**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when facility staff failed to obtain ordered medications in a timely fashion and failed to notify the physician of the missed doses one resident (Resident #1). The facility census was 34.Review of the facility's policy Unavailable Medications, revised 05/09/25, showed the following:-This facility shall use uniform guidelines for unavailable medications;-The facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (PRN), and emergency medications;-A STAT (immediately) supply of commonly used medications is maintained in-house for timely initiation of medications;-Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known the medication is unavailable:-Notify the Director of Nursing (DON) or on call Nursing Manager to determine if medication might be located within the facility or if it is obtainable in a timely manner from another source/satellite pharmacy;-If unable to obtain, determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication;-Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold;-If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. Review of the facility's policy Medication Reordering, revised 05/09/25, showed the following:-It was the policy of the facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident;-The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals to meet the needs of each resident;-Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner;-For stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container. 1. Review of Resident 1's face sheet (admission data) showed the following:-admission date of 05/08/25;-Diagnoses included chronic osteomyelitis (bone infection) of right ankle and foot, cognitive communication deficit, and other bacterial infections of unspecified site. Review of the resident's care plan, revised 05/29/25, showed the following:-The resident had an increased probability of infections related to his/her her right foot infection;-The resident was at risk for adverse reactions of his/her medications;-Administer the resident's medications as ordered. Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/08/25, showed the following:-Cognitive skills intact;-No behaviors;-Set up required with eating;-Supervision required with toileting and personal hygiene. Review of the resident's July 2025 Physician Order Sheet (POS) showed an order, dated 07/22/25, for Avycaz (antibiotic used to treat serious bacterial infections) Intravenous (IV- into or within a vein) Solution Reconstituted 2.5 gram, use 2.5 gram intravenously three times a day (TID) for osteomyelitis until 08/01/25 9:59 P.M. Dilute in 100 milliliters (ml) of normal saline and administer at 50 ml/hour. Review of the resident's progress note dated 07/23/25, at 8:04 A.M., showed Registered Nurse (RN) B noted the resident was nonresponsive and blood sugar was 53 milligrams/deciliter (mg/dL - below 70 mg/dL is considered low). RN B contacted the Director of Nursing (DON) and provider. Staff transferred the resident to the hospital by ambulance at 8:04 A.M. Review of the resident's July 2025 POS showed an order, dated 07/23/25, for linezolid intravenous solution 600 mg intravenously every 12 hours for osteomyelitis of the right foot until 08/01/25 at 11:59 P.M. Administer via PICC (long, thin flexible tube inserted into a vein to administer medications, fluids and blood products) line at 150 ml per hour. Review of the resident's progress note dated 07/29/25, at 11:05 P.M., showed a nurse documented the resident arrived at the facility by the ambulance and emergency medical transport. The resident was able to wheel down to the nurses' station to ask questions. The resident appears to be confused at times. Review of the resident's hospital discharge orders, dated 07/29/25, showed the following:-An order, dated 07/29/25, for vancomycin (an antibiotic used to treat serious bacterial infections) oral 125 milligrams (mg), four times a day. The last dose administered on 07/29/25 8:10 A.M.;-An order, undated, for linezolid (used to treat bacterial infections, including skin infections and pneumonia), 0.9% sodium chloride 600 mg intravenous every 12 hours, with time last taken unknown;-An order, undated, for Avycaz 2.5 grams intravenous every eight hours. Review of the resident's July 2025 POS showed an order, dated 07/29/25, for vancomycin HCL oral capsule 125 mg, one capsule by mouth (PO) four times a day for infection. Review of the resident's July 2025 Medication Administration Record (MAR) showed the following:-An active order for linezolid intravenous solution 600 mg/300 ml. Staff to use 600 mg intravenously every 12 hours for osteomyelitis for the right foot until 08/01/25 at 11:59 P.M. Administer via PICC line at 150 ml/hr;-An order, dated 07/29/25, for vancomycin HCL oral capsule 125 mg. Give one capsule PO four times a day for infection;-An order, no date, for Avycaz Intravenous Solution reconstituted 2.5 gm, use 2.5 grams intravenously three times a day for osteomyelitis until 08/01/25 at 09:59 P.M. Staff to dilute in 100 ml of normal saline and administer at 50 ml/hr;-On 07/29/25, at 9:00 P.M., staff documented the linezolid was not administered;-On 07/29/25 at 8:00 P.M., staff documented the vancomycin was not administered. Review of the resident's progress note dated 07/29/25, at 8:34 P.M., showed staff documented the vancomycin was on order. Staff did not document regarding the linezolid. Review of the resident's July 2025 MAR showed on 07/30/25, at 9:00 A.M., staff documented the linezolid was not administered.Review of the resident's progress notes showed on 07/30/25, at 9:23 A.M., a nurse documented the linezolid was not on-hand. Staff notified the pharmacy of the need, and they assured delivery. The medication was not received, and the pharmacy notified. (Staff did not document physician notification.)Review of the resident's July 2025 MAR showed on 07/30/25, at 9:00 P.M., staff documented the linezolid was not administered.Review of the resident's progress note dated 07/30/25, at 9:16 P.M., showed a nurse documented the linezolid not available at this time. Review of the resident's July 2025 MAR showed on 07/30/25, at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 08:00 P.M., a Certified Medication Technician (CMT) documented the vancomycin was not administered. Review of the resident's progress notes showed the following:-On 07/30/25, at 10:55 A.M., CMT E documented the vancomycin was not available;-On 07/30/25, at 11:12 A.M., CMT E documented the vancomycin was not available;-On 07/30/25 at 3:55 P.M., CMT E documented the vancomycin was not available;-On 07/30/25, at 7:23 P.M., CMT E documented the vancomycin was not available. (Staff did not document physician notification.)Review of the resident's progress notes showed on 07/30/25, at 9:21 P.M., a nurse documented the Avycaz did not arrive at this time and was not available. (Staff did not document physician notification.)Review of the resident's July 2025 MAR showed on 07/30/25, at 10:00 P.M., showed staff did not administer the Avycaz. Review of the physician's initial visit, dated 07/30/25, showed the following:-The resident had a complex medical history including right hip fracture, osteomyelitis and was evaluated today post hospital discharge;-Regarding the resident's chronic osteomyelitis of the great right toe, the resident was also evaluated by an infectious disease doctor who provided recommendations for antibiotics due to previous cultures that grew pan-resistant acinetobacter baumannii (common hospital-acquired pathogen) and methicillin-resistant staphylococcus aureus) (MRSA - type of staph that can be resistant to several antibiotics);-Medication of vancomycin HCL Oral capsule 125 mg, give one capsule PO four times a day for infection and Avycaz intravenous solution reconstituted 2.5 gm three times a day for osteomyelitis until 08/01/25;-Assessment and plan: chronic osteomyelitis of the right great toes. The resident is currently on a complex antibiotic regimen for chronic osteomyelitis of the right great toe, status post amputation. The treatment plan was recommended by the infectious physician. Continue the vancomycin, Avycaz, and linezolid. (The physician did not document regarding the missed doses.) Review of the resident's July 2025 MAR showed the following:-On 07/31/25, at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., CMT A did not administer the vancomycin;-On 07/31/25, at 9:00 A.M., showed staff did not administer the linezolid. Review of the resident's progress notes showed the following:-On 07/31/25, at 9:33 A.M., a nurse documented the linezolid was unavailable. Staff notified the DON. Staff spoke with the pharmacy, and they are to send the medication stat;-On 07/31/25, at 12:05 P.M., CMT A documented the vancomycin was on order;-On 07/31/25, at 1:32 P.M., CMT A documented the vancomycin was on order;-On 07/31/25, at 3:23 P.M. CMT A documented the vancomycin was on order;-On 07/31/25 at 07:34 P.M., CMT A documented the vancomycin was on order; -On 07/31/25, at 11:06 P.M., a nurse documented the resident continued on IV antibiotic for his/her wound. The resident picked a scab off of his/her leg this shift. (Staff did not document physician notification regarding the missed doses.) Review of the resident's August 2025 MAR showed on 08/01/25, at 12:00 P.M., 4:00 P.M. and 8:00 P.M., staff documented the vancomycin was not administered. Review of the resident's progress notes showed the following:-On 08/01/25, at 12:08 P.M., CMT E documented he/she called the pharmacy, and they stated the vancomycin would be at the facility this evening;-On 08/01/25, at 4:42 P.M., CMT E documented he/she called the pharmacy, and they stated the vancomycin would be at the facility tonight;-On 08/01/25, at 7:10 P.M., CMT E documented pharmacy stated the vancomycin would be at the facility this evening.(Staff did not document physician notification regarding the missed doses.) During interviews on 08/05/25, at 10:50 A.M. and 12:32 P.M., CMT A said the following:-The facility did not have the resident's vancomycin;-He/she reported the unavailable vancomycin to the nurse. The nurse stated the medication had been ordered;-He/she documented on 07/31/25 the four times of the vancomycin was not available;-He/she did not call the pharmacy due to the nurse stated the medication was ordered;-The facility did not have an emergency pharmacy close, so they did not deliver medications until 1:00 A.M.;-He/she documented in the progress notes of the vancomycin on order for the rest of his/her shift;-Nurses administer the IV antibiotics;-Nurses enter the physician orders in the computer; -He/she administered the oral antibiotics;-The facility has some of the medications in the medication machine;-Nurses and CMT's review the ordered medications the following morning and place them on the medication cart;-CMTS have access to the medication machine for regular medications;-He/she checks for the medication if it is unavailable;-He/she calls the pharmacy if a medication is unavailable to see if a medication was ordered;-He/she informs the nurse of an unavailable medications and documents in the progress note.During an interview on 08/05/25, at 2:35 P.M., CMT E said he/she did not administer any doses of the vancomycin on 08/01/25. He/she documented the medication was not available and he/she called the pharmacy who said the medication would be delivered that evening. He/she told the nurse and the DON on 08/01/25 who called the pharmacy on the vancomycin. During an interview on 08/05/25, at 12:12 P.M., Licensed Practical Nurse (LPN) D said the following:-He/she did not know the resident's vancomycin was not in. The resident was on an IV antibiotic. He/she saw the order for the vancomycin, but did not know it was not in the facility;-It was important for staff to start the resident's vancomycin. The resident had an infection;-He/she did not know the resident's vancomycin was not administered and unavailable;-Staff should call the pharmacy if a medication is not available;-The CMTs administer the vancomycin oral tablets and should notify the nurse if the medication is not available;-The CMT should notify the nurse and call the pharmacy if a medication is not available;-Staff should notify the physician if vancomycin is not in;-Delayed antibiotics for an infection could cause severe complications such as infections spreading and becoming septic; -Nurses enter the orders into the computer which connects to the pharmacy; -Staff should call the pharmacy if a medication is not delivered, find out the reason and notify the DON. During an interview on 08/05/25, at 12:01 P.M., Registered Nurse (RN) C said the following:-The resident's linezolid IV meds were on order, but the NP said to discontinue it;-The resident's Vancomycin should had started as soon as possible;-Nurses enter the physician orders in the computer;-Staff call the pharmacy if a medication is not available and document in the progress notes;-Staff should start vancomycin as soon as it is delivered from the pharmacy;-Nurses call the pharmacy to get an antibiotic STAT and should get it within four hours if it approved;-It could affect a resident's treatment if an antibiotic is not given, and staff should notify the physician to see if they want to change to another medication. During an interview on 08/05/25, at 12:34 P.M. and 2:13 P.M., the Director of Nursing (DON) said the following:-The nurse practitioner (NP) questioned the hospital discharge order of the resident's vancomycin due to the culture the facility had contraindicated the order. The NP sent communication and the lab to the infectious disease physician regarding the resident was resistant to vancomycin and did not see a response;-She did not know the vancomycin was not available;-The pharmacy said the linezolid needed mixed out of their facility and they were waiting for their components delivered to them (the pharmacy) to be mixed;-The linezolid was discontinued due to it was the end of the original order to give it. It was to end on 07/31/25 anyway;-She did not know if the nurse practitioner (NP) or physician was aware the resident did not receive the vancomycin and linezolid;-Vancomycin is used for an infection and microbes could grow and end up with a more severe infection if the antibiotic is not administered as ordered;-The resident was readmitted to the facility on [DATE] with an order for the vancomycin. She did not know why it was not given and it was not reported to her;-On 07/18/25, the pharmacy may have waited on approval for the Avycaz due to not administered;-She expected staff to notify the physician or NP of the Avycaz not administered on 07/18/25;-Nurses notify the provider of a resident's return to the facility from the hospital;-Nurses enter the physician order in the computer which communicates to the pharmacy;-A corporate entity which is an admission team reviews the discharge orders from the hospital;-The pharmacy delivers the medications that night if the medication is not in the emergency kit or STAT safe;-Staff should document in the progress notes if a medication is not available, notify the pharmacy and physician;-Vancomycin is used to treat infections. It could cause a more severe infection if not administered as ordered;-Nurses should document if a medication is not administered;-Nurses or CMTs should call the pharmacy if a medication is not available; -Nurses should notify the physician or NP if a medication is not available.During an interview on 08/05/25, at 12:54 P.M., the NP said the following:-She did not hear back from the infectious disease doctor on the resident's vancomycin;-She monitored the resident on the Avycaz which was the original treatment for the contagious infection;-The infectious disease physician recommended two to four weeks of the IV Avycaz;-The resident had a re-swab for the Avycaz and it showed a bacteria and vancomycin resistance;-She did not discontinue the vancomycin when the resident was readmitted to the facility on [DATE];-Facility staff did not notify her the vancomycin was not available; -She believed the hospital staff had a better understanding of the resident's condition due to diagnostic labs with immediate values and he/she would go along with the hospital's recommendations because they know best for the resident;-The resident was on linezolid while in the hospital and staff did not notify her of the linezolid not given here, it should had been at the facility for the resident;-She assumed the resident was on the vancomycin after the linezolid was discontinued and did not know the resident did not have the linezolid for 07/29/25 through 07/31/25; -She would have instructed the nurse to check the emergency kit then instruct them to call the pharmacy and pay to have it delivered STAT;-She expected staff to notify her when a resident is readmitted , she reviews the discharge orders in the computer. She does not verify accuracy but verifies safety of the interactions and if a resident is on two different antibiotics;-She expected staff to notify her if a medication is not available.During an interview on 08/05/25, at 1:42 P.M., the physician said he expected staff to notify him if an antibiotic or medication was not available. During an interview on 08/05/25, at 3:00 P.M., the Administrator said she expected staff to notify the physician if a medication/antibiotic is not available and document it in the progress notes. Complaint 2579006

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Please refer to Event ID NXM312, exit 03/27/25. Based on observation, interview, and record review, the facility staff failed to fully implement their abuse and neglect policies and procedures when staff failed to report an allegation of abuse made by one resident (Resident #1), who reported to the charge nurse that another resident (Resident #2) kissed him/her on the mouth, immediately to facility Administrator and within two hours to the state survey agency (Department of Health and Senior Services - DHSS). A sample of four residents was selected for review. The facility census was 46. Review of the facility's policy titled Abuse and Neglect Policy, revised September 2024, showed the following: -It was the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare had been or may be adversely affected by abuse or neglect caused by another person; -If there was any allegation of abuse, then the facility must report immediately to the administrator and to State Survey Agency, no later than two hours; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition; -Sexual abuse was the non-consensual sexual contact of any type with a resident and the individual acts deliberately; not that the individual has intended to inflict injury or harm. Any touching or exposure of the anus, breast or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion or sexual assault. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 12/26/24; -Diagnoses included depression, obesity, and panic disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/17/24, showed the resident's cognitive skills were intact and resident had no behaviors. Review of the resident's care plan, dated 06/26/24, showed the resident was at risk for mood problems as evidenced by his/her mood interview score. Staff to allow the resident to have control over situations, if possible. During an interview on 03/27/25, at 11:24 A.M., the resident said the following: -One evening, he/she played games in the main dining room and Resident #2 came into the dining room and came to him/her like he/she was going to kiss him/her; -He/she moved Resident #2 back and the resident came and gave him/her a quick kiss on the lips; -Resident #2 did hand gestures referring to his/her chest area. Resident #2 did not touch him/her; -He/she thought the kiss was gross and creepy; -He/she reported this to Licensed Practical Nurse (LPN) D. 2. Review of Resident #2's face sheet showed the following: -admission date of 09/23/24; -Diagnoses included Alzheimer's disease, cognitive communication deficit, and depression. Review of the resident's care plan, dated 12/05/24, showed the following: -The resident has a serious mental illness, intellectual disabilities, and a related condition; -Staff to address emotional issues; -The resident had cognitive loss and dementia; -Staff to provide cues and supervision to resident. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Cognitive skills severely impaired; -Rejection of care one to three days. Review of the resident's progress note dated 03/21/25, at 9:08 P.M., showed LPN D documented a resident (Resident #1) reported that Resident #2 made him/her uncomfortable. Resident #1 reported that Resident #2 came up to him/her in front of another resident and kissed him/her on the mouth. Resident #1 said he/she pushed Resident #2 and said no that is not ok. Resident #2 laughed as if it was funny. Resident #1 also reported that Resident #2 made gestures to him/her when he/she passes by. Resident #1 reports he/she felt uncomfortable and unsafe. 3. Review of DHSS records showed the facility reported the allegation of abuse to the state on 03/24/25 at 11:43 A.M. (three days after the allegation of abuse was made by Resident #1). 4. During an interview on 03/27/25, at 2:18 P.M., LPN D said the following: -On 03/21/25, Resident #1 came up to him/her and said Resident #2 came up and kissed him/her on his/her lips. Resident #1 said it made him/her feel weird; -LPN D texted the Director of Nursing (DON) on 03/21/25 of the incident; -Staff monitored Resident #2 with 15-minute checks; -The DON educated him/her the next time he/she was at the facility to report that Resident #1 said this incident made him/her feel unsafe; -LPN D considered the unwanted kiss as sexual abuse. During interviews on 03/27/25, at 1:30 P.M. and 02:30 P.M., the DON said the following: -LPN D reported to her that the resident said the kiss was unwanted and not to do it again; -LPN D texted her on Friday, 03/21/25, that Resident #1 said Resident #2 walked right up to him/her and kissed Resident #1 on his/her lips. Resident #1 said it was fast and it made him/her feel weird. Resident #1 told Resident #2 that it was not ok; -The DON said she did not know why she (the DON) did not call the allegation of abuse into the state; -LPN D reported that the resident went up and kissed Resident #1; -Resident #1 did not report Resident #2 made inappropriate gestures toward him/her. During interviews on 03/27/25, at 2:00 P.M. and 2:30 P.M., the Administrator said the following: -The allegation of abuse should have been reported to her and the state timely; -She found out about the incident on Saturday (03/22/25) and did not have all the information until Monday (03/24/25) when she talked to Resident #1; -On Sunday, 03/23/25, the DON reported that LPN D called her and said Resident #2 tried to kiss Resident #1; -After she talked to Resident #1 on Monday morning (03/24/25), it was a different story. Resident #1 said Resident #2 came up to tried to kiss him/her and he/she pushed Resident #2 away and said no, Resident #2 came back and forcibly kissed him/her on the lips and made a motion with his/her hands towards him/her; -Staff should had reported the incident immediately and reported to the state sooner. During an interview on 03/27/25, at 10:00 A.M., Certified Medication Technician (CMT) E said the following: -Examples of sexual abuse include touching inappropriate, kissing and fondling; -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:09 A.M., the Housekeeping Supervisor said the following: -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:47 A.M., Certified Nurse Aide (CNA)/CMT F said the following: -Staff should report immediately an allegation of abuse to the supervisor, charge nurse, DON or the administrator; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 1:30 P.M., the DON said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor; -Staff should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 2:00 P.M., the Administrator said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor and the supervisor reports to the administrator; -Staff should notify the state of any allegation of abuse within two hours. MO00251591

Based on observation, interview, and record review, the facility failed to assess the use of a seat belt, failed to obtain written consent for use of the seat belt, failed to document what less restrictive options were attempted, failed to document risk versus benefit review related to the seat belt use, failed to obtain a physician's order for use of the seat belt, and failed to care plan the use of the seat belt for one resident (Resident #11) who was unable to effectively and consistently remove the seat belt without staff assistance. The facility census was 44. Review of the facility provided policy titled Use of Restraints, dated December 2007, showed the following: -Restraints should only be used for the safety and well-being of the resident and only after alternatives have been tried unsuccessfully; -Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls; -Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body; -The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint; -Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to treat the medical symptom, to protect the resident's safety, and to help the resident attain the highest level of his/her physical or psychological well-being; -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms; - Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor); -The order shall include the specific reason for the restraint (as it relates to the resident's medical symptom), how the restraint will be used to benefit the resident's medical symptom, and the type of restraint, and period of time for the use of the restraint.; -Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment; -Reorders are issued only after a review of the resident's condition by his or her physician; -Restraints shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident; -Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency; -Restraints with locking devices shall not be used; -A resident placed in a restraint will be observed at least every thirty minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record; -The opportunity for motion and exercise is provided for a period of not less than ten minutes during each two hours in which restraints are employed; -Restrained residents must be repositioned at least every two hours on all shifts; -Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use; -Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination; -Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms; -Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. 1. Review of Resident #11's face sheet (brief information sheet about the resident), showed the following: -admission date of 04/06/24; -Diagnoses included quadriplegia (partial or complete paralysis of both the arms and legs especially as a result of spinal cord injury or disease in the region of the neck), degenerative disorders of nervous system (group of conditions that affect the nervous system, causing progressive deterioration and loss of function over time), inclusion body myositis (a rare, chronic, and progressive muscle disease characterized by inflammation and muscle weakness), post traumatic stress disorder (PTSD - disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying even). Observation and interview on 01/27/25, at 3:36 P.M., showed the following: -Certified Nurse Aide (CNA) H and CNA I entered the resident room with the Hoyer lift (mechanical lift used for non-weight bearing transfers); -Resident was seated in the electric wheelchair, covered with a blanket; -Staff removed the resident's blanket, the resident had a seatbelt across his/her lab; -CNA H unbuckled and removed the seatbelt; -The staff transferred the resident to the bed; -The staff completed resident personal cares; -The staff transferred the resident back to the wheelchair with the Hoyer lift; -The resident requested CNA H re-applied the seatbelt. CNA buckled the belt across the resident's lap area. Review of the resident's significant change in condition Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/30/24, showed the following: -Cognitively intact; -Restraints not used in chair or bed; -Required use of motorized wheelchair. Review of the resident's care plan, last updated on 01/06/25, showed the following: -Resident was admitted with specialized high back wheelchair with arms that hold his/her phone and tablet for ease of use; -Staff should Instruct his/her in the use of the wheelchair as needed; -Resident's wheelchair was his/her main mode of transportation; -Staff should assist the resident with mobility as necessary; -Resident was at risk for falling related to inability to ambulate; -Staff should encourage resident to use environmental devices such as hand grips or handrails. (Staff did not care plan related to resident's use of the seat belt.) Review of the resident's Physician's Order Sheet (POS), current as of 01/30/25, showed no orders for use of a seatbelt or restraint. During an interview on 01/27/25, at 4:27 P.M., the resident said he/she had a seatbelt on wheelchair. He/she was not able to take it off. He/she was aware the seatbelt was considered a restraint, but he/she had enough motion in his/her upper torso that he/she would adjust too much or have a muscle spasm was afraid of falling out of the wheelchair. The resident said he/she was of sound mind and wanted to have the seatbelt and he/she had signed consent. During an interview on 01/30/25, at 10:30 AM., Registered Nurse (RN) G said the resident had a seatbelt in his/her wheelchair and thought that most staff knew that. He/she said would think it was on the care plan, but did not know. He/she was aware of the seatbelt just from working with resident and in report. During an interview on 01/30/25, at 11:45 A.M., RN A said he/she was not sure if the resident had a seatbelt for his/her wheelchair, but if he/she did then he/she should be able to unbuckle him/herself, or it would be considered a restraint. He/she did not know the facility policy about restraints. He/she said there should be a physician's order, it should be in the care plan, and it would require close monitoring if used. During an interview on 01/29/25, at 2:15 P.M., CNA E said the resident had a seatbelt on his/her wheelchair that he/she requested. It should be in the care plan. The resident was repositioned in the wheelchair throughout the day and staff lay him/her down throughout the day for personal cares and to give him/her a break from the wheelchair. During an interview on 01/29/25, at 2:30 P.M., the Director of Nursing (DON) said the resident had a seatbelt in his/her wheelchair and that should be in the care plan. He/she did not know if there was signed consent for the seatbelt or a physician's order, but that should have been completed prior to using the seatbelt. During an interview on 01/29/25, at 2:45 P.M., the Administrator said she was not aware that the aides were putting the seatbelt on for the resident. The resident was not supposed to have a seatbelt. She had discussed with the resident in the past that it was a restraint, and the facility did not allow restraints. The resident had a fear of falling due to past trauma. His/her wheelchair was able to incline and decline. There was not any paperwork completed for consent or risks because the facility did not allow restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to fully implement their abuse and neglect policies and procedures when staff failed to report an allegation of abuse made by one resident (Resident #1), who reported to the charge nurse that another resident (Resident #2) kissed him/her on the mouth, immediately to facility Administrator and within two hours to the state survey agency (Department of Health and Senior Services - DHSS). A sample of four residents was selected for review. The facility census was 46. Review of the facility's policy titled Abuse and Neglect Policy, revised September 2024, showed the following: -It was the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare had been or may be adversely affected by abuse or neglect caused by another person; -If there was any allegation of abuse, then the facility must report immediately to the administrator and to State Survey Agency, no later than two hours; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition; -Sexual abuse was the non-consensual sexual contact of any type with a resident and the individual acts deliberately; not that the individual has intended to inflict injury or harm. Any touching or exposure of the anus, breast or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion or sexual assault. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 12/26/24; -Diagnoses included depression, obesity, and panic disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/17/24, showed the resident's cognitive skills were intact and resident had no behaviors. Review of the resident's care plan, dated 06/26/24, showed the resident was at risk for mood problems as evidenced by his/her mood interview score. Staff to allow the resident to have control over situations, if possible. During an interview on 03/27/25, at 11:24 A.M., the resident said the following: -One evening, he/she played games in the main dining room and Resident #2 came into the dining room and came to him/her like he/she was going to kiss him/her; -He/she moved Resident #2 back and the resident came and gave him/her a quick kiss on the lips; -Resident #2 did hand gestures referring to his/her chest area. Resident #2 did not touch him/her; -He/she thought the kiss was gross and creepy; -He/she reported this to Licensed Practical Nurse (LPN) D. 2. Review of Resident #2's face sheet showed the following: -admission date of 09/23/24; -Diagnoses included Alzheimer's disease, cognitive communication deficit, and depression. Review of the resident's care plan, dated 12/05/24, showed the following: -The resident has a serious mental illness, intellectual disabilities, and a related condition; -Staff to address emotional issues; -The resident had cognitive loss and dementia; -Staff to provide cues and supervision to resident. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Cognitive skills severely impaired; -Rejection of care one to three days. Review of the resident's progress note dated 03/21/25, at 9:08 P.M., showed LPN D documented a resident (Resident #1) reported that Resident #2 made him/her uncomfortable. Resident #1 reported that Resident #2 came up to him/her in front of another resident and kissed him/her on the mouth. Resident #1 said he/she pushed Resident #2 and said no that is not ok. Resident #2 laughed as if it was funny. Resident #1 also reported that Resident #2 made gestures to him/her when he/she passes by. Resident #1 reports he/she felt uncomfortable and unsafe. 3. Review of DHSS records showed the facility reported the allegation of abuse to the state on 03/24/25 at 11:43 A.M. (three days after the allegation of abuse was made by Resident #1). 4. During an interview on 03/27/25, at 2:18 P.M., LPN D said the following: -On 03/21/25, Resident #1 came up to him/her and said Resident #2 came up and kissed him/her on his/her lips. Resident #1 said it made him/her feel weird; -LPN D texted the Director of Nursing (DON) on 03/21/25 of the incident; -Staff monitored Resident #2 with 15-minute checks; -The DON educated him/her the next time he/she was at the facility to report that Resident #1 said this incident made him/her feel unsafe; -LPN D considered the unwanted kiss as sexual abuse. During interviews on 03/27/25, at 1:30 P.M. and 02:30 P.M., the DON said the following: -LPN D reported to her that the resident said the kiss was unwanted and not to do it again; -LPN D texted her on Friday, 03/21/25, that Resident #1 said Resident #2 walked right up to him/her and kissed Resident #1 on his/her lips. Resident #1 said it was fast and it made him/her feel weird. Resident #1 told Resident #2 that it was not ok; -The DON said she did not know why she (the DON) did not call the allegation of abuse into the state; -LPN D reported that the resident went up and kissed Resident #1; -Resident #1 did not report Resident #2 made inappropriate gestures toward him/her. During interviews on 03/27/25, at 2:00 P.M. and 2:30 P.M., the Administrator said the following: -The allegation of abuse should have been reported to her and the state timely; -She found out about the incident on Saturday (03/22/25) and did not have all the information until Monday (03/24/25) when she talked to Resident #1; -On Sunday, 03/23/25, the DON reported that LPN D called her and said Resident #2 tried to kiss Resident #1; -After she talked to Resident #1 on Monday morning (03/24/25), it was a different story. Resident #1 said Resident #2 came up to tried to kiss him/her and he/she pushed Resident #2 away and said no, Resident #2 came back and forcibly kissed him/her on the lips and made a motion with his/her hands towards him/her; -Staff should had reported the incident immediately and reported to the state sooner. During an interview on 03/27/25, at 10:00 A.M., Certified Medication Technician (CMT) E said the following: -Examples of sexual abuse include touching inappropriate, kissing and fondling; -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:09 A.M., the Housekeeping Supervisor said the following: -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:47 A.M., Certified Nurse Aide (CNA)/CMT F said the following: -Staff should report immediately an allegation of abuse to the supervisor, charge nurse, DON or the administrator; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 1:30 P.M., the DON said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor; -Staff should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 2:00 P.M., the Administrator said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor and the supervisor reports to the administrator; -Staff should notify the state of any allegation of abuse within two hours. MO00251591

