Every finding on record at Sikeston Convalescent Center

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 64.Review of the facility's policy titled, Sanitization, revised November 2022, showed:- The food service area is maintained in a clean and sanitary manner;- All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracked and chipped areas that may affect their use or proper cleaning;- All equipment, food contact surfaces, and utensils are cleaned and sanitized;- The policy did not address refrigerator and/or freezer defrosting. Review of the facility's policy titled, Food Receiving and Storage, revised November 2022, showed:- Foods shall be received and stored in a manner that complies with safe food handling practices;- Dry foods and goods are handled and stored in a manner that maintains the integrity of the package until they are ready for use;- Dry foods that are stored in bins are removed from original packaging, labeled and dated, (use-by date). Such foods are rotated using a first in - first out system;- All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date);- Refrigerated foods, are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. 1. Observation on 03/31/26 at 9:44 A.M., and 04/01/26 at 8:53 A.M., of the walk-in freezer next to the five-shelf metal rack showed:- Two uncovered glasses of milk not labeled or dated;- A bag of shredded cheese not labeled or dated;- A rubber seal around the door frame unattached and hung loose. 2. Observation on 03/31/26 at 9:51 A.M., and 04/01/26 at 8:59 A.M., of the dishwashing machine showed:- Three worn scour pads lay on top;- A dirty squeegee lay on top;- An open bottle of testing strips lay sideways on top;- A buildup of a hard white substance on the top and side surfaces. 3. Observation on 03/31/26 at 9:59 A.M., and 04/01/26 at 9:06 A.M., of the kitchen floors showed:- Dirt and debris under the steam table;- Dirt and debris under a table with a coffee maker and coffee supplies;- Dirt, debris, and food particles under and behind the stove;- Dirt and debris under and around the deep fryer;- A grease-like substance around the stove and deep fryer area. 4. Observation on 03/31/26 at 10:09 A.M., and 04/01/26 at 9:11 A.M., of the walk-in freezer located inside the canned/dry goods area showed:- A buildup of ice/frost on a plastic resealable bag of meat patties not labeled or dated;- A buildup of ice/frost on a plastic resealable bag of meat patties not sealed;- A buildup of ice/frost on a large brown paper bag of potato fries not sealed, labeled, or dated. Review of the Maintenance Log, dated 01/01/26 - 04/03/26, showed:- No documentation of the unattached rubber seal around the door frame of the walk-in freezer was addressed. During an interview on 04/03/26 at 9:37 A.M., the Maintenance Supervisor (MS) said the maintenance log was for all staff to use when something needed to be repaired. Nothing had been brought to his/her attention regarding the repair of an unattached rubber seal hanging from one of the walk-in freezer doors in the kitchen. During an interview on 04/03/26 at 9:52 A.M., [NAME] A said the kitchen floors should be cleaned and free of grease, dirt, and debris. Kitchen equipment should be cleaned after each use for sanitation purposes. Food items should be labeled and dated when opened and placed back into the freezer. Maintenance should be notified of any issues regarding kitchen repairs. During an interview on 04/03/26 at 9:59 A.M., the Dietary Manager (DM) said the kitchen floors should be cleaned and free of grease, dirt, and debris. Kitchen equipment should be cleaned after each use for sanitation purposes. Food items should be labeled and dated when opened and placed back into the freezer. Maintenance should be notified of any issues regarding kitchen repairs. During an interview on 04/03/26 at 10:52 A.M., the Administrator said the kitchen floors should be cleaned and free of grease, dirt, and debris. Kitchen equipment should be cleaned after each use for sanitation purposes. Food items should be labeled and dated when opened and placed back into the freezer. Maintenance should be notified of any issues regarding kitchen repairs and written down on the maintenance log.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) form to the resident and/or the resident's representative in writing at least two calendar days before discharge from skilled services. This notice informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting the financial liability for those services. This practice affected two residents (Residents #100 and #101) out of three sampled residents. The facility census was 64.Review of the facility's policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, undated, showed:- A resident (who is a Medicare beneficiary) is informed in advance and in writing when Medicare payment denial or change in coverage is likely;- Written notices of the likelihood of Medicare payment denial are provided to the resident/beneficiary: - As soon as the facility makes the assessment that Medicare payment certainly or probably will not be made and before the item or service is furnished;- Far enough in advance of an event (e.g., receiving a medical service) so that the beneficiary can make a rational, informed decision without undue pressure;- The SNF ABN is only issued if the resident/beneficiary intends to continue services, and the facility believes the services may not be covered under Medicare;- If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS form 10123) is issued to the resident at least two calendar days before Medicare covered services end (or the second to last day of service if care is not provided daily). 1. Review of Resident #100's medical record showed:- The resident was discharged from skilled services on 10/22/25, but remained in the facility;- The resident's skilled services end date was 10/23/25;- The NOMNC form was issued and signed on 10/22/25;- The SNF ABN form was issued and signed on 10/22/25;- The facility did not provide at least a two-day notice of the skilled services end date. 2. Review of Resident #101's medical record showed:- The resident discharged from skilled services on 02/06/26;- The resident discharged home on [DATE];- The NOMNC form was issued and signed on 02/05/26;- The facility did not provide at least a two-day notice of the skilled services end date. During an interview on 04/03/26 at 10:06 A.M., the Social Services Designee (SSD) said he/she was not working at the facility at the time when the two residents were discharged from service. The SSD was aware that the NOMNC and SNF ABN needed to be given to the resident 2-3 days prior to the discharge date . The SSD was unsure why Resident #101's NOMNC was not completed in the appropriate timeframe. During an interview on 04/03/26 at 1:05 P.M., the Administrator said the SNF ABN and NOMNC forms should be signed by the resident or the resident representative two days prior to discharge from skilled services.

Based on interview and record review, the facility failed to electronically transmit Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) in a timely manner and in accordance with guidelines for one resident (Resident #53) out of one sampled resident. The facility census was 64. Review of the facility's policy titled, Resident Assessments, dated [DATE], showed:- A comprehensive assessment of each resident is completed at intervals designated by the Omnibus Budget Reconciliation Act of 1987 (OBRA) regulations and Prospective Payment System (PPS) requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required;- OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare/Medicaid certified homes. OBRA assessments include admission assessment, quarterly assessment, annual assessment, significant change in status assessment, significant correction to prior comprehensive assessment, significant correction to prior quarterly assessment and discharge assessment;- Non-comprehensive MDS assessments include a select number of items from the MDS used to track the resident's status between comprehensive assessments and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status;- The Resident Assessment Instrument (RAI) User's Manual (Chapter 2) provides detailed information on timing and submission of assessments;- The resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments;- The policy did not address death in facility MDS assessment. 1.Review of Resident #53's MDS record showed:- admitted on [DATE];- Expired on [DATE];- Death in facility MDS assessment completed on [DATE];- No validation status the MDS assessment had been accepted;- The facility failed to electronically submit the MDS assessment in a timely manner (122 days late). During an interview on [DATE] at 10:46 A.M., the MDS Coordinator said Resident #53's death in facility assessment was completed but had not been accepted because the assessment had not been submitted for validation. The MDS Coordinator said the resident's assessment should have been submitted after completion and within a timely manner to meet the requirement. During an interview on [DATE] at 10:49 A.M., the Administrator said a resident's MDS death in facility assessment should be completed and submitted within a timely manner for validation purposes to meet the requirement.

Based on observation, interview, and record review, the facility failed to develop and implement care plans with specific interventions to meet individual needs for two residents (Residents #7 and #37) out of 16 sampled residents. The facility census was 64.Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, showed:- The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident;- The comprehensive, person-centered care plan: includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his/her rights, including the right to refuse treatment, any specialized services to be provided as a result of Preadmission Screening and Resident Review (PASRR - a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities) recommendations and which professional services are responsible for each element of care, includes the resident's stated goals upon admission and desired outcomes, builds on the resident's strengths, reflects currently recognized standards of practice for problem areas and conditions;- Care plan interventions are chosen after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making;- When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers;- Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change;- The IDT reviews and updates the care plan: when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff) assessment. 1. Review of Resident #7's medical record showed:- admitted on [DATE];- Diagnoses of chronic kidney disease (loss of kidney function, causing damage and cannot filter blood properly), spontaneous ecchymoses (bruises that occur without known trauma, often caused by fragile blood vessels, aging, medication (e.g., blood thinners), or underlying conditions like blood disorders), cerebrovascular disease (impaired blood vessels, restricting oxygen flow or causing bleeding, often leading to strokes), history of transient ischemic attack (TIA - when blood flow to a part of the brain stops for a brief period of time), and cerebral infarction (stroke) without residual deficits;- An order for apixaban (a blood thinner) 5 milligram (mg) by mouth two times a day for atrial fibrillation (abnormal heart rhythm), dated 11/07/24. Review of the resident's care plan, revised 01/13/26, showed:- Did not address the resident receiving a blood thinner medication and with person-centered interventions. 2. Review of resident #37's medical record showed:- admitted on [DATE];- Diagnoses of chronic obstructive pulmonary disease (COPD - a lung disease) and paroxysmal (a sudden, intense, and temporary onset of symptoms) atrial fibrillation;- An order for rivaroxaban (a blood thinner) 20 mg by mouth one time a day, dated 10/24/25. Review of the resident's care plan, revised 01/06/26, showed:- Did not address the resident receiving a blood thinner medication and with person-centered interventions. During an interview on 04/03/26 at 12:47 P.M., the Assistant Director of Nursing (ADON) said if a resident was on a blood thinner, it should be addressed on the resident's care plan with resident specific interventions. During an interview on 04/03/26 at 1:05 P.M., the Administrator said care plans should include medications, such as blood thinners, with specific interventions. During an interview on 04/07/26 at 2:00 P.M., the Director of Nursing (DON) said medications like blood thinners were discussed in the care plan meetings and should be on the care plan.

Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP - Precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganism that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and or indwelling medical device) and proper infection control practices when staff administered medications through a peripherally inserted central catheter (PICC - a tube/catheter inserted into a vein for medication administration) for one resident (Resident #30) out of one sampled resident. The facility also failed to follow EBP during a dressing change for a suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) for one resident (Resident #75) out of two sampled residents. The facility census was 64.Review of the facility's policy titled, Enhanced Barrier Precautions, dated March 2024, showed:- The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by the Center for Disease Control (CDC);- EBP will be initiated for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling/implanted medical devices (e.g., central lines, ports, urinary catheters, feeding tube, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO;- Make gowns and gloves available immediately near or outside of the resident's room;- Personal protective equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be put on prior to entering the resident's room;- Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room);- High-contact resident care activities include device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes and wound care: any skin opening requiring a dressing. Review of the facility's policy titled, Peripheral and Midline Intravenous (IV - administer into a vein) Catheter Flushing and Locking, dated June 2025, showed:- Disinfect needleless access device (end cap, access port) with disinfecting wipe for at least 15 seconds;- Allow to air dry completely (five seconds after disinfecting with 70% isopropyl alcohol, and at least 20 seconds when disinfecting with alcohol-based chlorhexidine gluconate);- Attach prefilled saline (salt water) syringe to needleless access device;- Unclamp catheter;- Flush with preservative-free 0.9% sodium chloride (salt water) using the push-pause technique. Leave 0.5 to 1.0 milliliters (ml) of flush in syringe to avoid pushing air into the catheter;- Disinfect needleless access device (end cap, access port) with disinfecting wipe for at least 15 seconds;- Allow to air dry completely (five seconds after disinfecting with 70% isopropyl alcohol, and at least 20 seconds when disinfecting with alcohol-based chlorhexidine gluconate);- Connect IV tubing. 1. Review of Resident #30's medical record showed:- admitted on [DATE];- Diagnoses of osteomyelitis (an infection of bone and bone marrow), congestive heart failure (impaired heart function), peripheral vascular disease (poor circulation), and acquired absence of toes of right foot (surgical amputation of toes);- An order to flush the PICC line each lumen (port) with 10 ml normal saline before and after each medication administration. Use at least a 10 ml syringe, dated 04/02/26;- An order for daptomycin (an antibiotic medication) 700 milligrams (mg) intravenously (administered into a vein) one time a day for 32 days, dated 03/27/26. Observation on 04/02/26 at 8:50 A.M., of the resident's IV medication administration showed:- EBP signage and PPE supplies outside of the resident's door;- Licensed Practical Nurse (LPN) B performed hand hygiene, put on gloves, and did not put on a gown;- LPN B removed the disinfection cap from the PICC line port, did not disinfect the PICC line port, attached a 10 ml syringe of normal saline to the port, flushed the port with 10 ml of normal saline, did not disinfect the port, and connected the IV tubing attached to the daptomycin IV bag;- LPN B started the IV pump to administer the daptomycin, removed gloves, did not perform hand hygiene, and exited the room. Observation on 04/02/26 at 9:53 A.M., of the resident's IV medication administration showed: - EBP signage and PPE supplies outside of the resident's door;- LPN B did not perform hand hygiene, did not put on a gown, put on gloves, and entered the resident's room; - LPN B removed the disinfection cap, used an alcohol swab to disinfect the PICC line port, the disinfected PICC line port touched the residents' pants, cleaned the PICC line port with an alcohol swab but did not scrub the port for at least 15 seconds to disinfect it, attached a 10 ml syringe of normal saline to the PICC line port, flushed the PICC line port with 10 ml of normal saline, disconnected the 10 ml syringe, did not disinfect the PICC line port, and connected the IV tubing attached to the daptomycin IV bag;- LPN B removed gloves, performed hand hygiene, and exited the room. Observation on 04/02/26 at 10:24 A.M., of the resident's disconnection from the IV medication showed:- EBP signage and PPE supplies outside of the resident's door;- LPN B did not perform hand hygiene, did not put on a gown, put on gloves, and entered the resident's room;- LPN B disconnected the IV tubing attached to the daptomycin IV bag from the PICC line port, did not disinfect the PICC line port, attached a 10 ml syringe of normal saline, flushed the PICC line port with 10 ml of normal saline, disconnected the 10 ml syringe, did not disinfect the PICC line port, and attached a disinfection cap to the PICC line port;- LPN B removed gloves, performed hand hygiene, and exited the resident's room. Observation on 04/03/26 at 11:15 A.M., of the resident's IV medication administration showed:- EBP signage and PPE supplies outside of the resident's door;- Registered Nurse (RN) C performed hand hygiene, put on gloves, did not put on a gown, and entered the residents' room;- RN C administered the daptomycin IV medication;- RN C removed gloves, performed hand hygiene, and exited the resident's room. During an interview on 04/02/26 at 10:30 A.M., LPN B said Resident #30 was on EBP for his/her wound and there was no need for the LPN to put on a gown when only administering IV medications. LPN B said he/she wasn't aware of a certain way to disinfect the PICC line port before and after accessing it. During an interview on 04/03/26 at 11:24 A.M., RN C said EBP was for residents with wounds and catheters. Resident #30 had a wound, but he/she wasn't providing care to the wound during the time he/she administered the resident's IV antibiotic medication. 2. Review of Resident #75's medical record showed:- admitted on [DATE];- Diagnoses of chronic obstructive pulmonary disease (COPD - a lung disease) and neuromuscular dysfunction of the bladder (the bladder does not empty properly due to nerve damage;- An order for a urinary catheter (a sterile tube inserted into the bladder to drain urine) 16 French (Fr - size of the catheter) 10 ml bulb every day shift starting on the 17th and ending on the 17th every month and as needed for occlusion (blockage) or leakage, dated 04/02/26;- An order for urinary catheter care- supra pubic catheter every shift for prophylaxis (prevention), dated 03/19/26. Observation on 04/03/26 at 11:33 A.M., of the resident's supra pubic catheter dressing change showed:- EBP signage and PPE supplies outside of the resident's door;- LPN D did not perform hand hygiene, put on gloves, and did not put on a gown;- LPN D cleaned the supra pubic catheter insertion site, removed gloves, and performed hand hygiene;- LPN D did not put on gloves, applied the split dressing to the supra pubic catheter insertion site with his/her bare hands, secured with tape, and dated and initialed the dressing;- LPN D did not perform hand hygiene and exited the resident's room. During an interview on 04/03/26 at 11:38 A.M., LPN D said he/she wasn't sure why Resident #75 was on EBP because he/she didn't have a wound. During an interview on 04/03/26 at 10:08 A.M., the Infection Preventionist (IP) said staff should wear gowns and gloves when providing care for residents on EBP. Residents that had wounds or any indwelling catheter, such as urinary or a PICC line, were put on EBP. The IP said before accessing the PICC line catheter, nurses should disinfect the connector for 10-15 seconds with an alcohol wipe before connecting and after disconnecting the flush or IV tubing and ensure the disinfection cap was replaced. During an interview on 04/03/26 at 12:47 P.M., the Assistant Director of Nursing (ADON) said residents with chronic wounds or indwelling devices, such as a urinary catheter or intravenous catheter, were put on EBP. Staff should put on gowns and gloves before providing care to residents on EBP. Nurses should disinfect the PICC line catheter connector before and after accessing it. During an interview on 04/03/26 at 1:05 P.M., the Administrator said he would defer to the IP or the Director of Nursing (DON) for guidance on EBP and accessing the PICC line catheter. During an interview on 04/07/26 at 2:00 P.M., the Director of Nursing (DON) said residents with wounds or catheters require EBP. Staff should put on PPE for direct care with residents on EBP. Before administering medications or accessing the PICC line catheter, nurses should disinfect the PICC line port before and after accessing the line with an alcohol swab.

