Every finding on record at Stonebridge Villa Marie

Based on observation, interview, and record review, facility staff failed to remove and discard discontinued medication and improperly labeled medication from two of two medication carts and one of two medication rooms. The facility census was 62.1. Review of the facility's policy titled Labeling of Medication Containers, revised 04/07, showed medications shall contain the expiration date when applicable.Review of the facility's policy titled Storage of Medications, revised 04/07, showed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be destroyed.Review of the facility's policy titled Discarding and Destroying Medications, revised 10/16, showed medications will be disposed of in accordance with federal, state, and local regulations.2. Observation on 03/12/26 at 9:46 A.M., showed the rehabilitation medication cart contained:-One bottle of Oyster Shell Calcium 500 milligram (mg) with Vitamin D with expiration date of 11/25;-One Novolog Insulin (a short-acting insulin) pen with an open date of 02/11/26, and an expiration date of 03/11/26-One Aspart Insulin (a short-acting insulin) pen opened and labeled do not use after 12/12/25;-One bottle of Systane (dry eyes) eye drops 0.4-0.3 % opened and undated for;-One Humalog Insulin (a short-acting insulin) pen opened and undated;-One Novolog Insulin pen and one Lantus insulin pen opened and undated;-One Lantus Insulin (a long-acting insulin) and one Novolog pen with opened dates of 02/11/26, and expiration dates of 03/11/26.3. Observation on 03/12/26 at 9:46 A.M., showed Licensed Practical Nurse (LPN) H administered Novolog insulin to Resident #2 and did not check the expiration date. Observation showed the Novolog insulin pen had an open date of 02/11/26 and an expiration date of 03/11/26. During an interview on 03/12/26 at 2:30 P.M., LPN H said he/she did not check the expiration date prior to giving Resident #2 his/her insulin and should have. LPN H said he/she was not aware the insulin had expired when he/she gave it. 4. Review of the Novolog insulin manufacturer's recommendations showed the Novolog is to be discarded 28 days after being opened. Observation on 03/12/26 at 10:00 A.M., showed the Memory Care Unit medication room contained one vial of Tuberculosis (TB) solution (a medication used to test for tuberculosis) with an open date of 08/01/25. 5. Observation on 03/12/26 at 10:20 A.M., showed the Memory Care Unit medication cart contained:-One Aspart Insulin pen open and undated;-One Humalog Insulin pen open and undated;-One Humalog Insulin pen open and undated. 5. During an interview on 03/12/26 at 1:45 P.M., LPN A said whoever opens a medication is responsible to date it. LPN A said all insulins should be dated as they have an expiration date once opened of 28 to 30 days. LPN A said staff administering the medications should check the expiration date prior to giving to a resident. Expired medication should never be administered to a resident. LPN A said if a staff member finds an expired medication, they should remove it from the medication cart and destroy it. During an interview on 03/13/25 at 10:40 A.M., the Infection Preventionist (IP) said if a staff member opens a new medication, it is their responsibility to date it at the time of opening. The IP said all TB solution, eye drops, and insulins should be dated when opened because certain medications expire faster than others. The IP said staff should check the expiration date on each medication prior to administration and should never give a resident an expired medication. The IP said if the medication is expired staff should remove the expired mediation. During an interview on 03/13/25 at 11:40 A.M., the Director of Nursing (DON) said whoever opens the medication should date it at that time. The DON said all insulins, eye drops, and TB solutions should be dated when they are opened. The DON said medications all have different expiration dates after opening. The DON said he/she expects staff to check the expiration date prior to administer a medication to a resident a medication. The DON said if a medication is expired it should be destroyed. Expired medication should never be administered to a resident. During an interview on 03/13/25 at 12:10 P.M., the administrator said he/she expects all insulins, eye drops, and TB solutions to be dated when opened and the person opening the medication is responsible to do it. The administrator said staff administering medications are responsible to check the expiration date on the medication prior to giving it to a resident and should never give a resident an expired medication. The administrator said he/she expects staff to remove and destroy expired medications, so they are not administered.

Based on observation, interview, and record review, facility staff failed to use enhanced barrier precautions (EBP, an infection control practice that requires staff to wear personal protective equipment (PPE, protective equipment such as gowns, gloves, goggles, and masks) to prevent or minimize exposure to hazards) for four residents (Resident #1, #5, #20, and #28) of 17 sampled residents. The facility census was 62.1. Review of the facility policy titled Enhanced Barrier Precautions, dated 04/04/24, showed it is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDRO). EBP refers to the use of gowns and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required PPE, and the high-contact resident care activities that require the use of a gown and gloves. An order for EBP will be obtained 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 medical devices (e.g., central lines, urinary catheters, feeding tubes) even if the resident is not known to be infected or colonized with a MDRO; -Implementation of EBP is to make gowns and gloves available immediately outside of 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 dressing, bathing, transferring, providing hygiene, device care or use, and wound care – any skin opening requiring a dressing. EBP should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/27/26, showed staff assessed the resident as cognitively intact with wounds. Review of the resident's care plan, revised 03/06/26, showed: -Risk for skin breakdown with venous ulcers on left lower extremity and foot; -Required assistance with cares; -Did not contain direction for EBP use. Review of the resident's physician's order sheet (POS), dated 03/10/26, showed: -03/04/26: Left dorsal foot wound: Apply Vaseline gauze cover with dressing, wrap with ACE bandage, change daily and as needed; -03/04/26: Left lower extremity: Cleanse wound, apply Vaseline gauze cover with dressing, cover with ACE bandage, change daily and as needed. Observation on 03/10/26 at 10:54 A.M., showed the resident in his/her wheelchair with his/her left lower extremity wrapped in a bandage. Observation showed the resident's room did not have an EBP sign to alert staff for EBP. Observation showed the resident's room did not have PPE inside or outside. Observation on 03/11/26 at 9:04 A.M., showed the resident in his/her wheelchair with his/her left lower extremity wrapped in a bandage. Observation showed the resident's room did not have an EBP sign to alert staff for EBP. Observation showed the resident's room did not have PPE inside or outside. Observation on 03/12/26 at 2:30 P.M., showed the resident in his/her wheelchair with his/her left lower extremity wrapped in a bandage. Observation showed the resident's room did not have an EBP sign to alert staff for EBP. Observation showed the resident's room did not have PPE inside or outside. Observation on 03/13/26 at 8:55 A.M., showed the resident in his/her wheelchair with his/her left lower extremity wrapped in a bandage. Observation showed the resident's room did not have an EBP sign to alert staff for EBP. Observation showed the resident's room did not have PPE inside or outside. During an interview on 03/11/26 at 10:45 A.M., the Infection Preventionist (IP) said the resident's lower extremities swell and cause fluid filled blisters that weep and open. During an interview on 0/13/26 at 12:10 P.M., the administrator said the resident should be on EBP due to chronic wounds on his/her left lower extremity. The administrator said he/she was not aware the resident did not have an EBP sign on his/her door but should have. 3. Review of Resident #5's Quarterly MDS assessment, dated 01/09/26, showed staff assessed the resident as: -Severely cognitively impaired; -At risk for pressure ulcers; -Dependent on staff for mobility, toileting, and shower/bathe self; -Required substantial/maximum assistance from staff for personal hygiene, and upper/lower body dressing; -Diagnoses of diabetes, dementia, anxiety, depression, and psychotic disorder. Review of the resident's care plan, dated 10/22/25, showed staff did not document the need for EBP. Review of the resident's POS, dated March 2026, showed the following orders: -02/19/26 cleanse open area to left gluteal cleft with wound cleanser, apply Vaseline guaze and cover with dressing daily and as needed PRN; -03/11/26 left ischium (lower portion of hip bone): cleanse wound and apply hydrocolloid sheet (A gel-forming bandage used to block water and bacteria) twice a week on Wednesday and Saturday and as needed. Observation on 03/10/26 at 10:43 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP, and showed the resident's room did not have PPE inside or outside the room. Observation on 03/11/26 at 8:57 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP, and showed the resident's room did not have PPE inside or outside the room. Observation on 03/12/26 at 8:16 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP, and showed the resident's room did not have PPE inside or outside the room. Observation on 03/13/26 at 8:51 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP, and showed the resident's room did not have PPE inside or outside the room. Observation on 03/12/26 at 11:41 A.M., showed Licensed Practical Nurse (LPN) A performed wound care to resident's left ischium, and Certified Nurse Aide (CNA) I assisted the LPN. LPN A and CNA I did not wear a gown when they provided care. During an interview on 03/12/26 at 11:50 A.M., LPN A said he/she would use a gown if a resident had a chronic wound to limit bacteria exposure. LPN A said the resident's wound was not considered chronic. The LPN said gowns and gloves should be used for close patient care contact, and if a resident has a tube feeding, catheter, and wounds for greater than 90 days. The LPN said he/she had been taught if a resident has a wound longer than 90 days, EBP should be used. LPN A said usually the Assistant Director of Nursing (ADON) will put up the EBP signs and place the PPE supplies. 4. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -At risk for pressure ulcers; -Did not reject care. Review of the resident's POS showed an order, dated 01/16/26, for right hand wound care, apply antimicrobial foam dressing twice a week on Tuesday and Friday and as needed for saturation, soiling or dislodgment. Review of the resident's care plan, dated 12/15/25, showed staff did not document the need for EBP. Observation on 03/10/26 at 10:44 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP, and showed the resident's room did not have PPE inside or outside the room. Observation on 03/11/26 at 9:04 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP, and showed the resident's room did not have PPE inside or outside the room. Observation on 03/12/26 at 8:16 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP, and showed the resident's room did not have PPE inside or outside of the room. Observation on 03/13/26 at 8:52 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP, and showed the resident's room did not have PPE inside or outside the room. Observation on 03/13/26 at 10:36 A.M., showed LPN F performed wound care to the resident's right hand, and CNA G assisted. LPN F and CNA G did not wear a gown during the care. During an interview on 03/13/26 at 10:42 A.M., LPN F said with any resident who has active open wounds, staff should wear a gown and gloves during care, and the resident should have a sign on the door that directs staff regarding the type of PPE to wear. LPN F said he/she did not know why the resident was not on EBP, as the DON would normally put up the signs and place the supplies. During an interview on 03/13/26 at 10:53 A.M., CNA G said EBP requires the use of gowns and gloves, and he/she believes it is for wounds that are present for three or more months, catheters, and feeding tubes. The CNA said EBP is used if staff are providing direct care like transfers, or any high-contact care activities. He/she said there is usually a sign on the door and PPE supplies available in a cart outside the room. CNA G said his/her understanding is if the resident had not had the wound long enough, then he/she does not have to wear a gown and did not know why the resident did not have EBP signs posted, but it is probably because the resident has not had the wound for very long. 5. Review of Resident #28's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and had a surgical wound. Review of the resident's care plan, dated 02/13/26, showed: -Ostomy (Surgical procedure that brings one end of the intestine out through the abdominal wall) and need for assistance to care for it; -Did not contain direction for EBP use. Review of the resident's POS, dated 03/13/26, showed an order, dated 03/04/26, for abdominal midline wound, cleanse with wound cleanser, apply antimicrobial foam dressing and cover with transparent film three times a week and as needed. Observation on 03/10/26 at 11:08 A.M., showed the resident in bed and had an ostomy that hung from under his/her shirt. Observation showed the resident's room did not have an EBP sign to alert staff of the need for EBP. Observation showed the resident's room did not have PPE inside or outside. Observation on 03/11/26 at 10:05 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP. Observation showed the resident's room did not have PPE inside or outside. Observation on 03/12/26 at 11:18 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP. Observation showed the resident's room did not have PPE inside or outside. Observation on 03/13/26 at 9:10 A.M., showed the resident's room did not have an EBP sign to alert staff of the need for EBP. Observation showed the resident's room did not have PPE inside or outside. During an interview on 03/10/26 at 11:08 A.M., the resident said he/she had a newer ostomy that had not healed completely. During an interview on 03/13/26 at 10:40 A.M., the IP said the resident has an unhealed surgical wound from his/her ostomy site and should have an EBP sign on his/her door. The IP said he/she was not aware there was not a sign on the resident's door and not sure who is responsible to ensure EBP signs are placed on doors. During an interview on 03/13/26 at 12:10 P.M., the administrator said the resident should be on EBP due to an unhealed ostomy surgical wound site. The administrator said he/she was not aware the resident did not have an EBP sign on his/her door but should have. 6. During an interview on 03/13/26 at 10:40 A.M., the IP said the purpose of EBP is to protect the residents from any germs staff may be carrying, and if a resident requires EBP then staff are to wear a gown and gloves when providing cares. The IP said EPB would be required for any residents with a chronic wound over 90 days old, and any unhealed surgical wound. The IP said if a resident has a new wound EBP would not have to be used, EBP is only for wounds older than 90 days. The IP said he/she is not sure who is responsible to put the EBP signs on the doors, or remove them, but without a sign on the door staff would not know to wear the PPE when needed. During an interview on 03/13/26 at 11:41 A.M., the DON said he/she has trained staff on hire, yearly, and with training fairs on EBP. He/she understood that EBP would be used for chronic wounds with no improvement, and Centers for Medicare Medicaid (CMS) guideline does not give a time frame for chronic wounds. He/she said the facility has determined that to be 90 days, but he/she is open to better practice. The DON said bacteria could be introduced, and EBP is to protect the resident from staff, and should be used during high-contact care activities, and would be for any resident with wounds and/or colostomy. The DON said typically he/she or the IP would put up the signs and place the PPE carts, and they are also available in central supply for staff to have access if it is needed on nights or weekends, and staff have been educated on where to get the signs and PPE supplies. The DON said due to the facility's previous criteria for wounds requiring EBP to be present 90 days or longer, he/she would not have expected Resident #5 or Resident #20 to be on EBP. During an interview on 03/13/26 at 12:09 P.M., the Administrator said EBP should be used on chronic wounds, anyone on antibiotics, catheters, PICC lines, tube feeding, and open ostomy or open wound. The administrator said he/she is new to the facility and believes the wound criteria for the facility is if a wound is chronic or older than 90 days, due to the definition of a chronic wound. The Administrator said EPB is used to prevent the spread of Methicillin-Resistant Staphylococcus Aureus (MRSA, a type of staph bacteria resistant to common antibiotics), or anything like that. He/she said if a wound is open it should qualify for EBP. The administrator said there was a misunderstanding for when EBP should be started, and the DON is responsible for putting up the signs and placing the PPE carts, since there is not an Assistant Director of Nursing (ADON) right now, and if the DON or future ADON is not available, like on a weekend or night shift, then it would be the charge nurse's responsibility and they have been educated on where to get the supplies.

Based on observation, interview, and record review, facility staff failed to develop a comprehensive care plan to reflect the care needs of two residents (Resident #1 and #28) out of 17 sampled residents. The facility census was 62. 1. Review of the facility's policy titled Care Plans, Comprehensive Person Centered, revised 10/17, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her representative develops and implements a comprehensive, person-centered care plan for each resident; -Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change; -The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcomes are not met; and at least quarterly in conjunction with the required quarterly Minimum Data Set (MDS), a federally mandated assessment tool. 2. Review of Resident #1's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with wounds. Review of the resident's care plan, revised 03/06/26, showed staff identified the resident as at risk for skin breakdown with venous ulcers on left lower extremity and foot. Review showed the care plan did not contain direction for EBP use. Review of the resident's Physician's Orders Sheet (POS), dated 03/10/26, showed: -03/04/26: Left foot: Cleanse wound, apply dressing, change daily and as needed; -03/04/26: Left lower extremity: Cleanse wound, apply dressing, cover with ACE bandage, change daily and as needed. Observation on 03/10/26 at 10:54 A.M., showed the resident in his/her wheelchair with his/her left lower extremity wrapped in a bandage. Observation on 03/13/26 at 8:55 A.M., showed the resident in his/her wheelchair with his/her left lower extremity wrapped in a bandage. During an interview on 03/11/26 at 10:45 A.M., the Infection Preventionist (IP) said the resident has fluid blisters that wept and popped open. 3. Review of Resident #28's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact, had a surgical wound, and received oxygen therapy. Review of the resident's care plan, dated 02/13/26, showed: -Chronic pain related to surgical non-healing wound; -Ostomy and need for assistance to care for it; -Did not contain direction for EBP use; -Did not contain directions for oxygen use. Review of the resident's POS, dated 03/13/26, showed: -02/03/26: Oxygen at 3 liters per nasal canula continuously; -02/05/26: Right ileostomy (opening in the abdominal wall with exposed intestine to rid the body of waste): Apply and change pouch every three days and at the first sign of a leak. -03/04/26: Abdominal surgical wound (from ostomy placement): Cleanse, apply methylene blue foam (a surgical wound dressing) and cover with transparent film three times a week and as needed. Observation on 03/10/26 at 11:08 A.M., showed the resident had an ostomy pouch that hung out from under his/her shirt. Observation showed the resident wore oxygen. During an interview on 03/10/26 at 11:08 A.M., the resident said he/she had a newer ostomy that had not healed completely, and his/her skin was irritated. Observation on 03/13/26 at 9:10 A.M., showed the resident wore oxygen. During an interview on 03/13/26 at 10:40 A.M., the IP said the resident has an unhealed surgical wound for his/her ostomy site and should have an EBP care plan. The IP said the resident requires continuous oxygen and he/she should have an oxygen care plan. 4. During an interview on 03/13/26 at 11:29 A.M., the MDS Coordinator said he/she had only been at the facility for a few weeks and is trying to get the care plans up to date. The MDS Coordinator said the floor staff can update the care plans. The MDS Coordinator said care plans should be updated quarterly and with any changes needed as they happen. The MDS Coordinator said the resident's care plan should contain EBP if the resident had wounds, and oxygen use. The MDS Coordinator said the care plan should be accurate and individualized so everyone would know what the resident needs. During an interview on 03/13/26 11:41 AM the Director of Nursing (DON) said EBP, and oxygen should be on the care plan so everyone knows what the resident requires for his/her care. The DON said he/she did not know the care plans were not updated, but he/she expects them to be updated quarterly and with changes as needed. During an interview on 03/13/26 at 12:09 P.M., the administrator said he/she has been at the facility for six weeks and there was not a MDS Coordinator in house until 2/23/26, so the interdisciplinary team was trying to keep on top of updating care plans. The Administrator said he/she would expect to see oxygen and EBP use on a residents' care plan. The Administrator said he/she would expect anything about how to care for the resident on the care plan.