Based on interview and record review, the facility failed to ensure all residents received care per professional standards of practice when staff failed to obtain ordered blood tests in a timely fashion for one resident (Resident #8) out of a total sample of 17 residents. The facility census was 44. Review of the facility's policy titled, Laboratory Services For Nursing Staff, dated 2025, showed the following: -The facility shall provide or arrange for laboratory services to meet residents' medical needs; -The nursing staff is responsible for coordinating, collecting, and documenting laboratory specimens in accordance with state and federal regulations; -All laboratory results must be reviewed, documented, and communicated to the provider in a timely manner. 1. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admission date of 08/31/22; -Diagnoses included atrial fibrillation (abnormal heartbeat), hyperlipidemia (high cholesterol), chronic kidney disease, and edema (swelling). Review of the resident's care plan, updated 10/01/24, showed the following: -The resident has urinary incontinence problems as evidenced by need for dependent on staff for assistance to use the bedpan for toileting; -The resident is at risk for increased probability of infections. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/03/24, showed the resident was cognitively intact. Review of the resident's progress note dated 11/29/24, at 1:02 A.M., showed a licensed practical nurse (LPN) documented the aides reported the resident had bleeding vaginally the past few days. The nurse reported that is why the Foley catheter (a tube that is inserted into the bladder, allowing urine to drain freely.) was discontinued. The aides reported the bleeding is heavier tonight. The nurse notified the physician of the resident's condition and orders received to get complete blood count (CBC) in the morning and he will follow up after the CBC results. Review of the resident's Physician Order Sheet showed an order, dated 11/29/24, for CBC sent to the lab company one time only related to urinary tract infection. Review of the resident's progress note dated 12/01/24, at 12:51 A.M., showed a nurse documented the resident stated he/she is still bleeding vaginally. The CBC has yet to be drawn. The nurse added the resident to the physician's list for him/her to assess the resident and follow up on order for the CBC. Review of the resident's medical record, on 01/29/25, showed staff had not obtained the CBC ordered 11/29/24. During an interview on 01/29/25 at 10:34 A.M., Registered Nurse (RN) A said the following: -When a nurse receives an order from physician, he/she gives the lab order to the Director of Nursing (DON) who enters the order into the computer; -Staff order lab orders for a change in condition, need for urinalysis, or edema issues; -Staff text or call the physician for needed labwork; -The DON is the only one who has access to enter lab requests; -The DON prints the lab results and gives it to staff; -Staff notify the physician and update him on the lab results; -The physician reviews the lab results and gives new orders based on the results; -He/she did not see the resident's CBC results ordered 11/29/24. During interviews on 01/29/25, at 11:29 A.M., and on 01/30/25, at 8:50 A.M., the DON said the following: -Nurses get a lab order and she enters the lab orders in the new lab company computer which started 01/01/25; -She checks the lab portal every day for lab results; -Nurses have a lab binder that has a log to enter information of the lab; -She prints lab results and puts them in the physician folder for him to review; -Staff call the physician with critical lab results; -The physician comes to the facility on Monday and Wednesdays and reviews the lab results and he/she writes orders if needed and the nurse documents it in the computer system; -Staff order labs for a change in condition, all new admissions, or a follow up lab; -With the old lab company, the nurse called the physician or texted to request a lab; -Staff wrote on the lab order requisition form and then staff progressed to enter the lab order in the computer and print out the requisition order, place it in the lab book at the desk under the date it needed drawn; -The old lab came Tuesday and Thursdays and emailed the facility the lab results, prior to emails the lab company faxed the results; -Staff checked the fax machine throughout the day for lab results; -She checked the computer daily until the facility received a result and would email the lab if no results;. -Staff wanted a CBC for the resident due to vaginally bleeding, but did not know for sure the reason; -The resident has improved with the bleeding; -She did not find the CBC results for the resident. During an interview on 01/30/25, at 01:32 P.M., the Administrator said if a resident had an order for labs to be drawn, they should be drawn as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care for residents on oxygen per professional standards of practice when staff failed to administer oxygen per physician orders for two residents (Resident #5 and Resident #7). The facility census was 44. Review of the facility's policy titled Monitoring Oxygen Use and Oxygen Saturation, undated, showed the following: -Purpose to ensure the safe and effective use of oxygen therapy and comply with regulatory requirements; -Applies to all residents receiving oxygen therapy and the nursing staff responsible for their care; -Oxygen therapy must be prescribed by a physician, including flow rate (liters per minute - lpm) and oxygen saturation range; -Only licensed nurses may adjust oxygen flow rates based on the physician's order; -Record oxygen flow rate, delivery method, and saturation levels in the resident's medical record; -Document any changes, incidents, or interventions related to oxygen therapy; -Review incidents related to oxygen use as part of the facility's quality improvement program. 1. Review of Resident #5's face sheet (a brief resident profile) showed the following: -admission date of 08/23/22; -Diagnoses included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breath), dependence on supplemental oxygen, pleural effusion (a buildup of fluid between the tissues that line the lungs and chest), pyothorax (a condition where pus collects in the space between the lungs and chest wall), and chronic respiratory failure with hypoxia (a condition where the body is not able to adequately exchange oxygen and carbon dioxide over a prolonged period). Review of the resident's January 2025 Physician Order Sheet (POS) showed an order, dated 09/30/24, for oxygen at 2 lpm by nasal cannula continuous while in bed to maintain oxygen level (saO2) greater than 91% every morning and at bedtime for shortness of breath related to COPD. Review of the resident's annual Minimum Data Set (MDS - federally mandated assessment tool completed by facility staff), dated 01/03/25, showed the following: -Moderately impaired cognition; -Received oxygen therapy. Review of the resident's care plan, last reviewed 01/03/25, showed a risk for signs and symptoms of COPD/chronic respiratory failure and may receive continuous oxygen at two lpm for shortness of breath. Review of the resident's January 2025 Medication Administration Record (MAR) showed the following: -An active order for oxygen at two lpm per nasal cannula, continuous while in bed to maintain saturation level greater than 91% every morning and at bedtime for shortness of breath related to COPD. -Staff did not document verification of number of oxygen liters provided to the resident. Review of the resident's nurses' notes, dated 01/26/25, showed the resident's oxygen set on three liters of oxygen per nasal cannula with an oxygen saturation of 94% at 5:24 P.M. and 97% at 5:58 P.M. Observation on 01/28/25, at 11:56 A.M., showed the following: -The oxygen concentrator sat in the resident's room and set on two and a half liters of oxygen per minute; -The oxygen tubing sat on top of the concentrator. Observation on 01/28/25, at 12:55 P.M., showed the following: -Resident sat in the wheelchair in his/her room; -The resident had oxygen on at two and a half liters per minute per nasal cannula. Observation on 01/29/25, at 11:17 A.M., showed the following: -Resident rested in bed with his/her eyes closed; -Resident had oxygen on per nasal cannula; -Oxygen concentrator was set at two and a half liters per minute. During an interview on 01/29/25, at 11:35 A.M., Certified Nursing Assistant (CNA) E said as far as he/she knew, the resident's oxygen setting should be on two liters of oxygen. During an interview on 1/29/25, at 11:43 A.M., Registed Nurse (RN) A said the following: -The resident's oxygen saturation level is checked two times per day; -The resident should be on two liters of oxygen per physician orders; -The resident takes his/her oxygen off on occasion or it gets misplaced, so staff replaces it for him/her as needed. Observation and interview on 01/29/25, at 12:00 P.M., showed the following: -The resident sat in the dining room waiting for lunch; -RN A checked the resident's oxygen concentrator and said his/her oxygen was set on two and a half lpm; -RN A checked the resident's oxygen saturation level and it was 99%; -RN A asked Certified Nurse Aide (CNA) E to turn the resident's oxygen down to two liters, while he/she was present; -CNA E changed the resident's oxygen to two lpm as instructed; -RN A confirmed the resident's oxygen was set on two liters of oxygen per nasal cannula before leaving the dining room. During an interview on 01/31/25, at 9:40 A.M., Licensed Practical Nurse (LPN) K said the following: -He/she checked the resident's oxygen saturation level daily and documents it in his/her electronic record. He/she believed the resident's oxygen saturation level was 94% when he/she checked it yesterday; -He/she looked at the resident's liters of oxygen every day and he/she has not noticed any problems or concerns with the resident's liters of oxygen. During an interview on 1/29/25, at 12:20 P.M., the Director of Nursing (DON) said if the resident's order was for two liters of oxygen, he/she should be on two liters. 2. Review of Resident #7's face sheet (a brief resident profile) showed the following: -admission date of 08/23/18; -Diagnoses included chronic diastolic (where the heart relaxes and fills with blood) congestive heart failure (CHF - a condition where the heart does not pump blood as well as it should) and COPD. Review of the resident's care plan, last reviewed 07/01/24, showed a risk for signs and symptoms of CHF/COPD and he/she received oxygen at three lpm continuously for shortness of breath. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Received oxygen therapy. Review of the resident's January 2025 POS showed an order, dated 09/30/24, for oxygen at three liters per nasal cannula, continuous to maintain saturation level of greater than 91% every morning and at bedtime for shortness of breath related to COPD. Review of the resident's January 2025 MAR showed the following: -A current order for oxygen at three liters per nasal cannula, continuous to maintain saturation level greater than 91% every morning and at bedtime for shortness of breath related to COPD. - Staff did not document verification of number of oxygen liters provided to the resident. Observation on 01/27/25, at 3:42 P.M., showed the following: -The resident sat in a wheelchair in his/her room; -The resident had oxygen on at two liters per minute per nasal cannula. Observation on 01/28/25, at 9:37 A.M., showed the following: -The resident sat in a wheelchair in his/her room and read a book; -The resident had oxygen on at two liters per minute per nasal cannula. Observation on 01/28/25, at 11:15 A.M., showed the following: -The resident sat in a wheelchair in his/her room completing a nebulizer treatment; -The resident had oxygen on at two liters per minute per nasal cannula. Observation on 01/28/25, at 12:01 P.M., showed the following: -The resident sat in a wheelchair in the restorative dining room, sleeping on and off while waiting for lunch; -The resident did not have on any oxygen. Observation and interview on 1/28/25, at 12:50 P.M., showed the following: -The resident sat in a wheelchair in his/her room; -The resident said he/she does not always wear his/her oxygen in the dining room, but he/she is okay with that. He/she wears oxygen when staff tells him/her to; -The resident had oxygen on at two liters per minute per nasal cannula. During an interview on 01/29/25, at 11:35 A.M., CNA E said he/she believed the resident's oxygen setting should be on three liters of oxygen. During an interview on 01/29/25, at 11:43 A.M., RN A said the following: -He/she checked the resident's oxygen saturation level two times per day; -The resident took his/her oxygen off sometimes, but he/she does not adjust his/her oxygen liters on the concentrator; -The resident had a physician's order for three liters of oxygen; -The resident keeps his/her oxygen on while eating. Observation and interview on 01/29/25, at 11:54 A.M. showed the following: -RN A checked the residents oxygen titration setting and said that his/her oxygen concentrator was set on two lpm; -RN A said he/she did not know how many liters of oxygen were ordered for the resident; -RN A checked the MAR and said the resident's lpm were a little off because his/her oxygen concentrator was set at two liters, but his/her order showed the resident should receive three liters of oxygen per minute. During an interview on 01/31/25, at 9:40 A.M., LPN K said the following: -He/she does not complete oxygen saturation level checks on the resident; -He/she puts the resident's oxygen back on him/her when he/she notices the resident does not have the oxygen on; -He/she looks at the resident's oxygen concentrator to make sure his/her liters of oxygen are correct when he/she places oxygen on him/her. During an interview on 01/29/25, at 12:20 P.M., the DON said if the resident's order is for three lpm of oxygen, then he/she should be on three liters. 3. During an interview on 01/29/25, at 11:35 A.M., CNA E said the following: -He/she talks to the nurse during their daily huddle if he/she needs to know which residents have oxygen and how many liters of oxygen they are on; -The nurse is responsible for making sure the residents are on the correct liters of oxygen and changing the oxygen settings; -If there is an issue or he/she notices that a resident's oxygen is not on the correct setting, he/she lets the nurse know immediately; -The resident's oxygen saturation level is checked as needed and one time every day on his/her shift. He/she does not document the resident's oxygen saturation level results, he/she reports the results to the nurse; -If a resident's oxygen saturation level is low, he/she automatically gets the nurse. During an interview on 01/31/25, at 9:40 A.M., LPN K said the following: -He/she monitors oxygen liters for each resident; -Generally, the residents are on two liters of oxygen, but some may have orders for a different number of liters; -If he/she notices a resident's oxygen is not in place, he/she replaces it. Some residents take their oxygen off or it gets removed for other reasons; -If a resident's pulse ox is low, he/she would review the electronic record to double check their oxygen order; -If he/she noticed a resident's liters of oxygen was not correct, he/she would verify the orders in their chart and change it to the correct number of liters. During an interview on 01/29/25, at 11:43 A.M., RN A said the following: -He/she knows which residents have oxygen because he/she does all the admissions; -He/she looks in the physician orders to know how many liters of oxygen the resident should be on and current oxygen settings for each resident on oxygen is communicated between staff during the shift change report; -CNA's do not have the authority to change or adjust a resident's oxygen setting; -The resident's oxygen saturation level is checked as needed; -Oxygen saturation level readings and liters of oxygen are documented in the resident's chart per physician orders; -If a resident's oxygen saturation level reading is low or abnormal and there is an order to put oxygen on the resident, they place oxygen on the resident, assess them and order a chest x-ray. Then they continue to monitor the resident; -If a resident does not want to wear his/her oxygen; then, staff documents his/her refusal in their chart; During an interview on 01/29/25, at 12:20 P.M., the DON said the following: -The facility has oxygen orders for residents in the electronic health record system; -Staff should review physician orders with a change in condition or if improvements are made; -He/she would expect staff to know how many liters of oxygen a resident is on from their orders in the chart; -If the CNA has a question about a resident's oxygen or the number of liters they are on, the CNA will first contact the nurse working with the resident; -Staff do walk rounds and shift reports between oncoming and outgoing staff. When a resident is on oxygen, the outgoing nurse provides a report to the oncoming nurse any change in condition; -Each resident's oxygen saturation level is checked depending on the individual resident. If the resident is on oxygen their oxygen saturation level is usually checked every shift; -The order for oxygen saturation level checks (pulse ox checks) and oxygen are on the resident's MAR; -If a resident's pulse ox is low the staff should immediately report to the nurse. The nurse should call the physician and put the resident on oxygen if ordered. During an interview on 01/29/25, at 1:00 P.M., the Administrator said the following: -Oxygen orders are in the resident's electronic record; -He/she would expect the resident's liters of oxygen to be accurate with what is ordered; -He/she would expect nursing staff and CNA's to know how many liters of oxygen a resident has ordered; -He/she would expect staff to communicate any changes in oxygen levels or liters of oxygen at shift change and as needed. MO00245504

Based on observation, interview, and record review, the facility failed to provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to document routine assessment and monitoring of the dialysis site and failed to document ongoing communication with the dialysis center for one resident (Resident #2) who received dialysis. The facility census was 44. Review of the facility's policy titled Dialysis Policy, dated 2025, showed the following: -Purpose to establish guidelines for nursing staff to manage and support residents undergoing dialysis, ensuring safety, infection control, and continuity of care; -Confirm dialysis treatment orders, including type of dialysis (in-center, home, bedside), frequency and duration of treatments and access site type (arteriovenous-an abnormal connection between an artery and a vein (AV)) fistula, graft, catheter); -Obtain contact information for the dialysis center or provider; -Document baseline vital signs, lab results, and current medications; -Share clinical updates, recent lab results, and medication changes with dialysis center; -Obtain the dialysis treatment schedule; -Pre-dialysis care included assess vital signs, inspect dialysis access site for signs of infection, bleeding or hematoma (bruising) and patency bruit (an audible vascular sound associated with blood flow) or thrill (indicates the fistula is working ) in AV fistulas); -Post-dialysis care included monitor residents for complications including hypotension (low blood pressure), dizziness, fainting, bleeding at the access site, and fatigue or cramps; -Maintain detailed records of pre and post dialysis assessments, communication with the dialysis center, and resident's condition and any complications. 1. Review of Resident #2's face sheet (admission data) showed the following: -admission date of 09/17/24; -Diagnoses included end stage renal disease (ESRD - a condition in which the kidneys lose the ability to remove waste and balance fluids). Review of the resident's care plan, initiated 09/27/24, showed the following: -The resident was at risk for infection related to receiving hemodialysis (a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately) three times weekly on Monday, Wednesday and Friday for treatment of chronic renal disease; -The resident had a dialysis fistula (a connection) is in his/her right upper arm; -Provide ongoing monitoring and care of the resident's vascular access and complications for hemodialysis; -Charge nurse to complete the dialysis communication form and send with the resident to the dialysis clinic to aide in communication between clinic and this facility; -Communicate any information including the resident's status with the dialysis clinic prior to and post dialysis; -Provide dialysis site care as ordered. Provide direct visual monitoring of his/her site before and after dialysis for signs of infection. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/24/24, showed the following information: -Moderate cognitive impairment; -Resident received dialysis; -No skin conditions or treatments. Review of the resident's January 2025 Physician Order Sheet (POS) showed an order, dated 09/30/24, for dialysis every Monday, Wednesday and Friday at 7:00 A.M. (Staff did not have an order regarding assessment of the resident's dialysis site.) Review of the resident's medical record showed staff did not have documentation of dialysis communication forms between the facility and the dialysis center. The nurses did not document follow-up contact with the dialysis center after each dialysis visit. The nurses did not document related to assessment of dialysis site. During interviews on 01/28/25, at 4:45 P.M., and on 01/29/25, at 10:34 A.M., Registered Nurse (RN) A said the following: -Nurses did not send communication forms for the resident's dialysis appointments on Monday, Wednesday and Friday; -The resident did not return from his/her dialysis appointment with a communication form; -The resident is at his/her appointment by the time he/she starts shift at 6:00 A.M.; -The dialysis center calls the facility with any abnormal problems with the appointment; -The dialysis center sends a form back to the facility only when they complete labs; -He/she checked the resident's fistula for bruit/thrill unofficially and did not document; -There is no order for dialysis site assessment; -Nurses should check the resident's dialysis site to ensure everything is functioning correctly; -Staff should check the resident's dialysis site for bruit, thrills and make sure is not bleeding or infected. During an interview on 01/29/25, at approximately 1:00 P.M., the physician said he/she expected staff to check a resident's fistula if they receive dialysis. During an interview on 01/29/25, at 11:29 A.M., the Director of Nursing (DON) said the following: -Nurses assess the resident's dialysis site every shift to make sure that it is working and document on the medication administration record or treatment administration record; -Nurses should check the resident's dialysis site upon return from the appointment for bleeding; -There should be an order from physician for dialysis site assessment; -There was no order for staff to check the resident's dialysis site; -The facility had dialysis communication forms but the dialysis center never sent them back to the facility; -Staff communicate with the dialysis center via telephone. During an interview on 01/29/25, at 12:50 P.M., the Administrator said he/she expected staff to send communication forms for dialysis to and from the dialysis center. She expected staff to check the resident's fistula and document on the TAR.

Based on observation, interview, and record review, the facility failed to acknowledge, assess, provide supportive services, and to develop a care plan that showed interventions the facility staff would take to try to protect the resident and prevent trauma from recurring for one resident (Resident #1), out of 17 sampled residents, who informed staff of past trauma. The facility census was 44 residents. Review of the facility's policy entitled Trauma-Informed Care, dated 2025, showed the following: -The facility will provide trauma-informed care (TIC) that recognizes, assesses, and responds to the effects of trauma on residents; -Staff will be trained in trauma-informed care principles, focusing on psychological safety, trust, and individualized care; -The facility will integrate evidence-based interventions and coordinate with behavioral health providers when necessary; -Person-centered approaches will be used to reduce re-traumatization and support residents in their recovery; -Upon admission screen all residents for history of trauma (physical, emotional, medical, or war-related PTSD (post-traumatic stress disorder), abuse, neglect, etc.); document any signs of trauma-related distress (anxiety, aggression, withdrawal, nightmares, etc.); identify triggers or care preferences that may help avoid re-traumatization; and obtain resident and family input (when appropriate) to develop a trauma-sensitive care plan; -Ongoing monitoring included staff to observe for emotional distress, PTSD symptoms, or behavioral outbursts and document concerns in the medical record and social services and nursing will conduct quarterly assessments and update care plans accordingly; -Develop individualized care plans that incorporate resident's history and identified triggers, preferred coping strategies, staff communication preferences, and special accommodations; review care plans and update regularly based on the resident's progress and feedback; -Resident have the right to trauma-informed care that supports dignity, respect, and autonomy. 1. Review of Resident #1's face sheet (gives brief profile information) showed the following information: -admission date of 11/14/24; -Diagnoses included bipolar disorder (mood swings), borderline personality disorder (characterized by unstable moods, behavior, and relationships), schizophrenia (affects a person's ability to think, feel, and behave clearly), depression, anxiety, and insomnia. Review of the resident's electronic medical record showed a hospital emergency department note, dated 11/13/24, with an indication of victim of emotional abuse and sexual abuse. Review of the resident's Social Service History & Initial Assessment, dated 11/15/24, showed the following information: -admitted from living in a hotel and homeless; -Close with parents and two siblings until both siblings sexually assaulted him/her. He/she was told it was his/her fault because he/she didn't tell them no; however he/she did not ask for it either. Review of the resident's reentry Trauma Informed Care Assessment, dated 12/17/24, showed the following information, per the resident's responses: -Experienced something unusually or especially frightening, horrible, or traumatic, but no specific triggers; -Tried hard not to think about the event(s) or went out of the way to avoid situations that reminded him/her of the event(s); -Been constantly on guard, watchful, or easily startled; -Felt numb or detached from people, activities, or surroundings; -Felt guilty or unable to stop blaming self or others for the event(s) or any problems the event(s) may have caused. Review on 01/28/25 of the resident's care plan, last updated on 01/02/25, showed the following: -Diagnoses of serious mental illness including schizophrenia, schizoaffective disorder bipolar type, generalized anxiety disorder, major depression disorder, and bipolar 1 disorder; -Address emotional issues, monitor and give medications as ordered; -History of suicidal ideations; monitor for signs/symptoms; -At risk for mood problems - allow control over situations if possible. (Staff did not document information pertaining to past identified trauma.) During an interview on 01/27/25, at 4:00 P.M., the resident said he/she had been sexually abused by his/her siblings growing up. The resident said he/she was sometimes uncomfortable with the thought of personal care being provided by a male caregiver. There was one male staff on night shift that could assist another aide with care and repositioning. During an interview on 01/31/25, at 9:08 A.M., Certified Nurse Aide (CNA) L said the resident always seemed nervous and anxious. The CNA was not aware of previous trauma or triggers for the resident. During an interview on 01/31/25, at 10:59 A.M., Certified Medication Technician (CMT) J said he/she was not aware of trauma or any specific triggers for the resident. During an interview on 01/31/25, at 8:40 A.M. Registered Nurse (RN) A said he/she just found out the day before about the resident's trauma history. The RN was not sure if the trauma would go on the MDS report, but it should be put on the resident's care plan by the MDS/Care Plan Coordinator. During an interview on 01/31/25, at 9:14 A.M., the Director of Physical Therapy (PT) said he/she was not aware of resident's trauma or specific triggers. Their department is usually given that type of information. The resident does have anxiety and psychological issues, but did not know any specific diagnoses. During an interview on 01/29/25, at 6:00 P.M., the Social Services Director (SSD) said the resident told him/her during the admission process about being sexually abused by both of his/her siblings growing up. The resident said his/her family said it was his/her fault for not saying no. The SSD was unaware of any triggers for the resident related to the trauma. The SSD said he/she informs the MDS/Care Plan Coordinator if the trauma should be added to any resident's MDS report and/or care plan. During an interview on 01/31/25, at 8:50 A.M., the MDS/Care Plan Coordinator said there should be an admission assessment for trauma. The SSD would tell him/her if trauma was indicated and MDS would see that on the assessment score. The MDS/Care Plan Coordinator said the resident's addition to MDS and the Care Plan was put in process the day before. During and interview on 01/29/25, beginning at 6:00 P.M., the Director of Nursing (DON) said he/she was unaware of the resident's report of sexual abuse or of any triggers. The DON was unaware of the resident's concern regarding personal care provided by male aide. During an interview on 01/31/25, at 1:32 P.M., the Administrator said the admission process should include a PTSD/Trauma-Informed Care assessment completed by the SSD. Information pertaining to PTSD and/or triggers should be passed on to the MDS/Care Plan Coordinator for inclusion. Other staff should be told in generality regarding a resident's history of sexual abuse or trauma and triggers, if known.