Based on interview and record review, the facility failed to follow their policy to notify the designated resident representative/emergency contact for one resident (Resident #1) out of three sampled residents who had a significant change in condition. The facility census was 72. Review of the facility's policy titled, Change in a Resident's Condition or Status, showed: - The facility promptly notifies the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status; - A nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. 1. Review of Resident #1's medical record showed: - admission date of 01/09/24; - Diagnoses of diabetes mellitus (a chronic metabolic disorder characterized by abnormally high blood sugar levels), muscle weakness (lack of muscle strength), Alzheimer's (a progressive disease that destroys memory and other mental functions ) disease, anemia (lower number of red blood cells), chronic kidney disease (CKD - a progressive loss of kidney function), and chronic obstructive pulmonary disease (COPD - lung disease that causes persistent airflow obstruction and breathing problem); - Severe cognitive impairment; - Emergency contact list did not include the family member present at the facility on 05/24/25, as the resident representative/emergency contact. Review of the resident's Care Plan, dated 03/31/25, showed: - Displayed a deficiency in cognition. Review of the resident's Progress Notes, dated 05/23/25, showed: - At 5:39 P.M., Certified Medication Technician (CMT) D went into the dining room to administer the resident his/her medication and the resident not responsive as normal. CMT D notified the nurse the resident needed assistance; - At 5:40 P.M., Licensed Practical Nurse (LPN) F assessed the resident, LPN G assisted LPN F. The resident was lethargic, cold, and not responding as normal. Blood pressure was 112/73, pulse was 30 per radial (inside of wrist), and unable to hear the apical (left side of the chest near the heart) pulse; - At 5:47 P.M., LPN F notified emergency medical services (EMS); - At 5:54 P.M., EMS arrived to the facility; - At 6:00 P.M., report called to the emergency department (ER); - At 6:08 P.M., EMS left the facility; - No documentation the family/resident representative was notified of the resident's decline in status and transported by EMS to the hospital. During an interview on 06/05/25 at 12:45 P.M., Registered Nurse (RN) E said if a change in condition of a resident happened, he/she would look at the face sheet in the electronic health record (EHR) and look for the emergency contact or power of attorney (POA) and notify that person, and if needed, would go down the list of contacts. During an interview on 06/05/25 at 12:50 P.M., the Director of Nursing (DON) said she would notify the family by calling the emergency contact, and if no answer. If the resident had a POA, then she would contact that person instead. She expected staff to do the same. During an interview on 06/05/25 at 3:40 P.M., the Administrator said a family member of the resident came into the facility before EMS left with the resident. He did not think the resident representative/emergency contact should have been notified since there was a family member in the facility. He would assume the family member would notify the resident representative/emergency contact of the resident's change in status and transfer to the hospital. Complaint #254888

Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #4 and #5) out of two sampled residents who were incontinent of bladder, received appropriate treatment and services after an incontinent episode which left the residents in urine saturated briefs and with a strong urine odor. The census was 72. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised April 2025, showed: - Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a.) hygiene (bathing, dressing, grooming, and oral care), b.) mobility (transfer and ambulation, including walking), c.) elimination (toileting), d.) dining (eating, including meals, and snacks), e.) communication (including speech, language, and other functional communication systems); - A resident's ability to perform ADLs is measured using clinical tools, including the Minimum Data Sets (MDS - a federally mandated assessment instrument completed by the facility staff). The facility did not provide a policy in regards of timing for residents to be assessed for incontinent episodes. 1. Review of Resident #4's medical record showed: - Diagnoses of cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) of the left side, and vascular dementia (dementia caused by impaired blood supply to the brain); Review of the resident's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Impairment on one side of the upper and lower extremities; - Substantial/Moderate assist for sit to stand and transfers; - Dependent for toileting hygiene; - Frequently incontinent of bladder and always incontinent of bowel. Review of the resident's Care Plan, revised 04/30/25, showed: - Required extensive assist with ADLs; - Incontinent of bowel and bladder and required assistance with toileting. Observation of the resident's incontinent care on 06/05/25 at 12:22 P.M., showed: - Nurse Aide (NA) A and Certified Nurse Aide (CNA) B, and CNA C performed hand hygiene and put on gloves; - NA A and CNA B unfastened the the resident's urine saturated brief with a strong urine odor; - CNA B washed the resident's buttocks and the back of the legs; - CNA B did not clean the resident's pelvic and groin areas; - NA A and CNA B placed a clean brief on the resident and covered the resident with a sheet and blanket. 2. Review of Resident #5's medical record showed: - Diagnoses of Parkinsonism (tremor, slow movements, rigidity, and postural instability), ataxia (impaired balance and movement), spinal stenosis (narrowing of spinal canal), and hemiplegia and hemiparesis of left non-dominant side; Review of the resident's quarterly MDS, dated , 04/01/25, showed: - Moderate cognitive impairment; - No impairment of the upper and lower extremities; - Partial/ Moderate assist for sit to stand and transfers; - Dependent for toileting hygiene; - Occasionally incontinent of bladder and always incontinent of bowel. Review of the resident's Care Plan, dated, 04/13/25, showed: - Required extensive assist with ADLs; - Incontinent of bowel and bladder and required assistance with toileting. Observation of the resident's incontinent care on 06/05/25 at 12:37 P.M., showed: - NA A and CNA B performed hand hygiene and put on gloves; - NA A and CNA B unfastened the resident's urine saturated brief with a strong urine odor; - NA A cleaned the resident's buttocks and the backs of the legs; - NA A removed the urine saturated brief and placed a clean brief under the resident; - NA A and CNA A did not clean the resident's pelvic and groin areas; - NA A and CNA B fastened the clean brief and covered the resident with a sheet and blanket. During an interview on 06/05/25 at 1:51 P.M., Resident #5 said he/she was not changed before lunch and that was why he/she had a urine saturated brief. The staff had changed him/her at least twice today. Staff did come around and checked him/her but didn't know how often. During an interview on 06/05/25 at 1:40 P.M., Resident #6 said he/she was able to use the call light if he/she felt wet but said that he/she waited a long time for them to check. He/She couldn't always tell when he/she was incontinent so depended on the staff to check him/her. During an interview on 06/05/25 at 1:52 P.M., Resident #8 said he/she had been wet for over an hour. He/She had pushed his/her call light, staff entered the room, turned off the light, said they you would get help, and never returned. During an interview on 06/05/25 at 1:55 P.M., Resident #7 said he/she had his/her call light on at this time. He/She needed assistance with care and wanted to go to bed. Staff would come in the room, turn the light off, and would not return sometimes to help him/her. During an interview on 06/05/25 at 1:39 P.M., the Infection Preventionist said staff should clean the front and peri areas when performing incontinent care to residents. During an interview on 06/05/25 at 2:51 P.M., the Director of Nursing said residents should be checked every two hours if they were incontinent and changed if they were soiled. If residents were non-verbal, residents should be checked at least every hour. When staff were performing incontinent care, the front and back peri areas should be cleaned before a clean brief was placed secured. During an interview on 06/05/25 at 2:51 P.M., the Administrator said that there was no regulation stating how often residents were to be checked for incontinence. It was a standard of practice to check the residents every two hours. During an interview on 06/09/25 at 11:05 A.M., CNA B said that he/she was unaware that any mistakes were made during the incontinent care given to the residents. All soiled areas of the resident should be cleaned before putting on a clean brief. Complaint #254888

Based on observation, interview, and record review, the facility failed to perform hand hygiene, change gloves and provide appropriate incontinent care for two residents (Resident #4 and #5) out of two sampled residents who were incontinent of bladder. The census was 72. The facility did not provide a policy addressing infection control practices during incontinent care. 1. Review of Resident #4's medical record showed: - Diagnoses of cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) of the left side, and vascular dementia (dementia caused by impaired blood supply to the brain). Review of the resident's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Impairment on one side of the upper and lower extremities; - Substantial/Moderate assist for sit to stand and transfers; - Dependent for toileting hygiene; - Frequently incontinent of bladder and always incontinent of bowel. Review of the resident's Care Plan, revised 04/30/25, showed: - Required extensive assist with ADLs; - Incontinent of bowel and bladder and required assistance with toileting. Observation of the resident's incontinent care on 06/05/25 at 12:22 P.M., showed: - Nurse Aide (NA) A and Certified Nurse Aide (CNA) B and CNA C performed hand hygiene and put on gloves; - NA A and CNA B unfastened the resident's urine saturated brief, did not change gloves, and did not perform hand hygiene; - CNA B washed the resident's buttocks and the back of the legs; - CNA B removed the urine saturated brief, did not perform hand hygiene, and did not change gloves; - CNA B placed a clean brief under the resident; - NA A and CNA B secured the clean brief, removed gloves, and performed hand hygiene. 2. Review of Resident #5's medical record showed: - Diagnoses of Parkinsonism (tremor, slow movements, rigidity, and postural instability), ataxia (impaired balance and movement), spinal stenosis (narrowing of spinal canal), hemiplegia and hemiparesis of the left non-dominant side. Review of the resident's quarterly MDS, dated , 04/01/25, showed: - Moderate cognitive impairment; - No impairment of the upper and lower extremities; - Partial/Moderate assist for sit to stand and transfers; - Dependent for toileting hygiene; - Occasionally incontinent of bladder and always incontinent of bowel. Review of the resident's Care Plan, dated, 04/13/25, showed: - Required extensive assist with ADLs; - Incontinent of bowel and bladder and required assistance with toileting. Observation of the resident's incontinent care on 06/05/25 at 12:37 P.M., showed: - NA A and CNA B performed hand hygiene and put on gloves; - NA A and CNA B unfastened the urine saturated brief, did not change gloves, and did not perform hand hygiene; - NA A washed the resident's buttocks and the back of the legs, removed the urine saturated brief, did not change gloves, and did not perform hand hygiene; - NA A and CNA B secured the clean brief, removed gloves, and performed hand hygiene. During an interview on 06/05/25 at 1:39 P.M., the Infection Preventionist said staff should change gloves and wash hands between dirty and clean tasks. During an interview on 06/05/25 at 2:51 P.M., the Director of Nursing (DON) said staff should change their gloves and wash their hands between dirty and clean tasks. During an interview on 06/09/25 at 11:05 A.M., CNA B said that he/she was unaware that any mistakes were made during the incontinent care given to the residents. Staff should change gloves when going from dirty to clean task. Complaint #254888

