Every finding on record at Riverview Nursing Center

Based on interview and record review, facility staff failed to prevent the commingling of 13 residents' (Resident #10, #33, #34, #38, #42, #43, #44, #45, #46, #47, #48, #49, #50) personal funds with the facility operating funds out of 37 sampled residents. The facility census was 37. Review of the facility's policy titled Conveyance of Resident Funds, revised 05/21, showed the residents personal funds and a final accounting of funds are returned to the resident, the resident representative, or the resident's estate as applicable within 30 days from the date of the resident's discharge from the facility or death. Should a resident pay for services which then retroactively become Medicare/Medicaid eligible, the facility promptly refunds the amount charged to the resident for those services as soon as the facility receives the intermediary's payment. Inquiries concerning refunds are referred to the administrator or Business Office Manager (BOM). Review of the facility-maintained Accounts Receivable Aging report, dated 05/19/25, showed the following residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account #10 $1618.00 #33 $917.00 #34 $1233.00 #38 $6400.00 #42 $60.17 #43 $571.00 #44 $70.15 #45 $368.00 #46 $1297.07 #47 $228.79 #48 $2718.65 #49 $7600.00 #50 $826.00 Total $23907.83 During an interview on 05/19/25 at 1:30 P.M., the BOM said he/she started as the BOM in November 2024. The BOM said he/she had no previous experience with this role and was supposed to be trained by the outgoing BOM before he/she left but that did not happen. The BOM said he/she reviews the A/R Aging report monthly and if credits are found he/she will submit a refund request to the Recovery Specialist and the Recovery Specialist is responsible to ensure all claims are paid and the money is refunded. The BOM said the Recovery Specialist sends the facility a copy of the refund check for the facility records and the Recovery Specialist is responsible to update the accounts receivable aging report when he/she gets a refund check. The BOM said the facility should refund a resident money within 30 days of discharge and he/she is aware this has not been done. The BOM said he/she does not know why the money has not been returned within the time frame as the Recovery Specialist is responsible for ensuring it is completed. The BOM said the facility does not having anything in writing to hold resident funds past the 30 days. During an interview on 05/20/25 at 10:30 A.M., the Recovery Specialist said when a resident refund is needed, he/she is made aware by the facility BOM. The Recovery Specialist said he/she is responsible to ensure all claims are paid. The Recovery Specialist said he/she is responsible for updating the accounts receivable aging report, mailing the check to the resident and/or responsible party, and sending a copy of the check to the facility for their records. The Recovery Specialist said he/she does not know refunds should be sent within 30 days of a resident discharge from the facility. The Recovery Specialist said he/she did not know why it takes over 30 days to get a refund issued. During an interview on 05/21/25 at 9:00 A.M., the Director of Banking Services said the Recovery Specialist is responsible for the accounts receivable aging report. The Director of Banking Services said once he/she gets a check request from the Recovery Specialist he/she cuts a check and sends it to the Recovery Specialist. The Director of Banking Services said he/she did not know a resident refund should be issued within 30 days of discharge from the facility. During an interview on 05/21/25 at 10:10 A.M., the Administrator said he/she reviews the accounts receivable aging report monthly with the BOM. The Administrator said he/she is aware there are outstanding credits that need to be refunded. The Administrator said after they review the report if they find any credits the BOM will submit a refund request to the Recovery Specialist. The Administrator said once the refund request is submitted the Recovery Specialist is responsible to ensure all the claims are paid and supply a refund check for the resident and/or responsible party. The Administrator said once the Recovery Specialist gets the refund check he/she is responsible for updating the accounts receivable report in the computer system and sending a copy of the check to the BOM for the facility records. The Administrator said resident refunds should be issued within 30 days of discharge from the facility and he/she is not sure why the Recovery Specialist is not doing this within the timeframe. The Administrator said he/she is aware the facility has credits more than 30 days old that need to be refunded and he/she said the only reason he/she knows they aren't refunded within 30 days is due to the Recovery Specialist not processing the requests timely after the facility submits them. The Administrator said the facility does not have written permission to hold the resident money after discharge. During an interview on 05/21/25 at 10:30 A.M., the Regional Director of Operations said the the facility BOM is responsible to review the accounts receivable aging report each month and submit any credits to the Recovery Specialist for a refund. Once the Recovery Specialist gets a refund request the Recovery Specialist is responsible to ensure all claims are paid, and request a check for the amount left to refund. Once the Recovery Specialist has the refund check it is his/her responsibility to update the acccounts receivable aging report, mail the check to the resident and/or responsible party, and send the facility BOM a copy of the check. Refunds are to be issued within 30 days of a resident discharge and he/she expects this to be done. It is corporate policy to pay refunds out by the 17th of each month. The Regional DOP said he/she is aware refunds were not being completely timely has determined they were not being processed timely by the recovery specialist.

Based on observation, interview, and record review, facility staff failed to store medications in a safe manner when staff failed to ensure expired insulin vials were not stored with current resident medications, and failed to ensure medications were not loose in one medication cart out of two sampled. The facility census was 37. 1. Review of the facility's policy titled Medication Labeling and Storage, dated February 2023, showed multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 2. Observation on [DATE] at 9:30 A.M. with the Director of Nursing (DON), showed: -One opened ,d+[DATE] full vial of Humalog (insulin) 100 units/milliliter (ml) with an open date of [DATE]; -One opened ,d+[DATE] full vial of Lantus (insulin) 100 units/ml with an open date of [DATE]; -One opened ,d+[DATE] full vial of Lantus 100 units/ml with an open date of [DATE]; -One opened ,d+[DATE] full vial of Insulin Lispro 100 units/ml with an open date of [DATE]; -One opened ,d+[DATE] full vial of Insulin Glargine with an open date of [DATE]. During an interview on [DATE] at 11:26 A.M., Licensed Practical Nurse (LPN) C said the insulin is supposed to be taken off the medication cart after it has been opened for 30 days. The LPN said night shift staff are responsible for checking the dates on the insulin. The LPN said staff should check the open dates on the insulin before administering the insulin to a resident. The LPN said he/she just did not check the dates on the insulin and he/she should have. Insulin that has been open longer than 30 days should not be on the medication cart. During an interview on [DATE] at 10:48 A.M., the Assistant Director of Nursing (ADON) said insulin should only be used for 28 days after it is opened. The outdated insulin should not have been on the medication cart. It is the responsibility of the ADON and DON to make sure the nurses are checking the open dates. The concern of giving insulin over the allotted open time is that the insulin won't be as effective. During an interview on [DATE] at 11:00 A.M., the DON said staff should only keep insulin on the medication cart for 28 days. The concern of keeping it past the 28 days is it will change the effectiveness of the medication. The DON said the vials of insulin and their open dates were probably not checked by the staff. The DON said it is the ADON and the DON's responsibility to make sure the nurses are checking the insulin dates. The DON said he/she does not have a process for ensuring the nurses check the dates. During an interview on [DATE] at 11:13 A.M., the Administrator said staff should put open dates on insulin when they place it on the medication cart. The administrator said he/she does not know how long insulin can be kept once opened. The administrator said he/she expects staff to take expired or outdated insulin off the medication cart. The administrator said the nursing staff should check the dates on the open vials of insulin every shift. The administrator said it is the responsibility of the ADON and the DON to make sure the nurses are checking the dates on the insulin vials every shift. 3. Observation on [DATE] at 9:44 A.M. with Certified Medication Technician (CMT) D showed the CMT medication cart contained 21 loose tablets and capsules of medications in the bottom of medication drawers and were identified as follows: -One capsule of colace (stool softener); -One tablet of 10 milligram (mg) Buspar (anti-anxiety medication); -One tablet of 10 mg of Simvastatin (lowers cholesterol); -One tablet of 100 mg Topamax (migraine medication); -One tablet of 20 mg Celexa (anti-depressant medication); -One tablet of 25 mg Topamax; -One capsule of 0.4 mg Tamsulosin Hydrochloride (used for urine retention); -One tablet of 10 mg Ampyra (used with Multiple Sclerosis); -One capsule of 1 mg Prazosin Hydrochloride (blood pressure medication); -One tablet of 20 mg Lasix (diuretic medication); -One tablet of 50 mg Metoprolol Tartrate (blood pressure medication); -One tablet of 25 microgram (mcg) Soloxine (thyroid medication); -One tablet of 4 mg Eliquis (blood thinner); -One half tablet of Buspar; -One brown capsule, unmarked and unidentifiable; -One half tablet of 500 mg metformin (used for diabetes); -Two white, round tablet, unmarked and unidentifiable; -One tablet of 200 mg Ibuprofen (analgesic); -One tablet of 15 mg Mirtazapine (anti-depressant medication); -One pink, round tablet, unmarked and unidentifiable. During an interview on [DATE] at 10:48 A.M., the ADON said the CMT's should ensure the cart is clean and free of loose pills at the end of every shift. The ADON said it is the responsibility of the ADON and DON to ensure the CMT's are cleaning the medication carts. There should not be loose pills in the medication carts. During an interview on [DATE] at 11:00 A.M., the DON said the CMT's should ensure the cart is clean and free of loose pills at the end of very shift during their narcotic medication count. He/she did not know why staff are not doing it, he/she has told them several times to do that. The DON said it is the responsibility of the ADON and the DON to make sure the staff check and clean the carts. The DON said he/she has not consistently been checking the carts as he/she should. It is not okay to have 21 loose pills in the medication cart drawers. During an interview on [DATE] at 11:13 A.M., the administrator said the CMT's should clean and check the medication carts for loose pills every shift. The administrator said he/she did not know why the CMT's are not checking their medication carts every shift. The loose pills should not have been in the medication cart. The administrator said he/she, the ADON and DON are ultimately responsible for checking the medication carts.

Based on record review and interview, facility staff failed to prevent the misappropriation of money from one resident's, out of four sampled residents, (Resident #1) checking account when Certified Nursing Aide (CNA) A stole checks from the resident, and had a third party cash the checks, without authorization of the resident. The facility census was 34. The administrator was notified on 3/13/24 of past Non-Compliance which occurred on 2/05/24. On 2/05/24, the administrator suspected CNA A used a resident's debit card to make multiple purchases from businesses, without the authorization of the resident. Upon discovery, staff suspended CNA A on 2/05/24. The facility conducted an investigation, in-serviced all staff on the facility's abuse, neglect, and misappropriation policies on 2/5/24, and terminated CNA A on 2/7/24 for violation of facility policy. 1. Review of the facility's Abuse, Neglect, and Misappropriation Policy, undated, showed the facility will assure all residents, responsible parties, and staff understand there is zero tolerance of verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property by an employee or any other person known or unknown to the resident. Review showed misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/29/23, showed staff assessed the resident with impaired cognition. Review of the facility's investigation, dated 8/01/23, showed staff documented the resident's family member notified the Social Service Director (SSD), on 08/01/23, someone was writing bad checks from the resident's checking account. Review showed the facility contacted the Department of Health and Senior Services (DHSS), the local police department, and the local sheriff's department to report the incident. Reviewed showed the SSD documented the investigation did not identify any staff member involved in the incident at that time. Facility in-serviced all staff on the facility's abuse, neglect, and misappropriation policies on 8/2/24. Review of the local county sheriff's department incident report, dated 8/9/23 and reviewed on 3/18/24, showed on 2/1/24 the investigator documented the video from the local bank had been reviewed and showed CNA A and CNA A's spouse cashed checks through the drive-thru of the bank on 7/22/23. On 2/6/24 the investigator documented he/she contacted the facility and reported the stolen checks and inquired if CNA A worked there and was informed he/she had been terminated on 2/7/24. Review showed the investigator documented, during an interview on 2/27/24, at approximately 8:28 A.M., CNA A said he/she knew the resident was missing money, but he/she, thought it was the resident's sibling or guardian who was responsible, and he/she was the connection between his/her spouse and the facility. Review showed the investigator documented CNA A's spouse said he/she and CNA A wrote checks numerous times, and CNA A was aware of the checks being cashed, he/she saw the checks and took them, and he/she needed the money because he/she was broke. Review showed the deputy interviewed CNA A and CNA's spouse on 2/27/24. Review showed the local Sheriff's Department charged CNA A with Financial Exploitation of Elderly/Disabled Person, and Fraudulent Use of Credit/Debit Device, Stealing $750.00 or more on 2/27/24. Review showed the local Sheriff's Department charged CNA A's spouse with Forgery, Financial Exploitation of Elderly/Disabled Person, Fraudulent Use of Credit/Debit Device, Identity Theft or Attempt, Stealing $750.00 or more, with the reporting person as the resident's guardian on 2/27/24. Review showed the local Sheriff's Department documented CNA A and CNA A's spouse misappropriated approximately $4,195.00 from the resident through cashed stolen/fraudulent checks. During an interview on 3/11/24 at 10:17 A.M. the administrator said he reported the arrest of CNA A and his/her spouse to DHSS on 2/28/24 in order to link the previous incident with CNA A. During an interview on 3/11/24, at 10:20 A.M., the Business Office Manager (BOM) said CNA A admitted to misappropriating the resident's funds, as well as stealing approximately $4000.00 from the facility. During an interview on 3/25/24 at 3:15 P.M., the administrator said they had not been notified by their local police and/or sheriff's department of the arrest of CNA A. He said a staff member in dietary watched the news and reported it to him. During an interview on 3/28/24 at 12:45 P.M., the Director of Nursing (DON) said the Social Services Director (SSD) had brought it to his/her attention that a resident had some checks stolen in 8/2023 but that at that time no one could be identified. He/She said when there was an allegation in February 2024 a resident had his/her debit card taken by CNA A and upon review it was found the resident had given the employee the card to use to get him/her items. After their investigation they let him/her go due to a policy violation. The maintenance supervisor who has affiliation with the local sheriff's department came in sometime after CNA A was terminated and said they had arrested CNA A and his/her spouse. During an interview on 3/28/24 at 1:06 P.M., the SSD said there was an employee from the bank who came in August, 2023 who was questioning Resident #1 about checks that had come through the bank to find out if the resident had approved them. The SSD said at that time no one had been identified and the investigation was ongoing. He/She said in February, 2024 there was a report of CNA A using a residents debit card but the resident had given him/her permission. The SSD said although he/she had permission everyone knows you don't do that and CNA A was terminated. MO00232513