Based on observation, interview, and record review, the facility failed to maintain a functional environment for all residents, when staff failed to maintain a bariatric Hoyer weight scale when staff were unable to take a weight on one resident (Resident #8), out of a total sample of 17 residents, for six months for one resident. The facility census was 44. Review of the facility's policy titled Weight Assessment and Intervention, revised September 2008, showed the following: -The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents; -The dietician will review the unit weight record monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight changes has been met. 1. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admission date of 08/31/22; -Diagnoses included atrial fibrillation (abnormal heartbeat), hyperlipidemia (high cholesterol), chronic kidney disease, and edema (swelling). Review of the resident's current physician orders showed an order, dated 03/03/24, for monthly weights one time a day starting on the 3rd and ending on the 3rd of every month for monthly monitoring. Review of the resident's vital signs, dated 07/03/24, showed the resident weighed 438.8 pounds. Review of the resident's care plan, dated 08/14/24, showed the following: -The resident has nutritional problems as evidenced by his/her weight being above the recommended BMI (body mass index) and diagnosis of morbid obesity; -The resident has a desired weight loss of eight pounds with increase of his/her Lasix (a diuretic medication); -Staff to monitor/record weight; -Staff to notify the physician and family of significant weight changes; -Monitor the resident's weight at least monthly. Notify the resident's physician and dietician per facility weight protocol. Review of the facility's rental agreement for patient lift electric bariatric up to 600 pounds showed the following: -On 10/21/24, from 9:00 A.M. to 5:00 P.M., showed the company delivered lift to the facility. Documentation at the top of the document showed rented 10/21/24 and delivered broken; -On 10/22/24, at 12:46 P.M., showed the company picked the patient lift electric bariatric up to 600 pounds/ Documentation at the top of the document showed returned next day because it was received broken; -On 10/22/24, from 9:00 A.M. to 5:00 P.M., service order reason for service was repair for the patient lift electric bariatric up to 600 lbs; -On 10/22/24, at 12:46 P.M., the company delivery order showed patient lift electric bariatric up to 600 pounds. Documentation at the top of the sheet showed rented new because other was received broken; -On 11/27/24, at 9:00 A.M. to 5:00 P.M., for patient lift electric bariatric up to 600 pounds reason for pickup was equipment not needed. Staff wrote at top of document, Returned broken and purchased new. The Hoyer broke while transferring patient and bolt holding sling fell out. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/03/24, showed the following: -Cognitively intact; -Weight of 439 pounds. Review of the facility's durable medical equipment invoice dated 12/05/24, at 9:42 A.M., showed an invoice for lift patient bariatric electric 600 pounds with total of $1398.00. Review of the resident's vital signs, dated 01/16/25, showed the resident weighed 398.8 pounds. During an interview on 01/30/25, at 8:43 A.M., Certified Nurse Aide (CNA) E said the following: -He/she did not know the resident had a weight loss; -Staff weigh residents on the scale monthly; -The nurses give the aides a list of residents to weight monthly; -Staff report the weight to the nurse and the nurse documents the weight in the computer. During an observation and interview on 01/30/25, at 11:15 A.M., the resident lay in his/her bed. The resident said staff weigh him/her one time per month with a Hoyer weight scale. He/she had tried to eat better and less. He/she wants to lose weight. During an interview on 01/31/25, at 8:57 A.M., CNA L said it was several months the durable medical equipment company brought a Hoyer scale and it was sent back, brought back another one the next day and for a short period, the company had trouble getting a Hoyer lift with a scale on it. The facility scale was not wide enough for the resident's wheelchair. During an interview on 01/31/25, at 9:08 A.M., CNA H said the following: -The facility had a Hoyer scale then did not have it and he/she did not know why; -Staff did not weigh the resident from July 2024 to January 2025 because the scale was broken; -The Administrator and Director of Nursing (DON) said they were working on it when staff reported the broken scale. During an interview on 01/30/25, at 12:01 P.M., Registered Nurse (RN) A said staff did not have a a way to weigh the resident from 07/03/24 to 01/16/25. During an interview on 01/31/25, at 9:55 A.M., the MDS/Care Plan Coordinator said she asked for the resident's monthly weights between the months of July 2024 through January 2025. The facility had two or three broken weight scales. During an interview on 01/31/25, at 8:59 A.M., the Director of Rehab said he attends the weekly risk meeting and staff discuss weights. He/she did not know the scale did not work for the resident. During an interview on 01/30/25, at 12:11 P.M., the DON said the following: -The facility had trouble with the Hoyer scale. The facility rented a scale that did not work and finally the facility purchased a hoyer weight scale; -Staff did not weigh the resident from 07/03/24 through 01/16/25 due to the facility did not have a Hoyer weight scale for the resident; -She did not know how much weight the resident had lost. Staff did not document the weight loss on 01/16/25. During interviews on 01/30/25, at 1:32 P.M., on 01/31/25, at 1:33 P.M., the Administrator said the following: -The facility's Hoyer lift for the resident was broken and she did not know staff did not weigh the resident from 07/03/24 to 01/16/25; -She did not know how long the Hoyer lift scale was broken; -Right before Christmas, she requested a weight and staff said the Hoyer scale was broken; -She purchased a new Hoyer lift scale December 2024; -She instructed staff to weigh residents who had not been weighed. -She expected staff inform her if equipment is broken; -She expected staff to document and notify the physician if staff did not get a monthly weight for longer than four months. MO00246960

Based on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a dignity bag for one resident's (Resident #34) Foley catheter (sterile tube inserted into the bladder to drain urine) bag (bag that collects urine drained from a catheter inserted into the bladder) and when staff yelled in the dining room, and when the facility smoking scheduled was at the same time as lunch causing smoking residents to choose between smoke break and a hot meal. The facility census was 44. Review of facility policy titled Procedure for Ensuring Resident Rights, dated 2025, showed the following: -Residents are encouraged to participate in the Resident Council; -The facility will support and facilitate resident-led discussions on improving care; -No staff member may interfere with or retaliate against residents for voicing concerns. 1. Review showed facility did not provide a policy related to catheter. Review of Resident #34's face sheet (brief information sheet about the resident) showed the following: -admission date of 05/01/24; -Diagnoses included neuromuscular dysfunction of bladder (loss of bladder control, inability to empty bladder), urinary retention, and urinary incontinence. Review of the resident's care plan, dated last updated 10/08/24, showed the following: -The resident required an indwelling urinary catheter due to diagnosis of neurogenic bladder; -The resident will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma; -Staff should provide catheter care per facility protocol or doctor's orders; -Store collection bag inside a protective dignity pouch. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/28/24, showed the following: -Cognitively intact; -Had an indwelling catheter (thin, hollow tube that's inserted into the bladder to drain urine). Review of the resident's physician's order sheet (POS), current as of 01/31/25, showed the following: -An order, dated 05/07/24, to check placement of Foley catheter securement device (anchor) and dignity bag (bag used to cover and hold the catheter collection bag so it is not visible) every shift; -An order, dated 10/01/24, to change Foley catheter bag monthly and as needed; -An order, dated 10/08/24, for Foley catheter care every shift and as needed; -An order, dated 10/18/24, to change Foley catheter monthly and as needed. Observation of the resident showed the following: -On 01/26/25, at 5:01 P.M., the resident was in bed with his/her eyes closed. A catheter bag was visible on left side of bed facing the open door with about 100 cubic centimeter (cc - a unit of volume used to measure liquids and medications) yellow urine visible. The catheter bag was not covered with a dignity cover; -On 01/27/25, at 3:29 P.M., the resident was in bed with eyes closed. The catheter bag was facing the door with yellow urine visible from hallway; -On 01/28/25, at 9:42 A.M., the resident was in bed with housekeeping in the room and nursing staff providing medications. The catheter bag was facing the door with about 200 cc yellow urine visible; -On 01/28/25, at 12:37 P.M., the resident was resting in bed with eyes closed. The catheter bag was facing the door with no dignity cover and had about 300 cc yellow urine visible from the hallway; -On 01/28/25, at 2:00 P.M., the resident was in bed on the telephone. The catheter bag was visible with over 300 cc urine visible from the hall. During an interview on 01/29/25, at 1:10 P.M., Certified Nurse Aide (CNA) C said that catheter bags should be in a dignity bag when resident is in a wheelchair or in the common areas. The catheter bag did not necessarily need to be in privacy bag when the resident was in their room unless the resident wanted that. He/she said that if the care plan had dignity bag us on it, then it should be done. During an interview on 01/29/25, at 1:25 P.M., CNA D said catheter bags should be in a dignity bag at all times so it was not visible to others. During an interview on 01/29/25, at 2:15 P.M., CNA E said residents should have catheter bags in dignity bag when out in public, but not necessarily in a dignity bag when in their room unless they want it. If it in their care plan to use one, then staff should follow care plan. During an interview on 01/29/25, at 2:24 P.M., Certified Medication Tech (CMT) F said catheter bags should be kept in dignity bags. During an interview on 01/29/25, at 3:00 P.M., Registered Nurse (RN) B said catheters should be covered if the resident wants it covered. Some residents do not care whether it is covered in their room or out of their room and just want to get to the activity. During an interview on 01/30/25, at 10:30 A.M., RN G said that catheter bags should be in a dignity bag at all times. Even in resident rooms the catheter bag should be in a cover because the resident might have a visitor. During an interview on 01/30/25, at 11:45 A.M., RN A said catheter bags should always be in a dignity bag, even in the resident room. During an interview on 01/30/25, at 3:00 P.M., the Director of Nursing (DON) said catheter bags should be in dignity covers. They should not be visible in common areas or in resident rooms. The bag should not be visible in resident rooms from the hallway. If a resident's care plan states a dignity bag should be used, there really should be a dignity bag. During an interview on 01/30/25, at 3:25 P.M., Administrator said staff should ensure that resident catheter bags were in dignity covers at all times. 2. Observation on 01/26/25, at 5:30 P.M., showed the Dietary Manager (DM) yelling does everyone have their food. Raise your hand if you do not. Observation on 01/29/25, at 1:09 P.M., showed the DM yelling, from behind the serving area to residents, who were sitting at their tables throughout the dining room, asking the residents if they wanted seconds. CNA C responded there is no need to yell. Observation on 01/31/25, at 12:42 P.M., showed Dietary Aide (DA) R behind the serving area yell through the dining room to Resident #19, do you want cheese. During an interview 01/31/25, at 8:50 A.M., Resident #41 said that staff often yell at meals, but they have to check who does not have food, they probably could be quieter. During an interview on 01/30/25, at 12:50 P.M., Resident #29 said mealtime in the dining room was very loud because of the staff yelling and some residents playing music. During an interview on 01/31/25, at 12:42 P.M., the DM said the he/she ensured that all residents had received their meals by checking all meal tickets and by screaming through the dining room asking the residents if they had received their food. During an interview on 01/31/25, at 10:57 A.M., the DON said a lot of yelling goes on during mealtime that is not necessary. The DON had spoken with the DM about the yelling during meal time. Facility staff members have complained about the DM yelling during meal time. Staff should be using their inside voice when in the building. The staff who are serving meals could ensure that all residents have received their meals so the DM would not have to yell. During an interview on 01/31/25, at 11:24 A.M., the Administrator said there was sufficient staff in the dining room to ensure that all residents received their meals. The kitchen staff should not be yelling through the dining room to the residents. 3. Observation on 01/29/25, at 12:40 P.M., showed the following: -Resident #33 eating lunch when CNA D asked the resident if he/she was going to eat or go out and smoke. The resident stayed at the table and finished his/her food; -Resident #14 was eating lunch when CNA D asked the resident, do you want to smoke or eat. We'll put a cover over your food and you can eat when you come back. The resident took a bite of his/her ham and beans and left the dining room to smoke. CNA C put a food cover over the resident's food that was left on the table. Observation on 01/30/25, at 12:45 P.M., of the lunch serve out showed the following: -DA N prepared Resident #14's plate and sent to be served to the resident. Resident #14 was outside smoking. The plate was put to the side and left uncovered; -DA N prepared Resident #33's plate and sent to be served to the resident. Resident #33 was outside smoking. The plate was put to the side and left uncovered. During an interview on 01/30/25, at 12:50 P.M., Resident #29, who was in the smoking area, said the he/she was often made to choose between smoking or eating. Meals being served by kitchen staff are often not on time. He/she had to leave his/her food on the table, and go smoke during smoking time. He/she would return to the dining room to finish the meal, which was often cold by this time. During an observation on 01/30/25, at 12:50 P.M., of Resident #33, who was in the smoking area said, It's time to go eat my cold sandwich. During an interview 01/31/25, at 8:50 A.M., Resident #41 said sometimes he/she had to choose between the schedule cigarette break and having a hot lunch because the staff would not take the residents to smoke until the next scheduled smoke break at 3:30 P.M. During an interview on 01/30/25, at 12:51 P.M., Housekeeper (HK) Q, who was supervising residents smoking, said the following he/she was told residents had to smoke at designated smoking times or they would not be allowed to smoke until the next designated smoking time. There were no exceptions or altering of the designated smoking times. Lunch is often served late and residents often had to choose between smoking and eating a warm meal. During an interview on 01/31/25, at 10:57 A.M., the DON said meals were not always served on time. When meals were served late residents should be given the option to smoke when they are done eating. Residents should not be made to choose between eating a hot meal or smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to act as a fiduciary and properly manage residents' funds when the facility failed to maintain access to a petty cash fund that ensured all resident could receive cash requests of less than $100.00 (or less then $50.00 if the resident received Medicaid) the same day for three residents (Resident #1, #26, and #44) out of a total sample of 17 residents. The facility census was 44. Review of the facility policy titled, Personal Needs Allowance (PNA), revised February 2019, showed the following: -All patients that the facility receives the original income checks in full are to be credited with $50.00 to their PNA account; -Petty cash in the amount of $750.00 is to be kept for small requests and should be replenished on a as needed basis; -All patients must sign their request and receipts acknowledging receipt of funds. (The policy did not address how quickly residents should be able to obtain their funds.) 1. Review of the resident council minutes, dated 12/30/24, showed the facility's banking hours were 10:30 A.M. to 3:00 P.M. 2. Review of Resident #1's face sheet (admission data) showed the resident admitted to the facility on [DATE] and readmitted on [DATE]. Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/24/24, showed the resident had intact cognitive skills. Review of the resident's authorization for patient account, dated 11/14/24, showed the resident signed to delegate the nursing facility to handle his/her financial transactions on his/her behalf. Review of the facility's maintained resident fund account showed as of 01/29/25 the resident with an ending balance of $38.76. During an interview on 01/28/25, at 10:15 A.M., during the group interview, the resident said he/she would like to have access to his/her funds available on the weekend. He/she had family visit this past weekend and wanted more money. 3. Review of Resident #26's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the resident had intact cognitive skills. Review of the resident's authorization for patient account, undated, showed the resident signed to delegate the nursing facility to handle his/her financial transactions on his/her behalf. Review of the facility's maintained resident fund account showed as of 01/29/25, the resident had a balance of $422.01. During an interview on 01/28/25, at 10:15 A.M., during the group interview, the resident said if he/she forgets to ask for his/her money during the week, he/she would like his/her personal funds on the weekends. 4. Review of Resident #44's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the resident's cognitive skills were moderately impaired. Review of the resident's authorization for patient account, undated, showed the resident signed to delegate the nursing facility to handle his/her financial transactions on his/her behalf. Review of the facility's maintained resident fund account showed as of 01/29/25, the resident had a balance of $637.00. During an interview on 01/28/25, at 12:50 P.M., the resident said he/she keeps in mind the time limits to access his/her money, but he/she plans ahead so it had not been an issue for him/her. There was a time when he/she wanted to buy a snack, but he/she did not have money to do so because it was outside the timeframe to obtain his/her money from the facility. He/she would like to have more access to his/her money. 5. Observations throughout the survey, 01/26/25 through 01/31/25, showed a laminated sign posted at the front office located near the facility entrance door which stated Resident trust banking Monday through Friday 10:30 A.M. until 3:00 P.M. 6. During an interview on 01/28/25, at 10:54 A.M., the Activity Director said the following: -The front office is open Monday through Friday from 10:30 A.M. to 3:00 P.M. if a resident wants cash; -The Business Office Manager (BOM) informs the resident how much money is available; -Residents sign a receipt book and the BOM writes it down on the log; -All the residents are pretty good about getting their money from 10:30 A.M. to 3:00 P.M. Monday through Friday; -Some residents occasionally say they want money after 3:00 P.M.; -He/she had heard residents say they have to wait till tomorrow to get money; -Residents did not have access to cash on the weekends. During an interview on 01/29/25, at 2:58 P.M., the BOM said the following: -He/she is responsible for the resident fund accounts; -Residents ask him/her for cash; -He/she writes the requested cash on a list and the resident signs a receipt; -Residents can access cash Monday through Friday from 8:00 A.M. to 4:30 P.M. The facility tries to have the banking hours from 10:30 A.M. to 3:00 P.M., but if a resident needs cash before then, staff can get the cash for them; -Residents come to the office to access cash and have it for the weekend; -Residents cannot get cash after hours or on the weekends. During an interview on 01/29/25 at 10:34 A.M., Registered Nurse (RN) A said residents cannot get money on the weekends because there is no one in the front office. During an interview on 01/29/25, at 11:29 A.M., the Director of Nursing (DON) said the following: -Residents go to the front office and ask the BOM for cash Monday through Friday during banking hours; -The resident are not able to get money on the weekends; -The residents know the office is closed on Saturday and Sundays. During an interview on 01/30/25, at 1:32 P.M., the Administrator said the following: -Residents access funds Monday through Friday from 10:00 A.M. to 3:00 P.M.; -Residents use the soda machine or the local store so staff get enough money for them to have until Monday.

Based on observation and interview, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment when a handrail in a common area remained in an unsafe condition, chair cushions in a common area were in disrepair, and two walls of one resident's (Resident #16) room were damaged. A sample of 17 residents was reviewed; the facility census was 44. Review of a facility policy entitled Maintenance Service, revised December 2009, showed the following: -The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include maintaining the building in good repair and free from hazards; -The Maintenance Director is responsible for maintaining work order requests. Review of the facility policy entitled Quality of Life - Homelike Environment, revised May 2017, showed the following: -Residents are provided with a safe, clean, comfortable and homelike environment; -Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences; -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment, inviting colors and décor, and personalize furniture and room arrangements. 1. Observation on 01/29/25, at 8:15 A.M., and on 01/30/25, at 8:20 A.M., of the 100 hall TV lounge area showed the following: -One rocking chair with a 4 to 6 inch tear in the right side of the cushion cover, exposing the foam interior and plastic piping with two rough/sharp ends, and a 3 to 4 inch tear on the left side exposing the plastic piping; -A second rocking chair with two 2 to 3 inch tears to the top of the cushion, revealing the inner foam. During an interview on 01/31/25, at 9:08 A.M., Certified Nurse Aide (CNA) L said he/she had not noticed the torn rocking chair cushions in the 100 hall TV lounge area. Several residents do like to sit there to watch TV. During an interview on 01/31/25, at 9:11 A.M., Certified Medication Tech (CMT) J said he/she was unaware of the torn rocking chair cushions. During an interview on 01/31/25, at 11:48 A.M., the Director of Nursing (DON) said he/she not aware of lounge rocking chair cushions that were torn with inner foam and piping exposed. Staff should have reported that to housekeeping. During an interview on 01/31/25, at 1:32 P.M., the Administrator said he/she was not aware of the torn rocking chair cushions. Staff should have told housekeeping or maintenance and those cushions should be thrown away and replaced. 2. Observations on 01/26/25, at 4:17 P.M., on 01/29/25, at 12:05 P.M., and on 01/30/25, at 12:05 P.M., of the hallway outside the dining room showed the handrail end cap was off and resting on top of the railing. The uncapped handrail end had two sharp connector edges, approximately 6 inches from the doorway into the dining room. The handrail was located directly under a hand sanitizer gel dispenser and adjacent sign board listing the meal service times. Review of the Maintenance Request Log located at the nurses' desk showed staff did not document repair needed to the hand rail outside the dining room. During an interview on 01/30/25, at 1:34 P.M., the Maintenance Director said nobody had told him/her about the broken hand rail. During an interview on 01/31/25, at 11:48 A.M., the DON said he/she was not aware of an issue regarding a hand rail that was in need of repair. 3. Review of Resident #16's face sheet (gives basic profile information) showed an admission date of facility on 06/13/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/27/24, showed the following information: -Severely impaired cognition; -Able to self propel wheelchair; -Required partial assistance for dressing, bathing, transfers, and toileting. Observations on 01/27/25, at 2:10 P.M., on 1/29/25 at 8:05 A.M., and on 1/31/25, at 9:25 A.M., of the resident's room showed the wall along bed had damage to an area at least 4 feet wide by 3 feet high. The area had multiple gouges of varying lengths, widths, and depths that penetrated through the paint, drywall paper, and drywall. Areas of orange coloring were visible in numerous spots where the paint and drywall paper was peeled/curled back. Observation and interview on 01/31/25, at 1:16 P.M., in the resident's room showed the resident in his/her room, sitting in a wheelchair. The 4 to 6 inch wall to the left of the sink area was visibly damaged, with egg-sized pieces of the drywall and part of the vinyl baseboard missing. During the observation, the resident said the walls looked messy. He/she said it looked like they had been hit quite a few times with wheelchairs or something, and he/she would like it to be fixed. Review of the Maintenance Request Log located at the nurses' desk showed staff did not document repair needed to the resident's walls. During an interview on 01/31/25, at 9:14 A.M., the Maintenance Supervisor said he/she was not aware of the condition of the resident's walls and it was not on the list of rooms needing repairs. The condition of the resident's walls was unacceptable. During an interview on 01/31/25, at 11:24 P.M., the Administrator said he/she was not aware of the condition of the resident's walls. The resident's room was not on the list of rooms that needed repairs. The condition of the resident's walls was unacceptable. 4. During an interview on 01/31/25, at 9:08 A.M., CNA L said staff should report maintenance needs and repair requests to the Maintenance Director or put it on the Maintenance Log at the nurses' desk. During an interview on 01/31/25, at 9:11 A.M., CMT J said staff should log in maintenance requests/repairs needed on the book at the nurses' desk. The Maintenance Director checked the log daily. During an interview on 01/31/25, at 10:40 A.M., Registered Nurse (RN) A said staff should put maintenance requests on the log at the nurses' desk. During an interview on 01/31/25, at 9:14 A.M., the Maintenance Supervisor said staff were to log any request for repairs in the maintenance log book. He/she had a list of rooms that needed repairs. During an interview on 01/31/25, at 11:48 A.M., the DON said staff should report all maintenance issues to the Maintenance Director by putting it on the log at the nurses' desk. The Maintenance Director checked the log every morning. During interviews on 01/31/25, at 11:24 P.M. and 1:32 P.M., the Administrator said the staff should log all maintenance request in the maintenance log book or telling the Maintenance Supervisor directly if the repair is more urgent.