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for five out of five medication carts. This practice had the potential to affect all residents. The facility census was 66. The facility did not provide a policy on narcotic reconciliation documentation. 1. Review of the A Hall Certified Medical Technician (CMT) Narcotic Count Log for Controlled Substances on 01/09/25 at 10:17 A.M., showed: - For 7 A.M. - 7 P.M. shift on 11/27/24 - 12/18/24, the staff missed 11 out of 44 opportunities to reconcile the narcotics; - For 7 P.M. - 7 A.M. shift on 12/18/24 - 01/08/25, the staff missed 13 out of 44 opportunities to reconcile the narcotics. 2. Review of the B Hall CMT Narcotic Count Log for Controlled Substances on 01/09/25 at 10:15 A.M., showed: - For 7 A.M. - 7 P.M. shift on 12/01/24 - 12/19/24, the staff missed 20 out of 44 opportunities to reconcile the narcotics; - For 7 A.M. - 7 P.M. shift on 12/20/24 - 01/05/25, the staff missed 11 out of 44 opportunities to reconcile the narcotics; - For 11 P.M. - 7 A.M. shift on 12/24/24 - 01/09/25, the staff missed nine out of 42 opportunities to reconcile the narcotics; - For 7 P.M. - 7 A.M. shift on 01/05/25 - 01/09/25, the staff missed four out of 10 opportunities to reconcile the narcotics. 3. Review of the C Hall CMT Narcotic Count Log for Controlled Substances on 01/09/25 at 10:17 A.M., showed: - For 11 P.M. - 7 A.M. shift on 11/23/24 - 12/09/24, the staff missed 20 out of 44 opportunities to reconcile the narcotics; - For 3 P.M. - 7 A.M. shift on 12/09/24 - 12/25/24, the staff missed nine out of 44 opportunities to reconcile the narcotics; - For 3 P.M. - 6 A.M. shift on 12/25/24 - 01/09/25, the staff missed nine out of 43 opportunities to reconcile the narcotics. 4. Review of the D Hall CMT Narcotic Count Log for Controlled Substances on 01/09/25 at 10:18 A.M., showed: - For 7 A.M. - 7 P.M. shift on 11/24/24 - 12/09/24, the staff missed 12 out of 44 opportunities to reconcile the narcotics; - For 3 P.M. - 7 P.M. shift on 12/09/24 - 12/24/24, the staff missed four out of 44 opportunities to reconcile the narcotics; - For 7 A.M. - 3 P.M. shift on 12/25/24 - 01/08/25, the staff missed five out of 44 opportunities to reconcile the narcotics; - For 7 A.M. - 3 P.M. shift on 01/07/25 - 01/09/25, the staff missed one out of six opportunities to reconcile the narcotics. 5. Review of the Medication Room Nurse Narcotic Count Log for Controlled Substances on 01/09/25 at 10:18 A.M., showed: - For 7 P.M. - 7 A.M. shift on 11/19/24 - 12/10/24, the staff missed nine out of 44 opportunities to reconcile the narcotics; - For 11 P.M. - 7 A.M. shift on 12/10/24 - 01/01/25, the staff missed 13 out of 44 opportunities to reconcile the narcotics; - For 7 P.M. - 7 A.M. shift on 01/01/25 - 01/09/25, the staff missed one out of 16 opportunities to reconcile the narcotics. During an interview on 01/09/25 at 10:18 A.M., CMT D said there should be two signatures on the Narcotic Count Log, one from on-coming staff and one from the out-going staff for each shift. During an interview on 01/13/25 at 11:23 A.M., the Corporate Nurse said the facility did not have a policy regarding how many staff and which staff should sign the narcotic reconciliation log, but it was best practice to have the on-coming staff member and the off-going staff member count the narcotics on each medication cart. During an interview on 01/13/25 at 12:09 P.M., the Director of Nursing said the on-coming staff and the off-going staff should sign the narcotic reconciliation log when counting the medication cart. That was the best standard of practice. During an interview on 01/13/25 at 12:10 P.M., Licensed Practical Nurse (LPN) E said CMT's on-coming to their shift should count with the off-going nurse. On-coming nurse counts with the off-going nurse in the medication room. There should be two signatures on the narcotic reconciliation log. During an interview on 01/15/25 at 11:12 A.M., the Administrator said it was the best practice to have two staff sign off for each shift, but the facility didn't have a specific policy to follow regarding the narcotic reconciliation.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 66. Review of the facility's policy titled, Sanitization, revised [DATE], showed: - The food service area is maintained in a clean and sanitary manner; - All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracked and chipped areas that may affect their use or proper cleaning; - All equipment, food contact surfaces, and utensils are cleaned and sanitized; - The policy did not address refrigerator and/or freezer defrosting. Review of the facility's policy titled, Food Receiving and Storage, revised [DATE], showed: - Foods shall be received and stored in a manner that complies with safe food handling practices; - Dry foods and goods are handled and stored in a manner that maintains the integrity of the package until they are ready for use; - Dry foods that are stored in bins are removed from original packaging, labeled and dated, (use-by date). Such foods are rotated using a first in - first out system; - All foods stored in the refrigerator or freezer are covered, labeled and dated; - Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. 1. Observations on [DATE] at 10:05 A.M., and [DATE] at 8:42 A.M., of the kitchen area, showed: - A buildup of grease and a black substance on several cooking pans on top of a four-tier metal shelf rack in front of the stove; - A buildup of grease and a black substance on several cooking pans on top of a five-tier metal shelf rack near the walk-in freezer; - A buildup of a white substance on the top and side surfaces of the dish machine; - A dirty bristle brush, dirty scrubbing pads, and miscellaneous debris under the three chemical dispensing switches on top of the dish machine; - Two soiled blankets lay on the floor in front of the dish machine. 2. Observations on [DATE] at 10:16 A.M., and [DATE] at 8:48 A.M., of the walk-in freezer near the five-tier metal shelf rack with the cooking pans, showed: - A bag of mozzarella cheese opened and expired [DATE]; - A plastic container of miscellaneous sliced cheeses with no label or date; - A metal container with a frozen thick white substance with no label or date; - An opened package of butter not sealed or dated; - A roll of deli bologna hung out of a zip lock bag, not sealed or dated. 3. Observations on [DATE] at 10:21 A.M., and [DATE] at 8:52 A.M., of the dry foods and can goods area, showed: - A bag of bread crumbs opened with no label or date; - A bag of marshmallows opened and not sealed; - A five pound (pd.) bag of yellow cake mix opened, not sealed and dated; - A bag of instant mashed potatoes opened, not sealed and dated. 4. Observations on [DATE] at 10:28 A.M., and [DATE] at 8:56 A.M., of the walk-in freezer next to the dry foods and can goods area, showed: - Large clumps of ice buildup on the floor and under the metal racks containing boxes of food; - A large clump of ice buildup on the double-fan freezer unit above the top shelf on the left side; - A bag of burritos opened, unsealed, with no label or date; - A bag of okra opened, unsealed, with no label or date; - A bag of hot dogs opened, unsealed, with no label or date; - A bag of hash browns opened, unsealed, with no label or date; - A bag of onion rings opened, unsealed, with no label or date; - A bag of fish sticks opened, unsealed, with no label or date; - A large bag of garlic bread opened, unsealed, with no label or date. During an interview on [DATE] at 3:17 P.M., the Assistant Dietary Manager (ADM) said he/she would expect staff to seal, label, and date any foods once it had been opened and placed back on the shelf or freezer. He/She would expect staff to keep the kitchen equipment cleaned, sanitized daily or after it was used for preparing food. During an interview on [DATE] at 4:07 P.M., the Dietary Manager (DM) said he/she would expect staff to seal, label, and date any foods once it has been opened and placed back on the shelf or freezer. He/She would expect staff to keep the kitchen equipment cleaned, sanitized daily or after it was used for preparing food. During an interview on [DATE] at 4:58 P.M., the Administrator said he would expect staff to seal, label, and date any food once it had been opened and placed back on the shelf or freezer. He would expect staff to keep the kitchen equipment cleaned, sanitized daily or after it is used for preparing food. The walk-in freezers and refrigerators should be free of ice buildup and defrosted as needed.

Based on interview and record review, the facility failed to document a code status for one resident (Resident #9) outside the sample of 17 sampled residents. The facility census was 66. Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR - lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped), revised [DATE], showed: - CPR will be provided to a resident who suddenly ceases to have a spontaneous pulse and respirations unless there is a physician's order for no CPR, Do Not Attempt Resuscitation (DNAR), or a do not resuscitate (DNR) order, Out of Hospital Do Not Resuscitate (OHDNR), or allow a natural death; - A minimum of one CPR certified staff will be available on each shift; - The policy did not address code status documentation throughout the resident's medical record. 1. Review of Resident #9's medical record showed: - admitted [DATE]: - Diagnoses of urinary tract infection (UTI - a bacterial infection that affects the bladder and kidneys), altered mental status (a change in someone's usual level of thinking or ability to respond to their surroundings) and cerebral infarction (stroke); - No documentation of a code status on the face sheet. Review of the resident's baseline care plan, dated [DATE], showed: - No documentation of the resident's code status. Review of the resident's [DATE] Physician's Order Sheet (POS), showed: - No order for the resident's code status. Review of the resident's care plan, dated [DATE], showed: - No documentation of the resident's code status. During an interview on [DATE] at 3:56 P.M., the Director of Nursing (DON) said she would expect a code status to be on the baseline care plan when a new resident was admitted to the facility. If not, it should be on the face sheet, POS, and should be care planned. During an interview on [DATE] at 4:16 P.M., the Administrator said he would expect a code status to be on the baseline care plan when a new resident was admitted to the facility. If not, it should be on the face sheet, POS, and should be care planned. 48532

