Based on observation, record review, and interview, the facility failed to support each resident's right to self-administer medication when the facility did not explore one resident's (Resident #1) ability to self-administer medications and creams the resident had in his/her room. The facility's census was 71. Review of the facility's policy titled, Medication Storage in the Facility, dated April 2017, showed the following: -Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate per facility policy; -A written order for the bedside storage of medications to be present in the resident's medical record; -Bedside storage of medications is indicated on the resident mediation administration record (MAR) and in the care plan for the appropriate medications; -For residents who self-administer medications, the following conditions are met for bedside storage to occur: the manner of storage prevents access by other residents. lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate; facility management should have a copy of the key in addition to the resident; the medications provided to the resident for beside storage are kept in the original containers; and the bedside medication record is reviewed per facility policy; -All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for beside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of the procedure and related policy when necessary; -Bedside medication storage is routinely monitored by facility nursing personnel. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 04/20/23; -Diagnoses included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and diabetes mellitus (commonly known as diabetes, is a chronic condition characterized by high blood sugar levels). Review of the resident's admission Agreement, dated and signed by the resident on 04/21/23, showed all prescribed medications and medications such as antacids, cough syrups, laxatives, and ointments brought into the facility, must be left at the nurses' station. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/01/24, and showed the following information: -Moderate cognitive impairment; -Staff did not mark application of ointments/medications other than to feet. Review of the resident's care plan, updated on 11/12/24, showed the following information: -The resident was at risk for skin breakdown related to history of burns, diabetes melilites, and oxygen use; -The resident's skin would remain intact; -The staff would observe the resident for presence of risk factors; -The resident's skin would be kept clean and dry as possible. Review of the resident's December 2024 Physician Order Summary Report (POS) showed the following: -An order, dated 05/31/23, for abilify (used to treat bipolar disorder) 20 milligram (mg), 1 tab, once daily at 8:00 A.M.; -An order, dated 11/05/24, for lexapro (used to treat anxiety) 20 mg, 1 tab once a day at 12:00 P.M. (Staff did not document any orders related to medicated shampoo or medicated cream.) Review of the resident's physician progress note, dated 12/06/24, showed the following: -The resident was getting meds from a telehealth mental health doctor and had someone take him/her to a local pharmacy to get them; -A box was found in the resident's room that contained abilify and lexapro, both of which he/she received at the facility, but with different dosages; -The resident was educated about it being a dangerous practice and that doubling doses could have serious and dangerous effects. Review of the resident's current care plan showed staff did not update the care plan to reflect the medication storage of the duplicate medications in the resident's room. Review of the resident's medical record showed staff did not document regarding if the resident would be a able to store his/her medications at bedside. Observation on 12/16/24, at 10:05 A.M., of the resident's face and ears showed the following: -The resident had scaly patches of skin, yellowish in color, on his/her forehead, in the temple area on both sides of his/her face, and on the resident's head; -A partially used tube, labeled ketoconazole (antifungal) cream 2%, was observed on the resident's bedside table; -The resident had a prescribed bottle of medicated shampoo, ketoconazole shampoo 2%, in his/her cabinet; -The shampoo was prescribed by a physician and was filled on 12/01/24; -The directions on the prescription read, shampoo scalp and beard 1 time daily for two weeks, let soak five minutes and rinse. During an interview on 12/16/24, at 10:05 A.M., the resident said the following: -The resident washed his/her face in his/her bathroom; -The resident applied the ketoconazole cream to his/her face one to two times a day; -The resident said he/she had a fungus on his/her skin that caused his/her skin to build up and get crusty; -The resident said his/her dermatologist prescribed the cream and shampoo; -The resident did not know if staff were aware that he/she had the prescribed shampoo and cream at his/her bedside. During an interview on 12/16/24, at 1:10 P.M., Certified Nursing Assistant (CNA) A said the following: -All prescription medication was to be kept in the medication cart or medication room; -Residents were not allowed to keep any medication at bedside without an order from the physician; -A prescription was required for a resident using a medicated shampoo or cream; -CNA A was not aware of the resident had a medicated shampoo or a medicated cream. During an interview on 12/16/24, at 3:37 P.M., CNA F said the following: -CNA F was not aware of the resident having any prescribed medication at his/her bedside; -CNA F was not aware of the resident having prescribed shampoo and cream to treat a fungus; -CNA F would report to the certified medication technician (CMT) or registered nurse (RN) any found prescribed or over the counter medication found at a resident's bedside. During an interview on 12/16/24, at 1:21 P.M., CMT B said the following: -No prescribed medications or creams were to be kept bedside without a physician order; -The nurse was responsible for providing treatments, including creams, to the residents; -CMT B looked at the resident's physician orders and did not see orders for a cream or shampoo. During an interview on 12/16/24, at 1:50 P.M., RN C said the following: -Residents should not have prescribed medication or treatments at bedside without an order from the physician; -The resident sees other physicians when he/she is out of the building and will set up procedures, obtain new prescriptions, and not inform the facility; -The resident had brought other creams and medication into the facility previously; -The resident was not compliant with following physician orders or facility policy. During an interview on 12/16/24, at 1:33 P.M., the resident's physician said the following: -The resident had no orders for a medicated shampoo or cream; -All prescribed treatments should be on the resident's Medication Administration Record (MAR); -The physician felt the resident would be a candidate to have medications, including the cream and shampoo at his/her bedside; -The physician is fine with residents keeping treatments at bedside as long as there is an order for the treatment. During an interview on 12/16/24, at 2:40 P.M., the Director of Nursing (DON) said the following: -Last month the resident had brought into the facility two prescriptions, abilify and lexapro; -The resident set up telehealth psych services on his/her own and did not inform the facility; -The resident was already prescribed ability and lexapro from the facility physician; -The DON spoke with the resident regarding the facility policy on bringing in outside medications; -The resident said he/she understood the safety concern. During an interview on 12/16/24, at 3:54 P.M., the Administrator said over the counter medications and prescription medications should not be kept at a resident's bedside without a physician order. MO00246507

Based on observation, interview, and record review, the facility staff failed ensure each resident's right to self-determination was supported when facility staff failed to offer and provide showers as preferred for one resident (Resident #1). The facility census was 71. Review of the facility's policy titled, Activities of Daily Living (ADLs), undated, showed the following: -This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. -Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including: bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating and communication. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 04/20/23; -Diagnoses included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and diabetes mellitus (commonly known as diabetes, is a chronic condition characterized by high blood sugar levels). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 11/01/24, and showed the following information: -Moderate cognitive impairment; -Required setup or clean-up assistance when shower/bathing. Review of the resident's monthly summary, dated 11/07/24, showed the following: -The resident required assistance with grooming and hygiene; -The resident required set-up assess with showering/bathing. Review of the resident's care plan, updated on 11/12/24, showed the following: -The resident had self-care deficits with ADLs such as bathing, hygiene, dressing, and toileting related to weakness and shortness of breath; -The resident will shampoo and shower two times a week with fingernails and toenails cleaned and checked; -The resident required one staff assistance with help getting dressed, toileting, and bathing. Review of the resident's shower sheets, dated 10/01/24 through 12/16/24, showed the following: -One shower sheet, dated 11/22/24, showed the resident showered by him/herself after supper; -There were no other shower sheets for the resident during that timeframe. Observation on 12/16/24, at 10:05 A.M., showed the following: -The resident had scaly patches of skin, yellowish in color, on his/her forehead, in the temple area on both sides of his/her face, and on the resident's head; -A partially used tube, labeled ketoconazole (an antifungal medication) cream 2%, was observed on the resident's bed side table; -The resident had a prescribed bottle of medicated shampoo, Ketoconazole shampoo 2%, in his/her cabinet; -The directions on the prescription read, shampoo scalp and beard one time daily for two weeks, let soak five minutes and rinse; -The tamper/safety seal was secured to the bottle showing that the shampoo had not been opened. During an interview on 12/16/24, at 10:05 A.M., the resident said the following: -The resident washes his/her face in his/her bathroom; -The resident has not had a shower in three weeks; -The resident has asked staff for a shower and staff blow him/her off; -The resident got tired of asking staff for a shower; -The resident had not refused any showers; -The resident wanted a shower at least once a week. During an interview on 12/16/24, at 1:10 P.M., Certified Nursing Assistant (CNA) A said the following: -Residents received a shower at least once a week; -A shower aide was available every day during the week; -Showers were documented on shower sheets and kept in the shower book at each nursing station; -CNA A was not sure when the resident last received a shower or how often the resident showered. During an interview on 12/16/24, at 1:21 P.M., Certified Medical Technician (CMT) B said the following: -Residents received showers twice a week; -CMT B was not aware of the resident's shower schedule. During an interview on 12/16/24, at 1:33 P.M., the resident's physician said the resident should receive a shower at least twice a week and/or as needed. During an interview on 12/16/24, at 1:50 P.M., Registered Nurse (RN) C said the following: -Residents received showers at least twice a week; -Resident showers were documented on shower sheets and kept in the shower books at each nursing station; -The resident was advised to wash his/her face and apply lotion; -The resident wants to do what the resident wants to do when he/she wants to do it; -The resident was not compliant with following physician orders or facility policy. During an interview on 12/16/2,4 at 2:04 P.M., CNA D said the following: -CNA D was a shower aide; -Residents' showers were documented on shower sheets and kept in the shower book at the nurses' station; -The last shower sheet for the resident was from 11/22/24 and showed the resident does self after supper. During an interview on 12/16/24, at 3:35 P.M., CNA E said the resident's shower day was Friday. The resident often refuses showers. During an interview on 12/16/24, at 3:37 P.M., CNA F said the following: -The resident showers him/herself and did not ask for help; -The resident was very independent; -The resident was offered a shower every Friday; -The resident was allowed to shower anytime he/she asked; -The resident had not showered on Fridays during the day for several weeks; -Resident showers are documented on shower sheets and kept in the shower book; -Residents refusing showers are documented on the shower sheet and kept in the shower book. During an interview on 12/16/24, at 2:40 P.M., the Director of Nursing (DON) said the following: -The resident typically showers on his/her own; -The resident has a history of refusing showers; -Residents should receive a shower at least twice a week. During an interview on 12/16/24, at 3:54 P.M., the Administrator said the following: -Resident showers are done a minimum of once a week, preferably twice a week; -Shower refusals by residents should be documented on a shower sheet and kept in the shower book. MO00246507

Based on observation, interview, and record review, the facility failed provide care per standards of practice to all residents when staff failed to to assess, identify, and provide appropriate treatment for a skin condition and failed to notify the physician of the change in condition for one resident (Resident #1) who developed a skin condition on the resident's face and head that required prescription shampoo and cream to treat. The facility census was 71 residents. Review of the facility's policy titled Wound Prevention, revised 8/2023, showed the following: -Conduct a comprehensive assessment upon move in to identify any existing wounds, skin conditions, or risk factors for wound development; -Perform routine skin assessments on all residents during regular monthly assessments; -Document and review the assessed information to establish appropriate wound prevention measures for each resident; -Promote good hygiene practices, including regular showering, and regular changing of soiled garments or incontinence products; -Ensure the use of mild, pH-balanced, fragrance-free soaps, moisturizers, and protective creams suitable for the individual resident's skin condition; -Document all wound prevention measures, assessments, and interventions in resident's service plan and medical records; -Promptly report an new wounds, changes in skin condition, or concerns related to wound preventions to the appropriate healthcare personnel. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 04/20/23; -Diagnoses included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and diabetes mellitus (commonly known as diabetes, is a chronic condition characterized by high blood sugar levels). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/01/24, and showed the following information: -Moderate cognitive impairment; -The resident had no ulcers, wounds, or skin problems; -The resident received no applications of ointment/medications. Review of the resident's monthly summary, dated 11/07/24, showed the condition of the resident's skin was fair, warm, and dry. Review of the resident's care plan, updated on 11/12/24, showed the following information: -The resident was at risk for skin breakdown related to history of burns, diabetes melilites, and oxygen use; -The resident's skin would remain intact; -The staff would observe the resident for presence of risk factors; -Staff would conduct a systematic skin inspection weekly and with showers. Review of the resident's weekly skin assessment, dated 12/04/24, completed by Registered Nurse (RN) C showed the resident's skin intact with no skin issues and no interventions or treatments in place. Review of the resident's weekly skin assessment, dated 12/11/24, completed by Licensed Practical Nurse (LPN) G showed the resident's skin intact with no skin issues and no interventions or treatments in place. Observation on 12/16/24, at 10:05 A.M., showed the following: -The resident had scaly patches of skin, yellowish in color, on his/her forehead, in the temple area on both sides of his/her face, and on the resident's head; -A partially used tube, labeled ketoconazole (antifungal) cream 2%, was observed on the resident's bed side table; -The resident had a prescribed bottle of medicated shampoo, ketoconazole shampoo 2%, in his/her cabinet; -The directions on the prescription read, shampoo scalp and beard one time daily for two weeks, let soak five minutes and rinse; -The fill date on the bottle showed 12/01/24; -The tamper/safety seal was secured to the bottle showing that the shampoo had not been opened. During an interview on 12/16/24, at 10:05 A.M., the resident said the following: -The resident washed his/her face in his/her bathroom; -The resident applied the ketoconazole cream to his/her face one to two times a day; -The resident said he/she had a fungus on his/her skin that caused his/her skin to build up and get crusty; -The resident said his/her dermatologist prescribed the cream and shampoo. Review of the resident's medical record showed staff did not document notifying the resident's physician the skin condition on the resident's face. During an interview on 12/16/24, at 1:33 P.M., the resident's physician said he was not aware of the resident having a fungus or skin condition affecting the resident's face or head. During an interview on 12/16/24, at 1:21 P.M., Certified Medical Technician (CMT) B said the following: -The nurse was responsible for completing weekly skin assessments on the resident; -The nurse is responsible for providing treatments, including creams, to the residents; -The resident appeared to have psoriasis (a chronic skin condition that causes inflamed, raised plaques of skin that are often covered in silvery scales) on his/her face. During an interview on 12/16/24, at 1:50 P.M., RN C said the following: -The resident had dry skin around his/her face and was referred to the physician; -The resident was advised to wash his/her face and apply lotion; -RN C had offered several times to assist the resident with washing his/her face; -The resident did have a rash; -RN C completes skin assessments; -RN C had notified the physician of the resident's skin condition before and the resident was on the physician's list to be seen; -RN C did not remember when he/she had notified the physician about the resident's skin condition. During an interview on 12/16/24, at 3:35 P.M., Certified Nurse Aide (CNA) E said the following: -He/she had not noticed any changes in the resident's skin condition; -When CNA E notices anything new regarding a resident's skin condition he/she reports it to the RN; -RN's are responsible for completing skin assessments with the residents. During an interview on 12/16/24 at 3:37 P.M., CNA F said the resident regularly had dry skin. During an interview on 12/16/24, at 3:45 P.M., the Assistant Director of Nursing (ADON) said the following: -Staff should report a change in the resident's skin condition to the charge nurse, who would then report it to the physician; -The ADON saw the resident this morning, but did not notice the dry skin on the resident's face; -The ADON was not aware that the resident had any orders for shampoo or cream to treat the dry skin or fungus. During an interview on 12/16/24 at 3:54 P.M., the Administrator said the following: -Residents should be receiving thorough skin assessments by the nurse; -Any changes in the residents' skin should be documented on the skin assessment; -Any change in a resident's skin should also be reported to the physician. MO00246507

