Based on interview and record review, the facility failed to ensure each resident was treated with respect and dignity at all times when the facility staff made harsh and upsetting comments to one resident (Resident #1) in front of other residents; when staff threatened two resident's (Resident #1 and #3) smoking rights if they shared cigarettes with one resident (Resident #1); and when staff talked with one resident (Resident #4) regarding being friends with one resident (Resident #1). A sample of six residents was reviewed in a facility with a census of 65. Review of the facility's policy titled Dignity, revised February 2021, showed the following information: -Residents are treated with dignity and respect at all times; -Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person, or entity associated with the facility; -Staff are to speak respectfully to residents at all times; -Staff are to protect confidential clinical information. Verbal staff to staff communication should be conducted outside the hearing range of residents and the public; -Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care; -Demeaning practices and standards of care that compromise dignity are prohibited. 1. Review of the Resident #1's face sheet (brief look at resident information) showed the following information: -admission date of 08/06/24; -Diagnoses included diabetes, liver cell carcinoma(cancer), high blood pressure, and chronic pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 02/19/25, showed the following information: -Cognitively intact; -No feelings of depression; -Not isolating socially. Review of the resident's care plan, revised 08/19/24, showed the following: -Provide a comfortable and safe environment; -Assist and encourage the resident to develop appropriate methods of coping and interacting rather than being accusatory; -Attempts to manipulate staff. During an interview on 05/01/25, at 10:30 A.M., the resident said the following: -He/she wanted to discharge from the facility due to the Director of Nursing (DON) making unwanted comments; -He/she has been self-isolating to his/her room, because the DON has told him/her if any other behaviors occur, he/she will be issued a 30 day notice; -He/she has never been verbally or physically aggressive with staff. The DON says he/she has behaviors because he/she requests timely pain management and/or has borrowed cigarettes from other residents; -He/she is afraid the facility is going to cause him/her to be homeless again; -The DON has gone into other resident rooms and talked badly about him/her; -He/she feels humiliated and hurt. Observation on 05/01/25, at 11:20 A.M., of a recording of the DON in her office showed the following: -Resident #2 and Resident #3 was in the DON's office. The DON was discussing Resident #1's behaviors and questioning mental illness. Resident #1 then entered the DON's office; -Resident #1 questioned the DON and other resident's as to why they were talking about him/her; -The DON said You have a history of lying a lot; -Resident #1 began pleading his/her case as to why he/she was borrowing cigarettes from the two residents in the room; -The DON said, You are doing something wrong. Take accountability for your actions. Take accountability for the sneakiness. The sneakiness is what I cannot stand; -Resident #1 began pleading his/her case again insisting the resident was given cigarettes, not stealing them; -The DON said, What's really screwed up is all the cigarettes you've taking from Resident #3. You want to discharge to another facility, but another facility won't take you because of these behaviors. You are just harming yourself by smoking; -Resident #1 said he/she was not a routine smoker. He/she was just craving some peace after his/her cancer diagnoses; -The DON said, Take some accountability and stop blaming everything on your cancer. Why are we wasting our time on taking you to your cancer appointments, if you are going to kill yourself by smoking; -The meeting ended with the DON asking Resident #2 if he/she had learned his/her lesson to not lend cigarettes out. During an interview on 05/01/25, at 1:29 P.M., Resident # 2 said the following: -Resident # 1 asks for cigarettes a lot, so the facility staff get onto him/her. -There was a recent meeting, and the DON did get onto Resident #1 during that time; -Facility staff are getting irritated with Resident #1; -The DON told him/her if he/she did not stop giving Resident #1 cigarettes, she would take away the Resident #2's smoking privileges. During an interview on 05/01/25, at 1:40 P.M., Resident # 4 said the following: -Resident #1 admitted to the facility with a past and is treated differently because of it; -Resident # 1 has been called into the DON's office several times; -The DON came into his/her room and told him/her to be careful with being friends with Resident #1 as he/she is manipulative and could take advantage of him/her easily. During an interview on 05/01/25, at 1:56 A.M., Resident # 3 said the following: -The DON has threatened to take away his/her smoking privileges due to him/her loaning out cigarettes; -He/she does not understand what the problem is, it's his/her property and money. During an interview on 05/01/25, at 2:25 P.M., Certified Mediation Technician (CMT) A said he/she would report if a resident was talked down to and/or humiliated by staff. Staff should not threaten to take away a resident's rights. During an interview on 05/01/25, at 2:32 P.M., Licensed Practical Nurse (LPN) B said if he/she heard a resident not being treated with dignity and respect, he/she would report it. During an interview on 05/01/25, at 2:40 P.M., the Social Services Director (SSD) said if he/she became aware of a resident not being treated with dignity and respect, he/she would report it to the Administrator, State Agency Office, and remove the resident from the situation. During an interview on 05/02/25, at 10:09 A.M., the Medical Records Nurse said residents should be treated with dignity and respect. If she became aware of a resident being talked down to or humiliated, she would report it. During an interview on 05/02/25, at 10:37 A.M., LPN C said it would not be appropriate to talk to any resident in a manner that degraded and or humiliated them. During an interview on 05/02/25, at 10:59 A.M., the Nurse Practitioner said all residents should be treated with dignity and respect regardless of diagnoses and/or past. During an interview on 05/02/25, at 11:30 A.M., the DON said the following; -The resident often threatens to report her to the State Agency Office; -The resident is very accusatory; -She talked with the resident recently about being sneaky when obtaining cigarettes to smoke; -She told the resident to stop stealing cigarettes from his/her peers; -The resident has his/her behaviors charted and that is why another facility won't accept him/her. Behaviors include manipulation and threatening; -She did approach Resident #4 regarding the resident, because she didn't want Resident #4 manipulated into giving Resident #1 money. She did not encourage Resident #4 to not associate with Resident #1; -The resident might not like what she has to say, because she is firm with him/her; -She should have not said the things she said to the resident. She was trying to educate the resident on his/her behaviors but did not intend to sound malicious. During an interview on 05/02/25, at 1:01 P.M., the Administrator said the following: -All residents should be treated with dignity and respect; -The DON made him aware of the statements she had made to the resident today; -The resident has behaviors and they are looking into additional placement for him/her. MO00251691

Based on observation, interview, and record review, the facility failed to implement and maintain an effective pain management for all residents when staff failed to accurately and consistently document pain levels and steps taken to address pain, failed to document timely physician notification of pain, and restricted a resident's access to certain medications without a physician order for one resident (Resident #1) out of six sampled residents. The facility census was 65. Review of the facility's policy titled Pain Care, undated, showed the following information: -The effectiveness of the facility's pain care program will be examined monthly; -Pain assessments should include the location, description, frequency, level, what alleviates or exacerbates the pain, history and effectiveness of pain medications, and the residents desires about future pain care; -For residents with daily or chronic pain, maximum relief is achieved with around the clock medications and as needed (PRN) medications for breakthrough pain; -New interventions must be implemented when old interventions are ineffective. 1. Review of the Resident#'s face sheet (brief look at resident information) showed the following information: -admission date of 08/06/24; -Diagnoses included diabetes, liver cell carcinoma(cancer), high blood pressure, and chronic pain. Review of the resident's care plan, revised 08/19/24, showed the following: -Staff to administer analgesic (non-opioid drugs used to alleviate pain) medications as ordered by the physician. Staff to monitor/document side effects and effectiveness every shift; -Staff to ask physician to review medication if side effects occur; -Staff to monitor/document/report as needed medication adverse reactions to analgesic therapy. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 02/19/25, showed the following information: -Cognitively intact; -No behavioral symptoms; -Administered a scheduled pain mediation regimen; -Received as needed pain mediation, as well as non-medication interventions for pain. Review of the resident's February 2025 Medication Administration Record (MAR) and Physician Order Sheet (POS) showed the following: -An order, dated 09/09/24, for Tylenol (analgesic medication used to relieve pain) Extra Strength 500 milligram (mg), give one tablet by mouth four times a day; -An order, dated 09/27/25, for ibuprofen (nonsteroidal anti-inflammatory drug used to relieve pain) 600 milligrams (mg), give one tablet by mouth every eight hours for pain; -An order dated 02/06/25, for Butrans Transdermal Patch (an opioid partial agonist medication used to treat chronic pain) 10 micrograms per hour (mcg/hr), apply one patch one time a day every seven days for pain. The order was discontinued 02/08/25; - An order, dated 02/09/25, for Butrans Transdermal Patch 10 mcg/hr, apply one patch one time a day every seven days for pain. The order was discontinued 02/27/25. Review of the resident's progress note dated 02/23/25, at 6:15 P.M., showed staff noted the resident was complaining of pain in the right upper quadrant (RUQ) and the right lower quadrant (RLQ) of the abdomen. Pain was controlled when heat was applied. The resident said the pain was sharp and did not last for long. (Staff did not document physician notification of the resident's complaint of pain.) Review of the resident's progress note dated 02/25/25, at 3:37 P.M., showed staff noted the resident was complaining of left quadrant abdominal pain and it was believed to be caused by an old hernia and/or weight loss injection. The nurse documented he/she would continue to monitor. (Staff did not document physician notification of the resident's complaint of pain.) Review of the resident's progress note dated 02/27/25, at 1:26 P.M., showed staff noted the resident was complaining of left mid-back pain, causing pain with breathing. The resident also complained of blood when wiping after toileting. Staff notified the physician and an order for a pelvic ultrasound was received. Review of the resident's progress note dated 02/27/25, at 3:52 P.M., showed staff noted the resident complained of having migraine headaches for the last couple of weeks. The resident described the pain at an eight out of 10 with light and sound sensitivity that encompasses the entire head. The time frame when headaches started coincided with starting the Butrans Patch. The medication can have adverse reactions that include headache disorder. The resident said to the nurse that he/she would rather have the other pain instead of the headaches. Staff notified the physician and received order to discontinue the Butrans patch. Review of the resident's progress notes, dated 02/28/25 through 03/18/25, showed staff did not document related to the resident pain. Review of the resident's March 2025 MAR and POS showed the order for ibuprofen 600 mg tablet was discontinued on 03/03/25. The resident continued to have an order for Tylenol for pain treatment. Review of the resident's MAR, dated 03/08/25, showed staff noted the resident's pain was rated at a four out of 10 on day shift. Review of the resident's medical record, dated 03/08/25, showed staff did not document steps taken to address the resident pain level of four out of ten on day shift or how/if the resident's pain was relieved. Review of the resident's care plan, revised 03/11/25, showed staff added the resident had a history of misusing pain medications and self-medicating while he/she was in the community. The physician was treating his/her pain with non-opioids because of his/her history. Review of the resident's MAR, dated 03/17/25, showed staff noted the resident's pain was rated at a seven out of 10 on day shift. Review of the resident's medical record, dated 03/17/25, showed staff did not document steps taken to address the resident pain level of seven out of ten on day shift or how/if the resident's pain was relieved. Review of the resident's progress note dated 03/19/25, at 11:53 P.M., showed the resident came to the nurses' station and requested to go to the emergency department (ED) for left flank pain, presenting with throbbing, stabbing and tenderness. Staff noted no signs and symptoms of distress. The resident was calm and collected during the nurses' assessment. Review of the resident's MAR, dated 03/19/25, showed a pain scale of 0/10 on both day and night shifts. (The assessments did not reflect the pain noted in the progress notes.) Review of the resident's progress note dated 03/20/25, at 9:00 A.M., showed the resident returned from the ED and was said to have lesions on the liver. Staff notified the physician of the resident's return. Review of the resident's progress notes, dated 03/22/25, showed the following: -At 10:10 A.M., staff noted the resident was expressing concerns that he/she had cancer due to the pain he/she was experiencing. -At 11:00 A.M., staff noted the resident reported to the nurse he/she was feeling bad with severe right side abdominal pain. The resident was crying and said that his/her pain was a 10 out of 10 and wanted to go to the ED. Staff notified the physician and the resident was sent to the ED. -At 11:25 A.M., staff noted the nurse on duty called the ED and instructed them that the resident was not allowed to have any narcotics per doctors orders. Review of the resident's March 2025 POS showed staff did not transcribe an order to indicate the resident had a physician order to not administer narcotics. Review of the resident's ED History and Physical, dated 03/22/25, showed the following; -The resident was found to have a possible metastatic disease (also known as stage IIII cancer that occurs when cancer cells from the original tumor spread to other body parts) due to multiple masses on his/her liver; -The nurse at the facility where the resident resided called the ED department and said that the resident could not have any narcotic pain medications and could not return to the facility if that was prescribed at the hospital. The reasoning for this needs to be explored as the resident has metastatic cancer and will need pain management. The resident does not know the reasoning why the facility treats him/her this way other than in his/her distant past he/she was homeless and had substance abuse issues, but that has not been the case for the last six years; -Contact with the facility was made regarding diagnoses of cancer. The resident was on a Butrans patch which was discontinued several days ago. The Director of Nursing (DON) told the ED that the resident can not get narcotic pain management at the facility and they would be unable to accept the resident back at the facility if that were the case. No specific reasoning given; -ED provider does not believe discharging the resident back to the facility is appropriate as they refuse to provide an appropriate pain management regimen. Review of the resident's MAR, dated 03/23/25, showed a pain scale of six out of ten on day shift and no assessment of pain on the night shift. (The resident was not in the facility on this date.) Review of the resident's MAR, dated 03/24/25, showed a pain scale of six out of ten on day shift and no assessment of pain on the night shift. (The resident was not in the facility on this date.) Review of the resident's ED After Visit Summary, dated 03/25/25, showed the following: -Resident was to discharge back to the facility with an order for Percocet (opioid controlled substance medication used to treat pain) 5-325 mg, take one tablet by mouth every four hours as needed for pain. -Hand written note on the After Visit summary showed staff noted they conferred with the Primary Care Physician (PCP) on 3/25/25, at 5:00 P.M. Review of the resident's March 2025 MAR and POS showed the following: -The hospital order for Percocet was not transcribed to the POS. -An new order, dated 03/25/25, for Fentanyl Patch 25 mg, apply new patch every three days. Review of the resident's progress note dated 03/25/25, 5:16 P.M., showed staff did not indicate the resident had returned from the hospital and said that the physician had reviewed orders from the resident's hospitalization and wanted to return to the previous orders. Review of the resident's MAR, dated 03/25/25, showed the resident had pain rated a six out of 10 on the day shift and a seven out of 10 on the night shift. Review of the resident's medical record, dated 03/25/25, showed staff did not document steps taken to address the resident pain level of six out of 10 on day shift and seven out of 10 on night shift or how/if the resident's pain was relieved. Review of the resident's MAR. dated 03/26/25, showed