents, talked to the resident to try to calm him/her down and was able to deescalate the resident; -The resident had a short fuse, a short temper, would sometimes need to go off by his/herself to calm down and then later apologize to others; -He didn't feel the resident was a physical threat to others as the resident's behaviors were always verbal aggression; -He was shocked when he heard the resident physically assaulted Resident #2; -He did not expect nursing staff to document behaviors in the resident's medical record. Behavior incidents were documented and kept only in soft files; -We chose to put behavior incidents in soft files instead of in the resident's medical record; -Soft files were investigations that are kept in-house; -Residents' behaviors were discussed in daily clinical meetings and the team would update care plans with interventions; -Only the interdisciplinary team (IDT) had access to soft files; -If a resident's behavior was not documented in their progress notes, nursing staff would know if a behavior occurred if they were told in report or read it on the 24 hour nursing report. The 24-hour report was not part of a resident's medical record; it was a communication tool for nurses from shift to shift; -The resident had verbal altercations with other residents and he would counsel the resident after the altercations occurred. He could not give details or particulars to each situation, just that the resident would argue or cuss at other residents and was generally very rude to other residents; -He offered the resident psychiatric services and counseling. The resident refused both services. He did not document the offers or the resident's refusals. MO00234631

Based on interview and record review, the facility failed to maintain complete and accurate medical files for residents. The facility failed to document verbal and physical aggressive incidents, encounters with the Social Services Director (SSD) discussing behaviors after they occurred and failed to document when psychiatric services or counseling was offered to one resident (Resident #1). The facility also failed to upload neurological checks into a resident's medical record in a timely manner for one resident (Resident #2). The sample was five. The census was 90. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/5/24, showed: -admitted on [DATE]; -Cognitively intact; -Verbal behavioral symptoms directed towards others occurs every four to six days, but less than daily; -Rejection of care occurred every one to three days; -Diagnoses included anxiety, depression, cognitive communication deficit and schizoaffective disorder (chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). Review of resident's progress notes, dated 7/14/23 through 4/23/24, showed: -The notes skip from 8/6/23 through 1/10/24; -On 1/12/24 at 7:12 P.M., (social services note) they met for a quarterly care plan meeting on 1/11/24, the resident was alert and oriented times four (to person, place, time and situation) and was able to make his/her needs known to nursing staff. The resident was cognitively intact. The resident had a history of loud outbursts towards staff with him/her cussing at them, no behaviors reported at this time; -On 1/25/24 at 8:23 P.M., (nurse's progress note) the resident had a verbal altercation with the Certified Medication Technician (CMT). Per the CMT, the resident rolled up to the CMT in his/her wheelchair, asking to have his/her Percocet (narcotic used for pain relief). The CMT explained the order was to give every six hours, as needed for pain, and it was too soon to give it to the resident, since the last administration. The resident got extremely upset and started cussing at the CMT. The CMT and the resident started going back and forth and the resident rolled off down the hall yelling and cursing. The Director of Nursing (DON) was contacted to report the incident and the resident was told the Director of Nursing (DON) would speak to the resident personally regarding the incident; -On 4/13/24 at 6:00 P.M., (late entry progress note) the resident had an incident with another resident and was given immediate discharge paperwork, The resident signed the paperwork and a copy was given to the resident. An ambulance transported the resident to a hospital for psychiatric evaluation and to find alternative placement; -There was no other documentation regarding the resident's behaviors towards staff or other residents; -There was no documentation the facility offering psychiatric services, counseling, or anger management classes to the resident and his/her denial of services; -There was no documentation the resident met with the SSD after altercations with staff or residents to help the resident de-escalate. During an interview on 4/23/24 at 1:20 P.M., the Administrator and the DON said: -On 4/13/24, the resident was talking to his/her family member on the phone and had a distressing conversation with them. He/She was trying to go out of his/her room to go and smoke when Resident #2 was in his/her way. That is when the resident physically attacked Resident #2; -The resident had a history of verbal aggression towards other residents, calling them racial slurs and cursing at them; -The resident had a history of verbal aggression towards staff, cussing at them and using racial slurs when he/she did not get his/her way in regards to getting pain medication outside of the administration orders and when not able to smoke when outside of the scheduled smoke breaks; -There were a few times when the Administrator and the DON were able to intervene when the resident was verbally abusive to other residents, to prevent him/her from escalating to physical violence; -The Administrator and the DON were able to calm the resident down when he/she almost became physically aggressive with them on several occasions; -They did not expect nurses to write progress notes on residents' behaviors; -They did not expect the SSD to write progress notes in the resident's medical record when he met with the resident regarding his/her behavior; -They kept behavior investigation in a soft file that was kept in house; -They did not have to upload behavior investigations into residents' medical records as they were in-house and accessible when asked for; -They did not expect the SSD to document in the resident's medical record when counseling or psychiatric services were offered to the resident. It was all kept in the soft files. During an interview on 4/25/24 at 1:34 P.M., the SSD said: -The resident had a history of outbursts with staff when he/she didn't get pain medication, when it wasn't time for administration. The resident would yell and holler, but never anything physical; -He met with resident and gave him/her psychosocial counseling after altercations with staff or residents, talked to the resident to try to calm him/her down and was able to deescalate the resident; -The resident had a short fuse, a short temper, would sometimes need to go off by him/herself to calm down and then later apologize to others; -He did not expect nursing staff to document behaviors in resident's medical record. Behavior incidents were documented and kept only in soft files; -The facility chose to put behavior incidents in soft files; -Residents' behaviors were discussed in daily clinical meetings; -Only the Interdisciplinary team (IDT) had access to soft files; -The IDT would see a trend if the resident had behaviors over and over again because they would discuss them in clinical meetings and keep updating the care plans with interventions. -Care plans were not necessarily updated with dates and details of a behavior; -The resident had verbal altercations with other residents and he would counsel the resident after the altercations occurred. He could not give details or particulars to each situation, just that the resident would argue or cuss at other residents and was generally very rude to other residents; -He offered the resident psychiatric services and counseling. The resident refused services. He did not document the offers or the resident's refusals. Review of requested soft files regarding the resident's verbal or physical altercations with staff and/or residents, sent by the Administrator on 4/25/24 at 4:29 A.M., showed: -A behavior note, dated 7/20/23 at 12:53 A.M., the resident went outside to smoke with another resident. The resident was re-educated on the facility smoking policy. The resident became upset, packed all his/her belongings and said his/her family member would come to pick him/her up. The resident's family member was contacted by staff and the family member told the resident they would not come to pick him/her up. The resident yelled at the family member over the phone. The resident then proceeded to go toward the back door, which led outside, saying if anyone touched him/her he/she would kick ass then sue the facility. Leaving against medical advice paperwork was started when the resident came back in and went to his/her room; -A behavior note, dated 7/26/23 at 3:26 A.M., the resident went outside to smoke at 2:30 A.M. when told by staff there were smoking rules and he/she could not be outside at that time. The resident refused to come back into the building and told staff they could not tell him/her what to do, to fuck off and the nurse was not his/her boss. When the nurse told the resident the incident would get reported to the management, the resident said he/she did not give a fuck and they could not tell him/her what to do either. When the resident went back into his/her room, he/she yelled out of the door to the resident across the hall to turn down the fucking TV; -A health status note, dated 7/26/23 at 6:11 A.M., the resident went outside again and stated he/she did not have to come in when asked by the nurse. The resident said staff could not tell him/her what to do and then cussed staff out; -A health status note, dated 9/26/23 at 6:25 A.M., the nurse wrote the resident went outside with others to the patio to the smoke. The resident came back inside after asked by staff. The resident went back out as soon as the day broke. The resident was aware the smoke break was at 8:00 A.M. to 8:00 P.M., -A health status note, dated 11/17/23 at 1:36 A.M., the resident came to the nurses' station saying he/she had asked for a pain pill two hours ago. While the nurse got up to get the resident a pain pill, the resident became argumentative. The nurse gave the resident the pain pill and told the resident he/she would not argue with the resident. The resident called the nurse the B word and said he/she would call 911. The resident then woke up another resident and they both went outside to smoke after staff told them they were not allowed to and that the door locked; -A Social Services note, dated 12/12/23 at 7:59 A.M., the resident was spoken to by the SSD due to a report the resident was outside smoking before the designated smoking schedule from residents. The resident was told he/she would be issued a 30-day discharge notice because every resident who smoked signed a behavioral contract stating they would only smoke during designated times, which the resident understood and said he/she would not do it again. Social Services would continue to follow and monitor the resident for any new concerns or needs the resident might have. Review of the facility's investigation, provided by the Administrator via email on 4/29/24 at 9:31 A.M., showed: -On 8/23/23, at 6:30 A.M., a video showed the resident wanted to go outside with other residents. Another resident told Resident #1 it was too early to smoke. The resident called the other resident a son of a bitch, accusing him/her of telling staff he/she was going outside to smoke. The other resident told Resident #1 he/she need to close his/her mouth talking about my momma and then pointed at the resident's face. Resident #1 called the other resident a son of a bitch and hit his/her hand. The other resident then slapped Resident #1's face. Review of the resident's medical record, during the investigation, showed: -There was no documentation regarding the resident's physical altercation with the other resident which occurred on 8/23/23; -There was no documentation of any incidents of the resident acting verbally aggressive, cussing and using racial slurs against other residents; -There was no documentation of any incidents of the resident acting verbally aggressive towards the Administrator or DON. 2. Review of the facility's neurological assessment policy, revised on 10/24/22, showed: -Purpose: To provide guidelines for the performance of a neurological assessment on residents; -The following information will be documented in the resident's medical record: -The date and time the procedure was performed; -The name and title of the individual(s) who performed the procedure; -All assessment data obtained during the procedure; -If the resident refused the procedure, the reason why and the intervention taken; -The signature and title of the person recording the data; -Nursing staff may use the Neurological Flow Sheet. Review of Resident #2's quarterly MDS assessment, dated 3/4/24, showed: -admitted on [DATE]; -Cognitively intact; -No behaviors noted; -Diagnoses included: seizures, vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage), Crohn's disease (intestinal disorder), diabetes mellitus and coronary artery disease. Review of the resident's progress notes, dated 8/31/23 through 4/23/24, showed: -A late entry note, effective date 4/13/24 at 6:00 P.M., the resident had an altercation with another resident. The resident received a small bruised to his/her right shoulder, an abrasion to his/her right temple area, scratches to his/her left side of his/her face and neck. Neurological checks were initiated and within normal levels; -On 4/14/24 at 6:57 A.M., neurological checks were done and the resident continues for incident follow up on days; -On 4/16/24 at 6:38 P.M., the resident remained on observation for an altercation with another resident. Neurological checks were continued. During an interview on 4/23/24 at 1:25 P.M., the Administrator and DON, said: -Nurses completed neurological checks on a 72 hour neurological flow sheet, which was on paper; -Nurses were expected to complete the 72 hour neurological flow sheet and turn the sheet into medical records for them to upload the neurological flow sheet into the residents' medical record; -They did not have an expected time frame in which medical records was expected to upload the neurological flow sheet into residents' medical records; -Neurological flow sheets did not have to be in the residents' medical record as the facility saved the flow sheets in house in soft files, which were available upon request. Review of the resident's medical record, on 4/23/24, showed there was documentation found of the Neurological Flow Sheet started on 4/13/24 and completed on 4/17/24, was uploaded into the resident's medical record.

Based on interview and record review, the facility failed to ensure 10 out of 10 Certified Nurse Aides (CNAs) received the required annual 12 hour resident care training. The census was 92. Review of the CNA Individual Service Records, showed the following: -CNA V hired 6/1/21, with no identified number of hours of in-service education; -CNA W hired 7/22/22, with no identified number of hours of in-service education; -CNA X hired 6/10/22, with no identified number of hours of in-service education; -CNA Y hired 12/1/21, with no identified number of hours of in-service education; -CNA Z hired 7/22/22, with no identified number of hours of in-service education; -CNA AA hired 4/20/22, with no identified number of hours of in-service education; -CNA BB hired 6/27/22, with no identified number of hours of in-service education; -CNA CC hired 4/20/22, with no identified number of hours of in-service education; -CNA DD hired 6/3/22, with no identified number of hours of in-service education; -CNA EE hired 4/19/22, with no identified number of hours of in-service education. During a interview on 8/28/23 at 11:00 A.M., the Director of Nursing (DON) said she did not have any documentation for CNA education hours. During an interview on 8/29/23 at 1:20 P.M., the Administrator said she would expect the CNA training to be completed and the training hours to be documented. The DON said they should have been completed and she now created a spreadsheet.