Based on observation, interview, and record review, the facility failed to have a system or records that showed provided an accurate reconciliation of controlled medications when facility's licensed staff failed to ensure the Emergency Kit (E-Kit) and the form titled BNDD (Bureau of Narcotics and Dangerous Drugs) Kit Administration Record matched the current narcotic count, when a random count of the narcotics in the E-Kit with the nurse did not match. The facility census was 44. Review of the facility provided policy titled BNDD Kit Policy, dated March 2019, showed the following: -The BNDD kit is owned, managed, and controlled by the long-term care facility; -The BNDD kit will be used when extenuating circumstances exist; -When accessing/opening the BNDD kit the nurse will contact the physician to obtain an order to access the BNDD kit and an order to administer the medication; -The nurse opening the BNDD kit will fill out the form titled Missouri Emergency Kit Order/Audit Form with a witness nurse; -A physical count will be performed on each medication each time the BNDD kit is opened. The quantity on hand shall be documented for each medication listed on the Order/Audit Form; -If a medication is removed from the BNDD kit for administration to a resident that quantity shall be documented in the column QTY ORDERED. This is the quantity that the nurse is requesting that the pharmacy replenish; -If a medication is added to the BNDD kit that quantity shall be documented in the QTY REFILLED. This is the quantity the pharmacy sent as a replacement for what needs to be replaced; -Two nurses shall initial the counts on the Order/Audit form each time the BNDD kit is opened; -The tag numbers shall be documented on the bottom of the Order/Audit form; -The Order/Audit form shall be faxed to the pharmacy upon completion so that the pharmacy knows to replenish the desired medication; -When removing a dose from the BNDD kit the nurse shall document the utilization on the BNDD kit administration record; -A daily shift audit will be performed on the tag numbers and documented on the Tag Log Audit Form; -The DON and/or consultant pharmacist will perform a periodic audit of BNDD kit utilization and records; -An annual physical inventory will be taken on the BNDD kit; -A list of the contents of the BNDD kit shall be displayed on the outside of the container; -A soonest to expire date shall be displayed on the outside of the container. 1. During observation, record review, and interview on 01/29/25, at 2:12 P.M., Registered Nurse (RN) A said the following: -The E-Kit was currently located in the locked black medication cart near the medication room. The cart had a key for the outside of cart and a key for the locked narcotic box on the inside. They did not use lock/tag numbers. The charge nurse was the only one that had the keys to the cart. The nursing staff did not count this cart at shift change. The medications were only counted when the nurse entered to sign out a medication. There was not a two person count of this cart. When signing out a medication, the staff person counted the pills and then sign out the needed medication on the log. The count should match the previous logged out dose. The current count of the Hydrocodone (controlled medication used to treat pain) 5/325 milligrams (mg) showed 6 tablets in cart and 5 tablets on the log. The nurse stated that it should be 6 tablets on the log and he/she would make the correction in the log. He/she said someone just documented incorrectly; -Review of the record, titled BNDD Kit Administration Record, showed the following: -The three-ring binder showed seven pages for the month of January; -On 01/10/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 10 on hand, 1 used, and 9 remaining; -On 01/11/25, staff signed out one dose of un-named medication, dosage 5/325 mg and showed 8 on hand, 1 used, and 7 remaining; -On 01/12/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 7 on hand, 1 used, and 8 crossed out to show 6 on hand; -On 01/13/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 6 on hand, 1 used, and 5 remaining; -On 01/13/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 6 on hand, 1 used, with 5 remaining; -On 01/23/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 9 on hand, 1 used and 8 remaining; -On 01/23/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 8 on hand, 1 used and 7 remaining; -On 01/24/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 7 on hand, 1 used and 6 remaining; -On 01/25/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 6 on hand, 1 used and 5 remaining; -On 01/29/25, observation showed Hydrocodone 5/325 mg with 6 tablets in the cart and 5 tablets on the log. During an interview on 01/30/25, at 10:30 A.M., RN G said the nurses were not counting the E-Kit each shift. The nurse counted the medication at the time of need. When pulling a medication, the nurse had to look back on the log and find the last time someone used the specific medication they were checking out and then add this to the log on the next open line. During an interview on 01/30/25, at 11:45 A.M., RN A said that the Director of Nursing (DON) stocks the E-Kit cart when the medications arrived from the pharmacy. The pharmacy does not enter the E-Kit or write on the log. When the nurse opened the cart he/she wrote the amount of the specific medication he/she was checking out. There was not a full count done with two nurses at each shift or when checking out medications. The log and amount available should match. He/she fixed the log from the inaccuracy on 01/29/25. During an interview on 01/30/25, at 12:00 P.M., the DON said that the current E-Kit was temporary, and they had used this set up for less than two months. The E-Kit was the black and red medication cart located near the medication room. The narcotics were double locked in the cart. The pharmacy delivered the medications and the nurses put all the non-narcotics in the E-Kit and the DON stocked the narcotics. She did not make any note that medications were added into the log. The pharmacy told the DON to put the medications into the cart and then circle on the packing sheet if anything was missing and return the packing sheet to the pharmacy. The nursing staff did not count the E-Kit narcotics every shift, they only count the specific medication needed by themselves when checking out a narcotic. The DON reviewed the log and noted areas where the staff only wrote the strength and did not write the medication name. She said that she had asked the nurses to write the name and strength of the medication in the QTY Ordered line. She audited the E-Kit on Mondays. During an interview on 01/30/25, at 12:15 P.M., the Administrator said she was not aware of the E-Kit process but was aware that it was rocky at the time. She said the facility was in the process of transitioning. She thought they had been using the current system since December.

Based on interview and record review, the facility failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 44. Review of the facility's policy titled, Director of Food and Nutrition Services, undated, showed the following: -The Director of Food and Nutrition Services (DFNS) will be responsible for all aspects of the food and nutrition services department including, but not limited to food safety, staff safety, cost management, and meeting nutritional needs of patients/residents served; -The DFNS will be hired by corporate staff, the Administrator, or by the immediate supervisor of the position as deemed appropriate by the facility; -The DFNS will be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. A facility that does not have a full time dietitian (registered dietitian nutritionist or RDN) or clinically qualified nutrition professional must designate a person to serve as DFNS. According to the Centers for Medicare and Medicaid (CMS) services State Operations Manual for nursing homes F tag 801, the DFNS hired prior to 11/28/16 must meet the following requirement no later than five years after 11/28/16, or no later than one year after 11/12/16, for those hired or designated to that position after 11/28/16: -The DFNS must be a certified dietary manager (CDM); certified food service manager; have a similar national certification for food service management and safety from a national certifying body; or have an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management from an accredited institution of higher learning; and in states that have established standards for food service managers or dietary managers, must meet state requirements for food service managers or dietary managers. During an interview on 01/31/25, at 8:59 A.M., the Dietary Manager said the following: -She started the DM position in December 2024; -She had been the DM assistant for a year; -She had two years of study and received a certificate in culinary arts from Le Cordon Bleu; -She was not a CDM and not enrolled in a training/certification course; -She was not a Certified Food Services Manager and did not have an associate's degree or higher in food service management or hospitality; -She did not have regular contact with a registered dietitian. Review of the DM's personnel file showed the facility did not provide documentation of certification, training, or experience that met the requirements for a DFNS in a long-term care setting. During an interview on 01/31/25, at 10:44 A.M the Registered Dietician (RD) said the DM should have the serv safe certification. She did not know what the corporate policy was or how soon after hiring for the DM was to have the certification. There was a correspondence course to go through to become knowledgeable which would prepare the DM to take the certified dietary manager exam. During an interview on 01/31/25, at 11:24 A.M., the Administrator said the following: -The DM is the Director of Food Services; -The DM had a degree in culinary arts; however the facility did not have a copy of it; -The DM was taking the safe serve class and test that day; -The Administrator thought the DM had the required qualifications.

Based on observation, interview, and record review, facility staff failed to ensure dietary staff had the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. The facility census was 44. Review showed the facility did not provide a policy regarding new employee training. 1. Review showed the facility did not provide completed training documents or skills test for the current kitchen staff. During an interview on 01/29/25, at 2:25 P.M., Dietary Aide (DA) P said the following: -DA P started in the kitchen on 01/24/25; -DA P was still in training and the Dietary Manager (DM) had not gone over any kitchen policies with him/her; -DA P did not feel that he/she had enough training to be serving lunch to residents ,but was told to do so. During an interview on 01/29/25, at 3:00 P.M., [NAME] O said the following: -Cook O started in the kitchen on 12/12/24; -The DM had not gone over facility policy with him/her; -The DM had not trained [NAME] O on facility policy and procedures; -The DM had not provided training to [NAME] O on the puree process. During an interview on 01/29/25, at 3:27 P.M., the DM said the following: -He/she started in the kitchen on 08/30/23; -None of the kitchen staff were safe serve certified including the DM; -New employees had one week of training before working on their own; -The DM had no orientation or training checklist for new kitchen staff; -The DM had no skills competency checks for kitchen staff; -The DM had no document showing staff had been trained; -The DM was not aware of any kitchen policies and procedures that the facility had; -The DM was not familiar with Centers for Medicaid and Medicare Services (CMS) dietary regulations; -DA P did not have enough training before being told to serve lunch; -DA N did not have enough training to puree food items without supervision; -Cook O had previous knowledge and experience and had adequate training; -The DM had provided sporadic in-services with kitchen staff. During an interview on 01/31/25, at 11:24 A.M., the Administrator said the following: -The kitchen staff have not had adequate training; -The DM is responsible for training the kitchen staff; -The DM should complete skills testing with all kitchen staff; -The DM should have gone over kitchen policy and procedures with new staff; -The Administrator did not review kitchen staff training, observe meal prep, or observe a meal serve out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed store, prepare, distribute, and serve food in accordance with professional standards when staff failed to use effective hair restraints; failed to remove dented cans from use; failed to consistently label and date food; failed to ensure the dishwasher machine sanitation was at the appropriate level; failed to keep trash covered when not in use; failed to wash hands and equipment appropriately during food prep and service; and when staff failed to ensure non-food contact surfaces were clean and maintained in good repair. The facility census was 44. 1. Review of the Food and Drug Administration (FDA) 2022 Food Code showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility's policy titled, Food Safety and Sanitation, not dated, showed the following: -Employees are required to have their hair styled so that it does not touch the collar; -Hair restraints are required and should cover all hair on the head; -Beard nets are required when facial hair is visible. Observations on 01/26/25, at 3:15 P.M., and on 01/27/25, at 3:03 P.M., of the kitchen staff showed [NAME] O had facial hair and did not wear a beard restraint. Observation on 01/28/25, at 10:21 A.M., of the kitchen staff showed [NAME] M had facial hair and was not wearing a beard restraint. Observation on 01/29/25, at 10:25 A.M., and on 01/30/25, at 11:53 A.M., showed Dietary Aide (DA) N had facial hair and was not wearing a beard restraint. During an interview on 1/29/25 at 2:25 P.M., DA P said the following: -All kitchen staff were responsible for putting food in the refrigerator and freezer; -Food was to be labeled with what it was and the date it was put in the refrigerator or freezer; -DA P did not know how long left over items can be stored in the refrigerator; -DA P said serving food out of dented cans could make the residents sick; -Resident food is stored in the facility walk in refrigerator and should be labeled and dated; -A hair/beard net must be worn anytime staff were in the kitchen or around food. During an interview on 01/29/25, at 3:00 P.M., [NAME] O said a hair and beard net should be worn at all times while in the kitchen or serving food. During an interview on 01/30/25, at 2:10 P.M., DA N said hair and beard nets were to be worn while preparing and serving meals. During an interview on 01/31/25, at 10:44 A.M., the Registered Dietician (RD) said staff should wear a beard guard if they have a beard. If staff did not have a beard guard, staff can wear a hair net over the beard. During an interview on 01/29/25, at 3:27 P.M., the DM said hair nets and beard nets were to be worn when in the kitchen. During an interview on 01/31/25, at 11:24 A.M., the Administrator said kitchen staff were required to wear hair nets and beard nets at all times while in the kitchen and serving food. 2. Review of the FDA 2022 Food Codes showed the following: -Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food; -If the integrity of the packaging has been compromised contaminants may find their way into the food. -Close inspection of cans for imperfections or damage may reveal punctures or seam defects; -Suspect cans must be returned. Review of the facility's policy titled, Food Safety and Sanitation, not dated, showed bulging or leaking cans, cans with severe dents on the seams, or broken containers of food will not be used. Observations on 01/26/25, at 3:15 P.M., 01/27/25, at 3:03 P.M., and on 01/28/25, at 10:20 A.M. of the of the dry food storage area showed the following: -One dented 6 pound (lb) can of diced peaches; -One dented 6 lb can of sausage gravy; -One dented 6 lb can of kidney beans; -One dented 7 lb can of pork and beans; -One dented 6 lb can of mandarin oranges. During an interview on 01/29/25, at 2:25 P.M., DA P said serving food out of dented cans could make the residents sick. During an interview on 01/31/25, at 11:24 A.M., the Administrator said dented cans should not be used and were to be returned to the distributor. 3. Review of the facility's policy titled, Food Safety and Sanitation, not dated, showed the following: -All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored; -When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food; -Leftovers are used within 72 hours (or discarded); -Perishable foods with expiration dates are used prior to the use by date on the package. Observations on 01/26/25, at 3:52 P.M., of the walk-in refrigerator showed the following: -One food tray containing 12 uncovered condiment containers with a red substance in them. A piece of tape on the food tray read, 1/8, Italian, Ranch, French; -One 3-quart deep clear food pan that contained lettuce, covered with aluminum foil that had a dried yellow/orange substance on it, with no date or label; -One 2-gallon plastic bag that contained approximately 25 baked potatoes with cheese that was not dated or labeled; -One ½ gallon of whole milk with a best by date of 12/15/24, labeled activities and dated 12/10/24; -One large pizza box containing four slices of pizza, not dated; -Two sandwich size plastic bags containing cubed cheese, not dated or labeled; -Two clear condiment containers with a white substance in them not dated or labeled. Observation on 01/27/25, at 3:03 P.M., of the walk-in refrigerator showed the following: -One gallon size plastic bag containing 3 pieces of pizza with a residents name on it and no date; -Two sandwich size plastic bags containing cubed cheese not dated or labeled; -Two clear condiment containers with a white substance in them not dated or labeled. Observation on 01/28/25, at 10:25 A.M., of the walk-in refrigerator showed the following: -One gallon size plastic bag containing 3 pieces of pizza with a resident's name on it and no date; -One sandwich size plastic bag containing cubed cheese not dated or labeled; -Two clear condiment containers with a white substance in them not dated or labeled;. During an interview on 01/29/25, at 2:25 P.M., DA P said the following: -All kitchen staff were responsible for putting food in the refrigerator and freezer; -Food was to be labeled with what it was and the date it was put in the refrigerator or freezer; -DA P did not know how long left over items can be stored in the refrigerator; -Resident food is stored in the facility walk-in refrigerator and should be labeled and dated. During an interview on 01/30/25, at 2:10 P.M., DA N said the following: -Kitchen staff are responsible for putting food in the refrigerator, labeling it and dating it; -Leftovers can stay in the fridge for two days after being made. During an interview on 1/29/25, at 3:00 P.M., [NAME] O said the following: -Kitchen staff were responsible for putting food in refrigerator, including resident food; -Items were to be labeled and dated before being put in refrigerator; -Leftovers could stay in the refrigerator for up to three days; -Resident food is also stored in the walk-in refrigerator and should be dated and labeled. During an interview on 01/31/25, at 10:44 A.M., the Registered Dietician (RD) said staff should label and date foods with date of delivery otherwise they cannot do the first in and first out. Staff should date the date food in the cold storage and date marked for seven days out. During an interview on 1/29/25 at 3:27 P.M., the DM said the following: -All kitchen staff are responsible for putting food in the refrigerator; -All items should be labeled with what it is and dated with the day it goes into the refrigerator; -Resident food is kept in the facility refrigerator and should be labeled with residents name and dated; -The activities director also stored food in the refrigerator and those items need to be dated and labeled; -The DM checked the refrigerator daily for items not dated/labeled and expired items. During an interview on 01/31/25, at 11:24 A.M., the Administrator said all items in the refrigerator and freezer should be labeled with what it is and dated. Resident food were to be labeled and dated prior to going into the refrigerator. Staff should pull items out of the refrigerator that had passed their used by date. 4. Review of the FDA 2022 Food Code showed the presence of adequate detergents and sanitizers is necessary to effect clean and sanitized utensils and equipment. Review of the facility's policy titled, Resource: Sanitation of Dishes/Dish Machine, not dated, showed the final sanitization for low temperature dishwasher, spray type dish machines using chemicals to sanitize should test at 50 parts per million (ppm) hypochlorite (a strong chlorine solution used for disinfecting and sanitizing). Review of the facility's policy titled, Cleaning Dishes/Dish Machine, not dated, showed the following: -All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Observations on 01/26/25, at 3:16 P.M., on 01/27/25, at 3:04 P.M., and on 01/28/25, at 10:21 A.M., of the kitchen showed several 12 ounce plastic, shatterproof, stackable, drinking cups drying on a dish rack and stacked on serving cart with white powdery residue on the outside and inside. The white powdery residue could be scratched off with a butter knife. Observations 01/26/25, at 5:06 P.M., on 01/28/25, at 1:15 P.M., and on 01/30/25, at 1:45 P.M., showed a table in the dining room that had pitchers of flavored drinks and a pot of coffee along with three trays that held 12, 8-ounce brown coffee mugs each. The coffee mugs had a white powdery residue on the inside of them and a buildup of white powdery residue on the bottom of the cups. This residue could be scratched off using an eating utensil. Observations on 01/27/25 ,at 3:06 P.M., on 01/28/25, at 10:38 A.M., and on 01/29/25, at 11:04 A.M., of the kitchen showed one blue plastic basket containing adaptive eating utensils sitting on a wire rack next to the dishwasher that contained three black handle knives with debris on the blades and one gray handle knife with debris on handle. During an interview on 01/29/25, at 2:25 P.M., DA P said the drinking cups were ran through the dishwasher 3 or 4 times and still have a residue on them. He/she did not know what caused the white powdery residue on the drinking cups. During an interview on 01/30/25, at 2:10 P.M., DA N said he/she did not know what caused the white powdery residue on the drinking cups. During an interview on 01/29/25, at 3:27 P.M., the DM said the following: -All kitchen staff were responsible for washing dishes; -Staff should check all items that came out of dishwasher to ensure the items are clean and free of debris; -The white powdery residue on the drinking cups was from hard water and not harmful to the residents. During an interview on 01/30/25, at 9:22 A.M., [NAME] M and DA N said the following: -Cook M and DA N did not know how to test the sanitizer in the dishwasher; -Cook M and DA N did not know who was responsible for testing them; -Cook M used a PH test strip to test the sanitizer in the dishwasher; -The PH test strip turned yellow in color when placed in the dishwasher water; -When the test strip was compared to the reference chart on the bottle of test stripes the color yellow read 0; -Cook M and DA N did not know what the reading meant. During an interview on 01/30/25, at 1:52 P.M., [NAME] O said the following: -Cook O did not know how to test the sanitizer in the dishwasher; -Cook O did not know who was responsible for testing the sanitizer; -Cook O used a PH test strip to test the sanitizer in the dishwasher; -The PH test strip turned yellow in color when placed in the dishwasher water; -When the test strip was compared to the reference chart on the bottle of test stripes the color yellow read zero (0); -Cook O did not know what the reading meant. During an interview on 01/30/25, at 1:56 P.M., the DM said the following: -The DM checked the chemicals on the dishwasher every morning; -The DM used a chlorine test strip to test the sanitizer on the low temperature dishwasher; -The chlorine test strip of the sanitizer on the low temperature dishwasher showed 200 PPM; -The DM did not know the manufactures recommendation for the strength of the sanitizer; -The DM did not keep a log of the test; -The cooks had been trained on how to test the chemicals in the dishwasher; -The cooks should be testing the chemicals on the dishwasher when the DM is not available. During an interview on 01/31/25, at 10:44 A.M., the RD said the sanitization is not correct if dishes have a white film. The low temperature sanitization dish machine sanitation should be 50 to 100 ppm. Staff should contact the company who services the machine and they need to turn it down. During an interview on 01/31/25, at 11:24 A.M., the Administrator said the following: -The white powdery residue on the drinking cups and coffee cups was from hard water and did not believe it was harmful to the residents; -The sanitizer strength on the dishwasher should meet the manufactures recommendation. 5. Observation on 01/27/25, at 3:06 P.M., on 01/28/25, at 10:38 A.M., and on 01/29/25, at 11:04 A.M., of the kitchen showed the following: -One 32-gallon gray trash can containing trash uncovered; -One black two-shelf bussing cart with an attached trash bin that contained trash, sitting next to dishwasher in kitchen not covered; -One white, round trash can with step on pedal that contained trash sitting open next to stove; -The trash cans were not in use. During an interview on 01/31/25, at 10:44 A.M., the RD said she expected the trash cans covered when not in use. 6. Review of the FDA 2022 Food Code showed food employees shall keep their hands and exposed portions of their arms clean. Review of the facility's policy titled, Hand Washing, not dated, showed the following: -Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures; -Hands and exposed portions of arms should be washed immediately before engaging in food preparation; -Wash hands when entering the kitchen at the start of shift, after touching bare human body parts other than clean hands and clean, exposed portions of arms, during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks, when switching between working with raw food and working with ready to eat food, before donning disposable gloves for working with food and after gloves are removed, and after engaging in other activities that contaminate the hands. Review of the facility's policy titled, Employee Sanitary Practices, not dated, showed the following: -All food and nutrition services employees will practice good personal hygiene and safe food handling procedures; -Wash hands before handling food; -Gloves must be worn if raw food is handled; -Clean and sanitize equipment and work areas after use; -Use clean hands, pick flatware ad cups up by their handles, pick dishes up by their [NAME], and pick glasses up by their base. Observation on 01/27/25, at 10:26 A.M., of [NAME] M showed the following: -Cook M went outside to get food item out of walk-in freezer; -Cook M re-entered the kitchen and did not wash his/her hands; -Cook M used the sprayer at the dishwasher and filled a pot with water; -Cook M placed the pot of water on the stove and put a smaller empty pot in the pot of water; -Cook M with ungloved hands put his hand in the second pot touching the bottom of the pot; -Cook M used the can opener to open four cans of tomato soup; -Cook M used his/her right hand to open the trash can next to the stove and left trash can open; -Cook M donned one glove on his/her right hand and poured the four cans of tomato soup in the empty pot on the stove; -Cook M doffed the glove on his/her right hand and put in open trash can; -Cook M went outside to get a food item out of the walk-in refrigerator and re-entered the kitchen and did not wash his/her hands. Observation on 01/27/25, at 10:41 A.M., of the DM showed the following: -The DM went outside to get a food item out of the walk-in refrigerator, re-entered the kitchen and did not wash his/her hands or don gloves; -The DM opened a stick of butter, put the butter in a bowl to be melted and set it next to microwave; -The DM did not wash his/her hands or don gloves during this process. Observation on 01/29/25, at 11:34 A.M., of the puree process showed the following: -DA N gathered the blender bowl, blade, lid and serving spoon to puree food items; -DA N did not wash his/her hands; -DA N placed sweet potatoes in blender bowl, pureed potatoes then poured into metal pan; -DA N removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender. The cook did not use soap or sanitize the equipment; -DA N did not wash his/her hands or don gloves; -DA N took the pan of pureed potatoes out of the kitchen to the serving area, placed on steam table, covered with lid, returned to the kitchen, cook did not wash his/her hands; -DA N went outside to get ham out of walk-in freezer, re-entered the kitchen and did not wash his/her hands; -DA N donned oven mitts to pour beans from pot to metal pan. [NAME] doffed the oven mitts and did not wash his/her hands; -DA N poured diced ham in to pan of beans; -DA N took pan of ham and beans to the serving area and placed on the steam table; -DA N re-entered the kitchen doffed his/her gloves and did not wash his/her hands; -DA N placed ham and beans in the wet blender bowl, pureed ham and beans then poured into metal pan; -DA N removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender. The cook did not use soap or sanitize the equipment; -DA N obtained a large black handled knife from the blue plastic basket containing adaptive eating utensils. The knife had food debris on the blade and was not clean; -DA N donned gloves, picked up the knife and started to make a cut in the pan of cornbread; -DA N took the knife and two other knives from the basket to the dishwasher; -DA N used his/her gloved hands to place three pieces of cornbread, into the wet blender bowl, pureed cornbread then poured into metal pan; -DA N doffed gloves and did not wash hands. Observation on 01/30/25, at 11:30 A.M., of the puree process showed the following: -Cook M donned gloves, sprayed a metal pan with nonstick spray, used his/her gloved hands to pick up three chicken patties, ground chicken to mechanical soft then poured in metal pan; -Cook M removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender. The cook did not use soap or sanitize the equipment; -Cook M put hot water from the coffee maker in the blender bowl, used his/her gloved hands to pick up four chicken patties and place in the blender bowl; -During the puree process cook M opened the blender, used his/her gloved hands to pull out three chicken patties and tear into smaller pieces and placed back in blender, pureed chicken then poured in metal pan; -Cook M performed this task while wearing the same gloves that he/she donned at the beginning of the task. Observation on 1/30/25 at 12:09 P.M., of lunch preparation showed the following: -Cook M donned gloves, went out of the kitchen to the steamtable, picked up two tomatoes, held them in the air while walking back into the kitchen, placed them on a plate, unwrapped plastic used to cover sliced cheese, took out two slices of cheese placed them on a plate, then opened container of jelly and a container of peanut butter; -Cook M obtained another knife, using one knife to spread jelly on a piece of bread, then using a separate knife to spread peanut butter on a piece of bread; -Cook M then doffed his/her gloves. Observation on 01/30/25, at 12:22 P.M., of the lunch serve out showed the following: -DA N washed hands and donned gloves; -DA N went from serving food with serving utensils, opened a bag of hamburger buns, using his/her hands retrieved one hamburger bun, and placed it on plate, then used tongs and placed chicken patty on bun; -DA N picked up resident menu card, then sent menu card along with plate to be served to resident; -DA N did not remove his/her gloves or wash his/her hands. -DA N returned to serving food with serving utensils; -DA N using his/her hands retrieved one hamburger bun, and placed it on plate, then used tongs and placed chicken patty on bun; -DA N retrieved a package of sliced cheese from the kitchen, unwrapped the cheese, using his/her hands retrieved one slice of cheese and placed it on a chicken patty; -DA N picked up resident menu card, then sent menu card along with plate to be served to resident; -DA N did not remove his/her gloves or wash his/her hands. -DA N repeated this process four times; -Cook N did not doff his/her gloves during the lunch serve out process. During an interview on 01/29/25, at 2:25 P.M., with DA P said the following: -The staff were to wash hands before and after touching food, doing dishes, before and after serving food, entering the kitchen, and putting on a hair net; -DA P said gloves should be worn when food is being touched. During an interview on 01/30/25, at 2:10 P.M., DA N said the following: -Hands were to be washed after touching any surface; -DA N looked over items coming out of the dishwasher to ensure they were clean; -Dishes are sanitized when they are run through the dishwasher; -The blender bowl, blade and lid should be run thru the dishwasher between each item and dried before next use During an interview on 01/29/25, at 3:00 P.M., [NAME] O said the following: -Staff should wash hands as often as possible, after touching doorknobs, when entering the kitchen, and when handling food or trash; -When using the blender bowl to puree food items it should be ran through the dishwasher between each use and set out to air dry; -Cook O has had to dry the blender bowl with a towel during meals if the blender bowl was needed. During an interview on 01/31/25, at 10:44 A.M., the RD said the following: -Staff should wash hands before starting a meal service and if staff stay on the serving line only touch the scoops. Staff should wash hands when change gloves and if they leave the serving line or go to the storage room, staff should wash hands before they come back to serve a meals; -She expects dietary staff to know policies for hand hygiene and sanitation. During an interview on 01/29/25, at 3:27 P.M., the DM said the following: -Hand hygiene should be performed every time staff enter the kitchen, touch any food item, trash cans, doors, and tables; -All kitchen staff were responsible for washing dishes; -The blender bowl, blade, and lid should be run through the dishwasher after each use to be cleaned and sanitized; -The blender bowl, blade, and lid should be air dried between each use. During an interview on 01/31/25, at 11:24 A.M., the Administrator said the following: -Kitchen staff were to wash hands every time staff entered the kitchen, when hands were soiled, before food preparation, before and after glove use and after touching contaminated surfaces; -Kitchen staff were to run the blender bowl through the dishwasher to be cleaned, sanitized and air dried between each use; -Food should not be put in a wet blender bowl; -Kitchen staff were to check all items coming out of the dishwasher for cleanliness and to ensure the items are free of debris. 7. Review of the facility's Daily Cleaning Schedule,, dated 2004, showed the following: -Clean outside and inside of microwave - dietary aide; -Clean food processor after each use and under the unit - day and evening cook; -Clean trash cans - evening aide. Review of the facility's Weekly Cleaning Schedule, dated 2004, showed staff were to clean inside of walk-ins, including fans and racks. Review of the facility's Monthly Cleaning Schedule, dated 2004, showed staff were to clean overhead pipes. Review of the facility's Deep Cleaning the Kitchen, to be done every March, June, September and December, undated, showed the following: -Wipe down all ceilings; -Clean all light fixtures, vent covers, and fan covers; -Clean all appliance and containers inside and out, even the appliances not used and cover with a fresh bag; -Clean all trash cans inside and out; -Check all dishes for cracks, scratches, or blemishes and report to the administrator the findings. Observations on 01/26/25, at 3:16 P.M., on 01/27/25, at 3:04 P.M., and on 01/28/25, at 10:21 A.M., of the kitchen showed the following: -A 6-inch area of peeling paint on the ceiling around the round vent above the food preparation table: -A 4-inch area of peeling paint on the ceiling around the round vent above the 5-shelf rack at the end of the prep table; -A round vent on the ceiling to the left of the range hood that was partially hanging off the ceiling and the area around the vent was yellow in color; -A square, white, steel vent cover partially hanging off the ceiling above the commercial coffee and tea maker; -The microwave in the kitchen had a two-inch area on the top, a 3-inch area on the bottom around the edge where the door seals and a 2-inch area under the turn table ring where paint had peeled off. Under the peeled paint in the microwave the surface was brown and orange in color and appeared to be rust. Observations on 01/26/25, at 3:52 P.M., on 01/27/25, at 3:03 P.M., and on 01/28/25, at 10:25 A.M., of the walk-in refrigerator showed dust and dirt build up on the white PVC pipes and the black cables coming from the cooler fans. The PVC pipe was directly over an opened box containing individual cartons of [NAME] Ready Care chocolate shakes. During an interview on 01/29/25, at 2:25 P.M., DA P said he/she was not aware of any cleaning list/schedule. DA P had been cleaning what the DM told him/her to clean. During an interview on 01/30/25, at 2:10 P.M., DA N said he/she was not aware of a cleaning schedule. He/she cleaned what the DM tells him/her to clean. During an interview on 01/29/25, at 3:00 P.M., [NAME] O said the DM tells him/her what he/she is responsible for cleaning. The DA's have a cleaning schedule. He/she was not aware of any cleaning list/schedule for the cooks. During an interview on 01/29/25, at 3:27 P.M., the DM said the following: -Kitchen staff had daily, weekly, monthly, and quarterly cleaning schedules; -The DM assigns cleaning jobs to staff weekly. During an interview on 01/31/25, at 11:24 P.M., the Administrator said the following: -There should not be peeling paint on the ceiling in the kitchen; -The vents should not be hanging off the ceiling in the kitchen; -The fans and pipe in the walk-in refrigerator and freezer should be cleaned on a regular basis and be free from dust and debris; -The microwave in the kitchen was to be free of peeling paint and rust; -Peeling paint, rust, debris, and dust could contaminate food which, when served to residents could cause residents to become ill; -Kitchen staff were to be following the daily, weekly, monthly and quarterly cleaning list for the kitchen; -All repairs should be logged in the maintenance book so maintenance staff were aware of the issue and can make necessary repairs.