Based on interview and record review, the facility failed to maintain an infection and control program, per standards of practice and facility policy, when the facility failed to ensure two employees (Housekeeper A and Licensed Practical Nurse (LPN) B), of six sampled residents, received tuberculosis (TB-a communicable disease that affects the lungs) screening tests as needed. The facility census was 75. General requirements for Tuberculosis Testing in Long-Term Care Facilities per 19 CSR 20-20.100: -Long-term care facilities shall screen staff for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -All skin test results are to be documented in millimeters (mm) of induration; -All new long-term care facility employees and volunteers who work ten or more hours per week are required to obtain a two-step TB test (skin test) within one month prior to starting employment; -If the initial test is negative, a second test is required within three weeks after employment begins, unless documentation is provided indicating a TB test in the past and at least one subsequent annual test within the past two years. Review of the facility's policy, Tuberculosis Control, Recommendations for Employees, undated, showed the following: -Every facility should have a tuberculosis surveillance program to include initial examination that provides a tuberculin skin test (Mantoux - five tuberculin units (TU) of purified protein derivative (PPD)) to all employees during pre-employment procedures, unless a previous reaction of greater than 10 mm is documented; -If the initial test is 0 to 9 mm, a second test should be given at least one week after and no more than three weeks after the first step; -The test is used as the baseline in determining treatment and follow-up of employees; -All employees with be screened for TB; -Once the decision is made to employ an individual, the individual will be asked for documentation of a prior PPD; -If the employee has documentation of a prior PPD, the first step PPD will be administered by the nursing department, documented on the employee immunization record, and must be read prior to or no later than the start date; -If an employee has had a documented evidence of prior two-step PPD, the decision tree for employee accepts position will be followed; -If the employee has a documented positive PPD in the past or an adverse reaction, the facility will follow the decision for a positive PPD; -All PPD's will be documented in the employee immunization record including new hires and annual administration. After the PPD has been administered, the results will be documented in mm. -Documented evidence of prior PPD will be maintained with the facility employee immunization records. 1. Record review of Housekeeper A's personnel file showed the following: -A date of hire 08/29/23; -Staff did not have documentation of administration a two-step TB at hire, or documentation of any prior TB tests or results. 2. Record review of LPN B's personnel file showed the following: -A date of hire of 06/06/23; -Staff did not have documentation of administration a two-step TB at hire, or documentation of any prior TB tests or results. 3. During an interview with on 01/18/24, at 3:25 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she is the infection preventionist and is responsible for ensuring TB testing is completed for all staff at the facility; -The first step of the TB test is supposed to be done upon hire and then read a few days later; -The facility staff is not supposed to start working until the first step TB test is read by a nurse; -All staff should be TB tested upon hire; -He/she did not realize that Housekeeper A did not have a record of a TB test being done in his/her employee file; -He/she was not aware that they did not have LPN A's TB test in her file. They thought that e/she had it done when he/she had started working at the hospital but they did not have any record of it. 4. During an interview on 01/19/24, at 1:47 P.M., the Director of Nursing (DON) said the following: -All new employees receive TB tests during orientation; -The TB test is read when staff come to orientation about 48 to 72 hours after administration; -He/she was not aware that Housekeeper A had not been TB tested prior to working at the facility. 5. During an interview on 01/18/24, at 3:15 P.M., the Administrator said the following: -The ADON is the infection preventionist and is in charge of TB testing the staff; -He/she was not aware that Housekeeper A had not had TB testing completed prior to him/her starting to work at the facility; -He/she was not aware that they did not have LPN B's TB test in her file. They thought that he/she had TB testing done when he/she had started working at the hospital but they did not have any record of it; -Generally, staff get their first TB test done upon hire and then they have it read when they come back for orientation.

Based on record review and interview, the facility failed to ensure a PASSAR (Preadmission Screening and Resident Review) level one was retained in the resident's medical record and accessible for one resident (Resident #14) of six residents reviewed for PASSAR. 1. During an interview on 01/10/24, at 10:46 A.M., the Administrator said they did not have any specific policy related to PASSAR. Review of Resident #14's Face Sheet, undated, located in the electronic medical record (EMR) under the profile tab, showed the following: -admission date of 09/28/12; -readmission date of 12/26/16; -Diagnoses included anxiety disorder, major depressive disorder, and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an Assessment Reference Date (ARD) of 11/18/23, showed the resident had moderately impaired cognition. Review of the resident's Nurse Practitioner Routine Visit note, located under the Resident Document tab of the EMR, dated 12/15/23, showed visit for schizoaffective disorder, increased crying and anxiety at times but improved, and for anxiety disorder, increased anxiety, crying at times but improved. Review of the resident's EMR showed no PASSAR level one available or accessible. During an interview on 01/09/24, at 12:19 P.M., the Director of Nursing (DON) said the PASSAR level one had gotten archived around 2014 to 2015. He stated he was the one who oversaw the PASSAR process, but had not audited the charts. He said he was not aware this resident did not have a PASSAR level one in the chart. He did not know what information was on the original PASSAR because it was not accessible. During an interview on 01/09/24, at 12:12 P.M., the Administrator said they did not have a physical copy of the PASSAR level one that was completed prior to admission. He said nothing had been in place since he had been at the facility since 2017.

Based on observations, interviews, and record review, the facility failed to ensure one resident (Resident # 41), of three residents reviewed for activities of daily living/restorative services, received services to maintain or improve walking ability when staff failed to offer to walk with the resident. This failure created a potential for further decline of the resident's lower body strength and walking ability. 1. Review of Resident #41's Profile tab of the electronic medical record (EMR) showed the following: -admission date of 03/20/22; -Diagnoses included dementia, anxiety, unspecified abnormalities of gait and mobility, cognitive communication deficit, generalized muscle weakness, cellulitis (skin infection) of right lower limb, chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), cerebrovascular disease, spinal stenosis (a narrowing of the spinal canal in the lower part of the back), weakness, and reduced mobility. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), located in the resident's EMR under the Resident Assessment Instrument (RAI), with an assessment reference date (ARD) of 09/24/23, showed the following: -The resident was moderately cognitively impaired; -The resident did not exhibit any behavioral symptoms, including rejection of care; -The resident required supervision or touching assistance with walking. During an observation and interview on 01/08/24, at 9:27 A.M., the resident was observed sitting in his/her wheelchair in his room. A walker was noted in the resident's room. The resident said he/she walked with assistance from staff using the walker, but could not walk on his own, as he/she was unsteady and afraid of falling. The resident said he/she did not receive assistance to walk as often as he/she would like, and he/she did not ask the staff to help him/her walk because they were busy taking care of others. During an interview on 01/08/24, at 2:36 P.M., the resident said he/she liked to walk and that he/she walked with staff about every other week. The resident said he/she enjoyed walking and would like to walk more often, but reiterated he/she did not want to ask the staff to walk with him/her as they were busy. Review of the resident's PT (physical therapy) Discharge Summary, located in the resident's EMR under the Documents tab, electronically signed and dated on 09/21/23, showed the following: -Discharge recommendations of RNP (restorative nursing program) for exercise and ambulation. RNP for LE (lower extremity)/core exercises and ambulation with 2WW (two-wheeled walker) to resident tolerance. Review of the resident's Care Plan, initiated 08/23/23 and located in the RAI tab of the EMR, showed the following: -Resident has potential risk of falling related to impaired mobility and weakness; -Give verbal reminders not to ambulate/transfer without assistance. (Staff did not care plan the resident's recommended restorative program for exercises and ambulation.) Review of the resident's Point-of-Care (POC) tab of the EMR for Restorative Nursing showed the resident ambulated with the Restorative Aide (RA) on 10/25/23, 10/26/23, 11/03/23, 11/07/23, 11/08/23, 11/09/23, 11/22/23, and 11/30/23 for 10 to 15 minutes. Review of the resident's Restorative Daily Documentation and Program Note, dated 12/07/23, showed the following: -Resident refused to do any LE ex (lower extremity exercises). He/she only wanted to do is AMB (ambulate) 40' x 2 (twice for 40 feet), used fall (precautions) and gait belt tolerated well; -Further review of the same document on 01/04/24 showed resident discharged and is non-compliant. Resident says that he/she works out in his/her room; -Staff did not document any further attempts or refusals to participate in the exercise and walking program, and no indication the resident refused to walk with restorative staff. During an interview on 01/10/24, at 11:45 A.M., the Restorative Aide (RA) said the resident was discharged from exercise and ambulation with restorative due to non-compliance. The resident refused to exercise, but the resident enjoyed walking with assistance. The RA said he/she had no further documentation regarding any provision of restorative services or refusals to participate. The RA said he/she was aware the resident did not refuse to walk. During an interview on 01/11/24, at 9:45 A.M., the Physical Therapist (PT) said the resident was discharged from the restorative program due to non-compliance. The PT had met with the RA and was informed that the resident was refusing to exercise. Once a resident was discharged from restorative services, the certified nurse aides (CNAs) should provide range-of-motion exercises during their care. The PT said he/she was aware the resident did not refuse to walk and stated the CNAs should walk with him upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure two residents (Resident #41 and #65), of five residents reviewed for immunizations, received the pneumococcal vaccination series or had documented refusals. These failures had the potential to increase the spread of pneumonia among the unvaccinated residents. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccination: Summary of Who and When to Vaccinate, dated 01/24/22 and accessed on 01/11/24 at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html showed the following: -For adults 65 years or older, who have not previously received any pneumococcal vaccine, the CDC recommends to give 1 dose of PCV [pneumococcal conjugate vaccine] 15 or PCV20; -If PCV15 is used, this should be followed by a dose of PPSV [pneumococcal polysccahride vaccine] 23 at least one year later; -If PCV20 is used, a dose of PPSV23 is not indicated; -For adults 65 years or older who have only received PPSV23, CDC recommends to give one dose of PCV15 or PCV20; -The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination; -Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it; -For adults 65 years or older who have only received PCV13, CDC recommends to give PPSV23 as previously recommended. Review of the facility's policy Immunization, undated, showed the following: -Pneumococcal: PCV 13 (PREVNAR 13) and PPSV23 (PNEUMOVAX23). Pneumococcal vaccination in persons ages 65 and older years, unless contraindicated, will be administered according to the following guidelines when determining the vaccination status: -If resident has not received either pneumococcal vaccine (PCV13 or PPSV23) or has unknown vaccination history, staff may administer PCV13, then wait one year and administer PPSV23; -If the resident has not received PCV13, but received PPSV23 at or after age [AGE] years, staff may administer PCV13 (at least one year after the most recent PPSV23); -If the resident had not received PCV13, but received one or more doses of PPSV23 at age [AGE] to 64, staff may administer PCVL3 (at least one year after the most recent PPSV23) and then administer PPSV23 (at least 1 year after PCV13 and at least 5 years after the most recent PPSV23); -If resident has received PCV13 at any age, but has not previously received PPSV23, staff may administer PPSV23 (at least one year after PCV13; -If resident has received PCV13 at any age and has received one or more doses of PPSV23 at age [AGE] to 54 years, staff may administer PPSV23 (at least one year after PCV13 and at least five years after the most receive PPSV23); -For any person who has received a dose of both pneumococcal vaccines at age greater than 65 years---revaccination is not indicated; -Contraindications to PCV13 (Prevnar13) include persons known to have severe allergic reactions (anaphylaxis) to any component of PCV13 or to any diphtheria toxoid-containing vaccine; -Requirements to administer the vaccination includes physician order, consent to receive signed by resident &/or legal representative, information sheet included with the consent to administer pneumococcal vaccine, includes general information, risks and side effects, and the resident will be monitored for fever for up to 72 hours. (The policy did not include any reference to the PCV15 or the PCV20.) 1. Review of Resident #41's Profile tab, of the electronic medical record (EMR), showed the following: -admission date of 03/20/22; -The resident was over [AGE] years old. Review of the resident's Immunizations tab, in the EMR, showed staff did not document information regarding offering or providing the pneumococcal vaccination series, or whether the vaccine had already been received. 2. Review of Resident #65's Profile tab, of the EMR, showed the following: -admission date of 04/07/21; -Resident was over [AGE] years old. Review of the resident's Immunizations tab, in the EMR, showed staff not document information regarding offering or providing the pneumococcal vaccination series, or whether the vaccine had already been received. 3. During an interview on 01/11/24, at 3:25 P.M., with the the Infection Preventionist (IP) and the Director of Nursing (DON) they said the following; -Both confirmed there was no other additional immunization information or documentation for the above residents, and they were unaware of the residents' pneumococcal immunization status; -They confirmed the facility's policy had not been updated to reflect the revised CDC guidance to offer PCV15 and PCV20; -The DON said pneumonia vaccinations had not been offered to the appropriate residents, as he had only been in the position for about a year and had not yet been able to audit pneumonia vaccinations to determine which residents required immunization; -The DON said the pneumonia vaccination should have been offered and administered, or a refusal documented, at or around the time of admission.