37681 Based on observation, interview and record review, the facility failed to follow recipes to ensure adequate nutritive value, taste and texture for pureed foods (a very smooth blended food like applesauce or mashed potatoes). In addition, the facility failed to ensure residents were served hot foods at the appropriate temperature of 120 degrees Fahrenheit (F). Also, the facility failed to serve foods that were palliative and appetizing for five residents (Residents #37, #19, #76, #51 and #24) of 19 sampled residents and members of the Resident Council. This deficient practice affected all residents who ate meals at the facility. The census was 92. 1. Review of the facility's morning menu sheet, dated 8/25/23, showed breakfast consisted of pancakes, sausage and oatmeal. Observation on 8/25/23 at 6:59 A.M., showed Cook II prepared pureed sausage for four residents. Two residents received double portions. Cook II retrieved a pan of six sausage patties from a pan with a gray looking substance already in the pan. He/She said the gray substance was the pureed sausage from the day before, and he/she removed the sausages from that pan. He/She placed the six sausage patties in the blender and added a half a quart of water and blended the items. He/She poured the mixture into a pan to serve. The sausage was runny, watery and choppy. Review of the facility's recipe for five servings of pureed sausage, showed: -Five portions needed from regular prepared recipe; -Place portions in food processor and process to fine consistency; -Add a small amount of hot water and process to achieve a smooth, whipped consistency; -If too thin, add a small amount of food thickener until whipped consistency is achieved; -Place in pan and cover; -Prepare gravy per recipe. Observation on 8/25/23 at 7:15 A.M., showed Cook II prepared pureed pancakes for four residents. He/She added three pancakes to the blender. He/She said he/she used only three pancakes because once it was blended, there would be enough for four. Cook II then added two drops of thickener and five liters of water to the blender and blended. He/She poured the mixture into a pan for serving. The texture was watery and runny. Cook II tasted the pancakes. Cook II said the pancakes tasted like water and pancakes. Review of the facility's recipe for five pureed pancakes, showed: -Five pancakes prepared per recipe; -Transfer to food processor and process until crumbly; -Add one third cup of hot milk, until smooth. During an interview on 8/25/23 at 7:37 A.M., the Dietary Manager said Cook II did not follow a recipe when preparing pureed foods. He/She should have used milk in the recipe for pancakes. For the sausage, Cook II should have used brown gravy, hot water and thickener. 2. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/12/23, showed: -Cognitively intact; -Required assistance with tray set up and was independent with eating. During an interview on 8/23/23 at 9:57 A.M., the resident said, he/she ate mostly in his/her room and sometimes the hot foods were not hot. 3. Review of Resident #19's admission MDS, dated [DATE], showed: -Cognitively intact; -Required assistance with tray set up and was independent with eating. During an interview on 8/23/23 at 4:07 P.M., the resident said the food was not hot. It did not matter if he/she ate in the dining room or in his/her room, the hot food was not served hot. 4. Review of Resident #76's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 8/24/23 at approximately 10:00 A.M., the resident said the food was usually cold when it was served in his/her room. The food was not always appetizing. 5. Review of Resident #51's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 8/23/23 at approximately 10:00 A.M., the resident said the food was horrible. He/She did not believe staff tasted the food before serving it. The food was often cold. 6. Review of Resident #24's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 8/23/23 at approximately 9:30 A.M., the resident said the food was often served cold and lacked flavor. 7. Observation on 8/25/23 at 8:47 A.M., showed resident meal trays delivered to the 100 unit. A test tray was obtained, and showed: -The meal consisted of pancakes, cooked ham, oatmeal and red juice; -The pancakes temperature measured at 87.2 degrees F and was cool to the touch. The pancakes were dry and difficult to chew; -The ham measured at 85.4 degrees F and was cold to the touch; -The oatmeal was hot but lacked flavor and was extremely thick; -The red juice, identified as cranberry juice, was watery. Observation on 8/25/23 at 9:01 A.M., showed breakfast trays arrived on the 300 hall food cart. A test tray was obtained and showed: -The temperature of the pancakes measured 89.0 degrees F; -The ham felt cool to the touch;. -The pancakes and ham felt cool when consumed; -The temperature of the oatmeal measured 122.0 degrees F. The oatmeal had an unidentified brown firm lump submerged in the bowl, approximately the size of a nickel, that did not appear to be sugar. 8. Review of the facility's lunch menu sheet, dated 8/28/23, showed meatloaf, macaroni and cheese, cauliflower and roll. Observation on 8/28/23 at 1:00 P.M., a test tray obtained from the 400 hall food cart, showed: -The temperature of the meatloaf measured 109.4 degrees F; -The temperature of the cauliflower measured 95.0 degrees F; -The temperature of the orange beverage with ice in it measured 44.0 degrees F Observation on 8/28/23 at 1:05 P.M., of the Unit 300/400 dining room, showed: -The lunch trays arrived and six residents were seated in the dining room; -The temperature of the meatloaf measured 117.0 degrees F; -The temperature of the cauliflower measured 119.0 degrees F. 9. Review of the facility's Resident Council Meetings, dated 8/17/23, showed: Temperature on hall trays, foods was not hot. During the group meeting on 8/25/23 at 10:43 A.M., six out of six residents said the food tasted stale. The food was not seasoned and they put too much salt on the food. The residents did not believe staff tasted the food that was served. When they use the grill, the bread tasted like something else. The grill might not be cleaned. The bread on the grilled cheese sandwiches was too greasy. All the oil could be seen if someone pushed down on the bread with his/her finger. Some of the residents sat in the dining room, but their tray was on the hall cart. The food was cold most of the time. They served Polish sausage for lunch and it was cold and hard. The mashed potatoes were cold too. 10. During an interview on 8/28/23 at 4:48 P.M., Dietary Aide (DA) C said residents always complained about the taste of the food. Residents also complained of food being too hot. 11. During an interview on 8/28/23 at approximately 9:00 A.M., Licensed Practical Nurse (LPN) G said nursing sometimes helped with meal services. If residents complained of cold food, staff sent it back to the kitchen to get different food. Nine times out of 10, the residents got a new plate. He/She had not received any complaints from the residents who ate in the dining room, only some complaints from residents who ate in their room. The plates were then sent back to dietary to get the temperature tested . 12. During an interview on 8/29/23 at 1:18 P.M., the Administrator and Director of Nursing (DON) said the dining room and hall tray temperatures for all meals should be the same, but sometimes were not. They did not know what the food temperature should be but guessed around 130.0 degrees F. The Administrator expected the cold food to be cold and the hot food to be hot. When residents complained, they expected staff to fix the problem. The facility had a food committee meeting and residents could bring their concerns to the meeting. MO00205092 42247 49149

37681 42247 Based on observation, interview and record review, the facility failed to maintain a homelike environment. Flies flew in the assisted dining room and in the main dining room during meal time, trash was on the floor in the main dining area, the shower rooms were untidy and used for storage (the resident shower room located in room [ROOM NUMBER], 100 hall shower room and 200 hall shower room, and in the resident shower room located in room [ROOM NUMBER] and and room [ROOM NUMBER]), one resident's room had paint peeling from the ceiling (room [ROOM NUMBER]), one resident's room had a hole behind their door and their foot board was in need of repair and there were several holes behind the resident's bed with chipped paint (Resident #76), one resident's bathroom toilet was filled with a brown substance and the sink was leaking (Resident #24), and one resident's room had a brownish discoloration stain on their privacy curtain (Resident #37). The census was 92. Review of the facility's housekeeping policy, revised 11/1/16, showed: -It will be the standard of this facility to provide effective and sanitary housekeeping and maintenance services; -The facility will maintain staff to provide routine cleaning and sanitation techniques for the facility; -The facility staff should maintain all equipment in good and cleanly repair to include, but not be limited to wheelchairs, IV poles, Feeding Tube poles, curtains, etc. in agreement with the resident's wishes/preferences; -Equipment should be maintained in fashion that does not impede the function of the staff or the residents; -Terminal cleaning of isolation rooms should be completed when a room or the resident residing in the room has been diagnostically cleared of the microorganism requiring isolation or if the resident is discharged from the facility or transferred to another room inside the facility; -Any concerns voiced by the residents, responsible parties, visitors or other vendors should be logged appropriately in the maintenance or grievance/concern log as is appropriate. If a concern is able to be resolved immediately by staff and does not require an extended wait for resolution, it is not necessary for the concern to logged in the maintenance log as that serves as notification that resolution is still needed; -Special consideration should be given to allergies or specific preferences of residents. 1. Observations on 8/23/23 at 9:10 A.M., 8/24/23 at 8:20 A.M. and 2:00 P.M., 8/25/23 at 11:00 A.M., 8/28/23 at 1:00 P.M., and 8/29/23 at 10:00 A.M., showed a hole behind the door in room [ROOM NUMBER]. The hole was approximately the same size as the door handle. Also, in room [ROOM NUMBER], an exposed outlet next to the bed closest to the door and the bathroom light was very dim. During an interview on 8/24/23 at 2:15 P.M., one of the two residents in the room said he/she would not consider this homelike. He/She was not sure how long both the hole and the exposed outlet had been like that. He/She said he/she told maintenance yesterday about the bathroom light being very dim but they had not been back to replace it. The bathroom was very dark with the dimmed light. 2. Observation of the dining room on the 300/400 hall on 8/23/23 at 12:21 P.M., showed staff assisted a resident with eating. A fly flew around the resident and the resident's food. The staff member waved his/her hand in the air to move the fly away from the resident. At 12:27 P.M., the fly continued to fly around in the dining room. 3. Observation of the dining room, showed: -On 8/23/23 at 12:26 during lunch service, several flies surrounded residents and landed on food. The floor was observed with empty bags of chips and a soda bottle; -On 8/25/23 at 5:44 A.M., several pieces of balled up paper were on the floor, empty soda bottles and empty bags of chips were on two tables. An opened bag of chips was in the middle of the dining room floor. 4. Observation on 8/23/23 at 1:15 P.M., of the residents' shower room in room [ROOM NUMBER], showed the left side of the shower room had no soap or paper towels in the dispensers, wet used towels on the floor and rolled up towels lay against the walls. Paint peeled on the ceiling and behind the door. The floor had debris and dirt throughout. The right side of the room had medical equipment and pillows stored on top of the toilet seat. The sink was dirty with used soiled paper towels with a pink and white runny substance throughout the sink. The floor was dirty with grime around the bottom area of the toilet. The middle area of the shower room had what appeared to be used medical equipment stored. During an interview on 8/25/23 at 10:16 A.M., Housekeeper D completed a walk through of shower room [ROOM NUMBER] and said housekeeping is responsible for the shower room but, only one side is being used for showers. He/She would not consider it to be clean. The second shower area is not being used, and the toilet does not have a working water supply. 5. Observation on 8/23/23 at 2: 17 P.M., showed the ceiling in room [ROOM NUMBER] with paint peeled above the bed. 6. Review of Resident #76's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/3/23, showed the resident was cognitively intact. Observations on 8/23/23 at approximately 9:20 A.M., 8/24/23 at 8:31 A.M. and 8/25/23 at 10:37 A.M., showed upon entrance of the resident's room, a hole, approximately the size of a door knob was behind the resident's door. The resident's wooden foot board was broken in half and the area behind the resident's bed had several small holes and chipped paint. During an interview on 8/25/23 at 10:37 A.M., the resident said the broken foot board and the hole in the wall had been like that for awhile. It was not considered homelike. During observations and an interview on 8/25/23 at 10:37 A.M., the Maintenance Director said he was making rounds to individual resident rooms and was not aware of the holes in the resident's walls or the foot board being broken. This was not homelike and should have been addressed. 