Based on staff interview and record review, facility staff failed to meet professional standards when staff did not document in the Medication Administration Record (MAR) they administered the physician ordered medication and treatment for four residents (Resident #1, #2, #3, and #4) out of four residents. The facility census was 33. 1. Review of the facility's Medication Administration Policy, dated April 2019, showed the Director of Nursing (DON) services supervises and directs all personnel who administer medication and /or have related functions. Review showed medications are administered in accordance with prescriber orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The individual who administers the medication will initial the resident's MAR on the appropriate line after they administered each medication and before they administer the next medication. As required or indicated for a medication, the individual who administer the medication, records in the resident's medical record the signature and title of the person who administered the drug. 2. Review of Resident #1's admission Minimum data set (MDS), a federally mandated assessment tool, dated 5/10/23, showed staff assessed the resident as: -Cognitively intact; -Neuromuscular dysfunction of bladder (the bladder's nerves do not work properly and the bladder may not fill and empty correctly), cerebral infarction (stroke caused by disruption of blood flow to the brain), major depressive disorder, anxiety disorder, Insomnia, Hypertension (high blood pressure), and hyperlipidemia (high cholesterol); -Indwelling urinary Foley catheter (stationary flexible catheter inserted to drain urine from the bladder). Review of the resident's Physician Order Sheet (POS), dated June 2023 through July 2023, showed the physician's orders directed staff as follows: -Aspirin (used as an anti-inflammatory and blood thinner) 81 milligrams (mg) one tablet by mouth daily; -Lisinopril (used to treat high blood pressure) five mg one and a half tablets by mouth daily; -Paroxetine (used to treat depression) 20 mg one by mouth daily; -Cephalexin (antibiotic) 500 mg one capsule by mouth four times daily for 10 days for Urinary tract infection; -Foley catheter care every shift. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's Cephalexin on 6/20/23, 6/21/23, and 6/22/23 as directed. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's Aspirin, Lisinopril, Paroxetine on 6/22/23 as directed. Review of the resident's TAR, dated June 2023 showed staff did not document they provided catheter care each shift on 6/30/23 as directed. Review of the resident's TAR, dated July 2023, showed staff did not document they provided catheter care each shift on 7/5/23 and 7/6/23 as directed. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Pressure ulcer of sacral region (buttocks),Stage IV (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures); -Indwelling urinary Foley catheter, bilateral nephrostomy tubes (stationary tubes which drain urine directly from the kidney's), colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall), and acquired absence of left foot. Review of the resident's POS, dated June 2023, showed the physician's order directed staff as follows: -Methocarbamol (used for muscle spasms and pain) 500 mg one by mouth every six hours; -Sacral Decubitius Ulcer wet to dry dressing, with normal saline twice daily; -Foley catheter care every shift; -Nephrostomy tube care every shift; -Colostomy care every shift; -Wet to dry dressing to left stump (site of amputation) twice daily. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's Methocarbamol on 6/7/23, 6/12/23, 6/13/23, and 6/14/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided wet to dry dressings to the resident's sacrum on 6/9/23, 6/10/23, and 6/11/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided Foley catheter care, nephrostomy care, or colostomy care on 6/7/23, 6/9/23, and 6/14/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided wet to dry dressing to the resident's left stump on 6/7/23 and 6/13/23 as directed. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Benign prostatic hyperplasia (BPH) (prostate enlargement causing urination difficulty), dementia, muscle wasting and atrophy (degeneration of cells), arteriosclerotic heat disease (thickening and hardening of the walls of the coronary arteries), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs causing pain), hyperlipidemia, hypertension, violent behavior, and retention of urine; -Indwelling urinary catheter. Review of the resident's POS, dated July 2023, showed the physician's orders directed staff as follows: -Lisinopril (used to treat high blood pressure) 5 mg one tablet by mouth daily; -Quetiapine (used to treat agitation and aggression) 50 mg one tablet by mouth daily; -Carvedilol (used to treat high blood pressure) 3.125 mg one tablet by mouth twice daily; -Gabapentin (used to treat nerve pain) 300 mg one capsule by mouth twice daily; -Quetiapine (used to treat schizophrenia, bipolar disorder, and depression) 75 mg one tablet by mouth at bedtime; -Memantine (used to treat dementia) 5 mg one tablet by mouth twice daily; -Atorvastin (used to treat high blood pressure) 40 mg one table at bedtime; -Donepezil (used to treat dementia) 10 mg one tablet at bedtime; -Health shakes twice daily; -Foley catheter care every shift; -Cleanse wound on left stump with wound cleanser, apply triple antibiotic ointment cover with a two by two gauze and tape. Change daily; -Cleanse wound on stump with pure and clean, apply xeroform (type of wound dressing),gauze, foam, and tape. Change daily. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's Gabapentin, quentiapine 75 mg, memantine, atorvastin, donepezil, and health shakes on 6/29/23 and 6/30/23 as directed. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's quentiapine 50 and Lisinopril on 6/30/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided Foley catheter care on 6/4/23 and 6/30/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided the resident's wound care treatment with triple antibiotic ointment on 6/4/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided the resident's wound care treatment with xeroform, gauze, and tape on 6/30/23 as directed. 5. Review of resident #4's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Bilateral primary osteoarthritis of knee (wearing down of the protective tissue at the ends of bones and worsens over time) and disorder of the kidneys and ureter (duct between the kidney and bladder); -Indwelling urinary catheter. Review of the resident's POS, dated June 2023 through July 2023, showed the physician's orders directed staff as follows: -Lidocaine (used to treat pain) patch 4% apply topically daily; -Foley catheter care every shift. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's lidocaine on 6/12/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided Foley catheter care on 6/24/23 and 6/25/23 as directed. Review of the resident's MAR, dated July 2023 showed the staff did not document they provided the resident's lidocaine patch on 7/1/23, 7/2/23, 7/3/23, 7/4/23, 7/5/23, 7/6/23, 7/7/23, 7/8/23, 7/9/23, 7/10/23, and 7/11/23 as directed. 6. During an interview on 7/13/23 at 1:35 P.M., the Registered Nurse (RN) said a hole on the MAR or TAR means the medication was not given and the DON should be notified. He/She said the Certified Medication Aide's (CMT's) and nurses are responsible for initialing the MAR or TAR upon giving the medication or providing the treatment. He/She said the DON is responsible for making sure the MAR and TAR are completed by staff. During an interview on 7/13/23 at 1:44 P.M., the CMT said a hole in the MAR or TAR means staff forgot to sign the medication or treatment was completed. He/She said it could also mean the medication or treatment was not completed. He/She said the CMT's and nurses are responsible for completing the MAR and TAR. He/She said he/she does not know who is responsible for making sure the MAR and TAR are initialed. During an interview on 7/13/23 at 1:49 P.M., MDS said a hole on the MAR or TAR would mean staff forgot to sign out the medication because there is always staff there to pass medications and complete treatments. He/She said the nurses and CMT's are responsible for documenting in the MAR or TAR and the DON is responsible for making sure the MAR and TAR are completed by staff. During an interview on 7/13/23 at 1:58 P.M., the administrator said a hole in the MAR or TAR means the medication or treatment was not completed. He/She said the CMT's and nurses are responsible for signing the MAR and TAR. He/She expects staff to let the DON know about the hole in the MAR or TAR. He/She said it is the DON's responsibility to make sure staff are initialing the MAR and TAR. During an interview on 7/13/23 at 2:41 P.M., the DON said a hole in the MAR or TAR means staff forgot to sign off or the medication or treatment was not completed. He/She said the nurses and CMT's are responsible for making sure the MAR and TAR are completed. He/She said he/she does audits on the MAR and TAR to catch when there are holes. He/She expects staff to let him/her know if there is a hole. MO00221275

Based on observation, interview and record review, the facility staff failed to store food in a manner to protect from potential contamination and out-dated use. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens and cross-contamination. The facility staff also failed to wear hair restraints to protect food and food contact surfaces from potential contamination. The facility census was 35. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy dated 2016, showed: -All food items will be labeled. The label must include the name of the food and date by which it should be sold, consumed, or discarded. -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. -Never leave any food item uncovered and not labeled. Review of the facility's Labeling and Dating Foods (Date Marking) policy dated 2016, showed: -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. -Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Once a package is opened, it will be re-dated with the date the items was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. -Prepared food or opened food items should be discarded when: *The food item does not have a specific manufacturer expiration date and has been refrigerated for seven days *The food item is leftover for more than 72 hours *The food item is older than the expiration date Observation on 01/24/23 during the kitchen tour, which began at 9:55 A.M., showed: -the reach-in freezer by the exit door contained opened and undated plastic bags of cookie dough rounds and bread roll dough and an undated plastic resealable bag of chicken breasts that were removed from their original packaging; -the chest freezer contained two opened and undated plastic bags of sausage patties opened, an undated and unlabeled bag of an unidentifiable diced meat; and an undated plastic resealable bag of boneless ham. Observation showed the ham covered with ice crystals. -the reach-in refrigerator in corner of cook's station contained: *an opened and undated five pound container of commercially prepared macaroni salad; *an opened and undated five pound container of cottage cheese; *an undated four quart plastic storage container of previously prepared peas; *an opened and undated five pound bag of shredded cheddar cheese; *an opened and undated five pound bag of salad mix; *a case of precooked bacon opened to the air and undated. During an interview on 01/24/23 at 10:05 A.M., the Dietary Manager (DM) said staff should label, date and seal all opened food items before they are put away. The DM said, while staff had been trained on how to store food properly, he/she has to tell them over and over that everything has to have a date on it. The DM said he/she is responsible to check the food every morning and afternoon to make sure it is stored appropriately. The DM said he/she checked the food storage that morning and probably saw the undated and unlabeled food items, but just did not pay that much attention to it. The DM said if he/she finds food not stored appropriately during his/her checks, he/she should fix it which would include dating or labeling it. The DM said if he/she did not know when staff opened and food item, then the food item should be thrown away. Observation on 01/24/23 at 10:25 A.M., showed the dry goods pantry contained a bulk container of flour, dated 10/22, stored on the bottom shelf of the shelving unit which also contained containers of oven cleaner, multipurpose cooktop cleaner, multipurpose antibacterial cleaner and disinfectant and foaming cleanser. During an interview on 01/27/23 at 3:27 P.M., the administrator said the DM is responsible to monitor food storage daily. The administrator said opened food items should be dated and timed and frozen food should be discarded when it shows signs of deterioration which would include an accumulation of ice crystals. The administrator said food items should be stored sealed and chemicals should not be stored near food. 2. Review of the facility's Proper Hand Washing and Glove Use policy, dated 2016, showed: the policy directed staff to wash their hands upon entering the kitchen from another location; between tasks; before and after handling foods; after they touch any part of the uniform, face, or hair; before donning gloves and after removing gloves. Review also showed the policy directed staff to change their gloves anytime handwashing would be required. Observation on 01/24/23 at 10:37 A.M., showed the DM lifted the trash can lid with his/her gloved hands to dispose of trash. Observation showed, without removing his/her gloves and performing hand hygiene, the DM continued to prepare food items for service to residents at the noon meal. Observation on 01/24/23 from 11:06 A.M. to 11:30 A.M., showed the DM washed his/her hands at the handwashing sink. Observation showed the DM turned the faucet off with his/her wet bare hands and prepared a beverage in a Styrofoam cup for service to a resident. Observation showed the DM then donned a pair of gloves and removed a pan of sweet potatoes from the oven, removed the foil and checked the internal temperature of the sweet potatoes with a thermometer. Observation showed the DM wrapped the pan with aluminum foil, put the pan back in oven, removed his/her gloves and then used his/her bare hands to lift the trash can lid to dispose of the soiled gloves. Observation showed, without performing hand hygiene, the DM used his/her cell phone, reviewed menus, adjusted his/her facemask, obtained a metal food preparation/service pan from the storage rack, got a cooking utensil, donned a pair of gloves, stirred the peas cooking on the stove, and checked the internal temperature of the peas with a thermometer. Observation showed the DM poured the cooked peas into a pan and placed the pan on the steamtable. Observation showed the DM removed his/her gloves, used his/her bare hands to lift the trash can lid to dispose of the soiled gloves, adjusted his/her facemask and, without performing hand hygiene, donned another pair of gloves and frosted the cake for service to residents at the lunch meal. Observation showed the DM removed his/her gloves, pulled up his/her pants, used his/her bare hands to lift the trash can lid to dispose of the soiled gloves, and, without performing hand hygiene, donned a pair of gloves and portioned cake into Styrofoam bowls for service to residents at the lunch meal. Observation showed the DM touched the cake with his/her gloved finger as he/she put the cake into bowls. Observation showed the DM removed his/her gloves, used his/her bare hands to lift the trash can lid to dispose of the soiled gloves, donned a new pair of gloves, and placed lids on the bowls of cake. Observation showed the DM then picked up two pieces of cake with his/her gloved fingers, put the cake into a bowl and sat the bowl down on counter by food processor. Observation showed the DM removed his/her gloves, lifted the trash can lid with his/her bare hands to dispose of the soiled gloves and, without performing hand hygiene, donned a pair of gloves, removed the pan of sweet potatoes from oven and checked the internal temperature of the sweet potatoes with a thermometer. During an interview on 01/24/23 at 11:31 A.M., the DM said staff should wash their hands in between tasks which would include after they touch a trash can lid, their clothes and facemasks and between glove changes. The DM said staff should scrub their hands with soap and water for 10 seconds when they wash their hands and then use paper towel to turn off faucet. The DM said staff should never turn the faucet off with their bare hands. The DM said he/she just got in a hurry and thought he/she had washed his/her hands when needed. Observation on 01/24/23 at 11:54 A.M., showed the DM washed his/her hands at the handwashing sink. Observation showed the DM scrubbed his/her hands with soap for five seconds, rinsed and dried his/her hands, donned a pair of gloves and then portioned prepared peas from the steamtable into a metal food preparation/service pan. Observation showed the DM used the peas to prepare pureed peas for service to resident on pureed diets at the lunch meal. Observation on 01/24/23 at 12:04 P.M., showed the DM washed the food processor at the mechanical dishwashing station with his/her gloved hands, removed his/her soiled gloves and, without performing hand hygiene, put away sanitized dishes from the clean side of the station. Observation showed the DM then washed his/her hands at the handwashing sink. Observation showed the DM scrubbed his/her hands for five seconds, rinsed and dried his/her hands and then removed the food processor from dishwasher. Observation showed the DM placed the food processor on its base, donned a pair of gloves, removed milk from the reach-in refrigerator, added prepared cake and milk to food processor to prepare pureed cake for service to residents on pureed diets at the lunch meal. Observation showed the DM washed the food processor at mechanical dishwashing station with his/her gloved hands, removed his/her soiled gloves and, without performing hand hygiene, picked up bowls of pureed cake with his/her hand placed over the top of bowls and placed the bowls on the countertop next to additional bowls of prepared cake. Observation showed the DM washed hands at handwashing sink for five seconds, dried his/her hands and then placed a lid on top of a bowl of pureed cake. Observation on 01/27/23 at 3:00 P.M., showed DA A donned a hairnet, touched his/her facemask and, without performing hand hygiene, prepared drinks in carafes for service to residents. During an interview on 01/27/23 at 3:20 P.M., the administrator said staff should wash their hands between tasks, when visibly soiled, after they touch anything dirty which would include the trash cans, and before and after glove use. The administrator said when staff wash their hands, they scrub their hands with soap for 20 seconds, rinse and dry their hands and then use another paper towel to turn off the faucet. The administrator said staff should be trained on proper handwashing procedures upon hire. 3. Review of the facility's Dishwashing: Machine Operation policy dated 2016, showed the policy directed staff to Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage. Observation on 01/24/23 at 10:20 A.M., showed a large stack of black service trays stacked together wet on the countertop by the steamtable. Observation on 01/24/23 at 12:17 P.M., showed the DM removed the food processor from the dishwasher while wet and placed the food processor on its base. Observation showed the DM then prepared pureed bread in the food processor to serve to residents on pureed diets at the lunch meal. Observation on 01/27/23 at 3:04 P.M., showed 11 insulated domed plate covers stacked together wet upside down on the storage shelf. During an interview on 01/27/23 at 3:06 P.M., the DM said after dishes are washed they should air dry before they are stored or used and all staff are trained on this requirement. The DM said he/she should have allowed the food processor to air dry before he/she used it, but he/she just did not think about it at the time. During an interview on 01/27/23 at 3:18 P.M., the administrator said staff should allow dishes to air dry after they are washed and before they are put away and used. The administrator said the DM is responsible to monitor dish washing and storage every time the dishes are washed. 4. Review of the facility's Hair Restraints policy, dated 2016, showed the policy directed all Dining Services staff to wear hair restraints in all food production, dishwashing and serving areas to prevent hair from contacting exposed food. Observation on 01/24/23 from 9:45 A.M. to 1:30 P.M., showed the DM prepared food for and served food to residents at the lunch meal without wearing a hair restraint. Observation on 01/27/23 at 2:58 P.M., showed DA A put away sanitized dishes from the clean side of the mechanical dishwashing station without wearing a hair restraint. During an interview on 01/27/23 at 3:00 P.M., the DA said he/she did not have a hair restraint on because he/she just got there. The DA said he/she had been trained to put on a hairnet as soon as he/she enters the kitchen and does any tasks. During an interview 01/27/23 at 3:07 P.M., the DM said staff are to put on a hairnet as soon as they walk in the kitchen door and do any tasks. The DM said he/she usually puts a hair restraint on the back of his/her hair and he/she and did not think about the sides of his/her hair being long and loose. The DM said he/she should have worn a hairnet when he/she prepared and served food to residents on 01/24/23. During an interview on 01/27/23 at 3:16 P.M., the administrator said kitchen staff should wear hair restraints and they should put them on when they enter the kitchen before they do any tasks. The administrator said the staff are trained on the use of hair restraints upon hire.

Based on observation, interview, and record review, facility staff failed to follow appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to remove soiled gloves and/or perform hand hygiene during the provision of care for two residents (Residents #12 and #16). The facility census was 35. 1. Review of the facility's Handwashing/Hand Hygiene Policy, revised August 2019, showed staff are directed to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -before and after direct contact with residents; -before performing any non-surgical invasive procedures; -before and after handling an invasive device (e.g., urinary catheters, IV access sites); -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 contact with a resident's intact skin; -after contact with blood or bodily fluids; -after handling used dressings, contaminated equipment, etc.; -after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; -after removing gloves. 2. Observation on 1/24/22 at 3:07 P.M., showed Registered Nurse (RN) L entered Resident #16's room to provide wound care. RN L did not wash or sanitize his/her hands before he/she entered the resident's room or before he/she applied clean gloves to perform care. The RN did not wash his/her hands after he/she removed the residents soiled dressing or before he/she applied new gloves. He/She then sprayed the resident's left heel wound with cleanser, removed his/her gloves and left the room. He/She did not wash his/her hands before he/she opened/closed several drawers on the treatment cart. He/She then re-entered the resident's room and did not wash his/her hands before he/she applied new gloves. He/She removed his/her gloves, placed them on the bed and did not perform hand hygiene. He/She then applied gauze to the resident's heel without gloves, dated and initialed the tape used to hold the gauze in place. He/She picked up the dirty gloves and dressing supply trash from the resident's bed and threw the items away on the treatment cart and closed several treatment cart drawers before he/she used hand sanitizer. 3. Observation on 1/26/23 at 10:30 A.M., showed Certified Nurse Aide (CNA) F and Nurse Aide (NA) H entered Resident # 12's room to provide care and transfer the resident to bed. CNA F and NA H performed hand hygiene and applied clean gloves. CNA F lifted the resident's catheter bag out of the privacy bag. NA H emptied the urine from the catheter bag into a graduated container and emptied the graduated container into the toilet. CNA F and NA H did not change their gloves or perform hand hygiene before they continued with the transfer. CNA F and NA H touched the resident and numerous surfaces around the resident. During an interview on 1/27/23 at 2:11 P.M., CNA F said you should wash your hands any time you come in contact with a resident. You should wash hands when they are soiled. He/She said anytime you go from dirty task to clean task you should change your gloves and wash your hands. During an interview on 1/27/23 at 2:15 P.M., Licensed Practical Nurse (LPN) C said you should wash your hands often. When you enter and/or exit a resident's room, after you use the restroom or when you have touched your face. He/she said you should wash your hands before you start a procedure and put on clean gloves. He/She said when you take an old dressing off you should take your old gloves off and wash your hands and put new gloves on. During an interview on 01/27/23 02:13 P.M., the Director of Nursing said you should wash your hands before starting a procedure. He/She said you should put gloves on when you enter the room, remove the old dressing take your dirty gloves off and wash your hands. He/She said you should put on new gloves before you put on the new dressing. He/She said after you put on the new dressing you should take your gloves off and wash your hands.