Based on observation, interview and record review, the facility failed to monitor and keep one resident's (Resident #4) equipment in good, working order. The facility also failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 66. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as a clean, sanitary and orderly environment. 1. Observations on 01/07/25 at 10:31 A.M., 01/08/25 at 9:24 A.M., and 01/09/25 at 8:34 A.M., showed: - A buildup of spider webs and dirt on the outside ceiling of the awning located at the front entrance; - A buildup of spider webs and dirt on the outside ceiling of the awning located at the exit near the personnel dining room and kitchen. 2. Observations on 01/07/25 at 10:41 A.M., 01/08/25 at 9:29 A.M., and 01/09/25 at 9:40 A.M., of room [ROOM NUMBER] showed: - Several long areas of exposed sheetrock and peeled paint behind the bed next to the door; - Several small areas of exposed sheetrock and peeled paint on the wall behind the nightstand by the bed next to the door. 3. Observations on 1/07/25 at 9:01 A.M., 01/08/25 at 9:48 A.M., and 1/09/25 at 9:26 A.M., of room [ROOM NUMBER] showed: - A large area of peeled paint and dark scuff marks along the bottom wall behind the door; - Several broken slats on the mini-blind hanging in front of the window. 4. Observations on 1/07/25 at 11:30 A.M., 01/08/25 at 9:56 A.M., and 1/09/25 at 9:30 A.M., of room [ROOM NUMBER] showed: - Several small areas of exposed sheetrock and peeled paint located on the bottom left-side wall in the hallway next to the door. 5. Observations on 1/07/25 at 11:30 A.M., 01/08/25 at 9:56 A.M., and 1/09/25 at 9:30 A.M., of Resident #4's Geri-chair (specialized recliner) showed: - The protective covering worn off and with rough edges on the left-side armrest. Observation on 01/13/25 at 11:12 A.M., of Resident #4 showed: - The resident sat in his/her Geri-chair in the dining room and his/her left arm lay on the left-side armrest. Review of the maintenance log, dated 12/01/24 - 01/09/25, showed no documentation of areas of concern addressed. During an interview on 01/09/25 at 4:15 P.M., the Maintenance Supervisor (MS) said he/she was responsible for the upkeep of the outside grounds and the building. The outside entrance awning and ceiling should be free of cobwebs and debris. Staff should be writing down any environmental concerns found inside the facility to be addressed in a timely manner on the maintenance log. During an interview on 01/09/25 at 12:18 P.M., the Administrator said he would expect maintenance to ensure the outside grounds and building to be free of debris and cobwebs. He would expect staff to write down environmental concerns inside the facility on the maintenance log to be addressed in a timely manner. During an interview on 01/13/25 at 9:19 A.M., Housekeeper A said there was a maintenance log at the nurse's station that staff could use to write down any environmental issues. Each housekeeper was assigned a hall and should be writing down any repairs that were found during the daily cleaning rounds. Housekeeping helped with some things outside the facility like window cleaning, but maintenance was responsible for most of the upkeep outside.

Based on interview and record review, the facility failed to develop and implement a baseline care plan (initial plan for delivering of care and services) within 48 hours of admission for one resident (Resident #9) outside the sample of two sampled residents that included the instructions needed to provide effective and person-centered care to meet professional standards of quality care. The facility census was 66. Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed: - A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, discussion with the resident/representative and physician orders; - The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed; - Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. Review of Resident #9's medical record showed: - admitted [DATE]: - Baseline care plan, dated 12/24/24; - The facility did not complete the resident's baseline care plan within 48 hours after admission to the facility. During an interview on 01/09/25 at 3:56 P.M., the Director of Nursing (DON) said she would expect a baseline care plan to be completed within 48 hours of a new admission to the facility which should reflect pertinent information regarding the resident's care areas. During an interview on 01/09/25 at 4:16 P.M., the Administrator said he would expect a baseline care plan to be completed within 48 hours of a new admission to the facility addressing the resident's care areas.

Based on observation, interview and record review, the facility failed to ensure an appropriate diagnosis for the use of a psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication for one resident (Resident #45) out of five sampled residents. The facility census was 66. Review of the facility's policy titled, Antipsychotic (medications that treat psychosis-related conditions and symptoms) Medication Use, dated July 2022, showed: - Residents will not receive medications that are not clinically indicated to treat a specific condition; - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; - Antipsychotic medications shall generally be used only for the following conditions/diagnosis as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders: a. Schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations); b. Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder); c. Schizophreniform disorder (a type of mental health disorder with symptoms similar to those of schizophrenia, but lasting for less than 6 months); d. Delusional disorder (a mental health disorder that causes people to have false beliefs, that are difficult to distinguish from reality); e. Mood disorder (e.g., bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia (a set of symptoms characterized by delusions, hallucinations, disordered thinking and speech and agitation); g. Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high-dose steroids); h. Tourette's Disorder (a neurological disorder that causes people to have sudden, repetitive and involuntary movements or sounds); i. Huntington Disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down); j. Hiccups (not induced by other medications); or k. Nausea and vomiting associated with cancer or chemotherapy. - Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self-care; c. Restlessness; d. Impaired memory; e. Mild anxiety; f. Insomnia; g. sadness or crying alone that is not related to depression or other psychiatric disorders; - Residents will be informed of the recommendations, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents may refuse medications of any kind. 1. Review of Resident #45's medical record showed: - An admitted [DATE]; - Diagnoses of congestive heart failure (CHF- a chronic condition where the heart can't pump enough blood to the body), type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar), muscle weakness, and insomnia; - An order for Seroquel (an antipsychotic medication) 50 milligram (mg) by mouth at bedtime for depression, dated 10/17/24; - No documentation of behaviors; - No documentation of an appropriate diagnosis for the Seroquel; - A patient note, dated 01/09/25, showed the Family Nurse Practitioner (FNP) reviewed the resident's extensive medical history. The resident had been on several different depression medications in the past, without success. He/She was started on Seroquel along with Zoloft (an antidepressant medication) to improve his/her symptoms. The resident's Patient Health Questionnaire evaluations in the past reflected feeling down, depressed and hopeless. Some of the symptoms have improved due to being in a safe, clean environment now. The previous psychiatric physician had treated the resident, made appropriate adjustments in the medications. The resident's diagnosis was corrected to major depressive disorder. Review of the resident's Pharmacy Consultant note, dated 09/03/24, showed: - A request to update the diagnosis associated with the Seroquel; - Seroquel was not indicated for the treatment of insomnia/depression. Review of the resident's progress notes dated 10/10/24 showed: - The facility staff sent a request to the previous psychiatric physician on 10/10/24, because the resident had requested the Seroquel 100 mg be decreased due to making the resident too sleepy and the resident refused the medication due to this; - An order, dated 10/10/24, was received to decrease the Seroquel to 50 mg by mouth at bedtime. Observation on 01/07/25 at 11:45 A.M., showed Resident #45 ate lunch in his/her room with the spouse. Observations on 01/07/25 at 3:00 P.M., 01/08/25 at 9:30 A.M., and 01/09/25 at 8:50 A.M., showed Resident #45 sat in his/her room and visited with the spouse. During an interview on 01/09/25 at 11:00 A.M., the Director of Nursing (DON) said after the pharmacy consultant was here, the recommendations came to her, and she sent them to the physicians or wherever they needed to go. During an interview on 01/13/25 at 9:23 A.M., Resident #45 said the medication caused him/her to be really sleepy, even after the dose had been reduced, so he/she had been refusing the medication. The resident did not want to take the medication. During an interview on 01/13/25 at 10:56 A.M., Licensed Practical Nurse (LPN) B said the resident had not had any behaviors that he/she knew of. He/She worked nights a few times and knew the resident took the Seroquel at bedtime. During an interview on 01/13/25 at 11:00 A.M., Certified Medication Technician (CMT) C said the resident had not had any behaviors. He/She didn't think the resident took the Seroquel anymore. During an interview on 01/13/25 at 11:15 A.M., the Director of Nursing (DON) said psychiatry would be here next month to see the resident. He/she said that it was discussed with psychiatry on the phone and the depression diagnosis was the only diagnosis that would cover that medication.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 27 opportunities with two errors made, resulting in an error rate of 7.41% for two residents (Residents #7 and #16) out of nine sampled residents. The facility's census was 66. Review of the facility's policy titled, Insulin Administration, last reviewed September 2014, showed: - Depress the plunger and remove the needle after approximately five seconds; - This policy did not address the priming of the insulin pen prior to each use. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Kwik Pen (insulin in a pen-type device) instructions, revised, July 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and zero is seen in the dose window, insulin will be visible at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. Leave the needle under the skin while counting to five slowly. Review of the Fiasp/insulin aspart (fast-acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen administration instructions, dated September 2021, showed: - Prime the pen by turning the dose selector to two units; - Keep the needle upwards and press the push-button until the dose selector reads zero; - Turn the dose selector to select the number of prescribed units; - Push the needle into the skin, then press the dose button until dose selector indicates zero; - Keep the push-button fully pushed in after the injection; - Leave the needle under the skin for six seconds and then remove it. 1. Review of Resident #7's Physician Order Sheet (POS), dated January 2025, showed: - An order for insulin aspart inject five units subcutaneously (injection under the skin) before meals, dated 10/17/24; - An order for insulin aspart subcutaneous before meals per a sliding scale of blood sugar if 140-180= 2 units; 181-220=4 units; 221-400=6 units, dated 10/17/24; Observation of Resident #7's medication administration on 01/09/25 at 11:09 A.M., showed: - Licensed Practical Nurse (LPN) F administered 9 units of insulin aspart subcutaneously per the resident's insulin aspart Kwik Pen for a blood sugar of 191 and the meal dosage. LPN F left the needle under the resident's skin for approximately one to two seconds after administering the insulin; - LPN F failed to prime the insulin aspart Kwik Pen per the manufacturer's instructions prior to the administration to the resident; - LPN F failed to leave the needle under the skin per the manufacturer's instructions. 2. Review of Resident #16's POS, dated January 2025, showed: - An order for Humalog insulin pen subcutaneous before meals per a sliding scale of blood sugar if 150-199=1 unit, 200-249=2 units, 250-299=3 units, 300-349=4 units, 350-399=5 units, 400+=6 units, dated 11/22/24. Observation of Resident #16's medication administration on 01/09/25 at 10:57 A.M., showed: - LPN F administered 3 units of Humalog subcutaneously per the resident's Humalog Flex Pen for a blood sugar of 250. LPN F left the needle under the resident's skin for approximately one second after administering the insulin; - LPN F failed to prime the Humalog Flex Pen per the manufacturer's instructions prior to the administration to the resident; - LPN F failed to leave the needle under the skin per the manufacturer's instructions. During an interview on 01/09/25 at 11:10 A.M., LPN F said he/she primed the insulin pens with one unit of insulin prior to each administration. During an interview on 01/09/25 at 11:15 P.M., LPN E said before administering insulin, the insulin pen must be primed with 2 units of insulin before administering the insulin to the resident. During an interview on 01/09/25 at 2:10 P.M., the Corporate Nurse said staff should prime insulin pens with 2 units with every insulin administration. During an interview on 01/15/2025 at 9:55 A.M., the Director of Nursing (DON) said staff should prime the insulin pen using 2 units before administering insulin to a resident.