7. Review of Resident #24's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Observations on 8/23/23 at approximately 9:20 A.M. and 6:44 P.M., 8/24/23 at 8:24 A.M. and 8/25/23 at 10:33 A.M., showed a smell of bowel upon entrance of the room. A wheelchair sat in the bathroom. The toilet was filled with a brown substance. A wash pan was under the resident's sink, leaking water into the pan. During an interview on 8/23/23 at approximately 9:30 A.M., the resident said the sink had been leaking for about two months. The toilet was always backed up and they tried to fix it about two weeks ago. The bowel had been in the toilet for about two weeks. During an interview on 8/25/23 at 10:18 A.M., the Maintenance Director said he found out about the resident's sink about three days ago. The drain needed to be replaced. He was aware of the toilet being backed up for about a week but did not know bowel was in the toilet. He attempted to flush the resident's toilet. He said this was not considered homelike. 8. During an interview on 8/24/23 at 2:30 P.M., Certified Nurse's Aide (CNA) FF said both the 100 and 200 hall shower rooms are used by staff on a regular basis for resident showers. He/She said they were last used today. Observations of the 100 Hall shower room on 08/24/23 at approximately 2:45 P.M., showed: -A trash can with used adult incontinence pads sitting on top of the can; -A toilet with brown substance and several pieces of tissue paper, unflushed and an adult diaper and toilet tissue surrounding the toilet; -Several wheelchairs on one side of the shower room; -Candy wrapper on the floor; -A used glove in the sink; -A used band aide on the floor under the sink; -A mechanical lift in the middle of the floor, upon entrance. Observations of the 200 Hall shower room on 08/24/23 at approximately 2:55 P.M., showed: -Upon entrance, a scale and mechanical lift blocked the doorway; -Several bed mattresses were in one section of the shower room; -Christmas decorations were also present in one section of the shower room; -A sign outside of the door said Activities Supply Room. No medical supplies and no shower equipment; -A toilet with brown substance, unflushed; -An overflowing bag of trash sat next to the toilet; -A bag with several items sat on top of the tank of the toilet; -Toilet paper, a green loofah and a razor sat on top of the sink; -A used towel on the floor. 9. Review of Resident #37's MDS, dated [DATE], showed the resident was cognitively intact. During observation and interview on 8/25/23 at 8:15 A.M., the resident said, there was poop on his/her privacy curtain and pointed to a small brownish discoloration, approximately. 3 inches by 3 inches, on the privacy curtain, located between the beds. 10. Observation on 8/25/23 at 10:30 A.M., of the resident's shower room in room [ROOM NUMBER], showed the left side of the shower room with wet towels on the floor with what appeared to be hair stuck to the towels. The toilet bowl had stains and a brown ring on the inside of the toilet. The middle area of the shower room had what appeared to be used medical equipment stored. The right area of the shower room had shower chairs and clothing. The floor was dirty throughout. During an interview on 8/25/23 at 10:30 A.M., Housekeeper E completed a walk through and said that the shower room in 309 he/she thinks is a home like environment especially when it is clean. He/She said the shower room was crowded with equipment and the clutter is not a home like environment. Housekeeping is responsible for cleaning every day and is supposed to check the shower rooms every 2 hours. The evening shift should be checking the soiled utility room trash, but was not sure about their other duties. 11. Observation on 8/25/23 at 10:43 A.M., of the resident shower room in room [ROOM NUMBER], showed the middle room with what appeared to be used medical equipment. During an interview on 8/25/23 at 10:43 A.M., Housekeeping Supervisor F completed a walk through and said all housekeepers are responsible for cleaning and disinfecting the shower rooms. The CNA is supposed to keep the shower rooms tidy. Regarding the shower room in room [ROOM NUMBER], right now it does not seem like a home like environment, but when clean, it is. Rounds are done when he/she gets to the facility, after lunch and prior to leaving for the day. Rounds are done three times a day. Evening shift starts at 3:00 P.M. Housekeeping will check the shower rooms at 5:00 P.M., and throughout the evening. 12. During the group meeting on 8/25/23 at 10:43 A.M., six out of six residents said the cleanliness in the facility is hit or miss. The dining room is not kept clean. The floors are sticky. They saw feces on the floor once and it took 30 minutes for someone to clean it up. It was during meal service. Residents want to eat in their rooms because the dining room will go days without being cleaned. There are flies in the dining room and other resident areas and rooms. The shower rooms are supposed to be kept clean, but residents go in there and find dirty clothes, towels and medical equipment. The residents either have to get it moved out or just not shower. The residents have showered with storage items in the shower room with them. It is not homelike. 13. During an interview on 8/28/23 at 11:40 A.M., the Administrator said she expected the facility environment to be homelike. The facility has gotten better but it is not clean. The flies are probably coming from the residents holding the doors open to go outside to smoke. She expected for the holes in the walls, water leaking in the wash room and the peeling paint on the ceiling to be repaired. 14. During an interview on 8/29/23 at 1:19 P.M., the Administrator and Director of Nursing said the facility should be safe, clean and homelike for the residents. MO00205092 MO00215696 MO00222426 44950 49149

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of an immediate discharge notice, including the reasons for the discharge for 5 of 9 sampled residents who transferred to the hospital (Residents #100,, #46, #353, #88 and #78). The census was 92. Review of the undated facility admission agreement, showed: -The Facility may involuntarily transfer or discharge a resident for only one or more of the following reasons: -For medical reasons; -For the resident's physical safety; -For the physical safety or other residents, the facility staff or facility visitors; -For either late payment or non-payment for the resident's stay, except as prohibited by Titles XVIII and XIX of the Federal Social Security Act; -The Resident's health has improved sufficiently so that the Resident no longer requires the services provided by the facility; -The Missouri Department or Social Services, Division of Medical Services or the Missouri Department of Health and Senior Services orders the resident's removal from the facility; -The facility ceases to operate; -The resident's needs cannot be met in the facility; or -When a resident has not resided in the facility for thirty days; -The facility may involuntarily transfer or discharge the resident for any of the reasons indicated. The facility shall give a private pay Resident at least a twenty-one (21) day written notice, and the Medicare, Medicaid Pending or Medicaid Resident at least a thirty (30) day written notice. When late payment or non-payment is the basis for transfer or discharge, the resident shall have the right to cure the default up to the date that the transfer or discharge is to be made, and then shall have the right to remain in the facility. 1. Review of Resident #100's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/11/23, showed: -discharged on [DATE] to an acute hospital; -Return not anticipated. Review of the resident's medical record, showed: -admitted [DATE]; -discharged to the hospital on 7/11/23; -Diagnoses included osteomyelitis (inflammation of the bone), acute metabolic acidosis (too much acid accumulation in the body), severe protein-calorie malnutrition, pleural effusion (build up of fluid around the lung), and paraplegia (paralysis of the lower body); -Review of the resident's progress note, dated 7/11/23, showed resident complained of shortness of breath, he/she requests to be sent to the hospital. Physician made aware. Sent for further evaluation and treatment; -No documentation of a letter for the transfer on 7/11/23 notifying the resident and/or representative of a transfer and the reason for the transfer; -No documentation of notification of the Ombudsman's office regarding the resident's transfer on 7/11/23. 2. Review of Residents #46's discharge MDS, dated [DATE], showed: -discharged on [DATE] to an acute hospital; -Return anticipated. -Diagnoses include neurogenic bladder (the bladder does not empty properly due to a neurological condition) and malnutrition. Review of the resident's progress note, dated, 8/18/23, showed resident informed of mutual order from primary and nurse from outside company to be sent to the hospital for evaluation and treatment. The resident also agreed. The nurse from outside company informs facility nurse they will handle calling in report to the hospital; -No documentation of a letter for the transfer on 8/18/23, notifying the resident and/or representative of a transfer and the reason for the transfer; -No documentation of notification of the Ombudsman's office regarding the resident's transfer on 8/18/23. 3. Review of Resident #353's discharge MDS, dated [DATE], showed: -discharged on [DATE] to an acute hospital; -Return anticipated. Review of the resident's EMR, showed: -Diagnoses included neurogenic bladder, anxiety, and malnutrition; -Review of the resident's progress note dated 7/31/23, showed physician notified of blood pressure 89/52 (normal 90/60 through 120/80) and heart rate 64 (normal 60 through 100). The physician also notified that the tube feeding/water is coming out the insertion site of the gastrostomy tube (g-tube, a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication) and the resident is experiencing wheezes (high-pitched whistling sound made while breathing). Oxygen saturation (percent of oxygen in the blood) at 94% (normal 95% through 100%) after suctioning. Okay to send to emergency room for evaluation and treat; -No documentation of a letter for the transfer on 7/31/23, notifying the resident and/or representative of a transfer and the reason for the transfer; -No documentation of notification of the Ombudsman's office regarding the resident's transfer on 7/31/23. 4. Review of Resident #88's discharge MDS, dated [DATE], showed: -discharged on [DATE] to an acute hospital; -Return not anticipated. Review of the resident's EMR, showed: -Diagnoses included stroke, seizures, and malnutrition; -No documentation of a letter for the transfer on 5/24/23, notifying the resident and/or representative of a transfer and the reason for the transfer; -No documentation of notification of the Ombudsman's office regarding the resident's transfer on 5/24/23. 5. Review of Residents #78's MDS, showed: -No discharge assessment completed; -Admission MDS, dated [DATE], last entry for the resident; -Diagnoses included cerebral palsy (CP, a disorder of movement, muscle tone or posture), anxiety, depression, psychotic disorder, anemia (decrease in the number of red blood cells) and malnutrition. Review of the resident's EMR, showed: -admitted [DATE]; -discharge date [DATE], to acute hospital; -Review of the resident's last progress note, dated 8/23/23, showed this nurse made aware resident being seen in the emergency room after appointment. The resident will not return to the facility tonight; -No documentation of a letter for the transfer on 8/23/23, notifying the resident and/or representative of a transfer and the reason for the transfer; -No documentation of notification of the Ombudsman's office regarding the resident's transfer on 8/23/23. 6. During an interview on 8/28/23 at 4:43 P.M., the Administrator said staff do not provide, in writing, notification of discharge or transfer to resident/resident family. On 8/29/23 at 1:26 P.M., the Administrator said she expected transfer/discharge notifications to be provided to the resident or resident representative. 44950 49149