Based on observations, record reviews, and interviews, the facility failed to ensure food was palatable, attractive, and at a safe and appetizing temperature in accordance with professional standards for eight residents (Resident #18, #20, #25, #51, #8, #12, #7, and #73) of 20 sampled residents. Review of the facility's policy titled, Food Temperatures, dated 05/2015, revealed Hot food should be at least 120 degrees F [Fahrenheit] when served to the resident. 1. Review of Resident #18's Face Sheet, undated, in the electronic medical record (EMR) showed the following: -admission date of 02/19/20; -readmission date of 03/21/23; -Diagnoses included vitamin deficiency. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 11/30/23, showed the resident was moderately cognitively impaired. During an interview on 01/08/24, at 11:09 A.M., the resident said the food was sometimes cold. The resident said the previous night had grilled cheese and it was cold, greasy, and nasty. He/She said the tomato soup was also cold. 2. Review of Resident #20's Face Sheet, undated, in the EMR, showed the following: -admission date of 04/25/23; -Diagnoses included severe protein calorie malnutrition. Review of the resident's quarterly MDS, with an ARD of 11/08/23, showed the resident was moderately cognitively impaired. During an interview on 01/08/24, at 12:31 PM, the resident said the food needed to be warmer. 3. During the resident group meeting on 01/09/24, at 1:55 P.M., showed the following: -Residents #25, #51, #8, #12, #7, #73, and #18), who were deemed cognitive intact and interviewable by the facility, were present; -The residents said the food was cold and undercooked; -The residents said some of the food looked like it was thrown on the plate; -The residents said some of the vegetables with excess liquid ran into other foods on the plate; -The residents said the food lacked seasoning and the food was just not good. 4. Review of the recipe for the buttered spinach showed the following: -Steam spinach; -Drain and add melted margarine, salt, and pepper. During an observation of the kitchen on 01/10/24, at 9:12 A.M., the Dietary [NAME] (DC) placed three cans of spinach into a large metal pan which contained the spinach and the liquid from the cans. The DC did not cook and drain before adding salt and butter to the spinach per recipe instruction. At 12:07 PM, the spinach was on the steam table and filled with excess liquid. During an observation in the dining room on 01/10/24, at 12:20 P.M., a resident poured his/her excess spinach liquid from his/her plate into her hot liquid beverage. During an observation and interview on 01/10/24, at 12:23 PM, the DC said they did their best on straining the spinach. The DC scooped spinach onto the plates with liquid from the spinach spreading throughout. During an interview on 01/11/24, at 9:45 A.M., the Dietary Manager (DM) said she had told dietary staff that if they were serving a juicy vegetable, then it needed to be in a bowl. She confirmed the spinach juice had spread across the plate. 5. During an observation on 01/11/24, at 11:35 A.M., the DC took temperatures of the food on the steam table. The spinach was 171 degrees Fahrenheit (F), the ham was 165 degrees F, and the sweet potatoes were 169 to 170 degrees F. The cook did not take temperatures of the pureed food items. During a test tray observation and interview with the DM on 01/10/24, at 12:39 P.M., the test tray was placed onto the cart. The cart left the kitchen at 12:44 P.M The staff started to pass trays on the hall at 12:45 P.M The last tray was passed at 12:52 P.M. Upon test tray evaluation, the pureed ham was 112 degrees F, the pureed spinach was 106 degrees F, the ham was 108 degrees F, the sweet potatoes were 118 degrees F, and the spinach was 118 degrees F. The DM said the temperature should have been at least 120 degrees F for the test tray. The DM confirmed residents had complained about food temperatures before and they told the residents that staff could reheat the food or get them a new plate. During an interview on 01/11/24, at 9:45 A.M., the DM said the pellet warmer only worked about half the time. They told the residents the staff could provide them with a fresh, hotter plate of food, or something different.

Based on observations, interviews, and record review, the facility failed to ensure pureed food was prepared properly with appropriate texture in accordance with professional standards for seven residents receiving pureed texture. Review of the facility's procedure titled, Pureed, undated showed pureed food should have a smooth texture with no lumps. During an interview on 01/10/24, at 9:37 A.M., the Dietary [NAME] (DC) said they had seven residents who received the pureed texture. Review of the recipe for the pureed brown sugar glazed ham showed the following: -Prepare according to regular recipe with food thickener and water or stock and process until smooth. During an observation on 01/10/24, at 11:56 A.M., the DC prepared pureed ham. He/she placed plain boiled diced ham into the Robot Coupe (mechanical blender) and turned the machine on for processing. He/she added some liquid to the mixture which contained small undissolved pieces of beef broth. She placed the finished product directly onto the steam table. The pureed ham had the appearance of a mechanical texture. The DC did not add brown sugar glazed ham, or thickener, to the product per recipe instruction. During an interview on 01/10/24, at 11:56 A.M., the DC said she tried to ensure pudding thick texture for the food items. She said some of the food items were harder to puree than others. During a test tray observation with the Dietary Manager (DM) and interview on 01/10/24, at 12:39 P.M., showed the pureed ham had the appearance of mechanical texture. The DM confirmed the pureed ham looked more like mechanical texture and needed to be smoother. At 2:38 P.M., the DM confirmed it was the wrong texture. During an interview on 01/11/24 ,at 9:45 A.M., the DM said the puree texture needed to be of mashed potato or pudding consistency. The reason for a smooth texture was to ensure food was easier to swallow and the residents did not choke.

Based on observations, interviews, and record review, the facility failed to ensure food was stored, prepared, and distributed free from possible contamination and in sound condition in accordance with professional standards when staff failed to dispose of food after expiration, ready-to-eat foods were touched with bare hands, a thermometer was not properly cleaned, and frozen meat was not stored properly. The failed practice had the potential to affect 76 census residents consuming food in the kitchen. Review of the facility's procedure titled, Basics for Handling Food Safety, undated, showed the following: -Do not buy food past sell by, use-by, or other expiration dates; -Don't cross contaminate; -Keep raw meat, poultry, fish, and their juices away from other food; -Make sure thawing meat and poultry juices do not drip onto other food. Review of the facility's policy titled, Dietary Personnel Guidelines, dated 05/2015, showed the following: -Hands and nails should be clean with no colored polish. Review of the facility's policy titled, Glove Use, dated 05/2015, showed the following: -Utensils or tongs should be used to serve or handle foods, both raw and cooked. 1. Observation of the kitchen on 01/08/24, at 8:57 A.M., showed the following: -Raw chicken was stored in the walk-in refrigerator on the second to top shelf. The chicken was frozen, thawing in large clear plastic bags. The chicken was stored next to lettuce, cheese, and on a shelf above Almond milk containers. During an interview on 01/08/24, at 9:02 A.M., the Dietary Manager (DM) said the raw chicken needed to be stored on the lowest shelf. The chicken was pulled from the freezer the day before. 2. Observation of the kitchen on 01/08/24, at 8:57 A.M., showed the following: -Two crates of low-fat cottage cheese stored close to the floor, nearest the door; -One crate with three (five-pound) containers of low-fat cottage cheese had a date of 12/19/23; -Four (five-pound) containers of low-fat cottage cheese had a date of 12/27/23. During an interview on 01/08/24, at 9:02 A.M., the DM confirmed the food was expired and proceeded to take them out of the walk-in. 3. Observation and interview on 01/10/24, at 9:44 A.M., showed the following: -The Dietary [NAME] (DC) had dark nail polish on his/her fingernails; -He/she opened a bag of shredded lettuce and took out some of the lettuce with his/her bare right hand and placed the lettuce into a bowl; -He/she took out shredded cheese using his/her bare right hand and placed the cheese into two small bowls; -At 9:47 AM, the DC said the lettuce and cheese were for the residents' lunch meal. During an interview on 01/10/24, at 9:54 A.M., the DC said he/she had not been trained in how to handle ready-to-eat food. He/She had learned things from other jobs, restaurants. 4. Observation on 01/10/24, at 11:26 A.M., showed the following: -The DC took temperatures of the food items on the steam table; -He/She placed a thermometer into the gravy while pushing the dirty plastic portion into the gravy; -He/She cleaned the metal stem and did not clean the dirty plastic portion of the thermometer; -He/She placed the thermometer into the sweet potatoes with the plastic portion pushed into the liquid; -He/She cleaned the metal stem with an alcohol pad and did not clean the dirty plastic portion. During an interview on 01/10/24, at 11:47 A.M., the DC said he/she had never seen the plastic portion of the thermometer cleaned. He/She said he/she wiped it down sometimes. 5. During an observation on 01/10/24, at 12:23 P.M., the DC was observed pulling out two hot dog buns with his/her bare hands and placed them onto a plate. He/She opened the buns with his/her bare hands and placed hot dogs inside for a resident. 6. During an interview on 01/11/24, at 9:45 A.M., the DM said the following: -The DC had placed the chicken in the wrong place in the walk-in refrigerator; -Everyone was responsible for ensuring expired foods were not used; -She not noticed the DC wearing nail polish; -She had cleaned the plastic portion of the thermometer several times and it probably needed to be cleaned again.

Based on interview and record review, the facility failed to report an allegation of possible abuse immediately to facility management and to the State Survey Agency (DHSS - Department of Health and Senior Services) within two hours when two staff failed to report one resident's (Resident #1) allegation of employee to resident physical abuse. The facility census was 81. Review of the facility's policy titled New Abuse/Neglect Report Regulations, dated 11/28/16, showed the following: -Immediately educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; -The Administrator or designee must report to the State Survey Agency no later than two hours after the allegation is made if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury; -Please ensure that the Administrator and Director of Nursing (DON) contact information is readily accessible to all staff for reporting purposes. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed an admission date of 07/17/23. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/25/23, showed the resident was moderately cognitively impaired. During an interview on 08/02/23, at 1:25 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she had walked into the resident's room around 6:40 A.M. and the resident was telling a certified nurse aide (CNA), that someone had hit him/her; -LPN A asked the resident, who hurt you? and the resident said you did; -The resident became agitated and then refused to take any medication; -LPN A decided to back off since the resident is confused with dementia and did not want to escalate the situation; -LPN A went back after giving the resident time to calm down and asked again who hurt him/her and this time the resident said, a big fat lady; -LPN A said he/she knows that any allegation of abuse needed to be reported immediately to a supervisor and that there is only two hours to report to state; -LPN A said he/she did not feel like it was a true report of abuse, because the resident is so confused and he/she knows they are confused. Review of resident's progress note dated 08/01/23, at 2:02 P.M., showed Licensed Practical Nurse (LPN) A documented the resident claimed someone on the night shift hit him/her (over six hours after the original allegation of abuse was made by the resident.) Review of the resident's progress note dated 08/01/23, at 5:00 P.M., showed the DON documented the following: -Completed self-report on allegation of staff member from night shift hitting resident; -Family members, Administrator, quality assurance (QA) nurse and physician were notified; -Investigation also initiated. (Staff noted the self-report over nine hours after the original allegation of abuse was made.) During an interview on 08/02/23, at 12:35 P.M., CNA B said the following: -He/she did not provide any information or report the allegation of abuse made by the resident prior to being asked; -He/she said if it were abuse, it should be reported right away; -He/she did not think of this as abuse due to the resident's confusion; -He/she said anything like this should be reported within 24 hours to the state. During an interview on 08/02/23, at 12:45 P.M., Certified Medication Technician (CMT) C said the following: -He/she would report any kind of abuse up to management; -Management should report it to DHSS; -Any allegation like this must be reported within two hours. During an interview on 08/02/23, at 12:55 P.M., CNA D said the following: -He/she would immediately report any allegations of abuse to the charge nurse and up to the DON and the Administrator; -This is the kind of incident that should be sent into the state; -Abuse allegations must be reported to state within two hours. During an interview on 08/02/23, at 1:05 P.M., the Housekeeping Supervisor said the following: -He/she would go to the charge nurse immediately if they saw or heard about this; -An allegation of someone hitting at a resident would require a report to the state; -The facility must report all allegations of abuse within two hours. During an interview on 08/02/23, at 1:15 P.M., CNA E said the following: -If he/she were to have a resident say they were hit, he/she would first help the resident to make sure they are okay and then go directly to the charge nurse; -They would then go to the DON and that must be reported to the state within two hours; -Any abuse allegation must be reported to state. During an interview on 08/02/23, at 2:45 P.M., the DON said the following: -Someone saying that someone else hurt them and not knowing any other information is definitely enough to make a report; -He/she did not see LPN A's note until 5:00 P.M., when someone else saw it and brought it to his/her attention. MO00222366