the resident had pain rated a seven out of 10 on the day shift and a six out of 10 on the night shift. Review of the resident's medical record, dated 03/26/25, showed staff did not document steps taken to address the resident's pain level of seven out of 10 on day shift and six out of 10 on night shift or how/if the resident's pain was relieved. Review of the resident's progress note dated 03/27/25 showed the resident took off his/her Fentanyl patch that was placed in the hospital due to increased irritation of the skin. Physician notified and new orders for MS Contin (opioid agonist controlled substance indicated for management of severe pain)15 mg two times a day (BID) received. Review of the resident's March 2025 MAR showed the following: -An order, dated 03/27/25, for Fentanyl Patch 25 mg, apply new patch every three days. The order was discontinued on 03/27/25 before it had been administered in the facility; -An order, dated 03/27/25, for MS Contin (opioid agonist controlled substance indicated for management of severe pain) 15 mg, give one tablet by mouth twice a day for pain. Staff administered medication at 5:00 P.M. on 03/27/25. The order was discontinued on 03/28/25; -An order, dated 03/28/25, for MS Contin 30 mg, give one tablet by mouth every 12 hours for pain. Review of the resident's MAR, dated 03/27/25, showed a pain scale of five out of 10 on the day shift and a 0/10 on the night shift. Review of the resident's medical record, dated 03/27/25, showed staff did not document steps taken to address the resident pain level of five out of 10 on day shift or or how/if the resident's pain was relieved. Review of the resident's progress note, dated 03/28/25, showed the DON said that the resident was screaming at her due to uncontrolled pain. The DON insisted that the resident wanted different types of medication based off his/her history with log term drug use to give the resident his/her desired effect. Continuing to educate the resident on non-pharmacological options for pain control. Review of the resident's progress note, dated 03/30/25, showed the resident was complaining of itching all over, nausea, generalized pain that was uncontrolled with administration of MS Contin 30 mg. The resident had recently been diagnosed with liver cancer and is very concerned with his/her condition. Staff notified physician and the resident was sent to ED. Review of the resident's care plan, revised 03/31/25, showed staff added the following: -Assist and encourage the resident to develop more appropriate methods of coping and interacting rather than being accusatory and indicating that his/her pain is not being appropriately treated; -The resident has a history of misusing controlled medication while in the community. The resident continues to demand instant release opioids rather than use extended-release medications. If the resident does not feel he/she has received his/her medication timely, he/she will request to go to the ED. Review of the resident's MAR, dated 03/31/25, showed the resident's pain rated at a six out of 10 on the day shift. Review of the resident's medical record, dated 03/31/25, showed staff did not document steps taken to address the resident pain level of six out of 10 on the day shift or how/if the resident's pain was relieved. Review of the resident's progress note dated 04/01/25, at 9:48 A.M., showed staff did not indicate the resident returned from the ED. Staff noted the resident was seeking more pain medication with complaints of headache and abdominal pain. The resident was notified he/she could not have any more pain medication. The resident was aware of this and knew the parameters of his/her pain medication orders. (Staff did not document of physician notification of the resident's complaints of additional pain.) Review of the resident's MAR, dated 04/01/25, showed a pain scale of 6/10 on the day shift and a 3/10 on the night shift. Review of the resident's medical record, dated 04/01/25, showed staff did not document steps taken to address the resident pain level of six out of 10 on day shift and three out of 10 on night shift or how/if the resident's pain was relieved. Review of the resident's April 2025 POS showed an order, dated 03/28/25, for MS Contin 30 mg, give one tablet by mouth every 12 hours for pain was increased on 04/01/25 to MS Contin 30 mg give one tablet by mouth three times daily for pain. Review of the resident's MAR, dated 04/02/25, the resident's pain rated at a five out of 10 on the day shift. Review of the resident's medical record, dated 04/02/25, showed staff did not document steps taken to address the resident pain level of five out of 10 on the day shift or how/if the resident's pain was relieved. Review of the resident's MAR, dated 04/03/25, showed the resident's pain rated as a six out of 10 on the night shift. Review of the resident's medical record, dated 04/03/25, showed staff did not document steps taken to address the resident pain level of six out of 10 on the day shift or how/if the resident's pain was relieved. Review of the resident's MAR, dated 04/04/25. showed the resident's pain rated as a three out of 10 on the night shift. Review of the resident's medical record, dated 04/04/25, showed staff did not document steps taken to address the resident pain level of three out of 10 on the night shift or how/if the resident's pain was relieved. Review of the resident's MAR, 04/06/25, showed the resident's pain rated as a three out o f 10 on the day shift and a two out of 10 on the night shift. Review of the resident's medical record, dated 04/06/25, showed staff did not document steps taken to address the resident pain level of three out of 10 on the day shift and a two out of 10 on the night shift or or how/if the resident's pain was relieved. Review of the resident's progress notes, dated 04/07/25, showed the following: -At 12:00 P.M., staff noted the resident came to the nurses' station numerous times and told the staff he/she was hurting due to his/her cancer diagnoses and needed something to be done. The staff member reported to the resident that he/she had seen the physician on Friday with no changes. The resident said he/she wanted to go to the hospital for pain management then as the medication was ineffective and his/her pain level was nine out of 10. The resident did not show any signs and symptoms of pain. He/she was up in the wheelchair and propelling self through the facility, eating meals, and attending smoke breaks. -At 3:18 P.M., the resident said he/she wanted to go to the ED and told staff that he/she can go whenever he/she wants as the physician has already told him/her that. DON and the Administrator spoke with the resident regarding the request to go to the ED. The physician was notified and gave the order to send the resident to the ED. Review of the resident's progress note dated 04/08/25, at 11:18 P.M., showed the resident returned from the hospital with new orders for Percocet 7.5/325 mg tablet every six hours for pain. Staff notified the physician and was awaiting confirmation. Review of the resident's ED's after visit summary, dated 04/08/25, showed a new order for Percocet 7.5/325 mg tablet by mouth every six hours as needed. Review of the resident's April 2025 POS showed an order, dated 04/10/25, for Percocet 5-325 mg by mouth every six hours as needed for pain. Observation and interview on 05/01/25, at 10:30 A.M., showed the resident said the following: -The resident wanted to discharge from the facility due to staff refusing to treat his/her pain; -The DON says he/she has behaviors because he/she requests timely and effective pain management. The DON would only allow him/her to have Tylenol until his/her most recent hospitalization where he/she was diagnosed with stage III cancer; -He/she has had to go to the ED so much for unrelieved pain that the DON now makes him/her sign an Against Medical Advice (AMA) Form if he/she wished to go to the ED for pain; -The resident provided the AMA form for the surveyor to view. During an interview on 05/01/25, at 2:25 P.M., Certified Mediation Technician (CMT) A said the following: -If a resident complained of pain, he/she would let the nurse know, assess the pain, and administer pain medication if it was available. After the administration of pain medication, effectiveness should be documented; -No resident's are denied pain medication, even if they have a history of substance abuse; -The facility has tried a few different things for the resident, but he/she would have interactions so those medications would get discontinued; -The resident complained of pain frequently. During an interview on 05/01/25, at 2:32 P.M., Licensed Practical Nurse (LPN) B said the following: -If a resident was complaining of increased pain and the current pain regimen was not controlling the pain, he/she would contact the physician; -The facility staff attempted to use all non-pharmacological means to treat the resident's pain prior to the use of narcotics related to his/her history of substance abuse. During an interview on 05/01/25, at 2:40 P.M., the Social Services Director (SSD) said the following: -The resident came in with the goal of sobriety, so non-narcotic medication was offered, but when he/she got a terminal diagnosis that changed everything; -She was not sure if the sobriety goal is documented anywhere; -She was aware of the resident's past substance abuse due to getting the resident from a halfway house. During an interview on 05/02/25, at 10:09 A.M., the Medical Records Nurse said the following: -If a resident complained of increased pain, she would report it to the charge nurse who would assess the pain and contact the physician; -The resident has a history of past substance abuse, so the facility attempted non-pharmacological attempts to relieve pain; -This should be documented in the POS and care plan. During an interview on 05/02/25, at 10:37 A.M., LPN C said the following; -If a resident is exhibiting increased pain, staff should assess the pain and try non-pharmacological attempts prior to administering pain medication. If those attempts do not work, administer pain medication, and notify the doctor; -The physician said he/she did not want the resident to have any narcotics. The resident could go to the ED if his/her pain was unrelieved; -The resident now has seemed to experience some relief with the new pain medications on board. During an interview on 05/02/25, at 10:59 A.M., the on-call Nurse Practitioner (NP) said effective pain medication should not be withheld from any resident regardless of their history. The resident is in a controlled environment, so there is not a concern of the resident becoming re-addicted to narcotics. She is not sure how or where the physician would have documented that the resident is not allowed to have narcotics. They expected to be contacted for uncontrolled pain and/or an ineffective regimen. During an interview on 05/02/25, at 11:30 A.M., the DON said the following; -If a resident was exhibiting pain, she expected the staff to assess the pain. Staff should also monitor if the resident is complaining of pain and is sleeping or not showing signs and symptoms of pain; -If the resident continued to complain of increased pain, they can go to the ED if the physician won't order anything additional; -Pain medication wasn't withheld from the resident, other avenues were explored due to his/her history; -The resident had a lot of behaviors and the physician determined what was appropriate for the resident and narcotics were chosen not to be allowed; -Just because a medication is not a narcotic does not mean it doesn't work for the resident's pain; -The resident will complain of pain but will appear drowsy and or laughing. -The resident would present as drowsy and fatigued since starting medication. She does not believe that this could be related to a diagnoses of stage IIII cancer. -Since the resident has had new medications on board, the resident has had much fewer complaints of pain. During an interview on 05/02/25, at 1:01 P.M., the Administrator said the following: -If a resident is complaining of increased pain, he expected staff to assess the pain and communicate with the physician; -The resident came to the facility with a history of substance abuse, so it was a goal for him/her to be sober; -The physician was on board with the resident remaining sober; -The resident went to the ED several times for pain not being relieved, but if they were to give him/her narcotics he/she would be addicted again; -Since the resident has had medication changes, he/she has not complained of pain as frequently. MO00251691

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff failed to follow proper technique during a mechanical lift transfer of one resident (Resident #1). The facility census was 68. The Director of Nursing (DON) was notified by facility staff on 04/24/24 of the noncompliance that occurred on 04/24/24. The DON and Administrator made an online self-report to the Department of Health and Senior Services, began an investigation, and began in-servicing with all nursing staff regarding transfers on 04/24/24. The facility implemented monitoring of the resident involved and all residents who required a two person assistance transfer assistance with a Hoyer lift (mechanical lift normally used to transfer non-weight bearing residents) to ensure transfers were completed safely and as required with two staff. The noncompliance was corrected on 04/25/24. Review of the facility policy titled, Safe Lifting and Movement of Residents, with a revision date of July 2017, showed the following: -In order to protect the safety and well-being of staff and residents, and promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Two staff members must be present when operating a mechanical lifting device. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admission date of 10/05/22: -Diagnoses included joint pain and Alzheimer (brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 03/25/24, showed the following: -Cognition severely impaired; -Dependent on staff for transfers, mobility, dressing, toileting, and bathing; -No falls with injury since admission. Review of the resident's Care Plan, dated 04/02/24, showed the following: -Required maximum staff assistance with activities of daily living; -Impaired visual function; -Impaired cognition and thought process due to dementia; -Limited physical ability due to Alzheimer, weakness, and contractures; -High risk for falls related to confusion. Review of of the resident's Progress Notes showed the following: -On 04/24/24, at 6:15 A.M., a certified nurse aide (CNA) reported possible injury to resident during transfer. The resident's right lower extremity (RLE) was caught or hit during the transfer and the resident began complaining of increased pain. The nurse's assessment of RLE showed a protruding area mid shin, tender to the touch. Staff administered pain medication immediately. Staff transferred the resident back to bed, stabilized leg, and ordered X-ray. -On 04/24/24, at 7:58 A.M., nurse arrived to work and report showed that during a transfer out of bed this morning resident either hit the foot of the bed or the Hoyer lift with right calf. The resident was crying in pain and pain medication had been administered per orders. Resident's leg had a hematoma and slight indent was noted to the shin area; -On 04/24/24, at 2:25 P.M., the physician reviewed the X-ray results and did not believe the resident was a candidate for surgery. The physician ordered a long leg splint that goes from above the knee to below the ankle, ace wrapped to immobilize the leg. Review of the resident's X-ray report, dated 04/24/24, showed an acute midshaft tibial (long bone in lower leg) fracture and osteopenia (a decrease in bone mineral density). Review of the resident's Care Plan, dated 04/24/24, showed the following update: -On 04/24/24, resident transferred by staff in Hoyer lift and right leg became entangled. Resident had large hematoma (bruising) immediately noted to right mid-calf. An X-ray showed mid-shaft fracture to right mid-calf. Staff to ensure that there are two staff for Hoyer lift transfers, sling is in proper position and right size, placement of my limbs during transfers, and make sure no obstacles in the path of the lift and resident. -Resident to wear a long leg splint above knee and below ankle. Resident is non-weight bearing and staying in bed until splint is applied. During an interview on 05/09/24, at 3:15 P.M., Nurse Aide (NA) A said the following: -He/she had training on use of a Hoyer lift when transferring a resident from bed to a chair and from chair to bed; -There should always be two staff when using the Hoyer lift; -The resident required total assistance from staff with transferring and mobility; -The resident required the use of a Hoyer mechanical lift for all transfers; -The resident was very fragile; -The resident complained of pain frequently; -On 04/24/24, he/she and CNA B were getting the resident up and dressed for the day; -CNA B controlled the mechanical lift while the resident was in the lift and he/she was supposed to guide the resident's legs and feet to ensure safety; -The mechanical lift sling had been placed on the resident and the resident was hooked up to the lift while lying in bed; -NA A stepped away from the resident in the lift to look for the resident's slipper; -CNA B did not notice he/she had walked away -NA A walked approximately six feet away from the resident when the resident yelled out in pain, -CNA B lifted the resident in the air using the mechanical lift while NA A was six feet away from the resident and he/she thinks the residents leg hit something while being lift; -NA A said he/she should not have stepped away from the resident during a transfer; -There should always be two staff when using a mechanical lift, one runs the lift and the other ensures the legs and feet are safe. During an interview on 05/09/24, at 3:40 P.M., Registered Nurse (RN) C said the following: -Hoyer lift transfers always require two staff members; -One staff guided while the other staff is driving the Hoyer lift; -The staff should never step away from the resident during the transfer; -If the staff have to walk away then the resident should be put back down until both staff can safely transfer the resident. During an interview on 05/09/24, at 3:45 P.M., Licensed Practical Nurse (LPN) D said the following: -When transferring a resident with a Hoyer lift there should always be two staff present; -The resident required the use of a Hoyer lift with all transfers; -The resident would [NAME] his/her legs straight out and become stiff; -The resident was very tiny and brittle. During an interview on 05/09/24, at 4:48 P.M., the DON said when transferring a resident using a Hoyer lift there should always be two staff. One staff should control the mechanical lift and the other staff member should guide the residents legs and feet. The staff should never walk away from the resident until the transfer is completed. During an interview on 05/09/24, at 4:51 P.M., the Administrator said there should always be two staff when transferring a resident using a Hoyer lift. One staff should control the mechanical lift and the other staff member control the resident so the residents legs and feet don't swing. The staff should never step away from the resident until the transfer is completed. If the staff have to step away the staff need to communicate with each other and the staff should stop the transfer until it is safe to transfer the resident. MO00235175