Based on interview and record review, the facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for 5 of 9 sampled residents who were transferred to a hospital (Residents #100, #46, #353, #88 and #78). The census was 92. Review of the facility's bed hold policy, dated 4/21/21, showed: -Standard: It will be standard of this facility to provide residents with bed-hold policies upon admission to the facility and at the time of transfer (when transferring to hospital or going on therapeutic leave) in accordance with federal and state regulations; -Guidelines: The initial bed-hold policy should be provided to the resident/responsible party as soon after admission as possible when completing the admission packet to the facility; -Should specify duration of bed-hold policy under the State Plan, if any, during which the resident is permitted to return and resume residence in the nursing facility; -Non-Medicaid residents may be requested to pay for all bed hold days; -The initial bed-hold policy in the admission packet should be considered an example of how the bed-hold policy works in the event it is required by the resident's conditions; -The bed-hold policy applies to all residents residing in the facility; -The second bed-hold policy should be provided at the time of transfer and if applicable, given with in advance to the transfer; -In emergency transfer situations, notice at the time of transfer refers to the provision of the resident's copy of the bed-hold policy will be provided along with the other transfer paper work to the hospital; -Bed-hold for days of absence in excess of the state's bed-hold limit are considered noncovered services and the resident could use his/her own funds to pay for the bed-hold if they desire; -Residents that are non-Medicaid in payer source may be requested to pay for all days of bed-hold; -Residents are eligible for re-admission following hospitalization or therapeutic leave. Per the facility's admission agreement, private pay, Medicare or other residents not meeting the requirement of Medicaid bed-hold: the facility will only reserve a bed for an absent resident if requested in writing by the resident or responsible party and applicable charges paid. In the event that a bed is not reserved, and the resident desires to re-occupy a room in the facility, the resident may be admitted to the next available bed. 1. Review of Resident #100's medical record, showed: -admitted [DATE]; -discharged to the hospital on 7/11/23; -Diagnoses included osteomyelitis (inflammation of the bone), acute metabolic acidosis (too much acid accumulation in the body), severe protein-calorie malnutrition, pleural effusion (build up of fluid around the lung), and paraplegia (paralysis of the lower body); -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of transfer. 2. Review of Resident #46's medical record, showed: -admitted [DATE]; -discharged to the hospital on 8/18/23; -Diagnoses included neurogenic bladder (the bladder does not empty properly due to a neurological condition) and malnutrition; -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of transfer. 3. Review of Resident #353's medical record, showed: -admitted [DATE]; -discharged to the hospital on 7/31/23; -Diagnoses included neurogenic bladder, anxiety and malnutrition; -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of transfer. 4. Review of Resident #88's medical record, showed: -admitted [DATE] -discharged to the hospital on 5/24/23; -Diagnoses included stroke, seizures and malnutrition; -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of transfer. 5. Review of Resident #78's medical record, showed: -admitted [DATE]; -discharged to the hospital on 8/23/23; -Diagnoses included cerebral palsy (CP, a disorder of movement, muscle tone or posture), anxiety, depression, psychotic disorder, anemia (decrease in the number of red blood cells) and malnutrition. -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of transfer. 6. During an interview on 8/29/23 at 1:26 P.M., the Administrator said she expected the bed hold policy to be provided to the resident or resident representative at the time of transfer. 44950 49149

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified six medication carts, one treatment cart, and two medication rooms. Four of the six medication carts, the treatment cart, and both medication rooms were checked for medication storage, and issues was found with all four carts and both of the medication rooms. Staff also failed to discard two bottles of expired medication stored in the refrigerator in one of medication rooms for one resident (Resident #353). The staff also had non-medication items such as two coffee makers plugged in, plates and a bowl in a medication drawer, and personal handbags in that medication room. The staff also failed to complete routine temperature monitoring for the other medication storage room. The sample was 19. The census was 92. Review of the facility's Medication Storage policy, revised 10/24/22, showed: -Standard: It will be the standard of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. -Guidelines: -1. Medications, drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received, unless otherwise necessary; -2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner; -3. Drug containers that have missing, incomplete improper or incorrect labels should be returned to the pharmacy for proper labeling before storing; -4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals; -5. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications; -6. Antiseptics, disinfectants and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use and shall be stored separately from regular medications; -7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view; -8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer or other holding area to prevent the possibility of mixing medications of several residents; -9. When a resident is returned to the hospital or on a temporary leave of absence (LOA) with the expectation to return to the facility and the orders are placed on hold in the Electronic Health Record, it is permissible to maintain said medications and supplies in the medication cart or storage areas until the resident returns or confirmation has been determined that the resident will not be return to the facility. When determination has been achieved that the resident will not return to the facility, it is appropriate to return the medications, drugs or supplies to the pharmacy, dispose of them properly or destroy them per medication destruction guidelines; , -10. Medications requiring refrigeration must be stored in a refrigerator located in the medication room at the nurse's station or other secured location. Medications must be stored separately from food and must be labeled accordingly. Routine temperature monitoring should take place to ensure proper maintenance of appliance and medication storage; -11. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys, unless accompanied by a licensed nurse; -12. Medications will be destroyed following FDA, State and Local requirements. 1. Observation of the 200 hall Certified Medication Technician's (CMT) cart on 8/24/23 at 8:25 A.M., showed several loose pills in the top and the bottom drawer of the cart. The CMT could not identify the pills or how long they had been in the cart. 2. Observation of the 100/200 hall Nurse cart on 8/24/23 at 8:45 A.M., showed multiple loose pills in the top and second drawer. The nurse could not identify the pills or how long they had been in the cart. 3. Observation of the 300 hall CMT cart on 8/24/23 at 9:00 A.M., showed multiple loose pills behind the resident medication cards in the second and third drawers of the cart. There were wrappers/trash behind the residents' medication cards as well. The bottom drawer had an open soda and a croissant wrapped in a paper towel. The bottom drawer also contained several loose pills. 4. Observation of the 400 hall CMT cart on 8/24/23 at 9:25 A.M., showed multiple loose pills in the back of the second and third drawer behind the resident medication cards. The CMT could not identify the pills or how long they had been in the cart. 5. Observation of the 300/400 hall medication room temperature logs on 8/24/23 at 9:15 A.M., showed: -Temperature logs on the refrigerator in a plastic sleeve for February 1, 2023 through August 24, 2023. The logs showed the following; -February 2023: 2/11/23, 2/15/23, 2/20/23 and 2/25/23 blank; -March 2023: 3/1/23, 3/11/23, 3/20/23, 3/25/23 and 3/28/23 blank; -April 2023: 4/1/23, 4/3/23, 4/4/23, 4/5/23, 4/7/23, 4/8/23, 4/9/23, 4/12/23, 4/17/23, 4/22/23, 4/23/23, 4/26/23 and 4/30/23 blank; -May 2023: 5/1/23, 5/3/23, 5/6/23, 5/10/23, 5/14/23, 5/15/23, 5/16/23, 5/19/23, 5/20/23, 5/22/23, 5/23/23, 5/24/23, 5/28/23 and 5/31/23 blank; -June 2023: 6/3/23, 6/7/23, 6/12/23, 6/17/23, 6/19/23, 6/20/23, 6/21/23, 6/26/23 and 6/28/23 blank; -July 2023: 7/1/23, 7/3/23, 7/4/23, 7/5/23, 7/10/23, 7/14/23, 7/15/23, 7/16/23, 7/19/23, 7/23/23, 7/24/23, 7/25/23, 7/28/23, 7/29/23, 7/30/23 and 7/31/23 blank; -August 2023: 8/6/23, 8/15/23, 8/16/23, 8/20/23 and 8/21/23 blank. During an interview on 8/24/23 at 9:15 A.M., Nurse U said the temperature logs need to be done daily. The holes mean they were not done. 6. Observation on 8/24/23 at approximately 9:35 A.M., showed CMT JJ entered the 100/200 hall medication room and propped the door open. Two nurses and the Director of Nursing (DON) stood by the nurses' station visible from the medication room. CMT JJ started to clean up the room, opening drawers/cabinets and removed items off the counter. Two coffee machines were on the counter and plugged in the outlet on the wall. The DON entered the medication room, unplugged and removed both coffee makers. As she left the room, she shook her head and said, If I have to tell them one more time. CMT JJ continued to clean up the room. 7. Observation of the 100/200 hall medication room on 8/24/23 at 9:35 A.M., showed: -Five stacked drawers in the front of the cabinet. The top drawer had liquid creamer and creamer packets. The bottom drawer held coffee filters, a bowl and a plate; -Two bottles of expired liquid antibiotic for Resident #353 in the refrigerator. On bottle expired on 7/18/23 and the other expired on 8/6/23. 8. During an interview on 8/24/23 at 10:30 A.M., the DON said the dishes looked like they had been in the drawer for a while and it is not okay to have those in there. The DON did not know why they have a chair next to the medication room exit but believes it is because staff may be taking breaks in the medication room. There is really no other place to store the personal bags where they can be locked up. She also said the refrigerator temperature checks should be done daily and there should not be any drinks/food in or on the medication carts. 9. During an interview on 8/29/23 at 1:20 P.M., the Administrator said it is not appropriate for staff to store coffee makers in the medication room. She is not sure about the personal bags. Temperature logs should be done daily. Any expired medications should be properly thrown away. There should be no loose pills/trash, food or drink in the medication carts.

37681 Based on observation, interview and record review, the facility failed to ensure menus were followed and updated periodically. The facility also failed to honor food preferences for five of 19 sampled residents and the resident council members (Residents #76, #51 #24, #12 and #32). This deficient practice had the potential to affect all residents who ate meals at the facility. The census was 92. Review of the facility's Always Available Menu, showed: -Soup of the day; -Small side salad/chef salad plate; -Turkey and cheese; -Hot ham and cheese sandwich; -Grilled cheese sandwich; -Peanut butter and jelly sandwich; -Tuna salad sandwich/Tuna scoop with crackers; -Egg salad sandwich/Egg salad scoop with crackers. 1. Review of Resident #76's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/3/23, showed the resident was cognitively intact. During an interview on 8/24/23 at 11:06 A.M., the resident said he/she called the kitchen and requested a hamburger and side salad on the Always Available menu. He/She was told they did not have the items because the truck never arrived to deliver the food items. They always served him/her eggs for breakfast and he/she never ate them. He/She requested cold cereal and coffee for breakfast every morning but never received it. During an interview on 8/28/23 at 4:37 P.M., the resident said he/she called the kitchen for a hot dog and was told they did not have any. 2. Review of Resident #51's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 8/23/23 at approximately 10:00 A.M., the resident said he/she did not receive choices when it came to meals. He/She was aware of the Always Available menu having peanut butter and jelly and grilled cheese, but nothing else. 3. Review of Resident #24's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 8/23/23 at approximately 9:30 A.M., the resident said they don't receive choices when served meals. They have an option to order a peanut butter and jelly or grilled cheese sandwich, but nothing else. He/She would like more choices such as fresh fruit salads. 4. Review of Resident #12's quarterly MDS, dated [DATE] showed the resident was cognitively intact. During an interview on 8/23/23 at 01:25 P.M., he/she said food is not good. They are given choices but don't get what they order. They are out of food a lot. 5. Review of Resident #32's quarterly MDS, dated [DATE] showed the resident was cognitively intact. During an interview on 8/25/23 at 9:50 A.M., the resident said he/she requested tuna for dinner on 8/24/23 and was told it was unavailable. 6. During the group meeting on 8/25/23 at 10:43 A.M., six out of six residents said the food tastes stale. The food is not seasoned and they put too much salt on the food. They do not believe staff taste the food that is prepared. When they use the grill, the bread tastes like something else. The grill may not be cleaned. The bread on the grilled cheese sandwiches is too greasy. All the oil can be seen when they push down on the bread with their finger. They have an alternate menu that includes grilled cheese, peanut butter and jelly sandwich, ham or turkey sandwiches. There is tuna or chef salad if they have it. Staff do not read the ticket and they do not ask what the residents want. They will serve the food on the ticket even though it was not what the resident wanted. Once or twice a month, they do not bring a tray. Some of the residents sit in the dining room, but their tray is on the hall cart. The food is cold most of the time. They served polish sausage for lunch and it was cold and hard. The mashed potatoes were cold too. 7. During an interview on 8/28/23 at 4:48 P.M., Dietary Aide (DA) C said the Always Available Menu always had grilled cheese, peanut butter and jelly sandwiches, turkey and cheese or ham and cheese sandwiches. Hamburgers, hot dogs or soup of the day were not always available. The residents complained about the lack of food choices regularly. 8. During an interview on 8/28/23 at 5:36 P.M., the Dietary Manager said residents complained about running out of food items and items not being available prior to her employment at the facility. She had been at the facility for 10 days. Since she has been there, they had not run out of items and all the foods listed on the Always Available Menu were available. 9. During an interview on 8/29/23 at 01:18 P.M., the Director of Nurses said if resident chooses something off the alternate menu, the listed options should be available. Staff should make sure residents get those options. 10. During an interview on 8/29/23 at 1:18 P.M., the Administrator said she expected items listed on the Always Available Menu to be available at all times. MO00198528 49149

