Every finding on record at Worth County Convalescent Center

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, when the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for four (Resident #3, Resident #4, Resident #5, and Resident #30) of the 12 sampled residents. The facility census was 33. Review of the facility's Resident Participation - Assessment/Care Plans policy, revised 2016, showed the residents/representatives have the right to be informed, in advance (by the physician, practitioner, or professional) of the risks and benefits of the care or treatment proposed. 1. Review of Resident #3's Care Plan, revised on 10/12/25, showed:- The resident had depression related to stroke and inability to be active and relied on nursing staff to anticipate and meet needs;- The resident had an alteration in neurological status/impaired brain function related to stroke and relied on staff to assess for effects of psychotropic medications, cue and reorient as needed, and review medications and record possible causes of cognitive deficit. Review of the resident's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 02/04/26, showed:- Resident had severe cognitive impairment;- High-risk drug classes including anti-psychotic and anti-convulsant were ordered;- Diagnoses of Dementia, Psychotic Disorder, and Stroke. Review of the resident's physician order summary report, dated 02/24/26, showed Quetiapine Fumarate (anti-psychotic) and Divalproex Sodium (anti-convulsant), for mood disorders, started on 10/16/24. Record review of the resident's Medical Records showed no documentation of informed consents with the resident or family for the use of anti-psychotic or anti-convulsant medications for the resident could be located. 2. Review of Resident #4's Care Plan, revised on 09/05/24, showed: - The resident had depression related to health problems and relied on nursing staff to anticipate and meet needs;- The resident used psychotropic medications related to major depressive disorder and staff were required to educate the resident about risks, benefits, and the side effects and/or toxic symptoms of the psychoactive medication drug being given. Review of the resident's, Annual MDS, dated [DATE], showed:- Resident was cognitively intact; - High-risk drug classes including anti-psychotic, anti-depressant, and anti-convulsant medications were used;- Diagnoses of depression, muscle wasting and atrophy, and wound infection. Review of the resident's physician order summary report, dated 02/24/26, showed Aripiprazole (anti-psychotic) and Sertraline (anti-depressant), for mood disorders, ordered on 08/15/24. Record review of Resident's Medical Records showed no documentation of informed consents with the resident or family for the use of anti-psychotic or anti-depressant medications for the resident were located in the clinical record. 3. Review of Resident #5's Care Plan, revised on 07/11/25, showed: - The resident had depression related to stroke and relied on nursing staff to anticipate and meet needs;- The resident had a mood problem related to stroke and staff were required to educate the resident about expectation of treatment, concerns with side effects and potential adverse effects evaluation and maintenance. Review of the resident's, Annual MDS, dated [DATE], showed:- Resident was cognitively intact; - High-risk drug classes including anti-psychotic and anti-depressant are ordered;- Diagnoses of dementia, depression, and stroke. Review of the resident's Order Summary Report, dated 02/24/26, showed Sertraline (anti-depressant) ordered on 03/04/24 and Quetiapine Fumarate (anti-psychotic) ordered on 07/11/25, for mood disorders. Record review of Resident's Medical Records showed no documentation of informed consents by the resident or family for the use of anti-psychotic or anti-depressant medications for the resident. During an Interview on 02/26/2026 at 8:57 A.M. the Director of Nursing (DON) said the residents should have written consents for the psychotropic medications and the facility is getting the proper form to document the written consents. During an Interview on 02/26/2026 at 8:58 A.M. the Administrator said the residents should have written consents for the psychotropic medications in their medical record. 4. Review of Resident #30's care plan, dated 12/11/24 showed it did not address the resident's use of psychotropic medication. Review of the resident's Annual MDS, dated [DATE] showed: - Cognitive skills for daily decision making moderately impaired. - No behaviors. - Antipsychotics were provided to the resident on a regular basis. - A gradual dose reduction (GDR) was documented by the physician as clinically contraindicated on12/16/25. - Diagnoses included non-traumatic brain dysfunction, Alzheimer's disease, stroke and depression. Review of the resident's POS dated February 2026 showed a start date of 12/16/25 for Seroquel 50 milligrams, one tablet at bedtime related to dementia. Review of the electronic medical chart on 2/25/26 showed no consents or education of risks and benefits for psychotropic medication use for the resident or family were found. The resident was not capable of an interview regarding the medication consents. During an interview on 2/26/26 at 8:57 A.M., the DON said the facility should have a written consent for the psychotropic medications prior to the start of the medications.

Based on record review and interview, the facility failed to establish and maintain a system that assured a full and complete, separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf when monthly personal funds reconciliation showed an accumulating reimbursement deficit to the account due to monthly bank charges owed by the facility. This affected four of 12 sampled residents (Resident #3, #4, #7, and #12). The facility census was 33.Based on record review and interview, the facility failed to establish and maintain a system that assured a full and complete, separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf when monthly personal funds reconciliation showed an accumulating deficit to the account due to monthly bank charges. This affected four of 12 sampled residents (Resident #3, #4, #7, and #12). The facility census was 33.Review of the facility's policy on management of the Resident Trust Fund (RTF) not provided;1. Review of Resident #3's Quarterly Minimum Data Set (MDS, a federally required assessment tool completed by facility staff), dated 1/2/26, showed:- Resident not cognitively screened;- Diagnoses: hypertension, diabetes, stroke, dementia, quadriplegia (paralysis of all four limbs), seizure disorder, traumatic brain injury, and psychotic disorder;2. Review of Resident #4's Annual MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnoses: anemia, hypertension, and GERD (Acid reflux);3. Review of Resident #7's Annual MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnoses: heart failure, hypertension, urinary tract infection, diabetes, dementia, and anxiety disorder;4. Review of Resident #12's Quarterly MDS, dated [DATE], showed:- Resident was not cognitively screened;- Diagnoses: hypertension, diabetes, Alzheimer's Disease, and depression;5. Review of the Resident RTF Account, dated February 2025 through January 2026 showed:- RTF charged a fee of $2.00 each month during the period for Paper Statement Fee;- No entries during the period showing reimbursement to the RTF Account for the bank charge of Paper Statement Fee;- Reconciliation of the RTF Account by the facility contained a running balance of money owed to the RTF by the facility which showed a current balance of $84.00 owed;- Interest was credited to the RTF monthly based on the ending account balance each month, which did not include the funds accrued, that the facility owed to the RTF account;- Residents #3, #4, #7 and #12 had funds in the interest bearing RTF as of 1/31/26;During an interview on 2/25/26 at 9:54 A.M., Administrator said:- We keep a running tally of the bank statement fees that are charged to the Resident Trust Fund and that total is money that the facility owes back to the resident trust account since the residents are not responsible to pay bank fees. It was last year sometime since we reconciled the account and put money back into the resident trust fund.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered plan which included measurable objectives and timeframes to address resident needs and preference when the care plans did not include Resident #29's preference for life saving measures or address Resident #34's desire to return to the community. The deficient practice affected two of the 12 sampled residents. The facility census was 33. Review of the facility's Resident Care Plan Policy and Procedure policy, dated [DATE], showed:- The purpose is the care plan shall be used in developing the resident's daily care routines and will be available to caregivers and other staff who have the responsibility for providing care or services to the resident;- Care plans for each resident will be developed upon admission and updated quarterly;- Completed care plans are placed in the resident's chart;- Aides are responsible for reporting to the charge nurse any change in the resident's condition and the care plan goals that have not been met;- Change in a resident's condition must be reported to the Director of Nursing so that a review of the resident's assessment and care plan can be made;- Documentation must be consistent with the resident's care plan. Review of the facility's Care Planning - Interdisciplinary Team policy, revised [DATE], showed:- Our facility's care planning/Interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident;- A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment. Review of the facility's Goals and Objectives, Care Plans policy, revised [DATE], showed:- Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence;- Care plan goals and objectives are defines as the desired outcome for a specific resident problem;- Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented, behaviorally stated, are measurable, and contain timetables to meet the resident's needs;- Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved;- Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition, when the desired outcome has not been achieved, when the resident has been readmitted to the facility, and at least quarterly. Review of the facility's Care Plans, Comprehensive Person-Centered policy, revised [DATE], 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 in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident;- Each resident's comprehensive, person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care;- The comprehensive, person-centered care plan will include measurable objectives and timeframes, describe services to be furnished and provided, include the resident's stated goals and desired outcomes, and include the resident's stated preference and potential for future discharge, including his or her desire to return to the community. 1. Review of Resident #34's, admission MDS, dated [DATE], showed:- The resident is cognitively intact; - The resident requires partial assistance with showering, bathing, and putting on footwear and only required setup assistance with most other activities of daily living (ADL's);- Diagnoses of heart failure, chronic lung disease, and kidney failure. Review of the resident's Care Plan, revised on [DATE], showed the care plan was incomplete and did not address the resident's wishes to discharge to the community.During an interview on [DATE] at 1:54 P.M., the resident said his/her goal was to return to the community and would like to be able to things outside of the facility. During an interview on [DATE] at 8:56 A.M., the Administrator said the resident's care plan should accurately reflect the resident's needs, wishes and goals of each resident. 2. Review of Resident #29's care plan dated [DATE] showed it did not address the resident's code status (preference for life saving measures). Review of the resident's face sheet showed Do Not Resuscitate (DNR, a medical instruction that indicates cardiopulmonary resuscitation (CPR), should not be performed if a person's heart stops beating or the person stops breathing). Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact. - No behaviors. - Upper extremity and lower extremity impaired on one side. - Diagnoses included stroke, depression, and hemiparesis (muscle weakness or paralysis on one side of the body)/hemiplegia (paralysis affecting one side of the body). Review of the physician orders dated February 2026 showed a start date of [DATE] to Do Not Resuscitate. During an interview on [DATE] at 8:57 A.M. the Director of Nursing (DON) said: - He/She was also the MDS/Care Plan Coordinator. - The care plans provide direction to the staff and should address the resident's code status.