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all allegations of abuse were immediately reported to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff witnessed one resident (Resident #1) touch another resident (Resident #2) in a sexual manner and the nurse failed to report the allegation to management or the SSA. The facility census was 62. Review of the facility's policy titled Abuse Reporting, revised 03/15/18, showed the following: -It is the policy of the facility that all personnel promptly report any incident or suspected incident of resident abuse; -The facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends or other individuals; -Any alleged violations involving mistreatment, neglect, or abuse must be reported to the Administrator and/or Director of Nursing (DON) as soon as suspicion has been formed; -If a suspicion of abuse has been formed at least one law enforcement agency as well as the State Survey Agency (SSA) must be notified immediately and no later than two hours after forming the suspicion; -All allegations of mistreatment, neglect or abuse, injuries of unknown source, and misappropriation of resident property are immediately reported to the Administrator and other officials in accordance with state law. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admission date of 03/16/23: -Diagnoses included, depression, personally disorder, heart failure, cognitive social or emotional deficit and a nontramatical chronic subdural hemorrhage (a bleeding in the area between the brain and the skull-head trauma). Review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 09/30/23, showed the residents cognition was moderately impaired. 2. Review of Resident #2's face sheet showed the following: -admission date of 08/24/23: -Diagnoses included traumatic brain injury, anxiety, schizoaffective disorder (a mental health condition with a combination of symptoms of schizophrenia and mood disorder), bipolar (psychiatric illness characterized by both manic and depressive episodes or manic ones ), depression, asthma, and arthritis in the right ankle and foot. Review of the resident's admission MDS, dated [DATE], showed the resident's cognition was intact. Review of the resident's nursing note dated 10/06/23, at 10:22 P.M., listed as a behavior entry, showed the following: -The resident was argumentative with other residents during the smoke time around dinner; -At the last smoke break of the evening, CNA B witnessed Resident #1 jiggling Resident #2's breast; -Resident #2 was visibly upset; -Staff removed Resident #1 from the situation and told the resident this behavior was unacceptable. (Staff did not document reporting the allegation of abuse to the Administrator or DHSS.) Review of the resident's nursing note dated 10/09/23, at 12:05 P.M., listed as an incident note, showed the following: -DON and Administrator interviewed Resident #1 about the allegations; -The resident said he/she was just trying to give Resident #2 a hug and grazed him/her; -The physician was notified and an order for medroxyprogesterone (a hormone treatment) 5 milligrams (mg) one time daily was received; -Staff implemented 15-minute checks. -Staff assessed the resident. 3. Review of the facility's incident report, dated 10/09/23, showed the following: -Date of incident was 10/06/23 with P.M. noted for time -Location of the incident was the residents smoke area hall; -Certified Nurse Aide (CNA B) reported Resident #1 touched Resident #2's breast. 4. Review of DHSS records showed the allegation was reported by a staff member on 10/09/2023, at approximately 2:34 P.M. (three days after a staff became aware of the allegation of abuse). 5. During an interview on 10/10/23, at 3:15 P.M., CNA B said the following: -On 10/06/23, at the last smoke break, residents were in the hall waiting by the door going to the smoke area. At approximately 8:00 P.M., he/she witnessed Resident #1 touching Resident #2 inappropriately and he/she approached the residents immediately and separated the residents; -He/she then took all the residents out to smoke and after the smoke break he/she reported the abuse to Licensed Practical Nurse (LPN) A. 6. During an interview on 10/10/23, at 3:47 P.M., LPN A said the following: -All abuse and neglect should be reported immediately; -All abuse has to be reported to SSA within two hours; -CNA B reported an allegation of sexual abuse between Resident #1 and Resident #2 on 10/06/23; -LPN A failed to report the allegation of sexual abuse to the DON and/or the Administrator; -He/she should have reported the allegations of sexual abuse involving Resident #1 and Resident #2 immediately to the DON and the Administrator. 7. During an interview on 10/10/23, at 12:40 P.M., the DON said the following: -On 10/09/23, she was monitoring weekend charting and when reviewing charts she saw an incident note dated 10/06/23 that stated Resident #1 had jiggled' Resident #2's breast and the two residents were separated; -She called LPN A and LPN A said he/she failed to report the situation; -DON started an investigation and reported the alleged abuse to the SSA on 10/09/23. 8. During an interview on 10/10/23, at 5:00 P.M.,the Administrator and the DON said the following: -All reports of abuse must be immediately reported to the charge nurse, DON, and the Administrator; -LPN A should have reported all allegations of abuse to the DON and the Administrator; -All reports of abuse should be reported to the SSA within two hours of the alleged incident. MO000225626

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document a timely investigation of an allegation of sexual abuse and failed to immediately take steps to protect all residents when Certified Nurse Aide (CNA) B alleged one resident (Resident #1) was observed to touch another resident (Resident #2) in a sexual manner. The facility census was 62. Review of the facility policy titled Abuse Investigating, revised 03/15/18, showed the following: -It is the policy of the facility that reports of abuse will be promptly and thoroughly investigated; -The administrator will provide to the person in charge of the investigation a copy of the Resident Abuse Report Form and any supporting documents relative to the investigation: -The representative's investigation shall consist of a review of the completed Resident Abuse Report Form and an interview with the person(s) reporting the incident. Review of the facility's Abuse Policy included a copy of a form, including the steps taken to protect residents, which showed the following: -Describe all steps taken immediately to ensure residents are protected; -Immediate assessment of the alleged victim and provision of medical treatment as necessary; -Evaluation of whether the alleged victim feels safe and if he/she does not feel safe, taking immediate steps to protect the resident, such as a room relocation and/or increased supervision; -Immediate notification to the alleged perpetrator's (if a resident) and/or the alleged victim's physician and the resident representative when there is injury, a significant change in condition or status, and/or a need to alter treatment significantly; -If the alleged perpetrator is facility staff, removal of the alleged perpetrator's access to the alleged victim and other residents and assurance that ongoing safety and protection is provided for the alleged victim and other residents; -If the alleged perpetrator is a resident or visitor, removal of the alleged perpetrator's access to the alleged victim and, as appropriate, other residents and assurance that ongoing safety and protection is provided for the alleged victim and other residents; -Other measures the facility is taking to prevent further potential abuse, neglect, exploitation, and misappropriation of resident property. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admission date of 03/16/23: -Diagnoses included depression, personality disorder, heart failure, cognitive social or emotional deficit, and a nontramatical chronic subdural hemorrhage (a bleeding in the area between the brain and the skull-head trauma). Review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 09/30/23, showed the resident's cognition was moderately impaired. 2. Review of Resident #2's face sheet showed the following: -admission date of 08/24/23: -Diagnoses included traumatic brain injury, anxiety, schizoaffective disorder (a mental health condition with a combination of symptoms of schizophrenia and mood disorder), bipolar (psychiatric illness characterized by both manic and depressive episodes or manic ones ), depression, asthma, and arthritis in the right ankle and foot. Record review of the resident's admission MDS, dated [DATE], showed the resident's cognition was intact. Review of the resident's nursing note dated 10/06/23, at 10:22 P.M., listed as a behavior entry, showed the following: -The resident was argumentative with other residents during the smoke time around dinner; -At the last smoke break of the evening CNA B witnessed Resident #1 jiggling Resident #2's breast; -Resident #2 was visibly upset; -Staff removed Resident #1 from the situation and told the resident this behavior was unacceptable. (Staff did not document the start of an investigation or what additional steps were taken to protect all residents.) Review of the resident's nursing note dated 10/09/23, at 12:05 P.M., listed as an incident note, showed the following: -DON and Administrator interviewed Resident #1 about the allegations; -The resident said he/she was just trying to give Resident #2 a hug and grazed him/her; -The physician was notified and an order for medroxyprogesterone (a hormone) 5 mg one time daily was received; -Staff implemented 15 minute checks put in place (3 days after the allegation occurred); -Staff assessed the resident. 3 Review of the facility's incident report, dated 10/09/23, showed the following: -Date of incident was 10/06/23 with P.M. noted as time; -Location of the incident was the residents' smoke area hall; -CNA B reported Resident #1 touched Resident #2's breast. (Staff did not document an immediate investigation or immediate steps taken to protect all residents.) 4. During an interview on 10/10/23 at 1:55 P.M., Resident #2 said the following: -While he/she sat in a chair in the hall waiting to go outside to smoke, Resident #1 wheeled his/her wheelchair up next to him/her and grabbed his/her right breast; -CNA B witnessed the incident and separated the residents; -Nobody came and talked to him/her that day or throughout the weekend; -The nurse did not assess the resident that day or anytime throughout the weekend; -The staff did not keep Resident #1 away from him/her. They all (residents) continued to wait in the hall waiting to go smoke and Resident #1 was in the same area in the smoking area. During an interview on 10/10/23, at 3:15 P.M., CNA B said the following: -On 10/6/23, at the last smoke break residents were in the hall waiting by the door going to the smoke area. At approximately 8:00 P.M., he/she witnessed Resident #1 touching Resident #2 inappropriate and he/she approached the residents immediately and separated the residents; -He/she then took all the residents out to smoke and after the smoke break he/she reported the abuse to Licensed Practical Nurse (LPN) A; -CNA B was not sure what had been done about this situation; -There was not any official monitoring of either resident; -There were no 15-minute checks of either resident until 10/09/23. During an interview on 10/10/23, at 3:47 P.M., LPN A said the following: -All abuse and neglect should investigated immediately; -The nurse should assess the residents involved in any reports of resident-to-resident abuse; -Residents involved in a resident-to-resident altercation should be monitored by initiating 15-minute checks; -CNA B reported an allegation of sexual abuse between Resident #1 and Resident #2 on 10/06/23; -LPN A did not go and assess either resident after the report was made; -LPN A did not initiated any monitoring of either resident; -No investigations was initiated after the report of resident-to-resident sexual abuse; -LPN A said he/she should have assessed both residents after the report of sexual abuse was reported to him/her; -An investigation should have been started and statements from staff should have been taken. During an interview on 10/10/23 at 12:40 P.M., the Director of Nursing (DON) said the following: -On 10/09/23, she was monitoring weekend charting and when reviewing charts she saw an incident note dated 10/06/23 that stated Resident #1 had jiggled' Resident #2's breast and the two residents were separated; -She called LPN A and LPN A said he/she failed to report the situation; -Staff initiated 15-minute checks on 10/09/23; -The residents should be kept separated and monitored for safety; -She started an investigation on 10/09/23. During an interview on 10/10/23, at 5:00 P.M., the Administrator and the DON said the following: -All reports of abuse must be investigated immediately; -During the investigation the accused resident should be placed on 15-minutes monitoring and the victim of the alleged abuse should be protected; -All investigations should be completed and sent to the SSA within five days. MO000226226

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document a full discharge summary with information regarding discharge for one resident (Resident #59). The facility census was 60. Review of the facility's policy titled, Discharge Procedure, revised 04/26/00, showed the following: -To assist family and resident to continue care if returning home; -To advise other departments promptly of dismissal; -To facilitate proper closing of records and collection of personal belongings; -Upon notification of dismissal, the records will be completed as quickly as possible assuring an organized dismissal. 1. Review of Resident #59's face sheet (admission data) showed the following information: -re-admission date of 04/14/18; -Diagnoses included unspecified dementia, obesity, and anxiety disorder. Review of the resident's progress note dated 06/28/23, at 2:14 P.M., showed the Social Service Director (SSD) documented the resident to discharge on [DATE]. The resident will stay with his/her family member. Nursing staff notified and an order to discharge with medications and an order for home health. The physician to send the prescription to the pharmacy for medications. Review of the resident's electronic and paper medical records showed staff did not document information pertaining to the resident's discharge. Staff did not document in the medical record when, how, where, or why the resident discharged from the facility. Staff did not document a post-discharge plan of care or review of medication. Staff did not document a recapitulation of the resident's stay. During an interview on 09/21/23, at 1:52 P.M., Licensed Practical Nurse (LPN) E said the following: -The nurses should notify the physician and review the medications with the resident and/or responsible party; -The nurses should give the medications and instructions to the resident/responsible party upon discharge if the medications are sent; -Nurses should have the resident and/or responsible party sign if narcotics are sent with the discharge. During an interview on 09/22/23, at 1:33 P.M., LPN F said the following: -The charge nurse should document in the resident's progress notes of a resident's discharge; -The charge nurse should document where the resident was discharged to, medications sent, belongings medications sent, and home health services. During an interview on 09/21/23, at 2:00 P.M., the SSD said the following: -She completes the discharge plan and summary for residents; -She discusses with the resident of discharge plans to home, home health services, or wishes to remain in the facility; -She gives home health brochures to the resident and/or responsible party to review and they notify her of the home health choice. The responsible party or resident sometimes contact the home health company; -Nursing staff should document a discharge summary in the resident's progress note; -She and nursing staff should develop a resident's discharge plan as a team; -She did not know of the of recapitulation of stay note when a resident discharged from the facility; -She did not document the resident's discharge plan or summary; -The resident discharged to home with his/her family; -She did not document a note on the resident's discharge date . During an interview on 09/21/23, at 2:33 P.M., the Director of Nursing (DON) said the following: -The charge nurse should document a discharge summary; -Nurses should send a medication list with the resident and instructions if the medications are sent; -Nurses should document a note in the resident's progress notes of the discharge. During an interview on 09/22/23, at 2:57 P.M., the Administrator said facility staff should complete a discharge summary of a resident's discharge.