Based on observation, interview, and record review, facility staff failed to update care plans to address the care needs of four residents (Residents #6, #7, #20, and #43) out of 17 sampled residents. The facility census was 62.1. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated March 2017, showed a comprehensive, person-centered care plan will describe services that would otherwise be provided but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; and will aid in preventing or reducing decline in the resident's functional status and/or functional levels. Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcomes are not met; and at least quarterly in conjunction with the required quarterly Minimum Data Set (MDS), a federally mandated assessment tool. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies. 2. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -In a persistent vegetative state without discernable consciousness; -Dependent on staff for all cares and mobility;-Had limited range of motion impairment in both upper and lower extremities; -Diagnoses of traumatic brain dysfunction; hemiplegia (a form of paralysis affecting one side of the body, usually caused by brain damage), and aphasia (a disorder that affects the ability to speak).Review of the resident's physician order sheet (POS) showed an order, dated 02/19/26, to ensure the resident has his/her leg and arm braces during the day and night shift for contractures (permanent tightening and shortening of muscles and other tissue around a joint causing stiffness). Review of the resident's care plan, dated 12/26/25, showed staff did not document the resident's contractures or use of splints. Observation on 03/11/26 at 12:45 P.M. showed the resident in bed and did not have his/her splints on. During an interview on 03/13/26 at 10:42 A.M., Licensed Practical Nurse (LPN) G said if a resident has contractures and require splints, the splints should be on the care plan, so staff know. During an interview on 03/13/26 at 10:53 A.M., Certified Nurse Aide (CNA) G said contractures and splints should be on the care plan, so staff know whether to provide the devices. The CNA said he/she was told about a month ago the resident is supposed to wear hand and knee braces. 3. Review of Resident #7's Annual MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Received antipsychotics and antidepressants;-Diagnoses of Alzheimer's disease, dementia, anxiety and depression. Review of the resident's POS, dated March 2026, showed the resident did not have current orders for antipsychotics or antidepressants. Review of the resident's care plan, dated 03/10/26, showed staff did not document the discontinuation of the antipsychotic and/or antidepressant medications. During an interview on 03/13/26 at 10:42 A.M., LPN F said nursing does not typically update the care plans because the MDS Coordinator does. LPN F said he/she would expect if a resident was no longer taking antipsychotics or antidepressants that the information would be removed from the care plan. 4. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Unable to complete the Brief Interview for Mental Status (BIMS), used to determine cognitive function; -Had limited range of motion on one side of the upper and lower extremities; -Dependent on staff for all mobility; -Had a fall since the prior assessment, one fall with injury; -Diagnoses of Alzheimer's Disease, aphasia, dementia, and hemiplegia; -Does not reject care. Review of the resident's progress notes, dated 02/25/26, showed the resident had a fall out of his/her Broda chair. Review of the resident's care plan, dated 12/15/25, showed staff were directed to place a rolled washcloth in the resident's hand as needed. Review showed the care plan did not contain an intervention for the resident's fall on 02/25/26, or direction for staff about the resident's refusal of care. During an interview on 03/12/26 at 3:17 P.M., LPN A said the resident's contracture is so tight the hand is hard to get open and he/she tried to use a washcloth when the resident lets him/her, but the resident will often pull it out, or refuse. LPN A said the resident does have a history of refusing care and it should be documented on the care plan. During an interview on 03/12/26 at 3:24 P.M., the Director of Nursing (DON) said the resident's hand is so tight it is hard to get anything in there. The DON said the resident will remove the washcloth or will refuse it. The DON said refusals should be documented. During an interview on 03/13/26 at 10:42 A.M., LPN F said falls should be updated on the care plan and can be complete by nursing staff or the MDS Coordinator. During an interview on 03/13/26 at 10:53 A.M., CNA G said contractures and falls should be listed on the care plan, so staff know how to provide care. The CNA said if a resident refuses care that should be on the care plan as well. The CNA said the resident refused the washcloth in his/her hand. 5. Review of Resident #43's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Moderate cognitive impairment;-Received an antipsychotic medication;-Diagnosis of dementia, major depressive disorder, anxiety and depression.Review of the resident's POS, dated 03/10/26, showed an order for Abilify (an antipsychotic medication) 2 milligrams (mg) daily. Review of the resident's care plan, revised 10/03/25, showed the care plan did not contain direction for antipsychotic medication use. 6. During an interview on 03/13/26 at 11:29 A.M., the MDS Coordinator said he/she had only been at the facility for a few weeks and is trying to get the care plans up to date. The MDS Coordinator said everybody can update the care plans. He/she said if a resident's psychotropic medications are discontinued the medications should be removed from the care plan, but behaviors to monitor for should be added. The MDS Coordinator said if a receives an antipsychotic medication it should be on the care plan. The MDS Coordinator said contractures, splint use and refusal of care should be on the care plan. During an interview on 03/13/26 11:41 AM the DON said care plans should be updated within 24 hours after a fall with a new intervention. The DON said contractures, devices, and splints should be on the care plan, so everyone knows what the interventions are and to help prevent further injury or decline. The DON said psychotropic use and refusal of care should be on the care plan, so staff can monitor for behaviors. The DON said he/she did not know the care plans were not updated, and had thought some of them had been updated with interventions, and that the MDS Coordinator, himself/herself and the interdisciplinary team (IDT) are able to update care plans. During an interview on 03/13/26 at 12:09 P.M., the Administrator said there was not a MDS Coordinator in house until 2/23/26, so IDT tried to stay on top of updating care plans. The administrator said nurses should be able to update care plans but does not know if they are trained to do that, as he/she has only been here since the middle of January. The Administrator said he/she would expect contractures, splints, and/or devices, anything about how to care for the resident should be on the care plan, and if the resident refuses cares or treatments that should be on the care plan as well.

Based on observation, interview, and record review, facility staff failed to document falls and neurological assessment for one resident (Resident #1) of two sampled residents. The facility census was 62.1. Review of the facility's policy titled Falls, revised 04/22 showed staff will evaluate and document falls that occur including an observation of the event identifying them as witnessed or unwitnessed. The nurse will assess and report the resident's neurological status; Review of the facility's policy titled Neurological Assessment, revised 10/2010, showed a neurological assessment is to be completed upon physician's order, after an unwitnessed fall, after a fall with suspected head injury, and when indicated by resident condition. Perform neurological checks with frequency as ordered per fall protocol. If the resident refused the procedure document the refusal.Review of the facility's form titled Post Fall 72 Hour Monitoring Report, dated 07/08, showed this assessment should be completed at the following intervals for a fall that is unwitnessed or in which the head is struck requiring neurological checks:-Initial assessment, followed by every 15 minutes for four sets, every 30 minutes for two sets, every hour for two sets, every shift for 72 hours;-Document vital signs, orientation, skin assessment, pain, range of motion and strength of extremities, eye/pupil response. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/27/26, showed staff assessed the resident as cognitively intact and had falls with injury. Review of the resident's care plan, revised 03/06/26, showed:-Cognition concerns related to a stroke;-Resistive to care-Required assistance with cares;-At risk for falls with multiple falls documented.Review of the resident's medical record nurse's notes showed staff documented the resident had falls on:-01/24/26: unwitnessed fall and did not contain documentation staff completed neurological checks; -02/02/26: unwitnessed fall and did not contain documentation staff completed neurological checks; -02/09/26: unwitnessed fall and did not contain documentation staff completed neurological checks; -02/21/26: unwitnessed fall and did not contain documentation staff completed neurological checks; -03/05/36: unwitnessed fall and did not contain documentation staff completed neurological checks; -03/06/26: unwitnessed fall and did not contain documentation staff completed neurological checks; -03/06/26: staff documented the resident had a fall. Staff did not documentation if the fall was witnessed or unwitnessed and did not contain a completed neurological check; -03/10/26: staff documented the resident had a fall. Staff did not documentation if the fall was witnessed or unwitnessed and did not contain a completed neurological check.During an interview on 03/13/26 at 10:40 A.M., the Infection Preventionist (IP)/charge nurse said if a resident falls the charge nurse to document their findings and if the fall was witnessed or unwitnessed in the resident's nurse's notes. The IP/charge nurse said if the fall was unwitnessed, or they hit their head staff are expected to complete a neurological check per the facility protocol. The IP/charge nurse said the form should be filled out and there should not be blanks. During an interview on 03/13/26 at 11:40 A.M., the Director of Nursing (DON) said if a resident falls, he/she expects staff to document the details of the fall including if the fall was witnessed or unwitnessed, or if the resident hit their head. The DON said if the fall is unwitnessed or if the resident hit their head staff are expected to begin neurological checks and follow the facility's form protocol. The DON said he/she expects the form to be completed in its entirety and not have any blank areas. The DON said if staff do not document properly and completely the next shift will not know what to do to ensure the resident gets the proper care. The DON said he/she is responsible to oversee and follow up to ensure staff are charting as required. During an interview on 03/13/26 at 12:10 P.M., the administrator said staff should determine if a resident fall was witnessed or unwitnessed and perform the correct assessments. The administrator said he/she expects staff to complete neurological checks per the facility form protocol for any unwitnessed fall or a fall with a head injury. The administrator said he/she has been at the facility for six weeks and was not aware not all fall documentation and neurological checks were not being completed.

Based on observation, interview, and record review, facility staff failed to obtain orders for a Bilevel Positive Airway Pressure (BiPAP) (a noninvasive ventilator) for one resident (Resident #2) of one sampled. The facility census was 62.1. Review of the facility's policy titled Oxygen Safety, revised 01/18, showed staff, residents and families will be educated on oxygen safety precautions in accordance with their roles and responsibility. Review of the facility's policy titled BiPAP Support, revised 03/25, showed only a qualified and properly trained staff member should administer oxygen through a BiPAP mask. Review the physician's order to determine the oxygen concentration and flow, and the Positive End Expiratory Pressure (PEEP) pressure for the machine. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/17/26, showed staff assessed the resident as cognitively intact with diagnoses of respiratory failure and obstructive sleep apnea (periods of breathlessness during sleep). Review of the resident's care plan, revised 02/21/26, showed BiPAP therapy per orders. Review of the resident's Physician Order Summary (POS), dated 03/10/26, showed POS did not contain orders for BiPAP use. Observation on 03/10/26 at 11:34 A.M., showed a BiPAP machine next to the resident's bed. Observation on 03/11/26 at 2:10 P.M., showed a BiPAP machine next to the resident's bed. Observation on 03/12/26 at 9:46 A.M., showed a BiPAP machine next to the resident's bed. Observation on 03/13/26 at 8:50 A.M., showed a BiPAP machine next to the resident's bed. During an interview on 03/13/26 at 10:40 A.M., the Infection Preventionist (IP)/charge nurse said the charge nurse is responsible to obtain any orders for a resident and ensure they are documented on the resident's POS. The IP/charge nurse said the Director of Nursing (DON) is responsible to oversee all staff and ensure the residents have proper orders and the orders are being followed. The IP/charge nurse said he/she was not aware the resident was missing orders for BiPAP. The IP/charge nurse said the resident should have those orders on his/her POS. During an interview on 03/13/26 at 11:40 A.M., the DON said the charge nurse is responsible to obtain orders for the resident and put the orders on the POS. The DON said he/she was not aware the resident did not have orders for BiPAP. The DON said the resident should have an order for BiPAP on his/her POS because the resident did use the BiPAP. The DON said the orders are needed so staff know what settings the BiPAP should be set on. The DON did not know why the resident did not have BiPAP orders but that it could have been missed to frequently admissions and discharges. During an interview on 03/13/26 at 12:10 P.M., the administrator said the DON is responsible to oversee the charge nurse to ensure a resident has correct orders to meet their care needs. The Administrator said the resident should have orders for his/her BiPAP.

Based on observation, interview, and record review, facility staff failed to obtain physician's orders for the use of side rails for two residents (Resident #2 and #23) of three sampled residents. The facility census was 62. 1. Review of the facility's policy titled Proper Use of Side Rails, revised 09/22, showed the facility will obtain a physician's order for the use of the specific side rails and medical diagnosis, condition, symptoms, or functional reason for the use of side rails. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's care plan, revised 02/21/26, showed staff documented a physician's order will be current for side rails to be used. Review of the resident's Physician Order Sheet (POS), dated 03/10/26, did not contain orders for side rail use. Observation on 03/11/26 at 10:15 A.M., showed the resident in bed with both upper side rails in the upright position. Observation on 03/12/26 at 3:00 P.M., showed the resident in bed with both upper side rails up on his/her bed. Observation on 03/13/26 at 8:50 A.M., showed the resident laid in bed with both upper side rails up on his/her bed. 3. Review of Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.Review of the resident's care plan, revised 01/18/26, showed a physician's order will be current for side rails to be used. Review of the resident's POS, dated 03/10/26, showed it did not contain and order for side rail use.Observation on 03/10/26 at 11:05 A.M., showed the resident in bed with both upper side rails up. Observation on 03/11/26 at 9:08 A.M., showed the resident in bed with both upper side rails in the upright position. Observation on 03/12/26 at 11:15 A.M., showed the resident in bed with both upper side rails up. 4. During an interview on 03/13/26 at 10:40 A.M., the Infection Preventionist (IP) said he/she was not aware these residents did not have orders for side rails. The IP said the residents should have an order for side rails on the POS.During an interview on 03/13/26 at 11:40 A.M., the DON said the charge nurse is responsible to obtain orders for the residents and document the orders on their POS. The DON said he/she was not aware these residents did not have orders for side rails. The DON said these residents should have an order for side rails. During an interview on 03/13/26 at 12:10 P.M., the Administrator said the charge nurse is responsible to obtain any new orders, and the DON is responsible to oversee the charge nurse to ensure a resident has correct orders to meet their care needs. The Administrator said if a resident has side rails on their bed, he/she would expect them to have a physician's order.

Based on observation, interview, and record review, facility staff failed to post the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SA) in an accessible location for residents and visitors to view in the memory care unit. The census was 62.1. Review of the facility's policy titled, Facility Postings, undated, showed facility staff will post the required postings in an area accessible to all staff and residents. Facility postings should include a list of names, addresses (mailing and email), and a telephone number of all pertinent state agencies including the SA. Observation on 03/10/26 at 10:30 A.M., showed staff did not post the name, address, and toll-free telephone number for the Elder Abuse Hotline in an accessible location on the memory care unit for residents or visitors to use if needed. Observation on 3/13/26 at 11:00 A.M., showed staff did not post the name, address, and toll-free telephone number for the Elder Abuse Hotline in an accessible location on the memory care unit for residents or visitors to use if needed. During an interview on 03/12/26 at 2:11 P.M., Certified Nurse Aide (CNA) C said he/she is unsure if there is a hotline number posted on the memory care unit. The hotline information is posted in employee break room. He/She said if a resident or family member had a concern, he/she would direct them to the charge nurse. During an interview on 03/12/26 at 2:18 P.M., Licensed Practical Nurse (LPN) A said he/she does not remember seeing the hotline number posted on the memory care unit. He/She said it is important to have the hotline number posted so residents, family members, and/or visitors can call if they have a complaint or need a resolution to a problem or concern. During an interview on 03/13/26 at 11:50 A.M., the Director of Nursing (DON) said he/she does not know if the elder abuse hotline number is posted on the memory care unit, but it should be. He/She said everyone should be able to call if they need to report something even on the memory care unit. During an interview on 03/13/26 at 12:26 P.M., the administrator said he/she does not know if the hotline number is posted on the memory care unit. The administrator said the hotline information is posted in the main entrance for everyone who comes and goes to see. He/She said he/she expects it to be visible for all residents and visitors. He/She said it's important to have the hotline number so residents can call if they feel threatened, abused, scared, or not treated right.

Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to change gloves and wash/sanitize hands during perineal care for two residents (Resident #1, and #2) of two sampled residents, and failed to properly dispose of contaminated linens from one resident's (Resident #3's) room. Facility staff failed to implement the enhanced barrier precautions (EBP) (an infection control intervention) policy when they did not properly alert staff of residents who required EBP and place appropriate personal protective equipment (PPE) in proximity for one resident (Resident #1) of one sampled resident that required EBP during perineal care and wound care. The facility census was 68. 1. Review of the facility's Infection Prevention and Control Manual-Standard Precautions policy, dated 2017, showed staff are directed as follows:-Hand hygiene continues to be the primary means of preventing the transmission of infections;-Alcohol-based hand rub (ABHR)/ hand sanitizer can be used instead of soap and water in all clinical situations except when hands are visibly soiled, or after caring for a resident with known or suspected infections;-Soap, water, ABHR, and a sink should be readily available in appropriate locations including but not limited to resident care areas;-Remove gloves after contact with a patient, bodily fluids, and the surrounding environment using proper technique to prevent hand contamination;-Change gloves during patient care if the hands will move from a contaminated body site (example, perineal area) to a clean body site (example, face, clothing);-Disposal of waste is also handled as though all body fluids are infectious;-Potential contaminated articles are stored and disposed of in appropriate containers (example, items saturated as evidenced by blood or body fluid should be placed in properly labeled biohazard bags).2. Review of Resident #1's Discharge-Return Anticipated-Minimum Data Set (MDS), a federally mandated assessment, dated 07/01/25, showed staff assessed the resident as severely cognitive impaired, dependent with toileting, and always incontinent of bowel and bladder.Observation on 07/09/25 at 1:34 P.M., showed Certified Medication Technician (CMT) D and Certified Nursing Assistant (CNA) E entered the resident's room to provide incontinence care. CMT D and CNA E did not wash his/her hands or use hand sanitizer between glove changes during incontinence care or before they left the room, to prevent the spread of infection. During an interview on 07/09/25 at 1:52 P.M., CNA E said he/she did not perform hand hygiene between glove changes because he/she did not have hand sanitizer close by, and he/she just forgot to wash his/her hands before he/she left the room. He/She said it is important to perform proper hand hygiene to prevent the spread of infection. During an interview on 07/09/25 at 2:32 P.M., CMT D said he/she did not perform hand hygiene between glove changes because of oversight and he/she did not have hand sanitizer close by. He/She said it is important to perform proper hand hygiene to prevent the spread of infection.3. Review of Resident # 2's Quarterly MDS, dated [DATE], showed the facility assessed the resident as follows:-Severe cognitive impairment;-Dependent on staff for toileting, transfers, personal hygiene and bathing;-Impairment to both lower extremities;-Always incontinent of bladder and bowel.Observation on 07/09/25 at 2:15 P.M., showed CNA F entered the resident's room to provide perineal care. CNA F did not wash his/her hands before he/she placed gloves on. CNA F removed the soiled brief and cleaned the residents front and back side. With the same soiled gloves, CNA F placed a clean brief, pants, and covered the resident with their blanket. CNA F gathered trash, removed gloves and left the room. During an interview on 07/09/25 at 2:35 P.M., CNA F said he/she should have washed his/her hands when he/she entered the room, before he/she placed his/her gloves on. CNA F said he/she should have changed his/her gloves between clean and dirty tasks. 4. During an interview on 07/09/25 at 3:25 P.M., the Assistant Director of Nursing (DON) said staff should wash hands before care, after care, when hands are visibly soiled, between dirty and clean tasks, and perform appropriate hand hygiene between glove changes. He/She said staff should also change gloves when soiled or when going from a dirty to clean task.During an interview on 07/09/25 at 3:54 P.M., the Director of Nursing (DON) said staff should wash hands before care, after care, when hands are visibly soiled, between dirty and clean tasks, and perform appropriate hand hygiene between glove changes. He/She said staff should change gloves when soiled or when going from a dirty to clean task, and he/she is responsible to ensure staff perform proper hand hygiene to prevent the spread of infections.5. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, and received anticoagulant medications. Observation on 07/09/25 at 9:37 A.M., showed the resident's head on a pillowcase with scattered dark reddish-brown stains, and multiple linens with dark reddish-brown stains, unbagged on a recliner in the resident's room.During an interview on 07/09/25 at 9:38 A.M., Licensed Practical Nurse (LPN) B said he/she assessed the resident around 7:45 A.M. for bleeding from his/her lips and skin, directed the CNAs to finish cleaning the resident and place the blood soiled linens in a red bag. He/She said he/she was not sure why the CNAs left the soiled linens unbagged inside the room. During an interview on 07/09/25 at 2:45 P.M., CNA J said it was a miscommunication, the nurse asked him/her to go finish assisting other residents while he/she took care of the resident's bandage, then come back and retrieve the soiled linens. CNA J he/she just forgot to go back to the room.During an interview on 07/09/25 at 3:25 P.M., the ADON said staff have been educated and are expected to place linens soiled with blood in a red biohazard bag and take to the dirty utility room for infection control.During an interview on 07/09/25 at 3:54 P.M., the DON said he/she expects staff to place blood soiled linens in a trash bag, removed from the room in a red bag, and placed in the dirty utility room for further treatment.6. Review of the facility's Enhanced Barrier Precautions policy, dated September 2022, showed staff are directed as follows: -EBP refer to the use of gown and gloves during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organism (MDRO) as well as those at increased risk of MDRO acquisition (example, residents with wounds or indwelling medical devices);-An order for EBP will be obtained for residents with any wounds (example, chronic wounds such as pressure ulcers, diabetic wounds, unhealed surgical wounds) and/or indwelling medical devices (example, urinary catheters, feeding tubes) even if the resident is not known to be infected or colonized with a MDRO;-Make gown and gloves available immediately outside of 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 dressing, bathing, providing hygiene, changing linens, changing briefs or assisting with toileting, wound care (any skin opening requiring a dressing);-EBP should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed.7. Review of Resident #1's admission MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, used a feeding tube for nutrition, and received pressure ulcer care. Observation on 07/09/25 at 11:35 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in proximity of the room.Observation on 07/09/25 at 1:34 P.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in proximity of the room. CMT D and CNA E did not wear a gown for EBP when they performed incontinence care.Observation on 07/09/25 at 1:51 P.M., showed Licensed Practical Nurse (LPN) A provided wound care to the resident and did not wear a gown when he/she performed wound care to the resident's left hip.During an interview on 07/09/25 at 1:52 P.M., CNA E said he/she was aware to use EBP for residents with a urinary catheter but was not sure if EBP was required for residents with open wounds or tube feedings.During an interview on 07/09/25 at 2:22 P.M., LPN A said the resident has a feeding tube and a wound, but he/she did not wear a gown for EBP during the wound care because he/she did not see a sign to indicate EBP was required for the resident during wound care.During an interview on 07/09/25 at 2:32 P.M., CMT D said he/she was not sure if EBP was required for residents with wound or tube feeding, and there should be a sign and supplies in a container outside the room to let staff know to use EBP during cares.During an interview on 07/09/25 at 3:25 P.M., the ADON said staff were told verbally that EBP was required to perform wound care and peri-care to the resident. He/She said he/she is responsible to properly alert staff and place appropriate PPE near the resident's room but had not yet had the chance to do so. During an interview on 07/09/25 at 3:20 P.M., the ADON said he/she is the Infection Preventionist (IP), and all staff have been educated on the usage of EBP. The ADON said there are no signs posted yet to direct staff on which specific residents require EBP, and no extra PPE readily available to staff, but there is a closet by the DON's office with PPE supplies in it. The ADON said it is a work in progress at this time. During an interview on 07/09/25 at 3:54 P.M., the DON said he/she expects staff to use appropriate EBP during wound care and incontinence care for residents with wounds, catheters, and feeding tubes. He/She said he/she was responsible to ensure the EBP policy was fully implemented, but it is still a work in-progress.#1539946

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for three residents (Resident #4, #5, and #6) out of three sampled residents. The facility census was 68.1. Review of the facility's Comprehensive Care Planning policy, dated 02/25, showed staff are directed as followed:-Develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and [NAME] and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality; -The care plan process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care; -The policy did not contain direction for staff in regard to revision after a change in condition or timeframes for updating the care plan. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as follows:-Severe cognitive impairment;-Did not contain documentation of preferences of customary routine and activities.-Did not exhibit of physical or verbal aggression towards others;-Did not significantly intrude on the privacy or activity of others;-Did not significantly disrupt care or living environment.Review of the resident's progress notes showed staff documented:-On [DATE], the resident held the arm of another resident and took him/her into the living room. Staff intervened and asked the resident to let go of the other resident's arm and eventually released the other resident's arm after the second request; -[DATE], the resident did not want to go to breakfast and refused to allow another resident to go to breakfast, grabbing the other resident left wrist and pulling him/her down into a chair despite staff intervention;-[DATE], the resident had been showing increased aggressive behavior with staff as they tried to care for another resident, he/she was fixated on;-[DATE], the resident was yelling at staff because he/she had another resident in his/her room and was attempting to prevent the resident from going to breakfast. Staff documented they went to resident's room, resident blocked the door and yelled at staff.Review of the resident's care plan, undated, showed the care plan did not contain interventions for resident behaviors.During an interview on [DATE] at 9:30 A.M., the Assistant Director of Nursing (ADON) said the resident believes he/she is Resident #5 caretaker. The ADON said the families approved the residents to sleep in the same room. The ADON said he/she believed it was documented in both resident's care plans. During an interview on [DATE] at 10:07 A.M., Certified Nurse Aide I said the resident interferes when staff are attempting to provide care to his/her roommate. During an interview at 12:67 P.M., the MDS Coordinator said he/she was aware the resident had behaviors but overlooked addressing interventions in the care plan. He/She said he/she was aware Resident #4 and Resident #5 were close, and Resident #5 liked to sleep in the room with resident #4, which should have been addressed in care plan. 3. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and did not contain documentation of preferences of customary routine and activities.Review of the resident's Physician Order Summary (POS), dated [DATE], showed an order for Do Not Resuscitate (DNR) (a medical order instructing healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a person's heart stops beating or they stop breathing).Review of the resident 's care plan, revised [DATE], showed staff documented the resident's advance directive as full code (every possible measure that can be used to save a patient's life). The care plan did not contain documentation of the resident activity preferences or relationship with another resident to include sleeping in the same room as the resident. 4. Review of Resident #6's re-admission MDS, dated [DATE], showed it did not contain documentation of a Brief Interview Memory Status (BIMS) or preferences of customary routine and activities. Review of the resident's care plan, dated [DATE], showed it did not contain direction for staff in regard to the resident's activities preference.5. During an interview at 12:67 P.M., the MDS Coordinator said he/she reviewed and revised care plans on a quarterly basis. He/She said he/she would expect behaviors and activity preferences to be addressed in the resident's care plan. He/She said each department provides information to add to the resident's care plan. He/She said the activities department did not provide Resident's #4, #5 and #6's activity preferences and he/she overlooked adding the resident's preferences in the activity section of the care plan. During an interview on [DATE] at 1:08 P.M., the administrator said the purpose of the care plan was to provide direction to staff in providing person-centered care for each resident. He/She said the care plans are updated by the MDS Coordinator or Director of Nursing (DON) as needed and on a quarterly basis. He/She said he/she expected the care plan to address activities, behaviors and significant changes. He/She said staff meet daily to discuss any incidents needed to be updated in a resident's care plan. He/She said there was not an audit system in place because he/she expected staff to complete their responsibilities. During an interview on [DATE] at 1:09 P.M., the Assistant Director of Nursing (ADON) said the purpose of the care plan was to provide direction to staff in providing person-centered care for each resident. He/She said the care plans are updated by the MDS Coordinator or Director of Nursing (DON) as needed and on a quarterly basis. He/She said he/she expected the care plan to address activities, behaviors and significant changes. He/She said staff meet daily to discuss any incidents needed to be updated in a resident's care plan.Intake # 2564165

Based on record review and interview, facility staff failed to thoroughly investigate an allegation of sexual assault for one resident (Resident #1) out of one sampled resident. The facility census was 69. 1. Review of the facility's policy titled, Abuse, Neglect, and Exploitation Program Responsibilities, dated September 2022, showed staff are directed as follows: -abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology; -The Abuse Coordinator in the facility is the Administrator, or facility appointed designee when the Administrator is absent. -Report allegations or suspected abuse, neglect, or exploitation immediately to the Administrator, Law Enforcement, and State Survey and Certification Agency through established procedures. --For investigation of alleged abuse, neglect and exploitation: When suspicion of abuse, neglect or exploitation, or reports of abuse neglect or exploitation occur, an investigation is immediately warranted. Components of an investigation may include: -Interview the involved resident, if possible, and document all responses; -If resident is cognitively impaired, interview the resident several times to compare responses; -Interview all witnesses separately; -If there is no discernable response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident; -Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area, obtain witness statements, according to appropriate policies; -All statements should be signed and dated by the person making the statement; -Document the entire investigation chronologically. -In response to allegation of abuse, neglect, exploitation or mistreatment, the facility must have evidence that all allegations are thoroughly investigated and completed within five days of forming a suspicion; -Report the results of all investigation to the resident's designated representative and to other officials including the State Survey Agency, within five working days of the incident. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/31/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Independent with bed mobility, supervision with transfers and ambulation; -Diagnoses to include Dementia, Traumatic Brain Injury, anxiety disorder. Review of the facility's investigation report, dated 01/14/25, showed the Director of Nursing (DON) documented he/she had been notified by LPN A the resident made an allegation of rape, started an investigation, and he/she interviewed the resident at approximately 12:10 P.M. Review showed the facility investigation did not contain signed and dated statements from staff or witnesses to the allegation, and did not contain documentation of interviews with other residents. During an interview on 01/17/25 at 1:40 P.M., the administrator said the DON & ADON gathered most of the information for the investigation, the DON had all the documentation on his/her computer, but he/she was off work at the time. During an interview on 01/17/25 at 2:42 P.M., Licensed Practical Nurse (LPN) A said he/she was not asked to provide a signed statement of the resident's allegation. MO00248175

Based on record review and interview, facility staff failed to contact local law enforcement, and failed to report to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe for one resident (Resident #1) out of one sampled resident with an allegation of sexual abuse. The facility's census was 69. 1. Review of the facility's policy titled, Abuse, Neglect, and Exploitation Program Responsibilities, dated September 2022, showed staff are directed as follows: -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology; -Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or resulting in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency and if a crime is suspected, law enforcement. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/31/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Independent with bed mobility, supervision with transfers and ambulation; -Diagnoses to include Dementia, Traumatic Brain Injury, Anxiety Disorder, a bladder infection. Review of the facility's investigation report, dated 01/14/25, showed the Director of Nursing (DON) documented he/she interviewed the resident at approximately 12:10 P.M., and the resident reported an allegation he/she had been sexual assualted two nights prior. The report did not contain documentation facility staff reported the allegation to DHSS within the two-hour timeframe after the resident reported the allegation of sexual abuse and did not notify the local law enforcement department. Review of the DHSS complaint/facility self-report database showed facility staff did not report the resident's allegation of sexual abuse to DHSS 72 hours after the resident initially reported his/her allegation to facility staff. During an interview on 01/17/25 at 1:40 P.M., the administrator said DHSS should be contacted within two hours after he/she receives a report/allegation of abuse. He/She said when staff reported the resident's allegation 01/16/25, he/she did not contact DHSS within two hours because after doing his/her internal investigation, the resident's allegation of abuse was not determined to be substantiated, so he/she made the report to DHSS within 24 hours. During an interview on 01/17/25 at 2:26 P.M., the Assistant Director of Nursing (ADON) said he/she was aware the resident reported the initial allegation at least two days prior to Licensed Practical Nurse (LPN) A, who had immediately reported it to the administrator and DON. The ADON said all allegations of abuse should be reported to DHSS within two hours after the allegation is made, and he/she was not sure why the DON or administrator did not report to DHSS within the two-hour timeframe. During an interview on 01/17/25 at 2:42 P.M., LPN A said the resident reported to him/her at least two days prior around lunch time, he/she was raped the night before. The LPN said he/she immediately reported the resident's allegation to the administrator, and the DON came to the unit and started an investigation. During an interview on 01/21/25 at 10:30 A.M., the DON said he/she started an investigation on 1/14/24 for the resident's allegation of abuse. He/She said abuse allegations should be reported to DHSS within two hours, but he/she did not report to DHSS because the internal investigation did not reveal that the resident was abused. MO00248175

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 66. 1. Review of the facility's Food Services Manager policy, dated December 2008, showed the daily functions of the Food Services Department are under the supervision of a qualified Food Services Manager. The Food Services Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement storage, handling, preparation, and delivery. Review of the dietary manager's (DM) personnel records showed a hire date for the DM position listed as 07/28/24. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 08/08/24 at 10:18 A.M., the DM said he/she had been the DM for about two weeks, and he/she did not have prior experience as a dietary manager in a nursing facility and he/she did not have a degree or certification related to food service management. The DM said the facility enrolled him/her in an online food protection manager's course at the beginning of the week, but he/she had not started the course yet. The DM said the RD only works part-time and the facility did not have any certified or clinically qualified nutritional staff employed full-time. During an interview on 08/09/24 at 1:43 P.M., the administrator said the previous DM, who had hired the current DM as a cook, quit without notice and he/she wanted to hire the DM's replacement from within the dietary department. The administrator said the facility's registered dietician works as a consultant on a part-time basis and the facility did not have any certified or clinically qualified nutritional staff employed full-time. The administrator said he/she did not know that the DM did not meet the requirements for the position.