Based on observation, interview, and record review, the facility failed to ensure the home was administered in an effective and efficient manner to ensure the highest practical well-being of all residents when the facility failed pay their bills in a timely manner. The facility census was 44. 1. Review of the facility's laboratory service invoices showed the following: -An invoice, dated 07/08/24, showed an amount owed of $2664.31. The invoice showed a note of terms of net 30 days; -An invoice, dated 08/08/24, showed an amount owed of $241.41. The invoice showed a note of terms of net 30 days; -An invoice, dated 09/05/24, showed an amount owed of $3466.70. The invoice showed a note of terms of net 30 days; -An invoice, dated 10/28/24, showed an amount owed of $2880.47. The invoice showed a note of terms of net 30 days. Review of the laboratory's accounts receivable (A/R) aging detail spreadsheet which listed the invoices showed the following: -An invoice, dated 07/08/24 with a due date of 08/07/24. The invoice total and open balance due were $2664.31; -An invoice, dated 08/08/24 with a due date of 10/07/24. The invoice total and open balance due were $241.41; -An invoice, dated 09/05/24 with a due date of 10/05/24. The invoice total and open balance due were $3466.70. Review of the facility check dated 11/25/24, paid to the laboratory showed an amount of $10,918.42. Review of the laboratory's accounts receivable (A/R) aging detail spreadsheet which listed the invoices showed an invoice, dated 10/28/24 with a due date of 11/27/24. The invoice total and open balance due were $2880.47. During an interview on 01/29/25 at 2:58 P.M., the Business Office Manager (BOM) said he/she had received invoices from the company that had not been paid. The company provides laundry soap and kitchen and housekeeping chemicals. He/she and corporate staff received invoices from the providers usually through email. He/she reviewed the invoices to make sure they were correct and emailed them to the billing system which are approved by the regional manager to be paid. He/she did not know the process from there. During an interview on 01/30/25, at 2:03 P.M., the Director of Fiscal Services said the facility paid the bill on 11/25/24. She did not know why it was late. The company provided chemicals for the dishwasher and laundry. During an interview on 01/31/25, at 10:09 A.M., the Laboratory Company Representative said his/her company provided the dishwashing detergent and sanitizers for the kitchen dishwasher and laundry and housekeeping chemicals to the facility. The facility did not show the bill paid up and had not paid the bill since July 2024. During an interview on 01/30/25, at 1:32 P.M., and 01/31/25, at 1:33 P.M., the Administrator said she did not know of the laboratory bill being late. The BOM is responsible to submit the bills to the corporate staff. She expected the facility bills to be paid. MO00246960

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's policy entitled Feeding Tubes, undated, showed the following: -Purpose was to establish guidelines for the safe and effective management of feeding tubes in residents requiring enteral nutrition in long-term care facilities, ensuring compliance with clinical standards and regulatory requirements; -Feeding tube care will be managed to promote resident comfort, minimize complications, and ensure nutritional needs are met, in accordance with clinical guidelines and resident-specific care plans; -Inspect the tube site daily for signs of infection, leakage, or irritation and clean the site with antiseptic solution as per facility guidelines. Review of Resident #149's face sheet showed the following: -admission date of 12/19/24; -Diagnoses included stroke, right dominant side weakness, fluid buildup in the brain, dysphagia (swallowing disorder), feeding tube malfunction, generalized muscle weakness, and acid reflux. Review of the resident's discharge (return anticipated) MDS assessment, dated 12/21/24, showed the following: -Total dependence on others for all activities of daily living (ADLs); -Received intake via tube feeding. Review of the resident's care plan, last updated on 01/02/25, showed the following: -Feeding tube required related to dysphagia following a stroke; -Check PEG (percutaneous endoscopic gastrostomy; surgically placed feeding tube into the stomach) placement previous to flushes, medications, and feedings; -Cleanse PEG tube site and apply new drainage gauze every day shift. Review of the resident's current Physician Orders Sheet (POS) showed an order dated 12/23/24, to cleanse PEG tube site and apply new drainage gauze every day shift. Observation on 01/29/25, at 8:50 A.M., showed Registered Nurse (RN) B sanitized his/her hands, donned a surgical gown and gloves, and entered the resident's room. RN B removed the gown and gloves, exited the room, and returned to the treatment cart in the hallway. The RN retrieved spray wound cleanser from the drawer and sprayed it onto gauze he/she placed into a plastic cup, returning the cleanser to the drawer. Without performing hand hygiene, RN B donned a new gown and gloves and re-entered the resident's room. The RN spoke to the resident, raised the resident's nightgown, and cleansed the stoma site. Using the same gloves, the RN dried the site with gauze. Without performing hand hygiene, RN B changed gloves and placed and taped a clean dressing to the site. Without performing hand hygiene, the RN changed gloves, removed the protective boot from the resident's right foot to view the heel status, replaced the boot, then removed the gloves and washed his/her hands before exiting the room. 6. During an interview on 01/31/25, at 10:55 A.M., CNA H said that staff should completed hand hygiene before and after any resident care. He/she usually completed hand hygiene between glove changes. He/she said it was not appropriate to touch soiled trash or items and then touch the resident. During an interview on 01/31/25, at 9:25 A.M., Certified Medication Tech (CMT) J said staff should complete hand hygiene during every resident care, between dirty and clean, and between glove changes. Staff should clean their hands all the time. During an interview on 01/31/25, at 9:45 A.M., Licensed Practical Nurse (LPN) K said staff should complete hand washing or using hand sanitizer when doing wound care and with any resident care. Staff should clean hands before cares, when changing gloves, before putting on new gloves, and after cares. Staff should clean hands with all dirty to clean process. He/she said he/she took extra gloves and hand sanitizer into the room with wound care. During an interview on 01/29/25, at 3:00 P.M., RN B said that staff should clean hands with soap and water or hand sanitizer when entering a resident room. Staff should apply gloves, remove soiled items, and re-glove and keep re-gloving any time touch something different. He/she said sometimes he/she used hand sanitizer between glove changes. Staff should clean their hands between removing soiled peg tube dressing and applying clean gauze dressing. During an interview on 01/30/25, at 10:30 A.M., RN G said that all staff should wash hands before and after all resident cares, including wound care, catheter care, and peg tube care. Hands should be cleaned after removing soiled gauze and before putting on clean gauze. Staff should clean hands between glove changes and between any dirty and clean process. Staff should not touch dirty trash, laundry, or anything possibly soiled and then touch the resident for cares without cleaning hands and changing gloves. During an interview on 01/30/25, at 11:45 A.M., RN A said staff should wash hands or use hand sanitizer before and after every resident care. Staff should clean hands with every glove change. Staff should not touch any soiled items with gloved hands and then touch the resident without cleaning hands and changing gloves. Staff should clean hands between dirty and clean process of wound care, catheter care, and peg tube care. During an interview on 01/30/25, at 3:00 P.M., the Director of Nursing (DON) said staff should complete hand hygiene between every task, upon entering the resident room, when leaving the resident room, between meal tray pass, after personal breaks, and any time touch anything soiled. Staff should clean hands during catheter care or toileting care. Staff should change gloves and clean hands between dirty to clean process. The same with wound care, clean hands and change gloves dirty to clean process. During an interview on 01/30/25, at 3:25 P.M., the Administrator said that all staff are trained and in-serviced on appropriate hand hygiene. Staff should clean hands all the time, after any resident cares, any touch of any contaminated items, and between dirty and clean process. Staff should not have gloves on and push down the red bag trash or any other trash and then touch the resident without changing gloves or cleaning hands. 7. Review of the facility's policy entitled Enhanced Barrier Precautions (last reviewed 3/2024) showed the following: -Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and gloves use during high contact resident care activities; -All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions; -All staff receive training on high-risk activities and common organisms that require EBP; -The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities; -An order for EBP will be obtained for residents with wounds and/or indwelling medical devices such as urinary catheters and feeding tubes, even if the resident is not know to be infected or colonized with a MDRO; -PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room; -The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education; -High-contact resident care activities include providing hygiene, changing briefs or assisting with toileting, device care or use related to urinary catheters, and feeding tubes; -EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk; -For a resident who has a wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO, use EBP. Review of Resident #44's face sheet (shows basic profile information) showed the following information: -admission date of 09/26/24; -Diagnoses included sepsis (infection in the bloodstream), gangrene (skin tissue death caused by an infection or lack of blood flow), below-the-knee amputation, chronic kidney disease stage 3, and neuromuscular dysfunction of the bladder. Review of the resident's significant change MDS, dated [DATE], showed the following information: -Cognition intact; -Bilateral lower limb impairment; -Indwelling catheter. Review of the resident's current POS, dated 01/31/25, showed orders for catheter care and monitoring. The POS did not include orders for EBP. Review of the resident's care plan, last updated 12/17/24, showed resident at risk for increased probability of infections. Place on EBP related to an indwelling Foley catheter and multiple wounds until resolved. Observation on 01/29/25, at 10:25 A.M., showed CNA C was in the resident's room, preparing to clean the resident's catheter. Upon the surveyor's entrance to the room, CNA C already wore gloves, but did not don a surgical gown. CNA C performed the catheter and peri area cleaning using pre-moistened wipes, bagged the trash, removed his/her gloves, and washed his/her hands at the resident's sink before exiting the room. During an interview on 01/29/25, at 10:35 A.M., the resident responded that the CNA did wash his/her hands prior to donning gloves. The resident said staff always wash their hands and don gloves before doing catheter and peri area cleaning, but he/she had not seen CNA C or other staff wear a surgical gown during that procedure. During an interview on 01/29/25, at 11:15 A.M., CNA C said he/she usually wore a gown and gloves to do catheter care and when assisting a nurse with wound care. The CNA said wearing the gown and gloves was based on the facility's EBP policy to protect the residents. During an interview on 01/29/25, at 4:25 P.M., CNA E said per facility policy staff should wash their hands and don a gown and gloves to assist residents on isolation, for catheter care, and any wound care. During an interview on 01/29/25, at 3:00 P.M., RN B said staff should use EBP including gown and gloves, for residents with open wounds, peg tubes, catheters. There should be a sign on that resident's door to remind staff when needed. During an interview on 01/30/25, at 10:30 A.M., RN G said staff should wear gown and gloves for EBP for residents with a catheter, wounds, or any indwelling medical device. During an interview on 01/30/25, at 11:45 A.M., RN A said staff should wear gown & gloves for residents with wounds, catheters, or tube feedings when completing personal cares. During an interview on 01/30/25, at 3:00 P.M., the DON said should use EBP for any resident that has a sign on their door, anyone with catheter cares, wound cares, open wounds, multi-drug resistant organisms, or peg tubes. 8. Review of a facility policy entitled Legionella Water Management Program, revised July 2017, showed the following information: -As part of the infection prevention and control program, the facility has a water management program, overseen by the water management team; -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread and to reduce the risk of Legionnaire's disease; -The water management program used by the facility is based on the Centers for Disease Control and Prevention (CDC) and ASHRAE (American Society of Heating, Refrigeration, and Air-Conditioning Engineers) recommendations for developing a Legionella water management program; -The water management program includes an interdisciplinary water management team; a detailed description and diagram of the water system in the facility, including: receiving, cold water distribution, heating, hot water distribution, and waste; the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains, and medical devices such as CPAP (continuous positive airway pressure; keeps the breathing airways open during sleep) machines, hydrotherapy equipment, etc.; -the identification of situations that can lead to Legionella growth, such as: construction, water main breaks, changes in municipal water quality, and the presence of biofilm, scale or sediment, water temperature fluctuations, water pressure changes, water stagnation, and inadequate disinfection; specific measures used to control the introduction and/or spread of Legionella; the control limits or parameters that are acceptable and that are monitored; a diagram of where control measures are applied; a system to monitor control limits and the effectiveness of control measures; -a plan for when control limits are not met and/or control measures are not effective; and documentation of the program; -The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur: control limits not consistently met, major maintenance or water service change, any disease cases associated with the water system, or changes in laws, regulations, standards or guidelines. Review of facility's records showed the facility did not provide documentation related to water testing pertaining to the facility's Legionella program. During an interview on 01/30/25, at 1:43 P.M., the Maintenance Director said the following: -The facility used to complete Legionella testing with testing strips, but he could not recall when the last time this was completed.; -There were issues in the past with getting testing strips, but did not know if it were a current issue; -He did not know if the facility had any Legionella testing materials onsite. During an interview on 01/30/25, at 1:52 P.M., the Administrator said the following: -The facility does not complete Legionella testing; -The facility staff conduct regular running of water to prevent growth of Legionella; -She checks the water quality reports every six months and as any issues are identified; -If any water quality issues are identified related to Legionella the facility immediately stops usage of facility water and enacts the water management plan; -The facility would complete Legionella testing if any concerns related to Legionella testing were identified in the water quality report; -The facility does not maintain any Legionella testing materials onsite. Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene after personal cares for two residents (Residents #11 and #8), during and after wound care for one resident (Resident #34), and during and after feeding tube care for one resident (Resident #149). Staff also failed to follow Enhanced Barrier Precautions (EBP) for one resident (Resident #44) who had an indwelling catheter and failed to follow their Legionella (severe form of pneumonia) Water Management Program. The facility census was 44. Review of the facility policy titled Hand Hygiene Policy and Procedure, dated 2025, showed the following: -Purpose to establish clear and standardized hand hygiene practices for all staff to prevent the spread of infections, maintain a safe environment. This policy includes specific hand hygiene practices related to peri-care to minimize the risk of urinary tract infections (UTI - bacterial infection in the urinary tract), and other infections; -This policy applies to all facility staff, including nurses, CNAs, therapists, dietary staff, housekeeping, and any personnel with direct or indirect resident contact; -All staff must perform hand hygiene correctly and consistently before, during, and after resident care activities, including peri-care, to prevent the transmission of infections; -Staff must perform hand hygiene before and after direct contact with a resident; before performing an aseptic task (e.g., wound care, catheter care); after contact with blood, body fluids, secretions, excretions, or contaminated surfaces; before and after wearing gloves; after using the restroom; before and after eating or handling food; after coughing, sneezing, or touching the face; after contact with a resident's environment (bed rails, bedside tables, medical equipment); and before and after performing peri-care; -Use alcohol-based hand rub (ABHR) with at least 60% alcohol when hands are not visibly soiled; -Use soap and water when hands are visibly soiled (e.g., dirt, blood, body fluids), after using the restroom, after caring for a resident with Clostridium difficile (C. diff - a bacteria that can cause inflammation of the colon) or Norovirus (highly contagious virus that causes gastroenteritis, or inflammation of the stomach and intestines); -Peri-care is a high-risk procedure requiring strict adherence to hand hygiene to prevent urinary tract infections (UTI's) and infections; -Before peri-care perform hand hygiene and put on gloves before providing care; -After peri-care remove gloves without touching contaminated surfaces and perform hand hygiene immediately after glove removal; -Gloves do not replace hand hygiene; -Perform hand hygiene before putting on gloves and immediately after removing them; -Change gloves when moving from a dirty to a clean task, when gloves become damaged or visibly contaminated, and when switching between different body areas (e.g., from peri-care to face washing). 1. Review of the facility policy titled Perineal Care, dated October 2010, showed the following: -The purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Assemble the equipment and supplies as needed; -Place the equipment on the bedside stand and arrange the supplies so they can be easily reached; -Wash and dry your hands thoroughly; -Put on gloves; -Wash perineal area, wiping from front to back; -Gently rinse and dry the area; -Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes; -Do not reuse the same washcloth or water; -Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth; -Gently dry perineum; -Assist the resident to turn on his/her side; -Wash the rectal area thoroughly; -Do not reuse the same washcloth or water; -Rinse thoroughly; -Dry area thoroughly; -Discard disposable items into designated containers; -Remove gloves and discard into designated container; -Wash and dry your hands thoroughly; -Reposition the bed covers; -Make the resident comfortable; -Place the call light within easy reach of the resident; -Clean the bedside stand; -Wash and dry hands thoroughly. 2. Review of Resident #11's face sheet (brief information sheet about the resident) showed the following: -admission date of 04/06/24; -Diagnoses included quadriplegia (partial or complete paralysis of both the arms and legs especially as a result of spinal cord injury or disease in the region of the neck), degenerative disorders of nervous system (group of conditions that affect the nervous system, causing progressive deterioration and loss of function over time), and inclusion body myositis (a rare, chronic, and progressive muscle disease characterized by inflammation and muscle weakness). Review of the resident's significant change in condition Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/30/24, showed the following: -Cognitively intact; -Required use of motorized wheelchair; -Impairment on both sides of upper extremity and lower extremity; -Dependent on staff for oral hygiene, toileting hygiene, shower, dressing, and personal hygiene; -Dependent on staff for mobility and transfers. Review of the resident's care plan, last updated on 01/06/25, showed the following: -Resident had activities of daily living functional problems as evidenced by need for dependence on staff assistance due to diagnosis; -Resident required staff assistance for oral hygiene, toileting hygiene, shower, upper and lower body dressing, personal hygiene, chair to bed transfers, shower transfers and wheelchair mobility; -Resident had an indwelling catheter related to diagnosis; -Staff should complete catheter care appropriately; -Staff should provide catheter care per facility protocol and physician's orders; -Resident was at risk for increased probability of Infections; -Staff should clean hands before entering room, before donning gloves, between tasks as appropriate, and when leaving the room; -Staff should wear glove for high-contact care and wound care. Observations on 01/27/25, at 3:36 P.M., showed the following: -Certified Nurse Aide (CNA) H and CNA I used hand sanitizer and applied gown, gloves, and masks before entering the resident's room; -The staff entered the resident's room with the Hoyer lift (medical device that helps caregivers move patients who have limited mobility); -The resident was seated in his/her motorized wheelchair; -CNA H removed the resident's blanket and the seatbelt; -CNA H pulled the resident's upper body forward; -CNA I put the Hoyer lift pad behind residents back; -The staff hooked the lift pad to the lift and transferred the resident to the bed; -CNA H pulled the residents pants down; -CNA I went to the cabinet and picked up a clean brief; -CNA H removed the tape and opened the brief; -CNA I handed the container of wet wipes to CNA H; -CNA H used two wet wipes and cleaned peri-area and catheter (a tube that is inserted into the bladder, allowing your urine to drain freely) tubing; -Without removing gloves or using hand sanitizer, the aide rolled the resident to his/her left side; -The staff used a wet wipe and cleaned soiled buttock; -The staff pulled the soiled brief out and put in the trash; -The staff continued wiping the buttocks; - Without removing gloves or using hand sanitizer, the staff applied the clean brief; -The staff rolled the resident to his/her right side; -CNA I pulled the clean brief through and rolled resident to back side; -CNA H applied fungal powder to the private area and taped brief; -With the same gloved hands, the staff rolled the resident to left side and pull up pants, then rolled to the right side and pulled pants; -The staff rolled the resident to his/her back and attached the lift pad to the Hoyer lift and transferred the resident back to wheelchair; -Without changing gloves or cleaning hands CNA H pulled the resident's upper body forward for CNA I to remove lift pad; -CNA H re-attached the resident's seatbelt and covered the resident with the blanket; -The staff picked up trash and soil linens, removed gown and gloves and washed hands at sink and left the room. 3. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admission date of 08/31/22; -Diagnoses included atrial fibrillation (abnormal heartbeat), hyperlipidemia (high cholesterol), chronic kidney disease, and edema (swelling). Review of the resident's care plan, dated 10/01/24, showed the resident was at risk for increased probability of infections. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for toileting hygiene, personal hygiene, dressing, shower, bed mobility. Observation on 01/28/25, at 1:35 P.M., showed the following: -CNA H and CNA I used hand sanitizer at door, applied gown, mask, and gloves and entered the resident's room; -The staff pulled the covers back from resident; -Rolled the resident to his/her left side and put the bed pan with brief under the resident; -Rolled the resident to his/her back and pulled the covers over the resident; -Pulled the residents privacy curtain and waited on the opposite of room; -While waiting CNA H pushed down soiled gowns in red bag container and noted he/she would remove the box when completed with cares; -He/she did not change gloves or use hand sanitizer; -The resident notified he/she was ready for staff to clean up; -Staff returned to resident's bed side and pulled down resident covers; -CNA H took a wet wipe and cleaned the front private area; -When putting wipe in the trash, he/she saw some bowel movement (BM) smear on his/her glove on the right hand; -He/she picked up another wet wipe with left gloved hand and wiped front area with his/her right hand; -He/she pushed the wet wipes and brief between the resident legs; -Using the interior side of his/her right glove hand touching the resident's outer thigh (with BM on opposite side of glove) and using his/her gloved left hand assisted the resident to roll to left side; -He/she then folded the soiled brief together and pulled from under resident and put into the trash bag; -He/she took the bag of soiled brief and wipes to the red bag trash on opposite side of the room;; -He/she removed soiled gloves into red bags; -CNA H returned to the resident and applied clean gloves without completing hand hygiene; -He/she picked up the bed pan and took to the resident's bathroom and put into a bag; -He/she returned to the resident's bed and assisted the resident to roll to left side, removed soiled sheet and applied a clean sheet; -CNA I assisted the resident to roll to his/her right side and pulled the clean sheet through; -CNA I assisted the resident to back side; -CNA H put pillow under the resident's right side of lower back; -CNA I put the pillow wedge under the resident's left leg; -CNA I picked up the oxygen tubing and CNA H pulled the covers over the resident; -CNA H then took the oxygen tubing and put on the resident's nose; -CNA H moved the bedside table to the resident; -CNA I ensured the resident had his/her call light and bed controls in his/her hand; -CNA H removed trash cups and papers from the resident's bedside table and picked up a pear from the resident table and the resident said he/she wanted to keep that pear; -CNA H put the pear back down on to the table; -CNA H put the trash in the red bag trash box in the room; -CNA H picked up the resident's cup from bedside table and took off the lid, poured water out of the cup into the sink and poured the contents of a new foam cup of water and ice from resident's bedside table into the resident's cup. He/she pushed the lid with straw back on the cup and put on the bedside table; -CNA I removed gown and gloves and washed hands at room and left the room to get more red bag trash boxes; -CNA H remained in room waiting for new red bag trash box to be brought to the room; -After putting boxes together and preparing soiled boxes he/she removed gown and gloves in the room and washed hands at sink and left the room. 4. Review of Resident #34's face sheet, showed the following: -admission date of 05/01/24; -Diagnosis included cellulitis (common and potentially serious bacterial skin infection) of buttock, chronic osteomyelitis (bone infection that occurs when bacteria invade and infect the bone tissue), pressure ulcer of sacral region stage 4 (severe pressure sore located on the sacrum (the bony area at the base of the spine) where the skin damage extends completely through all tissue layers), and urinary tract infection. Review of the resident's care plan, last updated 10/08/24, showed the following: -The resident was admitted with impaired skin integrity as evidenced by my being admitted with reoccurring chronic Stage 4 coccyx and right buttocks pressure ulcers; -Resident was dependent on staff for assistance with bed mobility; -Resident at risk for increased probability of infections; -Staff should clean hands before entering room before putting on gloves, between tasks as appropriate, and when leaving the room. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment on both sides of upper and lower body; -Dependent on staff for toileting hygiene, shower, and bed mobility; -Indwelling catheter. Observation on 01/29/25, at 9:00 A.M., showed the following: -RN B prepared wound care supplies at the treatment cart in the hallway for the resident; -He/she sprayed wound cleanser on gauze and put into a clean cup; -The nurse entered the resident room with supplies, placed supplies on a clean towel and a box of gloves on the bed; -The nurse applied a gown and gloves in room without using hand sanitizer or washing hands, the nurse said he/she had cleaned hands before preparing supplies; -The nurse moved the resident's bedside table and assisted the resident to roll to right side; -The nurse removed the soiled dressing and put it on resident's bed sheet; -The nurse wiped resident's buttock and back of upper thighs with wound cleanser on the gauze; -He/she picked up soiled gauze and dressing and took to trash can on the opposite of the bed; -He/she removed gloves and disposed in trash can; -He/she applied new gloves without using any hand sanitizer or washing hands; -Returned to the opposite side of the bed and applied a collagen pad to an area on the right buttock; -He/she then applied calcium alginate (a water-insoluble, cream-colored substance used in wound dressings) to the area on the coccyx; -He/she removed gloves and disposed to trash; -He/she put on new gloves without using any hand hygiene; -The nurse applied a protective outer dressing pad with tape and date; -He/she removed supplies from the bed, removed gloves and disposed of into the trash; -He/she applied new gloves without using hand sanitizer or washing hands; -Assisted the resident to roll to back side; -The nurse handed the resident bed controls and call light; -Then moved the bedside table to resident's bedside; -The nurse removed gloves and gown disposed to trash; -The nurse left the resident room and returned to treatment cart; -He/she had not completed hand hygiene; -He/she put on a glove and opened disinfecting wipe and briefly wiped the top of the treatment cart; -The nurse visited with a resident in the hallway and then gave the resident a fist bump; -The nurse turned to the treatment cart and used hand sanitizer and pushed cart down to nurse station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer their resources in a an effective manner to assure the highest practical well-being of all residents when the facility failed pay their DME (durable medical equipment) company per their rental agreement by the due date to ensure residents' medical equipment could remain in the building. This resulted in the company arriving on site to take back equipment actively being used by residents. This had the potential to affect all residents in the facility. The facility census was 45. 1. Review of the facility's DME invoices showed the following: -An invoice, dated 12/31/21, stamped past due, with a due date of 01/30/22. The invoice total was $2123.00 with a balance due after last payment of $325.50; -An invoice, dated 01/31/22, stamped past due, with a due date of 03/02/22. The invoice total was $3200.30 with a balance due after last payment of $527.00; -An invoice, dated 02/28/22, stamped past due, with a due date of 03/30/22. The invoice total and amount due were $3466.40. Review of the an email, dated 03/08/23, between the DME provider and the facility administrator showed due to sporadic payments to the account, to continue to service the facility, the DME required payment of the current outstanding balance of $33,448.33. Review of the facility's DME invoices showed the following: -An invoice, dated 03/31/22, stamped past due, with a due date of 03/31/22. The invoice total and balance due were $3837.80; -An invoice, dated 05/17/22, with a due date of 06/16/22. The invoice total and balance due were $2241.23; -An invoice, dated 05/31/22, stamped past due, with a due date of 06/30/22. The invoice total and balance due of $1450.80; -An invoice, dated 06/20/22, stamped past due, with a due date of 07/30/22. The invoice total and balance due were $1208.50; -An invoice, dated 07/31/22, stamped past due, with a due date of 08/30/22. The invoice total was $1187.30 with balance due of $846.30 after payment; -An invoice, dated 08/31/22, stamped past due, with a due date of 09/30/22. The invoice total and balance due were $2124.30; -An invoice, dated 09/30/22, stamped past due, with a due date of 10/30/22. The invoice total and balance due were $2264.50; -An invoice, dated 10/31/22, stamped past due, with a due date of 11/30/22. The invoice total and balance due were $3033.50; -An invoice, dated 11/30/22, stamped past due, with a due date of 12/30/22. The invoice total and balance due were $2711.00; -An invoice, dated 12/31/22, stamped past due, with a due date of 01/30/23. The invoice total and balance due were $1596.50; -An invoice, dated 01/31/23, stamped past due, with a due date of 03/02/23. The invoice total and balance due were $1596.50; -An invoice, dated 03/28/23, stamped past due, with a due date of 04/27/23. The invoice total and balance due were $3.20; -An invoice, dated 03/31/23, stamped past due, with a due date of 04/30/23. The invoice total and balance due were $1008.00; -An invoice, dated 04/30/23, stamped past due, with a due date of 05/30/23. The invoice total and balance due were $2473.00; -An invoice, dated 05/31/23, stamped past due, with a due date of 06/30/23. The invoice total and balance due were $3550.00; -An invoice, dated 06/05/23, with a due date of 07/05/23. The invoice total and balance due were $304.17; -An invoice, dated 06/28/23, stamped pas due, with a due date of 07/28/23. The invoice total and balance due $186.00; -An invoice, dated 06/30/23, stamped past due, with a due date of 07/30/23. The invoice total and balance due were $3817.50; -An invoice, dated 07/12/23, with a due date of 08/11/23. The invoice total and balance due were $160.94; -An invoice, dated 07/20/23, with a due date of 08/19/23. The invoice total and balance due were $112.06; -An invoice, dated 07/31/23, stamped past due, with a due date of 08/30/23. The invoice total and balance due were $4013.00; -An invoice, dated 08/31/23, stamped past due, with a due date of 09/30/23. The invoice total and balance due were $4060.25; -An invoice, dated 09/30/23, with a due date of 10/29/23 and balance due of $3715.50. Review of an email, dated 10/13/23, from the DME company to the facility's company, showed the DME provided the outstanding invoices for the facility. Review of the DME's open invoices report, dated 10/13/23, showed the facility had an outstanding balance of $16,355.87. Review of the facility's Rent Report, dated 10/13/23, showed the following rental equipment in the facility: -One pressure reducing mattress; -Three hi-lo beds; -One bariatric (used for heavier residents) hi-lo bed, 550 pounds; -One gravity foam mattress; -Two foam mattresses; -One 36 bed; -One bari bed; -One bolster mattress cover; -Seven low air loss mattress; -Two low air loss mattress bariatric bed; -One Medacure [NAME] bariatric bed; -Three high back wheelchairs; -Two wheelchairs; -One 600 pound lift with scale; -One CPAP (continuous positive airway pressure used to keep breathing airway open while one sleeps). Observation on 10/16/23, at 10:00 A.M., showed two DME company staff removing two bariatric beds out the front door. During an interview on 10/16/23, at 10:23 A.M., the DME company's Director of Operations said they were removing eight resident beds, three wheelchairs, a Hoyer (mechanical) lift, and one oxygen concentrator today. During interview on 10/16/23, at 12:05 P.M., the DME company's Director of Operations said the facility was behind payments for approximately $50,000.00. During interview on 10/16/23, at 10:12 A.M., the Housekeeping Supervisor, who was assisting staff on the 200 hall, said they should have beds to replace each bed removed. During an interview on 10/16/23, at 10:30 A.M., the Medical Records/Supplies Staff A said so far they had beds to replace the beds removed, and more beds to come in today. They knew about this last Friday and had text their corporate office about what replacements were needed. Observation on 10/16/23, at 10:50 A.M. showed several staff getting beds, mattresses, and supplies for residents in rooms where the DME staff removed the beds. Several residents were sitting in wheelchairs and watching the moving of beds in the main common room. During an interview on 10/16/23, at 10:00 A.M., the Director of Nursing said the staff were from the DME company and were there to take beds away that they had rented from the company. They were not taking other medical equipment. They did have replacement beds from an empty room down the 200 hall. They were removing two bariatric bed and four regular size beds and they do have these same bariatric and regular beds to replace them for the residents. The DME were eventually taking other equipment like oxygen concentrators, but they were to have equipment here today to replace what was taken by the DME company. They were to get equipment from other DME companies. During an interview on 10/16/23, at 10:52 A.M., the Administrator said the following: -She was unaware the DME company was going to come and remove their equipment today; -She had been trying to get the rental bill paid to the DME for the past two weeks, but she was not the one responsible for paying this to the DME company; -She spoke to the facility's corporate company last Thursday (10/12/23) to figure out how to get the bill paid. She thought the corporate office staff would call and let her know instead of the DME company showing up; -She usually can call and get the bill paid; -The bill comes to the facility's accounts payable account here at the facility. The business office manager creates a request for payment from an invoice. The facility was not involved with the finances; -She knew the bill wasn't paid last Thursday (10/12/23) because a staff member from the DME company called her about the approximately $80,000.00 bill (for all homes with the company). She told a person from their corporate office who said he/she would get to work on this and get back to the Administrator; -She called their corporate owner and then had the business office manager resend the invoices from the DME company who billed them. MO00225929