Based on observation, interview and record review, the facility failed to assure staff followed acceptable standards of practice for one sampled resident (Residents #4) of 12 sampled residents when facility licensed staff did not follow wound care orders correctly which placed the resident at risk for decline in physical health. The facility failed to ensure the setting on the low air loss mattress was correct for Resident #24. Additionally, the facility failed to ensure staff administered insulin correctly which affected three sampled residents (Resident #2, #7 and 11) of 12 sampled residents. The facility census was 33. The facility did not provide a policy for the Drive Low Air Loss Mattress (LAL mattress, is a therapeutic mattress designed to help prevent and treat pressure ulcers by controlling pressure and keeping the skin cool and dry). 1.Review of Resident #24's care plan dated 7/3/23 showed it did not address the use of a LAL mattress. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired. - Dependent on staff assistance for toilet use, and showers. - Required substantial to maximum assistance with transfers. - Always incontinent of bowel and bladder. - Weight - 115 pounds. - At risk for pressure ulcers. No pressure ulcers noted. - Diagnoses included stroke, depression, anxiety and diabetes mellitus. Review of the resident's POS showed: - There was no order for a LAL mattress or for the settings. - Start date: 7/19/24 - Admit to Hospice. Observation on 2/23/26 at 10:55 A.M., showed the resident lay in bed with the LAL mattress pressure set on 350 pounds. Observation on 2/24/26 at 12:57 P.M., showed the resident was not in bed, but the LAL mattress was pressure set on 350 pounds. Observation on 2/25/26 at 9:30 A.M. showed the resident lay in bed with the LAL mattress pressure set on 350 pounds. Observation on 2/26/26 at 7:24 A.M., showed the resident was not in bed, but the LAL mattress pressure set was set on 350 pounds. During an interview on 2/26/26 at 7:44 A.M., Licensed Practical Nurse (LPN) A said He/She did not know who was responsible to check the settings on the LAL mattress but thought it was probably housekeeping. During an interview on 2/26/26 at 8:57 A.M., the Administrator said if the resident was on Hospice, then Hospice should monitor to ensure the LAL mattress is on the correct setting. The facility did not provide a policy for the use of insulin pens. 2. Review of Resident #2's care plan, dated 7/7/22 showed the resident had Diabetes Mellitus as evidenced by increased blood sugar levels and need for insulin. Diabetes medication as ordered by the physician. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills for daily decision making intact. - Independent with eating, toilet use, showers, dressing and transfers. - Always continent of bowel and bladder. - Diagnosis included diabetes mellitus. Review of the resident's POS dated February 2026 showed: - Start date: 2/14/23 - Blood sugar per glucometer twice daily for diabetes mellitus. - Humalog insulin injection 12 units three times daily with meals for diabetes mellitus. Review of the resident's Medication Administration Record (MAR) dated February 2026 showed: - 2/25/26 - Blood sugar documented by staff as 184. - 2/25/26 - Staff documented Humalog insulin 12 units was administered. Observation on 2/25/26 at 6:40 A.M., showed: - The resident checked his/her blood sugar and reported to LPN A it was 184. - The Humalog insulin pen did not have a label to indicate which resident it belonged to and was not dated when opened. - Unknown staff had handwritten the resident's first name and 12 u on the lid. - LPN A did not clean the port before he/she attached the needle and did not prime it with two units. - LPN A dialed the insulin pen to 12 units and administered it in his/her right arm. 3. Review of Resident #11's care plan dated 6/14/25 showed the resident had Diabetes Mellitus. Diabetes medication as ordered by the physician. Review of the resident's Quarterly MDS dated [DATE] showed: - Cognitive skills intact. - Supervision/touch assistance with dressing,, personal hygiene and transfers. - Independent with eating. - Occasionally incontinent of bowel and bladder. - Diagnosis included diabetes mellitus. Review of the resident's POS dated February 2026 showed: - Start date: 12/13/25 - Check blood sugars before meals and at bedtime related to diabetes mellitus. - Start date: 7/7/25 - Humalog insulin pen, 8 units three tines a day for diabetes mellitus. Review of the resident's MAR dated February 2026 showed: - 2/25/26 - Staff documented the blood sugar as 154. - 2/25/26 - Staff documented eight units was administered in the resident's abdomen. Observation on 2/25/26 at 11:14 A.M., showed: - LPN A Obtained the resident's blood sugar which was 116. - The Humalog insulin pen did not have a label to indicate which resident it belonged to and was not dated when opened. - Unknown staff had handwritten the resident's initials on the lid and wrote 8U on the lid. - LPN A did not clean the port before he/she attached the needle and did not prime it with two units. - LPN A dialed the insulin pen to 8 units and administered it in his/her abdomen. During an interview on 2/26/26 at 7:44 A.M, LPN A said: - The insulin pens should be dated when opened and should have a label on then to indicate which resident it belonged to. - The insulin pens should not be used if they do not have a date when they were opened or a label to indicate which resident it belonged to. During an interview on 2/26/26 at 8:57 A.M., the DON said: - The Pharmacy label is placed on the box of insulin pens but there are labels in the drawer of the medication cart for staff to use to label the insulin pens with the resident's name, date opened and expiration date and type of insulin. - The insulin pens should have a label on them to indicate which resident it belonged to. - The insulin pens should be dated when opened. - The insulin pens should not be used if they have not been dated or labeled because there was no way to determine how long the insulin pen had been opened. Review of the facility's Physician Orders policy, dated 08/31/2016, showed:- The purpose is to ensure the physicians orders are followed as written for safety and well-being of the resident;- Physician orders should be followed as written. Review of the facility's Wound Care Clean Dressing Change policy, revised on 01/03/2018, showed:- The facility is committed to prevention of infections and promoting wound care;- The procedure included applying prescribed medication to wound/wound area, if ordered. 4. Review of Resident #4's Care Plan, revised on 09/05/24, showed: - The resident had two pressure ulcers related to decreased mobility and relied on nursing staff to administer treatments as ordered, monitor for effectiveness, and assess and document status of the wound;- The resident had a nutritional problem and chronic pain related to wound healing and relied on staff to anticipate and meet needs. Review of the resident's, Annual MDS, dated [DATE], showed:- Resident was cognitively intact; - Dependent on nursing staff for transfers and showers;- Diagnoses of: stage three pressure ulcers (severe, full-thickness skin injury extending through the outer skin layer into the subcutaneous fat, appearing as a deep crater, often with visible fat, slough, and possible tunneling) to both buttocks, muscle wasting and atrophy, and wound infection. Review of the resident's Physician Order Sheet, located in the resident's electronic medical record, showed:- Order entered on 01/20/2026, that Licensed nursing staff were to clean the right and left buttocks wounds with wound cleanser, use skin prep to peri-wound area, apply collagen powder and cover with bordered gauze one time a day on Monday, Wednesday, and Friday for wound treatment;- Order entered on 02/06/2026, that Licensed nursing staff were to apply protect zinc spray after skin prep to peri-wounds with dressing changes and daily. One time a day for wound treatment. During an interview on 02/23/2026 at 10:50 A.M., the Resident said:- He/She had sores on his/her bottom and the staff would change the dressings but they are supposed to look at the wounds every day shift but they don't.- Nursing staff would change the dressings every other day during the week, every shower day, but they are supposed to check the dressings every day shift;- Nursing staff are supposed to put spray on it; - The dressing gets bunched up sometimes and the nursing staff have had to change it on an off scheduled day;- He/She has been dealing with the sores for over a year and they used to be really bad but he/she stays on his/her side a lot; During an interview on 02/24/2026 at 11:03 A.M., the Resident said he/she felt like the only nurse that did his/her wound spray was Licensed Practical Nurse (LPN) A, who does the spray. During an interview on 02/24/2026 at 2:45 P.M., Nurse Practitioner (NP) A said:- The resident had been admitted with the wounds and she had had his/her left side healed and right side improved greatly. When she sees him/her weekly the wounds improve and when she doesn't see him/her weekly he/she doesn't seem to stay off the wound, offload enough;- The resident gets confused about the spray, because the zinc peri-wound spray is applied only when the dressing is changed and the skin prep spray is ordered for application more often. Observation on 02/25/2026 at 2:30 P.M., showed:- Registered Nurse (RN) C perform the morning dressing change on the resident;- RN C knocked, provided privacy, washed hands, and applied applicable Enhanced Barrier Precautions;- RN C removed the intact dressings and the affected areas looked like road rash with some bloody drainage noted to the removed dressings, the resident's skin, and on the bed mat beneath the resident;- RN C cleaned the areas with wound cleanser saline wash and four by four bandages with new ones for each buttock area;- RN C then applied the collagen powder and bordered gauze to each wound with the affected area appearing to extend beyond the bordered gauze, peri-wound area;- RN C changed the bed pad due to the blood soiling, covered the resident up and lowered the bed to it's lowest position, dated and initialed the dressings, and left the room;- Outside the room, RN C was asked about the skin prep spray and the zinc spray to the peri-wound as ordered with each dressing change. RN C said he/she didn't do it and believed the sprays are only done with the morning and night dressing changes;- This was the morning dressing change due to the dayshift nurse postponing the procedure for observation. RN C said he/she would have to check the order but did not return to the room. During an interview on 02/26/2026 at 7:30 A.M., the Resident said RN C did not return to apply the spray to the peri-wound, they hardly ever do the spray and they are supposed to each shift. He/She again said that LPN A is about the only one who does the spray. During an interview on 02/26/2026 at 7:32 A.M., LPN A said:- When licensed staff are doing the resident's dressing changes the nurse should definitely apply the skin prep spray and the zinc spray;- The nurses should be spraying the wounds each shift. During an interview on 02/26/2026 at 8:57 A.M., the Director of Nursing (DON) said:- RN C should have completed the entire ordered treatment for the resident;- RN C should have used the ordered sprays for the wound;- Nursing staff should be performing the treatments as ordered and according to the schedule ordered;- The products and sprays ordered by the providers help extend the life of the applied treatment and should be applied. Observation on 02/26/2026 at 7:04 A.M., showed:- LPN A prepared to administer insulin to resident #7. LPN A had already drawn up the 12 units and had already attached the needle to the pen;- LPN A had not primed the insulin pen and had not cleaned the port before applying the needle to the pen;- There was no open date written on the insulin pen. During an interview on 02/26/2026 at 7:07 A.M., LPN A said:- He/She did not prime the insulin pen. He/She believed nursing should only prime a pen when it is first opened and not any times following when the pen is used after the initial opening;- His/Her procedure for setting up the insulin pen is to just screw on the needle and dial in the amount of required insulin, that's it;- The insulin pen should be dated when opened;- LPN A did not say the port needed cleaned first. During an interview on 02/26/2026 at 8:56 A.M, the Director of Nursing (DON) said:- The insulin pens should have a label on them to indicate who they belong to;- The insulin pens should not be used if they have not been dated when opened or labeled because there is no way to know how long the pens have been open;- The insulin pens should have the port cleaned with an alcohol wipe before the licensed staff attached the needle;- The insulin pens should be primed with two units of insulin before use each time. #2708494

Based on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective administration system that was free of significant medication errors when staff failed to prime insulin pens prior to administering insulin which affected three of the 12 sampled residents, (Resident #2, #7 and #11). The facility census was 33. The facility did not provide a policy for administration of insulin or the use of insulin pens. 1. Review of Resident #2's Physician Order Sheet (POS) dated February 2026 showed: - Start date: 2/14/23 - Blood sugar per glucometer twice daily for diabetes mellitus. - Humalog insulin injection 12 units three times daily with meals for diabetes mellitus. Review of the resident's Medication Administration Record (MAR) dated February 2026 showed: - 2/25/26 - Blood sugar documented by staff as 184. - 2/25/26 - Staff documented Humalog insulin 12 units was administered. Observation on 2/25/26 at 6:40 A.M., showed: - The resident checked his/her blood sugar and reported to LPN A it was 184. - LPN A did not clean the port before he/she attached the needle and did not prime it with two units. - LPN A dialed the insulin pen to 12 units and administered it in his/her right arm. 2. Review of Resident #11's POS dated February 2026 showed: - Start date: 12/13/25 - Check blood sugars before meals and at bedtime related to diabetes mellitus. - Start date: 7/7/25 - Humalog insulin pen, 8 units three times a day for diabetes mellitus. Review of the resident's MAR dated February 2026 showed: - 2/25/26 - Staff documented the blood sugar as 154. - 2/25/26 - Staff documented eight units was administered in the resident's abdomen. Observation on 2/25/26 at 11:14 A.M., showed: - LPN A Obtained the resident's blood sugar which was 116. - LPN A did not clean the port before he/she attached the needle and did not prime it with two units. - LPN A dialed the insulin pen to 8 units and administered it in his/her abdomen. During an interview on 2/26/26 at 7:44 A.M, LPN A said: - He/She should have cleaned the port with an alcohol wipe before he/she attached the needle. - He/She primed new insulin pens with two units, but after that he/she did not prime the insulin pens. During an interview on 2/26/26 at 8:57 A.M., the DON said: - Staff should clean the insulin ports with an alcohol wipe and then attach the needle. - Staff should prime the insulin pen with two units of insulin each time before it is used. 3. Review of Resident #7's Physician Order Sheet (POS) dated February 2026 showed:- Start date: 01/28/25 - Blood sugar per glucometer twice daily for diabetes mellitus. - Lispro insulin injection 12 units two times daily with meals for diabetes mellitus. Review of the resident's Medication Administration Record (MAR) dated February 2026 showed:- 02/26/26 - Blood sugar documented by staff as 128.- 02/26/26 - Staff documented Humalog insulin 12 units was administered. Observation on 02/26/26 at 7:04 A.M., showed:- LPN A did not clean the port before he/she attached the needle and did not prime it with two units;- LPN A dialed the insulin pen to 12 units and let the resident administer to their lower right abdomen. During an interview on 2/26/26 at 8:57 A.M., the DON said: - Staff should clean the insulin ports with an alcohol wipe and then attach the needle. - Staff should prime the insulin pen with two units of insulin each time before it is used. Intake 270849

Based on observations, interviews, and record review, the facility failed to ensure staff properly labeled and dated opened insulin pens, which affected five of the 12 sampled residents, (Resident #2, #7, #11, #29, and #34), staff preset medications for Resident #10, #22 and #31. Additionally, staff taped seven Lorazepam (used to treat anxiety) tabs into the medication card which affected Resident #30. Resident #24 had an undated opened bottle of Morphine Sulfate (an Opioid used to treat moderate to severe pain) which was filled on 7/19/24. The facility census was 33. Review of the facility's policy for Drug/Medication Administration for Oral Medications, dated 7/29/13 showed: - The facility is committed to providing a safe environment for residents and staff. Medications will be administered in a safe and professional manner. - The purpose is to provide a uniform set of guidelines for giving and charting of medications and treatments. To determine standard medication administration times to e observed by the nursing staff in administration of medications ordered by the physician. - The seven rights will be observed. Right resident, right medications, right dose, right time, right route, the right to refuse and right to be educated. - You cannot pre-pour medications-this is not an acceptable standard of practice. Pour medications just prior to administering. 1. The facility did not provide a policy for the use of Insulin pens. 2. Observation and Interview on 2/24/26 at 8:40 A.M., showed in the top drawer of the medication cart: - Three paper cups with medications in them with the resident's first name on them. Resident #20 had one blue oblong pill, one white round pill and one white oblong pill. Resident #31 had one white capsule, one oblong white pill, two small round white pills, and two round red pills. Resident #22 had one pink oblong pill, two white oblong pills, one round tan pill and one round pink pill. Licensed Practical Nurse (LPN) A said he/she should not have preset the medication. - Unknown staff handwrote Resident #34's first initial and last name on the lid of the Lantus insulin pen and did not have a date when it was opened. - Unknown staff handwrote Resident #11's first and last initial and 8 on the lid of the Lispro insulin pen and did not have a date when it was opened. - Unknown staff handwrote Resident 2's first name and 12 U on the lid of the Lispro insulin pen and did not have a date when it was opened. - Unknown staff handwrote Resident #11's first and last initial and 24 on the lid of the Lantus insulin pen and did not have a date when it was opened. - Unknown staff handwrote Resident #7's first and last initial and 34 on the lid of the Lispro insulin pen and did not have a date when it was opened. - Unknown staff handwrote Resident #7's first and last initial on the lid of the Lispro Insulin pen and did not have a date when it was opened. - Unknown staff handwrote Resident #29's first and last initial on the lid of the Novolog insulin flexpen and did not have a date when it was opened. - Unknown staff handwrote Resident #34's first initial and last name and 5 on the lid of the Lantus insulin pen and did not have a date when it was opened. - The Director of Nursing (DON) said the pharmacy label was placed on the box of insulin pens when they arrived from the pharmacy and the staff have labels in the drawer of the medication cart which they are supposed to place on the insulin pens with the resident's name, date opened and expiration date. 3. Observation and interview on 2/24/26 at 9:17 A.M., showed: - Resident #30 had a bubble pack (a type of medication packaging where each dose of medication is sealed in its own small plastic bubble attached to a backing card) of Lorazepam and had seven dates where the bubble had been punctured and the medication taped in. - LPN A said the staff should not have taped the medication, it should have been destroyed by two nurses. 4. The facility did not provide a policy for how long Morphine Sulfate was to be used after opened. 5. Observation and interview on 2/24/26 at 9:25 A.M., showed: - Resident #24 had an undated opened bottle of Morphine Sulfate that was filled by the pharmacy on 7/19/24. - Review of the Narcotic Log Sheet showed staff opened the bottle of Morphine Sulfate on 7/23/24. It was not signed out from 7/30/24 until 2/18/25 and has been used on a regular basis and has not been used since 1/18/26. - LPN A said the Morphine Sulfate should have been dated when it was opened. During an interview on 02/26/2026 at 7:21 A.M., LPN A said he/she had pre-popped all of the morning medications and shouldn't have done it, it was a bad habit, and it's hard to get all the meds done without pre-popping. During an interview on 2/26/26 at 8:57 A.M. the DON said: - The insulin pens should have a label on them to indicate which resident they belonged to. - The insulin pens should not have been used if they had not been dated when opened because there was no way to know how long they had been opened. - Staff should not preset the medications. - Medication should not be taped into the bubble pack. - If the Morphine Sulfate was filled on 7/19/24, the pharmacy said it would be good until the expiration date.