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to report an allegation of abuse to the state survey agency (Department of Health and Senior Services - DHSS) when one resident (Resident #71) stated that Nurse Aide (NA H) and one resident (Resident #49) were having an affair. The facility census was 83. Record review of the facility's Abuse Prevention Policy, dated 11/28/16, showed the following information: -Immediately educate all staff to report to the administrator and/or designees any alleged (all allegations) violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; -The administrator or designee must report to the state survey agency no later than two hours after the allegation is made if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury; -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 1. Record review of Resident #71's face sheet showed the following: -admitted on [DATE] and readmitted on [DATE] ; -Diagnoses included schizoaffective disorder (mental illness that can affect your thoughts, mood and behavior), major depressive disorder, and anxiety disorder. Record review of the resident's quarterly MDS, dated [DATE] , showed the following: -Cognitively intact; -Physical behavior toward others (hitting, kicking, pushing) marked as occurred one to three days; -Verbal behavior toward others occurred one to three days; -Extensive assistance of two person required with bed mobility, transfer, dressing and personal hygiene. Record review of the resident's progress note, dated 6/26/21, showed Licensed Practical Nurse (LPN) I documented the following: -On 6/26/21, at 6:46 P.M., the Resident #71 was observed holding the door at the end of the 200 hall and refused to move to let Resident #49 in the facility. Resident #49 remained in the smoking area until Resident #71 was removed from the hall. Resident #71 told staff and another resident that Resident #49 and NA H were having an affair and he/she seen it last night with his/her own eyes. LPN I notified by an aide that the resident stated NA H was at the facility at 10:00 A.M. drunk. NA H did not arrive to the facility until 2:00 P.M. for his/her shift. NA H has not communicated or worked with the resident this shift. LPN I notified the Director of Nursing (DON) of the situation. Record review of DHSS records showed the facility did not report an allegation of abuse involving NA H and Resident #49. During an interview on 7/20/21, at 12:56 P.M., Certified Nurse Aide (CNA) E said the following: -Types of abuse include physical and verbal; -Staff should report immediately to the charge nurse if abuse is observed or reported; -Staff should notify the state within two hours with an allegation of abuse; -Resident #71 told him/her of a secret that NA H and Resident #49 were having an affair and NA H took Resident #49 home every night (thought was about two months ago). During an interview on 7/20/21, at 1:10 P.M., LPN J said the following: -Types of abuse include sexual, verbal, physical and mental; -Staff should contact the DON immediately with an allegation of abuse. The DON informs staff what to do after the situation is reported; -Staff should report to the state within two hours with an allegation of abuse; -Resident #71 said NA H and Resident #49 were having an affair. He/she does not remember when the allegation was stated; -He/she reported the allegation of abuse to the DON. He/she does not remember the timeframe; -He/she heard the allegation one time of NA H and Resident #49 having an affair. Resident #49 told him/her of the rumor that he/she and NA H were having an affair; -He/she said this is an allegation of abuse; -He/she did not ask Resident #71 what he/she meant by affair. During an interview on 7/20/21, at 1:56 P.M., Certified Medication Technician (CMT L) said the following -Types of abuse include physical, mental, and isolation; -Staff should immediately report to the charge nurse of an allegation of abuse; -Staff should report to the state an allegation of abuse within two hours; -Staff should report to the DON immediately if a resident states a staff member and resident are having an affair. During an interview on 7/20/21, at 2:03 P.M., Registered Nurse (RN) M said the following: -Types of abuse include physical, emotional, sexual and financial; -Staff should report an allegation of abuse to the administrator immediately. Staff should notify the state within two hours with an allegation of abuse; -Staff should report to the administrator immediately if a resident stated a staff member and a resident are having a relationship; -He/she was not aware of the nurse's note, dated 6/26/21, regarding Resident #71 stating Resident #49 and NA H having an affair. During a phone interview on 7/20/21, at 2:21 P.M., LPN I said the following: -Types of abuse include physical and mental; -Staff should report an allegation of abuse immediately to the administrator and to the state within two hours; -He/she reported the allegation of abuse to the DON; -He/she did not think this was considered an allegation of abuse. During an interview on 7/20/21, at 2:35 P.M., the DON said the following: -Types of abuse include financial, physical, emotional, verbal and sexual; -Staff should immediately notify her and the administrator with an allegation of abuse. The charge nurse should initiate the investigation; -The administrator should investigate and obtain statements from those involved; -Staff should notify the state within two hours with an allegation of abuse; -On 6/27/21, at 10:30 A.M., NA H informed her Resident #71 accused him/her and Resident #49 of inappropriate behavior; -NA H stated Resident #71 had screamed this allegation on 6/26/21 when he/she worked his shift; -LPN I moved him/her to work on the 300 hall because NA H was upset about the allegation. NA H typically works the 200 hall; -LPN I had texted her the previous night regarding the situation; -DON talked with NA H and Resident #49 on 6/27/21 who both denied the allegation; -She did not notify DHSS with the allegation of abuse due to NA H and Resident #49 were upset, denied the allegation and there was nothing else to investigate. She talked with staff and residents who had no concerns; -She did not talk with Resident #71 about the allegation due to the resident was upset and angry. She should have talked with Resident #71. During an interview on 7/20/21, at 3:11 P.M., the administrator said the following: -Types of abuse include physical, verbal and sexual; -Staff should report to him or the DON immediately with an allegation of abuse. The state should be notified of an allegation of abuse within two hours; -Staff should notify him immediately if a resident states a staff member is having an affair with a resident; -He was on vacation and was unaware of the allegation made by Resident #71 on 6/26/21. He expects staff to report an allegation of abuse to the DON if he is on vacation; -He would consider an allegation of abuse if a resident said a staff member and a resident were having an affair. He would have reported the allegation of abuse to the state if he had been in the facility. During a phone interview on 7/23/21, at 12:18 P.M., NA H said the following: -Types of abuse include physical, mental and talking down to resident; -He/she would immediately report an allegation of abuse to the charge nurse. State should be notified within two hours; -LPN I contacted the DON with the allegation of abuse. He/she worked the rest of the shift on the 300 hall; -He/she spoke with the DON the next morning due to he/she did not want it to get out of hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the cleanliness of resident oxygen nasal cannula tubing and failed to ensure the oxygen humidification bottle contained water for one resident (Resident #1). The facility census was 83. Record review of the Journal of Respiratory Care, Volume 58, Issue 8, article titled, Humidification of Inspired Oxygen, dated August 2013, showed the following information: -Exposure to dry and undiluted oxygen may cause mucosal dryness and irritation; -Chronic exposure may cause local inflammation, bleeding of the mucosa, and possibly nasal-septal perforation; -Oxygen therapy is usually combined with a humidification device, to prevent mucosal dryness; -Because oxygen concentrator tanks deliver absolutely dry oxygen, humidification is recommended by some; -If humidification is used, the most widespread system is the bubble through humidifier. Record review of the facility policy titled, Cleaning Guidelines Oxygen Equipment, (undated), showed the following: -The oxygen equipment will be cleaned to ensure safety in handling and administering oxygen; -Disposable oxygen equipment will be discarded after each resident use; -If using non-pre-filled humidifiers, use the following guidelines; -Minimum standards include changing humidified water, rinsing the humidifier and replacing the humidifier water; -Humidifiers must be emptied and refilled every 24 hours with distilled water; -Humidifiers are to be dated, initialed, replaced monthly, and as needed (PRN); -Pre-filled humidifier bottles will be discarded when empty; -Concentrators and connectors after each resident use; -Tubing, masks, and nasal cannulas used with oxygen therapy should be replaced monthly and PRN, and marked with date and initials. 1. Record review of Resident #1's face sheet showed: -re-admitted to the facility on [DATE] from the hospital; -Diagnoses included chronic obstructive pulmonary disease (COPD - a type of obstructive lung disease characterized by long-term respiratory problems and airflow limitation) and Alzheimer's disease. Record review of the resident's care plan, revised on 7/13/21, showed the following: -Required oxygen therapy, related to COPD diagnosis; -The resident will not exhibit signs of hypoxia (inadequate oxygen supply); -Break tasks into manageable sub-tasks. Encourage frequent rest periods; -Explain the importance of keeping oxygen at the prescribed setting. Stress more oxygen may not be better; -Monitor and report signs of hypoxia. Record review of the resident's physician order sheets, dated 6/26/21 through 7/26/21, showed the following: -A physician's order, dated 3/29/21, for oxygen at 2 liters per minute per nasal cannula as needed for shortness of breath; -A physician's order to change oxygen tubing monthly on the first of the month. Record review of the treatment administration record, dated 7/1/21 through 7/26/21, showed the following order: -Change oxygen tubing monthly; -A nurse signed completion of the task on 7/1/21. Observation on 7/19/21, at 11:45 A.M., showed the following: -The resident in the bed without oxygen; -The resident's (undated) nasal cannula oxygen tubing was on the floor next to the resident's bed. The nose piece contained a brown substance; -The oxygen tubing was connected to an empty (undated) humidifier bottle attached to the front of an oxygen concentrator; -The oxygen concentrator was operating. Observation and interview of the resident on 7/21/21, at 4:19 P.M., showed the following: -The resident's oxygen concentrator machine operated at 2 liters/minute; -The resident said his/her nose was dry; -The resident motioned to the (undated) oxygen tubing, and to the nose piece which contained a brown substance, and said, I need a new one, I guess, it is getting hard. -The (undated) humidifier bottle remained empty. During an interview on 7/22/21, at 10:33 A.M., Certified Nurse Aide (CNA) C said the following: -The resident pulled his/her oxygen tubing off at times, but the resident is supposed to wear the oxygen at all times. Observation on 7/22/21, at 10:40 A.M., showed the following: -The resident in the bed with oxygen on via (undated) nasal cannula tubing running from the oxygen concentrator through an empty (undated) humidifier bottle attached to the front of the concentrator. During an interview on 7/26/21, at 10:39 A.M., CNA E said the following: -He/she works full-time at the facility;. -He/she checks the resident's oxygen humidifier bottle every day he/she works and when the bottle runs out of water, he/she replaces it with a new bottle. Observation on 7/26/21, at 10:50 A.M., showed the following: -The resident in his/her bed with a sheet over his/her head; -The resident's (undated) oxygen tubing ran under his/her sheet in the direction of the resident's head; -The oxygen concentrator was operating and the oxygen tubing was connected to an empty (undated) humidifier bottle attached to the front of the concentrator. During an interview on 7/26/21, at 10:52 A.M., Licensed Practical Nurse (LPN) D said: -The resident is on oxygen via an oxygen concentrator; -The night nurse is supposed to change the oxygen tubing one time per month on the first of the month and as needed; -Any nursing staff can replace an empty humidifier bottle on any shift, when needed. During an interview on 7/26/21, at 1:16 P.M., with the administrator and Director of Nursing (DON), the DON said the following: -Residents with oxygen have physician orders for replacing the nasal cannula oxygen tubing one time monthly and as needed; -Staff should change out the oxygen tubing if it becomes discolored; -The oxygen humidifier bottles usually last approximately 10 days depending on use; -The DON said she expected staff to keep water in the residents' oxygen humidifiers at all times, otherwise the oxygen would dry out a resident's nose and cause nose bleeds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physicians' orders for bed rails and failed to complete bed rail assessments and measurements to check for risk of entrapment for two residents (Resident #180 and Resident #181). The facility census was 83. Record review of the facility's policy titled, Physical Restraints, undated, showed the following: -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body; -Determine the type of side rails to be used; -Determine the medical symptoms to be treated with side rails; -Involve the resident and the resident's representative in planning for side rail use. Many residents request to have side rails up when in bed to improve bed mobility and provide a feeling of safety 1. Record review of Resident #180's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included mild cognitive impairment and muscle weakness. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 7/20/21, showed the following: -Severely impaired cognition; -Extensive staff assistance required for bed mobility, transfer, dressing and toilet use; -Bed rails not used. Record review of the resident's care plan, dated 4/23/21, showed the following: -The resident had self care deficits with activities of daily living (ADLs), such as bathing, hygiene, dressing and toileting, related to functional and cognitive deficits; -The resident may use top short side rails as desired for bed mobility, grab bar for aid with transfers, and to steady self with sitting at bedside; -The resident is at risk for falling related to poor safety awareness, need for assistance with transfers and history of falls at home; -The resident has difficulty in making decisions for daily task of life related to confusion and cognitive deficits. Observation on 7/21/21, at 1:54 P.M., showed the resident in bed with the half side rail up on the right side of the bed. Observation on 7/22/21, at 11:47 A.M., showed the resident in bed with the back of the bed against the wall and a half bed rail in the up position on the right side of the bed. Record review of the resident's July 2021 physician's order sheet (POS) showed no physician order for bed rails. Record review of the resident's medical record showed staff failed to document ongoing assessments or inspections of the bed frame and rails to ensure the bed rails were appropriate for use. During an interview on 7/22/21 11:56 A.M., Certified Nurse Aide (CNA) K said the following: -The resident sits up on the side of the bed to transfer and holds onto the side rail to not lean from side to side; -The resident is alert and oriented to use the bed rail and does not crawl out of bed. During an observation and interview on 7/26/21, at 12:49 P.M., the MDS coordinator said the following: -The resident uses the bed rail for bed mobility; -The resident is able to get up on his/her own and move in bed; -A half side rail is on the right side of the resident's bed. During interviews on 7/22/21, at 2:08 P.M., and on 7/26/21, at 1:13 P.M., the Director of Nursing (DON) said the side rail assessment had not been completed for the resident prior to 7/22/21. During interviews on 7/26/21, at 1:13 P.M. and 4:00 P.M., the administrator said there was not a physician order for a bed rail for the resident. 2. Record review of Resident #181's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included repeated falls and reduced mobility. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Extensive assistance required with bed mobility, transfer, dressing and toilet use; -Bed rails not used. Record review of the resident's care plan, dated 4/13/21, showed the following: -The resident has self care deficits with ADL's such as bathing, hygiene, dressing and toileting related to recent heart surgery; -The resident has functional and cognitive deficits; -The resident may use top short side rails as desired for bed mobility, grab bar for aid with transfers and to steady self with sitting at bedside. Record review of the resident's July 2021 physician's order sheet (POS) showed no physician order for bed rails Record review of the resident's medical record showed staff failed to document ongoing assessments or inspections of the bed frame and rails to ensure the bed rails were appropriate for use. Observation on 7/22/21, at 11:52 A.M., showed the resident sitting up on the side of the bed. The side rail was up on the right side of the bed. During an observation and interview on 7/26/21, at 12:49 P.M., the MDS coordinator said there is a half side rail on the right side of the resident's bed. During an interview on 7/22/21 at 2:08 P.M. and 7/26/21 at 1:13 P.M., the DON said the side rail assessment had not been completed for the resident until 07/21/21. Observation on 7/26/21, at 3:23 P.M., showed the resident in bed. The side rail was up on the right side of the bed. The head of the mattress was down 8 to 10 inches from the head of the bed frame with two pillows underneath the mattress at the head of the bed. From the top of the mattress to the headboard an approximate 10 to 12 inch gap. During an observation and interview on 7/26/21, at 3:33 P.M., the administrator said the resident's mattress did not fit the bed frame. During interviews on 7/26/21, at 1:13 P.M. and 4:00 P.M., the administrator said there were no physician orders for the bed rails for the resident. 3. During an interview on 7/22/21, at 11:56 A.M., CNA K said the following: -Side rails can be used if a resident has weakness on one side, needs assistance with transfer, and as an aid to sit up; -Therapy department does the side rail evaluation; -Maintenance department installs the side rails. 4. During an interview on 7/22/21, at 1:37 P.M., CNA G said the following: -Nursing staff inform staff of the residents who have side rails; -Nurses are in charge of side rails assessments; -He/she is unaware of the process to have a side rail installed on a resident's bed. 5. During an interview on 7/23/21, at 9:38 A.M., Licensed Practical Nurse (LPN) Y said the following: -The DON and nurses complete the side rail assessment; -He/she has never completed the side rail assessment; -Side rail assessments are completed to determine if they are helpful, necessary or restraints; -Side rail assessments include gaps looked at and measurements; -Side rails are put on by maintenance; -Bed rails are helpful for residents to sit up or steady self on side of the bed. 6. During an interview on 7/23/21, at 1:08 P.M., the Maintenance Supervisor said the following: -He installs the bed rails when requested; -He does not complete the measurements for entrapment or bed dimensions for size or weight of the residents; -He does check for gaps when he installs a bed rail; -He does not have set schedule for monitoring the bed rails. Staff give him a work order if there is a broken or loose bed rail. 7. During an interview on 7/26/21, at 12:49 P.M., the MDS coordinator said the following: -Side rail assessments determine bed mobility, if it is a restraint or if it is used to sit up; -The former DON completed the side rail assessments. He/she is not sure who is completing the side rails assessments at this time; -Maintenance staff probably install the bed rails; -He/she is unsure how often the bed rails are checked for gaps and measurements; -Bed rails should be on care plan and marked in the MDS assessment; -He/she should discuss the use and hazards of the bed rail with the residents. He/she would assess if the resident uses the side rail for mobility; -He/she would communicate with the DON if a resident needed a side rail. 8. During interviews on 7/22/21, at 2:08 P.M., and on 7/26/21, at 1:13 P.M., the DON said the following: -The therapy staff screen the resident if there is a recommendation of a bed rail; -The majority of the beds have the quarter size bed rail and she is not sure if half size bed rails are in the facility; -The maintenance staff install the bed rails if requested; -The former DON used to monitor the measurements on each bed with side rails. The former DON left at the end of February 2021 and she is not sure if the bed rails have been monitored since she left; -The quality assurance (QA) nurse said side rails assessments should be completed on admission, readmission or a significant change. The QA nurse also wants the side rails assessments completed at MDS assessments or at care plan updates; -She has not been completing the assessments for the bed rails. 9. During an interview on 7/26/21, at 2:48 P.M., the physical therapist said nursing staff normally assess for the use of side rails for the residents. He/she does not do anything with the side rail assessments or procedures. 10. During interviews on 7/26/21, at 1:13 P.M. and 4:00 P.M., the administrator said side rail evaluations should be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain proper infection control practices based on facility policy and acceptable standards of practice when multiple staff did not properly wear face coverings while assisting/conversing with seven residents (Resident #2, #3, #9, #16, #28, #48 and #70) during a coronavirus disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) pandemic. The facility census was 83. Review of the updated guidance for healthcare workers from Centers for Disease Control and Prevention (CDC) titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 02/23/21, showed the following: -Health Care Providers (HCP) should wear well-fitting source control at all times while they are in the healthcare facility; -Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Review of the CDC guidance for healthcare workers, titled Facemask Do's and Don'ts, dated 06/02/20, showed the following: -Do secure the bands around the ears; -Do secure the straps at the middle of the head and the base of the head; -Don't wear the facemask under the nose or mouth; -Don't wear the facemask around the neck. Review of the facility's policy titled Outbreak Management, revised on 4/28/21, showed the following: -Ensure facility staff are educated, trained, and have practiced the appropriate use of PPE (personal protective equipment) prior to caring for a resident, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment; -Employees working in the observation unit should wear an N95 facemask and eye protection (example goggles or a disposable face shield that covers the front and sides of the face) at all times when on the unit. 1. Review of Resident #2's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 7/7/21, showed the following: -admitted to the facility on [DATE]; -Diagnoses included anemia (condition marked by deficiency of red blood cells or of hemoglobin (red protein responsible for transporting oxygen in the blood), and coronary artery disease (plaque buildup in the walls of the arteries). Observation on 7/19/21 at 12:38 P.M., showed the following: -Housekeeper (HK) O entered the resident's room on the 200 hall with his/her face mask down below his/her nose; -HK O stood behind the resident, within six feet of the resident, and opened sugar from his/her dresser drawer and placed it on the resident's bedside tray; -HK O, with his/her face mask below his/her nose and one strap hanging down, took the broom and exited the resident's room. During a phone interview on 7/26/21 at 10:59 A.M., HK O said the following: -Staff should not have their masks down below the nose; -The administrator is specific about how to wear face masks properly; -The administrator and DON have showed staff how to wear the face masks appropriately. It is brought up on the 10th of every month in a staff meeting. 2. Review of Resident #70's quarterly MDS, dated [DATE], showed the following: -readmitted to the facility on [DATE]; -Diagnoses included of anemia and heart failure. Observation on 7/20/21 at 10:26 A.M., showed Licensed Practical Nurse (LPN) J talked to the resident at the nurses' desk. LPN J's mask was down below his/her nose and mouth. The resident talked on the phone which was on top of the nurses' desk. 3. Review of Resident #48's annual MDS, dated [DATE], showed the following: -readmitted to the facility on [DATE]; -Diagnoses included cerebrovascular accident (CVA - stroke). Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -readmitted to the facility on [DATE]; -Diagnoses of anxiety disorder and anemia. Observation on 7/20/21 beginning at 11:13 A.M., showed the following: -Certified Nurse Aide (CNA) E sat in a recliner in room [ROOM NUMBER] and visited with Resident #9 and Resident #48; -During this time, CNA E's mask was below his/her nose and mouth; -Both residents sat on the side of the bed and visited with the CNA; -Both residents and the CNA were within six feet of each other. During an interview on 7/20/21 at 12:56 P.M., CNA E said the following: -He/she was aware of his/her mask down earlier when he/she talked with Resident #48 and Resident #9; -Resident #48 is hard of hearing. 4. Review of Resident #16's quarterly MDS, dated [DATE], showed the following: -admitted on [DATE]; -Diagnoses included asthma (a condition in which airways narrow and swell and may produce extra mucus. This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when breathing out and shortness of breath), diabetes mellitus (DM - an impairment in the way the body regulates and uses sugar) and renal insufficiency (kidney failure). Observation on 7/21/21 at 10:12 A.M., showed LPN J stood at the nurses' desk with his/her face mask down below his/her nose and mouth. The resident requested a cigarette (within a few feet of LPN J). LPN J handed the resident a cigarette. During a phone interview on 7/26/21, at 10:47 A.M., LPN J said the following: -The facility has provided inservices on COVID; -Staff should have their face mask up on top of the nose and down below the chin; -Administrative staff monitor the staff to make sure their masks are on appropriately; -He/she was told he/she could have his/her mask down when behind the nurses' desk and if a resident is on the other side of the nurses' desk; -There had been times when he/she has had the mask down when around residents. Sometimes he/she will pull down his/her mask if a resident cannot hear him/her; -Staff should not have their mask off when around residents. 5. Review of Resident #28's annual MDS, dated [DATE], showed the following: -admitted on [DATE]; -Diagnoses included anemia, dementia, and anxiety disorder. Observation on 7/21/21 at 2:47 P.M., showed the resident stood in front of Human Resources Staff (HR) P's desk. HR P wore his/her mask on top of his/her head with his/her nose and mouth showing. The resident wore a crocheted mask. During an interview on 7/26/21 at 12:25 P.M., HR P said the following: -Staff should always have his/her mask on when around residents; -He/she did not have his/her mask on when Resident #28 was in the office; -He/she knows the resident outside of the facility and they are basically family; -The resident wears a surgical mask under his/her crocheted mask. 6. Review of Resident #3's entry MDS, dated [DATE], showed the resident admitted from the hospital on 7/21/21. Review of the resident's face sheet (admission data) showed the following: -Resident admitted on [DATE] from the hospital; -Diagnoses included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing), shortness of breath, and chronic pain. Observations on 7/22/21 showed the following: -At 9:31 A.M., HK Q entered room [ROOM NUMBER] (observation hall for residents quarantined due to new admissions or admissions from the hospital). HK Q's mask had a bottom strap hanging down with the bottom of the mask exposing the chin. He/she exited the observation unit main door to don (apply) a new gown. A CNA gave HK Q a face shield also to wear on the observation hall. (The CNA did not instruct HK Q to fix the hanging strap.) HK Q said the office had not instructed him/her to wear a face shield when on the observation unit. HK Q still had the bottom strap of his/her mask hanging down with the face mask not fitting his/her face appropriately; -At 9:45 A.M. HK Q entered Resident's #3's room on the observation hall and carried bathroom cleaning supplies; -HK Q exited the resident's room with bathroom cleaning supplies and placed them in the housekeeping cart; -HK Q entered the room again and carried a broom and dust pan. The resident sat in his/her chair while HK Q swept around the resident's room and in front of the resident within two feet of him/her; -HK Q's face mask continued to not fit appropriately for his/her face; -At 9:51 A.M., HK Q mopped the resident's floor in the middle of the room and the bathroom. The resident was observed to wear no mask; -At 9:55 A.M., HK Q exited the resident's room and observation hall and rolled the housekeeping cart out of the unit. He/she continued to have the bottom strap hanging and bottom of mask not covering his/her chin; -At 10:00 A.M., HK Q swept the floor in the dining room on the 500 hall outside of the observation hall. HK Q swept around Resident #49. HK Q's mask continued to have the bottom strap hanging down with the bottom edge of the mask not fitting close to the chin. During an interview on 7/22/21 at 12:43 P.M., HK Q said the following: -The facility had provided inservices regarding COVID; -Staff should make sure his/her mask is on at all times; -His/her mask had not been fitted. He/she had not been instructed how it is to be worn; -He/she only used one strap because the rubber band breaks him/her out. He/she had not reported this to administration; -His/her mask is fitted up around his/her nose, but not around his/her chin. 7. During an interview on 7/22/21 at 12:46 P.M., HK R said the following: -The facility has provided inservices regarding COVID and appropriate ways to wear masks; -He/she occasionally will take his/her mask down to talk to a resident who may be hard of hearing, but steps back at least six feet. During an interview on 7/22/21 at 1:37 P.M., CNA G said the following: -The facility provided inservices on wearing PPE appropriately once per month; -Administration and nursing staff monitor staff are wearing masks appropriately; -Staff should only have masks off when they are outside on a break. During an interview on 7/22/21 at 1:54 P.M., Registered Nurse (RN) S said the following: -Staff should make sure both straps are up on his/her face mask; -Staff should not remove his/her mask when talking with a resident; -Staff should not pull down his/her mask if a resident is hard of hearing During an interview on 7/26/21 at 12:11 P.M., the medical director said staff should wear their masks at all times. Staff should not wear their masks down when around residents. During an interview on 7/26/21 at 1:13 P.M., the Director of Nursing (DON) said the following: -Staff should wear facemasks covering the mouth and nose and secured by two straps; -Staff should not talk to a resident with their mask down; -Staff should follow CDC guidance for wearing face masks appropriately. During an interview on 7/26/21, at 1:13 P.M., the administrator said the following: -Staff should wear face masks covering the mouth and nose and secured by two straps; -Staff should not talk to a resident with their mask down; -Staff should follow CDC guidance for wearing face masks appropriately; -Staff should have both straps on to ensure fully secured; -If he sees staff wear masks inappropriately, he instructs them to put mask back on appropriately.