42247 Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the transmission of infections. Staff failed to follow proper hand hygiene during wound care for one resident (Resident #63) and staff failed to don (put on) appropriate personal protective equipment (PPE) for one resident while providing wound care (Resident #353). Staff failed to perform hand hygiene during perineal care (peri-care, cleansing of the genitals and buttocks area) for two out of three residents observed. (Residents #5 and #73) Additionally, the facility failed to follow their communicable disease policy by failing to ensure newly hired employees and newly admitted residents received the Mantoux tuberculin skin test (TST), used to test for latent tuberculosis (TB) infection, two step as required for three out of five residents sampled (Residents #93, #72 and #80). The census was 92. Review of the facility's Hand Hygiene Policy, dated 10/16/23, showed: -This facility considers hand hygiene a primary means to prevent the spread of infections; -Guidelines: All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: -After contact with a resident with infectious diarrhea including, but not limited to infections caused by clostridium difficile (c-diff, bacteria that can cause swelling and irritation of the large intestine or colon); -Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents; -Before donning sterile gloves; -Before handling clean or soiled dressings, gauze pads, etc.; -Before moving from a contaminated body site to a clean body site during resident care; -After removing gloves; -Before and after entering isolation precaution settings; -After handling used dressings, contaminated equipment, etc. -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility's Perineal/Incontinence Care Policy, dated revised 10/24/22, showed: -It will be the standard of this facility to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition and provide appropriate care and services required to maintain functional levels while providing perineal/incontinence care; -Guidelines: Assemble the equipment and supplies as needed such as wash basin, towels, washcloths or wipes, peri-wash and personal protective equipment (i.e. gloves, gowns, mask, etc., as needed); -Explain to resident that care is being provided for perineal/incontinence care as is needed. Provide perineal/incontinence care in accordance with physician orders or resident's plan of care, while ensuring to maintain resident preferences as indicated and resident privacy/dignity. 1. Review of Resident #63's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/13/23, showed: -Cognitively intact; -Required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene; -Urinary catheter (a sterile tube inserted into the bladder through the urinary tract to drain urine) for urine, colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) for bowel; -Diagnoses included gastroesophageal reflux disease (GERD), neurogenic bladder (the bladder does not empty properly due to a neurological condition), end stage renal disease (ESRD), diabetes, depression and manic depression. Observation on 8/23/23 at 12:15 P.M., showed Certified Nurse Aide (CNA) GG assist Nurse HH with wound care. Nurse HH set up supplies and CNA GG assisted the resident to roll on his/her left side. CNA GG held the resident on his/her side while Nurse HH cleaned the resident's wound. The resident's bed started to beep. CNA GG said the noise was an alarm related to bed deflation and, with his/her gloved hand, turned off the alarm. CNA GG returned to the resident's side. CNA GG did not change gloves or perform hand hygiene. Nurse HH requested CNA GG hand him/her a piece of gauze that was located in an open package at the end of the resident's bed. CNA GG reached in the gauze package and pulled out several. Nurse HH grabbed the bottom gauze and wiped the resident's wound area. CNA GG put the gauze that was not used back on top of the gauze package. Both staff changed their gloves and performed hand hygiene, and put on new gloves. Nurse HH took a piece of gauze from the top and used it to wipe blood off the resident's wound. Nurse HH used more gauze from the top of the package and packed it into the resident's wound. Nurse HH removed his/her gloves and put on new gloves. Nurse HH did not perform hand hygiene in-between the glove change. He/She packed sponge in the wound and began to place a new wound vacuum (vacuum assisted closure used to conduct negative pressure wound therapy to promote healing) on the resident. Nurse HH finished the wound care, ensured the wound vacuum worked as ordered, and cleaned up supplies, then left the resident's room. 2. Review of Resident #353's admission MDS, dated [DATE], showed: -Cognitive impairment; -Total dependence for bed mobility, transfers, dressing, toileting and personal hygiene; -Urinary catheter and always incontinent of bowel; -Diagnoses included: cerebral palsy (CP, a disorder of movement, muscle tone or posture), neurogenic bladder and GERD. Observation on 8/25/23 at 11:30 A.M., showed CNA GG assist Nurse HH with wound care. The resident required special precautions while care is provided due to the resident tested positive for c-diff. Nurse HH said the PPE of gown, gloves, shoe covers, and mask were required upon entry into the room. Nurse HH assisted the resident to his/her left side and removed the previous wound dressing. Nurse HH cleaned the resident's wound. Nurse HH did not change gloves or wash his/her hands. Nurse HH packed clean gauze into the wound while wearing the same gloves. Nurse HH removed his/her gloves and put on new gloves without washing his/her hands. Nurse HH said, just write me up. CNA GG removed his/her gown and gloves, washed his/her hands, and left the resident's room to get the resident a new blanket. CNA GG returned to the room with the blanket to continue to assist Nurse HH. CNA GG returned to the room without wearing a gown. CNA GG donned gloves and went next to the resident to support the resident on his/her side while Nurse HH finished care. Nurse HH said, What are you wearing? CNA GG said I am wearing clothes, what are you wearing? CNA GG continued to assist with care for the resident. After Nurse GG completed the wound care, CNA GG placed protective boots on the resident and positioned the resident in bed. Nurse GG finished care, removed his/her gown and gloves, washed his/her hands and left the room. CNA GG removed his/her gloves, washed his/her hands and left the room. During an interview on 8/25/23 at 12:25 P.M., Nurse GG said CNA GG should have worn the appropriate PPE when he/she re-entered the room. Nurse GG said if he/she knew that CNA GG had put the gauze back into the clean package, he/she would have thrown the gauze package away and opened a new one. He/she said that should not have been used. When a dirty item is touched, gloves should be removed, hands sanitized, and new gloves put on before care is continued. During an interview on 8/29/23 at 1:20 P.M., the Administrator and DON said they expected staff to change gloves and sanitize their hands after touching a dirty surface. If gauze is pulled out of a package and not used, it should be thrown away. The Administrator also said if a CNA or nurse returns to a room on precautions, the staff member should put on the required PPE if they are to assist with care or touch the resident. Staff should also wear gloves at all times while care is provided. 3. Review of Resident #5's annual MDS, dated [DATE], showed: -Cognitively intact; -Required extensive assistance of one staff for bed mobility, toileting and personal hygiene; -Was frequently incontinent of urine and occasionally incontinent of bowel; -Diagnoses included debility, arthritis, anxiety and depression. Observation on 8/25/23 at 5:05 A.M., showed the resident lay in bed, CNA K unfastened the resident's brief. The resident's brief was wet. The CNA turned on the water, and wet one end of a towel and used peri wash to clean the resident. The CNA wiped down the outside of peri area and did not separate the labia and clean the inside area. Then the CNA asked the resident to roll over towards the window, and cleaned the back side using the same towel. The CNA left the room to obtain more towels. When the CNA returned to the room, the CNA did not perform hand hygiene. He/She placed a clean bed pad and brief on the resident. The CNA removed the soiled linens and trash from the room and performed hand hygiene in the soiled utility room. 4. Review of Resident #73's admission MDS, dated [DATE], showed: -Cognitively intact; -Required extensive assistance of one staff for bed mobility, toileting and personal hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses included debility, cancer, arthritis, anxiety and depression. Observation on 8/29/23 at 5:39 A.M., showed the resident lay in bed. Certified Medication Technician (CMT) J unfastened and rolled the resident's brief down between his/her legs, CMT J wet a towel with water. The CMT wiped down the outside of peri area without soap and did not separate the labia and clean the inside area. Then, the CMT rolled the resident over. The resident had a bowel movement. CMT J cleaned the resident using the same towel. The CMT changed his/her gloves, placed a new pad under the resident and put a new brief on the resident. Then, the CMT gathered the trash and linens, took them to the soiled utility room to dispose of them and went into another resident's room to perform hand hygiene. During an interview on 8/28/23 at approximately 8:40 A.M., Licensed Practical Nurse (LPN) G said residents are rounded on every two hours and peri care is provided to residents who are incontinent. Any one in nursing can do peri care. The process for peri care was that staff should gather all their supplies, trash bags, over bed table, 6-7 wash clothes, wash basins, soap and water, perform hand hygiene before they start, unfasten/remove brief and clean the peri area from front to back-using a separate wash cloth or a separate part of the towel for each wipe. Staff should separate the genital and clean the area. Hand hygiene is done before you start, between dirty and clean, and after care is provided. During an interview on 8/28/23 at 9:38 A.M. CNA L said when he/she provided peri care to the residents, he/she does not always use soap, because that part of the body can be sensitive, so he/she will ask the residents if they want soap. During an interview on 8/28/23 at approximately 11:00 A.M. the Infection Preventionist Nurse (IPN) said, the process for staff to perform peri care was staff should gather their supplies-a basin, wash clothes and soap and water, staff should provide privacy and expose as little of the resident as possible. Staff should wash their hands and don gloves. They should clean the peri area from front to back to back, change their gloves and perform hand hygiene when they go from dirty to clean and after they finish with care. The IPN expected staff to separate the genital and clean the area from front to back. During an interview on 8/29/23 at 1:58 P.M., the Director of Nursing (DON) said when staff are providing peri care, she expected staff to change their gloves between dirty and clean and she expected staff to spread apart the genital and clean. 5. Review of the facility's Employee Tuberculosis screening, revised 10/23/22, showed: -It is the policy of this facility that all healthcare workers be tested for tuberculosis upon hire unless contraindicated. Initial testing will be a two-step procedure with the first dose given before beginning work and the second booster dose given 7-21 days after the first if the first dose is negative along with an employee risk screening tool; -New employees who present a written report of a negative two-step Tuberculin Skin Test (TST) within the previous 12 months will not need their TB screen repeated, and an employee screening tool will be completed. Education will be provided to a new employee on reporting of new signs and symptoms as indicated on screening tool; -Previous documented negative TST result less than 12 months before employment, single TST needed for baseline testing; this will be the second step; -New Employees with a known, documented positive skin test will not receive a repeat TST but will undergo a chest x-ray (CXR) if they do not have a documented negative CXR after Tuberculin skin tested positive; -Individuals with a documented positive TST and a negative CXR will be assessed for signs and symptoms of active TB disease and counseled to report such symptoms to Infection Control immediately; -TST should be postponed if the employee has an acute viral illness to avoid the possibility of a falsely negative test; -New Employees will not be allowed to work until the TST, or CXR results are known; -Employees who will be receiving the two-step TST may begin work after the first step results are negative; -Second step TST can have a time frame suggested of 1-3 weeks, but not greater than 365 days; -TST results will be documented in the employee's medical record; -Skin test results will be recorded in millimeters of induration rather than stating result is positive or negative; -The tuberculin manufacturer and lot number will be recorded; -A record of all positive TSTs is readily available to facilitate annual and as needed assessment for TB disease in the employee. 6 Review of LPN H's employee record, showed: -Hired on 6/1/21; -First step TB completed on 4/26/23 with negative results; -No documentation of the date the first step results were read; -No documentation of second step TB. 7. Review of Dietary Aide C's employee record, showed: -Hired on 6/2/21; -First step TB completed on 6/12/23 with negative results; -No documentation of the date the first step results were read; -No documentation of second step TB. 8. Review of Housekeeping I's employee record, showed: -Hired on 7/19/23; -First step TB completed on 8/3/23; -TB test showed negative results on 8/3/23; -Second step TB completed on 8/16/23; -TB test showed negative results on 8/18/23. 9. During an interview on 8/29/23 at 1:19 P.M., the Administrator and DON said they expected all employees to have a first and second step TB timely and per facility policy. 