Based on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to properly monitor food storage temperatures. This had the potential to affect all residents in the facility. The facility census was 33.Review of facility policy, Food Storage (Dry, refrigerated, and frozen), revised November 2022, showed:- Keep potentially hazardous foods out of the temperature danger zone of 41 degrees to 135 degrees;- Follow and adhere to the guidelines regarding proper storage temperatures;- Set refrigerators to the proper temperature ensuring the internal temperature of the food is 41 degrees or lower;- Conduct random temperature checks of food items;- Keep freezer at a temperature that ensures products will remain frozen (0 degrees);- Check freezer temperature regularly;Observation in the kitchen on 02/23/26 at 9:26 A.M., showed:Main Kitchen Area:- Chest Freezer, Two Stand-up Freezers, Two large 2-Door Refrigerators, and One Stand-up Refrigerator were missing any refrigerator or freezer temperature logs;- Chest Freezer thermometer was buried beneath many frozen food items and after a few minutes of digging, was produced by the Dietary Manager (DM).During an interview on 02/23/26 at 9:28 A.M., the Dietary Manager (DM) said: - Kitchen staff were supposed to look at the thermometer but after truck deliveries the thermometer would get shoved around and covered up;- Dietary staff did not currently have temperature checks sheets. They used have temperature check sheets but the sheets didn't get filled out a lot so they stopped;- She would ask the dietary aides if they checked the temperatures and they say they did;- The Dietician would check the thermometers when he/she would come to visit the facility monthly.During an interview on 02/26/26 at 8:53 A.M., the Activities Coordinator said:- She had been a dietary aide before and currently helps out in the kitchen when needed;- The kitchen staff should always check the refrigerator and freezer temperatures and then record the temperatures;- Kitchen staff would always monitor and record the temperatures when she worked in there and should still.During an interview on 02/26/26 at 8:57 A.M., the Director of Nursing (DON) said refrigerator and freezer temperature checks should be completed daily and recorded on the temperature logs by dietary staff.Copies of the past year of temperature logs were produced after the DON interview on 02/26/26 and showed:- June 2025, none of the refrigerator or freezer temperatures varied by one degree, recorded daily, for the entire month and no initials provided for any documented reading;- July 2025, none of the refrigerator or freezer temperatures varied by one degree, recorded weekly, for the entire month and no initials provided for any documented reading;- September 2025, only temperatures documented for the first through the forth, no variance in the temperatures recorded, and no initials provided for the documented readings;- November 2025, no documented readings for the fifth both shifts, no reading for the 17th through the 30th for am shift and none for pm shift on the 13th through the 17th, or 18th through the 30th;- No log provided for December 2025;- January 2026, none of the refrigerator or freezer temperatures varied by one degree, recorded weekly, for the entire month and no initials provided for any documented reading;- February 2026, no documented readings until the 22nd.

Based on interview and record review, the facility failed to follow policy and screen six out of 10 employees for tuberculosis (TB - an infection disease characterized by the growth of nodules in the tissues, especially the lungs) prior to employment. The facility census was 33 residents. Review of facility policy, Employee Screening for Tuberculosis (TB) Policy and Procedure, revised 5/16/23, showed:- Each newly hired employee will complete a 2-step tuberculosis test prior to offer of employment and prior to employee's duty assignment. - Screening includes a baseline test, individual risk assessment and symptom evaluation.- All employees will complete a 1-step annual test following the new hire 2-step testing. - All potential employees will complete baseline testing prior to hire and before entering the facility. 1. Review of facility Human Resources and TB records, showed:- Certified Nursing Assistant (CNA) (A) was hired on 1/23/25 and TB baseline was established on 1/25/25, two days after the date of hire;- Dietary [NAME] (A) was hired on 6/9/25 and TB baseline was established on 6/20/25, 11 days after the date of hire;- Nursing Assistant (NA) (A) was hired on 7/25/25 and TB baseline was established on 7/30/25, 5 days after the date of hire;- Registered Nurse (RN) (A) was given 1st step TB test on 9/25/25 and it was read less than 48 hours later on 9/26/25;- RN (B) was given 1st step TB test on 10/3/25 and it was read over 72 hours later on 10/7/25. - CNA (B) was hired on 11/13/25 and TB baseline was established on 1/11/26, 59 days after the date of hire;- CNA (C) was hired on 12/18/25 with baseline established on 5/26/22 from another facility. No updated TB test on file with the current facility;During an interview on 2/25/25 at 9:10 A.M., the Director of Nursing (DON) said any TB test read outside the window of 48 hours to 72 hours from the initial injection is invalid and must be re-taken.During an interview on 2/25/25 at 1:15 P.M., the Administrator said:- Annual tests completed previously by new hires are good for up to one year prior to the date of hire at this facility.- TB tests shall be read between 48 to 72 hours from when the individual is injected. If this is not done the test is invalid and must be taken again.- She was not sure why CNA (B) did not have a TB test completed and on file prior to the employee starting work at the facility.- She was certain that CNA (C) was test prior to starting work at the facility but was unable to find the documentation.

Based on record review and interview, facility staff failed to prevent the misappropriation of one resident's (Resident #1) credit card which was used without authorization of the resident or the resident's financial guardian. The credit card was used between the dates of November 30, 2024 and February 22, 2025 with total charges to the card of $348.23. The facility census was 27 residents. Review of the facility policy titled,Abuse and Neglect, dated 4/10/24 showed: -It is the policy that all residents be free from financial exploitation; -Financial exploitation is a misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful use of a resident's belongings, or money without the resident's consent; -The Administrator will conduct all investigations. A formal investigation shall begin immediately and include: interviews with all staff, interview facility residents and document that interviews were completed. Review of Resident #1 Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 4/18/25 showed: -No cognitive impairment; -Supervision by staff for completion of Activities of Daily Living (ADL's: tasks completed in a day to care for ones self); -Diagnoses included: Anxiety, major depression, unsteadiness, diabetes and stroke. Record review on 5/15/25 showed no notes of when the card was in the resident's possession or that the card was missing. Record review on 5/15/25 of the one page summary from the Administrator showed: -She was notified on 4/21/25 by Resident #1's Financial Power of Attorney (POA) of 9 charges on the resident's card between November 2024 and February 2025 that the resident did not incur or approve, and POA did not approve or incur. Record review on 5/15/25 of the provided bank statements showed: - November to December 2024 charges for vending on 11/30 and 12/3 for $2.10 each, gas station on 12/9 for $34.53, and vending on 12/9, 12/11, 12/14 and 12/16 for a total of $13.15 and gas station on 12/16 for $50.00 for a total of $101.88; -December 2024 to January 2025 charges to a gas station on 12/26 for $45.00, 1/4 for $40, 1/13 for $64 and vending on 1/20 for $2.35 for a total of $151.35; -January to February 2025 charges to a gas station on 1/25 for $50 and 1/29 for $45. For a total of $95; -Total unauthorized charges on the card were $348.23. During an interview on 5/9/25 at 12:27 P.M. the Administrator said: -She was not aware the resident had a debit card; -She only interviewed with the resident and family involved; -She notified the Sheriff's office and they were performing an investigation; -The last time Resident #1 remembered having the card was before a room move about a year ago; -The facility does not have surveillance cameras. During an interview on 5/9/25 at 1:04 P.M. Resident #1 said: -He/She kept a debit card in his/her bag in a drawer; -He/She thought it was safe; -He/She only used the card for gas when he/she went to a doctor's appointment; -He/She had not given the card to anyone; -He/She had not given permission to anyone to use the card; -He/She did not realize the card was missing until the financial POA told him/her; -He/She thought it was pretty bad someone would do that to a resident in a nursing home. Observation on 5/9/25 at 1:04 P.M. showed: -A 2 drawer dresser was in the resident's room; -There were no locks on the dresser drawers; -There was a purse in the dresser drawer. During an interview on 5/15/25 at 11:57 A.M. Certified Nurse Aide A said: -He/She cared for Resident #1; -He/She was not aware the resident had a debit card; -He/She thought the resident had a purse, but was unsure. During an interview on 5/19/25 at 1:00 P.M. Sheriff Deputy A said: -The facility Administrator notified the Sheriff office of a missing debit card on April 21, 2025; -He/She talked with the resident and the family; -There is a suspect and the investigation was on going. MO253079

Based on interview and record review, the facility failed to follow their policy to maintain documentation and complete a thorough investigation of an alleged violation of misappropriation of resident funds after the facility was informed by the resident's Financial Power of Attorney, that Resident #1's debit card had unapproved charges from November 30, 2024 to February 22, 2025. The facility census was 27. Review of the facility policy tilted, Abuse and Neglect, dated 4/10/24 showed: -Financial exploitation is a misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful use of a resident's belongings, or money without the resident's consent; -The Administrator will conduct all investigations. A formal investigation shall begin immediately and include: interviews with all staff, interview facility residents, request written statements from involved parties and document that interviews were completed. Review of Resident #1 Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 4/18/25 showed: -No cognitive impairment; -Supervision by staff for completion of Activities of Daily Living (ADL's: tasks completed in a day to care for ones self) -Diagnoses of anxiety, major depression, unsteadiness, diabetes and stroke. Record review on 5/15/25 showed no notes of when the debit card was in the resident's possession or that the debit card was missing. Record Review on 5/15/25 of the one page summary from the Administrator showed: -She was notified on 4/21/25 by Resident #1's Financial Power of Attorney (POA) of 9 charges on the resident's debit card between November 2024 and February 2025 that the resident did not incur or approve, and the POA did not approve or incur; Record review on 5/15/25 of the provided bank statements showed: - November to December 2024 charges for vending on 11/30 and 12/3 for $2.10 each, gas station on 12/9 for $34.53, and vending on 12/9, 12/11, 12/14 and 12/16 for a total of $13.15 and gas station on 12/16 for $50.00 for a total of $101.88 -December 2024 to January 2025 charges to a gas station on 12/26 for $45.00 , 1/4 for $40, 1/13 for $64 and vending on 1/20 for $2.35 for a total of $151.35 -January to February 2025 charges to a gas station on 1/25 for $50 and 1/29 for $45. For a total of $95 -Total charges on the card were $348.23. During an interview on 5/9/25 at 12:27 P.M. the Administrator said: -She only interviewed the resident and family involved; -She did not interview other residents or staff about missing money or items; -She notified the Sheriff's office and they were performing an investigation. During an interview on 5/9/25 at 1:04 P.M. Resident #1 said: -He/She kept a debit card in his/her bag in a drawer; -He/She thought it was safe; -The Administrator and someone from the Sheriff's office talked to him/her after the card went missing. Observation on 5/9/25 at 1:04 P.M. showed: -A two drawer dresser was in the resident's room; -There were no locks on the dresser drawers; -There was a purse in the dresser drawer. During an interview on 5/15/25 at 11:57 A.M. Certified Nurse Aide A said: -He/She cared for Resident #1; -He/She was not aware the resident had a debit card; -He/She thought the resident had a purse, but was unsure. During an interview on 5/19/25 at 1:00 P.M. Sheriff Deputy A said: -The facility Administrator notified the Sheriff office of a missing debit card on April 21, 2025. MO253079