Based on interview and record review, the facility failed to complete a baseline care plan (the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) within 48 hours for one resident (Resident #150) out of a sample of 18 residents. The facility had a census of 51. Review of the facility provided policy, titled Care Plans - Baseline. undated, showed the following information: -A baseline care plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission; -To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to the initial goals of the resident; a summary of the resident's medications and dietary instructions; any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and any updated information based on the details of the comprehensive care plan, as necessary. 1. Review of Resident #150's face sheet showed an admission date of 04/06/23. Review of the resident's electronic medical record (EMR) on 04/11/23, at 1:00 P.M., showed the baseline care plan as initiated on 04/10/23, at 3:35 P.M. Record review of the resident's EMR on 04/13/23, at 10:30 A.M., showed the baseline care plan as signed on 04/12/23, at 10:35 A.M. During an interview on 04/14/23, 1:15 P.M., Social Services Director said when a new resident was admitted the baseline care plan should be started by the admitting nurse within 24 hours of the resident's admission and should be completed within 48 hours. During an interview on 04/14/23, at 2:00 P.M., Registered Nurse (RN) D said that resident baseline care plans are started within 24 hours of new admission and left open for other departments to complete their section, it is located in the electronic medical record under the assessment tab. Staff should not wait until four days after admission to start baseline care plan. During an interview on 04/14/23, 2:44 P.M., RN C said that nurses should start baseline care plan immediately on resident admission to the facility. During an interview on 04/14/23, at 4:25 P.M., with the Director of Nursing and Administrator. The DON said that baseline care plans are started by nursing staff on resident admission within 24 hours. Staff should not wait until four days after admission to initiate the care plan. She was unsure why the resident's baseline care plan was not completed within 24 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident's choice of code status (amount of medical assistance the resident wishes to receive if found though pulse or respirations) matched throughout the medical record for one resident (Resident #26) out of 18 sampled residents. The facility census was 51. Review of the facility policy, titled Do Not Resuscitate Order, dated [DATE], showed the following information: -The facility will not use cardiopulmonary resuscitation (CPR - giving strong, rapid pushes to the chest to keep blood moving through the body) and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order (DNR - instructs health care providers not to do CPR if a person's breathing stops or the heart stops beating) in effect; -DNR orders must be signed by the resident's attending physician on the physicians order sheet maintained in the resident's medical record; -A DNR order form must be completed and signed by the attending physician and resident, or resident's legal surrogate, as permitted by State law, and placed in the front of the resident's medical record; -DNR orders remain in effect until the resident, or legal surrogate, provided the facility with a signed and dated request to end the DNR order; -The attending physician must be informed of the resident's request to cease the DNR order; -The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives; -The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 1. Review of Resident #26's face sheet showed an admission date of [DATE]. The face sheet showed the resident listed as a DNR code status. Review of the resident's Physicians' Orders Sheet, up-to-date as of [DATE], showed an order, dated [DATE], for a DNR code status. Review of the resident's current care plan showed the resident was a full code (wishing to receive CPR) as of [DATE]. Observation on [DATE], at 2:40 P.M., showed the resident's name tag on door was on a purple background (indicating DNR code status). During an interview on [DATE], at 1:40 P.M., Certified Nurse Aide (CNA) H said that a resident's code status can be found on the electronic medical record face sheet. If he/she found a resident with a change of condition or unresponsive he/she would notify the charge nurse. During an interview on [DATE], at 2:00 P.M., Registered Nurse (RN) D said that staff can find a resident's code status in the physician orders and in the electronic medical record. Each resident also has their name on either a white or purple background for their door name tag. [NAME] is full code and purple is DNR, the purple is the same color as the DNR forms in the resident paper charts. During an interview on [DATE], at 2:44 P.M., RN C said that he/she would look in the computer on the face sheet when open up the electronic medical record for a residents' code status. He/she said it was also on the resident name tag on door, purple background for DNR, white for full code. He/she said that he/she would not typically look on the resident's care plan first, but that code status can be found in the care plans and should be the same. During an interview on [DATE], at 4:25 P.M., with the Director of Nursing (DON) and Administrator, the Administrator said that resident code status is found on the electronic medical record and there should be a signed purple DNR form in the paper chart. She said that staff should check the physician order and she would expect the code status to match throughout the chart.

Based on record review and interview, the facility failed to ensure a medication regimen was free from unnecessary medications when the facility failed to implement gradual dose reductions (GDR) for one resident (Resident #39) in a selected sample of 16 residents. The facility's census was 51. Review showed the home did not provide a policy addressing GDRs. 1. Review of Resident #39's face sheet (gives basic profile information) showed the following: -admission date of 01/11/22; -Diagnoses included Alzheimer's disease, unspecified intellectual disabilities, unspecified psychosis not due to a substance or now physiological condition, recurrent major depressive disorder with psychotic symptoms, vascular dementia with behavioral disturbance, anxiety disorder, and impulse disorder. Review of the resident's Physician Order Sheet (POS), current as of 04/14/23, showed an order, dated 03/31/22, for mirtazapine (antidepressant) 15 milligram (mg) tablet, give 15 mg by mouth at bedtime for depression. Review of the resident's care plan, last updated 03/01/23, showed the following information: -Diagnosis of serious mental illness, intellectual disabilities, and a related diagnosis of major depressive disorder; -Address emotional issues; emotional and depression; monitor/document/report to physician signs/symptoms of depression. Encourage resident to talk about feelings and deficits. Obtain mental health consult if indicated; -At risk for adverse reactions to psychotropic medications as evidenced by receiving antidepressant medication; -Pharmacy Consultant review at least monthly; assess and document effectiveness of drug treatment; attempt to give the lowest dose possible unless contraindicated; attempt a Gradual Dose Reduction per pharmacy recommendation - see chart for the last GDR Review of the resident's medical record showed staff did not have documentation of any attempted GDRs or pharmacy recommendations related to the mirtazapine. During an interview on 04/14/23, at 4:25 P.M., the facility Administrator, the Director of Nursing (DON), and the Corporate Consultant Nurse said the pharmacist reviews all residents' medications monthly and emails recommendations to the DON related to GDRs. The DON prints off the recommendations and sends them to the physician and discusses as necessary. The Administrator, DON and Consultant Nurse all said antidepressants should be included in the list of medications addressed through attempted GDRs. During an interview on 04/14/23, at 5:45 P.M., the Administrator, the DON, and the corporate Consultant Nurse said they had not located documentation of a GDR for the resident's mirtazapine.

Based on interview and record review, the facility failed to complete a Criminal Background Check (CBC) on two of ten sampled staff (Dietary Aide (DA) O and Maintenance Supervisor) and failed to ensure that three staff (Certified Nurse Aide (CNA) H, DA O, and Maintenance Supervisor) were not on the Missouri Employee Disqualification List (EDL - a list of individuals who are determined to be not able to work in long term care). A sample of 10 staff were reviewed in a home with a census of 51. Review of the facility provided policy, titled Background Checks Policy and Procedure, undated, showed the following information: -To comply with this responsibility, any and all owners, directors, officers, clinical staff, employees, vendors, independent contractors, volunteers, consultants and others working for the facility (Associates) that come in contact with residents are required to submit background checks; -New Associates must complete and return the attached criminal history record disclosure consent form to the facility Human Resources Director; -Associates shall be checked against the Missouri Family Care Safety Registry (FSCR). This registry helps ensure that persons who care for children, the elderly, and the physically or mentally disabled can easily be screened as required by law; -Associates shall also be checked against the Missouri Highway Patrol, the Missouri Department of Health and Senior Services (sanction list) and any agency thereof, the FBI and any other law enforcement agency of any state of the United States, the Office of Inspector General sanction list and the General Services Administration EPLS sanction list if necessary, as well as any other background screening that may be required by federal or state laws or regulations. Review of the facility provided policy titled Abuse-Reportable Events, dated 01/01/23, showed the following information: -Pre-employment screening will be completed on all employees, to include: -Criminal history check, revised 04/21/20, during COVID19 will not do fingerprint background checks; -Background check. 1. Review of CNA H's personnel record showed the following information: -Hire date of 11/30/22; -Staff requested a criminal background check on 11/18/22; -Staff received the criminal background check received 12/06/22; -The facility did not document completion of a check of the EDL. 2. Review of DA O's personnel record showed the following information: -Hire date of 08/22/22; -The facility did not document completion of a FCSR check, CBC, or EDL check. 3. Review of Maintenance Supervisor's personnel record showed the following information: -Hire date of 08/15/22; -The facility did not document completion of a FCSR check, CBC, or EDL check. 4. During an interview on 04/14/23, at 10:20 A.M., the Administrator said that the background check for DA O and Maintenance were requested, but the facility staff failed to follow up and ensure the results were received. 5. During an interview on 04/14/23, at 10:46 A.M., the Business Office Manager said the following information: -When preparing to print out the background checks for the requested sample of personnel, he/she realized that Dietary Aide O and Maintenance staff background checks were never completed; -He/she said when requesting background checks from the Family Safety Care Registry he/she did not check the EDL list because the FSCR report includes all of that information; -When CNA H report returned that he/she was not registered with the FSCR, staff ran the CBC, but did not check the EDL list because was used to the FSCR including that information; -When a staff member is hired the business office completed all checks required, once all the information is received and completed, he/she scans the information into the electronic personnel files and shreds the original paper copies; -He/she generally sends in the FCSR request and then waited for it to return before requesting a CBC, have not checked EDL.

3. Review of Resident #13's face sheet showed an admission date of 02/15/22. Review of resident's nurses' notes showed the following information: -On 04/8/2023, at 12:38 P.M., staff documented the nurse responded to residents yelling for help at approximately 11:50 A.M. to find the resident on the floor on his/her stomach. Assessment showed two head lacerations to right brow. Compression dressing applied. Range of motion, neurocheck and vital signs within normal limits. Residents reported passing by the resident room and seeing the resident attempting to get self out of bed and fell over the side of the bed before help could be retrieved. Staff notified the physician and received an order to send to the emergency room for evaluation of head laceration. ADON notified. Telephone message left for the resident's responsible party. The ambulance arrived at the facility at 12:20 P.M. Report and paperwork provided to emergency medical services (EMS) staff and left with the resident to the emergency room at 12:25 P.M. Staff did not documentation a transfer form or letter sent with the resident or to the resident's representative. Review of the resident's medical record showed staff did not have documentation of written notice of transfer or discharge to the resident or resident's representative at discharge. 4. Review of Resident #26's face sheet showed an admission date of 01/11/22. Review of the resident's nurses' notes, showed the following information: -On 03/25/23, at 2:07 P.M., staff documented the resident approached this nurse and stated that he/she has had two episodes of his/her body shaking vigorously followed by loss of sight and sound for an undetermined amount of time. Resident states his body is tingling all over and requests an evaluation. He is his own responsible party and the DON and provider were notified. EMS called and he was transported to via ambulance. Staff did not documentation a transfer form or letter sent with the resident or to the resident's representative. -On 04/9/23, at 9:41 A.M., staff documented the resident notified the nurse of complaints of stiff all over and inability to express himself. On call physician and ADON notified. Staff did not documentation a transfer form or letter sent with the resident or to the resident's representative. Review of the resident's medical record showed staff did not have documentation of written notice of transfer or discharge to the resident or resident's representative at discharge. 5. Review of Resident #32's face sheet showed an admission date of 01/14/22. Review of the resident's nurses' notes showed the following information: -On 02/14/23, at 6:32 P.M., staff documented the resident told a CNA that he/she did not want to live anymore. When the CNA left the resident room another resident told the CNA that Resident #32 asked him/her for a gun. This nurse spoke with the resident and when asked the resident what his/her plan with the gun was he/she replied, maybe kill myself. Notified the physician and DON. Notified the resident's power of attorney and aware of transportation to emergency room for further psychiatric evaluation. Staff continue close observation until Emergency Medical Staff arrived. Report called to the emergency room. Staff did not documentation a transfer form or letter sent with the resident or to the resident's representative. Review of the resident's medical record showed staff did not have documentation of written notice of transfer or discharge to the resident or resident's representative at discharge. 6. Review of Resident #35's face sheet showed an admission date of 09/19/22; Review of the resident's nurses' notes showed the following information: -On 03/03/23, at 6:23 P.M., staff documented the resident presented to the nurse that at 5:10 P.M., he/she had complaints of right-sided chest pain radiating to sternum. Vital signs completed. Resident was assisted to his/her room and initially refused interventions. Staff called the ambulance at 5:30 P.M., resident agreed to take Mylanta (antacid) and MS-Contin (pain medication). Oxygen placed on at 2 liter by nasal cannula. Nitroglycerin 0.4 mg (medication to treat and prevent chest pain) administered sublingually (under the tongue). Physician notified. Emergency medical staff arrived and left with the resident at 6:05 P.M. The Director of Nursing (DON) was notified. Staff did not documentation a transfer form or letter sent with the resident or to the resident's representative. Review of the resident's medical record showed staff did not have documentation of written notice of transfer or discharge to the resident or resident's representative at discharge. 7. During an interview on 04/14/23, at 11:14 A.M., the DON said the facility had not been sending any written notice of transfer to residents' families or responsible party when a resident was sent to the hospital. The staff does verbally notify the family of resident transfer. 8. During an interview on 04/14/23, at 1:15 P.M., the Social Service Director said that he/she did not send any written letters to resident responsible party regarding transfer to the hospital. 9. During an interview on 04/14/23, at 2:00 P.M., Registered Nurse (RN) D said that when he/she was sending a resident to the hospital he/she would send a face sheet, advance directives, medication list for the emergency medical staff and an additional copy for the hospital staff. He/she called the family about the transfer. He/she did not mail any information to the family or resident and was unsure if any administrative staff sent a letter. 10. During an interview on 04/14/23, at 2:44 P.M., RN C said he/she was not aware of any letter required to be sent to a resident's family with transfers. 11. During an interview on 04/14/23, at 4:25 P.M., with the DON and Administrator, the DON said that the staff complete a transfer summary, notice of discharge to another facility, medication list, and face sheet and send with the resident to the hospital. A copy is provided for the emergency medical staff. The whole packet goes with the resident. The staff had not been sending a copy of a transfer letter to the resident's responsible party. The nurse notified the family or responsible party by telephone verbally. The Social Service Director keeps track of resident discharges or transfers and sends a list to the ombudsman monthly. The department staff review all admissions and discharges in the morning meeting. Based on interview and record review, the facility failed to give written transfer notice to the resident and/or resident's representative for six residents (Residents #3, #14, #13, #26, #32, and #35) who were transferred out to the hospital. A sample of of 18 residents were reviewed in a facility with a census of 51. Review showed the facility did not provide a policy pertaining to written transfer notices of a resident's transfer to the hospital. Review of the facility provided policy, titled Transfer or Discharge Documentation, dated December 2016, showed the following information: -When a resident is transferred or discharged , detail of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider; -When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: -The basis for the transfer or discharge: -That an appropriate notice was provided to the resident and/or legal representative; -The date and time of the transfer or discharge; -The new location of the resident; -The mode of transportation; -A summary of the resident's overall medical, physical, and mental conditions; -Disposition of personal affects; -Disposition of medications; -The signature of the person recording the data in the medical record. 1. Review of Resident 3's face sheet (gives basic profile information) showed an admission date of 12/16/22. Review of the resident's nurses' progress notes showed the following: -On 03/09/23, at 3:30 P.M. the resident complained of shortness of breath and anxiety. Vital signs and oxygen saturation level stable and within normal limits. Resident educated to breathe in through the nose and out the mouth. Resident began saying, I'm scared, I can't breathe. Licensed practical nurse (LPN) attempted to reassure resident that he/she was okay and needed to slow his/her breathing down to help reduce anxiety. Resident resistant to recommendation from LPN and said, I'm going to call 911 for an ambulance. The LPN, Director of Nursing (DON), and Assistant Director of Nursing (ADON) told resident that there wasn't any reason to send him/her to the emergency room. Resident appeared content when leaving the room. Resident then called 911 with the Administrator at bedside requesting an ambulance. Dispatch called the facility and they were informed that the dispatch was unnecessary. The LPN attempted to call the resident's guardian. Guardian unavailable and voicemail left. The Administrator called appointee to the guardian to get orders to transfer resident to the hospital for evaluation for medical clearance of psychological evaluation. Orders granted, physician notified and agreed to transfer. Non-emergent transport called. Report was given to hospital. Staff did not document providing a transfer form or letter sent with the resident or to the resident's representative. Review of the resident's medical record showed staff did not have documentation of written notice of transfer or discharge to the resident or resident's representative at discharge. 2. Review of Resident #14's face showed an admission date of 03/18/22. Review of the resident's nurses' progress notes showed the following information: -On 03/02/23, at 6:03 A.M., resident noted to have blood sugar testing high. Staff called out to on-call physician with orders to give 5 units Novalog (insulin) and recheck in an hour; -On 03/02/23, at 7:01 A.M., nurse got a phone call from the Director of Nursing (DON) stating resident lab results came back with a critical lab result of blood glucose. Staff notified physician of findings, who stated to ship to hospital. Attempted to notify the resident's DPOA (Durable Power of Attorney), but the voicemail had calling restrictions. Attempted to contact family; unable to leave voicemail. The ambulance arrived at 7:05 A.M. Staff did not documentation a transfer form or letter sent with the resident or to the resident's representative. Review of the resident's medical record showed staff did not have documentation of written notice of transfer or discharge to the resident or resident's representative at discharge.