Based on observation, interview and record review, facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 66. 1. Review of the facility's Menus policy, dated October 2008, showed the policy directed that menus shall meet the nutritional needs of the residents, be prepared in advance and be followed. 2. Review of the facility menus, dated 08/08/24 (Week 2, Day 12), showed the menus directed staff to provide the residents on regular and dental/mechanical soft diet with a two inch by three inch cream cheese brownie at the lunch meal. Observation on 08/08/24 at 12:16 P.M., showed dietary staff with the noon meal,did not prepare or serve the cream cheese brownies as directed by the menus to residents who received regular and dental/mechanical soft diets. During an interview on 08/08/24 at 1:22 P.M., the dietary manager (DM) said staff should serve food in accordance with planned menus and he/she is responsible to ensure the full meal is served. The DM said he/she did not know why staff did not make the brownies and he/she just missed that staff did not provide the brownies. 3. Review of the facility menus dated 08/08/24 (Week 2, Day 12), showed the menus directed staff to provide the residents on pureed diets with the following at the lunch meal: -A #6 (5.3 ounce) scoop of pureed cheeseburger on bun; -A #8 (four ounce) scoop of pureed french fries; -A #10 (3.2 ounce) scoop of pureed mandarin oranges; -A #10 scoop of pureed cream cheese brownie. Observations on 08/08/24 at 11:35 A.M., showed [NAME] F and [NAME] G pureed previously prepared portions of roast beef, green beans and cinnamon rolls. Observation showed the cooks placed unmeasured amounts of the pureed food items into two divided plates, covered the plates with plastic wrap and put the plates in the hot holding cabinet. During an interview on 08/08/24 at 11:36 A.M., [NAME] F said the previous dietary manager (DM) instructed him/her to puree leftover meats, vegetables and desserts to serve to the residents on pureed diets instead of serving them what is directed by the menus and staff serve the pureed diets this way for each meal. Observation on 08/08/24 during the lunch meal which began at 12:16 P.M., showed Dietary Aide (DA) H served Residents #1 and #34 the divided plates of pureed roast beef, green beans and cinnamon rolls. During an interview on 08/08/24 at 1:22 P.M., the DM said staff should serve food in accordance with planned menus, but staff, including him/herself, had been trained by the previous DM to use leftovers from day before to prepared the meals for purees instead of the menu, and he/she had trained the new staff under his/her management to do the same. The DM said staff were trained to make sure the pureed meals consisted of a meat, vegetable, bread and dessert and he/she did not know they were suppose to serve the residents on pureed diets in accordance with the menus. 4. During an interview on 08/09/24 at 2:11 P.M., the administrator said staff should serve food in accordance with planned the menus and the cooks and DM are responsible to ensure all food items on the menus are served. The administrator said he/she just had a discussion with the dietary staff the previous week about using the menus and recipes and he/she did not know staff did not follow the menus.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to thaw frozen foods in a manner to prevent the growth of food-borne pathogens and cross-contamination with ready-to-eat food items. Facility staff failed to allow sanitized dishes to air dry before being stacked in storage to prevent the growth of food-borne pathogens. Facility staff failed cover kitchen waste containers when not in actual use to deter the attraction of pests and rodents. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. These failures have the potential to affect all residents. The facility census was 66. 1. Review of the facility's Food Receiving and Storage policy, dated July 2014, showed: -Foods shall be received and stored in a manner that complies with safe food handling practices; -All foods stored in the refrigerator or freezer will be covered, labeled and dated; -Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods. Review of the facility's Food Preparation and Service policy, dated July 2014, showed: -Potentially hazardous foods, including raw meats, which might contaminate other foods or the food preparation area, will be prepared in specified areas using appropriate measures to prevent cross-contamination; -Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. Review of the facility's Food Safety Requirements policy, dated September 2022, showed; -Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage; -Practices to maintain safe refrigerated storage included: *Separation of raw foods from each other and storing the raw foods on shelves below fruits, vegetables and other ready-to-eat foods; *Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and *Keeping foods covered or in tight containers. Observation on 08/06/24 at 6:49 P.M., showed the reach-in refrigerator by the drink station contained 12 unlabeled and undated pitchers of various beverages. Observation showed one of the 12 pitchers opened to the air. Observation showed an accumulation of food debris on the bottom shelf. Observations on 08/06/24 at 6:53 P.M., showed the glass-front refrigerator contained: -An undated metal pan of tartar sauce; -An opened and undated bottle of lime juice; -An opened and undated jar of mayonnaise; -An undated bag of shredded cheese opened to the air; -An undated piece of cake opened to the air; -An undated plastic container of orange sections; -A pan of patties in stainless steel tray undated and over the oranges Observations on 08/06/24 at 7:00 P.M., showed the walk-in refrigerator contained: -A plastic container of pineapple dated 2-7 and 3-16; -A large undated metal pan which contained bread soaking in an unidentified liquid, opened to the air; -Undated pieces of chocolate cake; -An undated plastic container of peas. Observations on 08/08/24 at 11:07 A.M., showed the reach-in refrigerator by the drink station contained six undated and unlabeled pitchers of various beverages. Observation showed a large amount of red liquid and food debris on the bottom shelf and the left facing gasket seal heavily soiled. Observations on 08/08/24 at 11:10 A.M., showed the bread rack contained: -An undated plastic bag that contained two hardened hamburger buns opened to the air; -An opened and undated plastic bag that contained four hamburger buns; -An opened and undated 16 ounce (oz.) package of sweet rolls; -An opened and undated plastic bag that contained two hot dog buns with mold growth on the buns and the bag; -An undated plastic resealable bag that contained four biscuits with mold growth on the biscuits; -An undated plastic resealable bag of bread sticks; -An undated and unlabeled plastic resealable bag of hardened cookies. Observation on 08/08/24 at 11:15 A.M., showed the second reach-in refrigerator by the drink station contained four undated and unlabeled two liter containers of various beverages, two undated and unlabeled 16 oz. containers of liquids and 16 undated and unlabeled pitchers of red liquid. During an interview on 08/08/24 at 11:19 A.M., the dietary manager (DM) said staff should date and label all opened and prepared food items and store them in sealed containers. The DM said staff had been trained on these requirements, but knew he/she continued to have staff who repeatedly did not date and label the food as instructed. Who is responsible for monitoring? Does anyone monitor?-Please see the interview with the DM on 08/8/24 at 4:20 P.M. Observations on 08/08/24 at 12:04 P.M., showed the glass-front refrigerator contained: -An opened and undated 30 oz. bottle of yellow mustard; -An opened and undated 20 oz. bottle ketchup; -An opened and undated 64 oz. jar of mayonnaise; -An opened and undated 11.5 oz. bottle of mayonnaise; -An opened and undated 30 oz. jar of grape jelly; -An unlabeled plastic resealable bag of an unidentifiable ground meat dated 8/4 opened to the air and a plastic resealable bag of cooked sausage links dated 8/7 stored shelf next to ready-to-eat foods, which included white cheese slices; -A plastic resealable bag of cooked sausage links dated 8/8 stored on bottom shelf next to loaf of sliced bread. During an interview on 08/08/24 at 12:10 P.M., the DM said foods that need to be cooked should not be stored near ready-to-eat food items and he/she did not know why staff had a loaf of bread in the refrigerator. Observation on 08/08/24 at 4:02 P.M., showed the aides preparation station contained an opened and undated 48 oz. jar of extra crunchy peanut butter and an opened and undated five pound container of creamy peanut butter. Observation on 08/08/24 at 4:05 P.M., showed the dry goods storage pantry contained a prepared graham cracker crust, removed from it's original packaging, covered with plastic wrap and undated. Observation showed an opened and undated five pound package of sweet cream pancake and waffle mix stored in an undated plastic resealable bag. Observation on 08/08/24 at 4:16 P.M., showed the walk-in freezer contained an opened and undated-plastic bag which contained two corndogs and an undated case of beef patties opened to the air. Observation on 08/08/24 at 4:19 P.M., showed the walk-in refrigerator contained: -an undated case of raw sausage links opened to the air; -an undated case of raw bacon opened to the air; -an opened and undated 15 oz. jar of salsa con queso; -three opened and undated 16 oz. containers of whipped topping; -an opened and undated five pound container of cottage cheese; -an opened and undated five pound container of sour cream; -a plastic container of previously prepared shredded chicken dated 8/1; -an undated plastic container of pineapple; -a plastic container of pineapple dated 8/3; -an opened and undated one gallon container of ranch salad dressing; -an opened and undated one gallon container tartar sauce opened and undated; -four plastic sleeves of raw muffin mix stored over ready-to-eat tossed salad; -two opened and undated one gallon containers of caesar salad dressing. During an interview on 08/08/24 at 4:20 P.M., the DM said left over food items should be discarded after three days and raw foods should not be stored near ready-to-eat foods. The DM said all staff are responsible to ensure food is stored properly and he/she tries to look at it once a week, but he/she had been preoccupied with trying to keep food in the kitchen because the previous DM, who changed all the passwords to their food ordering systems, quit without notice and left them with a mess. During an interview on 08/09/24 at 1:48 P.M., the administrator said opened and prepared food items should be labeled, dated with the date it is opened or made and stored in a sealed container. The administrator said leftover foods should be discarded after three days and staff should not store raw foods near ready-to-eat foods. The administrator said all dietary staff are responsible to monitor the food storage, but the DM, who had been trained on food storage requirements, is responsible to monitor food storage at least once a week. The administrator said they just did a complete clean out of the refrigerators the previous week and knew that food storage was an issue. The administrator said the previous DM, who they discovered did everything for the staff, recently quit without notice, they were just trying to keep the kitchen running and they just had not had a chance to retrain the staff. 2. Review of the facility's Food Preparation and Service policy, dated July 2014, showed: -Potentially hazardous foods, including raw meats, which might contaminate other foods or the food preparation area, will be prepared in specified areas using appropriate measures to prevent cross-contamination; -Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. -Foods will not be thawed at room temperature. Review showed the policy directed staff directed staff to thaw frozen foods: -In the refrigerator in a drip-proof container; -Submerged in cold running water; -In the microwave oven when cooked and served immediately after; -As part of a continuous cooking process. Observation on 08/08/24 at 11:10 A.M., showed four 32 ounce bags of frozen broccoli florets on countertop next to multiple packages of prepared hamburger buns. During an interview on 08/08/24 at 11:19 A.M., the DM said staff were thawing the broccoli to use for the evening meal. The DM said the broccoli should not have been left on countertop next to a ready-to-eat food item and frozen foods should be thawed in the refrigerator or under running water. Since the DM knew it was thawing on the counter-why did they not do something about it? During an interview on 08/09/24 at 1:55 P.M., the administrator said food should be thawed in the refrigerator or submerged in cold running water and should not be left on countertop to thaw. The administrator said staff should also not store foods that need cooked next to ready-to-eat foods and staff were trained on these requirements. 3. Review of the facility's Dishwashing Machine Use policy, dated March 2010, showed the policy directed staff to allow dishes to air-dry before they are put away after they are washed. Observation on 08/06/24 at 6:47 P.M., showed multiple metal food preparation/service pans stacked together wet on the storage rack. Observation on at 08/08/24 12:00 P.M., showed Dietary Aide (DA) I removed sanitized kitchenware from the mechanical dishwasher while wet and stacked them in storage. Observation also showed 12 metal food preparation/service pans of various sizes stacked together wet on the storage rack. During an interview on 08/08/24 at 1:22 P.M., the DM said staff should allow dishes to air dry before they are put away. The DM said some staff were trained on this requirement, but he/she had not had time to train all the staff. The DM said DA I had been trained to allow dishes to dry and he/she did not know that the DA did not allow the dishes to dry before he/she put them away. During an interview on 08/09/24 at 2:37 P.M., the administrator said staff should allow dishes to air dry before they are put away and staff should be trained on this requirement. 4. Review of the facility's Food-Related Garbage and Rubbish Disposal policy, dated April 2006, showed All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. Observation on 08/08/24 at 10:56 A.M., showed the waste container in the mechanical dishwashing station, which contained food and paper waste, uncovered and the area unattended by staff. Observation on 08/08/24 at 11:31 A.M., showed the waste container in mechanical dishwashing station, which contained food and paper waste, remained uncovered and the area unattended by staff. Observation on 08/08/24 at 4:00 P.M., showed the waste container in mechanical dishwashing station, which contained food and paper waste, uncovered and the area unattended by staff. Observation on 08/08/24 at 4:33 P.M., showed the waste container in the mechanical dishwashing station, which contained food and paper waste, remained uncovered and the area unattended by staff. During an interview on 08/08/24 at 4:53 P.M., the DM said staff should cover waste containers when not in use and before they leave an area. The DM said some staff had been trained on this requirement, but he/she had not had time to train all the staff. The DM said he/she did not know staff left the waste containers uncovered. During an interview on 08/09/24 at 2:36 P.M., the administrator said waste containers should be covered all the time and staff are trained on that requirement. 5. Review of the facility's Preventing Foodborne Illness-Employee hygiene and Sanitary Practices policy, dated October 2008, showed: -Food services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; -All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents; -Employees must wash their hands: a. After personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); b. After using tobacco eating or drinking; c. Whenever entering or re-entering the kitchen; d. Before coming in contact with any food surfaces; e. After handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; f. After handling soiled equipment or utensils; g. During food preparation as often a necessary to remove soil and contamination and to prevent cross-contamination when changing tasks; and/or h. After engaging in other activities that contaminate their hands; -Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness; -Gloves are considered single-use items and me be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing; -The policy did not contain instruction to staff on how to perform hand hygiene. Review of the facility's Food Preparation and Service policy, dated July 2014, showed: -Food service employees shall prepare and serve food in a manner that complies with safe food handling practices; -Bare hand contact with food is prohibited and gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use; -The policy did not contain instruction to staff on how to perform hand hygiene. Observation on 08/08/24 at 11:53 A.M., showed [NAME] G touched his/her facemask and, without performing hand hygiene, donned gloves and prepared food items for service to residents at the lunch meal. Observation on 08/08/24 at 11:54 A.M., showed [NAME] F: -Removed his/her soiled gloves and picked up the waste can lid with his/her bare hands to dispose of trash; -Rinsed his/her hands off under running water at the handwashing sink and turned the faucet off with his/her wet bare hand; -Donned gloves and then cut up prepared beef patties with cheese with a knife while he/she held the patties with his/her gloved hands; -Placed the chopped meat and cheese into a metal food preparation pan and put the pan into the hot holding cabinet for service to residents at the lunch meal. Observation on 08/08/24 at 12:32 P.M., showed the paper towel dispenser at the sink in the kitchenette of the memory care unit did not contain paper towels. Observation showed when Dietary Aide (DA) H washed his/her hands at the sink, the DA scrubbed his/her hands with soap for five seconds, rinsed his/her hands, turned the faucet off with his/her wet bare hands, picked up a cleaning cloth from the countertop and dried his/her hands with the cloth. Observation showed the DA donned gloves and continued to serve food to residents at the lunch meal. Observations showed the DA used the same gloved hands to reach into a pan that contained pickles and pickle juice to put pickles on a plate, get a lettuce leaves, tomato slices and onion slices from another pan to put on the plates, open the refrigerator and obtained ketchup, opened a cabinet and then obtained hamburger buns to put on the plates. Observation on 08/08/24 at 12:46 P.M., showed DA H removed his/her soiled gloves and washed his/her hands at the kitchenette sink. Observation showed when the DA washed his/her hands, the DA scrubbed his/her hands with soap for seven seconds, rinsed his/her hands, turned the faucet off with his/her wet bare hands, picked up the previously used cleaning cloth from the edge of the sink and used the cloth to dry his/her hands. Observation showed the DA then donned gloves and continued to serve food to residents in the memory care unit. Observation on 08/08/24 at 12:52 P.M., showed DA H removed his/her soiled gloves and washed his/her hands at the kitchenette sink. Observation showed when the DA washed his/her hands, the DA scrubbed his/her hands with soap for 10 seconds, rinsed his/her hands, turned the faucet off with his/her wet bare hands, picked up the previously used cleaning cloth from the edge of the sink and used the cloth to dry his/her hands. Observation showed the DA then donned gloves and continued to serve food to residents in the memory care unit. During an interview on 08/08/24 at 1:12 P.M., DA H said he/she did not get trained on hand hygiene upon hire, but he/she already knew the proper procedures to use to wash his/her hands. The DA said staff should scrub their hands with soap for 20 seconds when they wash their hands, turn the faucet off with a paper towel and not their bare hands and then dry their hands with a paper towel. The DA said he/she did not have paper towels to turn the faucet off or dry his/her hands. The DA said if he/she does not have paper towels then he/she should ask for some to be brought and not use his/her bare hands to turn off the faucet. The DA said he/she did not know if it was okay to repeatedly reuse cloth towels to dry his/her hands or not. The DA said he/she knew that he/she did not scrub his/her hands with soap for 20 seconds when he/she washed his/her hands and he/she was just in a hurry. The DA said gloves should be changed between tasks and after they touch anything dirty. The DA said he/she was in a hurry and just did not think to change his/her gloves as often as he/she should. Observation on 08/08/24 at 1:16 P.M., showed the DM washed his/her hands in the memory care kitchenette sink. Observation showed when the DM washed his/her hands, the DM scrubbed his/her hands with soap for three seconds, turned the faucet off with his/her wet bare hands, dried his/her hands with the cloth towel hung over the sink, previously used by DA H to dry his/her hands, donned gloves and then used his/her gloved hands to hold prepared french fries and hamburger patties with melted cheese to chop them with a knife for service to residents at the lunch meal. During an interview on 08/08/24 at 1:22 PM, the DM said he/she did not get trained on hand hygiene upon hire, but knew when and how to properly wash his/her hands. The DM said gloves should be changed when you change tasks, between different food items and anytime you touch something dirty. The DM said staff should scrub their hands with soap for 20 seconds when they wash their hands, turn the faucet off with a paper towel and dry their hands with a paper towel. The DM said he/she tries to be mindful about how long he/she scrubs his/her hands with soap, but could not say that he/she always scrubbed his/her hands with soap for 20 seconds. The DM said he/she did not have paper towels to turn the faucet off with and dry his/her hands, but that should not be an excuse to not wash hands properly. The DM said germs are spread when hands are not cleaned properly and he/she had not had an opportunity to train staff on hand hygiene since he/she became the DM about two weeks ago. During an interview on 08/09/24 at 2:00 P.M. , the administrator said staff should change their gloves and wash their hands between tasks and after they touch anything dirty. The administrator said the refrigerator and drawer handles would be considered dirty and gloves should be changed after contact with these items. The administrator said staff should also use utensils to serve food and not use their gloved hands to handle multiple different food items. The administrator said staff should also wash their hands when they are visibly dirty, before they prepare and serve food and after they touch anything dirty. The administrator said staff should scrub their hands with soap for 20 seconds and turn the faucet off with a paper towel and not their bare hands when they wash their hands. The administrator said if staff do not have paper towels to turn off the faucet and dry their hands, they should find some before they wash their hands and not use a cleaning cloth to dry their hands. The administrator said all staff are trained on glove use and hand hygiene upon hire as part of their orientation. 42484