Based on observation, interview, and record review, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pest out and/or to keep the garbage contained in the dumpster. The facility census was 66. Review of the facility's policy titled, Food Related Garbage and Refuse Disposal, revised October 2017, showed: - Food-related garbage and refuse (trash) are disposed of in accordance with current state laws; - Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests; - Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Observations made on 01/07/25 at 8:58 A.M. and 3:47 P.M., 01/08/25 at 8:36 A.M. and 3:10 P.M., 01/09/25 at 9:11 A.M. and 2:40 P.M., of the outside dumpster area showed: - A bed mattress lay on the ground behind the right side of the dumpster; - A box spring mattress lay on the ground beside the right side of the dumpster; - Several scattered white foam cups and bowls on the ground; - The dumpster lid on the right side opened with visible boxes, trash bags, soiled briefs, gloves, and scattered food; - The dumpster lid on the left side opened with visible boxes, trash bags, soiled briefs, gloves, and scattered food. During an interview on 01/09/25 at 5:07 P.M., the Assistant Dietary Manager (ADM) said staff should be closing the dumpster lids after trash or any other miscellaneous items were discarded. During an interview on 01/09/25 at 3:17 P.M., the Dietary Manager (DM) said staff should be closing the dumpster lids after trash or any other miscellaneous items were discarded. During an interview on 01/09/25 at 4:37 P.M., the Maintenance Supervisor (MS) staff should be closing the dumpster lids after trash or any other miscellaneous items were discarded. He/She was responsible for the upkeep of the outside grounds. During an interview on 01/09/25 at 4:58 P.M., the Administrator said he would expect all staff to close the dumpster lids after trash or any other miscellaneous items were discarded. He would expect no debris or large items to be laying around on the ground by the outside dumpsters. During an interview on 01/13/25 at 9:19 A.M., Housekeeper A said staff should always close the lid to the dumpsters after trash or anything else had been discarded into it.

Based on observation, interview, and record review, the facility failed to implement Enhance Barrier Precautions (EBP) during wound care for five residents (Residents #24, #32, #45, #46, and #60) out of five sampled residents and one resident (Resident #3) outside the sample. The facility census was 66. Review of the facility's policy titled, Enhanced Barrier Precautions, not dated, showed: - It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms; - EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities; - High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, and wound care of any skin opening requiring a dressing; - Initiation of Enhanced Barrier Precautions: enhanced barrier precautions will be initiated for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling/implanted medical devices (e,g., central lines, ports, urinary catheters, feeding tubes tracheostomy/ventilator tubes) even if the resident is known to be infected or colonized with a MDRO; - Implementation of Enhanced Barrier Precautions: make gowns and gloves available immediately near or outside of the resident's room. 1. Observation on 01/08/25 at 9:30 A.M., of Resident #60's wound care showed: - EBP signage not posted outside of the resident's room; - Licensed Practical Nurse (LPN) B did not put on an isolation gown, entered the room, performed hand hygiene, and put on gloves; - LPN B removed the saturated dressing from the resident's left heel; - LPN B performed hand hygiene and changed gloves; - LPN B cleaned the wound with wound cleanser, performed hand hygiene, changed gloves, applied Xeroform (a fine mesh gauze containing medications to promote wound healing) to the open area and placed a border gauze (a three layer adherent dressing) on top of the Xeroform; - LPN B removed the gloves, performed hand hygiene, and left the resident's room. 2. Observation on 01/09/25 at 2:43 P.M., of Resident #32's wound care showed: - EBP signage not posted outside of the resident's room; - LPN B did not put on an isolation gown, entered the resident's room, performed hand hygiene, and put on gloves; - LPN B cleaned the resident's wound on the coccyx (the small, curved bone at the base of the spine) with wound cleanser, changed gloves, performed hand hygiene, applied Santyl (an ointment that removes dead tissue from skin ulcers), and covered with border gauze. - LPN B removed the gloves, performed hand hygiene, and left the resident's room. 3. Observation on 01/09/25 at 2:56 P.M., of Resident #46's wound care showed: - EBP signage posted outside of the resident's room; - LPN B did not put on an isolation gown, entered the resident's room, performed hand hygiene, put on gloves, and removed the resident's saturated dressing from the right heel area; - LPN B changed gloves, performed hand hygiene, cleaned the wound with wound cleanser, patted dry with a 4 x 4 gauze, applied Santyl to the wound bed, cut and applied calcium alginate (highly absorbent wound dressing), and covered with a dressing; - LPN B removed the gloves, performed hand hygiene, and left the resident's room. 4. Observation on 01/09/25 at 3:16 P.M., of Resident #45's wound care showed: - EBP signage posted outside of the resident's room; - LPN B did not put on an isolation gown, entered the resident's room, performed hand hygiene, put on gloves, and cleaned the resident's left lower leg with wound cleanser; - LPN B changed gloves, performed hand hygiene, applied a large piece of Xeroform over the opened area, wrapped with a compressive bandage, performed hand hygiene, and left the resident's room. 5. Observation on 01/09/25 at 3:21 P.M. of Resident #24's wound care showed: - EBP signage posted outside of the resident room; - LPN B did not put on an isolation gown, entered the resident's room, performed hand hygiene, and put on gloves; - LPN B assisted the consultant wound care nurse with repositioning, provided stability for the resident to turn, removed gloves, performed hand hygiene, and left the resident's room. 6. Observation on 01/09/25 at 3:37 P.M., of Resident #3's wound care showed: - EBP signage not posted outside of the resident's room; - LPN B did not put on an isolation gown, entered the resident's room, performed hand hygiene, put on gloves, and used wound cleanser to clean the wound; - LPN B changed gloves, performed hand hygiene, applied Santyl to the wound bed, and covered the wound with a border gauze dressing; - LPN B removed gloves, performed hand hygiene, and left the resident's room. During an interview on 01/09/25 at 5:00 P.M., the Corporate Nurse said he/she would expect the staff to wear a protective gown and gloves when caring for residents with wounds, catheters, feeding tubes, and anything like that. During an interview on 01/13/25 at 10:38 A.M., the Infection Preventionist said residents that require EBP were residents that had any kind of opening, such as catheters, ostomies, wounds with drainage or required a dressing change. Staff should put on gown and gloves when providing high contact care, such as incontinent care, wound dressing changes and anything that required a sterile technique. During an interview on 01/13/25 at 10:54 A.M., LPN B said gloves and gowns should be worn when going into a resident's room with EBP and he/she just forgot to put a gown on when doing the residents' wound care. During an interview on 01/13/25 at 11:04 A.M., the Director of Nursing (DON) said gown and gloves should be worn anytime during resident care with EBP. 48532