Based on observation, resident and staff interview, and record review facility staff failed to provide alternative meals for residents which accommodated the residents' preferences. This had the potential to affect all residents. The facility census was 35. 1. Review of the resident council minutes from 12/27/22 through 1/23/23 showed the council addressed food preferences with the facility staff. 2. Observation on 1/24/23 at 12:05 P.M., showed the menu board in the dining area to have peanut butter and jelly sandwiches posted as the only alternative to the main menu item. 3. During an interview on 1/24/23 at 10:45 A.M., Resident #12 said the facility only offers a peanut butter and jelly sandwich for an alternative meal so if he/she does not like the main menu item he/she does not eat. During an interview on 01/24/23 at 11:35 A.M., Resident #23 said sometimes the food is undercooked and cold. He/She said facility staff give him/her sausage even though he/she doesn't like it, but he/she did not know he/she could ask for something different. During an interview on 1/24/23 at 11:44 A.M., Resident #32 said he/she eats vegetables, milk and juice from the facility but other food does not agree with him/her so he/she orders food and has it delivered. The resident said he/she tried to talk to the doctor and the cook about food and they said there wasn't anything they could do. During an interview on 1/25/23 at 10:40 A.M., Resident #25 said the food is disgusting and the facility only offers a peanut butter and jelly sandwich for an alternative. During an interview on 1/25/23 at 11:00 A.M., Resident #6 said he/she does not like the food and only knows of peanut butter and jelly sandwiches being an alternative. During an interview on 01/25/23 at 4:13 P.M., Resident #17 said the food ain't right and added he/she does not like beans but they give him/her ham and beans. He/She said peanut butter is the only thing they offer as an option. During an interview on 01/26/23 at 8:47 A.M., the Activity Director (AD) said some of the residents don't like to eat certain things and he/she informs the charge nurse or dietary manager so the resident may get something different. The AD said the nurses check for resident preferences and food allergies. During an interview on 1/26/23 at 11:38 A.M., Resident #4 said staff do not offer him/her a second meal option and he/she will eat what they bring or eat food that he/she buys. He/She said during admission, facility staff told him/her there was one meal for everybody and there aren't any options. He/She was not aware of the option to ask for a sandwich. During an interview on 1/26/23 at 2:18 P.M., the resident council said the facility does not offer any other food alternatives to the main menu item other than a peanut butter sandwich. During and interview on 1/27/23 at 8:27 A.M., dietary cook K said alternatives to the main menu are offered. Residents can have leftovers or a peanut butter and jelly sandwich, or an egg sandwich. During an interview on 1/27/23 at 8:40 A.M., the dietary manager said if a resident does not like the main menu item, the are given options. He/She said residents can have soup or a leftover meal. Additionally, peanut butter and jelly sandwiches are always written on the menu board as an alternative. During an interview on 1/27/23 at 9:00 A.M., the director of nursing (DON) said there should be more than just a peanut butter and jelly sandwich offered as an alternative meal choice. During an interview on 1/27/23 at 3:03 P.M., the administrator said facility staff offer meal alternatives and they are listed on a board in the dining room. He/She said the resident council, dietary manager and dietician all address food related issues but the dietary manager is responsible and the alternative should be nutritionally balanced. 45564

Based on record review and interview, facility staff failed to keep eight residents (Resident #6, #11, #14, #15, #17, #38, #189 and #190) from going into a negative balance, which allowed the residents to spend another resident's money without written authorization and failed to maintain written authorization to manage funds for two residents (Resident #1 and #18). The facility census was 35. 1. Review of the facility's Management of Resident's Personal Funds policy, revised in March 2021 showed: -Should the resident elect to have the facility manage his or her personal funds, it is authorized in writing by the resident or the resident's representative, and a copy of such authorization is documented in the resident's medical record; -The resident is informed in advance of any charges imposed to his or her personal funds. 2. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #6's account went into a negative balance on the following dates: -On 04/30/22 the balance was -$37.20; -On 10/31/22 the balance was -$11.55. 3. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #11's account had a negative balance of -$10.82 in all 12 months. 4. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #14's account went into a negative balance on 01/31/22 for the amount of -$1.09. 5. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #15's account went into a negative balance on 01/31/22 for the amount of -$1.52. 6. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #17's account went into a negative balance on the following dates: -On 11/30/22 the balance was -$22.67; -On 12/31/22 the balance was -$22.67; -On 01/27/23 the balance was -$22.67. 7. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #38's account went into a negative balance on 01/31/22 for the amount of -$2.96. 8. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #189's account went into a negative balance on the following dates: -On 01/31/22 the balance was -$2.73; -On 04/30/22 the balance was -$4.62. 9. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #190's account went into a negative balance on the following dates: -On 02/28/22 the balance was -$30.00; -On 03/31/22 the balance was -$30.00; -On 04/30/22 the balance was -$30.00. 10. Review of Resident #1's medical record showed the record did not contain written authorization to manage funds for the resident. 11. Review of Resident #18's medical record showed the record did not contain written authorization to manage funds for the resident. 12. During an interview on 01/27/23 at 11:15 A.M., the Business Office Manager (BOM) said he/she just started as BOM in the past few months. He/She said a resident should not have a negative trust account balance and there should be a written authorization to manage funds in the resident's records. During an interview on 01/27/23 at 3:03 P.M., the administrator said the facility should have written authorization to manage resident trust funds and a resident's trust account should never be negative. The administrator said the BOM is responsible for managing the resident trust fund.

Based on interview and record review, the facility staff failed to ensure five Nurse Aides (NA) ( NA H, NA J, NA M, NA N and NA O) completed the nurse aide training program within four months of their employment in the facility. The census was 35. 1. Review of the facility's Nurse Aide Qualifications and Training Requirements Policy, revised May 2019, showed the following: -The facility will not employ any individual as a nurse aide for more than four (4) months full-time, temporary, per diem, or otherwise; -That individual is competent to provide designated nursing care and nursing related services; -That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; -That individual has been deemed competent as provided in 483.150(a) and (b) of the Requirements of Participation. 2. Review of NA H's personnel file showed the following: -Date of hire as an NA was 6/22/22; -No documentation the NA had completed the nurse aide training program. 3. Review of NA J's personnel file showed the following: -Date of hire as an NA was 5/11/22; -No documentation the NA had completed the nurse aide training program. 4. Review of NA M's personnel file showed the following: -Date of hire as an NA was 12/1/21; -No documentation the NA had completed the nurse aide training program. 5. Review of NA N's personnel file showed the following: -Date of hire as an NA was 9/2/21; -No documentation the NA had completed the nurse aide training program. 6. Review of NA O's personnel file showed the following: -Date of hire as an NA was 9/28/21; -No documentation the NA had completed the nurse aide training program. During an interview on 1/27/23 at 9:22 A.M., the NA said he/she was hired on 9/28/21. He/She said he/she has been working as an NA since then and has not taken classes. He/She said he/she was waiting for classes to begin in February at the facility. 7. During an interview on 1/27/23 at 8:53 A.M., the Director of Nursing said he/she was aware there were NAs working who were not certified. He/She said on-site classes were to start in February at the facility and the NAs were enrolled. During an interview on 1/27/22 at 10:36 A.M., the Administrator said he/she was aware there were five NAs working past the four month period. He/She said he/she was dreading the conversation and knew the NAs should be certified within four months of employment as an NA. He/She said he/she applied for a training license and was approved. He/She said on-site classes will begin in February.

Based on observation, interview, and record review, facility staff failed to provide oxygen as ordered by the physician for one resident (Resident #4). The facility census was 35. 1. Review of the facility's Oxygen Administration policy, revised October 2010, showed: -Verify that there is a physician's order for this procedure. Review the physician's orders for oxygen administration; -Review the resident's care plan to assess for any special needs of the resident; -Did not include usage of oxygen concentrators or BiPAP. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 01/04/23, showed facility staff assessed the resident as follows: -Cognitively intact; -Diagnoses included pneumonia, chronic lung disease, obesity, atrial fibrillation (rapid beating of upper heart chambers), coronary (heart) artery disease, heart failure; -Received oxygen while a resident and while not a resident; -Used BiPAP/CPAP while a resident and while not a resident. Review of Resident #4's Physician Orders, dated January 2023 showed an order for oxygen at five liters per minute with BiPAP (Bilevel Positive Airway Pressure - machine used to support breathing and open airways) at night or when sleeping. Pressure setting 9-13 for OSA (Obstructive Sleep Apnea - airway closure when sleeping) Review of the resident's care plan dated 1/13/23, showed the staff documented problem approaches included the following: -Apply oxygen as needed; -Ensure equipment utilized appropriately; -Assist resident with BiPAP equipment each night and ensure machine is on proper settings. Observation on 1/24/23 at 10:50 A.M., showed the resident in bed with his/her BiPAP mask on. Further observation showed the oxygen concentrator was not plugged in and was not connected to the BiPAP mask. Observation on 1/26/23 at 11:26 A.M., showed the oxygen concentrator was not plugged in and did not have tubing long enough to reach the resident. Observation on 1/27/23 at 8:42 A.M., showed the oxygen concentrator was not plugged in and did not have tubing long enough to reach the resident. During an interview on 1/24/23 at 10:52 A.M., the resident said he/she had been in the facility for about one month and had not used oxygen due to bed positioning and the number of wall electrical outlets. He/She said the oxygen is supposed to be set at five liters per minute and connected to his/her BiPAP mask. He/She also said facility staff are supposed to be working on moving the bed so the oxygen concentrator could reach an electrical outlet. During an interview on 1/25/23 at 10:23 A.M., the resident said he/she did not have oxygen connected to his/her BiPAP last night. During an interview on 1/26/23 at 11:27 A.M., the resident said he/she did not have oxygen connected to his/her BiPAP last night. He/She also said facility staff were supposed to move his/her bed to be able to plug in the oxygen concentrator. During an interview on 01/27/23 at 8:43 A.M., the resident said he/she did not have oxygen connected to his/her BiPAP last night. During an interview on 1/27/23 at 8:45 A.M., LPN C said the resident had a CPAP (Continuous Positive Airway Pressure) machine and he/she thought the oxygen was with the CPAP mask. Licensed Practical Nurse (LPN) C said the resident had used oxygen with CPAP and he/she had checked and saw the oxygen connected. After observing the oxygen concentrator was not plugged in, LPN C said he/she thought it was plugged in and connected to the CPAP mask. LPN C said the nurses are responsible for making sure oxygen is set up and used as ordered. During an interview on 1/27/23 at 8:50 A.M., the Infection Preventionist (IP) said the charge nurse is responsible for proper oxygen set up and use. He/She also said facility staff are charting that oxygen is on but they are not recognizing that oxygen is not connected. The IP said the Director of Nursing (DON) is responsible for ensuring staff have been trained. During an interview on 1/27/23 at 1:14 P.M., the DON said the night shift nurse is responsible for making sure oxygen and BiPAP are used according to doctors orders. The DON also said nurses have not had formal training on BiPAP/CPAP machines.

40424 Based on observation, staff interview, and record review, facility staff failed to provide a safe, clean, homelike and comfortable environment when staff failed to maintain resident rooms, common areas and the building structure clean and in good repair. The facility census was 35. 1. Review of the maintenance director's inspection checklist for residents' rooms for the month of January, 2023 showed rooms #12, ##13, #21, #15, #18, #34, #25, and #23 were checked off as not needing repairs or maintenance. Observation on 1/24/23 at 10:42 A.M., showed the floor of room [ROOM NUMBER] with food and debris on it. Further observation showed ants crawling on the sink and the sink vanity. The transition strip from the hall flooring into the room was tall and in disrepair. The wall trim was off and lay on the floor. Additionally, residents were observed to have difficulty pushing their wheelchairs over the floor strip. Observation on 1/24/23 at 11:00 A.M., showed the floor of room [ROOM NUMBER] with a black/brown sticky substance in the spaces between sections of flooring. Further observation showed the privacy curtain and bathroom door jams with several stains on them. Additional observation showed spilled food from breakfast on the bedside table and on the floor by the resident's bed. Observation on 1/24/23 at 11:05 A.M., showed room [ROOM NUMBER] the trim on the floor between the hallway and the resident room was damaged and raised higher then the flooring. Observation on 1/24/23 at 11:10 A.M., showed the floor of room [ROOM NUMBER] with tears in the flooring and food debris on the floor. Additional observation showed the walls and door trim were damaged. Observation on 1/24/23 at 11:18 A.M., showed the floor of room [ROOM NUMBER] with holes in the flooring material. Additional observation showed the trim in the bathroom between the wall and floor falling away from the wall. Further observation showed the transition strip on the floor between the hall and the room damaged and raised up from the floor. Observation on 1/24/23 at 11:30 A.M., showed the carpet in the nurse desk area and down the length of 100 hall to be worn and heavily stained with dark stains. During an interview on 1/27/23 at 10:08 A.M., the housekeeping regional director said he/she took over in August of 2022 and this was the first time his/her staff cleaned the carpets in this building. Observation on 1/24/23 at 2:14 P.M., showed the floor in room [ROOM NUMBER] was sticky. Additionally, the room had a strong urine odor and the floor under the toilet tank wet, the walls around the toilet were urine stained with a brown substance and rust around base of toilet. Further observation showed rust on the bathroom door frame and part of the baseboard missing. Observation on 1/24/23 at 3:01 P.M., showed the bathroom floor of room [ROOM NUMBER] was soiled and there was a brown substance around base of the toilet. Additional observation showed a square blue plastic lid with a brown substance and a toilet plunger in it next to the toilet. Observation on 1/25/23 at 10:00 A.M., of room [ROOM NUMBER], an unused shower room, showed a brown wet substance spread on the floor and soiled clothing on the floor. During an interview on 1/25/23 at 3:34 P.M. Registered Nurse (RN) G said the plumbing is out of service for room [ROOM NUMBER], an unused shower room, and should not be in use. Observation on 1/25/23 at 10:39 A.M., showed the transition strip from the hall to resident room [ROOM NUMBER] was missing and replaced with duct tape. Additional observation showed the duct tape was torn and soiled. Observation on 1/25/23 at 3:17 P.M., showed the vinyl flooring in room [ROOM NUMBER] was sticky and had tears inside the door and a hole next to the resident's bed. Additionally, there were brown splash stains on the room privacy curtain. Further observation showed the room's bathroom showed brown splash marks on the walls and floor around toilet, and rust on the bathroom door frame. Observation on 1/26/23 at 10:22 A.M., showed room [ROOM NUMBER]'s floor with food on it and a dried dark stain. Observation on 1/26/23 at 10:30 A.M., showed room [ROOM NUMBER] with a black/brown raised substance in the joints of the flooring material throughout the entire room. Observation on 1/26/23 at 10:40 A.M., showed room [ROOM NUMBER] with ants crawling on the sink and the sink vanity. During an interview on 1/26/23 at 11:18 A.M., Housekeeper B said the resident room floors are mopped and bathrooms are cleaned every day. He/She said there are not enough staff to keep up and they are trying to hire more people. During an interview on 1/27/23 at 8:21 A.M., the activity director said housekeeping staff are aware of the stains on the flooring and scrub it with cleaning supplies but the stains come back. During an interview on 1/27/23 at 8:34 A.M., the director of nursing (DON) said the existing flooring should be cleaned better while waiting on replacement flooring. During an interview on 1/27/23 at 9:00 A.M., the administrator said housekeeping staff have been given a cleaning direction list. He/She said the existing floors should have more being done to keep them clean. 2. Review of the facility's Construction/Renovations policy, dated 09/19/22, showed Where major renovations, alterations, or modernizations are made the most current applicable code shall be enforced. Review showed the policy did not include information related to the repair of damage areas of the building. Observation on 01/27/23 at 10:00 A.M., showed the door to the center core housekeeping storage room, which also contained a functional shower, unlocked and unattended by staff. Observation showed a large section of the ceiling missing in the area where staff stored a mechanical lift and floor care equipment. Observation showed insulation, wood beams and plumbing pipes exposed in the ceiling and water dripped from the exposed pipes. Observation also showed yellow caution tape draped across entrance to the area. During an interview on 01/27/23 at 10:10 A.M., the Infection Preventionist said the room had plumbing issues which he/she believed started in May 2022 and there was some issue with getting it fixed. The Infection Preventionist said the shower in the room is still used for residents, but the door to the room should be closed and locked when not in use. During an interview on 01/27/23 at 11:30 A.M., the maintenance director said the ceiling in the housekeeping storage room had been that way throughout the duration of his/her employment at the facility which began about one and a half years ago. The maintenance director said he/she had not done anything to repair the room because he/she wanted to remodel the hole room. The maintenance director said he/she did not know about the water dripping from the pipe. The maintenance director also said the door to the room should be locked and residents should not use the room for bathing. Observation on 01/27/23 at 12:45 P.M., showed a large hole in the soffit (the underside of an architectural structure) to the roof adjacent to the fire pump room. Observation showed the hole created by broken and rotted wood and the hole exposed the interior support beam and joists of the structure. During an interview on 01/27/23 at 12:45 P.M., the maintenance director said the soffit had been that way throughout the duration of his/her employment which began one and a half years ago. The maintenance director said he/she had not contacted anyone to repair the soffit and he/she had planned to fix the soffit damage him/herself, but had not had the time to do so due to other things in the facility taking higher priority. During an interview on 01/27/23 at 4:30 P.M., the administrator said the maintenance director is responsible to maintain the building structure and make repairs as needed.