Based on observation, interview, and record review, the facility failed to provide timely and routine assessments, failed to consistently provide physician ordered treatment and antibiotic, and failed to develop a baseline and comprehensive care plan for one resident (Resident #61) with a right heel pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of a sample of three sample of three closed record (discharged ) residents. The facility census was 60. Review of the facility policy, Decub (pressure ulcer) Care Protocol, dated 02/01/07, showed staff to assess the resident at least weekly and document the assessment in the skin book and nurses notes. Review of the facility policy, Pressure Ulcers/Injuries Overview, revised July 2017, showed the following: -The purpose of this procedure is to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors; -Pressure ulcer/injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; -A pressure injury will present as intact skin and may be painful; -A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful; -Stage 2 pressure ulcer (partial-thickness skin loss with exposed dermis); -The stage 2 pressure ulcer appears as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer; -The wound bed is viable, pink or red, moist and may also present as an intact or open/ruptured blister; -Granulation tissue (the pink-red moist tissue that fills an open wound, when it starts to heal), slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture), and eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) are not present. Review of the facility policy, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, showed the following: -Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decision for improvement or individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship; -All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: resident name, date symptoms appeared, start date of antibiotic, outcome and adverse events. 1. Review of Resident #61's face sheet (admission data) showed the following: -admission date of 06/16/23; -Diagnoses included Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), chronic pain, and non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity. Review of the resident's nursing admission assessment, dated 06/16/23, showed the following: -Right heel marked as stage 2 pressure ulcer with measurements of 6.0 centimeters (cm) long by 6.0 cm wide by 0.5 cm deep; -Left heel marked as stage 2 pressure ulcer with measurements of 8.0 cm long by 6.0 cm wide by 0.25 cm deep; -Wound base pink, eschar present, and no drainage; -Surround skin dry/flaky and red; -Type of wound marked as pressure ulcer; -Wound present on admission. During an interview on 9/22/23, at 3:50 P.M., the Care Plan Coordinator said she did not develop the baseline or comprehensive care plan completed for the resident. Review of the resident's June 2023 Physician Order Sheet (POS) showed the following: -An order, dated 06/16/23, for staff to cleanse the resident's bilateral heels with hypochlorous acid (a skin disinfectant), pat dry, spray the surrounding tissue with skin prep (a barrier spray used to minimize adhesive removal damage to skin) spray, apply hydrogel (a water absorbing wound treatment material) to the wound bed, and cover with a dressing daily and as needed (PRN) until resolved. Review of the resident's June 2023 Treatment Administration Record (TAR) showed the following: -An order, dated 06/16/23, for staff to cleanse the resident's bilateral heels with hypochlorous acid, pat dry, spray surrounding tissue with skin prep spray, apply hydrogel to wound bed, and cover with a dressing daily and PRN until resolved. Staff to perform the treatment every day shift. Review of the resident's June 2023 (TAR) showed on 06/17/23, staff did not initial completion of the ordered bilateral heel treatment, or document a reason as to why he/she failed to complete the treatment. Review of the resident's skilled charting notes, dated 06/17/23, showed a nurse documented the following in the skin/wound section: -No new changes to skin integrity noted; -The nurse left the wound care section blank. Review of the resident's June 2023 TAR showed on 06/18/23, staff did not initial completion of the ordered bilateral heel treatment, or document a reason as to why he/she failed to complete the treatment. Review of the resident's skilled charting notes, dated 6/18/23, showed a nurse documented the following in the skin/wound section: -No new changes to skin integrity noted; -The nurse left the wound care section blank. Review of the resident's June 2023 TAR showed on 06/19/23 and 06/20/23 staff initialed completion of the ordered bilateral heel treatment. Review of the resident's admission Minimum Data Set (MDS - a federally-mandated comprehensive assessment instrument completed by facility staff), dated 06/20/23, showed the following: -Moderate cognitive skills; -Presence of one or more unhealed pressure ulcer at stage 1 (intact skin with a localized area of non-blanchable erythema (redness)) or higher marked; -Unhealed pressure ulcer; -Two stage 2 pressure ulcers that were present upon admission; -Other open lesions on the foot marked. Review of the resident's wound care report, dated 06/20/23, showed the following: -Stage 2 pressure ulcer; -Right heel with measurements of 6.0 cm long by 7.0 cm wide (with no depth documented); -Left heel with measurements of 8.0 cm long by 5.0 cm wide (with no depth documented); -Drainage marked as none; -Surrounding skin intact; -Consults: wound company; -Notifications: physician, Administrator, and Director of Nursing (DON). Review of the resident's June 2023 TAR showed on 06/21/23, 06/22/23, and 06/23/23 staff initialed completion of the ordered bilateral heel treatment. Review of the resident's June 2023 TAR showed on 06/24/23, staff did not initial completion of the ordered bilateral heel treatment, or document a reason as to why he/she failed to complete the treatment. Review of the resident's skilled charting notes, dated 06/24/23, showed a nurse documented in the skin/wound section the following: -No new changes to skin integrity noted; -The resident has treatable wounds to his/her bilateral heels; -The dressing change not required. Review of the resident's June 2023 TAR showed on 06/25/23, a nurse initialed completion of the ordered bilateral heel treatment. Review of the resident's progress note dated 06/25/23, at 5:22 P.M. showed Registered Nurse (RN) O documented: -The resident's dressings on the heels were changed today. The resident's right heel is open with darkened areas of skin on the outer aspects of the wound and toward the center. The resident's left heel has scaly skin, but the heel is not open. It is red and very tender. Review of the resident's June 2023 TAR showed on 06/26/23, a nurse initialed completion of the ordered bilateral heel treatment. Review of the wound care report, dated 06/27/23, showed the following: -Pressure ulcer, stage 2; -Right heel with measurements of 7.0 cm long by 7.0 cm wide (no depth documented); -Left heel with measurements of 7.0 cm long by 4.0 cm wide (no depth documented); -Drainage marked as none; -Surrounding skin intact; -Consults: wound company; -Notifications: physician, Administrator and DON. Review of the resident's June 2023 TAR showed 06/27/23, staff did not initial completion of the ordered bilateral heel treatment, or document a reason as to why he/she failed to complete the treatment. Review of the resident's skilled charting notes, dated 06/27/23, showed a nurse documented in the skin/wound section the following: -No new changes to skin integrity noted; -The resident has treatable wounds to bilateral heels; -The dressing change not required. Review of the resident's June 2023 TAR showed the following: -A nurse initialed completion of the treatment on 06/28/23; -A nurse did not initial completion of the treatment on 06/29/23 or a reason as to why he/she failed to complete the treatment. Review of the physician's visit notes dated 06/28/23, at 8:16 A.M. showed the following: -Physical examination: skin is warm, dry, bilateral heel ulcers; -Wound care for heel ulcerations. Review of the resident's skilled charting, dated 06/29/23, showed a nurse documented in the skin/wound section the following: -No new changes to skin integrity noted; -The resident has treatable wounds to bilateral heels; -The dressing change not required. Review of the resident's June 2023 TAR showed on 06/30/23, a nurse initialed completion of the treatment. Review of the July 2023 TAR showed the following: -A nurse initialed completion of the treatment on 07/01/23; -A nurse did not initial completion of the treatment on 07/02/23 or a reason as to why he/she failed to complete the treatment; -A nurse initialed completion of the treatment on 07/03/23 and 07/04/23. Review of the resident's wound care report, dated 07/04/23, showed the following: -Pressure ulcer stage II; -Right heel with measurements of 9 cm long by 9 cm wide (no depth documented); -Left heel with measurements of 6 cm long by 4 cm wide (no depth documented); -Drainage: nothing marked; -Wound red on right heel; -Surrounding skin: right heel wet/white, red and discolored; -Consults: wound care company; -Notifications: physician and DON. Review of the resident's July 2023 TAR showed a nurse did not initial completion of the treatment on 07/05/23 or a reason as to why he/she failed to complete the treatment. Review of the resident's skilled charting notes, dated 07/05/23, showed a nurse documented in the skin/wound section the following: -No new changes to skin integrity noted; -The resident has treatable wounds to bilateral heels; -The dressing change not required. Review of the resident's July 2023 TAR showed the following: -An order, dated 07/06/23, to cleanse with wound care the right heel necrotic areas, pat dry, apply Santyl (an enzymatic debriding agent, aides if removal of dead tissue) to necrotic (dead tissue) area and apply dressing. Change daily and prn soilage. every day shift for wound care right heel; -A nurse initialed completion of the treatment on 07/06/23; -A nurse did not initial completion of the treatment on 07/07/23 or a reason as to why he/she failed to complete the treatment. Review of the resident's medical record showed no skilled charting notes on 07/07/23. Review of the resident's progress note, dated 07/07/23, at 9:42 A.M., showed Licensed Practical Nurse (LPN) J documented the following: -The resident's right heel wound noted to have a foul smell and a moderate amount of green/brown drainage. The wound is very painful and red and swollen peri-wound (surrounding intact skin). Staff notified the physician. The resident has complained of increased anxiety; Review of the resident's progress notes dated 07/07/23, at 10:02 A.M., (late entry) showed the DON documented the following: -The resident continued to curse at staff repeatedly. The resident shouted he/she was calling, state, the governor, the entire state, and tell them what you've done to me. The DON, administrator and social worker sat down with the resident, the resident stated that the facility staff did not look at his/her foot for two weeks. The DON showed the resident the documentation and told him/her that RN personally looked at the wound. The resident said no one cares and it is infected, we need antibiotics, The DON told the resident he/she obtained a wound culture but it takes a day or two for the culture to come back. The DON called and obtained an order for a broad spectrum antibiotic until the culture had resulted. Review of the resident's progress note dated 07/07/23, at 12:10 P.M., showed LPN J documented a new order for Keflex (an antiinfective medication)500 mg by mouth twice a day for ten days and a standing order for probiotic. Staff faxed orders to pharmacy and resident updated. Review of the resident's physician order dated 07/07/23, at 12:10 P.M., showed an order for Keflex 500 mg by mouth two times per day for ten days and a standing order for a probiotic. Review of the resident's July 2023 Medication Administration Record (MAR) showed the following: -An order, dated 07/07/23, for Keflex oral capsule 500 mg, give 500 mg by mouth one time only for wound infection until 07/07/23; -An order, dated 07/07/23 for Keflex oral capsule 500 mg. give 500 mg by mouth twice a day for wound infection for ten days. Review of the resident's July 2023 TAR showed the following: -On 07/08/23, staff did not initial completion of the treatment or a reason as to why he/she failed to complete the treatment; -A nurse initialed completion of the treatment on 07/09/23; -A nurse did not initial completion of the treatment on 07/10/23 or a reason as to why he/she failed to complete the treatment; -A nurse initialed completion of the treatment on 07/11/23. Review of the resident's July 2023 MAR showed on 07/09/23 staff did not initial administration of the medication for the 5:00 P.M. dose (2nd dose). Review of the nurse practitioner's visit note dated 07/10/23, at 2:15 P.M., showed the following: -Evaluated today for follow up on right heel wound; -The resident reports continued pain and drainage from the right heel; -The resident denies fever, chills and body aches; -The resident states he/she noticed the bilateral heel blisters two weeks ago and developed pain in the right heel with drainage; -The resident states a specialist scheduled tomorrow to assess his/her right heel wound; -Physical exam showed right heel bandage without drainage and no erythema (reddening of the skin) or edema to surrounding skin on right foot. During an interview on 09/22/23, at 10:11 A.M., Licensed Practical Nurse (LPN) J/Wound Nurse said the following: -He/she just worked with the resident one time and changed his/her dressing on 07/06/23; -He/she called the physician and obtained the order for the antibiotic; -On 07/07/23, the physician gave him/her the order for the antibiotic; -The resident did not have fever and had no other indications of sepsis (infection); -Residents who have wounds have treatment orders on the TAR; -The wound nurse tracks the wounds weekly and completes the measurements. He/she is the wound nurse now; -Department staff discuss the wounds weekly in the risk meeting; -The wound order should be on the TAR and completed as ordered; -Nurses should monitor wounds for any changes and notify the physician; -Nurses should document on the TAR when the treatment is completed; -Nurse should monitor wounds for odor, drainage, what the skin looks like around the wound bed and pain; -Signs of infection include redness, pain, edema, drainage and nurses should document in the progress notes; -He/she would request an order for a wound company if a resident's wound is getting worse or unusual. During an interview on 09/22/23, at 1:16 P.M., LPN E said the following: -Nurses obtain physician orders for dressing and monitor residents with pressure ulcers; -Nurses monitor wounds for dark purple area, red if not blanchable and black could mean deep tissue; -The nurse is responsible for measurements of a resident's wound which monitors if worse or improving; -Nurses monitor the TAR which has weekly assessments that are due; -Nurses should document for a few days following the completion of an antibiotic to ensure no latent reactions. During an interview on 09/22/23, at 01:33 P.M., LPN F said the following: -The wound nurse/Assistant Director of Nursing (ADON) completes the weekly skin assessments on residents; -Nurses should document on the TAR of completed treatments; -If no documentation on the TAR, could mean the treatment did not get completed; -Nurses should document every shift until completion of a resident on antibiotic. During an interview on 09/22/23, at 1:34 P.M., the MDS/Care Plan Coordinator/Infection Preventionist said the following: -Staff should document in the nurses' notes if a resident is on an antibiotic; -Staff should document what the antibiotic is given for. During an interview on 09/22/23, at 02:25 P.M., Registered Nurse (RN) O said the following: -He/she sometimes had trouble getting the resident's wound treatments completed due to the resident was a smoker and seldom in his/her room; -The resident was not compliant with getting his/her treatments completed; -He/she left treatment documentation blank due to he/she thought he/she would catch back up with the resident later and another task came up; -He/she did not document the resident was unavailable or did not get back with the resident for the ordered treatment;. -The resident had one heel that was not bad and another heel was dark with a eschar cap. Most of his heel had a dark eschar cap with edges pulling around the perimeter. it usually had drainage; -The resident was admitted with the wounds on his/her heels; -The resident's wounds on his (right) heel drained from the beginning. The wound was sanguous (relating to or containing blood), yellowish drainage, greenish tint to it and seldom with blood or yellowish; -The resident transferred himself/herself and the wounds were painful. -He/she works every weekend and completes the wound treatments; -Nurses should document in the progress notes of a resident's temperature, issues with the antibiotic, wound appearance and signs of infection for a resident on an antibiotic. During an interview on 09/22/23, at 1:55 P.M., the Director of Nursing (DON) said the following: -She did not look at the resident's heels, she trusted the former wound nurse's judgment; -The resident was started on Keflex 500 mg and given as ordered except for one day; -The former wound nurse said he/she looked at the resident's foot everyday and now had drainage; -She told a former nurse to obtain a wound culture; -She did not remember seeing the wound culture results; -She thinks the resident's left heel was healing and closed by 07/12/23. -The right heel was superficial opened; -The wound nurse is responsible for wound care. The wound nurse is the ADON/LPN J; -The wound nurse is responsible for the completion of weekly assessments; -She expects the charge nurse to complete the wound treatment if the wound nurse is unable to complete; -She expects nurses to document on the condition of the resident's foot with the treatment; -She expects nurses to document on a resident on an antibiotic and should chart adverse reactions to the ABT. During an interview on 09/22/23, at 2:57 P.M., the Administrator said the following: -The resident was non complaint with his/her wounds and spent all day out front smoking with pressure on his/her feet; -Nurses should document on residents who are on antibiotics; -Nurses should document on the daily treatment. If the TAR is blank, means completed and did not sign or the treatment did not get completed; -Nurses should document daily on a resident with antibiotic; -He expects nurses to document on a resident with a wound and on antibiotic. During an interview on 09/25/23, at 3:02 P.M., the resident's physician said the following: -He saw the resident's heels on 06/28/23 which were closed at that time; -The nurses missing 10 days of treatments on the resident's heels could have had an adverse effect but he did not have information on that; -Nurses should have signed the TAR which showed the treatment to the heels were completed; -Nursing staff should have contacted him if treatments to the residents heels were not done and when the resident was not available for the treatment; -He vaguely remembers instructing nursing staff to obtain a wound culture of the resident's heels; -He would have not changed the antibiotic with the results of the wound culture. MO00222525