Based on interview, and record review the facility failed to provide a safe transfer per facility policy and the resident's assessed level of assistance needed when one Nurse Aide attempted to transfer the resident, who was a two person transfer, alone by bear hugging the resident and attempting to pivot him/her, twisting the resident's left leg and resulting in a left femur fracture and loss of the ability to bear weight on the left leg for one resident (Resident #1) out of six sampled residents. The census was 66. On 08/14/24 at 4:00 P.M., the Administrator was notified of the past non-compliance immediate jeopardy (IJ) which began on 08/02/24. The facility immediately conducted an investigation and inserviced staff on the Resident Transfer Safety policy. The IJ was corrected on 08/08/24. Review of the facility's policy titled, Resident Handling Policy, revised 2000 showed: -Policy exists to ensure a safe working environment for resident handlers; -Policy is to be reviewed and signed by all staff who perform or may perform resident handling; -Initial screening will be performed on all residents to assess transfer and ambulation status; -Resident transfer status will be reviewed via care plan time frame and on an as needed basis; -Transfers will be designated into one of the following categories: (I) Independent transfer, (1) One person transfer, (1+) One person transfer with assistive device, (2) Two person transfer or (M) Mechanical transfer [Hoyer, electric lift, etcetera]; -Mandatory gait belts for all resident handling with exception of bed mobility and medical contraindications; -Resident transfer status will be documented in the resident's chart and above the bed as to inform the staff of appropriate transfer use; -Policy is to be followed at all times and failure to adhere to will result in disciplinary action. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated, 06/11/2024, showed: - Diagnoses of hypertension (high blood pressure), peripheral vascular disease (condition in which narrowed blood vessels reduces blood flow to the limbs), heart failure, and diabetes mellitus (high blood sugar); -BIMS score 8, indicating moderate cognitive impairment; -Speech clear and usually makes self understood; -Usually understands others; -No behaviors; -No scheduled pain medication; -Receives as needed pain medication; -Dependent on helper for chair to bed transfers requiring two or more helpers to complete the activity. Review of the resident's care plan, last reviewed on 04/15/24, showed it did not address the resident's ability to perform activities of daily living such as transferring from bed to wheelchair. Review of the resident's medical record showed: -On 08/06/24 at 8:14 A.M., a late entry note was entered into the electronic medical record for 08/01/24 at 4:30 P.M. said a nurse was walking into the dining room when Resident #1 reported he/she did not want to eat supper and wanted to go back to his/her room. This nurse pushed him/her via wheelchair back to his/her room when he/she said his/her leg hurt and he/she wanted a pain pill. The resident states that during an earlier transfer with two aides, the resident's left leg got caught when transferring to the wheelchair. This nurse assessed the left leg. No abnormalities were noted, no bruising or swelling. He/she did ask for pain medication which was administered. -On 08/03/24 at 1:56 A.M., a nurse's note indicated an unidentified certified nurse aide (CNA) was performing bed checks and the resident stated his/her left leg was hurting. The left leg had no visible abnormalities noted. No edema/discoloration. The resident appeared to have altered mental status (AMS) and was alert to himself/herself. The resident was requesting an as needed (PRN) pain pill. Vital signs oxygen 92% on room air, pulse rate 75 and blood pressure (BP) 88/58. This nurse rechecked the BP and it was 88/56. This nurse then contacted the on call nurse practitioner, who said to monitor the resident's BP and to give a PRN pain pill. The blood pressure was rechecked 30 mins after the pain pill was given and was 93/61. The blood pressure was checked again 30 mins later and read 115/68. No new complaints from resident at this time. The bed was lowered and the call light was within reach; -On 08/03/24 at 6:56 A.M., a nurse's note showed the resident did not wish to get up this morning due to left leg pain. The resident states it hurts to move, but is not painful to touch. BP this A.M. was 110/72; -On 08/05/24 at 8:55 P.M., a nurse's note showed Resident #1 was sent to the hospital for a left leg injury that was causing substantial pain. The on call nurse practitioner was called and gave an order to send the resident out; -On 08/06/24 at 7:16 A.M., a nurse's note showed the hospital called and Resident #1 was admitted for a left leg femur fracture. During an interview on 08/13/24 at 1:55 P.M., NA A said he/she had been providing incontinent care with CNA B for Resident #1 before dinner at approximately 4:15 P.M. NA A said he/she and CNA B had previously transferred Resident #1 into bed using a 2 person assist. NA A said after completing incontinent care on Resident #1 he/she did not wait for CNA B to return to assist and bearhugged Resident #1 to transfer from the bed to wheelchair. During the transfer, NA A reported Resident #1's weight caused the resident to slide and the left leg slide under the wheelchair and got entangled in the wheel. NA A pulled Resident #1 up and his/her left leg landed in the seat of the wheelchair. NA A was holding Resident #1 up off the ground when CNA B returned to the room. CNA B then assisted NA A with transferring Resident #1 into the wheelchair. NA A said a gait belt was not used at any time during the transfer process and it should have been. NA A said he/she should not have transferred the resident by himself/herself, but thought CNA B had told him/her to just pick the resident up. NA A had been shown how to find a resident's transfer status in the electronic record system. NA A said he/she did not report the incident as he/she thought CNA B was reporting it to the nurse. During interviews on 08/13/24 at 2:19 P.M. and 08/14/24 at 11:45 A.M., CNA B said he/she assisted NA A with a transfer of Resident #1 from the wheelchair into bed. NA A provided incontinent care for Resident #1 as CNA B provided care to Resident #2. CNA B said he/she finished incontinent care on Resident #2 and transported Resident #2 to the dining room for dinner. CNA B said he/she told NA A he/she would be right back to assist with Resident #1. Upon returning to the room, CNA B saw NA A leaning back bearhugging and holding Resident #1 off the ground with the resident's left leg caught up in the seat of the wheelchair. CNA B said he/she assisted NA A by holding onto Resident #1's pants and helping move the resident forward to get the leg out of the seat of the wheelchair and then to sit in the wheelchair. CNA B said the resident complained of nausea after the transfer. CNA B said neither he/she nor NA A used a a gait belt during the transfer. CNA B said Resident #1 is a two person assist and Hoyer lift as needed. CNA B said he/she did not immediately report the incident. CNA B said, about 20 minutes later, he/she spoke with the DON regarding the incident. CNA B confirmed the incident regarding Resident #1 took place on 08/02/24. CNA B said Resident #1 would say Oh, no anytime when going in to provide care after the incident happened, but CNA B didn't think much about it being pain related and thought Resident #1 was just traumatized from the bad transfer. During interviews on 08/13/24 at 11:50 A.M. and 1:00 P.M., the Director of Nursing (DON) said on 08/01/24 around dinner time, Resident #1 asked him/her to push him/her back to his/her room from the dining room because his/her leg hurt and he/she wanted a pain pill. Resident #1 told the DON, during a transfer earlier in the day his/her leg got tangled in the wheelchair when the aides where moving him/her and the leg was hurting and wanted a pain pill. The DON assessed the leg and no abnormalities were noted. The incident had not been reported to the DON by the aides at that time. The DON said he/she asked CNA B what happened during the transfer with Resident #1 and CNA B said NA A transferred the resident by himself/herself and the resident's leg got caught up in the wheelchair. The DON did not start an investigation since he/she had talked with CNA B. The DON did speak with NA A to get a statement regarding what happened during the transfer of the resident. The DON said staff are able to see how a resident transfers on PCC (Point Click Care, facility's electronic medical record) under the area of the system the CNA's document in, as well as it is sometimes listed in the special instructions. The DON confirmed Resident #1 was to a 2 person assist and at times required as needed transferring with Hoyer lift. During an interview on 08/14/24 at 9:40 A.M., Licensed Practical Nurse (LPN) C said he/she was not notified Resident #1 had been involved in an incident regarding his/her leg getting tangled in a wheelchair. LPN C said during his/her night shift rotation on 08/02/24 the resident was complaining of left leg pain, as well as had some altered mental status and his/her blood pressure was low. LPN C said he/she called the on-call nurse practitioner. LPN C said he/she was told to monitor the blood pressure and give pain medication as ordered for the leg pain. LPN C said he/she would have reported the incident to the on-call nurse practitioner and asked for an x-ray had he/she been made aware of the incident that had occurred regarding Resident #1. During an interview on 08/13/24 at 3:15 P.M., LPN E said he/she had not been made aware of an incident regarding Resident #1's leg. LPN E said it was reported during shift change on 08/03/24 around 7:00 A.M. by night shift nurse, LPN C, the resident complained of left leg pain. LPN E said he/she did not observe Resident #1 complain during the day. LPN E said had Resident #1 complained of pain he/she would have repositioned the resident first then tried pain medication if repositioning was ineffective. If the resident still had pain, LPN E said he/she would have notified the physician to see if an x-ray was needed. LPN E said if a resident has had a fall or there is an incident and resident had pain an x-ray is normally ordered to rule out any issue, as well as pain management and monitoring. During an interview on 08/14/24 at 10:50 A.M., Registered Nurse (RN) D said he/she had not been made aware of an incident related to Resident #1s leg being injured during a transfer. RN D said on 08/05/24 Resident #1 had not acted like himself/herself and appeared in pain. RN D said an unidentified CNA reported he/she had heard the resident's leg got hurt during a transfer earlier in the week. RN D questioned Resident #1 and assessed the left leg and the resident complained of significant pain. RN D called the on call nurse practitioner and obtained an order to send to the ER for assessment. During an interview on 8/13/24 at 2:38 P.M., the CNA Instructor said he/she goes through the orientation process with the newly hired CNAs. The CNAs/ NAs are trained where to go in the PCC to find a resident's information on diet, transfer status, bowel and bladder status, etc. The CNA Instructor said he/she teaches the NAs how to use the gait belt and Hoyer lift, and then requires a return demonstration of the gait belt and Hoyer lift prior to signing off that skill. Review of NA A's orientation paperwork showed NA A had a signed competency regarding the resident handling policy dated 07/22/24 and signed off competency on lifting techniques and moving a resident on 07/23/24. During an interview on 08/14/24 at 1:00 P.M., the DON confirmed nursing would not have been able to see that an incident had occurred with Resident #1 as the late entry note was not put into the system until 08/06/24. The DON confirmed the late entry regarding the incident had been put in on the wrong date and the incident regarding Resident #1 took place on 08/02/24 at approximately 4:30 P.M. The DON said he/she did not report the incident to the charge nurses so they would be aware and could monitor the resident as the resident had complained of pain. The DON said the incident should have been reported to the charge nurse's so the resident could be monitored. The DON said he/she would expect all staff to utilize the appropriate transfer technique. During an interview on 08/14/24 at 12:53 P.M., the Administrator said he/she would have expected the incident to have been reported to the oncoming nursing staff so the resident could be monitored, as the documented incident note was a late entry and would not have been available for all nursing staff to see. During an interview on 08/14/24 at 10:10 A.M., the Nurse Practitioner (NP) said he/she had not been notified of an incident regarding Resident #1's leg being entangled in his/her wheelchair resulting in pain. The NP said he/she would have ordered an x-ray if an incident occurred to rule out possible injury. NP said he/she would expect the resident's plan of care to be followed. Complaint #MO00240456