Based on observation, interview, and record review, the facility failed to ensure the floors throughout the kitchen were kept clean and free from debris. The facility census was 83. Record review of Cleaning Schedules, dated April 2011, showed the following: -It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posed in the Dietary Department; -It will specify the days the cleaning schedule will be done, specify who is responsible to do the cleaning by shift and positions; -Post the schedule prior to the beginning of each week and the employee will initial in the column under the day the task is completed; -The purpose to develop detailed cleaning schedules is to ensure sanitation is at acceptable standards. Record review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Non food-contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, or other debris. 1. Observation on 7/19/21, at 11:20 A.M., of the kitchen showed shells and white crumbling looking substance on the floor by the back right leg of the flat grill. Observation on 7/20/21, at 9:37 A.M., of the kitchen showed white crumbling looking substance by the back leg of the flat grill and flies on the white substance. Observation on 7/21/21, at 10:18 A.M., of the kitchen showed white crumbling looking substance by the back leg of the flat grill and brown grime on the floor around the leg. Observation on 7/22/21, at 9:13 A.M., of the kitchen showed white and black crumbling looking substance by the back leg of the flat grill and brown grimy substance. Record review of Daily Cleaning Schedule sheets, dated April 2011, showed there was not a date provided that showed the kitchen floors had been swept and mop or the ceiling cleaned. The monthly cleaning schedule showed the baseboards was clean in the third week of March 2021. During an interview on 7/22/21, at 9:48 A.M., Dietary Aid (DA) A said there is a daily cleaning person, who will work 7:00 A.M. to 3:00 P.M. The cleaning person will help with dishes, sweep and mop, take the trash out and will supervise the residents who smoke. Staff is supposed to clean then initial the cleaning sheet. If cooks have free time, they will clean. The daily cleaning person does the daily cleaning, but the monthly cleaning sheet is initialed by whoever has time to clean. If the sheets are not initialed, it could mean it didn't get cleaned or somebody forgot to initial the sheets. If it is dirty, the cleaner will clean it. Sweeping and mopping gets done during the day or gets done after each meal. During an interview on 7/22/21, at 10:14 A.M., DA B said everybody is supposed to clean. There is a daily, weekly and monthly cleaning sheet and staff is supposed to initial what they clean. If the sheets are not initialed it could be because they are outdated, or staff forget to date them. Dietary Manager is supposed to check to make sure things are being done. The night staff usually clean the kitchen. During an interview on 7/22/21, at 10:45 A.M., the Dietary Manger (DM) said there is not a daily cleaner at this point, maybe two to three days a week. Everybody is responsible for daily cleaning; the daily cleaner is helping with washing dishes. Staff needs to clean and fill out the cleaning log sheets. She knows daily cleaning is not being done and she needs to follow up on it. If it isn't initialed, it probably isn't being done. The Registered Dietician (RD) does a walk through when she first gets here, she is a double checker. She will bring up things to DM if it needs to be clean. The floors are cleaned three times a day and is done at the end of the day. DM said the staff need to use a deck brush on the floor. During a phone interview on 7/22/21, at 11:59 A.M., the Registered Dietician (RD) said the daily cleaning sheets are posted and they should clean and initial what they clean. Staff is not filling them out as they should be. RD said she completes a walk through and is dealing with cleanliness, but she is only there two days a month. The RD said the floors are bad. During an interview on 7/22/21, at 1:00 P.M., the Administrator said his expectation on cleanliness is to maintain a kitchen free of bacteria agents, mold, and mildew. He does try to do a walk through at least once a week of the kitchen, but it has been three or four weeks since he completed a walk through. He expects the RD to make recommendations on the kitchen cleanliness and forward the report. He does expect the weekly and monthly to completed and filled out. The cleaning sheets should be handed into DM. If the sheets are not initialed, things are not being done.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in resident rooms on the 300 hall including rooms of six residents (Resident #11, #20, #40, #55, #56, and #57). The facility census was 83. Record review of the facility's policy Pest Control, undated, showed the following: -Purpose to provide an environment free of pests; -The facility will have a pest control contract which provides frequency treatment of the environment for pests. It will allow for additional visits when a problem is detected; -Monitoring the environment will be done by the facility's staff; -Pest control problems will be reported promptly. 1. Record review of the facility's completed maintenance work orders for April 2021 to July 23, 2021, showed no mention of flies in the facility. Record review of the pest control company's proof of service, dated 6/11/21, showed: -Inspected throughout all areas of the facility and found no pest concerns; -Sites inspected included kitchen, dining room, and exterior of building with no pest activity found in any of these areas (did not document inspection of resident rooms); -Serviced all insect light traps (ILT) and found bulbs needing replaced in all traps; -Treatment made to exterior of facility for aid in the control of spiders. Record review of the pest control company's proof of service, dated 6/14/21, showed: -Service completed along with main service on 6/11/21; -Commercial flying insect trap (ILT) maintenance service. Record review of the pest control company's proof of service, dated 7/9/21, showed: -Inspected the ILT fly lights and inspected and treated the exterior and treated the interior for fly prevention; -Materials (chemicals) used to treat exterior of building for occasional invaders and kitchen for house flies; -Sites inspected included kitchen, dining room, and exterior of building with no pest activity found in any of these areas (did not document inspection of resident rooms). Observation and interview on 7/19/21, at 11:30 A.M., showed the following: -Resident #40 in the bed while three flies buzzed the resident's face; -The resident said the facility is over run with flies. Observation and interview on 7/19/21, at 11:37 A.M., showed the following: -Resident #11 said the flies in his/her room are terrible. The flies buzz around his/her head; -The resident sat on the side of his/her bed with a fly on the resident's pillow on the head of his/her bed; -The resident said the flies bother him/her when she is in bed. Observation and interview on 7/19/21, at 11:38 A.M., showed the following: -Roommates Resident #56 and #20 sat in wheelchairs in their room; -Resident #56 had three flies on his/her bed; -Resident #20 said the flies have been bad in the facility for approximately the last month. There are flies in their room as well as the dining room. Observation and interview on 7/19/21, at 12:07 P.M., showed the following: -Resident #57 sat in a wheelchair in his/her room; -Flies buzzed the resident's face, ears, and head, and were crawling on the resident's face, pants, and bare feet; -Resident's pants were visibly wet and the resident said, he/she had incontinence and that attracted the flies. -The resident had approximately six flies on him/her during this time. Observation and interview on 7/19/21, at 2:04 P.M., showed the following: -Resident #55 in the bed; -The resident said the flies bother him/her all day and all night; -Flies buzzed the resident's face. Two flies crawled on the resident's pant legs and two crawled on the resident's shirt; -The resident attempted to swat at the flies with his/her hands. Observation and interview on 7/20/21, at 1:45 P.M., showed the following: -Resident #55 was laying on the bed, the resident's sweat pants were visibly wet in the groin area. -Flies buzzed the resident's groin area and face; -The resident waved his/her hands back and forth at the flies; -The resident said, The flies are still bad. Observation and interview on 7/21/21, at 4:14 P.M., showed the following: -Resident #57 in his/her bed with an open soda can and another cup with a straw on a over bed table next to the resident's bed; -Flies buzzed the resident's cups and landed on top of the cup and straw; -The resident's open laundry basket sat on the floor just inside the open door to the resident's room containing dirty laundry. Flies buzzed the basket of clothes; -The resident stated, Oh my God, the flies are driving me crazy. The resident said the flies had been bad in the facility for approximately two weeks. During an interview on 7/21/21, at 3:27 P.M., Certified Nurse Aide (CNA) F said the following: -He/she worked full time, evening and overnight shifts; -The facility has flies everywhere, in the resident rooms and in the dining room; -The residents complain about the flies; -The flies have been bad for approximately one and one-half to two weeks.; -He/she complained to several of the nurses and housekeepers about the flies; -He/she does not think the facility has done anything to get rid of the flies. Record review of the pest control company's proof of service, dated 7/23/21, showed: -Inspected exterior of building around the employee smoking areas and dumpsters with no activity found; -Inspected and performed a follow up treatment in the kitchen with no activity found; -Materials (fly spot bait) used to treat exterior of building around dumpsters and employee smoking area and to kitchen to target house flies. (The service did not address possibly concerns in resident rooms.) During an interview on 7/23/21, at 1:08 P.M., the Maintenance Director said the following: -If he sees pests or flies in the facility, he contacts the pest control company; -The pest control company comes to the facility one time per month to spray the outside of the building for pests; -The facility requested an extra visit from the pest control this month (July 2021) due to the abundance of flies; -The pest control company should be coming to the facility in the next couple of days to bait for flies in the kitchen; -Granulated fly bait can be used (thrown on the ground outside) and will kill the flies, these granules are used outside the kitchen door and at the outdoor employee smoking areas only, because the granules are toxic; -These granules are not used at the resident smoking area; -Inside the facility, the pest control company is not allowed to spray chemicals around the residents' rooms; -He implemented more fly swatters and insect lights by the kitchen due to the increased number of flies; -The flies are coming in from the outside smoke areas and the kitchen door during deliveries, and from staff come in for COVID screening near the time clock, -Some of the residents complained about the flies and staff distributed fly swatters to some of those residents. During an interview on 7/26/21, at 10:39 A.M., CNA E said the following: -The flies are not too terrible as long as staff do not leave the doors wide open letting the residents who smoke in and out of the facility; The flies also enter the facility when dietary staff prop the outside kitchen door open while taking trash out; -The resident's complain about the flies; -When the residents complain about the flies, the CNA tries to tell maintenance staff and ensure trash bins are empty in the resident rooms. During an interview on 7/26/21, at 10:52 A.M., Licensed Practical Nurse (LPN) D said the following: -He/she worked full-time on the day shift; -There are flies in the resident rooms; -The flies are an issue all summer; -The nurse said he/she has mentioned the issue to maintenance and they tell the nurse the flies are coming in through the door used to for residents to exit the building to smoke cigarettes; -The doors have to be held open for a little while because there are approximately 10 residents that smoke and staff hold the doors open for all the residents to exit and re-enter the facility. During an interview on 7/26/21, at 11:03 A.M., CNA G said the following: -The facility has an issue with flies; -The residents are complaining about the flies; -The fly problem has been ongoing for approximately one month; -The staff try to get more fly swatters for the residents from the Activity Director; -The CNA spoke to the maintenance director about the problem; -The CNA thinks the flies are coming in to the building due to higher outside temperatures and higher humidity this summer; -The CNA said the flies enter the facility when staff, residents, or visitors open outside doors. During an interview on 7/26/21, at 12:26 P.M., the Activity Director said the following: -When a resident complained about the flies and asked for a fly swatter, he/she gave the resident a fly swatter; -The flies are a problem some days in the facility; -If staff or residents leave the outside doors open, then the flies are worse in the facility. During an interview on 7/26/21, at 1:15 P.M., the administrator said the following: -The pest control company visits the facility every week, but the flies are horrible this year; -The pest control company re-baited for flies on Friday, 7/23/21; -The administrator said he did not know staff were propping doors open to allow for delivery of food and supplies, or for removal of trash; -The facility has a fly catching light near those areas; -The facility has a total of 10 residents who go outside for 7 scheduled smoke breaks in every 24 hour period and staff holds the door open to allow the residents to go in and out of the facility during those times; -The residents have not complained to him or the Director of Nursing (DON) about the flies; -He did not notice flies in the facility until the past week; -On approximately 07/13 or 07/14, he told maintenance to have the pest control company come to the facility to treat for flies, and the administrator said he believed the pest control company started baiting for flies at that time; -The administrator said facility staff and residents should notify the administrator or the DON, if there are flies in the facility.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean manner when staff failed to keep the handsink clean, failed to keep walls in the dishwashing area clean, failed to keep shelves in the walk-in cooler clean, failed to keep an air vent clean, and failed to keep flies to a minimum. The facility census was 83. Record review of Cleaning Schedules, dated April 2011, showed the following: -It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posed in the Dietary Department; -It will specify the days the cleaning schedule will be done, specify who is responsible to do the cleaning by shift and positions; -Post the schedule prior to the beginning of each week and the employee will initial in the column under the day the task is completed; -The purpose to develop detailed cleaning schedules is to ensure sanitation is at acceptable standards. Record review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Food contact surfaces and utensils shall be clean to the sight and touch. 1. Observation on 7/19/21, at 11:20 A.M., of the kitchen showed the hand washing sink had black substance all around the front and back of the bottom of the faucet and there was brown grimy substance stuck on the bottom and the sides of the sink. Observation on 7/20/21, at 9:37 A.M., of the kitchen showed the hand-washing sink had black substance all around the front and back of the bottom of the faucet and there was brown grimy substance stuck on the bottom and the sides of the sink. Record review of Daily Cleaning Schedule sheets, dated April 2011, showed the last time a staff initialed cleaning of the hand sink was 2/19/21. During an interview on 7/22/21, at 9:48 A.M., Dietary Aide (DA) A said the hand sink was not clean on Monday, but it was done Tuesday (7/20/21). During an interview on 7/22/21, at 10:14 A.M., DA B said he/she cleaned the hand sink to get the buildup off it. He/she did not know what the black or brown substance was on the sink. He/she had cleaned the hand sink Sunday night. During an interview on 7/22/21, at 10:45 A.M., the Dietary Manger (DM) said the hand sink should be cleaned weekly. During a phone interview on 7/22/21, at 11:59 A.M., the Registered Dietician (RD) said the hand sink didn't look clean. 2. Observation on 7/19/21, at 11:20 A.M., of the kitchen showed the wall in the dishwasher area had brown and black substance on the walls and black substance that went across the wall where the sink and wall met. Observation on 7/20/21, at 9:37 A.M., of the kitchen showed the wall in the dishwasher area had brown and black substance on the walls and black substance that went across the wall where the sink and wall met. Observation on 7/21/21, at 10:18 A.M.,of the kitchen showed the wall in the dishwasher area had brown and black substance on the walls and black substance that went across the wall where the sink and wall met. Observation on 7/22/21, at 9:13 A.M., of the kitchen showed the wall in the dishwasher area had brown and black substance on the walls and black substance that ran across the wall where the sink and wall met. During an interview on 7/22/21, at 9:48 A.M., DA A said the dishwashing area should be cleaned on a daily basis; the wall had just been replaced. Everybody is responsible for cleaning that area. The dishwashing area is not clean, but he/she hadn't noticed the black substance in the dishwashing area. During an interview on 7/22/21, at 10:14 A.M., DA B said the dishwasher area gets clean daily at the end of the shift, two times a day. He/she doesn't pay attention how clean that area is. During an interview on 7/22/21, at 10:45 A.M., the DM said the dishwasher area should be cleaned weekly. 3. Record review of the Refrigerator and Freezer guideline, dated April 2021, showed the following: -Refrigerator and freezer should be cleaned per cleaning scheduled; -Spills should be wiped up immediately; -Shelves and walls should be washed with warm water and a detergent; -Sanitize refrigerators and freezers with a sanitizing solution after each washing; -Floors in the walk-ins should be swept and mopped weekly and as needed. Observation on 7/20/21, at 9:37 A.M., showed wire shelves in the walk-in refrigerator had a black substance on the shelves and some areas had black and dark green furry substance on the wire shelves. There was cheese product sitting on the wire shelves where some of the furry black and dark green substance was located. Observation on 7/20/21, at 11:35 A.M., showed shelves in the walk-in refrigerator had black substance on the shelves and some area had black and dark green furry substance on the shelves. Food product sat on the shelves. Observation on 7/21/21, at 10:22 A.M., showed shelves in the walk-in refrigerator had black substance on the shelves and some area had black and dark green substance on the shelves. Food product sat on the shelves. Record review of Daily Cleaning Schedule sheets, dated April 2011, showed the last time a staff initialed cleaning of the refrigerator was 2/19/21. During an interview on 7/22/21, at 9:48 A.M., DA A said the walk-in refrigerator was cleaned a month ago and he/she hadn't noticed the black substance on the wire shelves. The walk-in refrigerator does need to be cleaned. During an interview on 7/22/21, at 10:14 A.M., DA B said the walk-in refrigerator should be cleaned monthly and it is arranged with the maintenance supervisor. He/she could not say when the walk-in refrigerator was cleaned last time, but the racks were cleaned two months ago. He/she hasn't seen the black furry stuff on the walk-in shelves. If he/she saw it, he/she would clean it immediately. During an interview on 7/22/21, at 10:45 A.M., the DM the wire shelves and walls are cleaned every six months in the walk-in refrigerator. The last time it was done was in January and it is due for another cleaning. 4. Observation on 7/20/21, at 9:37 A.M., of the kitchen showed the air exchange vent, sprinkler head and ceiling over a serving table and two feet away from serving steam table had black lint substance on them. The substance could drop on the serving area or on the steam table and into food. Observation on 7/21/21, at 10:18 A.M., of the kitchen showed the ceiling, sprinkler head and air exchange vent had a black lint substance on them. Observation on 7/22/21, at 9:13 A.M., of the kitchen showed the ceiling, sprinkler head and air exchange vent had a black lint substance on them. During an interview on 7/22/21, at 10:14 A.M., DA B said the air exchanged vent in the kitchen is cleaned by the maintenance. During an interview on 7/22/21, at 10:45 A.M., the DM said maintenance should be cleaning the vent in the ceiling. The DM did not know when the last time the vent was cleaned. During an interview on 7/23/21, at 9:14 A.M., the Maintenance Staff (MS) N said maintenance is responsible for cleaning the air exchange vent in the kitchen every six months. The vent was cleaned a couple of months ago. The kitchen supervisor will ask maintenance to clean the vent. 5. Record review of the pest control company invoice, dated 6/11/21, showed a service was completed and three insect light traps had no activity. A treatment note showed that all insect light traps were serviced and found the bulbs needed replaced in all three traps. Record review of the pest control company invoice, dated 7/9/21, showed the service was completed and three insect light trap had no activity. One insect light trap was unserviceable. A treatment note showed the interior was treated for fly prevention. Observation on 7/19/21, at 11:20 A.M., of the kitchen showed two flies in the dishwasher area flying around the area. Observation on 7/20/21, at 9:37 A.M., of the kitchen showed a fly on the table by the coffee urn and a fly flying around the kitchen area. There was a fly flying around the walk-in refrigerator by the back door. There were four flies on the stainless steel table by the serving line where staff serve drinks for the meals. Observation on 7/21/21, at 9:33 A.M., of the kitchen showed a fly sitting on the rack where toast rest comes out after cooking. There was one fly flying around the kitchen and two flies landed on the wall where there was brown grimy substance that had dried on the wall. Observation on 7/21/21, at 11:50 A.M., during serve out, showed a fly landed on the table that had drinks for lunch on it. A fly landed on a plate lid and the lid was used to cover the next plate served out to the residents. There were three flies flying around the serve out steam table. Observation on 7/22/21, at 9:31 A.M., showed the back door to the kitchen was propped open to allow the delivery man to bring in groceries from the truck. Flies were flying around the door and coming into the building. During an interview on 7/22/21, at 09:48 A.M., DA A said there are flytraps by the back door. When the truck delivers, the back door is propped open. A person can go in and out of the backdoor without staff letting them in each time. There is a fly issue, they are in the kitchen. If he/she saw flies landing on the food, he/she would dump it out. During an interview on 7/22/21, at 10:14 A.M., DA B said the facility is working on the fly problem. There are flytraps by the backdoor. The delivery guys leave the backdoor propped open when they deliver. During an interview on 7/22/21, at 10:45 A.M., the Dietary Manger (DM) said the backdoor is left open when the delivery trucks are there. During an interview on 7/23/21, at 9:14 A.M., the Maintenance Staff (MS) N said pest control comes out at least monthly, if not more. The pest control does not do a lot for flies; flies are bad this year. During an interview on 7/23/21, at 1:08 P.M., the Maintenance Supervisor said if they see pests, the control company, who comes once a month, sprays the outside of the building and have come out for extra visits this month due to abundance of flies. There is bait in kitchen and employee smoking area. The facility has implemented use more fly swatters and lights by the kitchen doors. One light is down right now. There are sticky traps in the back of the lights. When employees come in for check in and during kitchen deliveries, the door is left open. 6. During an interview on 7/22/21, at 9:48 A.M., DA A said there is a daily cleaning person who will work 7:00 A.M. to 3:00 P.M. and will help with dishes, sweep and mop, take the trash out, and will supervise the residents who smoke. Staff is supposed to clean, then initial the cleaning sheet. If cooks have free time, they will clean. The daily cleaning person does the daily cleaning, but the monthly cleaning sheet is initialed by whoever has time to clean. If the sheets are not initialed, it could mean it didn't get cleaned or somebody forgot to initial the sheets. If something is dirty, the cleaner will clean it. During an interview on 7/22/21, at 10:14 A.M., DA B said everybody is supposed to clean. There is a daily, weekly and monthly cleaning sheet and staff is supposed to initial what they clean. If the sheets are not initialed it could be because they are outdated, or they forget to date them. Dietary Manager is supposed to check to make sure things are being done. Thursday through Sunday is when most of the cleaning on the list is done. He/she thinks the cleaning list are being done. The night staff usually clean the kitchen. During an interview on 7/22/21, at 10:45 A.M., the DM said there is not a daily cleaner at this point, maybe 2-3 days a week. Everybody is responsible for daily cleaning; the daily cleaner is helping with washing dishes. Staff needs to clean and fill out the cleaning log sheets. She knows daily cleaning is not being done and she needs to follow up on it. If it isn't initialed, it probably isn't being done. During a phone interview on 7/22/21, at 11:59 A.M., the Registered Dietician (RD), said the daily cleaning sheets are posted and they should clean and initial what they clean. Staff is not filling them out as they should be. RD said she completes a walk through and is dealing with cleanliness but she is only there two days a month. During an interview on 7/22/21, at 1:00 P.M., the Administrator said his expectation on cleanliness is to maintain a kitchen free of bacteria agents, mold and mildew. He does try to do a walk through at least once a week of the kitchen, but it has been three or four weeks since he completed a walk through. He expects the RD to make recommendations on the kitchen cleanliness and forward the report. He does expect the weekly and monthly to completed and filled out. The cleaning sheets should be handed into DM. If the sheets are not initialed, things are not being done.