Based on interview and record review, the facility failed to obtain physician orders for the care and treatment of one resident's (Resident #3's) colostomy (a surgical opening on the outside of the body called a stoma. The opening creates a passage from the large intestine to the outside of the body for passage of feces.) out of two sampled residents with stomas. The facility census was 60. Review of the facility policy titled, Colostomy/Ileostomy Care/Irrigation, undated, showed the following: -Goal to promote positive self-image and comfort by maintaining clean, odor-free environment without peristomal (around the stoma) skin excoriation. Prevent constipation or bowel obstruction and establish bowel regularity by cleansing intestinal tract of fecal material; -Physician's order regarding type of irrigation, amount, frequency, type and location of ostomy stoma, time and frequency of irrigation usually performed, ability and willingness of resident to participate in self-care, peristomal skin condition, stoma discharge for color, amount, odor, and consistency of fecal material; -Chart date and time, procedure, condition of stoma and surrounding area, results of irrigation, how procedure tolerated by resident, and signature. 1. Review of Resident #3's face sheet showed: -admission date of 08/10/23; -Diagnoses included pulmonary embolism (a blood clot blocking an artery in the lung), schizoaffective disorder (a disorder characterized by symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder, such as mania and/or depression), intellectual disability, and encounter for attention to ostomy (surgery to create an opening (stoma) from an area inside the body to the outside). Review of the resident's care plan, dated 8/11/23, showed the following: -Resident required disease/illness management related to ostomy; -Administer treatments as ordered by medical provider; -Monitor condition, progress of illness. Report to DON/medical provider as needed; -Monitor for complications of illness; -Monitor lab values and report to the medical provider; -Provide comfort and care. Review of the resident's admission Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 08/23/23, showed the following: -admission date of 08/10/23 from the hospital; -Cognitively intact; -Supervision and set up assistance with toilet use and personal hygiene; -Presence of an ostomy for bowel elimination. Review on 09/18/23 of the resident's physician orders from 08/10/23 to present (09/18/23) showed no orders for care or monitoring of the resident's ostomy. During an interview on 09/18/23, at 10:37 A.M., the resident said: -He/she has a colostomy; -He/she was able to empty and change the colostomy bag when out of bed, but when in bed and at night the resident required staff assistance with the emptying the colostomy bag, and changing the wafer and bag. During an interview on 09/20/23, at 4:28 P.M., Licensed Practical Nurse (LPN) F said the following: -Staff frequently changed the colostomy bag and wafer on a daily basis, due to the colostomy coming loose and leaking; -The resident did not currently have a physician's order to change and care for his/her colostomy; -The resident frequently changed his/her own colostomy; -The resident should have a physician's order to change the colostomy wafer/bag every three days and as needed; -The resident should have a physician's order to assess the stoma. During an interview on 09/21/23, at 2:51 P.M., the Director of Nursing (DON) said upon a resident's admission, the admitting nurse should obtain physician orders for colostomy care to include wafer and bag changes every three days and as needed and obtain a physician's order to monitor the condition of the stoma. During an interview on 09/22/23, at 2:57 P.M., the Administrator said the nurse should obtain a physician's order on admission for colostomy care for any resident with a colostomy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents received assistance to maintain proper nutrition and hydration unless unavoidable when staff failed to ensure one resident (Resident #6) received his/her ordered house shakes two times daily and failed to ensure a physician order was appropriately received when a staff member placed a nothing by mouth (NPO) sign on the outside of one resident's door (Resident #41). A sample of two residents were reviewed in a facility with a census of 60. Review of the facility's policy titled Weight Assessment and Intervention, revised 03/22, showed the following: -Resident weights are monitored for undesirable or unintended weight loss or gain; -Interventions for undesirable weight loss are based on careful consideration of the following: resident choice and preferences; nutrition and hydration needs of the resident; functional factors that may inhibit independent eating; environmental factors that may inhibit appetite or desire to participate in meals; chewing and swallowing abnormalities and the need for diet modifications; medications that may interfere with appetite, chewing, swallowing, or digestion; the use of supplementation and/or feeding tubes; and end of life decisions and advance directives. 1. Review of Resident #6's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 06/26/20; -Diagnoses included breast cancer, depression, dementia and high blood pressure. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/20/23, showed the following: -Moderate cognitive impairment; -Required no assistance from staff for eating; -The resident had no signs or symptoms of a swallowing disorder; -The resident had no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of the resident's Physician's Order Sheet (POS), dated 09/2023, showed an order, dated 03/03/23, for house shakes two times a day. Review of the Registered Dietician's (RD) progress notes showed the following: -A note dated 04/27/23, at 2:52 P.M., the resident is on a heart healthy diet, eating an average of 75 to 100% of most meals and 1100 milliliters (mL) of fluid. His/her weight is 163 pounds (lb.) which is 7 lbs. greater than his/her weight six months ago. His/her medications were noted. He/she is on a house shake twice a day and on hospice. Review of the resident's weights showed on 06/01/23 the resident weighed 165.3 lbs. Review of the resident's POS, dated 09/2023, showed an order, dated 06/23/23, for heart healthy diet, mechanical soft texture, and honey consistency. Review of the resident's weights showed on 07/26/23, the resident weighed 154.6 lbs. (a loss of 10.7 lbs.). Review of the RD's progress notes showed the following: -A note dated 07/27/23, at 1:45 P.M., the resident is on a heart healthy diet, mechanical soft texture and honey consistency fluids. His/her weight is 154 lbs. This is down eleven lbs. in the past month. However his/her weight six months ago was 156 lbs. Fluid intake is between 1000 and 1400 mL per day. Would consider liberalizing heart healthy diet considering hospice to encourage oral intake. Review of the resident's weights showed on 08/01/23 the resident weighed 154.8 lbs. Review of the resident's care plan, revised 08/30/23, showed the following: -The resident had a diet order for heart healthy diet, regular texture and thin liquid consistency; -He/she received health shakes two times a day for weight loss.; -Monitor for safety with swallowing; -Monitor his/her intake record; -Monitor his/her weight; -Provide diet as ordered; -He/she was able to feed self with set-up assistance and supervision. Review of the resident's weights showed the following: -On 09/05/23, the resident weighed 152 lbs. (a loss of 2.8 lbs since the last weight); -On 09/19/23, the resident weighed 147 lbs. (a loss of 5 lbs since the last weight). Review of the resident's August 2023 and September 2023 Treatment Administration Record showed no staff documentation related to staff providing house shakes to the resident. Review of the resident's dietary card showed no health shakes listed. Review of the lists created by kitchen staff from the residents' dietary cards for breakfast, lunch, and dinner drinks showed no health shakes listed for the resident. During interviews on 09/20/23, at 10:36 A.M. and 3:05 P.M., the Dietary Manager (DM) said the following: -The resident received house shakes twice a day; -He/she knew a resident had a new order for house shakes when the Director of Nursing (DON) or charge nurse told him/her. The DON printed him/her an updated list of residents on supplements every once in a while. He/she received this list twice in the last four months; -He/she just started going to weekly risk meetings. He/she could not attend regularly due to having to cook; -He/she added the resident to a list that hung on the wall on the outside of the cooler so the dietary staff knew who received house shakes. During an interview on 09/20/23, at 10:54 A.M., [NAME] D said the following: -He/she did not know if the resident received house shakes twice daily because house shakes were not on the resident's diet card; -They required a physician's dietary order for house shakes; -If a resident received an order for house shakes, the DM added the house shakes to the resident's diet card; -Dietary aides (DA) passed house shakes to residents; -The DM was responsible for ensure the DAs know what residents to pass house shakes to. During an interview on 09/20/23, at 11:10 A.M., Dietary Aide (DA) C said the following: -The resident did not receive house shakes; -House shakes were not on the resident's card or their drink list; -He/she knew if a resident received a house shake when other dietary staff told him/her; -He/she did not know of a list anywhere in the kitchen that told who received house shakes. Observation on 09/20/23, at 12:22 P.M., showed the resident sat in the dining room eating. He/she did not have a house shake. During an interview on 09/21/23, at 8:50 A.M., DA A said the following: -He/she knew if a resident received a house shake from a list in the kitchen; -He/she looked at the list and if they received one, he/she placed it on their tray to pass; -Supplements were on residents' diet cards. During an interview on 09/21/23, at 8:59 A.M., Certified Nurse Aide (CNA) K said the following: -The resident was supposed to receive house shakes and was on thickened liquids; -The resident received a house shake this morning for breakfast, but he/she had not seen the resident receive one before that for some time; -He/she had not said anything to dietary staff or the charge nurse because he/she did not know the resident had an order for house shakes; -The resident did not have house shakes on their diet card and the CNA did not see that the resident should receive them anywhere else; -He/she knew if a resident received a house shake by looking at their care plan, when charting on the resident in the dining room or from the charge nurse; -Dietary staff delivered trays to residents and did not leave the residents' diet card with their plate; -The dietary staff should know who received house shakes; -House shakes were on the residents' diet cards and the resident would have an order for house shakes; -If dietary staff served a tray without the ordered house shake, he/she told the dietary staff and the charge nurse; -House shakes helped with weight loss if a resident did not receive food or another type of nutrition. During interviews on 09/21/23, at 11:29 A.M. and 11:49 A.M., Restorative Nursing Assistant (RNA) L said the following: -The resident had not received a house shake to his/her knowledge for several months; -The resident did not receive a house shake this morning; -The resident had a weight loss. The resident's weight had fluctuated and the resident's weight was up in the 160's but the resident lost another 5 lbs. since the beginning of September. The resident's weight as of 09/19/23 was 147 lbs.; -He/she weighed residents; -If he/she noticed a resident had a weight loss, he/she told the charge nurse; -The facility had a risk meeting every Tuesday morning where they discussed weight loss and the DM received a copy of weight losses as well; -He/she did not know who made recommendations for supplements; -If a resident had an order for house shakes twice daily the resident should receive them; -Dietary staff passed house shakes; -At one time, the aides knew who received house shakes, but did not know now; -At times aides assisted dietary with passing drinks; -If a resident received house shakes, it should be on their diet card; -If he/she noticed a resident who should receive a house shake did not, he/she asked dietary staff for a house shake. During an interview on 09/22/23, at 9:26 A.M., Nursing Assistant (NA) M said the following: -The resident had a weight loss; -The resident required supervision to eat and sometimes required assistance; -The resident received house shakes and had one for breakfast this morning. -House shakes can help with weight gain. During an interview on 09/21/23, at 10:19 A.M., Certified Medication Technician (CMT) I said the following: -He/she knew if a resident received house shakes by their dietary order; -Dietary staff passed house shakes at meal times and should send the house shake out with the residents tray. During interviews on 09/21/23, at 9:06 A.M., and 09/22/23, at 9:31 A.M., Licensed Practical Nurse (LPN) E said the following: -The resident had a weight loss and had a physician's order for house shakes twice daily; -He/she had not seen the resident receive house shakes; -If the resident had an order for house shakes twice daily, the resident should receive them; -He/she did not see any documentation to know if the resident received the ordered house shakes; -The charge nurses monitor residents' weights and if they did not have an increase, they educated the aide to offer the residents' house shakes if the resident was not eating. He/she also instructed the aides to offer juice or snacks, anything to increase a residents' caloric intake; -If a resident needed an order for house shakes, he/she called the physician and request an order. If the physician agreed, he/she entered the order into the computer and told dietary staff; -Dietary staff should add the house shake to the resident's diet card and pass them the resident; -House shakes should be on the resident's Treatment Administration Record (TAR) so nursing could ensure the residents received the house shakes; -The physician ordered house shakes; -He/she knew a resident received house shakes by looking at their diet card; -Staff should document house shakes on the resident's intake; -The aides or charge nurse should document if a resident refused a meal or house shake; -He/she did not know how to look at the RD's recommendations; -Kitchen staff passed house shakes, but there was no documentation to show if a resident received the ordered house shakes; -The charge nurses were responsible for ensuring residents' received their ordered house shakes. During an interview on 09/22/23, at 9:50 A.M., LPN J said the following: -The resident had a weight loss; -The resident was on hospice services but that would not be a reason to prevent weight loss; -He/she did not know if the resident had an order for house shakes or received them; -House shakes required a physician's order and kitchen staff passed them; -The charge nurse or RD let the kitchen staff know about physician's orders for house shakes; -The kitchen staff should pass ordered house shakes with the resident's meals; -Dietary staff should add the house shakes to the resident's diet card. That is how the dietary staff and aides who assisted the resident's with eating know who received house shakes; -Residents received house shakes for weight loss, extra nutrients and wound healing. During an interview on 09/20/23, at 4:30 P.M., LPN F said the following: -House shakes were dietary orders; -The dietician ordered house shakes and dietary staff were responsible for giving residents house shakes; -If a resident received house shakes, it should be on their diet card and dietary staff should pass them with their meals; -The aides assisting residents with eating should help dietary monitor this as well. During an interview on 09/21/23, at 12:15 P.M., the MDS/Care Plan Coordinator said the following: -The dietary manager runs the weight loss report weekly for the risk management meeting; -The RD comes to the facility monthly; -The RD reviews resident's weight loss and documents in the resident medical record; -She has not seen the RD report or dietary recommendations; -She has not received any RD or dietary recommendations for residents; -Dietary recommendations should be on a resident's care plan; -She did not know how the staff are aware of residents on health shakes. During an interview on 09/20/23, at 5:01 P.M., the Registered Dietician (RD) said the following: -He/she came to the facility once a month; -He/she did not give a facility a report of who he/she saw, but wrote a dietary progress note in their chart; -If he/she thought a resident could use a supplement, he/she left a note for the physician. He/she did not communicate this to the DM because he/she did not want the DM to implement until the physician agreed; -If the physician did agree and wrote an order for house shakes, the kitchen staff would pass these; -The kitchen staff should administer house shakes per the physician's orders; -If a resident had weight loss and had an order for house shakes twice daily, he/she expected kitchen staff to pass the house shakes twice daily. During an interview on 09/22/23, at 1:42 P.M., the Director of Nursing (DON) said the following: -The resident had a weight loss and was on hospice services; -He/she had no documentation to show the resident received the house shakes per the physician's orders; -If a resident had an order for a supplement, staff should ensure the resident received the supplement; -House shakes were used as a supplement to slow or prevent weight loss even if a resident was on hospice services; -Dietary staff passed house shakes and aides charted resident's intakes. During an interview on 09/22/23, at 2:47 P.M., the Administrator said dietary staff were responsible for passing house shakes. 2. Review of the facility policy, 'Medication and Treatment orders, revised July 2016, showed the following: -Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Orders for withholding food prior to a test or treatment (NPO) shall be made by the attending physician as necessary; -Nursing will use a diet change notification form to inform the food services staff when it is necessary to hold the resident's food tray and when the tray delivery can resume; -Nursing staff will review the overall situation for a resident for whom one or more meals is to be held to ensure any related issues are addressed. Review of Resident #41's face sheet (admission data) showed the following: -admission date of 05/22/23; -Diagnoses included Alzheimer's disease, anxiety disorder, and dementia. Review of the resident's admission MDS, dated [DATE], showed the following: -Severely impaired cognitive skills; -The resident required limited assistance with eating. Observation on 09/17/23, at 4:30 P.M., showed a NPO sign hung on the outside of the resident's door. Review of the resident's record showed no order for the resident to be NPO. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Severely impaired cognitive skills; -The resident required limited assistance with eating. Review of the resident's care plan, revised 09/21/23, showed the following: -The resident has a diet order for regular pureed diet and thickened liquids; -Staff should monitor the resident for swallowing; -Staff should monitor the resident's weight; -The resident has hospice care. During an interview on 09/20/23, at 4:29 P.M., LPN F said the following: -The resident did not have an order for NPO; -He/she took the NPO sign down in the morning on 09/18/23. During an interview on 09/20/23, at 5:14 P.M., CNA N said the resident's family member handed him/her the NPO sign and instructed him/her to hang it up on the resident's door. The resident's family member stated he/she was afraid the resident would choke with food and water. The family member said the charge nurse stated it was ok to hang up the NPO sign outside the resident's door. CNA N said he/she placed the NPO sign outside the resident's door. He/she should have checked with the charge nurse first. During an interview on 09/20/23, at 05:29 P.M., Registered Nurse (RN) O said the following: -On 09/17/23, the resident's family member talked to the RN and a staff gave the resident food and liquid and the resident did not respond; -He/she explained to the family member sometimes an order for NPO is obtained and put up if a resident is to not have any food or drink for a test; -He/she did not know staff placed the sign up on the resident's door; -On 09/17/23, between 9:00 A.M. and 11:00 A.M., the resident's family member was concerned staff offered the resident a protein shake; -The resident's family member was concerned the resident would choke on the shake and concerned with aspiration; -He/she did not think the resident's family member wanted any food or drink given to the resident; -He/she reported this to the DON who educated the family; -CNA N did not ask him/her of the NPO sign; -He/she did not tell the family member to put up the NPO sign on the outside of the resident's door; -He/she saw the NPO sign on the door but did not register with him/her of the sign being there; -Nurses should call the physician to obtain a physician order for NPO. During an interview on 09/21/23, at 8:59 A.M., CNA K said the following: -Nurses get the physician order for NPO; -Aides at no time should put up a NPO sign on a resident's door. During an interview on 09/21/23, at 09:06 A.M., LPN E said the following: -Staff should evaluate the resident for swallowing if any issues with food and/or water; -Nurses should call the physician for NPO order; -The nurse should put up the NPO sign if they have an order for that; -He/she would inform and educate the nurse aides if a resident had a NPO order; -Staff should not place a NPO sign up until staff have received the physician order; -The nurse aide should not have placed the NPO sign on the resident's door; -He/she did not know of the NPO sign up for the resident. During an interview on 09/21/23, at 10:19 A.M., CMT I said the following: -Nurses call for resident physician order for NPO; -An aide should not place a NPO sign on a resident's door. During an interview on 09/21/23, at 02:33 P.M., the DON said the following: -The nurse should get the NPO order for a resident; -A nurse aide should not hang up a NPO order on a resident's door; -She saw the NPO sign on the resident's door and removed it in the morning on 09/18/23. During an interview on 09/25/23, at 10:00 A.M., the Administrator said a nurse aide should not put up a NPO order on a resident's door. Staff should not place a NPO order on a resident's door without a physician order or without nurse direction.