Based on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The facility census was 66. 1. Review of the facility's policies showed staff did not provide a policy in regard to the qualifications of the Infection Preventionist. 2. During an interview on 08/08/24 at 12:22 P.M., Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) said he/she enrolled in the required IP training Monday night or Tuesday morning after the DON put his/her notice in. The LPN/ADON said he/she is not a trained IP. During an interview on 08/08/24 at 12:44 P.M., the administrator said the former Director of Nursing (DON) had been enrolled in the IP training since hired back in April and had not completed the course prior to turning in his/her resignation on Monday. The Administrator said the ADON and another Registered Nurse (RN) who works at the facility are now enrolled in IP training, so the facility has a back up. The Administrator said the facility did not have an IP since April.

Based on interview and record review, facility staff failed to ensure Level I Pre-Admission Screening (used to evaluate for the presence of psychiatric conditions to determine if a Pre-admission Screening and Resident Review (PASARR) level II screen is required) were completed for three (Resident #25, #48 and #59) of seven sampled residents. The facility census was 66. 1. Review of the facility's PASARR Procedure policy, undated, showed staff are instructed as follows: -Regardless of source of payment and on the day of acceptance of the referral the Clinical Liaison will request a completed DA-124 A/B (form for the PASARR), a federally mandated screening process for individual with serious mental illness and/or mentally regarded/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility; -If the DA-124 forms are received from a referral source prior to admission: a. If the resident does not trigger for a Level II screening and is not applying for Medicaid but is in a Medicaid certified bed the completed DA-124 A/B is placed in the client's chart under the Social Services tab until the client requires a Level II Screening or/or applies for Medicaid Reimbursement. b. If the resident is in a Medicaid Certified bed and has a Medicaid payer source but does not trigger for mental illness, submit the completed DA-124 A/B to the Central Office Medical Review Unit (COMRU) on the day of admission. c. If the resident is in a Medicaid certified bed, regardless of payer source, and triggers for a mental illness; a DA-124 A/B must be submitted along with a Level I Pre-Admission Screening to COMRU by the referring hospital. Review and determine if a Level II screening is required. This should be done prior to admission unless a valid special admission category has been determined. Central Office Medical Review Unit (COMRU) will notify the hospital regarding the ability to accept the referral. The Social Services Director (SSD) must notify the Clinical Liaison (acts as a mediator, who aids the communication between patients, family, and care professionals) immediately that a Level II screening is required, and the referral requires additional discharge planning follow up from the referring facility; -If the DA-124 forms are not received from a referral source prior to the day of admission: a. The SSD will be responsible for collecting referring medical records to do an initial review of the Level I Pre-Admission Screening. b. If on pre-admission initial review the resident does not trigger for Level II Screening and is not applying for Medicaid but is in Medicaid certified bed the SSD will interview the resident/responsible party on day of admission and complete the Level I Pre-Admission Screening. The Level I Pre-Admission Screening will be forwarded to the primary care physician for signature. Upon receipt of the physician signature the Level I Pre-Admission Screening will be placed in the client's chart under the Social Services tab until the client requires a Level II screening and/or applies for Medicaid reimbursement. c. If on pre-admission initial review and if the resident is in a Medicaid certified bed and has a Medicaid payer source but does not trigger for mental illness, submit the completed Level I Pre-Admission Screening to the primary care physician for signature. Upon receipt of the physician signature, submit the DA-124 A/B and the Level I Pre-Admission Screening to COMRU; -If the resident is a nursing home transfer: a. The Clinical Liaison will be responsible for requesting a copy of the DA-124 A/B and Level I Pre-Admission Screening from the receiving facility. b. When persons transfer from one nursing facility to another and application for Medicaid is not indicated the original Pre-Admission Screening form must follow to the next facility. 2. Review of Resident #25's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/02/24, showed staff assessed the resident as: -admitted on [DATE] and Re-entered on 04/18/24 ; -Did not contain an evaluation with PASARR; -Moderate cognitive impairment; -Diagnoses of Dementia, Depression, and Schizophrenia; -Received anti-psychotic, antianxiety, and anti-depressant medication in the seven day look back period (period of time used to complete assessment). Review of the resident's medical record showed the record did not contain a level I Pre-Admission Screening or PASARR level II screen. 3. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Did not contain an evaluation with the PASARR; -Entered from an Inpatient psychiatric facility; -Severe cognitive impairment; -Diagnoses of Dementia, Anxiety, Depression, Psychotic Disorder, and Schizophrenia; -Received anti-psychotic, antianxiety, and anti-depressant medication in the seven day look back period (period of time used to complete assessment). Review of the resident's medical record showed the record did not contain a level 1 Pre-Admission Screening or PASARR level II screen. 4. Review of Resident #59's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Did not contain an evaluation with the PASARR; -Entered from another skilled nursing facility (SNF); -Moderately cognitively impaired; -Diagnoses of Non-Traumatic Brain Dysfunction and Psychotic Disorder (other than schizophrenia); Review of the resident's medical record showed the record did not contain a Level I Pre-Admission Screening or PASARR level II screen. 5. During an interview on 08/09/24 at 09:37 A.M., the administrator said he/she started at the facility in March and there has been a big turnover in staff. Items such as PASARR's had not been reviewed due to other priorities addressed by the leadership. -During an interview on 08/09/24 at 6:53 P.M., the SSD said all current new residents have PASARRs which are complete. The previous SSD completed the PASARRs however it has been difficult to find the records. The SSD said PASARRs are ultimately his/her responsibility, but as he/she is new to the position he/she has not had the chance to fully locate and review all of the current residents' records. 50432

Based on observation, interview and record review, the facility staff failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items placed in hot holding at 140 F or higher. Facility staff also failed to reheat pureed food items to an internal temperature of 165 degrees Fahrenheit ( F) before service to prevent the growth of food-borne pathogens and potential for food-borne illness. These failures have the potential to affect all residents who dined in one of two dining rooms. The facility census was 66. 1. Review of the facility's Food Preparation and Service policy, dated July 2014, showed: -Food service employees shall prepared and serve food in a manner that complies with safe food handling practices; -The danger zone for food temperatures is between 41 F and 135 F . This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness; -The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens; -Previously cooked food must be reheated to an internal temperature of 165 F for at least 15 seconds; -Mechanically altered hot foods prepared for a modified consistency diet must stay above 135 F during preparation or they must be reheated to 165 F for at least 15 seconds; -The temperatures of foods held in steam tables will be monitored by food service staff. 2. Review of the facility's Food Safety Requirements policy, dated September 2022, showed: -Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety; -When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards; -Foods shall be prepared as directed until recommended temperatures for the specific foods are reached. Staff shall refer to the current Food and Drug Administration (FDA) Food Code and facility policy for food temperatures as needed; -Staff shall monitor the food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed; -Food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 F. Ready-to-eat foods that require heating before consumption must be heated to at least 135 F; -Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the danger zone. 3. Review of the facility menus, dated 08/08/24 (Week 2, Day 12), showed the menus directed staff to provide the residents on regular diets with a three ounce grilled cheeseburger on a bun and four ounces of french fries. Observation on 08/08/24 at 11:48 A.M., showed [NAME] F removed pans of prepared hamburger patties with melted cheese on top and french fries from the hot holding cabinet and, without checking the internal temperature of the food items, placed the pans into an insulated food cart for delivery to the dining room for service at the lunch meal. Observation on 08/08/24 at 12:16 P.M., showed staff wheeled the insulated cart of food to the memory care dining room and put the food on steamtable without checking the internal temperatures of the food items. Observation on 08/08/24 at 12:25 P.M., showed Dietary Aide (DA) H served food from the steamtable without checking the internal temperatures of the food items. Observation at this time showed the internal temperature of the hamburger patties with melted cheese measured 123 F. During an interview on 08/08/24 at 12:27 P.M., DA H said he/she does not check the internal temperatures of foods before he/she serves them. Observation on 08/08/24 at 12:44 P.M., showed the internal temperature of the hamburger patties with melted cheese measured 116 F and the internal temperature of the french fries measured 93 F. 4. Review of the facility menus dated 08/08/24 (Week 2, Day 12), showed the menus directed staff to provide the residents on a dental/mechanical soft diets with a #10 scoop of ground cheeseburger on a bun made with once ounce of cheese and four ounces of soft chopped french fries with ketchup. Observation on 08/08/24 at 11:54 A.M. showed [NAME] F removed a pan of prepared hamburger patties with melted cheese on top from the food warmer, stacked the patties on a cutting board and then used a knife to cut the patties into small diced pieces. Observation showed the cook transferred the diced meat and cheese into a metal food preparation pans and, without checking the internal temperature, placed the pans in the insulated food service carts for delivery to the dining rooms for the lunch meal. During an interview on 08/08/24 at 11:56 A.M., [NAME] F said the diced hamburger patties with cheese were to be served to the residents on mechanical soft diets. Observation on 08/08/24 at 12:16 P.M., showed staff wheeled the insulated cart of food to the memory care dining room and put the food on steamtable without checking the internal temperatures of the food items. Observation showed the staff placed the pan of diced hamburger patties with melted cheese into a cold well of the steamtable. Observation showed staff had not turned the heat to the steamtable well on at this time. Observation on 08/08/24 at 12:25 P.M., showed DA H served food from the steamtable without checking the internal temperatures of the food items. Observation at this time showed the internal temperature of the diced hamburger patties with melted cheese measured 105 F. During an interview on 08/08/24 at 12:27 P.M., DA H said he/she does not check the internal temperatures of foods before he/she serves them. Observation on 08/08/24 at 12:44 P.M., showed the internal temperature of the diced hamburger patties with melted cheese measured 106 F and the internal temperature of the french fries measured 93 F. 5. Observations on 08/08/24 at 11:35 A.M., showed [NAME] F and [NAME] G pureed previously prepared portions of roast beef, green beans and cinnamon rolls. Observation showed the cooks placed unmeasured amounts of the pureed food items into two divided plates and, without checking the internal temperatures of the food items, covered the plates with plastic wrap and put the plates in the hot holding cabinet. During an interview on 08/08/24 at 11:36 A.M., [NAME] F said the previous dietary manager (DM) instructed him/her to puree leftover meats, vegetables and desserts to serve to the residents on pureed diets instead of serving them what is directed by the menus and staff serve the pureed diets this way for each meal. The cook said the previous DM just showed him/her how to make the purees and he/she does not follow recipes. Observation on 08/08/24 at 11:48 A.M., showed [NAME] F removed the plates of pureed food from the hot holding cabinet and, without checking the internal temperature of the food items, placed the plates into an insulated food cart for delivery to the dining room for service at the lunch meal. Observation on 08/08/24 at 12:16 P.M., showed staff wheeled the insulated cart of food to the memory care dining room and put the food on steamtable without checking the internal temperatures of the food items. Observation showed the staff placed placed the two plates of pureed food into a cold pan placed into a cold well of the steamtable. Observation showed staff had not turned the heat to the steamtable well on at this time. Observation on 08/08/24 at 12:25 P.M., showed DA H served the food from the steamtable without checking the internal temperatures of the food items. Observation at this time showed the internal temperature of the pureed roast beef measured 74 F, the internal temperature of the pureed green beans measured 72 F, and the internal temperature of the pureed cinnamon roll measured 77 F. During an interview on 08/08/24 at 12:27 P.M., DA H said he/she does not check the internal temperatures of foods before he/she serves them. Observation on 08/08/24 at 12:44 P.M., showed the internal temperature of the pureed roast beef and pureed green beans measured 74 F and the internal temperature of the pureed cinnamon roll measured 75 F. Observation showed DA H served the plates of cold pureed food to Residents #1 and #34. 6. During an interview on 08/08/24 at 1:22 P.M., the DM said the serving temperatures of hot foods items should be at least 145 F and if it drops below that temperature then staff should reheat the food to 165 F before they serve it. The DM said staff are responsible the check the internal temperature of food items after they are prepared and before they are served. The DM said he/she did not know staff did not check the internal temperatures of food before service. 7. During an interview on 08/09/24 at 2:29 P.M., the administrator said foods should be cooked to appropriate temperatures based on the food item and kept out of the temperature danger zone of 41 F to 132 F. The administrator said if the temperature of hot foods fall into the danger zone, staff should reheat the food to 165 F. The administrator said staff should check the temperature of food after it is cooked, processed, such in the case of pureed foods, and before they are served. The administrator said the dietary staff were educated the previous week on food temperature requirements and he/she did not know staff did not check the internal temperatures of food before service.