40424 Based on observation, interview, and record review, facility staff failed to ensure hazardous chemicals were stored in safe manner not accessible to residents, failed to provide safe mechanical lift transfers for two residents (Residents #11 and #12) and failed to propel two residents (Residents #27 and #8) in a wheelchair in a manner to prevent accidents. The facility census was 35. 1. Review of the facility's policies provided showed the staff did not provide a policy for the storage of chemicals. Observation on 01/24/23 at 9:35 A.M., showed the door to room [ROOM NUMBER] unlocked and unattended by staff. Observation showed the room under construction and used for the storage of toxic chemicals which included paint, floor adhesive, and disinfectant spray. Observation showed residents traversed in the hallway by the room. Observation on 1/25/23 at 10:00 A.M., showed an unused shower room was unlocked and unattended by staff. Further observation showed the room contained a open pine scented cleaning solution that was within reach of residents. Observation on 01/27/23 at 10:00 A.M., showed the door to the center core housekeeping storage room, which also contained a functional shower, unlocked and unattended by staff. Observation showed a large section of the ceiling missing in the area where staff stored a mechanical lift and floor care equipment. Observation showed insulation, wood beams and plumbing pipes exposed in the ceiling and water dripped from the exposed pipes. Observation also showed yellow caution tape draped across entrance to the area. During an interview on 01/27/23 at 10:10 A.M., the Infection Preventionist said the room had plumbing issues which he/she believed started in May 2022 and there was some issue with getting it fixed. The Infection Preventionist said the shower in the room is still used for residents, but the door to the room should be closed and locked when not in use. During an interview on 01/27/23 at 11:30 A.M., the maintenance director said the ceiling in the housekeeping storage room had been that way throughout the duration of his/her employment at the facility which began about one and a half years ago. The maintenance director said he/she had not done anything to repair the room because he/she wanted to remodel the hole room. The maintenance director said he/she did not know about the water dripping from the pipe. The maintenance director also said the door to the room should be locked and residents should not use the room for bathing. Observation on 01/27/223 at 10:33 A.M., showed a 24 ounce bottle of toilet bowl cleaner with bleach and a one quart bottle of porcelain bowl and surface cleaner stored unsecured by the toilet in the shared toilet room between the activity office and resident occupied room [ROOM NUMBER]. Observation of the product label for the porcelain cleaner showed a warning that stated the product was corrosive. Observation showed the door to the activity office unlocked and unattended by staff and the resident in room [ROOM NUMBER] in bed. Observation on 01/27/23 at 10:55 A.M., showed the door to unoccupied resident room [ROOM NUMBER] unlocked and the room unattended by staff. Observation showed a one quart bottle of porcelain bowl and surface clean unsecured in the room. Observation on 01/27/23 at 11:05 A.M., showed the door to the storage room located across from the medication cart storage room unlocked and the room unattended by staff. Observation showed a can of foam fire block penetration sealer stored unsecured in the room. Observation of the product label on the can showed warnings that the products was toxic and hazardous to humans. Observation on 01/27/23 at 11:08 A.M., showed the key to the housekeeping supply room door hung exposed on the wall beside the door which allowed public access to the room. Further observation showed multiple bottles of cleaning chemicals, which included a corrosive lime descaler, corrosive commercial porcelain bowls and surface cleaner, quaternary ammonium disinfectant , glass and multi-surface cleaner, and heavy duty antibacterial cleaner. Observation of the product labels for the chemicals showed the labels contains warnings that the chemicals were toxic, hazardous to humans and/or corrosive. During an interview on 01/27/23 at 11:30 A.M., the maintenance director said the key to the housekeeping supply room had hung by the door throughout his/her employment at the facility which began about one and a half years ago and he/she was told by management that the arrangement was acceptable to the state. The maintenance director said they key hung by the door would make the contents of the room accessible to residents and there were residents in the facility that would know how to use the key. During an interview on 01/27/23 at 1:25 P.M., the maintenance director said chemicals should not be stored accessible to residents and doors to hazardous areas should self-close, lock and latch. The maintenance director said he/she did not know about the issues with the doors. During an interview on 01/27/23 at 4:30 P.M., the administrator said he/she did not have a policy for the storage of chemicals, but chemicals should be stored behind a locked door and not accessible to residents. The administrator said all staff are responsible for the proper storage of chemicals and all staff had been trained how to properly store chemicals. 2. Review of the Invacare Reliant 600 Hoyer Lift manual showed staff were directed as follows: -The legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient of the surface of the bed. When the legs of the lift are no longer under the bed return the legs of the lift to the maximum position and lock the shifter handle immediately. Review of Resident #11's annual minimum data set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for transfers. Observation on 1/24/23 at 2:00 P.M., showed Certified Nursing Assistant (CNA) F and Nursing Assistant (NA) H used a mechanical lift to transfer the resident from his/her wheelchair to his/her bed. Observation showed CNA F did not widen the lifts legs to the maximum open position when he/she lifted the resident from a wheelchair and then turned the resident. The CNA then pushed the resident to the bed where NA H assisted lowering the resident to the bed. The mechanical lift legs remained closed during the transfer. During an interview on 1/24/23 at 2:15 P.M., NA H said the legs of the mechanical lift should have been left open during the transfer from the wheelchair to the bed while the resident was suspended by the lift. Review of Resident #12's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Totally dependent on two plus staff for transfers. Observation on 1/26/23 at 10:30 A.M., showed NA H and CNA F used a mechanical lift to transfer the resident from his/her wheelchair to his/her bed. The NA spread the legs of the lift to the maximum open position and pushed the lift under the wheelchair. The CNA and NA connected the resident's lift sling and began to lift the resident. The CNA did not lock the wheelchair and the NA did not lock the mechanical lift legs causing the resident to slide out of the wheelchair before being suspended by the lift. During an interview on 1/26/23 at 10:45 A.M., NA H said he/she should have locked the wheels on the lift, but he/she just forgot to do so. During an interview on 1/26/23 at 10:54 A.M., NA J said mechanical lift legs should be spread to the open position, and the wheels of the lift should be locked. During an interview on 1/26/23 11:17 A.M., Licensed Practical Nurse (LPN) C said mechanical lift legs should be spread apart and free from obstructions during transfers and the wheels should be locked when staff are lifting the resident. During an interview on 1/27/23 at 8:18 A.M., the activity director said mechanical lift legs should always be open and the wheels locked when lifting a resident. During an interview on 1/27/23 at 8:24 A.M., CNA F said mechanical lift should have the legs spread and the wheels locked. During an interview on 1/27/23 at 8:35 A.M., the director of nursing said mechanical lift legs should be spread wide for stability during transfers. During an interview on 1/27/23 at 8:59 A.M., the administrator said mechanical lift legs should be open for stability, and the wheels of a lift should be locked when lifting the resident. 3. Review of Resident #8's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Locomotion on unit set up only. Observation on 1/24/23 at 11:45 A.M., showed CNA F propelled the resident in a wheelchair without footrest at a rapid rate from the nurse's desk down the hall to the resident's room. The residents feet slid along the flooring during the entire move. Review of Resident #27's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Locomotion on unit set up only. Observation on 1/25/23 at 10:30 A.M., showed CNA I propelled the resident in a wheelchair without footrests from the dining area to the resident's room in a rapid manner. The resident's feet slid along the floor during this move from room to room. During an interview on 1/26/23 at 10:54 A.M., NA J said wheelchairs should have footrests locked into the chair, residents should not be pushed without footrest. During an interview on 1/26/23 11:17 A.M., Licensed Practical Nurse (LPN) C said wheelchair footrests should be placed on the wheelchair when pushing a resident also staff should go slow. During an interview on 1/27/23 at 8:18 A.M., the activity director said staff should make sure the footrests are on the wheelchair and the resident's feet are on on them. During an interview on 1/27/23 at 8:24 A.M., CNA F said residents in wheelchairs should have the footrests on if staff are pushing them, and you go slow. During an interview on 1/27/23 at 8:35 A.M., the director of nursing said residents should be pushed in a wheelchair with footrests on, they should not be moved with their feet on the floor. During an interview on 1/27/23 at 8:59 A.M., the administrator said residents should be propelled with footrests on the wheelchair when going forward. 45564

Based on interview and record review, facility staff failed to implement policies and procedures to ensure 100% of staff were fully vaccinated for COVID-19 (a highly contagious virus that causes serious illness or death) or have been granted a qualifying exemption, or have a temporary delay as recommended by the Centers for Disease Control (CDC) for two employees (Certified Nurse Assistant (CNA) D and CNA D). The facility census was 35. 1. Review of facility's Covid-19 Vaccine Policies and Procedures, updated 4/22, showed: -Per the CMS Memorandum - Center for Clinical Standards and Quality/Quality, Safety & Overight Group Ref: QSO-22-09-All Date: January 14,2022: -Within 60 after the issuance of this memorandum, if the facility demonstrates that less than 100% of all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule. Review of the facility's records showed the facility had zero resident COVID-19 infections in the previous four weeks. Review of the facility's COVID-19 Staff Vaccination Record showed: -58 total staff; -2 staff without second dose; -96.6% of staff were fully vaccinated. Review of CNA D's COVID-19 Vaccination Record Card showed he/she received a Moderna Covid-19 vaccination on 2/18/22. The record did not contain documentation the staff received a second dose or had an approved exemption. Review of CNA E's COVID-19 Vaccination Record Card showed he/she received a Pfizer Covid-19 vaccination on 1/04/22. The record did not contain documentation the staff received a second dose or had an approved exemption. During an interview on 1/27/23 at 3:03 P.M., the administrator said CNA D was going to request an exemption, but had not done so. The administrator said CNA E told him/her that he/she received a second vaccine dose but could not provide documentation. The administrator said it is his/her responsibility to monitor staff COVID vaccination status.

Based on observation, interview and record review the facility staff failed to keep a safe, clean and homelike environment for residents by not fixing a leaking roof in a timely manner and having an unknown black substance in multiple areas of the facility. The facility census was 37. 1. Review of the facility's homelike environment policy, revised February 2021, showed resident's are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Review showed the facility staff and management maximizes, to the extent possible, the characteristics of the facility reflect a personalized, homelike setting. Additionally the facility is have a clean, sanitary and orderly environment. Observation on 8/8/22 at 1:35 P.M., showed unoccupied resident room #1 with multiple areas of an unknown black substance on the ceiling. Observation on 8/8/22 at 1:40 P.M., showed a black substance had grown on the ceiling, the length of the stairwell in the basement. Additional observation showed a black substance on the roof in the oxygen storage room in the basement and removed ceiling tiles that contained a black substance sat in the boiler room. Observation on 8/8/22 at 1:42 P.M.,showed unoccupied resident room #1 with multiple areas of an unknown black substance on the ceiling. During an interview on 8/8/22 at 12:55 P.M., the administrator said he/she is aware there is mold in the basement, on the ceiling in the stairwell down to the basement and in the storage room. He/She said the facility is working on dehumidifiers to help control moisture, has fans in use and the facility ordered a new air condition to help decrease condensation in the attic but it is on backorder. During an interview on 8/8/22 at 1:12 P.M., the regional consultant said the facility is trying to control the mold by ordering industrial grade dehumidifiers. During an interview on 8/8/22 at 1:40 P.M., the maintenance director said the mold in the basement has been an ongoing issue for the facility for over a year. He/She said he/she believes it is from the condensation of the air condition unit in the attic which is not properly ventilated, He/She said he/she can not get in the attic but is speculating there is mold in the attic, in addition part of the roof is leaking. He/She said he/she cleans the moldy areas with bleach water to help kill it, but it does come back. During an interview on 8/8/22 at 2:45 P.M., the maintenance director said he/she did not want to go to the length of removing sheet rock to remove the mold until the leaking water is fixed because it would just be ruined again and bleach water temporarily takes care of it. During an interview on 8/8/22 at 3:56 P.M., the environmental director said the facility has had mold and it has been in the basement for as long as he/she has worked here, over a year. He/She said the staff bleach it but it keeps coming back. He/She said all the facility laundry is done in the basement and the water from the ceiling, where it is molded, drips down on the residents clothes as they are being brought up. He/she is unsure how long the mold has been in resident rooms #1 or #3. He/She said the facility put a resident in one of the rooms and the family noticed and made them move the resident. MO 102

Based on interview and record review, facility staff failed to ensure one sampled resident (Resident #1) was free of significant medication errors when staff failed to administer the resident's [MEDICATION(S)] (opioid analgesic used for pain) in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 37. 1. Review of the facility's Administering Medications-Medications are administered in a safe and timely manner, and as prescribed policy, dated April 2019, showed: -Medications are administered in accordance with prescriber orders, including any required time frame; -Medication administration times are determined by resident need and benefit, not staff convenience; -Medications are administered within (1) hour of their prescribed time, unless otherwise specified; Review of the facility's Emergency Kit (E-Kit) System with Controlled Substances Policy, dated 2015, showed staff are to open the E-Kit by breaking the plastic seal, remove the item or items needed, and remove only enough of the medication to last until the order is filled and can be delivered. Additional review showed staff are to administer the medication as ordered. Review of Resident #1's face sheet, dated 07/25/22, showed facility staff documented the resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medication Administration Records (MAR), dated July 2022, showed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed staff documented they did not administer the medication on 7/10/22 at 6:00 A.M., 7/10/22 at 12:00 P.M., 7/10/22 at 6:00 P.M., 7/11/22 at 12:00 A.M., 7/11/22 at 6:00A.M., and 7/11/22 at 12:00 P.M. Review of the resident's nurses notes, dated 07/11/22, showed Licensed Practical Nurse (LPN) D documented the resident in bed screaming, frantic, crying, and sweating profusely. Review showed staff documented the resident had not received his/her [MEDICATION(S)] all weekend because he/she was out of the medication. LPN D documented he/she contacted hospice and received orders to give one [MEDICATION(S)] 7.5/325 mg now from the E-kit and pull two more for the scheduled 12:00 A.M. and 6:00 A.M. doses for 07/12/22 from the E-Kit. Three pills pulled from E-kit as advised. During an interview on 08/03/22 at 1:32 P.M., LPN C said normally when a resident is out of a scheduled narcotic they would pull it from the E-Kit, but that he/she did not because the resident seemed to sleep the entire two shifts for him/her, and did not appear to be in any pain. LPN C said he/she did not notify the physician, pharmacy, or hospice to report the resident had run out of his/her scheduled pain medication. During an interview on 8/8/22 at 2:24 P.M., LPN D said while he/she performed his/her rounds the resident was found to be frantic, sweating, crying, and in horrible pain so he/she went to check the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . That is when he/she saw the resident had not had any pain medication for almost 48 hours so he/she contacted the hospice nurse and they gave orders to remove three from the E-Kit, to give one now, and the other two at the next two scheduled times. LPN D said they are instructed to pull narcotics from the E-Kit anytime they run out of them if they are in the E-Kit. If it is a medicaton that is not in the E-Kit then they are to contact the pharmacy and request it and they are available 24 hours a day 7 days a week and will typically bring it out same day. Review of the resident's Controlled Drug Record, dated 06/23/22 through 07/10/22, showed staff signed out the last [MEDICATION(S)] 7.5-325 mg at 12:00 A.M., on 07/10/22. Review of the Security Lock Register, dated July 2022, showed the lock was removed on 07/11/22 and [MEDICATION(S)] 7.5/325 mg total of three tablets removed for the resident. Further review showed staff did not document any prior [MEDICATION(S)] 7.5/325 mg had been removed from the E-Kit for the resident. Review of the E-Kit contents list showed it contained [MEDICATION(S)] 7.5/325 mg quantity 10 available. During an interview on 07/25/22 at 12:15 P.M., LPN A said staff are expected to check the E-Kit if they run out of a medication and pull it from there. If it is a medication that is not in the E-kit then they are to notify the pharmacy to request it to be delivered as soon as possible. During an interview on 07/25/22 at 12:18 P.M., Registered Nurse (RN) B said if a resident was out of their pain medications then he/she would pull it from the E-Kit and would expect that to be done right away. He/She said it is not acceptable for a resident to go all weekend without their pain medications since it can either be taken from the E-Kit or the pharmacy could be notified and they would bring it to the facility the same day. During an interview on 07/25/22 at 12:45 P.M., the Administrator said if a resident was out of their pain medications then he/she would expect them to call the Doctor and either get a new script and call the pharmacy to have the medication delivered or get an order to pull the medication from the E-Kit. He/She said, No I would not expect a resident to go all weekend without their pain medication. MO 961