3. Review of the facility's policy titled Administering Medications, dated 04/2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -The Director of Nursing Services (DON) supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions; and honoring resident choices and preferences, consistent with his or her care plan; -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose; -New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility; -The charge nurse must accompany new nursing personnel on their medication rounds for a minimum of three days to ensure established procedures are followed and proper resident identification methods are learned. Review of the facility's policy titled Medication Ordering, revised 01/29/09, showed the following: -Goal is to economize on time, to maintain adequate supply of medication on hand and to control waste and cost for the resident; -Make out drug list daily in the morning on Friday, make sure enough drugs are ordered to cover until Monday evening; -Check all routine drugs thoroughly; -Mark each drug in which there is less than one week supply on hand, pull label for re-order and place on page to be faxed to pharmacy; -After checking all drugs, the ward clerk and or CMT will make a comprised list of drug needs. List according to pharmacy. Information needed for re-ordering: resident name, drug name, dosage, instructions and script number; -After comprised list is completed, the ward clerk or CMT will fax pharmacy giving the complete list for refill; -Medication will often be received on the same day as ordered; -Received drugs will be checked by on duty LPN or CMT sign slips and return to pharmacy to verify receiving drugs and mark each drug as received in the drug order book. (Double check labels for correct name, doctor, drug name, dosage, directions. and pharmacy. Review of Resident #25's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 09/27/22; -Diagnoses included heart attack, restless leg syndrome (a neurological disorder that causes unpleasant or uncomfortable sensations in your legs and an irresistible urge to move them), and anxiety. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/24/23, showed the following: -Cognitively intact; -Required limited assistance from staff for transfers, walk in corridor, locomotion and dressing, and supervision for bed mobility, eating, toilet use and personal hygiene; -The resident used a wheelchair for locomotion. Review of the resident's care plan, revised 09/21/23, showed the following: -He/she required disease/illness management related to Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Assist him/her with his/her activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) and meals as needed secondary to disease progression. Monitor conditions and progress of illness. Report to DON and medical provider as needed. -Monitor medications side effects and effectiveness; -He/she required psycho-social well-being care. His/her mood and behavior would be monitored and managed medically and through nursing care until further instructions by the care plan or Quality Assurance (QA) team. Monitor for medication side effects and effectiveness. Review of the resident's Physician's Order Sheet (POS), dated 09/2023, showed the following: -An order, dated 10/04/22, for pramipexole dihydrochloride tablet (a medication used to treat Parkinson's disease) .5 milligrams mg. Give one tablet by mouth at bedtime for restless leg syndrome. Review of the resident's August 2023 and MAR showed the following: -On 08/11/23, at 8:00 P.M., staff did not administer pramipexole dihydrochloride with a reason of drug unavailable; -On 08/12/23, at 8:00 P.M., staff did not administer pramipexole dihydrochloride with a reason of see other/progress note. Review of the resident's August 2023 nurses' progress notes showed the following: -A medication administration progress note dated 08/12/23, at 8:31 P.M., that pramipexole dihydrochloride tablet .5 mg not available to be given; -Staff did not document notifying the resident's physician of the missed doses for 08/11/23 and 08/12/23. Review of the resident's August 2023 MAR showed the following: -On 08/17/23, at 8:00 P.M., staff did not administer pramipexole dihydrochloride with a reason of drug unavailable; -On 08/27/23, at 8:00 P.M., staff did not administer pramipexole dihydrochloride with a reason of see progress note; -On 08/31/23, at 8:00 P.M., staff did not administer pramipexole dihydrochloride with a reason of hold/see progress note; Review of the resident's August 2023 nurses' progress notes showed the following: -A medication administration progress note dated 08/31/23, at 8:00 P.M., pramipexole dihydrochloride tablet .5 mg, not available; -Staff did not document notifying the resident's physician of the missed doses for 08/17/23, 08/27/23, and 08/31/23. Review of the resident's September 2023 MAR showed the following: -On 09/09/23, at 8:00 P.M., staff did not administer pramipexole dihydrochloride a reason of drug unavailable; -On 09/16/23, at 8:00 P.M., staff did not administer pramipexole dihydrochloride with a reason of other/see progress note. Review of the resident's September 2023 nurses' progress notes showed the following: -A medication administration progress note dated 09/15/23, at 8:38 P.M., pramipexole dihydrochloride tablet on order; -Staff did not document notifying the resident's physician of the missed doses for 09/09/23 or 09/16/23. During interviews on 09/18/23, at 10:14 A.M., and 09/21/23, at 10:23 A.M., the resident said he/she did not receive his/her medication for restless legs regularly. When they did not give him/her the medication for restless legs, his/her feet and legs jerked. He/she did not have pain, but had increased difficulty sleeping those nights. During an interview on 09/20/23, at 4:30 P.M., Licensed Practical Nurse (LPN) F said the following: -The resident's medications were on bubble pack cards; -Staff should give restless legs medications per physician's orders; -Some residents' medications were in cellophane packets and some were on bubble pack cards; -Agency nurses may not know that some residents' medications are on bubble pack cards or where they were located in the cart; -If staff did not educate agency nurses on this and they did not see their medication in the cellophane packets, they would document the medication was not available; -If a medication was not available on the medication cart, the nurse should look for the medication in the STAT safe, notify the physician and notify the pharmacy. During an interview on 09/21/23, at 10:33 A.M., CMT R said the following: -The resident reported to him/her this morning that the resident did not receive their evening medications last night. She reported it was her medication for restless legs syndrome and anxiety; -He/she looked at the MAR and saw staff did not sign out the resident's anxiety medication, but was not sure if the restless legs medication was; -The resident received medication for restless legs syndrome at bedtime and had a PRN (as needed) medication for muscle spasms as well; -The resident reported this morning that their legs were bothering them so he/she gave the resident the PRN medication for muscle spasms; -The resident reported to him/her in the past about not receiving their pramipexole dihydrochloride in the past and he/she reported this the charge nurse and the charge nurse reported this to the DON. The DON contacted the agency and that agency staff member did not come back to the facility; -If he/she did not see the medication on the medication cart, he/she checked the medication room overflow and then if it still was not available, he/she notified the charge nurse. The charge nurse checked the STAT safe for the medication and if not available and they called the pharmacy; -The facility used three pharmacies; -The bubble pack cards were located in the bottom drawers of the medication cart; -If an agency nurse did not know where to find the medications, they should call the DON; -He/she educated agency nurses where to find medications when he/she did shift change with them. During an interview on 09/21/23, at 3:42 P.M., LPN G said the following: -He/she remembered the resident did not have a certain medication, but could not remember what it was; -He/she did not remember if he/she contacted the DON about the medication being unavailable; -He/she did not look in medication room overstock for the medication, only in the medication cart; -If the resident did not receive the medication for restless legs syndrome, the resident could become restless and have difficulty sleeping; -He/she worked at the facility as an agency nurse; -Staff did not educated him/her on the different places for medications in the medication cart or the overflow stock in the medication room. He/she had to figure the medications on the cart out on his/her own; -He/she was not instructed what the facility's policy was if a medication was not available; -If a medications was not on the medication cart, he/she marked the MAR as unavailable. He/she made a list and told the charge nurse the next morning; -Some residents had medications in bubble pack cards in the lower bottom drawer of the medication cart. During interviews on 09/21/23, at 11:12 A.M., and on 09/22/23, at 9:31 A.M., LPN E said the following: -The resident should receive their scheduled pramipexole dihydrochloride. -He/she received an order for medication, checked the MAR and looked in the medication cart for the cellophane package of medications and double checked the medication with the MAR to ensure it as the correct medication for that time and then documented when he/she gave the medications on the MAR; -If he/she did not find the medication in a cellophane package, he/she looked through the bubble pack cards of medications. He/she knew if the medication was in a bubble pack card by the pharmacy the resident used; -The facility did not fully train him/her on the different medication packaging for different pharmacies; -If a resident reported they did not receive a medication, he/she checked the MAR to see if the medication was given and then checked the cellophane packages. He/she could not tell by looking at the bubble pack cards if staff did not give a medication; -If a resident with restless legs syndrome did not receive their prescribed pramipexole dihydrochloride, the resident could have tingling in their legs and difficulty sleeping; -When he/she completed shift change with an agency nurse, he/she showed the agency nurse where all of the medications were located in the cart, including the bubble pack cards and showed them the overflow in the medication room; -If an agency nurse could not find a medication, they should contact the DON and he/she pointed out the DON's phone number at the nurse's station; -When a resident was low on medication, the charge nurses or CMTs put an order on a sheet and faxed to the pharmacy. The CMTs notified the charge nurses if a medication was low and they had not received the order and the charge nurse then called the pharmacy to see when the pharmacy could send the medication; -Residents should not run out of medications. During an interview on 09/22/23, at 9:16 A.M., CMT S said the following: -He/she did not know what medications the resident received at night, but if the resident had an order for pramipexole dihydrochloride at bed time, staff should give the resident that medication at bed time; -The resident's medications were in bubble pack cards; -He/she gave medications at the right time, right resident, and right route; -If he/she did not have a medication in the cart, he/she looked in the medication room and then asked the charge nurse; -The residents used different pharmacies. One pharmacy used prepackaged cellophane packages and two other pharmacies used bubble pack cards; -When he/she passed the medication cart to an agency nurse, he/she showed the agency nurse where medications were located in the medication cart and showed them the overflow medications in the medication room; -If a resident did not receive their medication for restless legs syndrome, they could leg cramps and difficulty sleeping; -The CMTs and charge nurses ordered medications on Mondays and Thursdays; -The only reasons a medication should not be passed was if the pharmacy did not send the medication, the pharmacy was out of the medication or the physician did not approve the order for the medication; -Medical records and the charge nurses monitored the MARS and the DON was responsible for ensuring staff passed medications per physician's order. During an interview on 09/22/23, at 9:50 A.M., LPN J said the following: -Resident received pramipexole dihydrochloride for restless leg syndrome and should receive it at bed time per physician's orders; -Staff should give medication per physician's orders; -If a medications was not available on the medication cart, the CMT should notify the charge nurse and the charge nurse would check for the medication in the stat safe. If the medication was not in the stat safe, the charge nurse called the pharmacy to order the medication; -The facility ordered medications from different pharmacies and they medications were not all packaged the same. Some medications were in prepackaged cellophane packets and some were on bubble pack cards; -Every resident had an area for their medication in the medication cart and they kept the bubble pack cards in a different drawer; -Staff should order medications before they run out. If the medications did not come, the CMT notified the charge nurse; -Staff kept overflow medications in the medication room in cubbies with the residents' names on them; -When he/she passed the medication cart to an agency nurse, he/she counted the medications with the nurse, let the nurse know which key opened the cart and showed the nurse where the medications were on the cart and how they were organized. He/she told them if a resident's medications were not in the cellophane packets to look in the bubble pack cards in a different drawer. He/she also educated them on the overflow medications in the medication room; -If an agency nurse could not find the medication on the cart, they should check the overflow and the stat safe and if they still could not find the medication, they should notify the physician and call the pharmacy; -If a resident had an order for pramipexole dihydrochloride at bed time, the resident should receive the medication at bed time; -If a resident did not receive the medication for restless legs syndrome at bed time, they resident could have a rough night sleep because of pain or discomfort from restless legs; -The charge nurse should ensure CMTs passed medications per physician's order and the DON should ensure all staff that passed medications, passed them per physician's orders. During an interview on 09/21/23, at 4:01 P.M., LPN P said the following: -He/she worked at the facility as an agency nurse; -All resident's medications were prepackaged in cellophane packs; -He/she did not believe any residents had bubble pack cards of medication and did not believe any staff educated him/her if they did, where they were located in the medication cart; -Staff educated him/her on where the medications were in the medication cart, but not on overflow medications in the medication room; -Staff educated him/her on where the narcotics were located and that all residents' medications were in cellophane packets; -If a medication was not available on the medication cart to give, he/she looked in the STAT safe and if the medication was not there, he/she called the pharmacy; -If a resident did not receive a medication for restless legs syndrome, they could become restless and not sleep well During an interview of 09/22/23, at 1:42 P.M., the Director of Nursing (DON) said the following: -On 09/09/23, she looked for the resident's medication and could not find it. She did not believe they had it in the stat safe. She either called or faxed the pharmacy and called the physician, but did not document this anywhere. She did not give the resident a PRN medication; -On 09/16/23, she looked for the resident's medication in the medication cart and the overflow in the medication room but could not find it. She contacted the pharmacy the next day because the medication was ordered. She did not contact the physician and did not document contacting the pharmacy anywhere; -If the resident did not receive the pramipexole dihydrochloride per physician's orders, the resident could have restless legs and difficulty sleeping; -He/she did not notice the resident having those side effects on 09/09/23 or 09/16/23; -The nursing staff trained agency staff on where medications were located when they did shift change with an agency nurse; -If a staff member could not give a medication, he/she expected them to document who they contacted related to the medication and not just medication unavailable or on order. During an interview on 09/22/23, at 2:47 P.M., the Administrator said the following: -He/she expected charge nurses or CMTs to give report to agency nurses on where medications were located; -Medical records, the Assistant Director of Nursing (ADON), and DON should perform audits on residents' MARS. Based on interview and record review, the facility failed to maintain a system of counting of controlled medications to ensure accuracy of count for one of two medication carts and for the nurse medication room controlled medications (used for the entire facility). The facility failed to ensure agency staff were trained on location of all medication. The facility failed to ensure one resident (Resident #25) received his/her medication as prescribed by the physician. Five residents were sampled out of a facility census of 60. 