Based on observation, interview and record review, facility staff failed to prepare and serve food items at an appropriate texture for 10 of 10 residents (Residents #9, #20, #24, #25, #29, #32, #47, #48, #51 and #58) who received dental/mechanical soft diets. The facility census was 52. 1. Review of the facility's Menus policy, dated October 2008, showed the policy directed menus shall meet the nutritional needs of the residents, be prepared in advance and be followed. Review of the facility's Standardized Recipes policy, dated April 2007, showed the policy directed standardized recipes shall be developed and used in the preparation of foods and only tested , standardized recipes will be used to prepare foods. Review of the facility's recipe for Ground Cheeseburger on Bun, dated 2002, showed the recipe direct staff to place one prepared hamburger patty per serving into the food processor and grind into small pieces. Review showed the recipe directed staff to place a #10 (3.2 ounce) scoop of the ground hamburger patty and one ounce of cheese on a hamburger bun for service. Review of the meal tray service cards for Residents #9, #20, #24, #25, #29, #32, #47, #48, #51 and #58, showed the cards directed staff to provide the residents with a dental/mechanical soft diet. Review of the facility menus dated 08/08/24 (Week 2, Day 12), showed the menus directed staff to provide the residents on a dental/mechanical soft diet with a #10 scoop of ground cheeseburger on a bun with once ounce of cheese. Observation on 08/08/24 at 11:54 A.M. showed [NAME] F removed a pan of prepared hamburger patties with melted cheese on top from the food warmer, stacked the patties on a cutting board and then used a knife to cut the patties into small diced pieces. Observation showed the cook transferred the diced meat and cheese into a metal food preparation pans and placed the pans in the insulated food service carts for delivery to the dining rooms for the lunch meal. During an interview on 08/08/24 at 11:56 A.M., [NAME] F said the diced hamburger patties with cheese were to be served to the residents on mechanical soft diets and that is the dietary manager (DM) trained him/her to prepare the mechanical soft meat. Observation on 08/08/24 during the lunch meal service which began at 12:16 P.M., showed dietary staff served a #16 (two ounce) scoop (1.2 ounces less than directed by the menus) of the diced hamburger patties with cheese on a bun to Residents #9, #20, #24, #25, #29, #32, #47, #48, #51 and #58. 08/08/24 01:35 PM Observation also showed, upon eating the diced hamburger with cheese on a bun, Resident #9 began to cough repeatedly. During an interview on 08/08/24 at 1:22 P.M., the DM said staff should prepared foods in accordance with the recipes and serve food in accordance with planned menus, but staff, including him/herself, had been trained by the previous DM to just cut food items for the mechanical soft diets with a knife and he/she had trained the new staff under his/her management to do the same. The DM said the previous DM said that they were to cut the foods with a knife because the residents did not like the food ground up in the food processor, but after some thought, not all of the residents who receive mechanical soft diets would be cognitively able to make that choice so he/she did not know why the previous DM had said that. The DM said the staff should still serve the food items at the portions directed by the recipes and menus and he/she did not know that staff did not follow the portion sizes on the menu. During an interview on 08/09/24 at 2:11 P.M., the administrator said staff should serve food in accordance with planned the menus, which included the portion sizes listed, and the foods listed on the menus should be prepared in accordance with the recipes. The administrator said he/she just had a discussion with the dietary staff the previous week about using the menus and recipes and he/she did not know staff did not follow the recipes or menus. The administrator said meats for mechanical soft diets should be ground in the food processor and not cut up by hand unless otherwise directed by the recipes.

Based on interview and record review, the facility failed to ensure the Director of Nurses (DON) did not work as a charge nurse when the facility had an average daily occupancy of 60 or more residents. This had the potential to affect all residents at the facility. The census was 68. 1. Review of the facility's Sufficient Nursing Staff policy, dated October 2022, showed The DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Review of the Facility Assessment, dated 11/1/22, showed the following: -The fluctuations in census and acuity may impact staffing needs; -One DON Registered Nurse (RN) full time; -One RN on the dayshift. -Two licensed practical nurse (LPN) for each shift. -Two nursing staff with Administrative duties on the dayshift; -Dayshift is identified as 7:00 A.M. to 7:00 P.M. and Nightshift is identified as 7:00 P.M. to 7:00 A.M. Review of the facility's nursing schedule dated 4/16/23 through 5/18/23 showed the following: - On 4/16/23, the DON served as the charge nurse during the dayshift. The census was 70; - On 4/20/23, the DON served as the charge nurse during the dayshift. The census was 70; - On 4/28/23, the DON served as the charge nurse during the nightshift. The census was 68; - On 4/29/23, the DON served as the charge nurse from 7:00 P.M. to 11:00 P.M. The census was 68; - On 5/3/23, the DON served as the charge nurse from 7:00 A.M. to 11:00 A.M. The census was 69; - On 5/4/23, the DON served as a charge nurse from 8:30 A.M. to 7:00 P.M. The census was 69; - On 5/17/23, the DON served as a charge nurse during the dayshift. The census was 67; - On 5/18/23, the DON served as a charge nurse during the dayshift. The census was 67. Observation on 5/17/23 at 8:15 A.M., showed the DON passed medication on the memory care unit. Observation on 5/18/23 at 2:28 P.M., showed the DON performed wound care on a resident that resided on the memory care unit. During an entrance conference interview, on 5/16/23 at 9:53 A.M., the Administrator said the facility does not have a Registered Nurse waiver and has full-time DON coverage from 8:00 A.M. to 4:00 P.M., Monday through Friday. During an interview on 5/18/23 at 8:07 A.M., the DON said he/she works the floor when there are call-ins. He/She said he/she gets most weekends off, but does have to work often and was not able to keep up with his/her duties. During an interview on 5/19/23 at 12:30 P.M., the Administrator and DON said when staff call- in the DON had to cover the floor which caused all his/her duties to become behind or unfinished. The Administrator said a contract was signed with an agency the week of May 8th, have recruitment ads, word of mouth, online advertising, sign-on bonus, referral bonus for hiring and retention. The Administrator said a nurse walked out last week and another was on medical family leave.

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Resident #2 touched Resident #1 inappropriately. The facility census was 71. The administrator was notified on 3/27/2023 of past Non-Compliance, which occurred on 3/25/2023. On 3/25/2023 at approximately 8:00 P.M., facility staff observed Resident #2 standing over Resident #1 with his/her hand in Resident #1's pants. Upon discovery, the two residents were separated and placed on 15-minute checks. Staff updated resident assessments and plans of care. Staff made all appropriate notifications and staff have been in-serviced on inteventions in place for Resident #2. Staff corrected the deficient practice on 3/25/2023. 1. Review of the facility's Administrative Manual, revised September 2022, showed each resident has the right to be free from all types of abuse, neglect, exploitation and misappropriation of property. Review showed the goal always will be the protection of the residents. Review showed the facility will not tolerate the abuse or mistreatment of residents by facility staff, by other residents, by family members or other visitors, by consultants or volunteers, or by any other individual. Review of Resident #1's medical record showed he/she was admitted to the facility on [DATE] with a diagnosis of dementia. Review of the resident's nurses note, dated 3/25/2023 at 8:34 P.M., showed the resident sat at a table in the dining room when a nurse and two Certified Nursing assistants (CNAs) observed Resident #2 with his/her hand down the resident's pants in what appeared to be a sexual act. After separating the residents the nurse asked Resident #1 if he/she was hurt and the resident stated No. I'm only embarrassed. When staff asked Resident #1 if he/she would like staff to assist to their room the resident said he/she she preferred to stay where he/she could see staff. The nurse notified the administrator, the on call nurse practitioner and Resident #1's emergency contact. Both residents were put on 15-minute face checks. During an interview on 3/27/2023 at 11:31 A.M., Resident #1's family member said if the resident was aware of the incident, the resident would be upset about it. The family member said the resident would have said no. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 1/21/2023 showed facility staff assessed the resident as follows: -Cognitively impaired; -No behaviors; -Independent with transfer and mobility; -Diagnoses of dementia without behavioral disturbance. Review of the resident's plan of care, updated 02/15/23, showed staff assessed the resident with sexual behaviors with another resident and family is aware. Review showed staff did not document interventions for the sexual behaviors. Review showed staff documented on 3/25/23 the resident with hypersexuality behavior. Review showed staff documented on 3/27/23 resident had a psychiatric evaluation. Staff are to adminster medication as directed, monitor and document side effects and effectiveness of the medication. Review of the resident's behavior note, dated 2/15/2023, showed staff documented the resident found in the TV room with another resident sitting on his/her lap. Review showed staff documented a message was left for the resident's family member and staff indicated they would monitor closely. Review of the facility investigation, completed on 3/27/2023 showed on 3/25/2023 at approximately 8:00 P.M., staff witnessed Resident #2 with his/her hand in the pants of Resident #1. Both residents were redirected by staff and placed on 15-minute checks. Facility staff notified both family representatives and physician. Review showed staff documented Resident #2's medical record reviewed by the facility physician on 3/26/2023 and the resident was seen by psychiatry on 3/27/2023. Review of the resident's behavior note, dated 3/25/2023, showed staff documented at 8:00 P.M. staff observed the resident standing over another resident in the dining room. Review showed the resident had his/her right hand down the front of the Resident #1's pants and moved his/her hand around. Review showed the nurse placed himself/herself between the residents to separate them. Review showed the resident refused to leave and sat down at another dining room table. Review showed staff notified the administrator, the on call nurse practitioner and Resident #1's emergency contact. Both residents were put on 15-minute face checks. During an interview on 3/26/2023 at 12:10 P.M., Certified Nursing Assistant (CNA) B said both residents remained on 15-minute checks until further notice. During an interview on 3/26/2023 at 1:10 P.M., the administrator said the residents would continue on 15-minute checks until the inter-disciplinary team reviewed the incident and made necessary changes. During an interview on 4/08/23 at 6:26 P.M., Licensed Practical Nurse (LPN) C said he/she had worked with Resident #2 before the incident and he/she had never witnessed the resident demonstrate any verbal or physical sexual behaviors. During an interview on 4/08/23 at 7:29 P.M., LPN D said on 3/25/23 at approximately 8 P.M. he/she was at the nurse station and noticed Resident #2 standing over Resident #1 in the dining room. As he/she approached the residents he/she could see Resident #2 had his/her hand down Resident #1's pants. LPN D asked two CNAs to come help with the residents. LPN D placed his/her body between the residents to separate them and asked the CNAs to take Resident #2 to his/her room. LPN D said Resident #1 was upset because he/she believed Resident #2 was his/her spouse. LPN D said he/she notified the administrator and then made the facility self report. LPN D said he/she had noticed Resident #2 to be territorial around residents of the opposite gender but had never observed any verbal or physical behaviors. During an interview on 4/08/23 at 7:42 P.M., CNA E said on 3/25/23 he/she was asked to assist with two residents in the dining room. CNA E said when he/she got to the table, Resident #2 was kissing Resident #1 and had his/her hand down his/her pants. CNA E said LPN D asked him/her to assist Resident #2 back to his/her room. CNA E said he/she had never witnessed Resident #2 demonstrate any sexual behaviors but had heard of an incident between Resident #2 and a different resident a month or so ago. MO00216001

Based on observation, interviews and record review, the facility failed to provide timely toe nail trimming to one of six sampled residents (Resident #1) which resulted in one of this resident's toe nails growing past the tip of the toes and into the pad of toes, causing a wound and pain when walking and necessitating treatment by a physician. The facility's census was 67. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 9/17/14, showed staff assessed the resident as follows: - adequate hearing, vision and speech, able to understand others and be understood; - requiring supervision only for personal hygiene and bathing; - no wounds. Review of the resident's care plan, most recently updated on 9/19/14, showed the plan did not address the resident's assessed, required supervision for personal hygiene and bathing. Review of the resident's nurses' notes dated 9/14/14 to 11/3/14 showed staff did not document regarding the condition of the resident's toe nails. Review of the resident's shower sheet, dated 10/9/14, with the notation "nails trimmed". Review of the resident's nurses' notes dated 11/3/14 showed staff documented telephone contact with the resident's podiatrist for "ingrowth and infection symptoms of foot". Staff scheduled an appointment for 11/5/14. Review of pictures taken during the resident's podiatrist appointment, dated 11/5/14, showed the resident's toe nails long and curved over the top of the toes and into underside. The pictures showed the right 3rd toe with a shallow open wound, approximately 0.5 centimeters (cm) long and 0.2 cm wide at the right edge of the toe nail. The pictures showed the right 3rd toe after the nail was trimmed with a shallow open wound, approximately 0.5 cm long and 0.3cm wide at the right edge of the toe nail. During an interview on 11/14/14 at 8:45 A.M. Registered Nurse (RN) A said the resident had an ingrown toe nail. He/she said he/she did not know how this toe nail was missed by staff since care givers watched for these types of problems. Observation on 11/14/14 at 9:10 A.M. showed all toenails properly trimmed and a wound underneath the right third toe freshly healed. Staff present applied a dry gauze dressing. During an interview on 11/14/14 at 9:45 A.M. RN B said, shower aides checked toenails and trimmed them if needed during bathing. If they were unable to trim the nails, they notified the nurse. During an interview, on 11/14/14 at 12:15 P.M. the resident said, he/she told staff he/she had problems with that toenail (right third toe), it hurt when he walked and one of the nurses looked at it and applied medication, but did not trim it. The resident said his/her toenails were trimmed in his/her podiatrist's office on 11/5/14. He/she said he/she trimmed his/her own fingernails, but staff trimmed toenails on bath days when nails were soft from the bath. During an interview on 11/14/14 at 12:25 P.M. RN A said, shower aides were supposed to address toenails and communicate with the nurse. He/She said that "obviously is not happening" and he/she did not realize there was a breakdown. He/she said sometimes he/she did not feel comfortable trimming nails. In such a situation staff could obtain a referral to a podiatrist. He/she said the resident did his/her own care such as putting socks and shoes on and staff did not see his/her toes much. The resident was not able to trim his/her own toenails and he/she did not complain of problems with his/her toenails to him/her. During an interview on 11/14/14 at 12:30 P.M. Certified Nurse Aide (CNA) C said he/she checked residents' nails during showers/baths and reported to the charge nurse if there was a need for trimming. During a telephone interview on 11/18/14 at 10:45 A.M. the resident's podiatrist said the resident came in for an ingrown right third toenail that had grown over the top of the toe and also caused a wound on the next toe. The physician said to reach such a length would have taken several months and indicated no trimming had been done for several months. MO 608