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Resident #2 touched Resident #1 inappropriately, by placing his/her hand under Resident #1's clothing. The facility census was 37. 1. Review of the facility's Abuse Prevention Program, updated 9/2021, showed the facility will not tolerate verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, visitors, or other residents. Review showed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended injury or harm. Sexual abuse is defined as non-consensual contact of any type with a resident. 2. Review of Resident #2's MDS, 2/02/22, showed staff assessed the resident a follows: -Moderately impaired cognitive skills for daily decision making: -Required limited, one person assistance for transfers; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Did not have any behaviors directed at others during the seven day look back period. Review of Resident #2's plan of care, dated 11/17/21, showed staff documented the resident had difficulty making his/her own decisions related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review showed staff documented the resident can display verbal and physical aggression as well as sexually inappropriate behaviors, and documented on 7/14/21 the resident is visually impaired and is unable to recognize object or people, and is usually unaware of where he/she grabs people or objects. Review showed staff interventions to redirect the resident as needed, ensure the resident is six feet away from residents of the opposite sex due to sexually inappropriate behavior, and monitor for inappropriate sexual behavior. Review showed staff documented the resident was sexually inappropriate with a resident on 8/09/21 and 4/07/22. 3. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 2/23/22, showed staff assessed the resident with the following: -short and long term memory problems; -moderately impaired cognitive skills for daily decision making; -required extensive assistance and one to two person assistance for Activities of Daily Living (ADLs); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's plan of care, dated 12/02/21, showed staff are directed to preserve the resident's dignity and self-esteem by minimizing the risk for anxiety, agitation, and inappropriate behaviors. 4. Review of the facility investigation, dated 4/07/22, showed Certified Nurse Aide (CNA) A documented he/she witnessed Resident #2 inappropriately touch the private area of Resident #1. Review showed CNA B documented he/she heard Resident #1 yelling, and noted Resident #2's hand under Resident #1's clothing. CNA B documented at that time, Resident #1 said, I'm good. Review of Resident #1's nurses' notes, dated 4/07/22, showed staff documented the resident was in the day room when Resident #2 put his/her hand underneath Resident #1's clothing. Review showed staff documented when interviewing the resident shortly after the incident, and he/she did not recall the incident. Observation on 4/08/22, at 10:20 A.M., showed Resident #1 in a reclining wheelchair in the day room. During an interview at that time, the resident said no residents had been inappropriate with him/her. During an interview on 4/08/22, at 10:12 A.M., the MDS Coordinator said Resident #1 does not have a guardian or any family or friends involved in his/her care. During an interview on 4/08/22, at 10:45 A.M., the Social Service Director (SSD) said Resident #1 does not have a guardian or any family or friends involved in his/her care. He/She said the Public Administrator is in the process of obtaining guardianship over the resident. Review of Resident #2's nurses' notes, dated 4/07/22, showed staff documented the resident put his/her hand under Resident #1's clothing, and staff immediately separated the residents from one another. Review showed when staff asked Resident #2 about the incident, the resident stated he/she did not do it. Staff documented interventions will include the resident last up for meals, and serving the resident's meals in a separate dining room with no residents of the opposite sex. During an interview on 4/08/22, at 9:15 A.M., the administrator said Resident #2 has not had any sexually inappropriate behaviors since August, 2021. At that time, they moved the resident to a locked unit, with all same sex residents. She said they opened the locked unit approximately one month ago. The administrator said staff are directed to monitor Resident #1 when he/she was in common areas. She said neither resident remembered the incident immediately afterwards, and Resident #2 denied inappropriately touching Resident #1. During a telephone interview on 4/08/22, at 11:45 A.M., CNA A said staff are directed to monitor Resident #2 when he/she in common areas. He/She said staff were assisting other residents when he/she heard Resident #1 yell. He/She said the resident did not yell any words. He/She said he/she saw Resident #2 with his/her hand under Resident #1's clothing, and immediately separated the residents. MO 520

Based on observation, interview, and record review, facility staff failed to answer call lights in a timely manner for two dependent sampled residents (Resident #3 and #4), when staff turned off the resident's call light, and did not return to provide the resident with needed assistance. Staff failed to provide appropriate incontinence care for one dependent sampled resident (#4). The facility census was 65. 1. Review of the facility's call light policy, revised March of 2021, showed if a resident needs assistance, indicate approximate time it will take you to respond. Review showed if the resident's request is something you can fulfill, complete the task within five minutes if possible, if you are uncertain as to wether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. If assistance is needed when you enter the room, summon help by using the call signal. 2. Review of Resident #3's annual Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Moderately impaired cognition; -Extensive physical assist of one person with bed mobility, dressing and hygiene; -Total of two person physical assist with toilet use; -Total of one person physical assist with bathing; -Always incontinent of Bowel and Bladder. Review of the resident's plan of care, dated 11/29/21 , showed staff are directed to anticipate resident's needs and pay attention to nonverbal cues. Observation on 12/13/21 at 5:50 A.M., showed the resident's call light on. Further observation at 5:51 A.M., showed Certified Medication Technician (CMT) D entered the resident's room and turned off call light. The CMT said, Just give us a minute, then left the room. Additional observation showed the CMT went to another room to answer the call light, then to a different room to provide care. The CMT did not return to original resident's room. Observation on 12/13/21 at 6:06 A.M., showed the resident in his/her bed without a blanket. The resident said he/she pushed the call light because he/she needed a blanket. Observation on 12/13/21 at 6:10 A.M., showed CMT D left another resident's room and went to the nurse's station. The CMT did not return to Resident #3's room to assist the resident. Observation 12/13/21 at 6:24 A.M., showed the resident asleep in his/her bed. The resident did not have a blanket on him/her. Observation on 12/13/21 at 7:18 A.M. through 7:53 A.M., showed the resident in his/her bed without a blanket. During an interview on 12/13/21 at 7:21 A.M., Licensed Practical Nurse (LPN) A said call lights should be answered as soon as possible. LPN A said CMT D had to leave the facility for a minute, so that's were the breakdown was. During an interview on 12/13/21 at 7:54 A.M., CMT D said he/she got busy getting people up. He/She said he/she was looking to get someone to help get the resident up because he/she uses a mechanical lift. The CMT said he/she didn't know why he/she went to the next resident. 3. Review Resident #4's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Limited, one person physical assist with bed mobility; -Total, two person physical assist with transfers; -Extensive, one person physical assist with dressing and hygiene; -Range of Motion (ROM) impairments to both sides of lower extremities; -Modified independence with cognition; -Always incontinent of Bowel and Bladder; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's plan of care, revised 10/27/21, showed staff are directed to care for care for resident as follows; -Answer call light promptly; -Resident is at risk for breakdown, due to incontinence and inactivity; -Provide incontinence pad of choice; -Resident wants bed pads changed when needed and the resident is able to alert staff; -Resident's dignity will be preserved through next review period. Observation on 12/13/21 at 6:00 A.M., showed the resident's call light on. Additional observation showed LPN A entered the resident's room, turned off call light, and left the room. During an interview on 12/13/21 at 6:08 A.M., the resident said the pad on his/her bed is wet and needs changed. The resident said he/she pushed the call light, staff answered it and did not change the pad. Observation at this time showed the room had an odor of urine. Observation on 12/13/21 at 6:29 A.M., the LPN told CMT D, he/she needed him/her to hang out and answer call lights. Observation on 12/13/21 at 6:44 A.M., showed the resident's room with an odor of urine. Further observation showed the resident pushed the call light again. At 6:48 A.M. CNA E entered the residents room. The resident said he/she still needed his/her pad changed. CNA went out into hall and brought the resident a clean pad for the resident's bed. During an interview on 12/13/21 at 6:56 A.M., the resident said he/she waited 45 minutes for staff to change his/her bed pad after he/she pushed the call light The resident said he/she usually waits 20 minutes and then pushes his/her call light again. The resident said he/she usually waits 20 to 40 minutes. During an interview on 12/13/21 at 7:21 A.M., LPN A said staff should have been in the resident's room sooner. The LPN said he/she should have double checked with the resident to make sure it was done. The LPN said he/she thinks he/she told CMT D to assist the resident. During an interview on 12/13/21 at 7:54 A.M., CMT D said the LPN did not tell him/her the resident needed changed. The CMT said as soon as a call light goes off it should be answered. MO 256

Based on observation, interview and record review, facility staff failed to properly sanitize mechanically washed dishes to prevent cross-contamination. Facility staff failed to allow clean dishes to air dry prior to stacking in storage or use to prevent the growth of food-borne pathogens. Facility staff failed store food in a manner to prevent cross-contamination and out-dated use. Facility staff failed to store cleaning cloths in a manner to prevent cross-contamination and the growth of food-borne pathogens. Facility staff failed to wash their hands as often as necessary to prevent cross-contamination during mechanical washing of soiled dishes. Facility staff failed to maintain the kitchen floors in a clean and sanitary manner to prevent the growth of bacteria and potential harborage of pests. Facility staff failed to reheat mechanically processed foods to an internal temperature of 165 degrees Fahrenheit (° F) prior to service to prevent the growth of food-borne pathogens that can lead to food-borne illness. Facility staff failed to maintain the internal temperature of hot foods placed in the steamtable at a minimum temperature of 135° F during service to the residents. Facility staff also failed to maintain the internal temperature of hot foods served to residents in their rooms at 120° F or higher at the time of service. The facility census was 30. 1. Review of the facility's Dishwashing: Machine Operation policy dated 2016, showed the policy directed staff as follows: -All dishwashing machines should be operated according to manufacturer recommendations. Tableware, utensils, and pots and pans should be cleaned and sanitized in either a high-temperature dishwashing machine that uses hot water, or a chemical-sanitizing dishwashing machine that uses a chemical sanitizing solution. -Check the dishwashing machine each morning before first set of dishes are to be washed. This is usually before the breakfast meal and again in the PM or generally before the supper meal. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. Check the dials to ensure that the wash and rinse cycles are achieving proper temperature per manufacturer guidelines. If a chemical sanitizer is used, check the concentration using the correct test tape for type of sanitizer in use. If not at the correct hot water temperature or the proper chemical sanitizing concentration, do not proceed to wash dishes. Empty dishwashing machine, check nozzles and empty bottom screen and restart the dishwashing machine. Review of the facility's Sanitizing Solution policy dated 2016, showed the policy directed staff as follows: -If a dispensing system is used it will be tested daily to ensure solution is dispensed at the appropriate concentration level. -Bleach solution should be at a concentration of greater than or equal to 50 to 100 ppm or in accordance with label instructions for other types of sanitizers. Observation on 11/17/20 at 9:15 A.M., showed Cook J washed soiled dishes in the chemical sanitizing mechanical dishwasher. Observation showed a chlorine based sanitizer connected to the dishwashing machine and the area did not contain a chlorine sanitizer test kit. Further observation showed, when asked for a test kit for the mechanical dishwasher, the Dietary Manager (DM) provided a quaternary ammonium sanitizer kit. Review of the sanitization logs for the mechanical dishwasher located on the wall across from the dishwasher, showed staff last documented the concentration of the chlorine based sanitizer as 50 parts per million (ppm) on 09/20/20. During an interview on 11/17/20 at 11:10 A.M., the Dietary Consultant said the facility did not have a chlorine sanitizer test kit. Observation on 11/18/20 at 8:50 A.M., showed a full sheet pan inside the mechanical dishwasher. Observation showed the area did not contain a chlorine sanitizer test kit. Further observation showed the bucket for the chlorine sanitizer connected to the dishwasher was empty. Observation after a full cycle of the mechanical dishwasher, showed the ppm concentration of the sanitizer did not register when tested with a chlorine sanitizer test strip. Observation on 11/18/20 at 9:20 A.M., showed Cook J washed soiled dishes in the mechanical dishwasher. Further observation showed the bucket of sanitizer connected to the dishwasher remained empty. During an interview on 11/18/20 at 9:20 A.M., the cook said he/she had never checked the concentration of the sanitizer in the dishwasher, he/she had never been shown how to check the sanitizer, and he/she did not know what a chlorine sanitizer test kit looked like. During an interview on 11/19/20 at 11:52 A.M., the administrator said anyone in dietary that uses the dishwasher should check its operation. The administrator said he/she would expect staff to check the chemical buckets daily and check the sanitizer concentration with a test strip and log the results. The administrator said the DM had been training staff on the use of test strips. 2. Review of the facility's Dishwashing: Machine Operation policy dated 2016, showed the policy directed to Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage. Observation on 11/17/20 at 9:30 A.M., showed nine metal food preparation pans stacked together wet on the shelf beneath the toaster. Further observation showed three additional metal food preparation pans stacked together wet on the storage shelf near the steamtable. Observation on 11/17/20 at 9:32 A.M., showed Cook J removed the food processor from the clean side of the mechanical dishwashing station while wet and placed it back on the base in the upright position for use. Observation on 11/17/20 at 9:35 A.M. showed 18 plastic service trays, 18 insulated plate holders stored in the upright position and 10 insulated dome plate covers stored in the upside down position, stacked together wet on the countertop next to the steamtable. Further observation showed, when turned right-side up, pooled water streamed out from inside the insulated dome plate covers. Observation on 11/17/20 at 9:48 A.M., showed Cook J dried a plastic food storage container with a towel and placed it on the shelf. During an interview on 11/17/20 at 9:48 A.M., the cook said he/she had worked in this kitchen since September and knew dishes should be air dried, but he/she was in a hurry. During an interview on 11/17/20 at 9:50 A.M., the DM said dishes should be air dried and not stacked together wet. Observation on 11/17/20 at 11:35 A.M., showed Dietary Aide (DA) K removed three white compartment plates from the clean side of the mechanical dishwashing station while wet and placed them on the storage rack in the upright position. Observation on 11/17/20 at 12:45 P.M., showed Cook J used the three white compartment plates to serve prepared pureed food to residents at the noon meal. Observation on 11/17/20 at 11:55 A.M., showed Cook J picked up the food processor from the clean side of the mechanical dishwashing station while wet, placed it on its base and then used the food processor to prepare the pureed pork for service at the noon meal. During an interview on 11/19/20 at 11:56 A.M., the administrator said dishes should be air dried prior to storage and not dried with a towel or used while wet. The administrator said staff should be trained on this requirement upon hire and he/she would expect the dietary manager to monitor dish storage daily. 3. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy dated 2016, showed the policy directed staff as follows: -All food items will be labeled. The label must include the name of the food and date by which it should be sold, consumed, or discarded. -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. -Never leave any food item uncovered and not labeled. Review of the facility's Labeling and Dating Foods (Date Marking) policy dated 2016, showed the policy directed staff as follows: -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. -Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Once a package is opened, it will be re-dated with the date the items was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. -Prepared food or opened food items should be discarded when: *The food item does not have a specific manufacturer expiration date and has been refrigerated for seven days *The food item is leftover for more than 72 hours *The food item is older than the expiration date Observation 11/17/20 at 9:40 A.M., showed the following in the dry goods storage pantry: -two boxes of baking soda opened to the air and undated; -a one gallon bottle of barbeque sauce opened and undated; -a one gallon bottle of distilled vinegar opened and undated; -a 124 ounce (oz.) bottle of pancake syrup opened and undated; -a 16 oz bag of whipped topping mix opened to the air and undated. Observation on 11/17/20 at 9:42 AM, showed a plastic bag of frozen omelettes opened the air and undated in the reach-in freezer. Observation on 11/17/20 at 9:46 A.M., showed a 32 oz. carton of frozen orange juice and two 46 oz. cartons of apple juice opened and undated in the reach-in refrigerator. Observation on 11/17/20 at 9:50 AM, showed plastic storage containers of fruit whirls, krisp rice, raisin bran and cornflake cereals undated on the countertop across from the reach-in refrigerator. Further observation showed a plastic storage container of cheerios dated 1/3/20 on the countertop. During an interview on 11/17/20 at 9:50 A.M., the Dietary Consultant said the containers of cereal should be dated and the date on the container of cheerios was not the correct date of the last batch put in the container. Observation on 11/17/20 at 9:52 A.M., showed the following in the reach-in refrigerator by the cook's food preparation sink: -a one pound block of butter opened to the air; -two five pound bags of shredded cheddar cheese opened and undated; -a plastic resealable bag of yellow American cheese slices opened and undated; -two plastic resealable bags of white American cheese slices opened and undated; -a plastic resealable bag of an unidentified dark colored luncheon meat opened to the air and undated; -a one gallon container of ranch dressing opened and undated; -a one gallon container of sweet pickle relish opened and undated; -a one gallon container of french dressing opened and undated; -a one gallon container of yellow mustard opened and undated; -a one gallon container of pickle slices opened to the air and undated; -a one gallon container of barbeque sauce opened and undated; -an 8.5 pound container of salsa opened and undated; -two bottles of soy sauce opened and undated; -an unidentified container of food wrapped in aluminum foil and undated. During an interview on 11/17/20 at 9:53 A.M., the Dietary Consultant said opened food items should stored covered and dated. During an interview on 11/19/20 at 12:01 P.M., the administrator said food should be stored at appropriate temperatures and in an appropriate place. The administrator said opened food items should be stored in sealed containers, labeled and dated. The administrator said the dietary manager is responsible for monitoring food storage at least daily and dietary staff are trained on proper food storage upon hire. 4. Review of the facility's Sanitizing Solution policy dated 2016, showed All rags used for sanitizing must be kept in sanitizing solution when not in use. Observation on 11/17/20 at 10:05 A.M. showed a soiled wet cleaning cloth on a service cart next to stacks of disposable food bowls. Observation on 11/17/20 from 11:05 to 12:00 PM, showed a soiled wet cleaning cloth on the countertop in front of the microwave and two soiled wet cleaning cloths on the countertop by the steamtable. During an interview on 11/19/20 12:05 P.M., the administrator said staff cleaning cloths should be stored in the dirty rag bin or in a bucket of sanitizer when not in use. The administrator said dietary staff should be trained on this requirement upon hire. 5. Review of the facility's Proper Hand Washing and Glove Use policy dated 2016, showed All employees will wash hands upon entering the kitchen from another location, after all breaks (including bathroom and smoking breaks), and between all tasks. Hand washing should occur at a minimum of every hour. Review of the facility's Dishwashing: Machine Operation policy dated 2016, showed the policy directed staff to use clean, washed hands to pull out clean racks from the dishwashing machine. Observation on 11/17/20 from 11:20 A.M. to 11:26 A.M., showed DA K washed dishes at the mechanical dishwashing station. Observation showed on multiple occasions, without washing his/her hands, the DA put away dishes from the clean side of the station. Observation on 11/17/20 at 11:38 A.M., showed the DA washed dishes at mechanical dishwashing station. Further observation showed, without washing his/her hands, the DA put away dishes from the clean side of the station. During an interview on 11/17/20 at 11:26 A.M., the DA said he/she had worked at the facility for about a month and he/she had not been trained on handwashing procedures. The DA said staff should wash their hands when they leave and enter the kitchen and between handling dirty and clean dishes. The DA said he/she just did not think to wash his/her hands. During an interview on 11/19/20 at 12:12 P.M., the administrator said staff should wash their hands when visibly soiled, between task, handling cooked to raw food items, before leaving kitchen and when entering, between handling dirty and clean dishes. The administrator said staff are trained on handwashing procedures upon hire, quarterly and as needed. 6. Review of the facility's Cleaning Rotation policy dated 2016, showed the policy directed staff to clean kitchen floors daily. Observation on 11/17/20 at 9:15 A.M. showed an accumulation of dirt and debris on the floor under the mechanical dishwashing station. During an interview on 11/17/20 at 9:38 A.M., the DM said he/she became the dietary manager two weeks ago. The DM said when he/she started there were a lot of things that had not been done in the kitchen, including cleaning, and he/she was in the process of trying to get all of that fixed. Observation on 11/17/20 at 10:10 A.M., the kitchen did not contain a posted cleaning schedule. Further observation showed an excessive accumulation of trash and debris, including dirty plastic cups, plastic silverware, a clip board, and a pile of cloth towels on the floor behind the reach-in refrigerator and chest freezer. Review also showed an accumulation of trash and debris behind the reach-in refrigerator near the cook's area. During an interview on 11/19/20 at 12:08 P.M., the administrator said the kitchen has a cleaning schedule they are suppose to follow. The administrator said the DM is responsible to set out the cleaning schedule and instruct staff when cleaning is to be done. The administrator said he/she goes to the kitchen daily and he/she often checks on things. The administrator said he/she identified that the floors needed cleaned last week and he/she did not know why staff had not cleaned the floors after he/she identified the issue. The administrator said the DM is new and is still being trained. 7. Review of the facility's Pureed Food Preparation Policy dated 2016, showed the following: -Standardized recipes will be used to prepare all pureed foods. -Pureed foods will be heated to a minimum of 165° F before serving and used or discarded within two hours. -Staff will be in-serviced on proper preparation of pureed foods. Observation during the initial kitchen tour on 11/17/20 beginning at 9:15 A.M., showed the kitchen did not contain standardized recipes for texture modified food items. Further observation showed, when asked about the recipes, the DM and Dietary consultant left the kitchen and returned with a binder that contained the texture modified recipes. Observation showed the Dietary Consultant placed the binder of recipes on the countertop next to the food processor. Review of the recipes for pureed mixed greens and pureed autumn pork roast dated 2020, showed the recipes directed staff to reheat the pureed products to 165 ° F for at least 15 seconds prior to service. Observation on 11/17/20 at 11:45 A.M. showed Cook J placed heated prepared spinach into the food processor to prepare the pureed mixed greens for service at the noon meal. Observation showed the cook scraped the pureed spinach into a pan and, without checking the internal temperature of the pureed product, placed the pan on the steamtable. Further observation showed the internal temperature of the pureed spinach measured 147° F when placed on the steamtable. Observation showed the cook did not review the recipe for pureed mixed greens before or during the preparation of the pureed product. Observation on 11/17/20 at 11:55 A.M., showed Cook J placed an unmeasured amount of heated prepared autumn pork roast and cold tap water into the food processor to prepare the pureed autumn pork roast for service at the noon meal. Further observation showed the cook scraped the pureed pork into a pan and, without checking the internal temperature of the pureed product, placed the pan onto the steamtable. Observation showed the internal temperature of the pureed autumn pork roast measured 115° F when placed on the steamtable. Observation showed the cook did not review the recipe for pureed autumn pork roast before or during the preparation of the pureed product. During an interview on 11/17/20 at 11:58 A.M., the cook said no one showed him/her how to puree food and he/she had never seen recipes for pureed foods. Observation on 11/17/20 at 12:20 P.M., showed the internal temperature of the pureed spinach at the time of service measured 161° F. Further observation showed the internal temperature of the pureed autumn pork roast at the time of service measured 117° F. During an interview on 11/19/20 at 12:16 P.M., the administrator said staff should follow the pureed recipe guide to prepare pureed food items. The administrator said processed foods should be reheated to 165° F before they are placed on the steamtable. The administrator said staff should be trained on food preparation and service upon hire and how to use the menus and recipes. 8. Review of the facility's Monitoring Food Temperatures for Meal Service policy dated 2016, showed the policy directed staff to reheat prepared food items to 165° F for a minimum of 15 seconds prior to service if the serving/holding temperature of a hot food item is not at 135 ° F or higher. Review of the facility's Standardized Recipes policy dated 2016, showed Standardized recipes will be used for all menu items, including pureed and therapeutic diets. Observation during the initial kitchen tour on 11/17/20 beginning at 9:15 A.M., showed the kitchen did not contain standardized recipes for texture modified food items. Further observation showed, when asked about the recipes, the DM and Dietary consultant left the kitchen and returned with a binder that contained the texture modified recipes. Observation showed the Dietary Consultant placed the binder of recipes on the countertop next to the food processor. Review of the recipe for ground autumn pork roast dated 2020, showed the recipe directed staff to reheat the ground product to an internal temperature of 165° F for at least 15 seconds Observation 11/17/20 at 11:55 A.M., showed Cook J placed an unmeasured amount of heated prepared autumn pork roast into the food processor to prepare the ground autumn pork roast. Observation showed the cook scraped the ground pork into a pan and, without checking the temperature of the ground pork, placed the pan on the steamtable. Observation showed the internal temperature of the ground pork measured 134 ° F when placed on the steamtable. Observation showed the cook did not review the recipe for ground autumn pork roast before or during the preparation of the ground pork. During an interview on 11/17/20 at 11:58 AM, the cook said he/she had never seen recipes for mechanical soft foods. Observation on 11/17/20 at 12:20 PM, showed the internal temperature of the ground autumn pork roast at the time of service measured 150° F. During an interview on 11/19/20 at 12:16 PM, the administrator said staff should prepare all food items in accordance with the recipes. The administrator said processed foods should be reheated to 165° F before they are placed on the steamtable. The administrator said staff should be trained on food preparation and service upon hire and how to use the menus and recipes. 9. Review of the facility's Monitoring Food Temperatures for Meal Service policy dated 2016, showed the policy directed staff to reheat prepared food items to 165° F for a minimum of 15 seconds prior to service if the serving/holding temperature of a hot food item is not at 135 ° F or higher. Observation on 11/17/20 at 12:20 P.M., showed the internal temperature of the mashed potatoes at the time of service measured 130° F. During an interview on 11/19/20 at 12:16 P.M., the administrator said the temperature of hot foods should be between 135 and 140° F while in steamtable. The administrator said staff should be trained on food preparation and service upon hire. 10. Review of the facility's In-Room Dining policy dated 2016, showed Food temperatures of hot foods on room trays at the point of service are preferred to be at 120° F or greater to promote palatability for the resident. Observation on 11/17/20 at 12:20 P.M., showed the internal temperatures of the autumn pork roast on the steamtable measured 147° F. Further observation from 12:20 P.M. to 12:40 P.M., showed Cook J prepared room trays for service. Observation showed the cook placed food items on unheated plates, covered the top of plates with insulated plate holders (bottom portion of insulated dome plate covers used to hold the plates), and placed the plates on plastic service trays on a wheeled cart. Observation showed dietary staff wheeled the cart of room trays out to the dining room at 12:40 P.M. where nursing staff then prepared and placed beverages on the trays before taking the cart to the hall. Observation at 12:50 P.M., showed nursing staff delivered the cart to the hall and began to pass the trays. Observation showed the internal temperature of the autumn pork roast measured 101° F upon service. During an interview on 11/19/20 at 12:16 P.M., the administrator said the temperature of hot foods should at least 120°F upon service to the residents. The administrator said staff are supposed to use both the plate holder and dome cover for room trays and they have been trained to do so.