Based on interview and record review, the facility failed to notify a resident's family in a timely manor, after a transfer where the resident's left leg became entangled in the wheelchair resulting in pain and subsequent injury, for one resident (Resident #1) out of six sampled residents. The facility also failed to notify the resident's family/responsible party when the resident was transferred to the hospital related to increased pain in the affected leg which was determined to be a fractured femur. The facility census was 66. The facility did not provide a policy regarding the guidelines to notify the resident's family/representative. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated, 06/11/2024, showed: - Diagnoses of hypertension (high blood pressure), peripheral vascular disease (condition in which narrowed blood vessels reduces blood flow to the limbs), heart failure, and diabetes mellitus (high blood sugar); -BIMS score 8, indicating moderate cognitive impairment; -Speech clear and usually makes self understood; -Usually understands others; -No behaviors; -No scheduled pain medication; -Receives as needed pain medication; -Dependent on helper for chair to bed transfers. Review of the resident's medical record showed: -On 08/06/24 at 8:14 A.M., late entry note put in by the Director of Nursing (DON) regarding incident on 08/01/24 at 4:30 P.M. showed: This nurse was walking into the dining room when resident asked to see me. He/she said he/she did not want to eat supper and wanted to go back to his/her room. This nurse pushed him/her via wheelchair back to his/her room when he/she said his/her left leg hurt and he/she wanted a pain pill. The resident continued to state that during a transfer with two aides, the resident's left leg got caught when transferring to the wheelchair. This nurse assessed the left leg. No abnormalities were noted, no bruising or swelling. He/she did ask for pain medication which was administered; -No documentation of family/responsible party notified of the transfer resulting in the resident's leg being caught and the resident's complaints of pain; -On 08/05/24 at 8:55 P.M. note by Registered Nurse (RN) D showed Resident #1 was sent to the hospital for a left leg injury that was causing substantial pain. The on call nurse practitioner was called and gave an order to send the resident out; -No documentation showed the family/responsible party was notified of the resident's transfer to the hospital emergency room . -On 08/06/24 at 7:16 A.M., a nurse's note showed the hospital called and Resident #1 was admitted for left leg femur fracture; -No documentation the family/responsible party was notified of the resident's admission to the hospital. During an interview on 08/14/23 at 9:40 A.M., Licensed Practical Nurse (LPN) C said if there was an incident, the family/responsible party should be notified, as well as the physician. LPN C said anytime a resident is sent to the hospital the family/responsible party is to be notified. During an interview on 08/13/24 at 11:50 A.M., the DON said, he/she did not call the family/responsible party when Resident #1 reported his/her leg was bent back during a transfer into the wheelchair by two aides, reported pain, and requested a pain pill. The DON said the nurse that sent the resident to the hospital should have made the family/responsible party aware of the transfer. During an interview on 08/14/24 at 10:50 A.M., RN D said he/she had not been made aware of an incident related to Resident #1's leg being injured during a transfer. RN D said on 08/05/24 Resident #1 had not acted like himself/herself and appeared in pain. RN D said an unidentified certified nurse aide (CNA) asked him/her to look at Resident #1's leg because the resident complained of pain and the CNA reported he/she had heard the resident's leg got hurt during a transfer earlier in the week. RN D assessed the left leg with no visible abnormalities noted. RN D said Resident #1 complained of significant pain with movement of the left leg. RN D called the on-call nurse practitioner and an order was obtained to send the resident to the emergency room (ER) for assessment. RN D said he/she failed to call and notify the family/responsible party of Resident #1's transfer to the ER. RN D said the family should have been During an interview on 08/12/24 at 3:04 P.M., the resident's Responsible Party (RP) said when he/she visited Resident #1 on 08/03/24, the resident complained of left leg pain and would say don't touch it. The RP thought Resident #1 was sore or uncomfortable as nothing had been reported to him/her. The RP said on 08/06/24 he/she went to visit Resident #1 at the nursing home and was unable to find him/her and was told by staff Resident #1 was sent to the hospital on 08/05/24. The RP said he/she had not been notified there had been an incident nor was he/she notified when Resident #1 was sent to the hospital. During an interview on 08/13/23 at 4:39 P.M., the Administrator said he/she would expect the nurse to notify the family/responsible party if a resident is going to the hospital. Complaint #MO00240456

Based on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of residents' personal funds) for at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months from November 2022 through October 2023. The facility census was 74. Review of the facility's policy titled, Surety Bond, revised March 2021, showed: - A surety bond is an agreement between the facility, the insurance company, and the resident of the State acting on behalf of the resident, wherein in the facility and insurance company agree to compensate the resident for any loss of residents' funds that the facility holds, accounts for, safeguards, and manages; - The facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf of its residents; - All funds (including refundable deposits) entrusted to the facility for a resident are covered by the surety bond; - The purpose of the surety bond is to guarantee that the facility will pay the resident for losses occurring from any failure by the facility to hold, account for, safeguard, and and manage the residents' funds (i.e., losses occurring as a result of acts of errors of negligence, incompetence, or dishonesty). Review of the residents' personal funds account for the last 12 consecutive months from November 2022 through October 2023 showed: - The facility's approved bond amount equaled $66,000.00; - The average monthly balance of the residents' personal funds equaled $50,558.82; - An average monthly balance of $50,558.82 rounded to the nearest thousand equaled $51,000.00, at one and one-half times would equal the required bond amount of at least $76,500.00. During an interview on 12/15/23 at 10:27 A.M., the Business Office Manager (BOM) said the surety bond should be one and one-half times the amount on the ledger. During an interview on 12/15/23 at 9:28 A.M., the Administrator said the surety bond amount should be one and one-half times the amount of the resident trust balance to meet the regulatory requirement.

Based on on observation, interview and record review, the facility failed to maintain an environment free of accident hazards for one (Resident #1) of four reviewed residents. The facility placed hot coffee within reach of the unsupervised resident who had been identified as having a cognitive deficit and a history of spilling beverages. The hot coffee spilled on the resident resulting in second degree burns. The facility's census was 63. 1. Record review of Resident #1's physician's orders [REDACTED]. Review of the plan of care, dated 1/10/12, showed it directed staff to assist in feeding Resident #1 due to the resident wanted to feed him/herself, spilling food and throwing cups. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/2/12, showed Resident #1 required oversight and set-up for meals. Review of a physician's note, dated 4/4/12, showed the physician identified the resident had a second degree burn to the right groin due to spilled coffee. Observation on 4/18/12 at 9:00 A.M. showed Resident #1 had a nine inch by two inch irregular shaped wound to the right thigh. The wound started in a nine inch, straight line across the top of the resident's thigh. (Where the resident's incontinent brief stopped). From the brief area the wound became more irregular. The center of the wound had bright yellow slough and the outside edges were bright red. During an interview on 4/18/12 at 7:30 A.M., the Certified Dietary Manager (CDM) said staff made coffee in the kitchen then poured it into an urn in the dining room. She said the staff normally added milk to Resident #1's coffee to cool it. The CDM said she had been monitoring the temperature of the coffee and that the freshly made coffee in the kitchen measured 170 ?F. During an interview on 4/18/12 at 7:30 A.M., Dietary Staff B said, on 4/3/12, he/she had been asked to get coffee in a sippy cup (Dietary Staff B indicated a tall cup with a lid and straw) for Resident #1. Dietary Staff B obtained the coffee directly from the coffee maker in the kitchen and could not recall if he/she added milk or if he/she placed the hot coffee within the resident's reach. Dietary Staff B said he/she did not know if the resident could drink without assistance but was aware the resident spilled items "all the time". During an interview on 4/18/12 at 11:20 A.M., Certified Nurses Aide (CNA) D said on the day of the incident he/she noticed the resident's cups were empty and asked him about them. The resident did not say he/she spilled the beverages and CNA D assumed the resident drank them. The resident's clothing was covered with a clothing protector and CNA D did not notice spills. During that time period, the resident had to be assisted with meals as he/she knocked items over. During an interview on 4/18/12 at 8:45 A.M., Registered Nurse (RN) A said he/she was notified by staff that the resident had burns. RN A looked at the resident and found a red area on the right upper thigh with skin peeling. RN A said, at the time of the incident, Resident #1 tended to knock over cups and was given assistance with meals. During an interview on 4/18/12 at 1:00 P.M., the Director of Nursing (DON) said the facility did not have a policy for monitoring the dining room. At 1:05 P.M., the DON provided a copy of an assisted feeding policy. Upon further questioning, the DON said the policy was not used by the facility but that it had just been printed from the computer. During an interview on 4/18/12 at 1:15 P.M., the Administrator said RN A conducted the investigation. Interventions to correct the problem included monitoring the resident and providing coffee only when monitored. The Administrator said the incident was discussed with dietary staff but no formal inservice had been conducted. During an interview on 4/18/12 at 1:15 P.M., the Quality Assurance (QA) Nurse said dietary staff should not put coffee out for residents. MO 976