Based on observation, record review, and interviews, the facility failed to ensure staff developed, reviewed, and revised a Comprehensive Care Plan to include an indwelling catheter (a sterile tube inserted into the bladder to drain urine) and its care for one resident (Resident #58), and bed rails used for mobility for one resident (Resident #6) in a sample of 21 residents. The facility census was 85. 1. Record review of Resident #58's face sheet (basic resident information) showed the following information: -Original admission date of 2/21/19; -Diagnoses included displaced bicondylar fracture of right tibia (a break in the upper part of the tibia (shin bone)), Parkinson's disease (a progressive nervous system disorder that affects movement), anxiety disorder, and pain. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 2/28/19, showed the following information: -Cognitively intact; -Extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene; -Indwelling catheter marked. Record review of resident's Observation Detail List Report, dated 2/21/19, showed the following information: -Resident is a two staff person assist for bed mobility, transfers, toileting, and bathing; -Resident is continent of bladder - including dribbles or use of catheter; -Resident has an indwelling catheter. Record review of the resident's nurses' notes dated 2/22/19, at 4:49 A.M., showed the following information: -Resident is a two staff person assist with activities of daily living (ADLs- dressing, grooming, bathing, eating, and toileting) and transfers; -Continent of bowel; -Foley catheter patent draining clear amber urine. Record review of the resident's Care Area Assessment (CAA) Summary, dated 3/24/19, showed the following information: -Urinary incontinence and indwelling catheter triggered to be care planned and that it was care planned. Record review of the resident's care plan, last revised on 4/5/19, did not include the Foley catheter and maintenance of the catheter. Observations on 4/7/19, at 3:22 P.M.; on 4/8/19, at 1:19 P.M.; on 4/18/19, at 2:00 P.M.; on 4/9/19, at 9:33 A.M.; on 4/10/19, at 10:38 A.M.; and on 4/10/19, at 1:46 P.M., showed the resident had a catheter. During an interview on 4/10/19, at 3:13 P.M., Licensed Practical Nurse (LPN) L said: -Foley catheters should be on the care plan; -The care plan is developed from the MDS indicators; -If he/she noticed it was not included he/she would report it to the MDS Coordinator to be corrected. During an interview on 4/10/19, at 3:56 P.M., the MDS Coordinator said: -Whatever flags on the CAA would be included in the care plan; -Examples include skin, nutrition, medications, code status, and catheters; -Catheters will flag under the incontinent area on the CAA. During an interview on 4/10/19, at 4:36 P.M., the facility administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and corporate quality assurance (QA) nurse said: -All catheters should be included on the care plan; -Were not aware that it was not included on the resident care plan. 2. Record review of Resident #6's medical chart showed the following information: -admitted to the facility 12/6/16; -Cognitively intact; -Diagnoses included weakness and left-sided (non-dominant) weakness and paralysis following stroke, arthritis (define); -Required extensive assist of two staff for bed mobility. Record review of the resident's care plan, last updated 1/3/19, showed staff documented the following: -ADL deficiency related to history of stroke with left-sided paralysis; -Assist with ADLs if fatigued. Observe for the need of assist and allow resident to be as independent as possible. Hoyer or sit-to-stand (mechanical) lift for transfers. Observe left arm tray/rest positioning on wheelchair; -Staff did not document the resident's use of bedrails for mobility. Observation made on 4/8/19, at 9:23 A.M., showed the resident had 1/2 side rails on each side of his/her bed. During an interview on 4/8/19, at 9:23 A.M., the resident said he/she was able to use the bed rails to assist him/herself with turning and repositioning in the bed. During an interview on 4/10/19, at 4:36 P.M., the facility administrator, DON, ADON, and corporate QA nurse said that a resident's use of bed rails for mobility should be included on their care plan.