Based on observation, record review, and interview, facility staff failed to provide a safe and homelike environment when staff failed to remove shards of glass from a resident's room window and failed to ensure a hot stand light was not accessible to the residents. The facility census was 30. Review of the facility policy, Maintenance Service, dated 12/2009, showed the following: - The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe manner at all times; - Functions of the maintenance personnel includes maintaining the building in good repair and free from hazards. Review of the facility's policy, Safety and Supervision of Residents, dated 7/2017, showed the following: - Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; - Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. Observation on 11/17/20 at 11:30 A.M., showed an electrical wire on the floor in the dining room/common area. Additional observation showed the electrical wire attached to an outlet on one end and had a wire cap in the other end. Further observation showed residents and staff present in the area near the wire. Observation on 11/18/20 at 12:50 P.M., showed an open window in the dining room/common area and the window did not have a screen. Further observation showed an open window in the business office and the window did not have a screen. Observation on 11/17/20 at 11:30 A.M. and 11/18/19 at 2:23 P.M., showed a portable stand work light stood in the dining room near the resident tables. Additional observation showed the lights were on and stood at elbow height. The lights radiated heat and were very hot to the touch. Further observation showed residents were present in the dining room and sat at tables around the lights. Observation on 11/18/20 at 1:27 P.M., showed the window in room [ROOM NUMBER] was broken and covered with plastic and duct tape. The plastic hung loosely from the window frame, and the window was accessible. Broken glass was present in the window pane, and shards of glass were present in the window sill. A resident bed was positioned near the window, and a resident sat in his/her wheelchair in the room. Review of the facility's resident roster showed two residents lived in the room. During an interview on 11/18/20 at 1:35 P.M., the Maintenance Director said the window was broken a month ago. He has submitted a request to Corporate Office for the repairs and was waiting for an approval to fix the window. The Maintenance Director also said the broken glass should have been removed from the window and the window sill. The shards of glass were a hazard to the resident. During an interview on 11/18/20 at 2:23 P.M., the Maintenance Director said the portable work light was brought into the dining room for additional lighting and should not be accessible to the residents. He was aware the light produced heat and was hot to the touch. The Maintenance Director said the electrical wire should not be accessible to residents, and he expects staff to report the wire so it could be fixed. The Maintenance Director said he did not know that open windows should be screened. During an interview on 11/19/20 at 3:35 P.M., the administrator said the Maintenance Director is responsible to check windows weekly to ensure they are intact and functional. The administrator said the Maintenance Director should also ensure the windows have screens. The administrator said the Maintenance Director should report any missing window screens or windows that need to be replaced to him/her. The administrator said he/she was not previously aware of the broken window in the resident's room. The administrator said he/she expects the Maintenance Director to remove any pieces of broken glass upon discovery. During an interview on 12/4/20 at 2:15 P.M., the administrator said it is expected for staff to report any hazard accessible to residents so the hazard can be removed or fixed. She expects the staff to report the downed electrical wire and the stand light if they noticed it was hot.