1. Review of the facility's policy titled, Med Pass Policy, undated, showed staff to count all narcotics and overflow narcotics and sign narcotic sheet prior to taking over the narcotic cart. Review of the facility form titled, Controlled Substance and Security Lock, showed the following information: -Signing indicates all doses are recorded on Medication Administration Record (MAR) and the lock numbers and emergency kits have been verified; -The form contained spaces for the following information: date, time, number of packages, a place for the oncoming and offgoing nurse to initial the total number of controlled drug packages/controlled count, a space for nurse signatures and corresponding initials. Review of the facility's Controlled Substance and Security Lock, form, dated September 2023, for the mauve hall medication cart showed staff failed to initial the count at the following times: -On 09/01/23, at 6:00 A.M., offgoing staff failed to initial the count; -On 09/01/23, at 6:00 P.M., oncoming staff failed to initial the count; -On 09/02/23, at 6:00 A.M., offgoing staff failed to initial the count; -On 09/03/23, at 6:00 P.M., oncoming and offgoing staff failed to initial the count; -On 09/04/23, at 6:00 A.M., offgoing staff failed to initial the count; -On 09/13/23, at 6:00 A.M., oncoming and offgoing staff failed to initial the count; -On 09/15/23, at 6:00 A.M., offgoing staff failed to initial the count; -On 09/18/23, at 6:00 A.M., offgoing staff failed to initial the count; -On 09/18/23, at 6:00 P.M., offgoing staff failed to initial the count; -On 09/19/23, at 6:00 P.M., offgoing staff failed to initial the count; -On 09/20/23, at 6:00 A.M., offgoing staff failed to initial the count; -On 09/20/23, at 6:00 P.M., oncoming staff failed to initial the count. Review of the facility's Controlled Substance and Security Lock, form, dated September 2023, for the nurse medication room showed staff failed to initial the count at the following times: -On 09/01/23, at 6:00 A.M., offgoing staff failed to initial the count; -On 09/06/23, at 6:00 A.M., offgoing staff failed to initial the count; -On 09/06/23, at 6:00 P.M., oncoming and offgoing staff failed to initial the count; -On 09/08/23, at 6:00 A.M., oncoming staff failed to initial the count; -On 09/08/23, at 6:00 P.M., oncoming and offgoing staff failed to initial the count; -On 09/10/23, at 6:00 P.M., oncoming staff failed to initial the count; -On 09/14/23, at 6:00 P.M., offgoing staff failed to initial the count; -On 09/16/23, at 6:00 A.M., offgoing staff failed to initial the count; -On 09/16/23, at 6:00 P.M., oncoming staff failed to initial the count. During an interview on 09/21/23 at 11:10 A.M., Licensed Practical Nurse (LPN) E said the following: -The nurses are responsible for counting the controlled medications located in the nurse medication room and refrigerator; -Nurses count the medications at the beginning and end of each shift; -Both the oncoming and offgoing nurses should sign or initial the controlled substance log; -When he/she began working at the facility, he/she did not initial the log each time he/she counted the controlled medications; -The facility conducted a meeting and discussed the need to sign the log with each change of shift; -He/she had issues with a couple of temporary agency nurses refusing to count the controlled drugs at the end of their shift before leaving the facility; -The LPN said he/she did not notify anyone of the agency nurses refusal to count controlled medications; -The LPN was unaware of any missing or stolen controlled medications. During an interview on 09/22/23, at 10:30 A.M., LPN J said the following: -Nurses and CMTs should count controlled medications with each change of shift and any time the keys change hands from one staff to another; -Staff utilize three controlled substance logs for controlled medication counts, one on each of the two medication carts and one in the nurse medication room; -Two staff should always sign controlled substance log, the oncoming and the offgoing staff. During an interview on 09/21/23, at 2:51 P.M., the Director of Nursing (DON) said the following: -The oncoming and offgoing nurses should count the controlled medications located in the nurse medication room at the beginning and end of each shift and sign the controlled substance log; -The oncoming or offgoing certified medication technicians (CMTs) or nurses responsible for passing resident medications should count the controlled medications located in the medication carts and sign the controlled substance logs located on the medication carts; -Sometimes the nurses/CMTs forgot to sign the controlled substance log when counting the medications and the DON reminded the staff to sign the form; -If an agency nurse refused to count controlled medications, the facility nurse should call the DON immediately and the DON would investigate the issue; -The DON said he/she should monitor the logs daily for signatures/initials, but he/she did not monitor the logs on a regular basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for four residents (Resident #16, #25, #29, and #31). The facility census was 60. Review of the facility's policy titled, Advance Directives, revised [DATE], showed the following: -Advance directives will be respected in accordance with state law and facility policy; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 1. Review of Resident #'16's face sheet (admission data) showed the following: -admission date of [DATE]; -Code status of Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) Review of the resident's current Physician's Order Sheet (POS), dated [DATE], showed the resident's code status as a DNR. Review of the list of residents on the crash cart located at the nurses' station showed code the resident's code status as a DNR Review of the resident's care plan, revised [DATE], showed the resident's code status as full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep alive). During an interview on [DATE], at 12:15 P.M., the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff)/Care Plan Coordinator said the resident's code status showed as full code on the care plan. 2. Review of Resident #'25's face sheet showed the following: -admission date of [DATE]; -Code status of DNR. Review of the Outside the Hospital DNR form showed the following: -The resident signed the form on [DATE]; -The resident's physician signed the form on [DATE]. Review of the resident's current POS showed the resident's code status as a DNR. Review of the list of residents on the crash cart located at the nurses station showed the resident's code status as a DNR Review of the resident's care plan, dated [DATE], showed a the resident's code status as full code. During an interview on [DATE], at 12:15 P.M., the MDS/Care Plan Coordinator said the resident's code status showed as full code on the care plan. 3. Review of Resident #'29's face sheet showed the following: -admission date of [DATE]; -Code status of DNR. Review of the resident's DNR form showed the following: -The resident's representative signed the form on [DATE]; -The resident's physician signed the form on [DATE]. Review of the resident's current POS showed the resident's code status of code status as a DNR. Review of list of residents on the crash cart located at the nurses station showed the resident's code status as DNR Review of the resident's care plan, dated [DATE], showed the resident's code status as full code. During an interview on [DATE], at 12:15 P.M., the MDS/Care Plan Coordinator said the resident's code status showed as full code on the care plan. 4. Review of Resident #'31's face sheet showed the following: -admission date of [DATE]; -Staff did not document the resident's code status on the face sheet. Review of the resident's care plan, dated [DATE], showed the resident's code status as full code. Review of the resident's current POS, dated [DATE], showed the resident's code status, dated [DATE], as a DNR. Review of the crash cart located at the nurses station showed the resident's code status as DNR. During an interview on [DATE], at 12:15 P.M., the MDS/Care Plan Coordinator said the resident's code status showed as full code on the care plan. 5. During an interview on [DATE], at 11:30 A.M., Certified Nurse Aide (CNA) H said the following: -He/she finds the code status in the care plan book at the nurses' desk in the unit; -Full code means perform CPR; -DNR means to not perform CPR. 6. During an interview on [DATE], at 1:14 P.M., Certified Medication Technician (CMT) I said the following: -He/she would get the nurse if a resident was found unresponsive; -Staff should check the resident's code status on the crash cart in the binder; -DNR means do not perform CPR; -CPR means to resuscitate. 7. During an interview on [DATE], at 1:35 P.M., Licensed Practical Nurse (LPN) J said the following: -Staff find a resident's code status in the book located on the crash cart; -Staff find a resident's code status in the care plan; -Full code means perform CPR; -DNR means No CPR -Code status should match throughout the residents' medical record. 8. During an interview on [DATE], at 12:15 P.M., the Care Plan Coordinator said the following: -She is responsible for updates to the residents' care plans; -She reads the 24 hour report everyday; -Staff should inform her of any updates needed to the residents' care plans; -Nurse aides find the care plans in the computer system; -Staff find a resident's code status on the crash cart, care plan, face sheet, and the physician order; -The code status should match throughout the resident's medical record; -She checked the code status to make sure resident's code status matched throughout the medical record. 9. During an interview on [DATE], at 2:33 P.M., the Director of Nursing said the following: -Staff discuss changes for care plans in the weekly risk meetings; -The care plan coordinator updates the care plans; -Code status should be in the book on the crash cart which staff should look at first; -Code status can be found in the computer system on the care plan; -Code status should match throughout the resident's medical record. 10. During an interview on [DATE], at 2:57 P.M., the Administrator said a resident's code status should be consistent throughout the resident's medical record.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to clean the hand washing sink, sink in the food preparation area, floor under the three vat sink, the area between the wall and the stove, fryer, and warming cart, the vent above the ice machine, and failed to repair the walls behind the dishwasher and in the beverage room and tiles and wall under the three vat sink to ensure they were washable surfaces; staff failed wear hair nets appropriately to prevent contamination of food; staff failed to regularly test and have knowledge of the correct temperatures of the dishwashing machines; and the drain from the ice machine had no air gap between it and the drain. The facility census was 60. 1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the facility policy titled Job Description for Certified Dietary Managers (CDMs), undated, showed the following: -Prepare cleaning schedules and maintain equipment to ensure food safety; -Ensure proper sanitation and safety practices of staff. Review showed the facility did not provide a policy related to cleanliness of the kitchen. Observations on 09/17/23, at 4:15 P.M., on 09/18/23, at 3:24 P.M., and on 09/19/23, at 8:54 A.M., showed the following: -The handwashing sink had a grayish colored film in the bowl and around the edges; -The sink in the food preparation are had a brownish film in both bowls and around the edges; -The vent above the ice machine, it's latch that held it shut, and the top approximate two feet of an approximate three foot chain had a thick layer of what appeared to be dust on it; -The floor that was approximately fourteen feet in length between the wall and stove, fryer, and warming cart had a buildup of dirt, food debris and paper on it. The pipes and fittings that ran into the back of the stove and fryer in this same area had a thick layer of what appeared to be dust; -The floor under the three vat sink had a buildup of food debris and had five tiles that were partially missing; -The covering on the wall and cobase under the three vat sink was coming away from the wall; -The wall behind and to the right of the dish washer and the wall behind the juice and coffee machines and to the right of them was peeling. During an interview on 09/20/23, at 10:19 A.M., Dietary Aide (DA) A said the following: -The kitchen had cleaning schedules that showed to sweep, mop, clean, no food on floors or counters, all trash picked up, wipe off carts and food warmers, clean the microwave, and wipe the sinks off and make sure they are dry; -When he/she completed a task, he/she put his/her initials next to that task; -The DA's and dishwasher were responsible for cleaning the hand washing sink and the sink in the food preparation area and the dishwasher was responsible for sweeping and mopping under the three vat sink and behind the stove; -The maintenance man was responsible for cleaning the vent above the ice machine; -There should not be a buildup of dust on the vent, latch or chain above the ice machine because it could fall into the residents' ice or drinks; -There should not be a buildup of dust, food debris or paper behind the stove, fryer and warming cart or under the three vat sink because it was unsanitary; -The wall behind the dishwasher was not a cleanable surface because it was peeling. He/she had not told anyone about the wall, but should report this to the DM; -All kitchen staff should keep the kitchen clean; -The Dietary Manager (DM) was responsible for ensuring staff cleaned the kitchen. During an interview on 09/20/23, at 10:41 A.M., DA B said the following: -The cleaning schedule for the dishwasher was on a clipboard in the dish washing area and for the dietary aides on the microwave; -DAs cleaned the sink in the food preparation area and the dishwasher cleaned the hand washing sink and swept and mopped under the three vat sink and behind the stove and fryer. Kitchen staff should clean the sinks and there should not be food, paper or dust behind the stove area or under the three vat sink because it could contaminate the food and attract pests; -All kitchen staff should clean the vent above the ice machine. There should not be dust on the vent, latch or chain because it could fall in the ice machine and contaminate the ice in the residents' drinks; -The DM was responsible to ensure kitchen staff completed the cleaning tasks. During an interview on 09/20/23, at 10:54 A.M., [NAME] D said the following: -Every station should have a cleaning schedule posted. He/she did not have one posted now; -The DA and dishwasher were responsible for cleaning the hand washing sink and sink in the food preparation area; -The cook was responsible for sweeping and mopping under the three vat sink and behind the stove, fryer, and warming cart; -All kitchen staff could clean the vent above the ice machine, but the task was not on a specific cleaning schedule; -There should not be food and broken tiles under the three vat sink or food, dust and paper behind the stove, fryer and warming cart because it could attract pests and contaminate food; -There should not be a buildup of dust on the vent above the ice machine because it could contaminate the ice, cups, coffee pots and tea pots in the room; -The DM and cooks were responsible for ensuring staff completed the cleaning tasks. During an interview on 09/20/23, at 3:05 P.M., the DM said the following: -The kitchen had cleaning schedules, but had not been using them and had slacked off on cleaning; -All kitchen staff were responsible for cleaning the hand washing sink, the DAs were responsible for cleaning the sink in the food preparation area, maintenance was responsible for cleaning the vent above the ice machine, and all kitchen staff were responsible for cleaning the floor behind the stove, fryer and warming cart; -The floor under the three vat sink was not cleanable due to the missing/broken tiles; -He/she told the Administrator about the missing/broken tiles under the three vat sink and the Administrator did a walk-through with the Maintenance Director to show him/her the tiles; -The walls in the dish washing room and the beverage room were not cleanable. He/she told the Administrator about the walls; -It was important for kitchen staff to keep the kitchen clean for sanitation and prevention of pests; -He/she was responsible for ensuring kitchen staff completed the cleaning assignments. During an interview on 09/22/23, at 8:37 A.M., the Maintenance Director said the following: -He/she and the maintenance assistant cleaned the vent over the ice machine and kitchen staff cleaned it too; -The vent, latch and chain should not have a buildup of dust due to sanitary reasons; -He/she and the DM were responsible for monitoring the vent for cleanliness and ensuring the vent was kept clean. During an interview on 09/22/23, at 2:47 P.M., the Administrator said the DM was responsible for ensuring the cleanliness of the kitchen. 2. Review of the FDA 2013 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 policy titled Job Description for Certified Dietary Managers (CDMs), undated, showed the following: - Protect food in all phases of preparation, holding, service, cooking, and transportation, using Hazard Analysis and Critical Control Points (HACCP) Guidelines. Review of the facility's policy titled Personnel, undated, showed the following: -Dietary employees will use effective hair restraints to prevent the contamination of food or food contact surfaces. Observation on 09/17/23, at 4:15 P.M., showed a DA, preparing residents' drinks. The DA wore a hair net covering the top and back of his/her head, but did not cover his/her bangs. Observations on 09/19/23, at 8:54 A.M. and 11:10 A.M., showed DA A wore a hairnet over the top of his/her head and left the back of his/her hair hanging out of the hairnet. He/she prepped salads for residents. During an interview on 09/20/23, at 10:19 A.M., DA A said the following: -Staff should wear hairnets covering all of their hair; -If he/she saw a kitchen staff not wearing a hairnet appropriately, he/she told the staff member to fix it; -Staff should not wear hairnets with their bangs or back of their hair hanging out because they could get hair in the residents' food. During an interview on 09/20/23, at 10:36 A.M., DA B said the following: -Staff should wear hairnets covering all of their hair; -Staff should not wear hairnets with their bangs or back of their hair hanging out because they could get hair in the residents' food; -The DM was responsible for ensuring kitchen staff wore hairnets appropriately. During an interview on 09/20/23, at 10:54 A.M., [NAME] D said the following: -Staff should wear hairnets covering all of their hair; -Staff should not wear hairnets with their bangs or back of their hair hanging out because they could get hair in the residents' food; -If he/she saw a kitchen staff member wearing their hairnet wrong, he/she corrected them; -The cooks were responsible for ensuring kitchen staff wore hairnets appropriately. During an interview on 09/20/23, at 3:05 P.M., the DM said he/she expected kitchen staff to wear hairnets appropriately and he/she was responsible for ensuring kitchen staff did. During an interview on 09/22/23, at 2:47 P.M., the Administrator said the DM was responsible for ensuring the kitchen staff wore hairnets appropriately. 