Based on observation, interview, and record review, the facility failed to ensure staff obtained complete physician orders for an indwelling catheter (a sterile tube inserted into the bladder to drain urine) and its care for one resident (Resident #58) from a sample of 21 residents selected for review. The facility census was 85. Record review of the facility's policy titled Physician Orders, dated March 2015, showed the following information: -Each resident must be under the care of a licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty days; -Physician's orders must be signed by the physician and dated when such order was signed; -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Orders must be written and maintained in chronological order; -Physicians orders must be reviewed and renewed; -Content of orders for Foley catheter include: if as needed, specify why it is needed; irrigation - specific type, amount, frequency, and reason; specify the size and the frequency of the change; catheter care specifies what is to be used or according to facility procedure. 1. Record review of Resident #58's face sheet (basic resident information) showed the following information: -Original admission date of 2/21/19; -Diagnoses included displaced bicondylar fracture of right tibia (a break in the upper part of the tibia (shin bone), Parkinson's disease (a progressive nervous system disorder that affects movement), anxiety disorder, and pain. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 2/28/19, showed the following information: -Cognitively intact; -Extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene; -Supervision with eating; -Indwelling catheter marked. Record review of the resident's admission physician's order sheet (POS), dated February 2019, showed the following information: -No order for a Foley catheter; -No order for catheter care. Record review of resident's Observation Detail List Report, dated 2/21/19, showed the following information: -Resident is continent of bladder - including dribbles or use of catheter; -Resident has an indwelling catheter. Record review of nurses' notes, dated 2/22/19, at 4:49 A.M., showed the following information: -Continent of bowel; -Foley catheter patent draining clear amber urine. Record review of the resident's care plan, last revised on 4/5/19, showed staff did not include the Foley catheter and maintenance of the catheter. Record review of the resident's POS, dated April 2019, showed the following information: -No orders for a Foley catheter; -No orders for catheter care; -An order dated 4/2/19 to discontinue urinary catheter. The order was discontinued on 4/2/19. Record review of the resident's orthopedic clinic note, not dated, showed the following information: -Recommend to discontinue urinary catheter. Record review of the resident's nurses' notes dated 4/2/19, at 8:03 P.M., showed the following information: -Resident returned from appointment with orthopedic doctor with new orders to discontinue urinary catheter; -Orders carried through. During an interview on 4/10/19, at 3:13 P.M., Licensed Practical Nurse (LPN) L said: -Foley catheters require a physician order; -The admitting nurse or the charge nurse is in charge of ensuring the order is received and documented in the electronic medical record (EMR); -When an order is received by an outside physician, the charge nurse is in charge of ensuring that the house physician is notified and orders are clarified (obtain a new order or continue with current care); -The charge nurse will document new orders received or to continue with current orders in the nurses' notes in the EMR; -This should be communicated at shift change during report either verbally or on the written report form. During an interview on 4/10/19, at 3:20 P.M., LPN M said: -All catheters require a physician order; -If the resident is a new admit, the house physician is contacted to obtain an order to continue with the catheter or to discontinue the catheter; -The new order is entered into the resident's EMR, if it is a telephone order then it is put into the hard chart for physician's signature but it is still added to the EMR at that time; -A nurse's note is entered into the EMR showing what the order states and that the order was carried through; -The admitting nurse is responsible for doing all of this; -If the resident obtains an order recommendation from an outside physician, the charge nurse on duty is responsible for contacting the house physician to determine if the new order will be written or if current care will continue; -Once the house physician gives the nurse this information, the nurse is responsible for entering the information into the EMR; -The nurse will input a nurses' note notating the house physician's order and either continue current treatment or order carried through; -The resident has had a catheter since admitting to the facility; -LPN M was unaware that there was not an order for the catheter or catheter care; -If he/she had noticed this then it would have been fixed immediately; -Information is communicated at report either verbally or on the report form. During an interview on 4/10/19, at 3:27 P.M., the Director of Nursing (DON) said: -A physician order is required for a Foley catheter; -The house physician will be contacted for any resident admitting with a catheter to obtain or clarify the order; -If an outside physician makes an order change, the house physician is contacted prior to the order being carried out, this should be done immediately after the resident's return to the facility; -Once the house physician has given new orders or to continue with treatment, then it will be added to the resident's EMR; -The nurse will input a note notating the new order or to continue with current care and if the order was carried out; -The resident admitted with a Foley catheter; -The resident should have had an order for the catheter; -The DON was not aware an order had not been obtained or entered; -While out on a consultation appointment with his/her orthopedic physician, the physician recommended discontinuing the Foley catheter; -The resident refused to do this due to being fearful of transfers to use the toilet; -The nurse should not have noted that the order was carried through and should have noted that the resident refused to discontinue the catheter and notated that the physician was notified; -The information should be communicated through report either verbally or in written format. During an interview on 4/10/19, at 4:36 P.M., the administrator, DON, Assistant Director of Nursing, and Corporate Nurse said: -All catheters require a physician order; -The resident should have had an order; -The nurse should have contacted the physician when the resident refused to have the catheter removed and notated this in the EMR in the nurses' notes.