10. Review of the facility's Tuberculosis Screening, Residents, dated revised 10/23/23, showed: -For all new admissions, a TST will be done within 72 hours after admission if there is no documented TST result from within three months before admission; -The 2-step TST method will be performed using five units (0.1 ml) of purified protein derivative (PPD) tuberculin given intracutaneously (under the skin); -The first step must be performed within 72 hours of admission; -If the first step is non-reactive, the second test will be administered one to three weeks later; -Residents with a documented history of a previous positive TST will not be retested ; -TST results will be documented in the resident's medical record. 11. Review of Resident #93's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Diagnoses included: amputation, anemia (low red cell count), heart failure, high blood pressure, end stage renal disease and diabetes. Review of the medical record, showed: -First step completed on 8/29/22 with negative results; -No documentation of a second step. 12. Review of Resident #72's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Diagnoses included high blood pressure, septicemia (a serious bloodstream infection), diabetes, dementia and anxiety. Review of the medical record, showed: -First step TB completed on 2/1/22 with negative results; -Second step TB Historical on 2/1/22 with negative results; -First step TB completed on 9/20/22 with negative results; -No second step documented; 13. Review of Resident #80's admission MDS, dated [DATE], showed: -admitted [DATE]; -Diagnoses included high blood pressure, diabetes and depression. Review of the medical record, showed: -First step TB completed on 3/29/23 with negative results; -Second step TB Historical on 3/29/23 with negative results. 14. During an interview on 8/28/23 at approximately 11:00 A.M., the IPN said when a resident is admitted to the facility, they are given a TST. The first step is given, then it is read within 48 to 72 hours. The second TST is given seven to 14 days later and it is read in the same time frame. The TST is documented on the Medication Administration Record (MAR) and under the immunization tab in the resident's electronic medical record. 15. During an interview on 8/29/23 at 1:00 P.M., the DON said the residents should have received a 2 step TST. She expected staff to follow the facility's policy and procedures. 44950

Based on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for eight of 19 sampled residents (Residents #51, #80, #97, #76 #2, #24, #37 and #63). The census was 92. Review of the facility's Bed Rails policy, dated 4/1/2009, showed: -It is the standard of this facility to ensure the safe use of resident mobility aids and to prohibit the use of bed rails as restraints unless necessary to treat a resident's medical symptoms; -If a bed or side rail is used, the facility will ensure correct installation, use and maintenance of bed rails. 1. Review of Resident #51's care plan, revised 3/6/23, showed: -Focus: Resident has bed rails related to resident or family request; -Goal: Resident will safely use appropriate bed rails as needed; -Interventions: Assess to be sure that the provided bed rails aren't preventing the resident from getting out of bed or making it difficult to get out of bed. Review of the resident's medical record, showed no maintenance assessments for the use of side rails. Observations on 8/23/23 at approximately 9:20 A.M., 8/24/23 at 8:22 A.M. and 8/25/23 at 4:55 A.M., showed the resident lay in bed. A quarter length side rail was raised on the right side of the bed. 2. Review of Resident #80's quarterly Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 8/3/23, showed: -Diagnoses included deep vein thrombosis (blood clot in the lower extremities), depression, high blood pressure and left leg amputation; -Bed mobility: Independent; -Cognitively intact. Review of the resident's medical record, showed: -No order for side rails; -No side rail maintenance documentation. Observations on 8/25/23 at 6:02 A.M., 8/28/23 at 8:14 A.M., and 8/29/23 at 10:01 A.M., showed the resident lay in bed on his/her back. Quarter length side rails were raised on both sides of the bed. 3. Review of Resident #97's medical record, showed: -A nursing assessment for the use of side rails, dated 8/10/23 -No maintenance assessment for the use of side rails Observations on 8/24/23 at 8:26 A.M. and 8/25/23 at 4:57 A.M., showed the resident lay in bed. Half-length side rails were raised on both sides of the resident's bed. 4. Review of Resident #76's medical record, showed: -An order, dated 8/7/23 for a unilateral bedrail on the right side of the bed; -No maintenance assessment for the use of bed rails. Observations on 8/23/23 at approximately 9:20 A.M., 8/24/23 at 8:31 A.M. and 8/25/23 at 10:37 A.M., showed the resident lay in bed. A quarter length side rail was raised on the right side of the resident's bed. 5. Review of Resident #2's medical record, showed: -An order, dated 7/24/23 for bed rails times two to the resident's bilateral side of the bed; -No maintenance assessment for the use of side rails. During an interview on 8/23/23 at 6:45 P.M., the resident said he/she used side rails on both sides of the bed for positioning. 6. Review of Resident #24's medical record, showed: -An order, dated 3/7/23, for bedrails times two to the resident's bilateral side of the bed; -No maintenance assessment for the use of bedrails. Observations on 8/23/23 at approximately 9:20 A.M. and 8/24/23 at 8:24 A.M., showed the resident lay in bed on his/her back. Half-length side rails were raised on both sides of the bed. 7. Review of Resident #37's medical record, showed: -Cognitively intact; -An order for bed rails times two to resident's bilateral side of bed; -No maintenance assessment for the use of bedrails. Observation on 8/23/23 at 9:57 A.M., 8/24/23 at approximately 9:00 A.M., 8/25/23 at 7:45 A.M. and 8/28/23 at 8:17 A.M., showed the resident in bed with the top quarter side rails up on each side of the bed. During an interview on 8/23/23 at 9:57 A.M., the resident said he/she used the side rail to help him/her position in bed. 8. Review of Resident #63's medical record, showed: -An order, dated 8/22/23 for bedrails times two to the resident's bilateral side of the bed; -No maintenance assessment for the use of bedrails. Observations on 8/23/23 at 9:10 A.M., 8/24/23 at 8:20 A.M. and 2:00 P.M., 8/25/23 at 11:00 A.M., 8/28/23 at 1:00 P.M., and 8/29/23 at 10:00 A.M., showed the resident lay in bed on his/her back. One half-length side rails was raised on the left side of the bed. 9. During an interview on 8/25/23 at 7:09 A.M., the Maintenance Director said he had not completed assessments on bed rails because he did not have the equipment to do so. He was aware assessments should be done as part of a routine maintenance program. 10. During an interview on 8/29/23 at 11:58 A.M., the Administrator said she expected Maintenance to do routine inspections of the bed frames, mattresses and bed rails. There should be an assessment, orders, and care plan documentation for residents who had bedrails. An audit for all three items had been completed within the past two weeks. 42247 44950 49149

44950 Based on interview and record review, the facility failed to ensure physician's orders and/or signed consent for code statuses were obtained and documented in the medical record for two residents (Residents #353 and #97) of 19 sampled residents. The facility also failed to ensure the code status was consistent and accurate for one resident (Resident #43). The census was 92. Review of the facility's Code Blue and cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) policy, revised [DATE], showed: -Definitions: Advance directive is defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated; -Basic life support is a level of medical care which is used for victims of life threatening illnesses or injuries until they can be given full medical care at a hospital, and may include recognition of sudden cardiac arrest, activation of the emergency response system, early CPR, and rapid defibrillation with an automated external defibrillator, if available; -CPR refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased; -Code Status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops; -DNR (do not resuscitate) Order refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Existence of an advance directive does not imply that a resident has a DNR order. The medical record should show evidence of documented discussions leading to a DNR order; -Standard: This facility will honor the resident's/resident representative's wishes regarding either the provision or withholding of CPR. To ensure that each facility is able to and does provide emergency basic life support immediately when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physicians orders, such as DNRs, and the resident's advance directives; -In the event a resident experiences cardiac arrest (cessation of pulse and/or respirations), CPR will be provided in the absence of a valid Physician's Order for Do Not Resuscitate (DNR), a State of Missouri Outside the Hospital Do-Not Resuscitate (OHDNR) Order Form (Statutory citation 190XXX,d+[DATE].621RSMo), or documented verbal wishes indicating otherwise which are pending physician order. 1.-Review of Resident #353's medical record, showed: -No code status listed at the top of the resident information; -No order for code status in the physician orders; -A progress note on [DATE] at 6:36 P.M., showed the resident arrived to the facility via stretcher. The resident is a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). -Review of the resident's care plan, dated [DATE] showed: -Focus: Resident is a full code; -Goal: If the resident's heart stops, or if they stop breathing, CPR will be initiated in honor with their full code wishes; -Interventions: Resident is a full code. Allow opportunity to review and initiate advance directives with the resident and/or appointed health care representative. During an interview on [DATE] at approximately 11:30 A.M., the Administrator said a resident who is a full code should have a physician order and it should be listed at the top of the resident's information sheet under in the electronic medical record (EMR). The Administrator opened the resident's EMR and verified there was no order and the code status was not listed under on the information sheet. 2. Review of Resident #97's EMR, showed: -admitted [DATE]; -An order, dated [DATE] for DNR; -No signed consent for a DNR order. Review of the resident's care plan, revised on [DATE], showed: -Focus: Resident is DNR; -Goal: If the resident's heart stops, or if he/she stopped breathing, CPR will not be initiated in honor with his/her wishes; -Interventions: Resident is a DNR. During an interview on [DATE] at 9:18 A.M., the Administrator brought a signed copy, dated [DATE], of the resident's DNR order. She said she would expect the policy to be followed. 3. Review of Resident #43's quarterly Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Cognitive impairment; -Extensive assistance with transfers, dressing, toilet use, and personal hygiene; -Limited assistance with bed mobility; -Indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) and frequently incontinent of bowel; -Diagnoses include cancer, heart failure, obstructive uropathy (a urinary tract disorder that occurs due to obstructive urinary flow), diabetes, malnutrition, anxiety, depression, manic depression, chronic obstructive pulmonary disease (COPD, lung disease), and schizophrenia. Review of the resident's scanned documents, showed: -An OHDNR, dated and signed by the resident and the physician on [DATE]; -An OHDNR, dated and signed by the resident on [DATE] and signed by the physician on [DATE]; -An OHDNR, dated and signed by the resident and physician on [DATE]. -Review of the resident's electronic medical record showed: -admitted : [DATE]; -Advance directive: Full code. -Review of the electronic physician orders sheet (ePOS) showed: -An order, dated [DATE], advanced directives: full code; -Review of the resident's care plan, revised [DATE] and in use at the time of the survey, showed: -Focus: Resident has advanced directives on record DNR; -Goal: If the resident's heart stops, or if they stop breathing, CPR, will not be initiated in honor with their DNR wishes; -Intervention: Resident is a DNR, Advise resident and/or appointed health care representative to provide copies to the facility of any updated advanced directives, for DNR status verify presence of physician's order for DNR. -Review of the resident's care plan, initiated [DATE] and in use at the time of the survey, showed: -Focus: Resident is a full code; -Goal: If the resident's heart stops, or if they stop breathing, CPR will be initiated in honor with their full code wishes; -Interventions: Resident is a full code. Allow opportunity to review and initiate advanced directives with the resident and/or appointed health care representative. -Review of the resident's progress notes, showed: -A progress note, dated [DATE], resident arrived to the facility via stretcher. The resident is alert to person, alert to place, and alert to situation. The resident has elected to be a full code; -A nurse practitioner note, dated [DATE] and signed [DATE], the resident is a long term care resident seen today per nursing staff request for pulmonary (lungs) follow up. Code status: DNR. During an interview on [DATE] at 4:30 P.M., the administrator said the resident flip flops between full code and DNR. She said the order should absolutely be consistent with the care plan and the signed DNRs in the chart and the physician/nurse practitioner notes. She said the facility has started in-services on code status and a complete audit. She said she will talk to the Director of Nursing to determine and correct the resident's chart.