Based on observation, record review and interviews, the facility failed to update and revise the care plan with fall interventions for four of four sampled residents (Resident #1, #2, #3, and #4) who had experienced falls. The facility census was 27. Review of facility fall policy and procedure, dated 7/29/13. showed: -Falls are the most common injury sustained by residents in the long term healthcare setting. They are a major cause of injury and death among the elderly and debilitated patients. Environmental, physical, and psychological factors contribute to patient falls and the ensuing injuries. The goal of the fall program is to identify the resident who is at risk to fall, institute proactive efforts to reduce the occurrence of fall related incidents, respond, and provide a safe environment. -All residents will be assessed on admission and continuing throughout the stay using the fall assessment guidelines. -Implement fall protocol as determined by the resident's assessed needs; -Post fall assessment is done by Registered Nurse (RN) or Licensed Practical Nurse (LPN) to include fall risk assessment, incident report to be completed by RN or LPN; -Notify physician and family/legal representative of fall as indicted; -Review and update care plan; -RN or LPN will continue to monitor status for minimum of 24 hours. Review of resident care plan policy and procedure, dated 4/19/23, showed: -The care plan shall be used in developing the resident's daily care routines and will be available to caregivers and other staff who have the responsibility for providing care or services to the resident. -Care plans for each resident will be developed upon admission and updated quarterly. -Certified Nurses Aides (CNA)'s are responsible for reporting to the charge nurse any change in the resident's condition and the care plan goals that have not been met. -Change in a resident's condition must be reported to the Director of Nursing/Assistant Director of Nursing so that a review of the resident's assessment and care plan can be made. -Documentation must be consistent with the resident's care plan. -Information contained on the care plan, and other documents used by the caregiver and nursing staff, shall be maintained in a confidential manner in accordance with established facility policy. 1. Review of Resident #1's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/23/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 99, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was not able to be tested . -He/She had one fall with injury since prior assessment on 11/24/23; -He/She had unclear speech with slurred or mumbled words; -He/She only sometimes understands others or is able to make self-understood; -He/She was dependent on a wheelchair for mobility; -He/She required partial to moderate assistance with eating, rolling left to right, and sitting to lying; -He/She required substantial/maximal assistance with oral hygiene, bathing, upper and lower body dressing, personal hygiene, and transitioning from lying to sitting on side of bed, sitting to standing, chair to bed transfers, and toilet/bath transfers; -He/She was dependent for toileting and putting on and taking off footwear; -Diagnoses included dementia (a condition characterized by impairment of at least two brain functions such as memory loss and judgement), myeloma in remission (a cancer of plasma cells that is no longer present), vitamin D deficiency, and gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of facility falls, from 1/1/24 to 3/25/24, showed he/she had experienced a fall on 1/26/24 and 3/16/24. Review of incident/accident reports showed: -On 1/11/24, Resident was heard saying oh and found on the floor. No interventions or steps taken to prevent reoccurrences were documented on the form. -On 1/26/24, Resident was found on the floor by his/her bed. His/Her head was bleeding from a laceration to the back and side of his/her head. No interventions or steps taken to prevent reoccurrences were documented on form. -On 3/16/24, Resident was found on the floor on his/her back the dining room. No interventions or steps taken to prevent reoccurrences were documented on form. Review of care plan, dated 6/19/23, showed: -He/She was at moderate risk for falls due to decreased functions related to disease process. -Anticipate and meet needs; -Be sure call light is within reach and provide prompt response to all requests for assistance; -Ensure that he/she was wearing appropriate footwear when ambulating or mobilizing in wheelchair; -He/she need a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, and the bed in low position at night. -Monitor and document for risk of falls. Educate resident, family/caregivers on safety measures that need to be taken in order to reduce risk of falls (if resident has a care plan for falls, refer to this). -No new interventions care planned after 1/11/24, 1/26/24, and 3/16/24 falls. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -He/She had a BIMS score of 14, showed resident was cognitively intact; -He/She had two more falls with no injury since prior assessment on 11/20/23; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on a walker and wheelchair; -He/She was independent with eating, oral hygiene, toileting , putting on and taking off footwear, personal hygiene, rolling left and right, sit to lying, lying to sitting , sit to stand, chair to bed/chair transfer, and toilet transfers. -He/She required supervision or touching assistance with bathing, and walking 10 feet, 50 feet, and 150 feet. -He/She required set up or clean up assistance with upper and lower body dressing, shower transfers -Diagnosis included hydrocephalus (a condition causing fluid build-up in the cavities deep within the brain), high blood pressure, diabetes (a condition causing too much sugar in the blood), weakness, pain in hip, spinal stenosis (a condition where the space inside bones of spine get too small), generalized muscle weakness, and unsteadiness on feet. Review of facility falls, from 1/1/24 to 3/25/24, showed he/she had experienced a fall on 1/13/24 and 3/15/24. Review of incident/accident reports showed: -On 1/13/24, Resident was using the toilet, when getting up from toilet he/she stated he/she lost his/her balance and sat down on the floor. No interventions or steps taken to prevent reoccurrences were documented on form. -On 3/15/24, Resident found sitting on the floor stating he/she slid out of his/her wheelchair. No interventions or steps taken to prevent reoccurrences were documented on form. Review of care plan, dated 12/6/23, showed: -He/She had an actual fall with no injury; -For no apparent acute injury, determine and address causative factors of the fall; -Monitor/document/report as needed for 72 hours to medical doctor for signs and symptoms of pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation; -Provide activities that promote exercise and strength building where possible. -Physical therapy consult for strength and mobility. -No new interventions care planned after 1/13/24 and 3/15/24 falls. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed: -He/She had a BIMS score of 15, he/she was cognitively intact; -He/She was dependent on wheelchair for mobility; -He/She had 2 or more falls without injury since last assessment on 11/5/23; -He/She required partial to moderate assistance with toileting, bathing upper and lower body dressing, putting on footwear, and personal hygiene; -He/She required supervision or touching assistance with rolling left and right, sit to lying, and lying to sitting; -He/She required partial to moderate assistance with sitting to standing, chair to bed transfers, toilet transfers, and tub transfers. -Diagnoses included Chronic Obstructive Pulmonary Disease (COPD) ( a group of lung disease that block airflow and make it difficult to breathe), difficulty in walking, unsteadiness on feet, weakness, osteoarthritis (a condition that causes flexible tissue at the end of bones to wear down), and stroke (damage to the brain from interruption of blood supply which can result in trouble walking, speaking or paralysis or numbness of face, arm, or leg). Review of facility falls, from 1/1/24 to 3/25/24, showed he/she had experienced a fall on 1/7/24, 1/24/24, and 2/8/24. Review of incident/accident reports showed: -On 1/23/24, Resident was found with the call light engaged and on his/her knees on floor and upper body on bed. Resident stated he/she did not fall. Both knees found with abrasions and bruising. No interventions or steps taken to prevent reoccurrences were documented on form. Review of care plan, dated 8/16/18, showed: -He/She was at moderate risk for falls related to history of frequent falls when at home; -Be sure call light is within reach and encourage to use it for assistance as needed; -Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as exercise class. -Ensure the resident is wearing appropriate footwear nonskid soled shoes when ambulating; -Physical therapy to evaluate and treat as ordered or as needed. -Restorative aide program. -Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caretakers and interdisciplinary team to causes. -Resident uses an electric wheelchair for mobility. He/she needed assistance of two with ambulation and walker. -Use electric wheelchair, safety evaluation done yearly. He//She can clap own seatbelt, has had this chair when he/she was at home. -No new intervention strategies care planned after 1/23/24 fall. 4. Review of Resident #4's quarterly MDS, dated [DATE], showed: -He/She had a BIMS of 13, he/she was cognitively intact; -He/She was dependent on walker or wheelchair for mobility; -He/She had no falls since prior assessment on 10/6/23; -He/She required set up or clean up assistance with oral hygiene, personal hygiene, and toileting; -He/She required partial to moderate assistance with bathing, upper and lower body dressing, putting on and taking off footwear, sitting to standing and chair to bed transfers, toilet transfers, and shower transfers; -He/She required supervision or touching assistance with rolling left and right, sitting to lying, lying to sitting on bed mobility; -Diagnoses included stroke (damage to the brain from interruption of blood supply which can result in trouble walking, speaking or paralysis or numbness of face, arm, or leg), difficulty in walking, weakness, generalized muscle weakness, lack of coordination, and macular degeneration (a long-lasting eye disorder that causes blurred vision or a blind spot in the central vision). Review of facility falls, from 1/1/24 to 3/25/24, showed he/she had experienced a fall on 3/3/24. Review of incident/accident reports showed: -On 3/3/24, resident transferred self from toilet to wheelchair without assistance and did not engage the call light for help. No interventions or steps taken to prevent reoccurrence were documented on form. Review of care plan, dated 4/14/22, showed: -Resident had an actual fall with serious injury; -Check range of motion daily or as physical therapy/occupational therapy protocol; -Continue interventions on the at-risk plan; -Provide activities that promote exercise and strength building where possible; -Resident had limited physical mobility related to past cerebral infarction. -No new interventions care planned after 3/3/24 fall. 5. During an interview on 3/25/24 at 10:12 A.M., Administrator said: -Director of Nursing (DON) handled fall investigations to include interventions; -After a fall orders may be changed, items added to care plans, and possible medication changes may occur. During an interview on 3/25/24 at 10:15 A.M., DON said: -Process for fall investigations included looking at fall, determining reason for the fall that occurred; -If equipment caused fall would change something in his/her care plan; -Depended on resident and the situation on what interventions would be added to care plan; -If resident slept on edge of bed, he/she may have had bolsters added to his/her bed; -Care plans are updated every three months and more often if needed. During an interview on 3/25/24 at 11:15 A.M., Administrator said: -The facility incident/accident report was being used as the facility's fall assessment form. During an interview on 3/25/24 at 11:15 A.M., LPN A said: -If resident fell he/she would leave resident in position until they were assessed and vitals were checked; -He/She would then report fall to DON, complete an incident/accident report, chart in medical record for three days during every shift after the fall, notify family and physician, and when it was an emergency would contact 911. During an interview on 3/25/24 at 12:03 P.M., Administrator said: -The quality assurance team discusses fall interventions; -Interventions would be added to care plan if they were needed; -Care plan should be updated 24-48 hours. During an interview on 3/25/24 at 1:13 P.M., CNA B said: -He/She looked at care plans; -Updates to the care plan are completed by the DON; -He/She was not notified of changes to resident's care plans. During an interview on 3/25/24 at 1:20 P.M., CNA C said: -He/She did not look at resident's care plan; -Social services director notifies staff of changes to care plans During an interview on 3/25/24 at 1:43 P.M., DON said: -He/She was responsible for updating care plans -Care plans should be updated if something comes up in between quarterly care plan meetings; -Facility did not document discussions of possible fall interventions. MO233069