Based on observation, interview, and record review, facility staff failed to obtain medical treatment for one dependent sampled resident (Resident #3) of 15 sampled residents, who repeatedly complained of pain to his/her lower extremities after a fall in the facility. Facility staff injected the resident with [MEDICATION NAME] (an antipsychotic medication) to address his/her complaints of pain. Additionally, staff failed to obtain an x-ray of the lower extremities until over 48 hours after the fall, which showed a [MEDICAL CONDITION] hip. Facility staff also failed to provide comfort measures for one dependent sampled resident (Resident #4) in the dying process. The facility census was 71. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed staff assessed the resident as: - Moderately impaired cognitive skills for daily decision making; - Had hallucinations (perceptual experiences in the absence of real external sensory stimuli); - Exhibited verbal behavioral symptoms directed toward others; - Exhibited other behavioral symptoms not directed toward others (hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds); - Did not exhibit behaviors of wandering or rejection of care; - Required extensive assistance of one staff member with bed mobility, dressing, eating, toileting, and personal hygiene; - Required extensive assistance of two or more staff members with transfers; - Used a wheelchair; - Always incontinent of bowel and bladder; - Had a stroke, dementia, [MEDICAL CONDITION]/[MEDICAL CONDITION] (paralysis to one side of the body), [MEDICAL CONDITION]; - Received scheduled and as needed (PRN) pain medication; - Did not have any falls; - Received an antipsychotic medication on two of the last seven days. Review of the resident's nurse's notes, dated [DATE] at 2:30 P.M., showed staff documented the physician ordered a psychological evaluation for the resident. Review showed staff documented they transferred the resident to a hospital for an evaluation. Review showed the resident was admitted to the hospital under psychiatric care. Review of the resident's nurse's notes, dated [DATE], showed staff documented the resident returned to the facility. Review of the resident's physician's orders [REDACTED]. - [MEDICATION NAME] injection five milligrams (mg)/milliliter (ml); give two mg IM every four hours as needed for agitation (ordered [DATE]); - [MEDICATION NAME] 50 mg daily for pain (ordered [DATE]). Review of the resident's POS, dated [DATE] through [DATE], showed the POS did not contain an order for [REDACTED]. Review of the resident's nurse's notes, dated [DATE] at 7:00 P.M., showed staff documented the resident's roommate got the attention of staff and staff found the resident on the floor beside his/her bed in a supine position. Staff documented the resident screamed that his/her left leg hurt. Staff documented they performed passive and active range of motion (ROM) without difficulty to the resident's legs. Review of the resident's nurse's notes, dated [DATE] (no time), showed staff documented the resident complained of pain to the left lower extremity. Staff documented the resident continued to have full ROM with "some difficulty" to the right lower extremity. Staff documented they would request orders for an x-ray from the physician when he/she returned the facility's call. Review of the resident's nurse's notes, dated [DATE] (no time), showed staff documented they spoke with the Director of Nursing (DON) who had concerns regarding the resident having increased anxiety and agitation if he/she went to the hospital for an x-ray. Staff documented the DON directed staff to administer intramuscular (IM) [MEDICATION NAME] and [MEDICATION NAME] (antianxiety medication) and attempt to reassess the resident after he/she calms down. Staff documented they continued to wait for a call from the resident's physician. Staff documented they received an order from the physician to obtain an x-ray in the facility if the resident continued to complain of pain after he/she received [MEDICATION NAME]. Review of the resident's nurse's notes, dated [DATE] at 7:35 P.M., showed staff documented they administered 0.4 milliliters (ml) of [MEDICATION NAME] IM to the resident. Review of the resident's nurse's notes, dated [DATE] at 2:30 A.M., showed LPN X documented the resident complained of pain to his/her left lower extremity and "screaming out" and displayed "increased anxiety." Staff documented they administered IM [MEDICATION NAME] to the resident. Review of the resident's nurse's notes, dated [DATE] at 6:30 A.M., showed LPN X documented the resident "was screaming" and one-on-one interaction did not improve the situation. Staff documented they administered IM [MEDICATION NAME] to the resident and would continue to try redirection and one-on-one contact. Review of the resident's nurse's notes, dated [DATE] at 10:20 P.M., showed staff documented staff reported the resident continuously complained of discomfort to his/her right hip region and displayed an inability to sit properly in his/her wheelchair. Staff documented mobile x-ray staff were en route to the facility. Review of the resident's nurse's notes and POS, dated [DATE] through [DATE], showed staff did not document any information to show they notified the physician of the resident's continued complaints of pain. Review of the resident's nurse's notes, dated [DATE] at 2:00 A.M., showed staff documented the x-ray results were called to the facility and showed the resident had a [MEDICAL CONDITION] on his/her left side. Staff documented they notified the DON, who directed staff to fax the results of the x-ray to the physician and to call the on-call physician if the resident's pain increases. Review of the resident's nurse's notes, dated [DATE] at 8:30 A.M., showed staff documented the resident's physician ordered facility staff to send the resident to the emergency room to see a surgeon. During an interview on [DATE] at 11:10 A.M., Licensed Practical Nurse (LPN) M said the resident had a history of [REDACTED]. LPN M said on [DATE] the resident had been screaming in the dining room and staff wheeled the resident to his/her room, where he/she then fell from the wheelchair. LPN M said the resident screamed after he/she fell , but this was not unusual for the resident. LPN M said he/she monitored the resident and put him/her in bed after assessing that the resident had normal range of motion in his/her legs. LPN M said he/she "was going to get an order" from the physician "to send the resident to the hospital" until the DON directed LPN M to give the resident an injection of [MEDICATION NAME]. During an interview on [DATE] at 11:30 A.M., the DON said after the resident fell on [DATE] it was unclear if the resident's screams were due to a behavior or an injury. The DON said he/she contacted the physician who agreed to allow staff to give the resident an injection of [MEDICATION NAME] and then reassess for pain. The DON said staff were directed to follow up with an x-ray if the resident continued to complain of pain. The DON said she expected staff to notify the physician since the resident continued to complain of pain through the night. During a telephone interview on [DATE] at 1:30 P.M., LPN X said normally one injection of [MEDICATION NAME] would calm the resident and he/she would sleep. LPN X said on the night shift on [DATE] the resident continued to be agitated, with screaming and crying, and the [MEDICATION NAME] injection "didn't phase" the resident. LPN X said he/she did not contact the physician for follow up during the night shift. 2. Review of Resident #4's admission MDS, dated [DATE], showed staff assessed the resident as: - Moderately impaired cognitive skills for daily decision making; - Required extensive assistance of two or more staff with bed mobility, transfers, dressing, and toileting; - Had impairment in range of motion in bilateral lower extremities; - Used a wheelchair; - Frequently incontinent of bowel and bladder; - Received scheduled pain medication for occasional severe pain; - At risk for pressure ulcers; - On a turning/repositioning program. Review of the resident's corresponding plan of care, dated [DATE], showed staff documented the resident required extensive assistance from staff with bathing, bed mobility, dressing, grooming, hygiene, toileting, and transfers due to bilateral extremity pain and weakness. Staff documented the resident had pain and burning of the lower extremities and generalized pain. Review of the plan of care directed staff to: - Assist to turn in bed every two hours and reposition; - Provide pain medications according to physician's orders [REDACTED]. - Assess for verbal or non verbal signs and symptoms of pain including moaning, groaning, facial grimacing, crying, restlessness, and off pain medications as ordered; - Document/report restlessness or sleeplessness at night; ask resident if in pain when signs/symptoms are observed. Review of the resident's Report Sheet (used by licensed nurses to pass information about residents to the oncoming shift), dated [DATE], showed staff documented the resident had increased lethargy all weekend. Review of the resident's Report Sheet, dated [DATE] on the 7:00 A.M. to 3:00 P.M. shift, staff documented the resident "refused lunch." Review of the resident's nurse's notes, dated [DATE] at 1:30 P.M., showed staff documented the resident had an open area on his/her left ankle with slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy (at times)). Review of the resident's Dietician's Nutrition Assessment, dated [DATE], showed the dietician documented the resident had very poor intake, increased confusion and lethargy, weight loss, and wounds to his/her left ankle and right heel. Review of the resident's Report Sheet, dated [DATE] on the 7:00 A.M. to 3:00 P.M. shift, showed staff documented the resident refused breakfast and lunch. Review showed staff documented on the 3:00 P.M. to 11:00 P.M. shift the resident did not eat dinner. Review showed staff documented on the 11:00 P.M. to 7:00 P.M. shift the resident refused dinner. During an interview on [DATE] at 11:00 A.M. during the initial tour, LPN L said the resident's condition recently declined. LPN L said the resident required total assistance of staff with his/her care needs. Review of the resident's nurse's notes, dated [DATE] at 12:45 P.M., showed staff documented the resident had refused to eat for the last few days. Staff documented they notified the physician of the resident's decline and received an order for [REDACTED]. Observation on [DATE] at 3:15 P.M., showed the resident lay in bed asleep on his/her back with the head of the bed elevated. Observation showed the call light on the floor beside the resident's bed and the resident alone in his/her room. Observation at 4:05 P.M., showed the resident lay in bed on his/her back with the head of the bed elevated, and alone in his/her room. Observation showed the resident made grunting noises and coughed. Observation at 4:50 P.M., showed the resident lay in bed on his/her back with the head of the bed elevated. Observation showed CNA K entered the resident's room with ice cream and a clothing protector. CNA K asked the resident if he/she was thirsty and the resident responded, "you bet." Observation showed CNA K fed the resident ice cream while the resident lay on his/her back in bed with his/her eyes closed. Review of the resident's Report Sheet, dated [DATE] on the 7:00 A.M. to 3:00 P.M. shift, showed staff documented the resident was admitted to hospice services. Review showed staff on the 11:00 P.M. to 7:00 A.M. shift documented the resident as "very tired." Observation on [DATE] at 8:55 A.M., showed the resident alone in his/her room in bed with his/her eyes closed and the bed in an approximately 90 degree angle. Observation showed the resident made small movements in bed. Observation showed heel protectors attached to the resident's feet but did not cover the resident's heels and a pillow lay to the side of the resident's legs and did not float the resident's heels. Additionally, the call light lay at the foot of the bed and out of the reach of the resident. Observation showed the resident moaned, coughed, and moved frequently. Observation at 10:00 A.M., showed the resident in his/her room alone in bed with his/her eyes closed and the bed in an approximately 90 degree angle. Observation showed the resident moaned at times. Observation at 10:45 A.M., showed the resident in his/her room alone in bed with his/her eyes closed and the bed in an approximately 90 degree angle. Observation showed the resident's heels out of the heel protectors and rested directly on the bed, and the resident moaned at times. Observation at 12:15 P.M., showed the resident alone in his/her room and lay in bed asleep on his/her back with the head of the bed slightly elevated. Observation showed the resident's heel protectors not on and his/her feet rested directly on the mattress. Observation showed the resident made small movements and exhibited facial grimacing. Observation at 1:05 P.M., showed the resident in his/her room in bed with his/her eyes closed and the bed in an approximately 90 degree angle. Observation showed food particles on his/her lips. Observation showed the resident made small movements in bed and moaned, and the resident's heels rested on the bed. Observation at 3:10 P.M., showed the resident alone in his/her room and lay in bed on his/her back with eyes closed with the head of the bed slightly elevated. Observation showed the resident's heels rested directly on the mattress. Observation showed an oxygen concentrator by the resident's bed in the off position and packaged oxygen tubing rested on the floor. Observation showed the resident continued to make slight movements in the bed and exhibited facial grimacing. Observation at 3:40 P.M., showed the resident continued to lay in bed on his/her back with his/her neck hyperextended on the pillow with labored breathing and alone in his/her room. Observation showed the resident's heels rested on the mattress. Review of the resident's Report Sheet, dated [DATE] on the 7:00 A.M. to 3:00 P.M. shift, showed staff documented the resident "remained in bed, moaning, and not eating." Review of the resident's nurse's notes, dated [DATE], showed the day shift nurse did not document any information regarding the resident's condition on [DATE]. Review showed staff on the day shift did not document any information to show they notified hospice services or the resident's physician of the resident's condition. Observation on [DATE] at 4:20 P.M., showed LPN M entered the resident's room. Observation showed the resident lay in his/her room in bed on his/her back with the head of the bed slightly elevated. Observation showed the resident's neck hyperextended on the pillow and the resident had labored breathing and moaned. LPN M repositioned the resident's head on the pillow and put oxygen on the resident. During an interview on [DATE] at 4:20 P.M., LPN M said the resident had labored breathing and he/she needed oxygen. LPN M said the resident also needed pain medication. LPN M said he/she would call hospice to obtain an order for [REDACTED]. Review of the resident's nurse's notes, dated [DATE] at 4:55 P.M., showed the evening shift nurse documented that the resident exhibited increased restlessness, "appeared to be in pain," and staff noted abdominal breathing. Staff documented they notified the hospice nurse of the resident's condition at this time and obtained orders for a pain medication and antianxiety medication. Review of the resident's physician's orders [REDACTED]. - [MEDICATION NAME]/APAP ,[DATE] milligrams (mg)- one tablet at bedtime for pain as needed (ordered [DATE]); - [MEDICATION NAME]/APAP ,[DATE] mg- one tablet every six hours as needed for pain (ordered [DATE]); - [MEDICATION NAME] 0.25 mg every two hours as needed for anxiety (ordered [DATE]); - Heel booties to be worn at all times (ordered [DATE]). Review of the resident's MAR, dated [DATE], showed staff did not document that they administered any medication for pain to the resident on [DATE]. Review showed staff documented they administered one dose of [MEDICATION NAME]/APAP to the resident on [DATE] at 9:00 A.M. for "pain all over." Review showed staff did not document any results from the pain medication. Review of the MAR indicated [REDACTED].M. for increased anxiety and on [DATE] at 12:50 P.M. for increased anxiety. Review of the resident's nurse's notes, dated [DATE] at 11:34 P.M., showed staff documented the resident expired. During an interview on [DATE] at 8:40 A.M., LPN M said the day shift nurse on [DATE] told LPN M the following information during shift report: - The resident "was put on hospice" on [DATE]; - The resident had not been eating; - The nurse gave the resident [MEDICATION NAME]; - The resident remained in bed. During an interview on [DATE] at 10:30 A.M., LPN D said he/she did not remember if he/she checked the resident's vital signs on [DATE] during the day shift. LPN D said he/she administered routine and as needed (PRN) [MEDICATION NAME] to the resident and administered a PRN pain medication on [DATE] during the day shift. LPN D said direct care staff should have put the resident's heel protectors back on after the resident kicked them off. During an interview on [DATE] at 3:30 P.M., the DON said staff should have turned and repositioned the resident and addressed the resident's pain. The DON said staff should have put the resident's heel protectors on after he/she kicked them off. Additionally, the DON said staff should have assessed the resident's vital signs every shift.