Based on interview and record review, the facility failed to provide care in a manner which prevented or minimized the possibility of accidental injury to one of three sampled residents (Resident#1) by performing transfers inconsistent with the resident's care plan. Staff also failed to report a fall promptly to the nurse, in accordance with the facility's policy, so the resident could be assessed and the incident reported to the physician. Resident #1 sustained a fracture. The census was 98. Review of the facility's policy titled Standards and Guidelines: SG Mechanical Lifts revised 3/27/21, showed it was the standard of the facility to provide a safe environment for residents and staff. The nursing and therapy departments were to coordinate the screening of residents to determine the appropriateness of mechanical lift transfers and/or repositioning. Staff responsible for the transferring/ repositioning residents would receive instruction on the safe operation of the mechanical lifts. The nursing department/designee was to maintain a list identifying all residents who need to be transferred using mechanical lifts. The use of the mechanical lift should be included in the resident's plan of care. When using the mechanical lift, staff was to adhere to the manufacturer's guidelines, physician's orders and/or the plan of care. The interdisciplinary team (IDT) or specified members of the IDT should meet to eliminate any fears or concerns expressed by residents or responsible party/resident representatives refusing the use of the mechanical lift for transfer(s) as is needed. Review of the facility's policy titled Standards and Guidelines: Falls revised 3/27/21, showed staff was to evaluate and document falls that occurred while the resident was active in the facility census. In the event of major injury or suspected major injury, the resident should be sent to a higher level of care, such as the hospital, as ordered by the physician. If the nurse was unable to reach the physician, it was permissible for the nurse to initiate the resident transfer to the hospital if there was a concern for the resident's safety, well-being, potential for injury or voiced expressed desire. Following a fall, post event monitoring should occur to monitor vital signs, change in function, change in condition, increased pain or changes in skin condition, etc. The physician and responsible party (if applicable) notification should be documented in the clinical record, when a fall occurs. Residents should be reviewed routinely or upon change of condition, if needed, to monitor for changes in fall risk factors. Review of Resident #1's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/8/22, showed the following: -Moderate cognitive impairment; -Weight 264 pounds, 67 inches tall; -Required supervision of locomotion off unit; -Required set up and supervision of eating; -Required extensive assistance of one staff person with bed mobility, dressing, toilet use and personal hygiene; -Required extensive assistance of two or more staff with transfers; -Total dependence on assist of one staff person with bathing; -Impairment on one side of upper and lower extremities; -Not steady when moving from seated to standing position and during surface-to-surface transfers, only able to stabilize with human assistance; -Wheelchair mobility; -No falls since admission or prior assessment; -Diagnoses included: stroke, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (loss of sensation or movement on one side of the body), muscle weakness (generalized), abnormal posture, dependence on wheelchair, high blood pressure, anemia, cataract, anxiety disorder and depression. Review of the resident's care plan, updated 12/2/22, showed the following: -3/4/21, mechanical lift for transfers: Hoyer (assistive mechanical device which utilizes slings and pads to safely lift and transfer residents with reduced mobility); -Turn and reposition as needed, shifting weight to enhance circulation; -Report and document any declines in ability; -Resident is at risk for falls. The resident has impaired cognition and impaired safety awareness; -Resident is at risk for abnormal bleeding related to the use of anticoagulant therapy; -He/She has an alteration in neurological (of or relating to the nervous system/brain, spinal cord and nerves) status; -Monitor for changes/declines in physical and cognitive function. Notify physician as needed; -Risk for falls related to behaviors, limited mobility, diabetes mellitus, cerebrovascular accident (CVA, stroke) and hemiparesis with left-sided weakness. Review of the resident's care plan, showed no documentation of any objections voiced by the resident to transfers via Hoyer lift, and no interventions to address refusal to transfer with the Hoyer lift or direction to staff regarding documenting or reporting his/her refusals or requests for sit-to-stand transfers. Review of the resident's physical therapy evaluation and plan of treatment, signed 1/13/23, showed the following: -Start of care: 1/12/23; -Resident presented with decreased strength, decreased balance, poor posture which required physical therapy services to assess functional abilities; -Weight bearing: lower extremity weight bearing status: weight bearing as tolerated; -Functional mobility assessment: dependent bed mobility and transfers; -Balance: maximal assistance (physical assistance of over 75% provided by the caregiver) assist to sit at the edge of the bed, time resident can sit unsupported=unable seconds, resident stands without upper extremity support with AD (assistive device) as needed X 10 seconds? no; -Impaired right and left lower extremity strength; -Impaired right and left hips, knees and ankles; -Right and left hip strength: flexion (bending a joint so the bones that form the joint are pulled closer together) and extension 1/5 (muscle contraction is seen or identified with palpation, but is insufficient to produce joint motion, even with elimination of gravity). Review of the e-mailed statement of CNA A, dated 1/18/23, showed on 1/14/23, CNA A and CNA B went in to put the resident into bed. The resident told them to put him/her on the sit-to-stand lift, after CNA A told the resident that he/she was a Hoyer lift. The resident insisted that staff had put him/her on the sit-to-stand lift that morning. They put the resident on the sit-to-stand lift per his/her request. CNA A raised the resident up with CNA B behind the resident. As the lift rose, the resident told them his/her leg went out. As soon as he/she said that, CNA A lowered the resident to a sitting position as quickly as possible and CNA B held the resident's head and back, so the resident would not hit the ground. The resident never fell on the ground so CNA A did not report the incident to the charge nurse as a fall. Otherwise, CNA A would have given report, because CNA A knew the resident was large and could have injured him/herself had he/she fallen. After they got the resident into bed, they made sure the resident was okay. The resident said yes. The resident's foot could have been broken, due to him/her being heavy weight and his/her leg giving out, while he/she was on the lift. Review of the resident's progress notes, showed the following: On 5/31/23 he/she was diagnosed with hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Hospital records show that he/she reported her legs were painful to walk on and x-rays showed mild osteoarthritis of the hips and left ankle. According to the facility physical therapist, the resident was weight bearing as tolerated due to pain. Her most recent oxycocdone-APAP count sheet showed she received it almost daily (except for the 5th, 8th, and 13th) from 12/29/22-1/16/22. -1/16/23 at 4:28 P.M., called the resident's physician to request order for x-ray of left knee and hip for pain. At 5:12 P.M., staff documented the late entry: resident had complaint of left leg pain. Physician made aware. New order to obtain x-ray of left leg; -1/17/23 at 6:39 P.M., resident sent via emergency medical services transport to the hospital. Resident has a fracture to the left lower extremity, according to the x-ray. Primary care physician contacted regarding findings and notified that resident would be sent to the hospital. The assistant director of nursing notified the family of the resident's transfer. At 9:55 P.M., Situation, Background, Assessment, Recommendation (SBAR) note: Situation: the change in condition was pain (uncontrolled). Functional status evaluation: general weakness. The resident had pain. An x-ray showed a fracture to the left lower extremity. The resident stated he/she had a fall prior to this shift; -1/18/23 at 8:01 A.M., late entry: the nurse was informed by CNA (certified nurse aide) at end of shift on 1/16/23 at 2:55 P.M., the resident complained of pain. Staff administered as needed (PRN) pain medication by CMT (certified medication technician). This nurse made the oncoming nurse aware. Review of the resident's progress notes, did not show any documented refusals of Hoyer lift transfers, requests for staff to transfer him/her via sit-to-stand lift or notification to the resident's physician and responsible party of refusals and/or requests of that nature. There were no documented meetings or determinations by the IDT regarding efforts to address the resident's expressed fear that staff could not handle him/her and concerns about the Hoyer lift sling being so uncomfortable that he/she would not allow staff to transfer him/her via Hoyer lift. Review of the resident's undated controlled medication utilization record, showed the following: -12/17/23, Oxycodone (opiod used to treat moderate to severe pain)-acetaminophen (APAP) 10-325 milligrams, take 1 tablet every 6 hours PRN for pain; -1/14/23, 11:00 A.M., 1 dose administered; -1/14/23, 8:00 P.M., 1 dose administered; -1/15/23, 10:30 A.M., 1 dose administered; -1/16/23, 6:00 A.M., 1 dose administered; -1/16/23, 2:00 P.M., 1 dose administered. The staff should have rated the resident's pain level on the MAR. Review of the MAR showed staff either left each date blank, documented not applicable (NA), or rated the pain level at a zero from 1/1-1/18. No reasons for administration of pain medications were documented in progress notes with the exception of the late entry on 1/8, showing that staff administered the PRN medication for pain on 1/16. A noted dated 1/16, showed she had complained of left hip, knee and leg pain (no description of intensity, duration or effectiveness of the medication administered). Review of the facility mechanical transfer list, dated 1/18/23, showed the resident's transfer status was listed as a sit-to-stand transfer. The DON compiles this list. It is based upon PT recommendations. According to the DON, staff had been transferring the resident via sit-to-stand, because they said the resident refused to allow Hoyer lift transfers. However, the DON said the resident was supposed to be transferred via Hoyer lift per a directive from physical therapy. The administrator said it should have been noted in the care plan if the resident preferred a sit-to-stand transfer and refused the Hoyer lift. Review of the investigation summary, dated 1/18/23, showed on 1/14/23, the resident fell from the sit-to-stand lift. The incident was reported on 1/16. the Administrator was informed the resident did not complain of pain. Staff followed policy (two CNAs were present) and proper notification was made. It was then brought to the Administrator's attention on Tuesday, 1/17/2023, that an x-ray was ordered because the resident had pain. The result showed a fracture of the femur. The facility sent an email to the Department of Health and Senior Services (DHSS), to inquire since all protocol was followed. Staff notified the physician regarding results. The Administrator requested that nursing/therapy do in-servicing on Hoyer and sit-to-stand transfers, to ensure everyone was compliant. There were no signs of abuse or neglect and proper procedure was followed. Review of hospital records, dated 1/17/23, showed the resident presented at the hospital reporting significant leg pain after a fall at the facility. He/She reported that he/she had been wheelchair bound for over ten years, because his/her legs were painful to walk on. During a physical examination, the resident experienced severe pain with palpation (examined by touch) of the distal femur. The resident was diagnosed with a comminuted (the broken ends of bone are shattered into more than two pieces) mildly displaced supracondylar fracture of the left distal femur (knee fracture) with intracondylar (the region between the two ends of the femoral bone which protrude and stabilize structures of the knee joint) intra-articular extension (when the fracture extends into the joint) with moderate left knee lipohemarthrosis (a mixture of blood and fat in a joint cavity following trauma). During interviews on 1/19/23 at 1:58 P.M. and 2/2/23 at 1:32 P.M., the resident said the incident occurred during the evening shift on Saturday 1/14/23. Staff put the resident in a sit-to-stand lift. He/She could not stand up at all and his/her legs gave out, causing him/her to fall out of the lift. Afterwards, he/she was not assessed by a nurse. Staff just put the resident into his/her wheelchair. On Saturday, Sunday and Monday, he/she told staff that he/she was in a lot of pain and staff did nothing. The resident never refused to allow staff to transfer him/her via Hoyer lift or said that the sling was uncomfortable. Staff just started using the sit-to-stand lift for his/her transfers, without giving him/her a reason. During an interview on 2/2/23 at 11:40 A.M., CNA A said he/she was very familiar with the resident and the resident's care needs. The resident asked to be transferred via sit-to-stand lift and said the previous shift had used that lift. CNA A had never transferred the resident using a sit-to-stand lift but decided to go ahead and use that lift with assistance from CNA B. CNA B stood behind the resident as CNA A started to raise the resident. The machine was on the second or third notch when the resident said, oh my leg gave out and his/her leg had bent inward, as if he/she was about to sit down. As CNA A started to lower the lift, the resident slid down out of the straps. CNA B caught the resident, as the resident's buttocks landed on the floor. The resident was lying between the wheelchair and sit-to-stand lift. CNA A and CNA B could not move the resident and struggled to get the Hoyer lift into the proper position. They rolled the resident onto the Hoyer lift pad, hooked it onto the machine and transferred him/her into bed. The resident did not complain of pain and said everything was fine. CNA A did not feel what occurred was a fall and, since the resident did not complain of pain, the CNA A did not report the incident to the resident's nurse. During an interview on 2/1/23 at 2:57 P.M., CNA B said he/she had worked at the facility for three years and was aware of the resident's care needs. Although the resident's medical chart said he/she was supposed to be transferred via Hoyer lift, the staff normally transferred him/her via sit-to-stand lift, because he/she refused to get on the Hoyer lift. He/she said the DON was aware staff used the sit-to-stand lift to transfer the resident. Staff had been complaining the resident barely stood up. On the day in question, CNA B was assisting CNA A who was assigned to provide the resident's care. They sat the resident up on the side of the bed and got him/her onto the sit-to-stand lift. CNA A began raising the lift. The resident said, Oh, my leg is giving out. So, they lowered the sit-to-stand platform. CNA A moved the lift platform to the floor, they removed the straps and lowered the resident onto the floor. CNA A removed the sit-to-stand lift and returned with the Hoyer lift. They put the sling onto the floor beside the resident, rolled him/her onto the sling, clipped it to the lift and transferred him/her back to bed. He/She did not know if CNA A reported the incident to the nurse. During an interview on 2/1/23 at 3:14 P.M., Nurse C said the CNAs normally told him/her whenever anything happened. However, on 1/14/23 CNA A and CNA B did not say anything about the incident. Nurse C had never known staff to transfer the resident via Hoyer lift. No one reported to Nurse C that anything was wrong or that the resident had complained of pain. Nurse C did not enter the resident's room that night. During an interview on 2/2/23 at 2:17 P.M., CMT D could not recall whether or not the resident complained of pain to him/her on the evening of 1/14/23. However, the resident always complained of pain. CMT D did not find out about the resident's fall, until the following week. The resident had always struggled with sit-to-stand lift transfers, because his/her legs were weak, he/she had no mobility and one side of his/her body was dead. During an interview on 2/2/23 at 10:53 A.M., the DON said the resident was definitely a Hoyer lift transfer. One side of his/her body was weak. However, the resident refused Hoyer lift transfers and always requested to be transferred via sit-to-stand lift. He/She said the Hoyer lift sling cupped him/her in an uncomfortable manner. The resident was quite alert, so staff complied with his/her request. Staff received general orientation on mechanical lift transfers, but did not receive any instruction specific to safe methods of transferring the resident