Based on record review and interview, the facility failed to thoroughly investigate an allegation of injury of unknown origin when one resident (Resident #1) was found to have bruising that spread across his/her abdomen, perineal area, and legs. The facility failed to implement the abuse and neglect policy and failed to provide documentation that all staff working were interviewed, failed to interview facility residents, and failed to provide complete and thorough documentation of the investigation. This affected one of four sampled residents. The facility census was 27. Review of facility policy, abuse and neglect, dated 1/1/23, showed: -It is the policy of the facility that all residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion, and financial exploitation. -All allegations of abuse will be investigated and documented. -Abuse means willful indication of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Alleged incidents will be identified and investigated. Interventions will be implemented as needed to correct a situation and/or potential situation which may lead to abuse, neglect, or misappropriation of resident property. -The administrator and/or Director of nursing, and Social Services Designee shall conduct all investigations. -The investigation shall include interviews with staff, visitors, or residents who may have knowledge of the alleged incident. Written statements from involved parties should be requested. The documentation of the investigation will be held confidential and kept in the Administrator's office or Designee's office. -The medical record shall be reviewed to determine the resident's history and condition and its relevance to the alleged violation. -The Director of Nursing or Designee shall notify the resident's representative regarding the alleged violation and reassure the resident's representative that an investigation had bee initiated and appropriate action will be taken. The contact shall be documented. -The Director of Nursing or Designee shall notify the resident's physician. This contact shall be documented. 1. Review of Resident #1's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/23/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 99, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was not able to be tested . -He/She had unclear speech with slurred or mumbled words; -He/She only sometimes understands others or is able to make self-understood; -He/She was dependent on a wheelchair for mobility; -He/She required partial to moderate assistance with eating, rolling left to right, and sitting to lying; -He/She required substantial/maximal assistance with oral hygiene, bathing, upper and lower body dressing, personal hygiene, and transitioning from lying to sitting on side of bed, sitting to standing, chair to bed transfers, and toilet/bath transfers; -He/She was dependent for toileting and putting on and taking off footwear; -Diagnoses included dementia (a condition characterized by impairment of at least two brain functions such as memory loss and judgement), myeloma in remission (a cancer of plasma cells that is no longer present), vitamin D deficiency, and gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of care plan, dated 6/19/23, showed: -He/She had impaired cognitive function and impaired thought processes due to dementia; -He/She had impaired cognitive visual function due to aging; -He/She had a communication problem due to disease process; -He/She will remain free of injuries or complications related to decreased mobility through refuse; -Monitor and document for risk of falls. Educate resident, family/caregivers on safety measures that need to be taken in order to reduce risk of falls. -He/She was at moderate risk for falls due to decreased functions related to disease process; -He/She had potential to demonstrate physical behaviors hitting, kicking, and trying to bite due to dementia; -He/She had activities of daily living (ADL) self care performance deficit due to dementia; -He/She was totally dependent on staff for toilet use; -He/She required two staff participation to use toilet; -Bed mobility: He/She required 1 staff participation to reposition and turn in bed; -He/She required skin inspection every shift. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. -He/She required physical assistance with transferring; Review of medical record showed on 2/21/23 was last entry from physician that included no entries regarding bruising or assessments from physician or nurse practitioner. Review of electronic medical record showed: -On 3/2/24 at 3:59 P.M. Resident had bruising across his/her lower abdomen, a dark purple area in center umbilical area and lower, with light purple/green areas towards both sides of abdomen. The resident did not show signs of pain when touching the bruising. No known falls or rolling out of bed. -On 3/3/24 at 5:44 A.M., When two Certified Nurse Aides (CNA)'s were getting resident up for the morning the resident cried out when he/she put weight on his/her left leg. The resident had dark purple bruising at umbilical site on abdomen and less purple colored bruising going across low abdomen and downward. -On 3/3/24 at 1:15 P.M., Bruising noted to pubic area and left interior thigh. the resident grabbed his/her left leg and moaned in pain when he/she was moved or transferred. Director of Nursing (DON) was notified and he/she reported that he/she had already seen it. Review of medication administration record (MARS) showed: -Facility used MARS to document weekly skin assessment weekly on Friday: -On 3/1/24 showed scattered bruises and scratches; -On 3/8/24 showed leg bruise and abdomen and redness under breasts; -On 3/15/24 showed bruises abdomen and to thighs; -On 3/22/24 showed bruising the his/her abdomen and left thigh with scratches. Review of skin assessments showed: -Facility used a monthly shower log with area to write in skin issues; -On 3/4/24 notes showed red under breast; -On 3/7/24 no skin issues documented; -On 3/11/24 no skin issues documented; -On 3/14/24 bruise on left thigh. Review of facility incident reports showed no incident report was completed on the injury of unknown origin discovered on 3/2/24. Review of facility abuse and neglect training showed: -3/5/24 facility provided a read and sign in-service on abuse and neglect: prevent, recognize, report and the facility abuse and neglect policy. Training was signed and dated by twenty-four employees. During an interview on 3/25/24 at 10:15 A.M., the DON said: -When a bruise of unknown origin occurs the social worker would do an investigation; -He/She was not aware of any recent investigations. During an interview on 3/25/24 at 11:15 A.M., Licensed Practical Nurse (LPN) A said: -He/She did not know anything about the resident's bruise; -Resident can be feisty at times; -When resident wants up, he/she will get up on his/her own; -If injury of unknown origin he/she would report concerns to DON, complete an incident report, chart for three days on every shift, notify family, notify physician, and if/when it was an emergency he/she would call 911. During an interview on 3/25/24 at 11:53 A.M., CNA A said: -He/She primarily worked as bath aide and first noted resident's bruise on his/her bath day which was Monday or Thursday; -Bruise he/she saw looked like it could have been a result of resident picking; -He/She sometimes documents skin observations on the shower sheet and sometimes he/she did not document skin concerns; -He/She was not sure who the facility investigator was but felt it may be Administrator or Business office manager; -He/She did not give a statement regarding resident's bruise; -He/She would not expect the resident to have a bruise in lower abdomen and groin area. During an interview on 3/25/24 at 12:03 P.M., Administrator said: -He/She did not do formal investigation on resident's bruise of unknown origin; -He/She discussed with all staff at the stand up meetings held at shift changes for three days; -He/She had no staff who knew what had happened to resident to cause bruise; -He/She obtained no documentation from staff regarding the discovered bruise; -He/She spoke with all CNA's; -It was not facility's standard of practice to not document their investigations; -He/She was not sure if staff contacted resident's family regarding bruising; -If resident had a significant change he/she expected staff to contact the nurse practitioner or physician and document in the resident's hard chart. During an interview on 3/25/24 at 12:37 P.M., DON said: -He/She had talked to everyone who had worked; -Bruise was found on 3/1/24 at 5:06 A.M. by CNA and charted by the LPN; -A cause for the bruise was not determined; -There was medical cause or expectation to find bruise in that area of resident based on resident's medical history; -Resident was first admitted to facility with pelvis/abdomen fracture; -The nurse practitioner saw resident on 3/4/24 when he/she was in facility as he/she pulled him/her into the shower to look at resident's bruising; -The nurse practitioner did not make any documentation regarding the assessment or observation. During an interview on 3/25/24 at 1:13 P.M., CNA B said: -He/She heard about the resident's bruise on the last day of February but saw it on 3/1/24; -The bruise was in the peri area; -He/She had never seen bruises in resident's peri-area previously; -He/She observed the bruises grow day by day from inside of the legs and by the folds of skin around the urethra; -He/She observed no measurements taken of bruises; -He/She was not asked questions or asked to provide statement regarding the observed bruise; -He/She had not witnessed any staff being rough with resident; -He/She did not document the bruises as he/she's job was to notify the nurse, the nurse documents injury; -He/She knows every nurse looked at and saw the bruise; -He/She was aware that no staff had informed the family of the bruise. During an interview on 3/25/24 at 1:20 P.M., CNA C said: -He/She came to work at 2:00 A.M. on 3/1 and found bruise during his/her first bed check of resident; -He/She reported bruise to the nurse who went and looked at it; -He/She observed the bruise to be in abdominal area the size of a dime; -When the DON arrived to building he/she took him/her to the resident's room to look at the resident's bruise; -At that time the bruise covered the entire perineal area and was very dark purple in color. The bruising had progressed down the residents right leg; -He/She did not get interviewed or provide any statements regarding the bruise; -He/She did not document any of his/her observations of the skin. During an interview on 3/25/24 at 1:31 P.M., Administrator said: -Facility did not do abuse and neglect training with staff upon hire; -Staff just receive the normal CNA training; -Upon hire staff received orientation on exits, what to do during power failures, where water shut offs are located; -Facility did not provide specific training on resident care; -No measurements were documented of resident's bruise. During an interview on 3/25/24 at 1:43 P.M., DON said: -No staff took measurements of resident's bruising in notes; -He/She was aware that staff drew a line around bruise and the bruise spread over that line; -Bruising was purple oval shaped and as the days went on it spread out and went down the resident's legs; -He/She did not make a note of observation of bruise; -Nurse practitioner did see bruising but did not make documentation of observation; -Facility did discuss bruise as a group at morning meeting; -Social Services staff normally completes investigations. MO233069

