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

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

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

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

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

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

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

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

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff provided transfer or discharge notification to residents and their responsible party and the reasons for the transfer/discharge in writing in a language they understood. This affected two of twelve sampled residents (Residents #7 and #176). The facility census was 26. The facility did not provide a policy for transfer letters. 1. Review of Resident #7's annual Minimum Data Set (MDS, a federally mandated assessment that is completed by facility staff), dated 7/17/21 showed: -admitted on [DATE]; -re-admitted on [DATE]; -Diagnosis include: hypertension (high blood pressure), pneumonia (infection that inflames the air sacs in one or both lungs, which may fill with fluid), diabetes, depression, and respiratory failure. Record review on 09/14/21 at 09:29 A.M. showed: -Resident admitted on [DATE]. -On 3/29/21 resident was hospitalized for shortness of breath. Diagnosed with pneumonia. -On 8/26/21 resident was sent to emergency room due to staff feeling that resident was sleeping more and eating/drinking less. -No documentation of a transfer letter given. 2. Review of Resident #176's quarterly MDS, dated [DATE], showed: -re-admitted on [DATE]; -Diagnosis include: anemia (a condition in which the blood doesn't have enough healthy red blood cells, this leads to reduced oxygen flow to organs), coronary artery disease (CAD, damage in the heart's major blood vessels; arteries are narrow, limiting blood flow to the heart), hypertension, diabetes, anxiety, depression, Bipolar, and lung disease. During an interview on 09/14/21 at 9:23 A.M. the Resident said: -He/she just came back from the hospital last week. -He/she was admitted on [DATE]. Record review on 09/16/21 09:37 A.M. showed: - On 8/31/2021 called physician to inform of residents vitals, increase in weight, shortness of breath, and lab results. New order given to send to emergency room for evaluation. Notified guardian. - On 8/31/2021 hospital called to report resident was being admitted for fluid overload, and congestive heart failure (CHF) exacerbation. -No documentation of a transfer letter provided. During an interview on 09/15/21 at 09:20 A.M. Social Services said: -He/she does not provide transfer letters. During an interview on 09/15/21 at 03:24 P.M. Licensed Practical Nurse (LPN) B said: -Nursing doesn't do transfer letters to resident or guardians. They call guardians. During an interview on 09/16/21 at 10:15 A.M. the Acting Director of Nursing (DON) and LPN A said: -Transfer letters are not given. -Guardians are called. -Was not aware that transfer letters needed to be given. During an interview on 09/16/21 at 10:25 A.M. the Administrator said: -Was not aware that transfer letters needed to be completed with hospitalizations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident and the resident's family/legal representative of the facility's bed-hold policy at the time of transfer/discharge to the hospital. This affected two of twelve sampled residents (Residents #7 and #176). The facility census was 26. The facility did not provide a policy for bed-hold. 1. Review of Resident #7's annual Minimum Data Set (MDS, a federally mandated assessment that is completed by facility staff), dated 7/17/21 showed: -admitted on [DATE] -re-admitted on [DATE] -Diagnosis include: hypertension (high blood pressure), pneumonia (infection that in flames the air sacs in one or both lungs, which may fill with fluid), diabetes, depression, and respiratory failure. Record review on 09/14/21 at 09:29 A.M. showed: - Resident admitted on [DATE]. -On 3/29/21 resident was hospitalized for shortness of breath. Diagnosed with pneumonia. -On 8/26/21 resident was sent to emergency room due to staff feeling that resident was sleeping more and eating/drinking less. -No documentation of a bed-hold policy given. 2. Review of Resident #176's quarterly MDS, dated [DATE], showed: -re-admitted on [DATE] -Diagnosis include: anemia (a condition in which the blood doesn't have enough healthy red blood cells, this leads to reduced oxygen flow to organs), coronary artery disease (CAD, damage in the heart's major blood vessels; arteries are narrow, limiting blood flow to the heart), hypertension, diabetes, anxiety, depression, Bipolar, and lung disease. During an interview on 09/14/21 at 9:23 A.M. the Resident said: -He/she just came back from the hospital last week. -He/she was admitted on [DATE]. -He/she could not recall if given the bed-hold policy. Record review on 09/16/21 09:37 A.M. showed: - On 8/31/2021 called physician to inform of residents vitals, increase in weight, shortness of breath, and lab results. New order given to send to emergency room for evaluation. Notified guardian. - On 8/31/2021 hospital called to report resident was being admitted for fluid overload, and congestive heart failure (CHF) exacerbation. -No documentation of a bed-hold policy provided. During an interview on 09/15/21 at 09:20 A.M. Social Services said: -He/she does not provide bed-hold policies with hospitalizations. During an interview on 09/15/21 at 03:24 P.M. Licensed Practical Nurse (LPN) B said: -Nursing doesn't provide the bed-hold policies with hospitalizations to residents or guardians. They call guardians. During an interview on 09/16/21 at 10:15 A.M. the Acting Director of Nursing (DON) and LPN A said: -Bed-hold policies are not given. -Guardians are called. -Was not aware that bed-hold policies needed to be given. -Thought the Business Office Manager might do the bed-hold policies. During an interview on 09/16/21 at 10:20 A.M. the Business Office Manager said: -He/she does not do bed hold policies with hospitalizations. During an interview on 09/16/21 at 10:25 A.M. the Administrator said: -Was not aware that the bed hold policy needed to be provided with hospitalizations.

Based on interviews the facility failed to review and update the facility-wide assessment (an assessment that determines what resources are necessary to care for its residents competently during both day-to-day operations and emergencies) at least annually, . The facility census was 26. The facility did not have a policy for facility assessment. During an interview on 09/14/21 at 03:45 P.M. the Administrator said: -The facility did not have a facility assessment. The facility assessment has not been updated since 2019. The previous Director of Nursing (DON) was responsible for the facility assessment; the current DON started in 2019.

Based on interviews, the facility failed to maintain the Quality Assurance and Performance Improvement (QAPI) program, failed to complete quarterly meetings, and failed to maintain documentation of the facility's ongoing QAPI program. The facility census was 26. The facility did not have a policy for QAPI. The facility did not provide a QAPI plan. During an interview on 09/13/21 at 04:37 P.M. the Administrator said: -There was not a QAPI plan. -The facility has not had a formal meeting, but rather informal meetings to discuss needs. During an interview and record review on 09/15/21 at 08:37 A.M. the Administrator said and showed: -The Director of Nursing was doing a QAPI activity for hand hygiene and infection control. -The plan was dated 2020. -He/she said it has been missed having the formal meeting quarterly. He/she did not know how it got missed.

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