via sit-to-stand with his/her one-sided muscle paralysis/weakness. During an interview on 2/2/23 at 11:55 A.M., the resident's family member said the resident had always been transferred via Hoyer lift and never refused it. One week prior to the incident, the family member attended a care plan meeting and no one said anything about the resident refusing to be transferred via Hoyer lift or requesting sit-to-stand transfers. The facility never reported to the family that the resident was refusing Hoyer lift transfers, requesting sit-to-stand transfers or that staff was using the sit-to-stand lift for the resident's transfers. During an interview on 2/2/23 at 11:04 A.M., the Rehab Director said the resident was dependent for transfers and was assessed as requiring Hoyer lift transfers. The therapy department recommended Hoyer lift transfers only. During an interview on 2/2/23 at 2:56 P.M., Physical Therapist E said he/she assessed the resident as being weight bearing as tolerated due to pain, not due to any orthopedic restrictions. Hoyer lift transfers were the safest mode of transferring the resident due to the fact that no participation from the resident was necessary. The resident refused to allow staff to transfer him/her via Hoyer lift, because he/she did not want to sit on the Hoyer pad all day. Normally, when physical therapy recommended Hoyer lift transfers, but the resident refused to allow them, that refusal was care planned with interventions. During an interview on 2/3/23 at 11:51 A.M., the resident's physician said he was not aware staff transferred the resident via sit-to-stand lift instead of Hoyer lift as was recommended by the therapy department. He expected staff to notify him, before using the sit-to-stand to transfer the resident. If they had done so and reported the resident was requesting sit-to-stand transfers, then he would have recommended they have physical therapy re-evaluate the resident. Risk for harm was determined by the physical therapy assessments. Staff should follow physical therapy transfer recommendations. During an interview on 2/3/23 at 2:40 P.M., the Administrator said the resident's transfer status should never have been a question for direct care staff. She expected staff to document refusals of Hoyer lift transfers and requests for sit-to-stand transfers in the resident's progress notes as well as on his/her care plan and include interventions. Staff should have more than one conversation regarding safety, when a resident declined the transfer method recommended by the physical therapy department. The resident's nurse should have notified the resident's physician or left a note for the Assistant Director of Nursing to do so, if he/she could not reach the physician. When the resident fell out of the sit-to-stand lift, the CNAs should have immediately notified the nurse. They were both re-educated and written up. The CNA involved in the incident, who was not assigned to provide the resident's care that shift, was still responsible for ensuring the nurse was notified. Per the facility fall policy, post event monitoring and notification of the physician should have occurred right after the incident. MO00212780 MO00212886

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status by not providing diets and supplements as ordered and not providing feeding assistance for one resident who experienced a significant weight loss (Resident #7). The sample size was seven. The census was 93. Review of the facility's Standards and Guidelines for Weighing/Weight Loss Protocol, revised on 3/5/21, showed: -Standard: It will be the practice of this facility to implement the following systems regarding weight documentation; -Guidelines: New admits and readmissions will be weighed upon admission, monthly and/or as ordered by the physician; -Staff will be responsible for obtaining weights for these admits and will have this information available for morning stand-up meeting. Weights will be recorded; -The Registered Dietician (RD) is to review all admission weight for possible interventions; -Consistent weight loss noted during the admission weight process will be brought to the attention of the medical doctor and responsible party; -Weight refusals, not consistent with the resident's known preferences or expressed desires should be documented by the attending nurse in the resident's chart with notification to the medical doctor and responsible party; -Weekly and daily weights may be obtained per RD and physician orders in order to monitor clinical status of a resident requiring closer monitoring and intervention. Review of the facility's Standards and Guidelines for Nutrition and Hydration Assistance Policy, revised 3/27/21, showed: -Standard: It will be the standard that this facility will provide the level of assistance required to the residents while maintaining their highest practical level of function and personal preferences. Staff will help to ensure residents receive adequate assistance and provision of services for nourishment and hydration; -Guidelines; -Residents' hydration and nutritional needs are met throughout the day from various sources. A major portion of the total fluids and foods are provided at meal times, either in a dining room setting or on trays served in the rooms; -A variety of fluids and liquids are provided on meal trays daily. Other sources of hydration are offered through the course of the day for most residents such as water maintained at bedside or recreation/activity programs; -The resident's ability to perform Activities of Daily Living (ADLs), including eating, should be considered when assisting the resident with dining needs. ADLs may vary from day to day or during the course of the day, so this should also be taken into account as well. Staff should provide the level of assistance required to ensure the resident is able to receive his or her daily nutritional or hydration needs while maintaining the highest practical level of functioning. Review of Resident #7's Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/8/22, showed: -admitted on [DATE]; -Cognitively intact; -Exhibited no behaviors such as rejection of care; -Required Extensive assistance of two staff for bed mobility and transfers; -Required limited assistance of one staff for eating; -Diagnoses included heart failure, high blood pressure, arthritis and depression; -Weight of 259 pounds. During an interview on 11/28/22 at 2:07 P.M., the RD said the resident's weight of 259 pounds was incorrect. The scales were not properly calibrated at the time. The resident was re-weighed on 9/29/22. Review of the resident's care plan, in use during the time of the investigation, showed: -Focus: Initiated 9/2/22: The resident requires a therapeutic diet or modified texture diet; -Goal: Resident will receive diet as ordered; -Interventions: Provide diet as ordered; -Focus: Initiated 9/2/22: Resident needs assist with ADLs; -Goal: Resident will have ADL needs met; -Interventions: Assist and provide ADL care and support as needed. Review of the resident's physician's orders, showed an order, revised 9/13/22, for a no added salt diet, mechanical soft texture (texture-modified diet that restricts foods that are difficult to chew or swallow) with regular liquid consistency. Review of the resident's Weight Summary, showed: -On 9/29/22, a weight of 215.5 pounds; -On 10/10/22, a weight of 203.8 pounds. Review of the resident's dietary note, showed on 10/11/22 at 10:38 A.M., Note written in regards to resident's significant weight loss of 5.4 % since 9/29/22. Went into the resident's room to provide a nutrition consult and he/she was sleeping. Task section shows that most of the time the resident is eating 76-100 % of his/her meals. Recommend providing a nutritional health shake every day. RD to follow as needed. Review of the resident's physician's orders, viewed on 11/22/22 at 10:39 A.M., showed no order for a nutritional health shake. Review of the resident's Medication Administration Review (MAR), dated 10/1/22 through 10/31/22, showed no order or administration of a nutritional health shake. Review of the resident's MAR, dated 11/1/22 through 11/30/22, showed no order or administration of a nutritional health shake from 11/1/22 through 11/27/22. Review of the resident's Weight Summary, showed on 11/7/22, a weight of 209.4 pounds. Observation on 11/22/22 at approximately 9:30 A.M., showed the resident lay on his/her back on his/her bed. The resident's bed was slightly raised. An over bed table sat over the resident's bed with a covered plate of food. The food consisted of mechanical soft sausage, oatmeal, eggs and an English muffin. The tray and food was untouched by the resident. A cup of juice sat on top of the night stand. The resident made several unsuccessful attempts to reach the juice. The resident's body leaned towards the right side of his/her bed. During an interview on 11/22/22 at approximately 9:35 A.M., the resident said he/she was very thirsty and had not eaten or had a drink because he/she could not reach the food. He/she never received help with meals. His/her family will assist with meals and this was the only time he/she ate or had a drink. The resident attempted to reach for the carton of juice and said, I have been trying all morning and cannot get to it. Observations on 11/22/22 at 9:45 A.M., showed the resident lay on his/her back and attempted to reach for the carton of juice. His/her hand began to shake. Certified Nursing Assistant (CNA) G walked past the resident's room, looked at the resident and walked towards another resident's room. The resident started crying and said he/she was thirsty. At 9:50 A.M., the Director of Nursing (DON) entered the resident's room and asked if the resident wanted his/her food warmed up. CNA G entered the resident's room and asked if he/she needed assistance. The DON left to warm up the resident's food. At 9:53 A.M., the DON arrived with the plate of food and offered the resident juice. The DON placed the carton of juice in the resident's hand and sat him/her up. The resident drank all of the juice at once. At 9:55 A.M., the DON and CNA G closed the resident's door to provide personal care. At 10:15 A.M., the DON and CNA G exited the resident's room. The resident lay in bed on his/her back and said he/she was leaning to the left and felt he/she was about to fall. The resident's food sat untouched on top of the night stand. The surveyor notified CNA G of the resident's need for assistance as he/she said he/she was leaning to the left and felt he/she was about to fall. CNA G adjusted the resident and left the room. At 10:25 A.M., CNA G entered the resident's room and asked if he/she wanted another plate of food. The resident said he/she did not want the food. CNA G removed the tray of food from the resident's room. During an interview on 11/22/22 at 10:30 A.M., CNA G said the resident was very alert and could make his/her needs known. During an interview on 11/22/22 at 10:35 A.M., CNA H said the resident could feed him/herself but needed assistance with set up. The resident was alert and could communicate his/her needs but was in need of assistance. Observation on 11/28/22 at 9:41 A.M., showed the resident lay on his/her back in bed. The bed was elevated at approximately 45 degrees. A covered tray of food sat on the night stand next to the resident's bed. A cup of cranberry juice and a carton of milk sat on the night stand. During an interview on 11/28/22 at 9:42 A.M., the resident said he/she had not eaten because he/she could not reach the food. He/she was thirsty. When asked if he/she could ask for assistance, the resident said They won't help me. Observation on 11/28/22 at 9:45 A.M., showed Certified Medication Technician (CMT) F entered the resident's room. He/she adjusted the resident's bed and repositioned him/her. CMT F placed the night stand with the covered food over the resident's bed. He/she uncovered the resident's food. The meal consisted of scrambled eggs, a scoop of oatmeal, a whole English muffin and a sausage patty. CMT F opened the resident's carton of milk and placed a straw in the milk. He/she left the room and did not offer assistance with feeding the resident. The resident attempted to pick up the carton of milk. His/her had shook as he/she tried to reach for the milk. At approximately 9:47 A.M., the resident was able to grab the milk carton. He/she then tried to bring the milk up to his/her mouth to take a drink. The resident was unable to do so. The resident continued to make unsuccessful attempts to drink his/her milk. At 9:55 A.M., CNA I passed the resident's room and entered. He/she asked the resident if he/she was eating. The resident said he/she was trying but could not reach the food. CNA I gave the resident the milk. The resident drank all of the milk in one gulp. CNA I began feeding the resident the eggs. The resident ate all of the eggs. CNA I asked the resident if he/she wanted the other items on the plate. The resident said no. CNA I gave the resident the cup of cranberry juice. The resident drank the juice in one gulp. At approximately 10:02 A.M., CNA I left the room with the resident's tray. CMT F re-entered the resident's room with a cup of ice water and placed it on the resident's night stand. He/she left the room. The resident attempted to reach for the water but was unsuccessful. During an interview on 11/28/22 at 10:05 A.M., the resident said he/she ate the eggs but did not eat the rest of the food because it was not appealing and was dry. The resident was unsure if he/she was supposed to receive a mechanical soft diet. He/she said he/she needed total assistance with meals and could not reach his/her water. During an interview on 11/28/22 at 11:20 A.M., CNA I said he/she was not assigned to the resident today. He/she saw the resident needed assistance with his/her meal and assisted. He/she was not sure if the resident required assistance at all times. During an interview on 11/28/22 at 11:25 A.M., CMT F said the resident was able to feed him/herself but was total care when it came to ADLs. The resident rarely got out of bed. The resident could ask if he/she needed assistance. CMT F was not usually assigned to the resident. He/she was helping out today and this was the first time he/she worked with the resident. During an interview on 11/28/22 at 1:06 P.M., the resident's family member said staff won't feed the resident and he/she was unable to feed him/herself. The only time he/she eats is when family members visit with the resident and feed him/her the food left on the night stand. The resident had asked for assistance in the past but staff told the resident that he/she could feed him/herself. Observation on 11/28/22 at 1:20 P.M., showed Nurse B and Nurse E weighed the resident using a mechanical lift device. The resident weighed 190.0 pounds, indicating a 9.26 % weight loss from 11/7/22. During an interview on 11/28/22 at 2:36 P.M., the administrator and DON said the resident could feed him/herself and may not be interested in the food served. If the resident is positioned correctly, he/she could feed him/herself. The resident was supposed to have a nutritional health shake but had not received it. The administrator would have expected staff to enter the order for the health shake and administer it as ordered. When told of the observations of the resident, the DON said she would have expected staff to feed the resident and offer assistance. The administrator and DON said a 9.26% weight loss was considered significant. The administrator said the resident did have an order for a water pill, which could have contributed to the resident's weight loss. Review of the resident's physician's orders, viewed on 11/28/22 at 2:05 P.M., showed an order, dated 11/26/22 for Lasix Tablet 40 MG (used to reduce extra fluid in the body caused by conditions such as heart failure and high blood pressure). During an interview on 11/28/22 at 1:57 P.M., the Medical Director said a 9.26% weight loss was considered severe. He was aware the resident lost a significant amount of weight in October and ordered a hospice consultation. Staff were expected to follow physician's orders and the RD's recommendations. He would expect staff to assist the resident with meals. During an interview on 11/28/22 at 2:07 P.M., the RD said the resident had been having issues with his/her weights since October. She recommended the resident receive double vegetables, a nutritional supplement and a mechanical soft diet. When she made the recommendation for the nutritional health shake, she sent the recommendation to the administrator, DON, Assistant Director of Nursing, nurse manager and two additional staff members. She would have expected the orders to be carried out, if the resident's input was low. The resident had not received his/her nutritional health shake, which could have contributed to his/her weight loss. The resident should have received a mechanical soft diet. Staff should have assisted the resident with meals if the resident had a difficult time eating on his/her own. These factors would have contributed to the resident's weight loss. The resident was on Lasix as of 11/26/22. Although this would assist in removing fluid, this would not contribute to a significant weight loss. During a telephone interview on 12/2/22 at 9:37 A.M., the administrator said the resident was re-weighed on a different scale by the restorative aide on 12/1/22. The weight was 204.9 pounds. MO00209675