Based on observation, interview and record review, the facility staff failed to replace one of three sampled resident's (Resident #4's) right wheelchair arm and left the resident unattended leading to the resident falling out of the chair and sustaining an 11 centimeter (cm) x 10 cm skin tear to his/her left forearm, an 18 cm x 12 cm skin tear to his/her right forearm and a 6 cm x 4 cm skin tear to his/her right forearm. Additionally the facility staff failed to ensure that two residents at risk for falls with pressure alarms are maintained in good working condition on two of three residents reviewed. One resident (Resident #2) pressure release bed alarm failed to sound loud enough to alert staff of his/her attempt to get out of bed unassisted. The resident was readmitted from a local hospital the morning of 4/7/2011, got up unassisted from bed and fell the same afternoon which resulted in a fractured left arm. Review of Resident #3's unoccupied bed with a personal alarm showed the alarm failed to sound when pressure was removed. The total sample size was six residents. The facility census was 73. 1. Record review of Resident #4's nurses notes dated 03/08/11 at 11:00 A.M., showed licensed staff recorded the following information: - "When the resident returned from therapy, he/she was placed in his/her room. Licensed staff recorded the resident's spouse called the nursing staff into the resident's room because he/she thought the resident was having a seizure. Licensed staff recorded upon assessment of the resident, he/she was found to be "ok". Licensed staff recorded leaving the resident's room. Licensed staff recorded the resident's spouse yelled for assistance upon finding the resident on the floor. Licensed staff recorded an assessment was done of the resident and was found to have multiple skin tears to his/her elbows. Licensed staff recorded it was then noticed the resident's wheelchair did not have the right side of his/her wheelchair in place. Licensed staff recorded an 11 cm x 10 cm skin tear to the resident's left forearm, an 18 cm x 12 cm skin tear to his/her right elbow and a 6 cm x 4 cm skin tear to his/her right forearm." Record review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/11/11 showed staff assessed the resident with the following: - Dependent on staff for his/her Activities of Daily Living; - Unsteady balance, only able to stabilize with human assistance; - Impairment in range of motion on both sides in all extremities. During an interview on 04/01/11 at 3:00 P.M., Physical Therapist Assistant (PTA) H said on 03/08/11, he/she removed the resident's right wheelchair arm to enable him/her to transfer the resident a little easier over to the therapy exercise mat. PTA H said he/she didn't realize he/she had not replaced the right wheelchair arm until the nursing staff came to retrieve it. PTA H said when he/she returned the resident to his/her room, he/she did let nursing staff know the resident was back in his/her room. During an interview on 04/01/11 at 3:15 P.M., the Assistant Director of Nursing (ADON) said when therapy returned the resident to his/her room, on 03/08/11, his/her spouse asked the charge nurse to come into the resident's room because the spouse thought there was something wrong with the resident. The ADON said the charge nurse assessed the resident and found his/her vital signs to be within normal limits. The ADON said the resident stated he/she had to go to the bathroom, so the nursing staff went to find a sit-to-stand lift (mechanical lift to assist the resident to go from a sitting position to a standing position) to transfer the resident to the bathroom. The ADON said within a few minutes the resident's spouse started yelling for nursing staff because he/she found the resident on the floor next to the right side of his/her wheelchair. The ADON said staff did not replace the resident's right side of his/her wheelchair arm. During an interview on 04/04/11 at 9:00 A.M., the administrator said she expected staff to ensure the resident's equipment was in place, as needed, at all times. 2. Review of the facility's Fall Protocol Policy dated 05/01/2006 showed: -All residents will be evaluated for fall risk on admission and with a significant change in status. Modifiable and non modifiable risks will be evaluated. Review of the facility's Fall Facts Sheet dated June 2009 showed the following information related to Alarm Check Sheets: -Sheets are to be initialed every two hours by Certified Nurse Assistants (CNA) or Certified Medication Technician (CMT) who are checking placement and function of resident alarms; alarm sheets are found on the computers at each nurses' station, nurses should be updating these when new residents get alarms. Review of Resident #2's quarterly minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/02/11, showed staff assessed the resident as follows: -Severely impaired decision-making skills; -Required extensive assistance of one person with transfers; -Required extensive assistance of one person to walk in room; -Frequently incontinent of bladder; -[DIAGNOSES REDACTED]. Review of the resident's Fall Risk assessment dated [DATE] showed staff assessed the resident with a score of 18, (above 10 is high risk for fall). Record review of the resident's plan of care last updated 02/23/11, showed staff planned the following interventions: -Apply bed alarm (since 7/26/10); -01/04/11-ask resident to call for assistance (fell while attempting to clean up juice spill on floor when he/she tried to stand up lost balance and fell on buttocks); -02/23/11-ensure the resident's bed alarm is turned on (Found on floor in front of bed, skin tear to right elbow acquired); -Report decline in mobility status; -Ensure call light is in reach at all times. Review of the resident's physician's orders [REDACTED]. -Full weight bearing; -Side rails up "times two." Review of the Hospital's Discharge Order and Summary Sheet dated 04/07/11 at 8:05 A.M. showed the physician ordered the following: -Discharge to extended care facility today; -Family wishes comfort care only; -Hospice. During an interview on 04/08/11 at 4:00 P.M., an anonymous family member said while waiting in the resident's room at the facility for the resident to return from the hospital, the resident's bed alarm sounded. He/she said the alarm was not very loud. He/she said staff did not respond to the room to check on the alarm until they came in with the resident "about 10 minutes later." Review of the resident's nurses notes dated 04/07/11 at 11:30 A.M. showed staff recorded the resident was admitted to the facility from a local hospital. Record review showed staff did not assess the resident's risk for falls following the admission or change in condition to evaluate interventions to prevent the resident from falls as directed in the facility's Fall Protocol Policy. During a interview on 04/15/11 at 1:00 P.M. the Acting Director of Nursing said she would expect staff to implement additional interventions related to falls when the resident was admitted . During a interview on 04/15/11 at 9:40 A.M. Licensed Practical Nurse (LPN) A said, he/she was on duty the morning of 04/07/11 when the resident returned from the hospital. LPN A said the resident's bed alarm was working and they did not implement other interventions to ensure the resident's safety from falls. Review of the resident's nurses notes showed on 04/07/11 at 3:20 P.M. staff recorded, "found resident on floor. Left arm under him/her. Complaint of severe pain in left upper extremity. Large skin tear cleansed and steri strips applied. Assisted up per four staff to wheelchair and to desk. Hospice to get high-low bed (a bed that can be lowered close to the floor). Mobile x-ray notified to x-ray left shoulder." Further review of the resident's nurses notes dated 04/07/11 at 5:35 P.M. showed staff recorded, "low bed here, full side rails up with bed alarm and pad on floor." Review of the resident's Radiology Report dated 04/07/11 showed the following: -Fracture of proximal left humerus (upper arm close to shoulder); -Moderate left pleural effusion (fluid in the lining of lungs), atelectasis (collapsed lung) or pneumonia (infection of lungs) considered. During a interview on 04/07/11 at 9:04 P.M. an anonymous family member said LPN D told him/her the bed alarm sound level was on "medium" and should have been on "high." LPN D told the anonymous family member staff did not hear the resident's bed alarm sound and did not know anything happened until other residents told staff the resident lay on the floor. During a interview on 04/14/11 at 10:10 A.M. Certified Nurse Assistant (CNA) E said, the resident tried to "get up a lot." During a interview on 04/14/11 at 1:45 P.M. LPN B said the resident used a walker and stand-by assistance of one person to walk. LPN B said the resident had a bed alarm to alert staff of his/her attempts to walk without assistance. During a interview on 04/14/11 at 3:45 P.M. LPN D said he/she heard a resident "call out." LPN D said when he/she got to the room the alarm was sounding but it was not loud enough for staff to hear outside of the resident's room. LPN D said he/she did not know you could set the sound level on the alarms. LPN D said the aides should check the residents' alarms to ensure they worked. LPN D said the bed alarm was on the bed when he/she came in to work that day. During a interview on 04/14/11 at 3:50 P.M. LPN C said he/she did not hear the resident's bed alarm sound that night. LPN C said he/she heard someone yell for help. LPN C said the aides check the alarms every shift and document when checked and the nurses reviews to see that it is done. During a interview on 04/15/11 at 10:00 A.M. the Assistant Director of Nurses (ADON) said the sound level on the bed alarms could not be adjusted. The ADON said the aides check to see that the light is blinking on the battery box that attached to the pressure pad, but they did not check the volume. 3. Review of Resident #3's Fall Risk Assessment last updated 11/10/10 showed staff assessed the resident at nine (total score of 10 or above represented high risk). Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment instrument completed by facility staff dated 02/07/11, showed staff assessed the resident as follows: -Severely impaired decision-making skills; -Required extensive assistance of one staff with transfers; -Did not ambulate; -Not steady moving from seated to standing without assistance; -Not steady during surface to surface transfer (between bed and chair or wheelchair); -[DIAGNOSES REDACTED]. Record review of the resident's plan of care last updated 05/14/11, showed staff assessed the resident had a problem with history of falls due to gait being unsteady, last admission had facture humerus (arm). Staff planned the following interventions: -Attach bed alarm at all times when in bed to alert staff of needed assistance, (6/24/10 resident observed on floor next to bed bruise to left upper back and left elbow). -Apply chair alarm to alert staff of needed assistance; -Check for placement and functioning of alarms every two hours per CNA, every shift per charge nurse. Observation and interview on 04/15/11 at 9:50 A.M. showed the resident's bed in his/her room empty. A pressure alarm was attached to the bed. The battery box attached to the pressure pad blinked to show it was on, but the alarm did not sound. The ADON applied pressure to the bed to activate the alarm but the alarm failed to activate. During interview the ADON said the facility did not have a formal plan to check to ensure the alarms activated when pressure is released. The ADON placed a new pressure pad on the resident's bed. When pressure was applied to the new pad, the alarm sounded. Review of the Alarm Flow Sheet on 04/15/11 at 10:00 A.M. showed staff did not record they checked the resident's bed alarm at 8:00 A.M. or at 10:00 A.M. During a interview on 04/15/11 at 10:10 A.M. the ADON said staff were responsible to check and report if there was a problem with the alarms. MO 639 and MO 244

Based on interview and record review, licensed facility staff failed to report critical lab results to one resident's (Resident #1) physician. The staff administered [MEDICATION NAME] (blood thinner) to the resident on a daily basis. On [DATE] at 12:15 P.M., the laboratory service called the facility to report the resident's [MEDICATION NAME] time (PT) and international normalized ratio (INR) (measures of how quickly the blood clots) were critically high. The licensed nurse faxed the report to a physician, but failed to notify the resident's physician by phone of the critically high PT and INR. Licensed staff working the following days (a weekend) also failed to contact the resident's physician and administered one additional dose of [MEDICATION NAME]. On [DATE], the resident developed rectal bleeding and staff sent the resident to the hospital. Additionally, staff failed to follow physician's orders [REDACTED].#3) to obtain PT/INR laboratory samples as ordered and failed to report results to the physician to ensure they administered the correct dosage of [MEDICATION NAME] to maintain therapeutic PT/INR levels. The facility census was 73. 1. Review of the facility's Lab and Diagnostic Test Results - Clinical Protocol (Revised [DATE]) under Identifying Situations that Warrant Immediate Notification, showed the following: High or toxic drug levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed facility staff assessed the resident as follows: -No memory problems; -Transferred with assistance of two staff; -Did not ambulate; -[DIAGNOSES REDACTED]. Review of the resident's Physician order [REDACTED]. - [DIAGNOSES REDACTED]. -[MEDICATION NAME] ([MEDICATION NAME]) 2.5 milligram (mg.) one tablet by mouth on Tuesday, Wednesday, Thursday, Saturday, and Sunday at 5:00 P.M. -[MEDICATION NAME] 5.0 mg. tablet by mouth on Monday and Friday. Review of a "STAT" (complete immediately) Laboratory Report dated [DATE] showed the resident's PT was 28.5 (normal 11.3 - 14.3) and INR 2.55 (normal 0.8 - 1.2). Review of the report showed facility staff faxed the result to the resident's physician who then faxed back an order to continue the present dose of [MEDICATION NAME], repeat INR on [DATE], and fax the results to the [MEDICATION NAME] Clinic. Review of a "STAT" laboratory result collected on [DATE] at 3:12 A.M. showed the laboratory service called a critically high PT of 61.8 and INR of 6.35 to a facility nurse on [DATE] at 12:15 P.M. Review of the lab report showed the facility nurse wrote the resident's current [MEDICATION NAME] dose on the bottom of the report and faxed the critically high results to a physician's office on [DATE] (a Friday). During a interview on [DATE] at 1:25 P.M. Licensed Practical Nurse (LPN B) said he/she did not call the resident's physician with the critically high results and did not know why he/she did not call the physician to notify him/her of the resident's critically high PT/INR results. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On [DATE] [MEDICATION NAME] 5.0 mg "held;" -On [DATE] [MEDICATION NAME] 2.5 mg "held;" -On [DATE] [MEDICATION NAME] 2.5 mg given; -On [DATE] [MEDICATION NAME] 5.0 mg "held." Review of the resident's critically high PT/INR results drawn on [DATE] showed the physician who staff faxed the results to on [DATE], returned the fax on [DATE] and wrote on the report, "not my patient." Review of a nurses' note dated [DATE] (no time) during the 11:00 P.M. to 7:00 A.M. shift showed licensed staff recorded another staff member notified the nurse the resident had blood in his/her stool. The nurse recorded the resident had been having episodes of loose watery stools. The nurse recorded he/she notified the resident's physician who directed staff to send the resident to the emergency room for evaluation. During a interview on [DATE] at 2:00 P.M. the Director of Nursing (DON) said nurses were responsible for monitoring [MEDICATION NAME] using the [MEDICATION NAME] Clinic. The DON said the charge nurse should follow up with laboratory reports. The DON said she would expect the nurses to call the physician with a critical laboratory result. During a interview on [DATE] at 9:15 A.M. Physician A said the facility staff should call the [MEDICATION NAME] Clinic with PT/INR results. Physician A said if staff could not contact the [MEDICATION NAME] Clinic, they should call him/her. The physician said he/she asked the facility staff to "be careful" and "not fax critical results." Physician A said the resident expired while hospitalized , but he/she could not say the critically high PT/INR level contributed to the resident's death. Physician A said he/she did not see the resident at the hospital, but if the PT was elevated it could have been the cause. 3. Review of Resident #2's laboratory results for PT/INR dated [DATE] showed a PT of 21.3 and INR of 1.79. Review of a physician's orders [REDACTED]. The physician directed staff to recheck the resident's PT/INR on [DATE]. Review of a nurses note dated [DATE] 1:00 P.M. showed staff recorded the resident's PT 31.8 and INR 2.90. Staff recorded the resident's physician did not make any [MEDICATION NAME] dosage changes and directed staff to "recheck PT/INR in two weeks." Review of the resident's PT/INR results dated [DATE] showed a PT of 39.2 (high) and INR of 3.70 (high). Review of the resident's physician orders [REDACTED]. The physician directed staff to repeat the PT/INR on [DATE]. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s [MEDICATION NAME] dose as ordered on [DATE] and continued to give the same dosage. Review of the resident's laboratory reports showed there are no PT/INR results dated [DATE] as ordered. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed facility staff assessed the resident as follows: -Memory problems; -Required extensive assistance of two staff with transfers, dressing, and hygiene; -Incontinent of bowel and bladder; -History of a stroke; -Limited range of motion of upper and lower extremities on both sides. Review of the resident's care plan updated on [DATE] showed staff planned the following interventions: -Administer medications as ordered; -Complete [MEDICATION NAME] lab draws as scheduled per physician's orders [REDACTED]. Review of the resident's POS dated [DATE] through [DATE] showed the following orders: -PT/INR per [MEDICATION NAME] Clinic; -[MEDICATION NAME] tab 2.5 mg take one tab by mouth on Monday, Wednesday, Friday, Saturday (started on [DATE] and discontinued on [DATE]); -[MEDICATION NAME] tab 5.0 mg take one tab by mouth on Tues, Thursday, Sunday (started [DATE] and discontinued on [DATE]). Review of the resident's MAR indicated [REDACTED]. Review of a nurses' note dated [DATE] at 9:00 A.M. showed staff recorded, "noted PT/INR drawn [DATE] had order to redraw [DATE] not done. Contacted [MEDICATION NAME] Clinic with order to redraw [DATE]. No signs or symptoms of bleeding." During a interview on [DATE] at 4:35 P.M. Licensed Practical Nurse (LPN) C said staff did not check the resident's PT/INR on [DATE] as ordered. LPN C said he/she called and got an order not to give the resident's [MEDICATION NAME]. Review of a PT/INR lab result dated [DATE] showed the laboratory services called results to a facility nurse at 11:08 A.M. on [DATE] which showed the resident's PT 54.2 (high) and INR 5.43 (high). Review of a nurses' note dated [DATE] at 11:15 A.M. showed staff recorded they called the resident's PT/INR result to the [MEDICATION NAME] Clinic. The nurse recorded he/she notified direct care staff of the resident's high PT/INR, not to use a regular razor, and to report any bleeding. Additionally staff recorded the clinic returned the call and ordered staff not to administer the resident's [MEDICATION NAME] on [DATE] and [DATE] then redraw a PT/INR on [DATE]. During a interview on [DATE] at 9:15 P.M. Physician A said staff notified him/her of the resident's high PT/INR. 4. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed facility staff assessed the resident as follows: -No memory problems; -Required extensive assistance of two staff with transfers, dressing, and hygiene; -Did not ambulate; -Incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -[MEDICAL CONDITION] (paralysis of arms and legs). Review of the resident's Phyiscian Order Sheet (POS) dated [DATE] showed the physician ordered the following: -[MEDICATION NAME] Clinic for [MEDICATION NAME] dosage management; -Administer [MEDICATION NAME] 4.0 mg one tablet by mouth every day at 5:00 P.M. Review of the resident's MAR indicated [REDACTED]. once daily. Review of the resident's PT/INR lab results dated [DATE] showed the laboratory company called a facility nurse to notify him/her of the resident's high PT of 33.2 and INR of 3.04. Review of a Telephone Order dated [DATE] showed facility staff contacted the resident's personal physician who directed staff to continue the resident's present dose of [MEDICATION NAME] and recheck the resident's INR on [DATE]. Record review of a "Stat" PT/INR results for [DATE] showed the laboratory service called a facility nurse to report the resident's high PT level of 48.3 and INR of 4.74. Review of the physician's orders [REDACTED]. -Stop current orders for [MEDICATION NAME]. Hold the resident's [MEDICATION NAME] on [DATE] then begin [MEDICATION NAME] 2.5 mg Monday and Saturday and 5.0 mg all other days. -Recheck the resident's PT/INR on [DATE]. Review of the [DATE] MAR indicated [REDACTED]. Review of the facility's chart audit dated [DATE] showed on [DATE] the resident's physician ordered staff to hold the resident's [MEDICATION NAME] and recheck the INR daily until the INR measured less than three. Review of the resident's lab results did not show facility staff obtained daily PT/INRs as directed by the physician. Additional review of the facility's [DATE] chart audit report showed staff recorded, "there are two different orders related to the [MEDICATION NAME] on the resident. The first order to hold [MEDICATION NAME] [DATE] then start 2.5 mg every Monday and Saturday and 5.0 mg all other days- recheck PT/INR [DATE]. The second to hold [MEDICATION NAME] and recheck daily until INR less than three. Staff recorded no lab draw on [DATE] or any other days. Will redraw on Monday [DATE]. Review of the resident's PT/INR results dated [DATE] showed the resident's PT measured 34.4 and his/her INR measured 3.17. Facility staff recorded on the bottom of the report the resident's current dose of [MEDICATION NAME] was 2.5 mg Monday and Saturday and 5.0 mg all other days. Staff faxed the report showing the resident's current [MEDICATION NAME] dose to the [MEDICATION NAME] Clinic at 12:18 P.M. The [MEDICATION NAME] Clinic staff returned the fax at 12:30 P.M. and recorded on the report, "please verify dosage patient should be taking 2.0 mg Saturday and Monday and 4.0 mg rest." Review of the resident's physician telephone orders, dated [DATE], showed the physician directed staff to administer 2.0 mg of [MEDICATION NAME] on Saturday and Monday and 4.0 mg all other days. Review of a nurses' note dated [DATE] at 9:30 A.M. showed staff recorded the resident's personal physician directed staff to go through the [MEDICATION NAME] Clinic for PT/INR labs. During a interview on [DATE] at 2:00 P.M. the Director of Nursing said they reviewed orders for all residents taking [MEDICATION NAME] and clarified orders when there was conflict with physicians and the [MEDICATION NAME] Clinic. Note: At the time of the complaint investigation, the violation was coded at "J", Immediate and Serious Jeopardy Level. By [DATE], the facility had implemented measures that adequately addressed the jeopardy by completing a chart audit of all residents in the facility on [MEDICATION NAME]. The facility resolved/clarified all inconsistencies in [MEDICATION NAME] orders. The DON inserviced licensed staff on-duty regarding the facility's new [MEDICATION NAME] Protocol including direction to call and fax all abnormal lab results to the physician or [MEDICATION NAME] Clinic. If the physician did not call back, the next shift nurses should repeat the call and document this in the nurses notes. If no call back within 24 hours the nurse is to notify the Administrator or DON. The grid placement was lowered to a "D" level. This statement does not denote that the facility has complied with Section 198.026.1 RsMO, regarding prompt remedial action for a violation of a Class I standard. See below for remaining deficient practice: As of the [DATE] exit conference, the facility failed to do the following: - provide inservices to all licensed nursing staff regarding the new [MEDICATION NAME] Protocol. MO 495