Based on observation, interview and record review, facility staff failed to prepare and serve food in accordance with nutritionally calculated menus for four residents (Residents #10, #12, #22 and #28) who received a pureed diet. The facility census was 30. 1. Review of the facility's The Dining Experience: Objectives policy dated 2016, showed Meals will be planned to meet the nutritional adequacy and according to the resident's plan of care, while not limiting the resident's right to make personal choices. Residents will be guided by staff to select well-balanced meals for good health. Any resident who is assessed to not be capable of making informed serving choices will receive the meal as planned according to the menu spreadsheet and individualized meal card. Review of Resident #10's Minimum Data Set (MDS) (federally mandated assessment completed by facility staff), dated 09/09/20, showed staff assessed the resident as follows: -[DIAGNOSES REDACTED].>-brief interview for mental status (BIMS) score of 99 (unable to complete one or more questions of the interview); -moderately impaired decision making regarding tasks of daily life; -required extensive assistance with eating. Review of the resident's meal tray card showed staff were directed to provide the resident with double portions of a pureed diet. Review of Resident #12's MDS dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED].>-BIMS score of 3 (severe impairment); -required limited assistance with eating. Review of the resident's meal tray card showed staff were directed to provide the resident with a pureed diet. Review of Resident #22's MDS dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED].>-severely impaired decision making regarding tasks of daily life; -totally dependant on staff for eating. Review of the resident's meal tray card showed staff were directed to provide the resident with a pureed diet with nectar thickened liquids. Review of Resident #28's MDS dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED].>-severely impaired decision making regarding tasks of daily life; -totally dependant on staff for eating. Review of the resident's meal tray card showed staff were directed to provide the resident with double portions of a pureed diet. Review of the facility menus dated 11/17/20 (Week 3, Day 17), showed staff were directed to provide the residents pureed diets with a #12 (2.6 ounce) scoop of pureed mixed greens and a #20 (1.6 ounce) scoop of pureed buttered white bread. Observation on 11/17/20 during the noon meal service beginning at 12:20 PM, showed Cook J served Resident #12 and Resident #22 a #8 (four ounce) scoop of pureed spinach (1.4 ounces more than directed by the menus). Observation showed the cook served Resident #10 and Resident #28 two #8 scoops of pureed spinach (more than directed by the residents' diets). Further observation showed the cook did not prepare or service Residents #10, #12, #22 and #28 the pureed buttered white bread as directed by the menus. During an interview on 11/17/20 at 12:55 P.M., Cook J said staff are directed to serve food in accordance with the menus. The cook said staff do not ask the residents who receive pureed diets what they want to eat and they are to be served what is on the menu. The cook said he/she thought the menus said a #12 for the pureed spinach and he/she did not see the pureed buttered bread on the menu. During an interview on 11/19/20 at 12:16 P.M., the administrator said staff should prepare all food items in accordance with the recipes and serve food as directed by the menus. The administrator said staff should be trained on food preparation and service, including how to use the menus and recipes, upon hire.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #9) remained free of mental abuse when staff forced the resident to shower against his/her will, resulting in bruising and failed to ensure one resident (Resident #1) remained free of verbal abuse when staff yelled at and threatened the resident. The facility census was 40. Review of the Facility's Abuse Prevention Program, updated (YEAR), showed the following: -Zero tolerance of verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, visitors, or other residents; -Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; -Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but not limited to, threats of harm, saving things to frighten a resident; -Mental abuse includes, but not limited to humiliation, harassment, and threat of punishment or deprivation. 1. Review of Resident #9's quarterly minimum data set (MDS), an federally mandated assessment instrument, dated 6/6/18, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Physical and verbal behaviors present 1-3 days; -Rejected care 1-3 days; -Required extensive assistance of one staff for bed mobility and dressing; -Required extensive assistance of two or more staff for transfers and toileting; -Required limited assistance of one staff for personal hygiene, and physical help in part of bathing activity; -Totally dependent on one staff for locomotion; -Always incontinent of bowel and bladder. Review of the resident's plan of care, updated on 11/29/17, showed staff documented: -The resident frequently refuses to take showers, will hit and curse at staff and non compliant with staff; -The resident sometimes will refuse to let staff change him/her when soiled; -Please make sure the resident's hands and nails are clean as he/she tends to scratch self on bottom; -Encourage resident to wash, rinse, and dry the areas of his/her body that are within physical ability; -Can be verbally abusive to staff and other residents; -Offer opportunities for choice, simplify instructions,be flexible, and patient, and encourage involvement in daily life; -If behaviors occur assess for underlying causes and alert physician immediately. During an interview on 5/25/18 at 11:40 A.M., Certified Medication Technician (CMT) C said the resident was frequently incontinent and refused showers. The resident goes up to 3 weeks at times without showers. On 5/22/18 the resident was covered in his/her own feces. The feces covered his/her back, in his/her hair and under his/her finger nails from scratching his/her buttocks. CMT C said several staff approached the resident through out the day asking him/her to shower. Each time the resident became upset and refused. Staff educated him/her on the importance of being clean and having good hygiene. Staff offered additional snacks, drinks and smoke breaks but each time the resident became upset and still refused to shower. Staff decided to give the resident a shower regardless of his/her refusals and did not try alternate methods of bathing. CMT C and CNA D transferred the resident to a shower chair and transported him/her to the shower room. The resident was very upset, yelling at the staff and swinging/hitting them on the way to the shower room. The resident continued to be very upset, yelling and hitting at staff during the shower. CMT C said they asked Registered Nurse (RN) A to come and assist with the shower since the resident was being so combative and hitting at the staff. CMT C said RN A placed the resident's arms in his/her lap, placed towels over the arms and waist area and then RN A placed his/her hands on top of the towels to control the resident's resistance and swinging. CMT C said the resident received bruises on the top of his/her forearms from swinging his/her arms against the wall and shower chair during the shower. Observation and interview on 5/25/18 at 12:30 P.M., showed the resident sat in his/her wheelchair. The resident appeared calm. The resident had several large splotchy red bruises on the top of his/her forearms. When asked about the bruises the resident said that[***] (RN A) grabbed me. The resident was unable to recall where or when it occurred and did not recall having a shower. During an interview on 5/25/18 at 3:10 P.M., CNA D said she/he was asked to assist with the resident's shower on 5/22/18 due to the resident being covered in feces and he/she refused to shower. CMT C and CNA D assisted the resident to the shower room. The resident was swinging and cussing at the staff. RN A came in a little later to assist. The resident was upset yelling and hitting at staff throughout the shower. The resident seemed to be more upset with RN A. RN A placed towels over the resident's arms and mid section to try to prevent harm from the resident swinging and hitting at staff, walls and shower chair. During an interview on 5/25/18 at 3:30 P.M., RN A said he/she felt it was neglectful to allow the resident to remain in the soiled condition he/she was in. RN A was worried about skin breakdown, unsanitary conditions for the resident to eat, due to feces under the fingernails and health risks associated with poor hygiene. RN A assisted CMT C and CNA D with the resident's shower. The resident was yelling, cursing and swinging at staff. RN A placed towels over the resident's arms and mid section, and then placed open hands on top of the towels, to try to prevent harm from the resident swinging and hitting at staff, walls and chair. RN A said he/she did not apply pressure to the resident's arms. RN A was not aware of the resident's bruising until later. During an interview on 5/25/18 at 4:00 P.M., the Administrator said the resident was incontinent and refused to allow staff to clean him/her up or take a shower. On 5/25/18 the resident was covered in feces, up his/her back, in his//her hair, under finger nails and had a terrible body odor. The Administrator did not feel it was abuse to force the resident to shower against his/her wishes. During an interview on 5/31/18 at 1:00 P.M., the resident's physician said facility staff did not contact him/her until after the incident and the Physician was only told that the resident became pretty belligerent in the shower. The physician said he has since spoken to the facility and ordered the resident to have a beer before shower time since that seemed to work with the resident years ago. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/23/18 , showed staff assessed the resident as follows: -Moderate cognitive impairment; -No behaviors; -Independent with bed mobility transportation, and locomotion on unit; -Required limited assistance of one staff member for dressing; -Always continent of bowel; -Frequently incontinent of bladder. Review of the resident's plan of care, last updated 6/5/18, showed the resident was prone to agitation, aggression, paranoia, and delusions due to dementia and facility staff were directed to do the following: -Provide medication as ordered; -Provide with psychiatric evaluation as needed; -Notify charge nurse if he/she showed increased agitation during care due to refusal to change soiled clothing; -Keep posture opened versus closed and maintain intermittent eye contact; -Maintain a distance, do not crowd; -If possible do not touch the resident, always prepare the resident if you are going to touch him/her; -Assess for underlying cause of behaviors and immediately notify the physician; -If the resident refused care leave and approach him/her later and he/she will usually comply. Review of the resident's nurses notes, dated 6/10/18, showed staff documented they were notified that the resident had been outside smoking cigarette and had a large bowel movement on himself/herself and it was running down his/her leg. Staff took him/her to his/her room to be changed. The resident was cooperative and went to his/her room, but when he/she got there, he/she wanted to lay down instead of being changed. Certified Nurses Assistant (CNA) stated he/she told him/her that he/she needed to be changed and could not get into bed yet because it was all over him/her. The resident became angry because he/she could not lay down at that time. In the bathroom doorway the resident got in the CNA's face, clinched his/her fist, and stated he/she was going to knock the staff member out. The CNA stated before he/she could think he/she stated if you do I will slap the F out of you. Supervisors at facility were notified and told to send the CNA home until further notice. Review of Registered Nurse (RN) A written statement dated, 6/9/18, showed RN A documented on 6/9/18 he/she was outside supervising the residents during the 8 P.M. smoke break and he/she overheard what sounded to be an argument. He/She said all he/she could hear was a female voice and a male voice but could not understand what was being said. He/She said then suddenly a female voice shouted you have[***]running down your leg and a brief pause then heard a female yell, I'll slap the [***] out of you. RN A said he/she immediately ran inside and went to the residents room and opened the door. CNA B was standing by the door and Resident #1 was ambulating on his/her own. RN A stated to CNA B I heard what he/she stated. CNA B admitted he/she made the comment but stated the resident threatened him/her first. The DON was immediately called and aid was taken of the unit and sent home. Review of CNA B's statement, dated 06/09/18, showed he/she documented he/she had Resident #1 come to his/her room because he/she was dirty and the resident told him/her that he/she was going to sit on the bed. CNA B documented he/she asked the resident not to. The resident called him/her a [***] and that he/she would knock the [***] out of me and he/she document he/she said the same to him/her. Lost my head. Review of the facility's Resident Abuse/Neglect Investigation Report, dated 6/10/18, showed staff documented Registered Nurse (RN) A reported he/she was outside with the smoking residents when he/she heard a female voice state I will slap the [***] out of you. RN A immediately went to the unit to confront the CNA who admitted stating that to Resident 1. Review showed staff documented the incident occurred 6/9/18 at 8:30 P.M. and was verbal abuse. Further review of report showed staff documented CNA B admitted to stating he/she would slap the [***] out of Resident A. The summary of the investigation showed CNA B was verbally abusive to Resident #1 and will be terminated. During an interview on 6/10/18 at 10 A.M., RN A said on 6/9/18 he/she was outside in front of the building supervising the smoking residents at the 8 P.M. smoke break. RN A said all of a sudden he/she and the residents that were outside smoking heard yelling and screaming between a man and a woman. Then the women very loudly screamed I'm going to slap the [***] out of you. RN A said he/she could tell it was a woman and it was on the unit about 2-3 windows down by the drain on the outside of the room. RN A said he/she ran inside to the unit and opened the door to the resident room and CNA B said what, then turned to see it was the nurse and said oh. RN A said CNA B admitted to telling the resident I'm going to slap the [***] out of you. RN A said the resident was assessed and there was no injuries and CNA B was sent home. He/She said he/she called and notified the Director of Nursing (DON) about 8:20 P.M., who called CNA B and sent her home and then called RN A back and told him/her the staff member was suspended for 3 days. RN A said he called the administrator on 6/10/18 and notified her of what happened the night prior and she was not aware of the situation prior to that. During an interview on 6/10/18 at 10:11 A.M., Resident #2 said he/she heard a black lady tell a resident he/she would smack the[***]out of him. He/She said the lady was very loud. Resident #2 said CNA B was the black lady who yelled at the resident. He/She said CNA B always wants to work by herself. During an interview on 6/10/18 at 10:12 A.M., Resident #3 said on 6/9/18 at the 8 P.M. smoke break he/she heard a female say I'm going to slap the crap out of you then there was some cussing. The resident said the charge nurse ran inside at that time. During an interview on 6/10/18 at 10:17 A.M., Resident #4 said on 6/9/18 at the 8 P.M. smoke break he/she was outside and heard some one say I'm going to knock the [***] out of you. The resident said it was a loud woman's voice and very threatening. The resident said the nurse ran in and he/she heard some yelling after the nurse went in but could not make out what was said. During an interview on 6/10/18 at 10:20 A.M., Resident #5 said on 6/9/18 at the 8 P.M., smoke break he/she was outside smoking. The resident said he/she heard yelling coming from the unit about three rooms down. The resident said the yelling got louder and louder and there was cussing. The resident said it was very threatening. The resident said he/she heard a female say I will slap the [***] out of you and she was mad. The resident said he/she knew it was a woman. During an interview on 6/10/18 at 10:26 A.M., Resident #7 said on 6/9/18 at the 8 P.M., smoke break he/she was outside smoking. The resident said all of a sudden he/she heard screaming and yelling and then CNA B said I'm going to slap the [***] out of you. The nurse then ran inside and there was some more yelling that he/she could not understand. The resident said he/she knows CNA B's voice. During an interview on 6/10/18 at 10:44 A.M. Resident #8 said on 6/9/18 at the 8 P.M., smoke break he/she was outside smoking. He/She said he could hear women yelling at each other. Then one woman was keep your hands off me. The resident said there were lots of F you's and what the hell are you doing. During an interview on 6/10/18 at 11:08 A.M., the Director of Nursing (DON) said she was informed on 6/9/18 Resident #1 was outside smoking and had poop running down his/her leg. The staff member CNA B got the resident to come in to the bathroom and started to get the resident cleaned up then the resident put his/her fist up and said I will knock the F out of you and the CNA B said If you do I will slap the F out of you. The DON said CNA B was able to change the residents gown and then took the resident to the TV room. CNA B then called the DON and told her what had happened herself. The DON said he/she told CNA B to let RN A know he/she had to go home and to write a statement and that state would be called to do an investigation. The DON said CNA B called her at 8:21 P.M. and the nurse called at 9 P.M. The DON said she thinks CNA B was just caught off guard, but she sent her home. The DON said he/she thought he/she did not have to report it in 2 hours if there wasn't any injury. During an interview on 6/10/18 at 11:14 A.M., The administrator said RN A said on 6/9/18 that he/she was outside supervising the smoking residents at the 8 P.M. smoke break and he/she heard shouting and heard CNA B say he/she was going to slap the[***]out of someone. The administrator said RN A said he/she then ran into the unit. The administrator said RN A said CNA B was in the room with Resident #1 and he/she confronted him/her and CNA B admitted to it. The Administrator said they started their investigation on 06/09/18 and CNA B wrote his/her statement. The Administrator said she thought it was verbal abuse and the DON should have reported it to the administrator and should have been reported within 2 hours to DHSS. During an interview on 6/12/18 at 1:11 A.M., CNA B said Resident #1 had a bowel movement on the back of his/her pants and he/she went to clean the resident up. CNA B said the resident got up in his/her face and said, [***] if you don't get the [***] out of my face I'm going to knock the [***] out of you. CNA B said he/she then said, I'm going to knock the [***] out off you, to the resident. CNA B said he/she finished cleaning the resident up and put him/her in bed. CNA B said the charge nurse heard commotion and came in and told him/her they could hear him/her outside and walked out of room. CNA B said he/she then called the DON and wrote a statement and went home. CNA B said the DON told him/her he/she was suspended for just three days when he/she first spoke with the DON. CNA B the DON called him/her on 06/12/18 and said he/she was terminated. CNA B said he/she did not hit the resident and did apologize, I just got heated up and should not have said that. MO 528, MO 572