Based on observations, interviews, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when they did not close doors to COVID positive rooms, did not change gowns between COVID positive rooms, brought the roommate of a COVID positive resident to dining room for meals, and took off their N95 mask and applied a surgical mask prior to entering COVID positive rooms. The facility also failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, when the facility failed to follow their policy regarding employee tuberculosis testing when they did not administer the second step of the test which affected five of 10 staff member selected for review. The facility also failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia). This affected 6 of 12 sampled residents (Residents #2, #4, #13, #16, #17, and #22) and had the potential to affect all residents. The facility census was 24. Review of the facility policy titled isolation policy, dated 3/15/23, showed: - Transmission-based precautions are initated when a resident develops signs or symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. - When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door to alert personnel and visitors of transmission-ased precautions, while protecting the privacy of the resident. This will be accomplished by placing a notice at the doorway instructing visitors to report to the nurses' station before entering the room. - While transmission-based precautions are in effect, and when possible, non-critical resident-care equipment will be dedicated to a signle resident. Items reused will be cleaned and disinfected before use with another resident - Contact precautions: 1. Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's enviornment. 2. The decision on whether contact precautions are necessary will be evaluated on a case by case basis with final determination made by the Director of Nursing 3. The individual on contact precautions will be placed in a private room, if possible 4. Precautions will be taken during resident transport to minimize the risk of transmission 5. Staff will wear gloves and gown upon entering the room. Gloves will be removed and hand hygiene performed before leaving the room. Gown will be removed before leaving the room. Avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet precautions: 1. Droplet precautions may be impelmented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking, etc. 2. Residents on droplet precautions will be placed in a private room if possible. 3. When a private room is not available, a curtian will be used and a distance of at least 3 feet of space will be maintained between the infected resident and roommate. 4. A mask will be placed on the resident during transport from their room. The resident will be encouraged to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets. Airborne Precautions 1. All individuals who enter the room of a resident placed on airborne precautions must wear N95 mask, eye protection (face shield/googles), and gown. 2. Resdients on Airborne Precautions must wear a mask when leaving the room or when coming in contact with others. 3. N-95 masks will be worn when entering the room. Review of staff in-service log showed an in-service on 10/13/22 on infection control, hand washing, isolation, blood borne pathogen, and influenza with seventeen staff participating. Airborne precautions showed residents should have a private room, keep resident's room door closed, and wear a mask. 1. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/5/23 showed: - A Brief Interview Mental Status (BIMS) a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility, of 3, severely impaired cognition; - Diagnoses included Alzheimer's disease, generalized muscle weakness, and mild cognitive impairment; -Wandering behavior occurred one to three days; - Resident walked in corridor with supervision oversight, encouragement, or cueing and one person physical assist. Record review of facility COVID positive residents provided 5/15/23 showed resident is COVID positive. Observation on 5/16/23 at 1:25 P.M. showed no masks outside the resident's room door with other personal protective equipment. Observation on 5/18/23 starting at 7:48 A.M. showed Certifed Nurse Aide (CNA) A did the following: - Collecting breakfast room trays from COVID positive resident rooms. - Exited a room wearing gown, gloves, and N-95 mask. - Removed his/her gloves and applied hand sanitizer after leaving on gown and N-95 mask. - Entered Resident #6's room collecting tray, exits room at 7:50 A.M., removed his/her gloves and disposed of them in a bin - Sanitized his/her hands with hand sanitizer then wheeled down to Resident #22's room. - Applying new gloves and entered Resident #22's room wearing same gown and mask. - Exited the room and removed his/her gloves, then removed his/her gown, and placed them in the bin outside of the room. - Re-entered Resident #22's room to obtain hand sanitizer then wheeled the cart down hallway to kitchen. 2. Review of Resident #17's admission MDS, dated [DATE], showed: - BIMS of 15, cognitive intact; - Diagnoses included chronic pain syndrome, sleep apnea, spinal stenosis, morbid obesity, weakness, chronic atrial afibrillation; - Mobility device of wheelchair; - Independent with transfers, locomotion, eating; - Required limited assistance by one person with toilet use; Record review of facility COVID positive residents provided 5/15/23 showed resident is COVID positive. Observation on 5/17/23 at 7:52 A.M. showed the door to the resident's room stood open. Observation on 5/17/23 at 8:37 A.M. showed the door to the resident's room remained open and the resident did not have on a mask. Observation on 5/18/23 at 7:29 A.M. showed the door to the resident's room stood open as the resident at breakfast in the room. No gowns were available outside the room with the other PPE. 3. Review of Resident #2's admission MDS, dated [DATE], showed: - BIMS of 10, moderately impaired; - Diagnoses included paroxysmal atrial fibrillation (irregular heart beat that returns to normal in seven days), chronic pain syndrome, spinal stenosis (when space in spine narrows and puts pressure on spinal cord), diverticulosis of large intestine, depression, anxiety, stroke, arthritis; -Independent with mobility, transfers, toileting, hygiene, eating. Record review of facility COVID positive residents provided 5/15/23 showed resident is COVID positive. Observation on 5/16/23 at 12:47 P.M. showed CNA C did the followng: - Entered Resident #2's room not wearing N-95 mask. - He/she left his/her N95 mask in the hallway on the PPE station; he/she applied a gown, gloves, and surgical mask upon entry into Resident #2's room. Observation on 5/17/23 at 7:52 A.M. showed the resident's room door stood open. Observation on 5/17/23 at 8:37 A.M. showed the resident's room door remained open and the resident did not have on a mask. Observation on 5/18/23 at 7:29 A.M. showed the resident's room door stood open and the resident did not have on a mask. No gowns were available on PPE station outside of room. 5. Observation on 5/18/23 starting at 7:48 A.M. showed Certified Nurses Aide (CNA) A collected breakfast room trays from COVID positive resident rooms. CNA A exited a room wearing a gown, gloves, and an N-95 mask. He/she removed his/her gloves, applied hand sanitizer leaving on the gown and N-95 mask. He/she then entered Resident #6's room to collect the resident's breakfast tray, exited the room at 7:50 A.M. and removed his/her gloves and placed them in a trash bin. He/she sanitized his/her hands with hand sanitizer then wheeled the cart down to Resident #22's room. He/she applied new gloves and entered Resident #22's room wearing same gown and mask. CNA A exited the resident's room, removed his/her gloves, then removed the gown, and placed it in a bin outside of the room. CNA A re-entered Resident #22's room to obtain hand sanitizer and wheeled cart down the hallway to kitchen. During an interview on 5/18/23 at 9:10 A.M., CNA A said: - Adminsitration scheduled In-services sometimes in person and sometime they left a packet for staff to review on standard precautions. - He/she received infection control / standard precautions training in the last few weeks. - When interacting with COVID positive residents, he/she applied a gown, gloves, mask, sanitized or washed his/her hands before and after providing care. Then he/she placed all trash in red bags. All items doffed, which included gowns, gloves, and masks was kept in separate red containers placed in COVID positive rooms. - He/she could not close resident room doors of COVID positive residents due to them being at risk for falls. - Normally the facility separated COVID positive residents from residents who were not, he/she was not sure why Resident #13 and Resident #4 were not separated. - Resident #4 had COVID in very begininning about two years ago but not recently. - He/she did not change his/her gown when going in and out of COVID positive resident rooms when picking up trays but he/she probably should have changed his/her gown. He/she only changed gloves because he/she was only going into COVID positive rooms. He/she did not go into non-COVID positive room while gathering trays. He/she did change gloves every time entered and exited room and sanitized in between each room. - He/she had received training on taking an N-95 mask off and applying a different N-95 mask when entering and exiting resident rooms. During an interview on 5/18/22 at 9:28 A.M., CNA B said: - The facility did regular in-services but he/she had not had any recent training on transmission based precautions. - When entering resident rooms, he/she applied gowns, gloves and a mask, and they put all used PPE in red bags. - Staff should close doors to COVID positive resident rooms some of the residents who are COVID positive were fall risks and that was reason their doors were not shut - The facility had never had residents stay in the same room with COVID positive roommates unless they were both COVID positive at same time. - In past he/she would have changed his/her mask when entering and exiting COVID positive rooms by taking off N-95 mask and applying a different N-95 mask. During an interview on 5/18/23 at 9:41 A.M., Licensed Practical Nurse (LPN) A said: - He/she received in-service trainings every month. - The last training on infection control and standard based precautions was in last three months. - He/she applied a gown and gloves to go into to COVID positive resident rooms to do what he/she needed to do, when done he/she threw the items in red container, washed his/her hands or sanitized if not near a sink. - He/she should have a N-95 mask on when entering COVID positive resident rooms. - He/she believed they could wear the same gown and only have to switch gloves when going from COVID positive to COVID positive rooms. As long as they did not go into non-covid positive rooms he/she did not have to remove gown. If going in non-covid room he/she would remove gown. 46706 6. Review of Resident #4's care plan, dated 11/18/22, showed: - Assist of one for transfers and toileting; - Assist of one for dressing; - Covid 19 precautions: Encourage and remind resident to wear a mask when out of the room; - Covid 19 precautions: Encourage and remind resident to wash hands with soap and water or hand sanitizer frequently; - Maintain six feet distance between other residents and staff. Review of the resident's annual MDS, dated [DATE], showed: - Severe cognitive impairment; - Incontinent of bowel and bladder; - Assist of one for transfers and toileting; - Assist of one for dressing; - Diagnoses included heart failure, anxiety and thyroid disorder. Review of the facility's resident room roster, dated 5/16/23, showed: - Resident #13 in room [ROOM NUMBER]-A was Covid 19 positive; - Resident #4 in room [ROOM NUMBER]-B was not Covid 19 positive; - Resident #16 in room [ROOM NUMBER] was Covid 19 positive. Observation on 5/17/23 at 8:37 A.M. showed: - CNA E pushed the resident down the hall and into room [ROOM NUMBER]; - The resident was not wearing a mask; - Resident #13 was in the room; - Resident #13 was not wearing a mask; - CNA E did not pull the privacy curtain between Resident #4 and Resident #13. Observation on 5/17/23 at 8:41 A.M., showed; - Resident #4 sat in the dining room and was not wearing a mask; - Other residents sat in the dining room not wearing mask within six feet of resident. 8. Review of Resident #13's care plan, dated 11/18/22, showed: - Assist of one for transfers and toileting; - Assist of one for dressing; - Covid 19 precautions: Encourage and remind resident to wear a mask when out of the room; - Covid 19 precautions: Encourage and remind resident to wash hands with soap and water or hand sanitizer frequently; - Maintain 6 feet distance between other residents and staff. Review of the resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Incontinent of bowel and bladder; - Assist of two for transfers; - Assist of one for dressing; - Diagnoses included Alzheimer's disease (a disease that destroys memory and other important mental functions) heart failure, and high blood pressure. Observation on 5/16/23, at 12:19 P.M., showed: - CNA C put on a gown and gloves then removed his/her N-95 mask and put on a surgical mask before entering the resident's room; - CNA C sat next to the resident in his/her room offering the resident bites of food. Observation on 5/17/23, at 8:18 A.M., showed: - The door to room [ROOM NUMBER] stood open; - The resident lying in bed; - The privacy curtain was not pulled between Resident #13 and Resident #4; - No isolation sign was posted outside the room or on the door; - A bedside table in the hall outside room [ROOM NUMBER] with gloves, gowns and masks on it; - A biohazard receptacle was inside the room but not outside the room. Observation on 5/17/23, at 9:55 A.M., showed: - CNA E came out of the resident's room not wearing a gown or gloves holding a bag of trash; - He/she walked up the hall carrying the bag of trash. During an interview on 5/17/23, at 10:02 A.M., CNA E said: - He/she did not wear a gown or gloves when going in and out of the resident's room; - He/she was aware the resident has Covid; - He/she was not sure what the protocol was for isolation precautions; - He/she was in-serviced on Covid 19 precautions. 9. Review of Resident #16's care plan, dated 1/13/21, showed: - Assist of one for dressing; - Covid 19 precautions: Encourage and remind resident to wear a mask when out of the room; - Covid 19 precautions: Encourage and remind resident to wash hands with soap and water or hand sanitizer frequently; - Maintain 6 feet distance between other residents and staff. Review of resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Incontinent of bowel and bladder; - Assist of one for transfers and toileting; - Assist of one for dressing; - Diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), coronary artery disease (damage or disease in the heart's major blood vessels) and high blood pressure. Observation on 5/16/23, at 11:00 A.M., showed: - A bedside table with gloves, gowns and masks on it; - A red biohazard receptacle setting in the hall outside room [ROOM NUMBER]; - A sign on the open door to the resident's room that said STOP isolation precautions; - The resident sat in the room with the door open; - The resident was not wearing a mask. Observation on 5/17/23, at 7:52 A.M., showed: - The resident's door stood open: - The resident came out of his/her room and was not wearing mask; - The resident propelled himself/herself down the hall; - Staff and residents were in the hall. During an interview on 5/17/23, at 10:15 A.M., LPN A said: - He/she does not use a gown when he/she goes into Resident #4's room when she is dealing with Resident #13 because he/she is not in direct contact with the resident (Resident #4) who is positive; - Resident #4 should not be in the hall without a mask; - He/she was in-serviced on Covid 19 precautions. During an interview on 5/17/23, at 10:22 A.M., CNA D said: - The staff was made aware of the residents who were Covid positive during oncoming report from the charge nurse; - A PPE station should be outside each Covid positive room; - Each hall shared a biohazard receptacle because there were not enough biohazard receptacles for every Covid positive room; - A sign should be on each Covid positive door; - The Covid positive resident's doors were kept open because they were monitored for confusion; - He/she was in-serviced on Covid 19 precautions. 10. During an interview on 5/17/23, at 11:11 A.M., the Director of Nursing (DON) said: - The privacy curtain should be pulled to separate Resident #4 and Resident #13; - Resident #4's family was upset Resident #4 would be moved so the facility allowed him/her to stay in room [ROOM NUMBER] with Resident #13. - Resident #4 should wear a mask if he/she wss in the dining room or in the hall around other residents and staff; - Resident #16 should wear a mask when around other residents and staff; - Staff should use PPE when entering Covid positive rooms; - Employees are in-serviced on isolation precautions. 44939 11. Review of the facility's Employee Screening for Tuberculosis (TB) Policy, dated 5/16/23, showed: - Each newly hired employee will complete a 2-step tuberculosis test and screened for latent tuberculosis infection (LTBI) and active tuberculosis disease prior to offer of employment and prior to employee's duty assignment. Review of facility employee records on 5/17/23 showed: - Dietary Aide A's date of hire was 10/19/23. First step TB test was conducted on 10/8/21. It was read on 10/11/21 and was negative. There is no record of a second TB being conducted. - Housekeeper A date of hire was 4/22/22. First step TB test was conducted on 5/24/22. It was read on 5/26/22 and was negative. There is no record of a second TB test being conducted. - LPN B date of hire was 9/9/22. First step TB test was conducted on 5/24/22. It was read on 5/26/22 and was negative. There is no record of a second TB test being conducted. - CNA F date of hire was 8/7/22. First step TB test was conducted on 8/4/22. It was read on 8/6/22 and was negative. There is no record of a second TB test being conducted. - CNA G date of hire was 10/4/22. First step TB test was conducted on 10/24/22. It was read on 10/27/22 and was negative. There is no record of a second TB test being conducted. 12 . During an interview on 5/18/23 at 12:45 P.M., the Director of Nursing (DON) said: - When staff were passing meal trays to COVID positive residents if rooms are side by side staff do not take off gowns, they just re-gloved and sanitized their hands. - She expected staff entering and exiting COVID positive rooms to sanitize their hands by washing them or using alcohol based hand sanitizer, put on a gown and gloves, goggle or face shield, and when coming out do reverse process. After removing all PPE, staff were expected to change their face mask unless going directly to another room. - Personal Protective Equipment should be removed right at doorway of resident room. - An N-95 mask should be worn in COVID positive resident rooms. - Transmission based precautions should be posted on doors of residents whom are positive - Doors should be closed for COVID positive rooms; some residents do not sleep when staff keep opening and shutting doors to peak in on them. - Newly hired staff should have a 2-step TB test conducted, with the first step being conducted before the staff start working with residents. -She is responsible for the TB testing of newly hired staff. Ensuring the staff received the second step TB test fell through the cracks. During an interview on 5/18/23 at 1:10 P.M., the Administrator said: -Expected staff to follow protocol when entering and exiting COVID positive resident rooms -Staff should not remove their N-95 mask and apply a surgical mask when entering COVID positive rooms, staff are expected to wear an N-95 mask -Transmission based precautions should be posted on residents doors -Doors should be closed on COVID positive rooms -He/she would not expect a resident that is rooming with COVID positive resident to be in dining room. -New staff should have the 2-step TB test done before starting on the floor. 39366 13. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: - Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - The facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the Center for Disease Control and Prevention (CDC) toolkit. Review of CDC's guidance, dated 4/30/18, titled What Owners and Managers of Buildings and Healthcare Facilities need to Know about the Growth and Spead of Legionella, included the following: - Legionella grows best within a certain temperature range (77 degrees Fahrenheit (F)-113F). Review of the facility's undated policy titled Legionella Water Management Program, showed the following: - The facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella; - As a part of the Infection Prevention and Control Program, our facility has a water management program which is overseen by maintenance; - The Water Management team will consist of the following personnel: o Infection Preventionist/Director of Nursing (DON); o Administrator; o Maintenance; - The purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnair's Disease; - The water management program used by our facility is based on the CDC and ASHRAE recommendations for developing a Legionella water management program; - The water management prgrom includes the following elements: o An interdisciplinary team; o A detailed description and diagram of the water system in the facility included the following: - Receiving - Cold water distribution; - Heating; - Hot water distribution and; - Waste; o The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: - Water heaters; - Filters; - Showerheads and hoses; - Humidifiers; - Fountains; - Medical devices such as CPAP machines; o The identification of situations that can lead to Legionella growth, such as: - Construction - Water main breaks - Changes in the municipal water quality; - The presence of scale or sediment; - Water temperature fluctuations; - Water pressure changes; - Water stagnation, and; - Inadequate disinfection; o Specific measures used to control the introduction and/or spread of Legionella (for example, temperature, disinfectants); o The control limits or parameters that are acceptable and that are monitored; o A diagram of where control measures are applied; o A system to monitor control limits and the effectiveness of control measures; o A plan for when control limits are not med and/or control measures are not effective, and; o Documentation of the program; - The water management program will be revised at lease once a year, or sooner if any of the following occur: o The control limits are not consistently met; o There is a major maintenance or water service change; o There are any disease cases associated with the water system, or; o There are changes in law, regulations, standards, or guidelines. Review of the facility's water management records showed: - The facility had an assessment dated [DATE]. The assessment indicated the maximum water temperature at the point of delivery permitted by state and local regulations was 110F. (The State of Missouri actually allows for 105F-120F) ; - There was no record of a flow diagram, control measures, identifications of areas in the water system that could encourage growth and spread of Legionella, identification of situation that can lead to Legionella growth, control limits or parameters that are acceptable and are monitors, or a plan for when control limits were not met and/or control measures were not effective; - Weekly water temperatures, including several temperatures recorded in the 91F to 105F; - No documentation of any flushing, disinfecting, testing, or any other control measures were found. During an interview on 5/17/23 at 2:17 P.M. the Maintenance Director said: - He was over the water management for the facility; - He was familiar with Legionella, that is was a waterborne respiratory disease; - Water temperatures were checked weekly, two rooms on each wing and were typically around 100F; -He also ran water in vacant rooms daily and he told housekeeping to do that as well. They were not generally flushing the toilets but all but one bathroom was shared with an occupied room. Documentation of this was not being kept. During an interview on 5/17/23 at 2:30 P.M. the Infection Preventionist/DON said she had worked at the facility since 2019 and there had not been any cases of Legionnaire's. During an interview on 5/17/23 at 2:30 P.M. the Administrator said: - A plumber had recently came and looked at the facility's plumbing, and they did not have any recommendations. They offered a test but they did not do that. - They had tried to find a local location for testing but have not found anything yet; - The had created a policy on how to watch for legionella symptoms; - Her and the Maintenance Director had read through the CDC toolkit and they had completed an assessment; - Has talked during about Legionella and symptoms during Quality Assurance Performance Improvement meetings but the facility did not have a water management team; - The facility did not have a flow diagram for the water system.