Based on observation, interview, and record review, the facility failed to ensure staff provided monitoring and care of indwelling catheters (a sterile tube inserted into the bladder to drain urine) according to acceptable standards of practice to prevent urinary tract infections (UTIs) for one resident (Resident #58) when the catheter bag and/or tubing were allowed to rest or drag on the floor. A sample of 21 residents was selected for review. The facility census was 85. 1. Record review of the facility's catheter care policy titled, Catheter Care (Indwelling), dated March 2015, showed the following information: -Secure catheter utilizing a leg band (optional); -Check drainage tubing and bag to insure that the catheter is draining properly. Record review of Resident #58's face sheet (basic resident information) showed the following information: -Original admission date of 2/21/19; -Diagnoses included displaced bicondylar fracture of right tibia (a break in the upper part of the tibia (shin bone)), Parkinson's disease (a progressive nervous system disorder that affects movement), anxiety disorder, and pain. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 2/28/19, showed the following information: -Cognitively intact; -Extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene; -Indwelling catheter marked. Observation on 4/7/19, at 3:22 P.M., showed the following: -Resident lying in bed on back; -Catheter bag attached to rail of bed; -Catheter dignity bag and tubing lying on the floor. Observation on 4/8/19, at 1:19 P.M., showed the following: -Resident sitting up in wheelchair in room; -Catheter bag clipped underneath the wheelchair; -Catheter tubing lying on the floor. Observation on 4/8/19, at 2:00 P.M., showed the following: -Resident sitting up in wheelchair in room; -Catheter bag clipped underneath the wheelchair; -Catheter tubing lying on the floor. Observation on 4/9/19, at 9:33 A.M., showed the following: -Resident sitting up in wheelchair in room; -Catheter bag clipped underneath the wheelchair; -Catheter bag and tubing lying on the floor. Observation on 4/10/19, at 10:38 A.M., showed the following: -Resident sitting up in wheelchair in room; -Catheter bag clipped underneath the wheelchair; -Catheter tubing lying on the floor. Observation on 4/10/19, at 1:46 P.M., showed the following: -Resident sitting up in wheelchair in room; -Catheter bag clipped underneath the wheelchair; -Catheter tubing lying on the floor. During and interview on 4/10/19, at 3:15 P.M., Certified Nurses' Aide (CNA) J said the following -The catheter bag should be clipped to the bed below the bladder; -The tubing and the bag should be off the floor at all times; -Even if the bed is in the lowest position, the catheter bag and tubing should not touch the floor. During an interview on 3/15/19, at 12:21 P.M., Registered Nurse (RN) F said the following: -He/she expects the CNAs to clip the bag to the bed below the bladder; -Even when using a high/low bed, the catheter bag and tubing should remain off of the floor; -The tubing should not be kinked. During an interview on 4/10/19, at 1:52 P.M., CNA J said the following: -The bag should be clipped to the bed or under the wheelchair; -Catheter bags should be hung below the bladder; -Catheter bag should always be covered with a dignity bag; -The catheter bag and tubing should never touch the floor. During an interview on 4/10/19, at 1:55 P.M., CNA A said the following: -Catheter bags should be put into the dignity bags; -The dignity bag should be hung below the bladder on the side of the bed or under the wheelchair; -The catheter bag and tubing should never be on the floor; -Sometimes it is a hassle to keep the tubing off the floor; -When rounding on residents, should always check and adjust the bag and tubing as needed. During an interview on 4/10/19, at 1:56 P.M., RN K said the following: -Staff are expected to keep the catheter bags inside of the dignity bags; -The dignity bag should be hung below the bladder on the side of the bed or under the wheelchair; -The dignity bag, catheter bag, and catheter tubing should never touch the floor; -Staff should do rounding and if they see the tubing or bags on the floor they should fix it. During an interview 4/10/19, at 4:36 P.M., with the administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the corporate nurse the following was said: -Catheter bags should be kept in dignity bags at all times; -The bag should be hung below the bladder; -The bag and tubing should never touch the floor.

During an interview on 4/10/19, at 2:58 P.M., CNA A said hands should be washed any time gloves are changed during pericare and before touching anything else. During an interview on 4/10/19, at 4:40 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON), and the corporate quality assurance (QA) nurse said staff should wash their hands before donning gloves and after removing them. Gloves should be changed after peri care and prior to proceeding to another care area or touching anything else. Based on observation, interview, and record review, the facility staff failed to ensure infection control standard of practices were followed when staff failed to complete hand hygiene after providing incontinent care for one resident (Resident #6). A sample of 21 residents was selected for review in a home with a census of 85. Record review of a facility's policy entitled Gloves (Nursing Guidelines Manual, March 2015) showed the following information: -Gloves must be changed between residents and between contacts with different body sites of the same resident; -Gloves are not a cure-all. Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands. Record review of a facility's policy entitled Perineal Care (Nursing Guidelines Manual, March 2015) showed to wash hands after removing gloves. 1. Record review of Resident #6's medical chart showed the following information: -admitted to the facility 12/6/16; -Cognitively intact; -Diagnoses included history of urinary tract infection (UTI). Record review of the resident's care plan, last updated 1/3/19, showed staff documented the following: -Mixed incontinence related to urgency and requiring assistance with toileting needs; -Use incontinence pads when in bed and incontinence briefs when out of bed; -Provide incontinence care after each incontinent episode; provide full staff performance for peri care; -Report signs/symptoms of UTI. Observation on 4/8/19, at 9:41 A.M., showed Certified Nurse Aide (CNA) N and Nurse Aide (NA) H washed their hands and donned gloves. The aides performed incontinent care for the resident. Without performing hand hygiene, the aides changed gloves and proceeded to place a clean brief and pants on the resident. CNA C entered the room, did not wash his/her hands prior to donning gloves, and assisted CNA N and NA H to use a Hoyer (mechanical) lift to transfer the resident from the bed to the wheelchair.

Based on observation, interview, and record review, the facility failed to ensure staff prepared and served food in accordance with professional standards when staff staff stacked dishes while still wet and failed to ensure staff washed hands after touching unclean surfaces during meal serve out. The facility had a census of 85 residents. 1. Record review of the facility's policy titled, General Dishroom Sanitation, dated April 2011, showed the following information: -All items are to be air dried. No moisture can be found on any stacked item. Record review of the 2013 Missouri Food Code showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried; -May not be cloth dried. Observation of the kitchen on 04/07/19, at 3:19 P.M., showed the following: -Sixty plastic fruit cups stacked wet; -Ten stacks of two, plastic mugs stacked wet. Observation of the kitchen on 04/08/19, at 10:17 A.M., showed 22 plates stacked wet in the plate warmer. Observation of the kitchen on 04/10/19, at 02:10 P.M., showed the following: -Forty-two plastic fruit cups stacked wet; -Three stacks of two, plastic soup bowls stacked wet; -Thirty plates stacked wet in the plate warmer. During an interview on 04/10/19, at 2:20 P.M., Dietary Aide (DA) B said she/he makes sure dishes are clean and dry before storing. During an interview on 04/10/19, at 2:36 P.M., with the administrator and the Dietary Manager (DM), the DM said prior to the dishes being put away, staff should check for cleanliness and to ensure the dishes are dry. 2. Record review of the 2013 Missouri Food Code showed the following information: -Food employees shall clean their hands and exposed portions of their arms as immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles; -After engaging in other activities that contaminate the hands. Observation on 04/10/19, at 11:45 A.M., during the lunch meal, showed the following: -Certified Nurse Aide (CNA) C and CNA D did not complete hand hygiene prior to meal serve out; -CNA D pushed a resident in a wheelchair and continued to hand out meal trays, touching food contact surfaces of the glasses and plates, without performing hand hygiene; -CNA C adjusted a resident's blanket and did not complete hand hygiene prior to handing out trays, touching food contact surfaces of the glasses and plates; -CNA D delivered a tray to a resident's room and returned to the dining room to hand out trays, touching food contact surfaces of the glasses and plates. The CNA did not perform hand hygiene between tasks; -CNA D answered a call light, came up the nurse's desk, returned to the resident's room with a supplement drink, and returned to the dining room to hand out trays, touching food contact surfaces of the glasses and plates. The CNA did not perform hand hygiene between tasks; -CNA G brought a resident to the dining room in a wheelchair, went to a resident's room, and returned to the dining room to hand out trays, touching food contact surfaces of the glasses and plates. The CNA did not perform hand hygiene before serving trays; -CNA G picked up a cup by top, threw trash away, and then wiped his/her hands on their pants. He/she continued to pass out dining room/hall trays,touching food contact surfaces of the glasses and plates. The CNA did not perform hand hygiene. -CNA C returned from a resident's room and continued to pass out dining room trays, touching food contact surfaces of the glasses and plates. The CNA did not perform hand hygiene. -CNA G and CNA D delivered room trays, returned to hand out dining room trays, touching food contact surfaces of the glasses and plates. The CNAs did not perform hand hygiene. During an interview on 04/10/19, at 3:15 P.M., Nurse Aide (NA) H said he/she cleans hands with sanitizer between trays. During an interview on 04/10/19, at 3:20 P.M., CNA C said he/she uses hand sanitizer between every other tray. During an interview on 04/10/19, at 3:27 P.M., Registered Nurse (RN) I said staff need to use hand sanitizer between each tray when delivering room trays, and after every fourth tray when serving in the dining room. During an interview on 04/10/19, at 4:30 P.M., with the Administrator, Director of Nursing, and the Assistant Director of Nursing (ADON), the ADON said staff should use hand sanitizer between serving each tray and should wash their hands after every fifth tray. Staff should also wash hands or apply hand sanitizer if they touch other items between serving trays.

Based on observation and interview, the facility staff failed to ensure they installed backflow preventers (devices used to keep hoses from siphoning contaminants into the main potable water supply) on all hoses that extended below the flood plain. This had the potential to affect all residents. The facility census was 85. 1. Observation on 4/7/19, at 4:44 P.M., showed both shower hoses in a shower room had an extension hose to make them longer. The hose length allowed the hoses to lay on the shower floor (the flood plain). The hoses did not have a backflow preventer. During an interview on 4/7/19, at 9:00 P.M., the Maintenance Director said he knew hoses could not extend below the flood plain unless they had a backflow preventer. The hoses used to be too short to reach the floor. At some point in time, within the past year, someone added the extension pieces onto the hoses. He did not realize the hoses now extended below the flood plain.