Based on observation, interview and record review the facility failed to notify the physician about an abnormally high INR (blood test used to measure clotting time) in a timely manner. Licensed staff did not call the physician but faxed the INR result to his/her office and CMT (Certified Medication Technician) staff administered the evening [MEDICATION NAME] (blood thinner) dose despite the elevated INR. DHSS staff prompted the facility staff to obtain a stool sample to test for blood and the results showed positive for blood. Licensed staff faxed the physician and did not call the physician to inform him of the positive result. The facility census was 45. 1. Review of Resident #9's Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/12/13 showed the facility staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, personal hygiene; -Incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Constipation; -Received an anticoagulant medication in the last seven days. Review of the resident's comprehensive care plan dated 5/21/13 directed staff on the following interventions for risk of bleeding: -Monitor lab values as ordered by physician, report to physician when results become available; -Observe for blood in the stool or urine, report to physician if noted; -PT(blood thinning medication)/INR as ordered; -Observe for bleeding gums during oral care; -Notify charge nurse of any bruising or swelling. Review of the Physician's Order Sheet (POS) dated 8/2013 showed Physician M ordered [MEDICATION NAME] 4.0 mg (milligrams) daily at bedtime and a PT/INR weekly. Review of the resident's laboratory report dated 8/6/13 at 4:00 PM showed the resident's INR measured 4.8 (high). Review showed the report listed the therapeutic range as 2.5-3.5. Staff did not call the physician with the result (which measured as high), but instead faxed the results to the physician's office. Review of the resident's nurses' note dated 8/6/13 showed staff did not record an assessment of the resident to monitor for symptoms of abnormally high INR which include bleeding and or bruising. Review showed the notes do not contain any information to show staff reported the abnormal lab result to the resident's Physician. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. at bedtime (during the evening hours). Staff did not hold the resident's [MEDICATION NAME] even though the resident's INR was abnormally high. Review showed the resident Physician faxed the facility on 8/7/13 and directed staff to "Hold" the resident's [MEDICATION NAME]. Review of the resident's nurses' note dated 8/7/13 showed staff did not record an assessment of the resident to monitor for symptoms of abnormally high INR, which include bleeding and or bruising. Review showed the notes do not contain any information to show staff reported the abnormal lab result to the resident's Physician. Observation on 8/8/13 at 11:30 A.M. showed LPN K received a phone call from the laboratory to notify the facility of the resident's critically high INR of 6.5. Further review showed the laboratory report stated "anything above 5.1 is considered critical." During this time, LPN K attempted to contact the resident's Physician through a hospital page but was not successful. LPN K did not inform hospital staff of the resident's critically high INR. LPN K then faxed the results to the resident's Physician. During an interview on 8/8/13 at 2:30 P.M., LPN K said Physician M faxed an order at 2:30 to hold the resident's [MEDICATION NAME]. Review of the resident's Daily Bowel Movement record showed staff recorded the resident has large loose bowel movements on 8/7 and 8/8/13. Observation on 8/8/13 at 2:45 P.M. showed CNA staff approach the nurses' desk and told LPN K they provided the resident incontinence care "three to four times in the last 45 minutes due to diarrhea." LPN K responded "OK", but did not assess the resident. During an interview on 8/8/13 at 3:30 P.M. with the DON, DHSS staff asked if staff had checked the resident's stools for the presence of blood. The DON said the facility has stock supplies to perform occult blood test on stool specimens, but staff would not conduct that test without a Physician's order. During an interview on 8/8/13 at 3:45 P.M. LPN K said he/she faxed the resident's Physician and requested an order to test the resident's stool for the presence of blood (occult blood test). LPN K said the facility policy required licensed staff to obtain an order for [REDACTED]. LPN K said he/she did not have a response from Physician M, but performed the test to check for blood in the resident's stool and it showed a "positive" result. LPN K faxed the Physician reporting that the resident's stool specimen tested positive for the presence of blood. Facility staff did not call the physician with the positive results but waited for the physician to return the call. At 4:30 P.M. Physician M called and ordered staff to check the resident's stool for blood three more times, lab test of complete blood count (CBC), and to continue to monitor for changes. Review of the resident's CBC laboratory report dated 8/8/13, showed the resident's hemoglobin measured low as 9.2 (normal reference range is 11.5-16.0 gm/dl.) Review of the resident's CBC laboratory report dated 8/13, showed the resident's hemoglobin continued to measure low at 10.4 (reference range as listed above). Observation on 8/8/13 at 8:10 P.M. showed the resident lay in bed incontinent of loose stool. CMT L entered the resident's room to check the resident for incontinence. CMT L asked CNA I to assist the resident with his/her incontinence. During an interview at this time CMT L said he/she did not know anything about a Physician's order to check the resident's stool for the presence of blood. During an interview on 8/8/13 at 8:45 P.M. CNA I said he/she "just" provided incontinent care for the resident and did not collect a specimen or report the resident's loose stool to the charge nurse. CNA I said he/she did not know anything about checking the resident's stool for the presence of blood and had not been directed to notify charge nurse staff when the resident had a BM. Licensed staff did not inform the direct care staff of the need to collect a stool specimen as directed by the Physician. During an interview on 8/8/13 at 2:30 P.M. the DON said she expects licensed staff to call the Physician and report any critical laboratory results. The DON said staff are not expected to fax Physician's with any critical lab reports. The DON said she expects staff to notify the physician before they administer a dose of [MEDICATION NAME] to a resident with a elevated INR. During an interview on 8/8/13 at 2:50 P.M. Physician M said staff should have called him instead of faxing him with the resident's PT results of 4.8. The Physician also said staff should always call critically high laboratory results and if he is not available there is "always a Physician on-call." Review of the facility Policy and Procedure (undated) titled Physician Notification RE: Resident Change of Condition, shows staff are directed to: Immediate Notification: The physician should be informed at the time the event occurs either directly or by beeper. Assessment: The nurse should not hesitate to contact the physician at any time for a problem which in their judgement requires immediate medical attention. Implementation: Attempts to notify a physician should take place in the following order: -Attending physician -Alternate physician -DON or administrator assessment of urgency -Medical Director -For situations requiring immediate action, contact the hospital emergency room and request transport Conditions that require immediate notification are as follows: -Uncontrolled bleeding or repeat episode within 24 hours (bloody stools not from hemorrhoids, gross bloody urine); -INR of 4.0 or higher (hold [MEDICATION NAME]) NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility inserviced nurses regarding reporting high INR levels/change in condition to the physician by telephone instead of by facsimile. Staff implemented an anticoagulant flow sheet to track residents receiving the medication. Staff placed Resident #9 on fifteen minute checks to monitor for additional changes in condition. Inservices to nurses will be ongoing until all licensed staff are inserviced. This will be discussed in facility quality assurance meetings on an ongoing basis. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the " D " level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility staff failed to provide interventions to prevent the elopement of one sampled resident (Resident #1). Facility staff did not ensure one door leading to an outdoor fenced area on the facility's locked behavior unit remained locked when staff were not directly supervising the residents. In addition, facility staff failed to provide supervision for three additional sampled residents (Resident #2, #3, and #4) on the secured unit to prevent elopement. The facility census was 41. 1. Review of Resident #1's Physician order [REDACTED]. care unit (SCU), a locked unit of the facility. Review of the resident's nurses notes showed staff documented the following: - On 6/27/12 at 8:00 A.M. applied a wander alert bracelet on the resident's right wrist for safety. - On 6/27/12 at 10:15 A.M. obtained a physician order [REDACTED]. Review of the resident's Elopement Risk Assessment, dated 08/04/12, showed staff assessed the resident at risk for elopement due to: - "pertinent [DIAGNOSES REDACTED]. - independent ambulation; - medications that increased restlessness and agitation; - and family or responsible party that voiced concern regarding tendencies for wanting to leave the facility. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment used for planning care, dated 8/14/12, showed staff assessed the resident with the following: - Impaired cognitive skills for daily decision making; - Required supervision (oversight, encouragement, or cueing) with walking in corridor, locomotion on/off the unit, eating, and personal hygiene; - Functional limitations of all extremities. Review of the resident's care plan, last reviewed on 8/14/12, showed staff assessed the resident at risk for elopement related to poor impulse control. Staff planned the following interventions related to safety concerns: - Provide a room on the special care unit; - Complete an elopement assessment quarterly and as needed; - Assist and observe resident in courtyard during nice weather; - Allow to ambulate freely on unit; - Notify charge nurse of any attempts and/or verbalizations of eloping observed; - Apply a wander alert bracelet - check and record once daily for function and every shift for placement. Further review of the resident's care plan showed on 9/12/12 staff added the following related to resident safety: -Place on 15 - 30 minute condition checks. Review of the resident's POS, dated 09/15/12, showed [DIAGNOSES REDACTED]. Review of the resident's nurses notes, dated 10/08/12, showed staff documented the following: - At 2:00 P.M.- "notified by Certified Nurse Aide (CNA) that resident had been in the secured unit dining room at about this time and by a couple of minutes past two o'clock heard the gate alarm going off. Grounds and room searched and were unable to find the resident;" -At 2:10 P.M.- notified sheriff's department; -At 3:00 P.M.- building on lock down; -At 3:39 P.M.- notified guardian of the resident's elopement; -At 4:45 P.M.- staff found the resident and highway patrol returned him/her to the facility. During an interview on 10/09/12 at 10:18 A.M., the administrator said the facility social service director was on foot and found the resident less than a mile by foot, but driving a little less than five miles from the facility. The resident said he/she was chilly and hungry, but did not have any injuries. Review of weathersource.com showed the temperature in the area on 10/08/12 between 2:00 P.M. and 5:00 P.M. ranged between 60.1 degrees Fahrenheit and 59.0 degrees Fahrenheit. During an interview on 10/10/12 at 11:15 A.M., the resident said he/she left the faciity on [DATE] because, "I am tired of this place and just wanted to go for a walk". During an interview on 10/10/12 at 11:35 A.M. CNA A said he/she was off the unit showering another resident. When he/she returned to the unit he/she met CNA B coming out of a resident room after providing incontinent care. CNA A said that they heard an alarm going off and both responded to the sound of the alarm. The unalarmed door leaving the dining room to the outdoor fenced area was open. They went out the door and approached the gate to the courtyard. The courtyard gate was open and the string alarm on the gate was sounding. CNA A searched the area outside the gate while CNA B returned to the unit and searched for missing residents. CNA A said he/she searched the area outside the gate and did not see anyone, so he/she returned to the unit. He/she said they then determined Resident #1 was missing. The CNA A said they immediately notified the charge nurse. The CNA said normally the unalarmed door is kept locked unless monitored by staff. He/She said the key to the door used on the unit was missing, and they had to borrow a key from the charge nurse off the unit every time they needed to lock and unlock the door. During an interview on 10/10/12 at 1:00 P.M. CNA B said that he/she was in the dining room area with seven residents (including Residents #1, #2, #3, #4) when another resident was incontinent and had to be taken to his/her room to be changed. The CNA said that he/she knew the dining room door to the courtyard was unlocked and the second CNA on duty left the unit to shower a resident. CNA B said after he/she completed incontinent care for the resident and returned to the hallway, he/she heard an alarm sounding. He/She said CNA A just returned to the unit and they both responded to the alarm. CNA B said they found the unalarmed dining room door and the courtyard gate open with the gate alarm sounding. CNA B said he/she returned to the unit to search for missing residents while CNA A searched outside the gate. The CNA said during the search of the unit he/she determined Resident #1 was missing. The CNA said staff normally locked the courtyard door if staff did not monitor the door. He/She said the key to the door used on the unit was missing, and they had to borrow a key from the charge nurse located off the unit every time they needed to lock and unlock the door. During an interview on 10/10/12 at 1:15 P.M., the resident said he/she knew the door was not locked on 10/08/12 before he/she left the facility. During an interview on 10/10/12 at 1:55 P.M., CNA C said their normal practice was to keep the door leading to the courtyard area locked unless staff directly supervised the door for resident safety. During an interview on 10/10/12 at 1:43 P.M. both CNA A and CNA B said the key on the unit had been missing for about three weeks. They said they left the door unlocked since about 9:00 A.M. the day the resident eloped. They said the routine for the past few weeks was to leave the door unlocked most of the day as it placed them in a "sticky situation" having to leave the unit to get the key to lock and unlock the door throughout the day. During an interview on 10/10/12 at 1:50 P.M., the administrator said the door leading to the fenced area off the unit did not have a wander alert alarm and would not sound if a resident with a wander alert bracelet exited through the door. The administrator said she expected staff to keep the door to the courtyard area of the unit locked at all times when not monitored to prevent accidents and elopements. She said staff did not report to her the key to the door was missing. She said there were extra keys to that door available. 2. Review of Resident #2's Elopement Risk Assessment, dated 08/04/12, showed staff assessed the resident at risk for elopement due to the following: - cognitive impairment; - "pertinent [DIAGNOSES REDACTED]. - history of leaving facility without informing staff; - independent ambulation; - verbally expressed the desire to go home, packed belongings to go home, or stayed near exit doors; - wandered aimlessly; - required medications that increased restlessness and agitation. Review of the resident's care plan, last reviewed on 9/4/12, showed staff assessed the resident as an elopement risk with interventions to place on special care unit and apply wander alert bracelet, check every shift for presence and function. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment used for planning care, dated 9/10/12, showed staff assessed the resident as follows: - Impaired cognitive skills for daily decision making; - Disorganized thinking; - Experienced delusions and behavioral issues; - Rejected care; - Required supervision (oversight, encouragement, or cueing) with bed mobility, walking in corridor, locomotion on/off the unit, eating, and toilet use; - Required limited (one person) assistance with dressing and personal hygiene: - [DIAGNOSES REDACTED]. - Took antipsychotics, antianxiety, and antidepressant medications (increase fall risk). Review of the resident's Fall Risk Assessment, dated 9/10/12 showed staff assessed the resident at 12, with 10 or greater considered high risk for falls. Review of the resident's Physician order [REDACTED]. care unit (SCU), a locked unit of the facility. 3. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment used for planning care, dated 8/14/12, showed staff assessed the resident as follows: - Impaired cognitive skills for daily decision making; - Required supervision (oversight, encouragement, or cueing) with walking in corridor, locomotion on/off the unit, eating, and personal hygiene; - Functional limitations of all extremities. Review of the resident's Elopement Risk Assessment, dated 09/5/12, showed staff assessed the resident at risk for elopement due to: - "pertinent [DIAGNOSES REDACTED]. - risk of leaving facility without informing staff; - independent ambulation; - wandered aimlessly; - required medications that increased restlessness and agitation. Review of the resident's care plan, dated 9/8/11, showed staff assessed the resident as an elopement risk with interventions to place including locate on the special care unit and apply wander alert bracelet, check every shift for presence and function. Review of the resident's Fall Risk Assessment, dated 9/10/12 showed staff assessed the resident at 14, with 10 or greater considered high risk for falls. Review of the resident's Physician order [REDACTED]. care unit (SCU), a locked unit of the facility. 4. Review of Resident #4's Elopement Risk Assessment, dated 08/11/12, showed staff assessed the resident at risk for elopement due to: - cognitive impairment; - "pertinent [DIAGNOSES REDACTED]. - "unknown risk" of leaving facility without informing staff; - independent ambulation with or without an assistive device; - wandered aimlessly; - required medications that increased restlessness and agitation. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment used for planning care, dated 8/16/12, showed staff assessed the resident as follows: - Impaired cognitive skills for daily decision making; - Exhibited signs/symptoms of delirium (inattention and disorganized thinking); - Altered moods; - Exhibited wandering behaviors that place the resident at risk; - Required supervision (oversight, encouragement, or cueing) with walking in corridor; - Required limited (one person) assistance with bed mobility, transfers, and locomotion on/off the unit; - Required extensive (one person) assistance dressing, eating, toilet use, and personal hygiene; - Unsteady with balance during transitions and walking: - [DIAGNOSES REDACTED]. - and takes antipsychotics, antidepressants (increase fall risk). Review of the resident's care plan, dated 8/16/12, showed staff assessed the resident as an elopement risk with interventions planned including placement on the special care unit and application of a wander alert bracelet, check every shift for presence and function. Review of the resident's Fall Risk assessment dated [DATE] showed staff assessed the resident at 26, with 10 or greater considered high risk for falls. Review of the resident's Physician order [REDACTED]. care unit (SCU), a locked unit of the facility. Please note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. A monitoring visit was completed on October 10, 2012. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. Staff implemented frequent monitoring for Resident #1. Staff have replaced the key that the CNAs on the unit carry and implemented a sign out system for the key at the end of each shift. Staff provided inservice education for nurse aide staff and direct care providers which is ongoing until all staff are addressed. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a D grid level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address the Class I violation. MO 776

Based on observation and interview, staff failed to provide care to prevent avoidable accidents when transferring one resident with a history of skin tears into his/her wheelchair without leg rests attached causing the resident to scrape his/her skin on a rough edged metal peg resulting in a laceration requiring hospital treatment. Additionally, staff failed to implement safe storage of potentially hazardous chemicals in the common bath/shower rooms of the facility. The facility census was 32. 1. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/3/11, showed staff assessed the resident as; - Some cognitive deficit; - Extensive assistance and one person physical assist for transfers, dressing, toilet use, and hygiene; - Occasionally incontinent of bowel; - Frequently incontinent of bladder. Review of the resident nurses notes showed: -6/24/11- Staff transferred the resident from the weight chair to the resident's wheelchair and the resident cut his/her left shin on his/her wheelchair. The resident's scraped hi/her left leg which showed "profuse bleeding." The nurses notes showed staff called the ambulance and transferred the resident to the hospital. Review of the resident's nurses' notes dated 6/24/11 showed staff readmitted the resident to the facility at 7:25 PM, after hospital evaluation and treatment for [REDACTED]. During an interview on 7/22/11 at 11:15 AM CNA C said he/she transferred the resident from his/her weight chair to his/her wheelchair on 6/24/11. CNA C said the resident "cut" his/her left leg on the metal area where the foot rest normally fits. CNA C said during this time the resident's wheelchair did not have foot rests. Review of the residents most recent plan of care dated 5/3/11, directed staff to provide the following care to the resident: - Provide assistance and oversight with activities of daily living (ADS's); - Resident has a history of status ulcer (open skin areas due to poor circulation); - Resident is at risk for skin breakdown; - Resident is a fall risk and needs assistance with mobility for transfers; Further review of the resident's care plan dated 5/3/11, showed staff are to help the resident remain free of injury related to his/her use of blood thinners. The care plan does not contain any information to show staff updated the plan with any information to address placing the resident's foot rest on the wheelchair to prevent additional injury. Review of the resident's physician's orders [REDACTED]. -Keep the leg elevated as much as possible; Observation on 7/19/11 at 12:00 noon showed the resident sat in the dining room eating lunch. During this time both the resident's feet sat on the floor in front of his/her wheelchair. Observation showed the resident's left leg was not elevated as directed by the Physician. Additionally, the metal peg used to hold a foot rest was not covered to prevent additional skin tears. Observation on 7/19/11 at 5:30 PM showed the resident sat in the dining room eating supper. During this time both the resident's feet sat on the floor in front of his/her wheelchair. Observation showed the resident's left leg was not elevated as directed by the Physician. Additionally, the metal peg used to hold a foot rest was not covered to prevent additional skin tears. Observation made 7/20/11 at 1:30 P.M. and 2:30 P.M., showed the resident in his/her room with both feet on the floor. During this time the resident's wheelchair did not have leg rests (extenders that attach to the wheelchair and can be used to elevate or extend the legs) attached. Additionally, the metal peg used to hold a foot rest was not covered to prevent additional skin tears. Observation on 7/21/11 at 12:15 PM showed the resident sat in the dining room eating lunch. During this time both the resident's feet sat on the floor in front of his/her wheelchair. Observation showed the resident's left leg was not elevated as directed by the Physician. Licensed staff in the dining room did not assist the resident to elevate his/her left leg as directed by the physician to promote healing and prevent further decline. Staff did not cover the metal peg used to hold the leg rest to prevent additional injury when the resident transfers in and out of the wheelchair. Additional observation during this time showed the resident's wheelchair leg rests sat in the resident's room closet on the floor. During an interview on 7/22/11 at 11:15 A.M., the Director of Nursing (DON) said the resident is often "non compliant" with keeping his/her foot up in the leg rest on his/her wheel chair. Observation on 7/21/11 at 9:30 A.M., showed the resident in his/her room, sitting in his/her wheel chair with his/her foot elevated up in the wheel chair foot rest. During an interview at this time, the resident said he/she is "comfortable" with his/her left leg elevated on the foot rest. Observation made 7/20/11 at 1:30 P.M. and 2:30 P.M., showed the resident in his/her room with both feet on the floor. The leg rest for the residents chair sat in the resident's closet. Staff did not cover the metal peg used to hold the leg rest to prevent possible injury when the resident transfers in and out of the wheelchair. During an interview on 7/22/11 at 11:15 A.M., the Director of Nursing (DON) said the resident has a history of stasis ulcers on his/her shin area. He/she said the resident is often non compliant with using a foot rest. During an interview on 7/22/11 at 11:15 A.M., CNA C said the resident at times uses her leg rest and other times does not. CNA C said he/she did not know any information about a physician's orders [REDACTED]. In an interview on 7/21/11 at 9:30 A.M. the resident said she felt comfortable in this position and said it is good for her foot to be up. Staff did not cover the foot rest pegs with any protective covering to prevent further skin tears. 2. Observation on 07/19/11 at 6:00 P.M., showed the following uncovered items on a wheeled cart, located in unlocked shower/bathroom #22: - One 12 ounce container of incontinence prevention cream - directions showed for external use only; - One 1 pound container of zinc oxide ointment - directions showed to avoid contact with eyes; for external use only; if swallowed, get medical help or contact poison control center right away; - One 7 fluid ounce bottle of after shave - directions showed to keep away from children; flammable; keep from heat and flame; do not use while smoking; contains SD Alcohol 39-C; - One 9 fluid ounce bottle of classic splash after shave - directions showed to keep away from children; for external use only; flammable; contains SD Alcohol 40-B; - One 3.5 ounce deodorant body spray - directions showed to avoid spray in eyes and excessive inhalation; do not use on broken skin; inhaling contents can be harmful or fatal; contains SD Alcohol 40-B. Additional observation showed a one gallon container of perineal and skin cleanser, located on the floor of this bath/shower room. The observation showed this container's directions showed the following: - For external use only; - Avoid contact with eyes; - Keep out of reach of children. 3. Observation on 07/19/11 at 6:05 P.M., showed the following uncovered items on a wheeled cart, located in unlocked shower/bathroom #23: - One 11 ounce container of shaving cream - directions to keep out of reach of children; do not puncture or incinerate; contents under pressure. Contains cetyl alcohol, propane - Container of moisturizing skin lotion - directions to avoid contact with eyes; discontinue if irritation occurs; for external use only. Additional observation showed a one gallon container of shampoo/body wash, located on the floor of this shower room. The observation showed this container's directions showed for external use only. Observation on 07/20/11 at 8:57 A.M. showed the bath/shower room #23 remained open and accessible to residents. Further observation showed the room still contained the uncovered hazardous chemicals accessible to residents. Observation on 07/20/11 at 10:30 A.M. showed the bath/shower room #22 remained open and accessible to residents. Further observation showed the room still contained the uncovered hazardous chemicals accessible to residents. Observation on 07/21/11 at 2:41 P.M. showed the bath/shower room #23 remained open and accessible to residents. Further observation showed the room still contained the uncovered hazardous chemicals accessible to residents. Observation on 07/22/11 at 8:30 A.M. showed the bath/shower room #22 remained open and accessible to residents. Further observation showed the room still contained the uncovered hazardous chemicals accessible to residents. 4. During an interview on 07/22/11 at 11:00 A.M., the DON said he/she expects facility staff to cover or place lids on all containers and potentially hazardous chemicals that are accessible to residents. Furthermore, the DON said facility staff should store potentially hazardous chemicals in a locked cabinet.