3. Review of Resident #13's face sheet an admission date of 02/15/22. Review of resident's progress notes showed the following information: -On 04/8/2023, at 12:38 P.M., staff documented the nurse responded to residents yelling for help at approximately 11:50 A.M. to find the resident on the floor on his/her stomach. Assessment showed two head lacerations to right brow. Compression dressing applied. Range of motion, neurocheck and vital signs within normal limits. Residents reported passing by the resident room and seeing the resident attempting to get self out of bed and fell over the side of the bed before help could be retrieved. Staff notified the physician and received an order to send to the emergency room for evaluation of head laceration. Assistant Director of Nursing (ADON) notified. Telephone message left for the resident's responsible party. The ambulance arrived at the facility at 12:20 P.M. Report and paperwork provided to emergency medical services (EMS) staff and left with the resident to the emergency room at 12:25 P.M. Staff did not document sending a bed-hold policy with the resident or to the resident's representative. Review of the resident's medical record showed staff did document providing documentation of the bed hold policy to the resident or resident's representative at discharge to the hospital. 4. Review of Resident #26's face sheet showed an admission date of 01/11/22. Review of the resident's nurses' notes showed the following information: -On 03/25/23, at 2:07 P.M., staff documented the resident approached this nurse and stated that he/she has had two episodes of his/her body shaking vigorously followed by loss of sight and sound for an undetermined amount of time. H/She e states his/her body is tingling all over and requests an evaluation. He/She is his own responsible party and the Director of Nursing (DON) and provider were notified. EMS called and he was transported to via ambulance; -On 04/9/23, at 9:41 A.M., staff documented the resident notified the nurse of complaints of stiff all over and inability to express himself. On call physician and ADON notified; -Staff did not document sending a bed-hold policy with the resident or to the resident's representative. Review of the resident's medical record showed staff did document providing documentation of the bed hold policy to the resident or resident's representative at discharge to the hospital. 5. Review of Resident #32's face sheet showed an admission date of 01/14/22;. Review of the resident's nurses' notes showed the following information: -On 02/14/23, at 6:32 P.M., staff documented the resident told a CNA that he/she did not want to live anymore. When the CNA left the resident room another resident told the CNA that Resident #32 asked him/her for a gun. This nurse spoke with the resident and when asked the resident what his/her plan with the gun was he/she replied, maybe kill myself. Notified the physician and DON. Notified the resident's power of attorney and aware of transportation to emergency room for further psychiatric evaluation. Staff continue close observation until Emergency Medical Staff arrived. Report called to the emergency room. Staff did not document sending a bed-hold policy with the resident or to the resident's representative. Review of the resident's medical record showed staff did document providing documentation of the bed hold policy to the resident or resident's representative at discharge to the hospital. 6. Review of Resident #35's face sheet an admission date of 09/19/22. Review of the resident's nurses' notes showed the following information: -On 03/03/23, at 6:23 P.M., staff documented the resident presented to the nurse that at 5:10 P.M., he/she had complaints of right-sided chest pain radiating to sternum. Vital signs completed. Resident was assisted to his/her room and initially refused interventions. Staff called the ambulance at 5:30 P.M., resident agreed to take Mylanta (antacid) and MS-Contin (pain medication). Oxygen placed on at 2 liter by nasal cannula. Nitroglycerin 0.4 mg (medication to treat and prevent chest pain) administered sublingually (under the tongue). Physician notified. Emergency medical staff arrived and left with the resident at 6:05 P.M. The DON was notified. Staff did not document sending a bed-hold policy with the resident or to the resident's representative. Review of the resident's medical record showed staff did document providing documentation of the bed hold policy to the resident or resident's representative at discharge to the hospital. 7. During an interview on 04/14/23, at 11:14 A.M., the DON said the facility had not been sending any written bed hold policy to residents' families or responsible party when a resident was sent to the hospital. 8. During an interview on 04/14/23, at 1:15 P.M., Social Service Director said that he/she did not send any bed hold policy to the resident or resident's responsible party after transfer to the hospital. 9. During an interview on 04/14/23, at 2:00 P.M., Registered Nurse (RN) D said that when he/she was sending a resident to the hospital he/she would send a face sheet, advance directives, medication list with the emergency medical staff and one copy for the hospital. He/she called the family about the transfer, but did not provide or mail any information related to the bed hold policy. 10. During an interview on 04/14/23, at 2:44 P.M., RN C said that he/she did not do a lot of hospital transfers as since he/she was a contract nurse. The charge nurse usually completed that task. He/she was not aware of the requirement to notify the resident or resident's responsible party of the bed hold policy. 11. During an interview on 04/14/23, at 4:25 P.M., with the DON and Administrator, the DON said that the staff complete a transfer summary, notice of discharge to another facility, medication list, and face sheet and send with the resident to the hospital. A copy is provided for the emergency medical staff. The whole packet goes with the resident. The staff had not been sending a copy of the bed hold policy to the resident's responsible party. Based on interview and record review, the facility failed to ensure all residents received a written notice of the bed-hold policy upon transfer when staff failed to provide six residents (Residents #3, #14, #13, #26, #32, and #35) of 18 sampled residents, written notices of the facility's bed-hold policy when transferred to the hospital. The facility census was 51. Review of the facility provided policy, titled Bed Holds and Returns, undated, showed prior to transfers and therapeutic leaves, residents' representatives will be informed in writing of the bed-hold and return policy; 1. Review of Resident 3's face sheet (gives basic profile information) showed an admission date of 12/16/22. Review of the resident's nurses' notes showed the following: -On 03/09/23, at 3:30 P.M., resident complained of shortness of breath and anxiety. Vital signs and oxygen saturation level stable and within normal limits. Resident educated to breathe in through the nose and out the mouth. Resident began saying, I'm scared, I can't breathe. Licensed practical nurse (LPN) attempted to reassure resident that he/she was okay and needed to slow his/her breathing down to help reduce anxiety. Resident resistant to recommendation from LPN and said, I'm going to call 911 for an ambulance. The LPN, Director of Nursing (DON), and Assistant Director of Nursing (ADON) told resident that there wasn't any reason to send him/her to the emergency room. Resident appeared content when leaving the room. Resident then called 911 with the Administrator at bedside requesting an ambulance. Dispatch called the facility and they were informed that the dispatch was unnecessary. The LPN attempted to call guardian, guardian unavailable; voicemail left. The Administrator called appointee to the guardian to get orders to transfer resident to the hospital for evaluation for medical clearance of psychological evaluation. Orders granted, physician notified and agreed to transfer; non-emergent transport called. Report was given to hospital psych department. Staff did not document sending a bed-hold policy with the resident or to the resident's representative. Review of the resident's medical record showed staff did document providing documentation of the bed hold policy to the resident or resident's representative at discharge to the hospital. 2. Review of Resident #14's face showed an admission date of admission date of 03/18/22. Review of the the resident's nurses' notes showed the following information: -On 03/02/23, at 6:03 A.M., resident noted to have blood sugar testing high. Staff called out to on-call physician with orders to give 5 units Novalog (insulin) and recheck in an hour; -On 03/02/23, at 7:01 A.M., nurse got a phone call from the DON stating resident lab results came back with a critical lab result of blood glucose. Staff notified physician of findings and physician stated to ship to hospital. Attempted to notify the resident's DPOA (Durable Power of Attorney); but the voicemail had calling restrictions. Attempted to contact family; unable to leave voicemail. The ambulance arrived at 7:05 A.M.; notified the DON. Staff did not document sending a bed-hold policy with the resident or to the resident's representative. Review of the resident's medical record showed staff did document providing documentation of the bed hold policy to the resident or resident's representative at discharge to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician's order for and care plan the use of side rails for one resident (Resident #10) and failed to obtain written consent for side rail use, failed to complete a documented side rail assessment including risks versus benefits,and failed to complete gap assessments prior to installing side rails for three residents (Residents #10, #33, and #9) in a sample of 24 residents. The facility census was 51. Review of the facilities policy, titled Bed Safety, revised December 2007, showed the following: -Resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard and bed accessories), the facility shall promote the following approaches; -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risk and problems including potential entrapment; -Review that gaps within the bed system are within the dimensions established by the FDA; -Ensure that bed side rails are properly installed; -Identify additionally safety measure for residents who have been identified as having a higher than usually risk for injury including entrapment; -If side rails are used, there shall be an interdisciplinary assessment of the resident,consultation with the attending physician, and input from the resident or legal representative; -Staff shall obtain consent for use of side rails from the resident or resident's legal representative prior to their use; -After appropriate review and consent, side rails may be uses at the resident's request to increase the resident's sense of security; -Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; -Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; -When using side rails for any reason the staff shall take measures to reduce related risks. 1. Review of Resident #10's face sheet (admission information) showed the following information: -admission date of 08/31/22; -Diagnoses include muscle weakness, difficulty walking, obstructive Sleep Apnea (sleep-related breathing disorder that involves a decrease or complete halt in airflow), non-pressure chronic ulcer of other part of left foot (skin loss, leaving a raw wound), unilateral primary osteoarthritis of right hip (cartilage wears away over time), chronic kidney disease (gradual loss of kidney function), lymphedema (tissue swelling caused by an accumulation of protein-rich fluid) , and morbid obesity (weight is more than 80 to 100 lbs above their ideal body weight). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool complete by facility staff), dated 03/23/23, showed the following information: -No cognitive impairment; -Resident had no falls prior to admitting to the nursing home or after. Observations on 04/11/23, at 11:00 A.M., showed the resident in bed with quarter sized side rails in the in the raised position. Interview and observation on 04/11/23, at 3:45 P.M., showed the resident lying in bed with two quarter side rails in the raised position. The resident said he/she used the side rails to assist staff with changing his/her bed and for repositioning. During interview on 04/14/23, at 11:10 A.M., the resident said the side bars were put on his/her bed at his/her request about six months ago. He/she uses them to assist with pulling self up, when staff change him/her and for repositioning. Review of the resident's care plan showed staff did not care plan the use of side rails by the resident. Review of the resident's April 2023 Physician Order Sheet (POS) showed no orders for side rails. Review of the resident's electronic medical record showed the following information: -Side rails informed consent and release, signed by the resident on 04/11/23; -Bed rail assessment completed on 04/11/23; -Gap measurements for the resident's room with no date of completion. 2. Review of Resident #33's face sheet (admission information) showed the following information: -admission date of 03/18/23; -Diagnoses included cerebral infarction (disrupted blood flow to the brain), disorientation, weakness, morbid obesity, unspecified fall, diabetic neuropathy (nerve damage caused by diabetes), hyperlipidemia,obstructive sleep apnea, and lymphedema. Review of the resident's admission MDS, dated [DATE], showed the following information: -No cognitive impairment; -Resident had no falls prior to admitting to the nursing home or after. Observation and interview on 04/14/23, at 8:25 A.M., showed the resident had two quarter side rails in the in the raised position. The resident said he/she uses the side rails to turn over, assist with getting out of bed, and repositioning. Observation on 04/14/23, at 9:25 A.M., showed the resident in bed with eyes closed and both rails in the up position. Review of the resident's care plan, effective 03/29/23, showed the following: -Uses assist rails per physician's order for safety during care provision, to assist with bed mobility; -Observe for injury or entrapment related to assist rail use. Review of the resident's April 2023 Physician Order Sheet (POS) showed an order, dated 03/27/23, for assist rails to enable bed mobility. Review of the resident's electronic medical record showed the following information: -Bed rail assessment completed on 04/11/23; -Gap measurements for the resident's room with no date of completion. 3. Record review of Resident #9's face sheet showed the following information: -admission date of 08/23/18; -Diagnoses included generalized muscle weakness. Record review of the resident's significant change in status MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Required total dependence on staff for locomotion; -Required limited assistance of one staff for bed mobility. Observation and interview showed the following information: -On 04/11/23, at 10:43 A.M., bilateral half size side rails in the upright position on the resident's bed. The resident was in bed with television on; -On 04/13/23, at 9:15 A.M., bilateral side rails in the upright position on the resident's bed. The resident was in bed with breakfast tray on the bedside table. He/she said that he/she used the side rails to assist the staff with moving him/her in the bed. Review of the resident's physician orders, current as of 04/14/23, showed the following: -An order, dated 06/17/19, may use one-half side rail times one, to assist with turning and positioning. -An order, dated 02/23/23, may use assist rails in bed bilaterally as needed for bed mobility. Review of the resident's care plan, dated 02/28/22, showed the following: -Will use two half side rails for enhanced bed mobility and positioning; -The bed rails do not apply pressure to the air mattress. Review of side rail assessments in electronic medical record showed the following: -On 08/4/22, staff documented an assessment that side rails were indicated for use. -On 10/22/22, staff documented an assessment that side rails were indicated for use; -On 4/11/23, staff documented an assessment that side rails were indicated for use; Review of the facility provided gap measurement for the resident's room with no resident name and no date the measurements were completed. Review of the resident's electronic medical record showed no signed risk or benefit consent documented. 4. During an interview on 04/14/23, at 2:30 P.M., the Maintenance Supervisor that he completed the side rail measurements when staff let him know there are side rails requested. He did not put dates on the forms or resident names. 5. During an interview on 04/14/23, at 2:25 P.M., Certified Medication Tech (CMT) B said he/she didn't know the process if a resident needs side rails. 6. During an interview on 04/14/23 at 2:42 P.M , with Registered Nurse (RN) C, said the following: -Residents use the side rails to help them get up and out of bed; -Side rails require an order from the doctor and they need to be care planned; -The resident needs to sign a consent form and measurements; -When a resident wants side rails he/she tells the Director of Nursing (DON); -Consent should be done prior to installing the side rails on the resident's bed. 7. During an interview on 04/14/23 at 3:20 P.M., with RN D, said the following: -Residents use side rails to assist them with repositioning; -He/she notifies the Administrator when a resident requests side rails; -The resident signs a consent, the family is called and they get an order; -Maintenance does measurements; -All of the above should be done prior to the side rails being installed on the resident's bed. 8. During an interview on 04/14/23, at 4:25 P.M., with the Administrator and DON, said the following: -When residents request a side rail they are assessed; -Staff get measurements, consent is needed, bed rail assessment and this should be done prior to installing the side rails; -Some rented beds come with side rails attached. Do we have anything showing he had the bed rails before 4/11/23? -Gap measurements for room # 210, with no date of completion. (Was this the resident's room?) Yes, no name on the form

Based on observation, interview, and record review the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants, when staff failed to use appropriate hand hygiene while completing incontinent care for one resident (Resident #150) for one of 18 sampled residents Staff failed to complete and fully document tuberculosis (TB - infectious bacterial disease characterized by the growth of nodules (tubercles) in the tissues, especially the lungs) testing for three staff members (Certified Nurse Aide (CNA) H, Maintenance Supervisor, and Certified Medication Tech (CMT) B), in a sample of 10 staff members. The facility failed to accurately place, read, and record admission tuberculosis (testing for one resident (Resident #150) in a timely manner, out of a sample of 18 residents. The facility census was 51. Review of facility policy titled Handwashing / Hand Hygiene, dated 10/11/22, showed the following information: -This facility considers hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; -Use an alcohol-based hand rub containing at least 62% alcohol; or soap and water for the following situations: -Before and after coming on duty; -Before and after direct contact with residents; -Before preparing or handling medications; -Before and after handling invasive device (urinary catheters, IV access site, etc); -Before donning gloves; -Before handling clean or soiled dressings, gauze pads, etc; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a residents intact skin; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc; -After contact with objects (ex: medical equipment) in the immediate vicinity of the resident; -After removing gloves; -Before and after entering isolation precaution setting; -Before and after eating or handling food; -Before and after assisting a resident with meal; -After personal use of the toilet or conducting your personal hygiene; -Before, during, and after wound care (see wound care policy); -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing / hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of Resident #150's face sheet showed the following: -admission date of 04/06/23; -Diagnoses included sepsis of unspecified organism (serious condition resulting from the presence of harmful bacteria or virus in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), pneumonia (Infection that inflames air sacs in one or both lungs which may fill with fluid), cognitive communication deficit, need for assistance with personal care, weakness, chronic kidney disease stage 3 (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), type 2 diabetes mellitus (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Review of the resident's baseline care plan, dated 04/11/23, showed the following: -Always incontinent of bowel and bladder; -One staff person physical assist for personal hygiene -Two staff physical assist for toilet use, dressing, bathing, bed mobility, transfer. Observation on 04/12/23, at 9:20 A.M., showed the following: -Certified Nurse Aide (CNA) H and CNA I entered the resident's room with the Hoyer lift (assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power). The staff washed their hands at the sink and donned gloves; -The staff applied the lift sling (sling offering neck support, head support, and shoulder support for a safe transfer between surfaces like a hospital bed, power chair, or transport chair) hooks to the Hoyer lift and transferred the resident from the wheelchair to the bed; -The staff assisted the resident to roll to his/her left side and tucked the lift sling under the resident and untaped the resident's incontinent brief; -The staff assisted the resident to roll to his/her right side and removed the lift sling from under the resident; -CNA H removed the incontinent brief and put the wet brief onto the floor. -He/she opened the wet wipe container and removed a wet wipe. CNA I asked him/her where the trash can was. CNA H went over to the sink and moved the trash can to the side of the bed; -He/she then picked up the wet brief from the floor and put it into the trash can. -He/she then wiped the resident buttock with a wet wipe and put into the trash can and completed this step three times; -The staff assisted the resident to roll to his/her back and CNA I wiped the resident's private region with a wet wipe and handed the used wipe to CNA H to dispose into the trash and completed this step three times; -The staff assisted the resident to roll to his/her left side and applied a new brief, then rolled the resident to his/her back and pulled the brief into place and secured the brief; -The staff pulled the resident's pants up, pulled the resident's shirt down. and pulled up the resident's blanket with the same gloved hands and without performing hand hygiene; -CNA I removed his/her gloves and elevated the resident's HOB with controller, without completing hand hygiene; -CNA H removed his/her gloves and tied up the trash bag. He/she hooked the resident's call light to his/her shirt and then pushed the Hoyer lift to the hallway without completing hand hygiene. During an interview on 04/13/23, at 8:53 A.M., CNA I said that during personal cares for the resident he/she realized that he/she missed a step during incontinent cares. He/she said that after washing a resident's private area he/she should remove his/her gloves and use hand sanitizer and put on new gloves to finish cares. During an interview on 04/14/23, at 1:40 P.M., CNA H said that during any type of resident cares he/she should use hand sanitizer or wash hands before and after every resident care, between all glove changes, and should not touch clean items without completing hand hygiene. During an interview on 04/14/23, at 2:00 P.M., Registered Nurse (RN( D said that staff should complete hand hygiene, by hand sanitizer or hand washing, on entry to resident room, on exit from resident room, between every glove change and between dirty and clean process. During an interview on 04/14/23, at 2:44 P.M., RN C said that staff should always complete hand hygiene all the time, either by hand sanitizer or hand washing, and should be done before any resident interaction, after any resident interaction, and in between glove changes and resident cares. During an interview on 04/14/23, at 4:25 P.M., with the Director of Nursing (DON), Administrator, and Regional Nurse the following was noted: -Staff should always complete hand hygiene before and after resident care and after each glove change. The staff should not be touching any clean items in the resident room after completing resident cares until hand hygiene was done. 2. Record review of the facility policy titled Infection Control - Tuberculosis Testing of Employees, dated July 2019, showed the following: -It is the policy of the facility that all employees will be tested for tuberculosis within two weeks of hire and at least annually thereafter; -Administer the purified protein derivative (PPD - used in a skin test to help diagnose TB infection in persons at increased risk of developing active disease) tuberculin skin test to all new employees who do not have documentation of a positive TB test; -Assess induration (palpable, raised swelling, which is measured transversely by inspection and palpation) with 48 to 72 hours of administration; -If the first TB skin test is negative and there is not a documented negative test within the preceding 12 months, given a second TB skin test within one to three weeks; -If the second skin test is negative, the individual has not had TB infection. Retest and screen for symptoms annually or whenever exposure to a new TB case is identified. 3. Review of CNA H's personnel file showed the following: -Hire date of 11/30/22; -Received the first step TB test on 11/18/22; -The results documented showed 0 millimeter (mm - metric unit equal to one thousandth of a meter) induration and negative. There was no date read documented; -Staff did not document a 2nd step of the TB test. 4. Review of the Maintenance Supervisor's personnel file showed the following: -Hire date of 08/15/22; -Received the first step TB on 08/15/22. The results documented showed date of 08/17/22 with no results documented; -Staff did not document a 2nd step of the TB test. 5. Review of CMT B's personnel file showed the following: -Hire date of 05/1/22; -Received the first step TB test on 04/25/22;-The results documented showed the test read on 04/28/22 with results of negative and no induration amount noted. -Staff did not document a 2nd step of the TB test. 6. During an interview on 04/14/23, at 2:00 P.M., RN D said that when staff need a TB test read they will come to the nurse on duty and request they read the TB test. He/she will document the information and let RN K know the information. 7. During an interview on 04/14/23, at 10:45 A.M., RN K said that when an employee is hired a TB test is placed and read two to three days later by whatever nurse is available. The result should be dated and results should be document in millimeters of induration. /she He/she will check that the information is complete before filing the form into the personnel records. 8. During an interview on 04/14/23, at 4:25 P.M., with the DON, Administrator, and Regional Nurse the following was noted: -New staff should have TB testing done upon hire and then annually. The first step is done when starting and the second step within two weeks. -The staff should document the date the results are read the date and document in millimeters of the induration noted. The results should be read in 48-72 hours. 9. Review of the facility provided policy title Infection Control - Tuberculosis Testing of Residents, dated July 2019, showed the following information: -If it the policy of this home that all residents will be tested for tuberculosis (TB) upon admission, annually, and if a resident has been exposed or develops symptoms of tuberculosis (TB); -Staff should administer purified protein derivative tuberculin skin test to all new residents who do not have documentation of a positive TB test; -Assess induration within 48 to 72 hours of administration; -If the first TB skin test is negative, check to see if the resident has a documented negative skin test in the preceding 12 months; -If not, give a second skin test within one to three weeks; -If the second skin test is negative, the individual has not had TB infection. Screen for tuberculosis annually, whenever exposure to a new TB case is identified, or if resident exhibits symptoms. Review of Resident #150's face sheet showed an admission date of 04/06/23. Review of the resident's physician's order sheet, current as of 04/14/23, showed the following: -An order, dated 04/11/23, to give second step PPD and document under immunization, start date 04/20/23; -An order, dated 04/11/23, to read second step PPD and document under immunization, start date 4/22/23. Review of the resident's electronic medical immunization record,\ showed the following: -TB 1-step PPD given on 04/11/23; -No information related to date read or results available. During an interview on 04/14/23, at 9:49 A.M., RN D said that the admitting charge nurse should place TB test for any new resident within 24 hours of admission and the result of the test should be documented under the immunization screen. He/she said that the order and date to read the test would be located in the treatment administration record. During an interview on 04/14/23, at 3:25 P.M., RN K said that the admitting staff nurse should administer the tuberculosis test for residents with 24 hours per the facility policy. During an interview on 04/14/23, at 4:25 P.M., with the DON and Administrator. The DON said that staff should try to get the resident admission TB testing completed as soon as possible. Staff should document under immunizations tab in the electronic chart. She said would have to check the policy for further details.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assure five residents (Residents #9, #32, #44 #102, and #150) were offered any pneumococcal vaccinations (protects against serious and potentially fatal pneumococcal infections - also known as the pneumonia vaccines. Pneumococcal infections can lead to pneumonia, blood poisoning (sepsis) and meningitis) out of a sample of 18 residents. The facility census was 51. Record review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 03/15/23, showed the following information: -Two pneumococcal vaccines are recommended for adults; -CDC recommends vaccinations with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults 65 years or older and people 19 through 64 years with certain medical conditions, including chronic (ongoing) conditions; -CDC recommends vaccination with the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax 23) for all adults 65 years or older regardless of previous history of vaccinations with pneumococcal vaccines, and people 19 to [AGE] years old with certain medical conditions including chronic medical conditions. Record review of the facility provided policy titled Infection Control - Immunizations for Residents - Influenza and Pneumococcal, dated July 2019, showed the following information: -The facility will offer resident pneumococcal immunizations unless the immunization is medically contraindicated or the resident has already been immunized; -Before offering the pneumococcal immunization, each resident or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization; -The resident or resident's legal representative will have the opportunity to refuse the immunization; -The resident's medical record will include documentation that indicates the education provided and that the resident either received the immunization, refused the immunization, or the resident had a medical contraindication to the immunization; -There are two vaccines that can prevent pneumococcal disease; -PCV 13 (pneumococcal conjugate vaccine); -PPSV23 (pneumococcal polysaccharide vaccine; -Older adults need two pneumococcal vaccines; -The CDC recommends two pneumococcal vaccines for all adults 65 years or older; -The CDC recommends two pneumococcal vaccines for all adults 19-[AGE] years of age with certain chronic medical conditions or other risk factors, including such illness as diabetes, lung disease, kidney disease, heart disease, cancers. 1. Review of Resident #9's face sheet showed the following information: -admission date of 08/23/18; -Over [AGE] years old; -Diagnoses included chronic (long-term) congestive heart failure (inadequate functioning of the heart muscle such that fluid builds up in the lungs, abdomen, feet, and arms), chronic obstructive pulmonary disorder (COPD - group of lung diseases that block airflow and make it difficult to breathe), and pneumonia. Review of the resident's physician order sheet, current as of 04/14/23, showed no information related to pneumonia vaccines. Review of the resident's immunization record in the electronic medical record showed staff did not document a pneumonia vaccines provided or refused. 2. Review of Resident #32's face sheet showed the following information: -admission date of 01/14/22; -Over [AGE] years old; Diagnoses included pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity), hyrdonephrosis (swelling of a kidney due to a build-up of urine), and end state renal disease with dependence on renal dialysis (medical condition in which a kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) or a kidney transplant to maintain life). Review of the resident's physician order sheet, current as of 04/14/23, showed no information related to pneumonia vaccines. Review of the resident's immunization record in the electronic medical record showed staff did not document a pneumonia vaccine provided or refused. 3. Review of Resident #44's face sheet showed the following information: -admission date of 10/18/22; -Over [AGE] years old; -Diagnoses included cerebrovascular disease (heart disease and chronic obstructive pulmonary disease. Review of the resident's physician order sheet, current as of 04/14/23, showed no information related to pneumonia vaccines. Review of the resident's immunization record in the electronic medical record showed staff did not document a pneumonia vaccines as provided or refused. 4. Review of Resident #102's face sheet showed the following information: -admission date of 03/11/23; -Under [AGE] years of age; -Diagnoses included end stage renal disease, cerebral infarction (stroke), type 2 diabetes mellitus (chronic condition causing problems in the way the body regulates and uses sugar as a fuel), and chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should), dependence on renal dialysis. Review of the resident's physician order sheet, current as of 04/14/23, showed no information related to pneumonia vaccines. Review of the resident's immunization record in the electronic medical record showed staff did not document a pneumonia vaccine as provided or refused. 5. Review of Resident #150's face sheet showed the following information: -admission date of 04/06/23; -Over [AGE] years old; -Diagnoses included sepsis (serious condition resulting from the presence of harmful bacteria or virus in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), pneumonia, type 2 diabetes, and chronic kidney disease. Review of the resident's physician order sheet, current as of 04/14/23, showed no information related to pneumonia vaccines. Review of the resident's immunization record in the electronic medical record showed staff did not document a pneumonia vaccine as provided or refused. 6. During an interview on 04/14/23, at 2:00 P.M., Registered Nurse (RN) D said that he/she would provide any pneumonia vaccine to resident when, or if, the task showed up on the Treatment Administration Record(TAR). He/she said that usually RN K takes care of the resident immunizations. 7. During an interview on 4/14/23, at 3:52 P.M., RN K said that the facility had not routinely offered residents pneumonia vaccines. He/she said that he/she had just downloaded the CDC guidelines for who and when eligible for pneumonia vaccinations. 8. During an interview on 04/14/23, at 4:25 P.M., with the Director of Nursing (DON), Administrator, and Regional Nurse, the Administrator said that the staff identified that there was a problem with offering and provided residents with pneumonia vaccines within the last week. Staff should offer pneumonia vaccines on admission and document if the resident refused.