Based on observation, interview, and record review, the facility failed to ensure they developed a comprehensive person-centered plan of care consistent with measurable objectives and timeframe to meet the residents medical, nursing, mental, and psychosocial needs for one (Resident #22) of twelve residents sampled residents. The facility census was 24. Review of the facility care plan policy, dated 2/2/17 showed: -Within 48 hours of admission all residents will have a baseline care plan which included the instructions needed to provide effective and person-centered care that meets professional standards of quality of care. - During the care plan process, the facility will include the resident and or resident representative and the assessment will include residents' strengths and needs and residents' personal and cultural preferences will be used in developing care plan goals. - All nursing/dietary staff will be educated regarding the residents' baseline care plans to ensure that all residents' choices will be followed. - Residents or representatives will participate in establishing goals, outcomes of care and type/amount /frequency/ duration of care. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/5/23 showed: - A Brief Interview Mental Status (BIMS) a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility, of 3, severely impaired cognition. -Diagnoses included Alzheimer's disease, generalized muscle weakness, and mild cognitive impairment; -Wandering behavior occurred one to three days; -Resident walked in corridor with supervision oversight, encouragement, or cueing and one person physical assist. - Required physical help in part of bathing activity, dressing required limited assistance with one personal physical assist; - Staff did not complete any information for the resident's overall goals, no active discharge plan in place to return to community and resident's preference was not to be asked. Review of care plan dated 1/25/22 showed: - Care plan has only one care area addressed on low risk for falls -Elopement/wandering risk not addressed -ADL preferences not addressed -Do Not Resucitate not care planned -Discharge plan not care -Activity preferences not care planned -Trauma informed care not assessed -Food and nutrition services not care planned -Dementia interventions not care planned -Toileting schedule not addressed Review of care plan conference notes showed: -Quarterly meeting held on 8/10/22: -Attended by daughter and DPOA, Director of Nursing, Administrator, Business Manager; -One medication added was it something that should have been care planned? I didn't look closely at this so couldn't tell you what kind of medication was added in August. -He/she will take teeth out after fixadent; -He/she has been refusing meds, daughter advised to explain what medication is for, reassure resident #22 it is safe to take; -He/she was not eating well for awhile but doing better now; -He/she comes out to participate in bingo and other activties, otherwise he/she stays in room -Concerns about toileting help, staff will take him/her and he/she is not always finished; -When daughter comes in to facility at 4:30 P.M., will find wet incontinent pads in tall closet in room and Resident #22 not wearing a brief at all. Toileting schedule recommended every two hours during waking hours. -Quarterly Meeting held 11/30/22: -Attended by daughter, DPOA, DON, Administrator, Social Services/Activity Director; -His/her weight is stable -He/she would like ice cream for night time snack on occasion -Daughter noted Resident #22's glasses are dirty a lot when he/she visits. Requested staff check his/her glasses more often; -He/she does not have a restorative program or therapy program. Family interested in Resident #22 starting a restorative program. -Bathroom routine discussed, he/she has frequent checks every two hours and before activities and meals -Quarterly Meeting held 2/28/23: -Attended by Durable Power of Attorney (DPOA) by phone, Licensed Practical Nurse (LPN) A, Social Services/Activity Director, Registered Dietician; -Weight gain 130.5 pounds (lbs) in January 2023 and 135lbs in February 2023; -He/she used Nustep (a recumbent cross training exercise machine) and worked on balance with facility restorative aide five times a week; -His/her brief should be checked before activities; -He/she participates in most activities. Review of progress notes showed: -On 5/3/23 he/she eloped outside of facility, a wander guard was placed on resident; -On 5/5/23 wander guard activitated and placed on residents ankle following incident on 5/3/23. Observation on 5/16/23 at 1:25 P.M. showed Resident #22 sitting in chair looking at digital photo frame. He/she had visible chin hair quarter of an inch. He/she complained of being cold and had an empty plate laying in sink in room. Resident was on transmission based precautions due to being COVID positive. Observation on 5/17/23 at 2:30 P.M. showed Resident #22 in room, did not respond to tested fire alarm going off. During an interview on 5/17/23 at 7:40 A.M., Social Services/Activity Director said: -He/she did not write the care plan; -He/she wrote up notes from the care plan meetings; -The DON or Assistant DON wrote the care plan. During an interview on 5/18/23 at 9:10 A.M., Certified Nurse Aide (CNA) A said: - He/she knew residents based on working with them; - Care plans were available but he/she did not look at them; - He/she was made aware of care plan changes from people that attended the care plan meetings. During an interview on 5/18/23 at 9:28 A.M., CNA B said: - Resident specific care should be included in their care plan; - He/she did not look at care plans often; - He/she was made aware of care plan changes from the nurse who was notified by the DON. During an interview on 5/18/23 at 9:41 A.M., LPN A said: - He/she often sat in on care plan meetings. - Care plan team meeting wanted his/her input as charge nurse on residents' change in habits; - He/she was often notified of changes in residents' care through report. During an interview on 5/18/23 at 12:45 P.M., the DON said: - He/she wrote care plans for facility; - Care plans were updated after every meeting that was held or if there was something new that came up; - He/she would expect elopement risks and wander guard placements to be included in the care plan; - He/she would expect resident specific approaches to be included in the care plan. During an interview on 5/18/23 at 1:10 P.M., the Administrator said: - Care plans should be updated with every significant change, at admit, and quarterly - He/she would expect care plans to be specific to resident's care plan - He/she would expect a resident who had been in the facility over a year to have more than one care area care planned.

Based on observation, interview and record review, the facility failed to develop, review and revise comprehensive care plans with resident's specific conditions and needs, which affected eight of 12 sampled residents (Resident #5, #7 #9, #10, #15, #16, #18, and #25). The facility census was 24. Review of the facility's Care Plan policy, dated 2/2/17, showed: - It is the policy of the facility that each resident received the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and care plan. - The facility wants to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the resident's choices. -During the care plan process, the facility will include the resident and/or resident representative and the assessment will include resident's strengths and needs and resident's personal and cultural preferences will be used in developing care plan goals. -Residents have the right to request revisions to the person-centered care plan. 1. Review of Resident #7's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 3/23/23, showed: - admitted to the facility on [DATE]. - Diagnoses of heart failure, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), obesity, arthritis (inflammation of one or more joints, causing pain and stiffness), weakness, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), persistant mood disorder (a continuous, long-term form of depression). -Score of 14 on Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates intact cognition. - Total dependence on staff for activities of daily living (ADLs), including dressing, bathing, and personal hygiene. - Frequently incontinent of bowel and bladder. - No impairments to upper or lower extremities. Review of a side rail utiliztion assessment completed on 4/4/23 is this date correct? showed: - The resident requested bed rails; - Installed one side, quarter rails; - The resident had a history of falls and a fall from bed. - He/she did attempt to get out of bed on their own. - Participating in a restorative program. Review of the resident's comprehensive care plan, dated 5/17/23 showed: - No problem, goal or interventions for the use of bed rails or restorative program. 2. Review of Resident #9's annual MDS, dated [DATE] showed: - admitted to the facility on [DATE]. - Diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), difficulty walking, weakness/unsteady, aphasia (alanguage disorder that affects a person's ability to communicate), kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), and major depressive disorder. - A BIMS score of 12. This score indicates moderate cognitive impairment. - He/she required limited assistance from staff for Activities of Daily Living, including bathing, dressing and personal hygiene. -He/she had an impairment to upper and lower extremities on one side. He/she used a wheelchair for mobility. -Occasionally incontinent of bladder and always continent of bowel; -Had one fall since admitting to the facility. -He/she uses bed rails daily. Review of the resident's comprehensive care plan, dated 4/14/22, showed: - Staff did not develop any interventions for the resident's risk of falls or any actual falls. Review of the resident's electronic medical record showed: - Staff completed a Fall Risk Assessment on 4/28/22, determining the resident is a high risk for falls. -The resident had falls on 1/13/23 and 4/22/23. There were no updates made to the comprehensive care plan to address these falls. Review of the resident's progress notes showed: -On 1/13/23, the resident was found on the floor in his/her room. The resident said he/she slid from the wheelchair. -On 4/22/23, the resident was found on the floor in his/her room. The resident said he/she slid from the recliner. 3. Review of Resident #10's quarterly MDS, dated [DATE] showed: -He/she was admitted to the facility on [DATE]. -Diagnoses of major depressive disorder, retention of urine, vitamin deficiency, insomnia (persistent problems falling and staying asleep), weakness, constipation (occurs when bowel movements become less frequent and stools become difficult to pass), and macular degeneration (an eye disease that causes vision loss). -BIMS score of 15. This score indicates no cognitive impairment. -He/she is independent with Activities of Daily Living, including dressing, toileting and personal hygiene. -He/she is continent of bowel and bladder. Review of the resident's annual MDS, dated [DATE] showed: -Always continent of bowel and constipation was not present. -There were no CAAs written to address constipation/bowel issues. Review of the residents Physician Orders, dated May 2023, showed orders for: -Colace (a medication to prevent and treat constipation) 100 miligram (mg) capsule daily. -Miralax (a medication to treat occasional constipation) 1 packet daily. During an interview on 5/16/23 at 2:19PM, the resident said: -He/she struggled with constipation. -He/she took medications to help him/her have bowel movements. -The staff frequently asked him/her if he/she had a bowel movement then would write it down. Review of the resident's comprehensive care plan, dated 4/14/21, showed: -No care plan addressing the resident's constipation. 4. Review of Resident #25's Admission MDS, dated [DATE] showed: -He/she admitted to the facility on [DATE]. -Diagnoses of closed left hip fracture, weakness/unsteadyness, difficulty walking, chronic obtructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), malignant neoplasm of skin (an unusual growth of cells on the skin), gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints) and anemia (a condition in which the body does not have enough healthy red blood cells). -He/she has a BIMS score of 12. This score indicates moderately impaired cognitive skills. -He/she needed limited to extensive assistance with Activities of Daily Living, including toileting, bathing and personal hygiene. -He/she had lower extremity impairment to one side. -Always continent of bowel and bladder. Review of the resident's electronic medical record on 5/16/23 showed: -He/she was noted to have a 5% weight loss on 4/10/23. -On 4/14/23, the Registered Dietician noted the weight loss and recommended adding Ensure supplement twice a day. Review of the resident's comprehensive care plan, 3/9/23, showed: -The care plan was not updated to reflect the resident's weight loss dated 4/10/23 or any subsequent approaches to address the weight loss. 46706 5. Review of Resident #5's care plan, dated 1/21/23 showed: -Assist of one staff for transfers and toileting; -Assist of one staff for dressing; -No other care plans were found. Review of Resident #5's significant change in status MDS, dated [DATE], showed: -Moderate cognitive impairment; -Occasionally incontinent of bowel and bladder; -Total dependence of two staff for transfers and toileting; -Extensive assistance of two staff for dressing; -Diagnoses included atrial fibrillation (an irregular heart rate that causes poor blood flow), stroke, high blood pressure and fracture. Review of the resident's medical record showed: -The resident had a fall on 4/24/23; -On 4/24/23 the resident was seen by the physician for a left foot fracture; -A controlled ankle motion boot (CAM boot - an orthopedic device for the stabilization of fractures) was prescribed by the physician; -The resident has a follow up appointment on 8/9/23. Observation on 5/16/22, at 9:35 A.M., showed the resident sat in a chair with his/her feet up. During an interview on 5/17/23, at 10:22 A.M., CNA D said: -He/she looks at the care plan to see how to care for the resident; -The resident needs assist of two staff because he/she broke his/her foot; -Any change in ADL status should be care planned. During an interview on 5/17/23, at 3:02 P.M., the resident said: -The assistance of one staff member was needed to help him her transfer, toilet, dress and shower before he/she broke his/her foot; -It takes two staff members to transfer, toilet, dress and shower him/her now. During an interview on 5/17/23, at 3:16 P.M. LPN A said: -The resident needed only minimal assistance with ADLs before he/she fell and broke his/her foot; -Assistance of two staff are needed now because he/she is wearing a CAM boot; -Any change in ADL status should be care planned. During an interview on 5/17/23, at 4:15 P.M., the DON said: - The resident only needed the assist of one staff for ADL's when he/she was admitted ; - The resident's ADL status changed after he/she fractured her foot; - A change in the residents ADL status should be care planned. 6. Review of Resident #16's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Incontinent of bowel and bladder; -Assist of one for transfers and toileting; -Assist of one for dressing; -The resident is on Hospice. -Diagnoses included dementia a group of thinking and social symptoms that interferes with daily functioning), coronary artery disease (damage or disease in the heart's major blood vessels) and high blood pressure. Review of the resident's Physicians Order Sheet (POS), dated May 2023, showed an order to admit to Hospice with a start date of 12/19/22. Review of the resident's care plan, dated 11/8/22 showed staff did not develope any interventions related to the resident's admission to hospice. During an interview on 5/17/23, at 10:15 A.M., Licensed Practical Nurse (LPN) A said: -The resident was on Hospice; -Hospice provided baths three times a week and supplies; -Hospice should be on the resident's care plan. During an interview on 5/17/23, at 10:22 A.M., CNA D said: -The resident was on Hospice; -Hospice provided baths three times a week and supplies; -He/she did not know what other service Hospice provided for the resident; -Hospice should be care planned. During an interview on 5/17/23, at 4:15 P.M., the DON said: -The resident was on Hospice; -Hospice should be care planned. 7. Review of Resident #18's annual MDS, dated [DATE], showed: -No cognitive impairment; -Independent with ADLs; -Bed rails used daily; -Diagnoses included atrial fibrillation (an irregular heart rate that causes poor blood flow), high blood pressure and arthritis. Review of the resident's POS, dated May 2023, showed an order for for the use of horseshoe rail x 1 to assist with mobility with a start date of 8/10/22. Review of the resident's medical record showed a side rail assessment was completed on 8/10/22 that showed the resident requested the rail for bed mobility and the left side horseshoe rail was installed. Review of the resident's care plan, dated 11/25/22 showed staff did not address the use of side rails. Observation on 5/16/23, at 11:15 A.M., showed the resident had one horseshoe rail installed on the left side of his/her bed. During an interview on 5/16/23, at 4:12 P.M., the resident said he/she used the rail to turn over in bed to get comfortable. During an interview on 5/17/23, at 10:15 A.M., LPN A said: -The resident used the rail for positioning in bed; -The bed rail should be care planned. During an interview on 5/17/23, at 4:15 P.M., the DON said side rails should be care planned. 47195 8. Review of Resident #15's admission MDS, dated [DATE], showed: -He/she was admitted to facility on 11/9/20; -BIMS of 9, moderately impaired; -He/she has clear speech, ability to make self understood, and be understood; -Diagnoses included anemia, osteomyelitis, hypertension, renal insufficiency multi-drug resistant organism, stage 2 pressure ulcer, diabetes mellitus, dehydration (endocrine, nutritional, and metabolic disease), generalized muscle weakness, unsteadiness on feet, restlessness, and agitation; -Activities: very important - books/newspapers, magazines, listening to music, going outside to get fresh air, participating in religious services. Record review showed: -Quarterly care conference held 6/7/22 with guardian, dietary, administrator, social services who participated. -He/she sometimes is resistant to shower -He/she had a roommate for a few weeks, roommate moved after several incidents of disagreement in which he/she became agitated -Quarterly care conference held 9/13/22 with guardian, DON, and social services who participated -He/she had been taking Seroquel at beditme since 8/5/22, medication was requested as a result of his/her frequent outbursts and increased agitation. Medication appears to have been effective. Nursing staff will continue to monitor and request changes as needed -Typically participates in bingo -Annual care conference held 12/7/22 with guardian/conservator, DON, and social services who participated. -He/she has not been wanting to shower. Guardian/conservator said to try different times of day. He/she may not want to take showers due to the era he was raised. -Quarterly care conference held 3/8/23 with resident, family/DPOA, guardian/conservator, DON, and social services staff who participated -Louis had no med changes -He/she is to Receive ice cream at lunch and supper to help with his/her toe -Protein shakes are ordered for him/her to have -he/she enjoys bingo -He/she likes to watch westerns and football on TV Review of the the resident's care plan dated 11/19/20 showed: -No personalization to resident specific cares regarding interventions for ADL cares -No updates from 6/7/22 care conference regarding resident resistent to cares -No updates from 12/7/22 care conference regarding resident not wanting to take showers -No dietary preferences care planned -No activity preferences care planned -No dementia interventions care planned -Mobility interventions is not personalized to resident During an interview on 5/17/23 at 7:40 A.M., Social Services/Activity Director said: - He/she did not write care plan. - He/she wrote up notes from the care plan meetings. -The DON or ADON wrote the the care plans. During an interview on 5/18/23 at 9:10 A.M., CNA A said: -He/she knew residents based on working with them. -Care plans were available but he/she did not look at them. -The staff who attended the care plan meetings made him/her aware of any changes. During an interview on 5/18/23 at 9:28 A.M., CNA B said: -Resident specific care should be included in their care plan. -He/she did not look at care plans often. -The nurse or the DON made him/her aware of any changes to the care plan. During an interview on 5/18/23 at 9:41 A.M., LPN A said: -He/she often sat in on care plan meetings. -Care plan team wanted his/her input as charge nurse on residents' change in habits. -He/she often learned of changes in residents' care through report. During an interview on 5/18/23 at 12:45 P.M., the Director of Nursing said: -He/she wrote care plans for facility. -Care plans were updated after every meeting was held or if there was something new that came up. -He/she would expect elopement risks and wander guard placements to be included in the care plan. -He/she would expect resident specific approaches to be included in the care plan. -He/she would expect bed rails, constipation and weight loss to be included in the care plan. During an interview on 5/18/23 at 1:10 P.M., the Administrator said: -Care plans should be updated with every significant change, at admit, and quarterly. -He/she would expect care plans to be specific to resident's care plan. -He/she would expect a resident who had been in facility over a year to have more than one care area care planned.

Based on observation, interview, and record review, facility staff failed to complete entrapment assessments for one of 12 sampled residents with side rails (Residents #20) to ensure the environment remained safe and free of accident hazards. The facility census was 24. Review of facility policy Bed Safety and Bed Rails, dated August 2022, showed: -Bed frames, mattresses, and bed rails are checked for compatibility and size prior to use -Bed dimensions are appropriate for resident's size -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. -Maintenance staff routine inspects all beds and related equipment to identify risks and problems including potential entrapment risks. -Maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee -Bed rails are propertly installed and used according to the manufacturer's instructions, specifications, and other pertinent safety guidance to ensure proper fit (e.g. avoid bowing, ensure proper distance from the headboard and footboard, etc.) -Additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment (e.g., altered mental status, restlessness, etc.) -The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. 1. Review of Resident #20's quarterly minimum data set (MDS), a federally mandated assessment completed by facility staff, dated 3/13/23 showed: -Brief Interview Mental Status ((BIMS) a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) of 10, moderately impaired cognition. -Diagnoses included stroke, depression, muscle wasting and atrophy. -Range of motion included impairment of one side. -Transfers required two person assist. Review of care plan dated 3/24/23 showed bed mobility: resident is able to use grab bars on the bed to assist with mobility. Record review showed: -Side rail assessment completed on 4/4/23; -No entrapment assessment found. Observation and interview on 5/16/23 at 11:14 A.M. showed the resident's bed had side rails on both sides of bed. He/she said the side rails help him/her move in bed. During an interview on 5/18/23 at 12:45 P.M., the Director of Nursing (DON) said: -Facility is not doing entrapment assessments -Most residents that had bed rails asked for them or required use of them for assistance in getting out of bed

Based on interview and record review, the facility failed to inform one of 12 sampled resident's (Resident #22) responsible party after the resident had an elopement from facility and staff applied a wander guard device to signal if he/she attempted to elope again. The facility census was 24. The facility did not provide policy regarding notifications. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/5/23 showed: - Brief Interview Mental Status (BIMS), a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility, of 3 indicating the resident had severely impaired cognition; - Diagnoses included Alzheimer's disease, generalized muscle weakness, and mild cognitive impairment - Wandering behavior occurred one to three days during the assessment period; - The resident walked in corridor with supervision oversight, encouragement, or cueing and one person physical assist. Review nursing progress notes showed on 5/3/23 showed Resident #22 had an elopement outside of facility. The facility nurse was notified by another resident whom observed Resident #22 leaving building. The nurse went outside and Resident #22 had made it to third square of the sidewalk with an artificial bucket of flowers he/she had obtained from table by front door. Resident #22 was redirected back into building. A daughter (not the Durable Power of Attorney (DPOA) was notified of the incident. The Director of Nursing was contacted and stated to put wander guard on the resident. The nurse was unable to activate wander guard as the PIN was unknown. Record review showed: -Wandering risk assessment completed on 1/25/22 with score of 4 or low risk for wandering; -No new wandering risk assessment completed following elopement of 5/3/23. Review of care plan dated 1/25/22 showed: -He/she had no elopement risk care planned During an interview on 5/17/23 at 2:21 P.M., DPOA of Resident #22 said: -He/she was the resident's health durable power of attorney. -He/she did not know the resident had eloped from the facility. -His/her sibling lived closer to facility and was often in the facility to see Resident #22 more frequently so staff may have told them about elopement incident. -He/she was not aware staff applied a wander guard to resident. During an interview on 5/18/23 at 9:41 A.M., Licensed Practical Nurse (LPN) A said: -When a resident has a change in condition he/she would notify the doctor, DON, Administrator, and the Durable Power of Attorney (DPOA). -He/she should always contact the DPOA. -It is not normal practice to tell other family members of change of condition of a resident. -He/she would still contact the DPOA if a family member visited facility frequently but was not the DPOA, the DPOA has to be contacted. -Staff should document on incident report what time they contact the DPOA. During an interview on 5/18/23 at 12:45 P.M., the DON said: -Staff should completed a wandering/elopement assessments with every MDS -He/she would expect staff to complete a new assessment after a resident exhibits an elopement -The DPOA should be notified with a significant change with a resident. -The DPOA would be expected to be contact prior to a wander guard being placed. During an interview on 5/18/23 at 1:10 P.M., the DON said: -DPOA of health should be notified of significant change with resident. -It is not appropriate for a family member who was not the DPOA and visited facility frequently to be notified of a resident's significant change. The DPOA should always be notified of any change in condition.

Based on record review and interview, the facility failed to ensure they conducted a regular, periodic Employee Disqualification List (EDL) check for five of six staff members hired since the last full survey and who were selected for review. The facility also failed to date the Nurse Aide Registry check for five of six staff members hired since the last full survey and who were selected for review. The facility census was 26. Review of the facilities Abuse and Neglect policy, dated 9/8/2021, showed: -The facility will not employ individuals who have been found guilty of abusing, neglecting or mistreating individuals by a court of law or who have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -All Applicants will have a Criminal Background Check. -All Applicants will have an EDL check. -All Applicants will be check on the Missouri Certified Nurse Assistant Registry according to state regulations. -All Applicants will have drug testing according to facility policy. 1. Review of Certified Nurses Assistant (CNA) A's personnel records showed: -Hire date of 10/23/2019; -No record for EDL checks upon hire or in 2020; -Initial EDL check was conducted on 9/23/2021; -No date on the Nurse Aide Registry check to show when the check was completed 2. Review of Laundry Aide A's personnel records showed: -Hire date of 01/02/2021; -Initial EDL check was conducted on 12/28/2020; -No additional EDL check was conducted since 12/28/2020; -No date on the Nurse Aide Registry check to show when the check was completed. 3. Review of CNA B's personnel records showed: -Hire date of 9/30/2020; -Initial EDL check was conducted on 9/23/2020; -No additional EDL check was conducted since 9/23/2020; -No date on the Nurse Aide Registry check to show when the check was completed. 4. Review of Activity Director's personnel records showed: -Hire date of 9/23/2019; -Initial EDL check was conducted on 9/12/2019; -No additional EDL check was conducted since 9/12/2019; -No date on the Nurse Aide Registry check to show when the check was completed. 5. Review of the Director of Nursing's (DON) personnel file: -Hire date of 6/9/2021; -Initial EDL check conducted on 6/2/2021; -No additional EDL check was conducted since 6/2/2021; -NO date on the Nurse Aide Registry check to show when the check was completed. During an interview on 9/15/2021 at 11:40 A.M., the Business Office Manager said: -He/she was not aware that regular, periodic EDL checks were required for current employees. -He/she thought the dates were on the print out from the Nurse Aide Registry. During an interview on 9/15/2021 at 1:45 P.M., the Administrator said: - She was unaware that regular EDL checks were needed on current employees. She was unaware the Nurse Aide Registry checks were undated. -She would expect the personnel files were to be correct and complete, including dating of background checks.

Based on record review and interviews, the facility failed to purchase a surety bond in a sufficient amount to ensure the security of all residents' personal funds deposited with the facility. The facility census was 26. The facility did not provide a policy for surety bonds. Review of facility's surety bond dated November 2009 showed a bond amount of $5,000. Review of the Residents Funds Worksheet on 9/15/21, completed with the last twelve months of non-reconciled bank statements showed the required bond amount needed was $15,000. During an interview on 09/15/21 at 03:02 P.M. the Business Office Manager said: -He/she just renewed the surety bond. -He/she was not sure who monitored for sufficient bond amount. -The bond probably needed to be increased to $15,000 after he/she reviewed the bank statements. During an interview on 09/16/21 at 10:25 A.M. the Administrator said: - The surety bond should be sufficient.

Based on observation, interviews, and record review, the facility failed to maintain a reconciliation of petty cash amounts for resident money located in the facility's locked box. This affected six residents (Residents #3, #7, #11, #16, #19, and #22). Facility census was 26. The facility did not provide a policy for petty cash. During an observation and interview on 09/15/21 at 1:00 P.M. the Business Office Manager showed and said: -Resident #3. #7, #11, #16, #19, and #22 had envelopes with money in a locked box. -Amounts were not reconciled. -He/she did not know petty cash amounts in the locked box needed to be reconciled. -He/she knew how much money should be in the envelopes but it was not documented anywhere. During an interview on 09/16/21 at 10:25 A.M. the Administrator said: -Petty cash should be reconciled.