Based on observation, interview, and record review the facility failed to ensure food was stored, prepared, and distributed in a manner to prevent possibly contamination when staff failed to maintain food contact services as clean, failed to keep ice machine free of black substances, failed to store bulk food scoops outside of the the containers, and failed to date and store refrigerated foods appropriately. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 51 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Review of the facility's Policy & Procedure Manual, Chapter 3: Food Production and Food Safety, General Food Preparation and Handling showed the following: -The kitchen will be kept neat and orderly; -The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Observations of the kitchen on 4/11/2023, beginning at 9:11 A.M., and on 4/12/2023 at 10:53 A.M., showed the following: -Two metal shelves used to store large baking sheets, cups and bowls had a sticky brown substance and lint on each shelf. - A metal table in the middle of the room had part of the topcoat gone and brown liquid and brown food debris; -Table in the back right of the kitchen had white substance over much of the table. During an interview on 04/13/23, at 1:40 P.M., Dietary Aide (DA) E, said cleaning the shelves every dietary staff's responsibility. During an interview on 04/13/23, at 1:50 P.M., Dietary Aide F, said everyone is responsible for cleaning the shelves in the kitchen. During an interview on 04/13/23, at 2:40 P.M., the Administrator, said cleaning is supposed to be done by schedule. There are cleaning sheets for daily, weekly and monthly. 2. Observations on 4/11/2023, beginning at 9:11 A.M., and 4/12/2023 at 10:53 A.M., showed the following: -The reflector shield of the ice machine in the kitchen had 10 spots of black substance and the outside of the machine had white, crusty substance along the crevices in the front and sides of the machine; - The ice machine in the dining room had three to four spots of black substance on the reflector shield. During an interview on 04/13/23, at 1:40 P.M., DA E said the ice machine was deep-cleaned by the Dietary Manager last Monday. The Dietary Manager cleans the ice machine one time per week by unplugging, removing all the ice inside and cleaning. It's not acceptable to have black substance inside of the ice machine. During an interview on 04/13/23, at 1:50 P.M., DA F said the Dietary Manager cleans the ice machine ,usually one time per week. It would not be acceptable for the ice machine to have a black substance inside of the machine. During an interview on 04/13/23, at 2:40 P.M., the Administrator, said the ice machine is cleaned monthly and there is a log on the side of the ice machine. It would not be appropriate for black substances to be inside of the ice machine. 3. Review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, updated 03/04/23, showed food shall be stored in a safe manner (no open containers, without covers, spillage from one food item onto another, etc.) to prevent cross-contamination. Review of the facility's Policy & Procedure Manual, chapter 3: Food Production and Food Safety, Food storage showed scoops must be provided for bulk foods and scoops are not to be stored in food. Observations of the kitchen on 4/11/2023, beginning at 9:11 A.M., and on 4/12/2023, at 10:53 A M., showed the following: -Clear plastic cup was buried down inside of the dry beans, about ¼ of the cup was visible; -Container of brown sugar on the steam table was uncovered and had a small metal spoon in it. During an interview on 04/13/23, at 1:40 P.M., DA E said staff should not leave scoops inside of dry food items like beans or sugar. During an interview on 04/13/23, at 1:50 P.M., DA F said dry food bins should not have cups or scoops left in them. During an interview on 04/13/23, at 2:40 P.M., the Administrator said staff should not leave scoops inside of dry food items like beans or sugar. 5. Review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, currently updated 03/04/23, showed the following: -Facility staff must ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated; -Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. Review of the facility's Policy & Procedure Manual, chapter 3: Food Production and Food Safety, Food storage: -Food should be dated as it's placed on the shelves; -Date marking will be visible on all high risk food to indicated the date by which a ready to eat, Time temperature controlled for safety food should be consumed, sold or discarded; -Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within seven days or discarded as per the 2017 Federal food code; -All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded; -All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded; -The day or date marked on the food item to be consumed by or discarded may not exceed the manufacturers use by date. Observations of the kitchen on 4/11/2023, beginning at 9:11 A.M., and on 4/12/2023, at 10:53 A.M., showed the following -Refrigerated metal bowl undated with metal foil labeled mechanical gravy; -Refrigerated metal container, covered with saran wrap, undated and unlabeled of what appeared to be shredded cheese; -Refrigerated container, large gallon jug of fat free Italian dressing open date of 11/26 and manufacture expiration date of 08/17/22; -Refrigerated container of corn beef dated 04/03; -Refrigerated container of pork roast undated, in a pan with foil cover; -Refrigerated, 8 small plastic cups undated and unlabeled of what appeared to be applesauce; -Refrigerated, 6 small cups of red sauce dated 03/06; -Refrigerated, 7 plastic cups unlabeled and undated of what appeared to be diced peaches; -Refrigerated metal container labeled vanilla pudding dated 04/01. During an interview on 04/13/23, at 1:40 P.M., DA E said prepared food put in the refrigerator is good for four days. All food should be have dates, when manufactured food is opened, it should have the date it's opened on the product. If it's past the manufacture's recommended date, staff would not use it. During an interview on 04/13/23, at 1:50 P.M., DA F said food should be dated and labeled when prepared or opened and I would not use if it's not dated. Prepared foods should be thrown away after three days. If it's past the manufactured date on the product, staff would throw it away. During an interview on 04/13/23, at 2:40 P.M., the Administrator, said food should be dated, labeled and stored per policy. Staff would not use food if it's past the manufacture's dates.

Based on observation, interview, and record review the facility failed to provide a sanitary environment when staff failed to keep non-food contact surfaces, including the floor, vents, ceiling lights, and the outside of the dishwasher, clean and well maintained in the kitchen, dry storage area, and dining rooms. This has the potential to affect all residents who consumed food from the facility. The facility census was 51. Review of the Food and Drug Administration (FDA) 2013 Food Code showed non-food contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, or other debris Review of the facility's Policy & Procedure Manual, Chapter 3: Food Production and Food Safety 3-26, General Food Preparation and Handling showed the the kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Review of the facility's cleaning schedules showed staff did not document completion of the cleaning schedules. 1. Observations on 4/11/2023, beginning at 9:11 A.M., and on 4/12/23, beginning at 10:53 A.M., of the kitchen and dining areas showed the following: -Square vent in the left corner as you enter the kitchen, located over the cappuccino machine, had thick lint that covered 90% of the vent; -Right circular vent in the main dining room, to the right of the ceiling fan had lint hanging down. During and interview on 04/13/23, at 1:40 P.M., Dietary Aide (DA) E, said the vents are maintained by maintenance. Dining room vents are cleaned and maintained by maintenance. -Housekeeping cleans the floors in the dining rooms during the day and dietary does them at night. During an interview on 04/13/23, at 1:50 P.M., DA F said the kitchen staff have cleaning schedules. Maintenance is responsible for the vents in the kitchen and in the dining rooms. During an interview on 04/13/23, at 2:40 P.M., the Administrator, said cleaning is supposed to be done by schedule, there are cleaning sheets for daily, weekly and monthly. She believes dietary is responsible for cleaning the vents. 2. Observations on 4/11/2023, beginning at 9:11 A.M., and on 4/12/23, beginning at 10:53 A.M., of the kitchen and dining areas showed the dishwasher had white substance on much of the outside. 3. Observations on 4/11/2023, beginning at 9:11 A.M., and on 4/12/23, beginning at 10:53 A.M., of the kitchen and dining areas showed the following: -Floors had debris under the shelves and white dried liquid in various places. Dirt is present on much of the visible floor and the floor had a slippery coating; -Floor in the dining area around the steam table had dirt on the floor and appeared somewhat slippery. During and interview on 04/13/23, at 1:40 P.M., DA E said the floor should be cleaned by every staff. Housekeeping cleans the floors in the dining rooms during the day and dietary does them at night. Dietary staff is responsible for cleaning the floors in the kitchen. During an interview on 04/13/23, at 1:50 P.M., DA F said the cook is responsible for the kitchen floors. Dietary staff are responsible for cleaning the floors in the dining rooms and by the steam table. During an interview on 04/13/23, at 2:40 P.M., the Administrator said cleaning is supposed to be done by schedule, there are cleaning sheets for daily, weekly and monthly. -Monthly deep cleaning and certain items are assigned to certain aides/cooks, etc. 4. Observations on 4/11/2023, beginning at 9:11 A.M., and on 4/12/23, beginning at 10:53 A.M., of the kitchen and dining areas showed the following: -The light, just above a large fan had various pieces of lint and several spots of another substance on the florescent light cover; -Florescent lights in the storage room included one to the right has broken pieces on the corner and various dark spots inside and one light just before the broken one on the right had dark pieces inside of the light fixture; -Florescent light in the middle of the main dining room did not have a plastic cover; -The third florescent light from the window had various pieces of lint hanging down; -Assisted dining room has two florescent lights to the right of the room with no plastic covers; -Assisted dining room the back right light did not light up; -Assisted dining room the back left light has one bulb that did not work and the front left light cover is cracked about half way down the light cover During and interview on 04/13/23, at 1:40 P.M., DA E said the lights are maintained by maintenance. Dining room lights are cleaned and maintained by maintenance. During an interview on 04/13/23, at 2:40 P.M., the Administrator said she thinks dietary is responsible for cleaning the ceiling lights.

Based on interview, observation, and record review, the facility failed to follow their emergency water supply procedures when staff did not have a three day supple of water on hand for use in the case of loss of normal water supply. The facility census was 51. Review of an agreement letter with a water provider, undated, showed the following information: -The provider will assist in supplying bottled water to the facility in the event of a fire, hurricane, tornado, flood or loss of power in or around the facility; -Adequate water will be provided to service the facility's residents: 1.5 gallons of water per day per resident, family members and staff; -Response should be available within 48 hours of notification; however, is subject to facility accessibility and availability of delivery equipment and products consistent with the nature of the emergency event; -The company recommends that the facility maintain a three day water supply on site at all times. Review of a facility appendix to the Emergency Operations Plan entitled Disaster Water Supplies, undated, showed the following: -To ensure safe water for residents, staff and visitors during a crisis, the facility maintains an emergency water supply that is suitable, accessible, and consistent with applicable regulatory requirements; -Emergency water supply (minimum three-day supply) of 180 gallons, located in general storage. 1. During an interview on 04/11/23, at 9:15 A.M., the Administrator said he/she had noticed earlier that morning that there wasn't as much bottled water on hand as usual. He/she was unsure of the exact amount on hand. Dietary staff told him/her that expired bottles had been discarded by the former Dietary Manager, but had not been replaced. The Administrator said an order was being placed that morning with their distributor, but the order would probably not arrive until their normally scheduled food truck delivery day on 04/14/23. An observation on 04/13/23, at 3:45 P.M., of the kitchen storage room showed 12 gallons of bottled water stored on a metal shelf. During an interview on 04/13/23, at 3:45 P.M., Dietary Aide (DA) E said the previous Dietary Manager threw out the expired bottled water some time ago. It had been over a month. He/She was not aware of whether or not more water had been ordered. During an interview on 04/14/23, at 3:05 P.M. the Director of Nursing (DON) said he/she was not sure who was responsible for maintaining a supply of emergency bottled water. He/she thought they should keep about one gallon per resident per day, but was not sure about the number of days. The DON said they had a contract for delivery of emergency water in case of a crisis. During an interview on 04/14/23, at 3:25 P.M., the Administrator said the facility did not currently have a Dietary Manager. He/She was trying to provide help to the dietary staff. The Dietary Manager is responsible for maintaining the emergency water supply, checking the amount on hand, and the expiration dates. The facility's emergency water supply on hand should be one gallon per resident and staff per day times three days. The facility has an agreement with their food service company to deliver water in case of emergency.

Based on observation, record review, and interview, the facility failed to obtain a physician's order for the placement and maintenance of a percutaneous endoscopic gastrostomy (PEG tube - feeding tube directly into the stomach), to include a valid, clinical rationale for the PEG tube, for one resident (Resident #35). A sample of 12 residents was selected for review; the facility census was 42. Record review of the facility's policies showed the facility did not provide a policy for what PEG tube orders should include or labeling requirements of the bag. 1. Record review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/7/19, showed the following information: -Most recent readmission to the facility 10/23/19; -Diagnoses included high blood pressure, diabetes, stroke, difficulty with speech, one-sided weakness, anxiety, malnutrition or risk for, and COPD (chronic obstructive pulmonary disorder); -Total dependence on staff for all activities of daily living (ADLs) including eating/intake; -Received 51% or more of all nutrients via tube feeding; -Received 501 cubic centimeter (cc) of fluid per day via intravenous (IV) or tube feeding. Record review of the resident's physician order sheet (POS) showed the following information: -On 11/12/19, the physician ordered to increase the water flush to 50 milliliter/hour (ml/hr). Jevity 1.2 (liquid nutrient) at 70 ml/hr continuous. May use Glucerna 1.5 at 70 ml/hr if unable to obtain Jevity. -On 11/15/19, the physician ordered water continuous flush at 50 ml/hr; -On 11/15/19, a clarification order showed staff to administer Glucerna 1.5 Carbsteady (diabetic liquid nutrient) continuous tube feeding at 70 ml/hr. (Staff did not document a physician's order for the placement and maintenance of the PEG tube, to include the type and size of feeding tube, diagnosis for its use, and when or if the tube should be replaced.) Record review of the resident's nurses' notes, dated 11/19/19, showed a staff nurse documented the resident pulled out his/her PEG tube. Another nurse replaced the tube and checked the residual and documented stomach content green watery liquid. Staff called the physician who gave an order to obtain an abdominal x-ray to verify placement before tube feeding could start. Record review of the resident's POS showed an order, dated 11/20/19, to change pump tubing every 24 hours. Record review of the resident's nurses' notes showed staff documented the following information: -On 11/26/19, the resident pulled out his/her PEG tube. The nurse reinserted a 16 french (fr) male self catheter, reinforced with tape and an abdominal binder; -On 12/7/19, the resident pulled out his/her PEG tube. The nurse reinserted a 16 fr catheter. Observation on 12/9/19, at 3:20 P.M., showed the resident received liquid nutrients via a feeding tube infusing at a rate of 70 ml/hr concurrently with water infusing at a rate of 50 ml/hr on a programmable pump. Record review of the resident's nurses' notes, dated 12/11/19, showed the resident pulled out his/her PEG tube. The nurse reinserted a new catheter without issue and secured it with tape and abdominal binder applied. Observation on 12/12/19, at 9:35 A.M., showed the resident received liquid nutrient infusing at 70 ml/hr, simultaneous with water infusing at 50 ml/hr, via a feeding tube. Staff did not document the start date and time on the nutrient bottle. During an interview on 12/19/19, at 1:36 P.M., the facility Infectionist said they could not find any specific orders pertaining to the PEG tube itself, only for the enteral feeding. During an interview on 12/19/19, at 2:30 P.M., the administrator said the nurses should obtain complete orders for placement and care of feeding tubes. The order should include an appropriate diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain informed consent for the use of side rails and failed to complete side rail safety checks and regular inspections of the bed frame and side rails for the risk of entrapment for two residents (Resident #16 and #24) . A sample of 12 residents was selected for review; the facility census was 42. Record review of the facility's policy entitled, Proper Use of Side Rails, dated 2001 and revised December 2016, showed the following information: -Side rails are considered a restraint when they are used to limit the resident's freedom of movement; -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails; -When used for mobility or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, the risk of entrapment and that the bed's dimensions are appropriate for the resident's size and weight; -Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol; -The risks and benefits of side rails will be considered for each resident; -Manufacturer instructions for the operation of side rails will be adhered to; and -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). Record review of the facility's policy, entitled Bed Safety, dated 2001 and revised December 2007, showed the following information: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, and headboard, footboard, and bed accessories), the facility shall promote the following approaches: Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; Review that gaps within the bed system are within the dimensions established by the FDA; Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment; -The maintenance department shall provide a copy of inspections to the administrator and report results to the QA Committee for appropriate action; -Copies of the inspection results shall be maintained by the administrator; -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,; -If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and /or legal representative; -Before side rails can be used for any reason, staff shall inform the resident and family about the benefits and potential hazards associated with side rails; -When using side rails, staff shall take measures to reduce related risks. 1. Record review of Resident #24's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included cancer, paranoid schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression, asthma, hypertension (high blood pressure), high uric acid (excess of uric acid in your blood. Uric acid is produced during the breakdown of purines, which are found in certain foods and are also formed by the body), peptic ulcer and allergies. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 10/7/19, showed the following information: -Severely cognitively impaired; -Required extensive assistance with transfers, toileting, and dressing; -Resident used wheelchair; -No falls since admission; -Side rails not used. Record review of the resident's nursing initial and quarterly assessment, completed on 10/7/19, showed the resident did not require bed rails. Staff did not document a final recommendation decision of two options: side rails indicated and serve as an enabler to promote independence, or, side rails not indicated at this time. Record review of the resident's device decision guide (a tool to guide staff in determining if a resident required bed rails), completed on 10/10/19, showed the Director of Nursing (DON) signed the guide, but did not include the accompanying form regarding documentation for measurements/safety requirements. Record review of the resident's medical record on 12/12/19 showed the record did not include the following: -Bed rail consent form; -Bed rail safety check form or completion of a regular inspection of the bed frame or bed rails. Observation on 12/13/19, at 9:43 A.M., showed the resident's bed had quarter side rails, half-moon shape, in the up position on both sides of the bed. 2. Record review of Resident #16's nursing initial and quarterly assessment, completed on 3/23/19, showed staff documented the resident did not use side rails on his/her bed. Record review of the resident's nursing initial and quarterly assessment, completed on 6/21/19, showed staff documented the following information: -Resident used side rails for positioning or support, and the rails helped the resident rise from a supine position to a sitting/standing position; -Very limited mobility. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -admitted to the facility on [DATE]; readmitted to the facility on [DATE] from another facility; -Diagnoses included multiple sclerosis (MS - the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between the brain and the rest of the body), neuromuscular dysfunction of bladder, and chronic pain; -Moderate cognitive impairment; -Total dependence on staff for bed mobility, transfers, and most activities of daily living (ADLs); -Required limited assistance for eating. Record review of the resident's device decision guide, completed and signed by the DON on 10/10/19, showed the following information: -Full side rails bilaterally (both sides of the bed); -Side rails not an enabling device; -No safety risks. (Staff did not document measurements/safety requirements.) Record review of the resident's care plan, last reviewed/updated on 10/16/19, showed on 3/4/19, the resident required two full side rails for positioning. Staff to monitor for safety and effectiveness quarterly and as needed. Record review of the resident's physician order sheet (POS), dated 12/01/19 through 12/31/19, showed an undated order for two half-side rails to assist with repositioning; re-evaluate quarterly (diagnosis: MS). Record review of the resident's medical record showed the following: -No signed consent for the use of side rails; -No safety measurements completed for installed side rails. Observation and interview on 12/09/19, at 2:56 P.M., showed the resident's bed had bilateral side rails, which the resident said he/she used for security and to grab on to to get up and down. 3. During an interview on 12/13/19, at 10:15 A.M., the DON said the following: -There were not any measurements for the bed rails; -The facility did not have any consent forms for the use of bed rails. 4. During an interview on 12/19/19, at 1:38 P.M., Licensed Practical Nurse (LPN) A said: -Consent forms are obtained from the responsible party; -Assessments are completed upon the resident's admission and completed quarterly by nursing; -Everyone that walks into the room should look at the railings to ensure they are tight to the bed with no loose gaps; -Maintenance will be the one to check for gaps or make repairs when there are problems. 5. During an interview on 12/19/19, at 1:47 P.M., Certified Nursing Aide (CNA) C said: -Consents are gathered prior to the resident being able to use bed rails; -Nursing and therapy complete the assessments and take measurements; -If there is a problem, nursing will let maintenance know; -Maintenance measures the gaps. 6. During an interview on 12/19/19, at 2:30 P.M., the Administrator said they did not have the required gap measurements, assessments, or signed consents for the use of bed rails.

Based on observation, interview, and record review, the facility failed to maintain clean surfaces in a clean sanitary manner and failed to store and air dry drinking glasses in a sanitary manner. The facility census was 42. Record review of the facility's policy, titled Sanitization, dated 2001 and revised October 2008, showed the following: -All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter ad rubbish and protected from rodents, roaches, flies and other insects; -All utensils, counters, shelves and equipment shall be kept clean. 1. Observation of the kitchen on 12/09/19, at 9:20 A. M., showed the following: -The window ledge just above the sink had approximately 75-100 small flies, lying dead across the surface of the ledge; -One fly was squished on the window, about half way up; -The round, white eating utensils canisters (used to hold utensils when run through the dishwasher), sat on the window ledge; -Some small, wet, dead flies also observed smashed underneath the canisters. During an interview on 12/09/19, at 2:55 P. M., the dietary manager (DM) G said the following: -Staff does have to wash the back splash and window ledges; -Since this has not been done, it should be put on the list of kitchen duties. 2. Record review of the facility's policy, titled Dishwashing Machine Use, dated 2001 and revised March 2010, showed after running items through the entire cycle, allow to air dry. Observation on 12/09/19, at 9:20 A. M., showed the following: -Tall, clear drinking glasses sat on a tray, upside down, with the opening at the bottom (trapping water in the glasses); -Water droplets could be seen inside eight of the glasses. During an observation and interview on 12/19/19, at 11:15 A.M., Dietary Aide H, said the following: -He/she washed the dishes this morning following breakfast; -Staff should air dry all dishes before sitting the dishes on the shelves; -Dishes are never double-stacked; -Some of the drinking glasses continued to have water in them at the time of the interview; -He/she always airs them out but must have been in a hurry. During an interview on 12/19/19, at 11:21 A.M., Dietary Manager (DM) G, said the following: -Dishes must be air dried prior to being placed on the shelves; -All staff know to do this; -She has never noticed dishes remaining wet when put on the shelves.