3. Review of the 2013 Missouri Food Code showed a warewashing machine shall be equipped with a temperature measuring device that indicates the temperature of the water in each wash and rinse tank and as the water enters the hot water sanitizing final rinse manifold or in the chemical sanitizing solution tank. Review showed the facility did not provide a policy related to dishwasher temperature logs. Review of the facility's Temperature Record for Dishwasher, dated August 2023, showed the following: -Wash temperature 150 degrees Fahrenheit (F) and rinse 180 degrees F; -A spot to log wash and rinse temperatures and staff initials for breakfast, lunch and supper; -Staff did not record temperatures in the log for breakfast on 08/01/23, 08/03/23 through 08/16/23, 08/18/23 through 08/21/23, and 08/23/23 through 08/31/23; -Staff did not record temperatures in the log for lunch for the entire month of August; -Staff did not record temperatures in the log for supper on 08/03/23 through 08/04/23, 08/07/23, 08/09/23 through 08/10/23, 08/12/23 through 08/13/23, 08/15/23 through 08/18/23, 08/20/23 through 08/29/23 and 08/31/23; -Staff recorded rinse temperatures of 179 degrees F on 08/01/23, 177 degrees F on 08/05/23, and 172 degrees F on 08/30/23. Review of the facility's Temperature Record for Dishwasher, dated 09/2023, showed the following: -Staff did not record temperatures in the log for breakfast, lunch, and supper on 09/01/23 through 09/18/23, lunch and supper on 09/19/23 and 09/21/23 and supper on 09/20/23. During an observation and interview on 09/19/23, at approximately 10:00 A.M., DA C said the following: -The dishwasher temperature should be over 155 degrees F for the wash and he/she did not know what it should be for the rinse; -He/she believed this should be documented each shift, but he/she did not do this; -He/she ran the dishwasher and wash was 160 degrees F and rinse was 164 degrees F and then ran it again and the wash was 155 degrees F and rinse was 181 degrees F. During an interview on 09/20/23, at 10:19 A.M., DA A said the following: -The dishwasher used heated water to sanitize the dishes. The wash should be 180 degrees F and the rinse should be 180 to 185 degrees F; -Dishwashers documented that on a log on the wall. They wrote down the temperature and initialed the log and completed this each shift; -The dishwashers were responsible for completing the log and the DM was responsible for ensuring they completed the logs. During an interview on 09/20/23, at 10:41 A.M., DA B said the following: -The dishwasher used chemicals to sanitize and the dishwasher had test strips to check the levels; -He/she did not know if the water temperature had to be a certain degree F; -He/she had not tested the dishwasher before and did not know if the dishwasher had to complete a log; -He/she believed the DM tested the dishwasher and did not know how often. During an interview on 09/20/23, at 11:17 A.M., DA C said the following: -The dishwasher water temperature for the wash should be 160 degrees F and the rinse should be 180 degrees F; -The dishwasher documented the temperatures but he/she did not know how often; -The cooks and the DM were responsible for ensuring dishwashers completed the dishwasher logs. During an interview on 09/20/23, at 3:05 P.M., the DM said the following: -The dishwasher used heat sanitation. The wash should be 150 degrees F and the rinse should be 180 degrees F; -Dishwashers should document this each meal; -Every DA that washed dishes should know the temperatures and where to document them; -He/she was responsible for ensuring DAs that washed dishes knew the proper temperatures for wash and rinse and completed the dishwasher log. During an interview on 09/22/23, at 2:47 P.M., the Administrator said the DM was responsible for ensuring the kitchen staff completed the dishwasher logs. 4. Review of the 2013 Missouri Food Code showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch (1). Review showed the facility did not provide a policy related to the air gap. Observations on 09/17/23, at 4:15 P.M. and on 09/19/23, at 8:54 A.M., showed the drain from the ice machine was even with the drain in the floor and did not have an air gap. During interviews on 09/20/23, at 3:05 P.M., and on 09/22/23, at 8:37 P.M., the Maintenance Director said the following: -There should be an air gap between the drain on the ice machine and the drain in the floor; -The air gap should be two inches. During an interview on 09/20/23, at 3:05 P.M., the DM said the following: -There should be an air gap between the drain from the ice machine and the drain in the floor to prevent back flow. He/she did not know how much the air gap should be; -The Maintenance Director was responsible for ensuring there was an air gap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report all allegations of possible abuse immediately to the Administrator and to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours when the facility failed to report staff alleged one resident (Resident #1) had touched another resident (Resident #2) in a sexual manner until two days after the staff became aware of the allegation. The facility census was 59. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, showed the following: -If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law; -Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury. Review of the facility's policy titled Identifying Types of Abuse, dated April 2021, showed the following: -Sexual abuse is non-consensual sexual conduct of any type with a resident; -Sexual contact with a resident who lacks the cognitive ability to consent is considered non-consensual and therefore constitutes abuse. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admission date of 12/20/22; -Diagnoses included metabolic encephalopathy (a disease of the brain that changes brain function or structure), cerebral infarction (lack of adequate blood supply to the brain), and unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions and solve problems without a specific diagnosis). Review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/10/23, showed the following: -Severely cognitively impaired; -Required extensive assistance of two or more staff for bed mobility and transfers; -Required total dependence with locomotion on and off the unit, dressing, toileting, and personal hygiene. 2. Review of Resident #2's face sheet showed the following: -admission date of 10/05/22; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Required extensive assistance of one staff with bed mobility, locomotion on/off unit, dressing, eating, toileting, and personal hygiene; -Required extensive assistance of two ore more staff with transfers. Review of the resident's nursing note dated 05/28/23, at 2:31 P.M., listed as a late entry, showed the following: -It was reported a resident had his/her hand in the resident's lap; -Staff separated the residents immediately and moved the resident near the nurses' station; -The resident was placed on frequent observation and remained in the area surrounding the nurses' station; -The residents will continue to be separated at the next meal. (Staff did not document reporting the allegation of abuse to the Administrator or DHSS.) 3. Review of the facility's investigation, dated 05/28/23, showed the following: -At 4:20 P.M., staff messaged the Director of Nursing (DON) to report Resident #1 had placed his/her hand on Resident #2's lap; -The residents were in the 200 hall and Resident #1 was saying hello to Resident #2 and placed his/her hand in between the resident's legs near the private area; -Certified Nurse Assistant (CNA) A stated, on Saturday 05/27/23, sometime after lunch, he/she was walking from the assisted dining room to the nurses' station when he/she witnessed Resident #1 touching Resident #2 between his/her legs above clothing. He/she removed Resident #2 from the area and notified the charge nurse. Staff kept the residents separated; -The DON came to the facility to conduct an investigation. (Staff did not document notifying the Administrator or DHSS of the allegation of abuse.) Review of DHSS records showed the allegation was reported by a staff member on 05/29/2023, at approximately 8:39 A.M. (two days after staff became aware of the allegation of possible abuse). During an interview on 05/30/23, at 11:43 A.M., the DON said the following: -On 05/27/23, at approximately 4:20 P.M., staff reported to her Resident #1 was observed with his/her hands touching Resident #2 between the legs in the private area while fully clothed; -She came to the facility and interviewed both residents; -The facility kept the residents separated; -She investigated and determined the allegation was not reportable. During an interview on 05/30/23, at 12:46 P.M., CNA A said the following: -On 05/27/23, just after the lunch meal had ended, he/she observed Resident #1 rubbing Resident #2 between his/her legs in the private area and above clothing; -He/she immediately separated the residents and reported the incident to the charge nurse; -He/she believed the incident was abuse due to Resident #2 not having the cognitive ability to consent; -He/she would immediately report any abuse allegations to the charge nurse; -The facility has 24 to 48 hours to report abuse allegations to the state. During an interview on 05/31/23, at 9:57 A.M., Registered Nurse (RN) E said the following: -Staff is expected to report any abuse allegation to the charge nurse immediately; -He/she should report any abuse allegation to the DON immediately; -The DON should report any abuse allegation to the Administrator immediately; -The facility has two hours to report any abuse allegation to the state agency; -The DON and/or Administrator conducts investigations into abuse allegations; -On 05/27/23, sometime after the lunch meal, CNA A reported observing Resident #1 touching Resident #2 in the private area between the legs while sitting in the 200 hall; -Staff moved Resident #1 to the nurses' station for observation; -He/she reported the abuse to the DON as soon as possible while dealing with another resident who had to be sent out; -He/she would consider a resident touching another resident between the legs to be abuse, which should be reported to management and the state agency. 4. During an interview on 05/30/23, at 2:05 P.M., CNA B said the following: -He/she would report immediately report any abuse allegations to the charge nurse; -The facility has two hours to report an abuse allegation to the state agency; -He/she would consider a resident touching another resident between the legs on private parts to be abuse. 5. During an interview on 05/30/23, at 2:17 P.M., Nurse Assistant (NA) C said the following: -He/she would immediately report any allegation of abuse to the charge nurse; -He/she would consider a resident touching another resident between the legs to be abuse; -The facility has two hours to report an abuse allegation to the state agency. 6. During an interview on 05/30/23, at 2:24 P.M., CNA D said the following: -He/she would report an allegation of abuse to the charge nurse, DON, or social services; -The facility has two hours to report an abuse allegation to the state agency; -He/she would consider a resident touching another resident between the legs to be abuse. 7. During an interview on 05/30/23, at 2:51 P.M., the former Social Services Assistant said the following: -Staff should immediately notify the charge nurse of any abuse allegation; -The charge nurse should immediately notify the administration of any abuse allegation; -The facility has two hours to report an abuse allegation to the state agency; -He/she conducted interviews for investigations while in the role of social services assistant; -He/she had no knowledge of any history of allegations regarding Resident #1. 8. During an interview on 05/30/23, at 3:14 P.M., RN F said the following: -He/she would report any abuse allegation to the DON immediately; -The facility has four hours to report an abuse allegation to the state agency; -He/she would consider a resident touching another resident between the legs to be abuse; -The DON and Administrator conduct investigations of abuse allegations. 9. During an interview on 05/30/23, at 4:26 P.M., the DON said the following: -Staff is expected to report any abuse allegation to the charge nurse immediately; -Staff should ensure resident safety and then immediately notify DON of any abuse allegation; -The facility should report an abuse allegation to the state agency within two hours; -A resident having his/her hands in between another resident's legs is very subjective; -Unwanted touching is never okay, but she did not think there was any ill intent behind this incident; -The facility conducts an investigation when there is an allegation of abuse to determine the validity, and only reports to the state if the allegation is substantiated through the facility investigation; -She did not report the allegation to the Administrator. 10. During an interview on 05/30/23, at 4:50 P.M., the Administrator said the following: -Staff should immediately notify the charge nurse of any abuse allegation; -Staff should ensure resident safety and then immediately notify DON of any abuse allegation; -The DON should immediately notify the Administrator of any abuse allegation, notify family and physicians, and begin an investigation; -The facility has two hours to report any abuse allegation to the state agency; -The abuse allegation should have been reported to the state agency within two hours. MO00219120

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document a full investigation of an allegation of abuse when staff alleged one resident (Resident #1) was observed to touch another resident (Resident #2) in a sexual manner and staff did not include written interviews with multiple additional staff and residents in the investigation. The facility census was 59. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, showed the following: -All allegations are thoroughly investigated. The Administrator initiates investigations; -The Administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation; -The individual conducting the investigation at a minimum reviews the documentation and evidence; reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his or her interactions with staff and other residents; interviews the person(s) reporting the incident; interviews any witnesses to the incident; interviews the resident; interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interviews the resident's roommate, family members and visitors; reviews all events leading up to the alleged incident; and documents the investigation completely and thoroughly; -Witness statements are obtained in writing, signed and dated; -The investigator consults daily with the Administrator concerning the progress/findings of the investigation. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admission date of 12/20/22; -Diagnoses included metabolic encephalopathy (a disease of the brain that changes brain function or structure), cerebral infarction (lack of adequate blood supply to the brain), and unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions and solve problems without a specific diagnosis). Review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/10/23, showed the following: -Severely cognitively impaired; -Required extensive assistance of two or more staff for bed mobility and transfers; -Required total dependence with locomotion on and off the unit, dressing, toileting, and personal hygiene. 2. Review of Resident #2's face sheet showed the following: -admission date of 10/05/22; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Required extensive assistance of one staff with bed mobility, locomotion on/off unit, dressing, eating, toileting, and personal hygiene; Required extensive assistance of two ore more staff with transfers. Review of the resident's nursing note dated 05/28/23, at 2:31 P.M., entered as a late entry, showed the following: -It was reported a resident had his/her hand in the resident's lap; -Staff separated the residents immediately, and moved the resident near the nurses' station. 3. Review of the facility's investigation, dated 05/28/23, showed the following: -At 4:20 P.M., staff messaged the DON to report Resident #1 had placed his/her hand on Resident #2's lap; -The residents were in the 200 hall and Resident #1 was saying hello to Resident #2 and placed his/her hand in between the resident's legs near the private area; -The DON came to the facility to conduct an investigation; -The DON interviewed Resident #1 and Resident #2 regarding the allegation; -The DON interviewed Certified Nurse Aide (CNA) A and Registered Nurse (RN) E; (The DON did not document any addition resident or staff interviews.) 4. During an interview on 05/30/23, at 11:43 A.M., the Director of Nursing (DON) said the following: -On 05/27/23, at approximately 4:20 P.M., staff reported to her Resident #1 was observed with his/her hands touching Resident #2 between the legs in the private area while fully clothed; -She came to the facility and interviewed both residents. 5. During an interview on 05/30/23, at 12:46 P.M., CNA A said the following: -On 05/27/23, just after the lunch meal had ended, he/she observed Resident #1 rubbing Resident #2 between his/her legs in the private area and above clothing; -He/she immediately separated the residents and reported the incident to the charge nurse; -He/she believed the incident was abuse due to Resident #2 not having the cognitive ability to consent. 6. During an interview on 5/31/23, at 9:57 A.M., RN E said the following: -The DON and/or administrator conduct investigations into abuse allegations; -On 05/27/23, sometime after the lunch meal, CNA A reported observing Resident #1 touching Resident #2 in the private area between the legs while sitting in the 200 hall; -Staff moved Resident #1 to the nurses' station for observation; -He/she reported the abuse to the DON as soon as possible while dealing with another resident who had to be sent out; -He/she would consider a resident touching another resident between the legs to be abuse, which should be reported to management and the state agency. 7. During an interview on 05/30/23, at 3:14 P.M., RN F said the following: -He/she would consider a resident touching another resident between the legs to be abuse; -The DON and administrator conduct investigations of abuse allegations. 8. During an interview on 05/30/23, at 4:26 P.M., the DON said the following: -Staff is expected to report any abuse allegation to the charge nurse immediately; -Staff should ensure resident safety and then immediately notify DON of any abuse allegation; -A resident having his/her hands in between another resident's legs is very subjective; -Unwanted touching is never okay, but she did not think there was any ill intent behind this incident; -An investigation should be conducted for abuse allegations; -The investigation for the allegation included statements from CNA A and RN E and herself; -She did not interview other residents; -She interviewed other staff working at the time of the incident, but did not document. 9. During an interview on 05/30/23, at 4:50 P.M., the Administrator said the following: -Staff should immediately notify the charge nurse of any abuse allegation; -Staff should ensure resident safety and then immediately notify DON of any abuse allegation; -The DON should immediately notify the Administrator of any abuse allegation, notify family and physicians and begin an investigation; -An investigation should include what occurred, time, location, interviews with parties involved and additional residents and staff, and all information should be documented. MO00219120

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standard, the care plan, and the resident's choice when the facility failed to obtain complete orders for restorative therapy, failed care plan updates in restorative therapy, and failed to consistently provide restorative therapy for six residents (Residents #1, #2, #3, #4, #5, and #6) out of six residents sampled. The facility census was 59. Review of a facility policy entitled Restorative Nursing Services, revised July 2017, showed the following information: -Residents will receive restorative nursing care as needed to help promote optimal safety and independence; -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical occupational or speech therapies); -Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care; -The resident or representative will be included in determining goals and the plan of care; -Restorative goals may include, but are not limited to, supporting and assisting the resident in adjusting or adapting to changing abilities; developing, maintaining, or strengthening his/her physiological and psychological resources; maintaining his/her dignity, independence, and self-esteem; and participating in the development and implementation of his/her plan of care. 1. Review of Resident #1's face sheet (gives basic profile information) showed the following information: -admission date of 11/01/22; -Diagnoses included polyneuropathy (simultaneous malfunction of many nerves throughout the body) and low back pain. Review of the resident's care plan, last updated 02/23/23, showed the following: -Required limited assistance with grooming, hygiene, toileting, bathing, and dressing; -Assist with activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) and evaluate need for restorative nursing care; -Encourage self-care and participation; -Requires safety care related to poor safety awareness; -Assist with bed mobility and ambulation. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/12/23, showed the following information: -Cognition intact; -Independent for bed mobility, transfers, dressing, ambulation using a walker, bathing, and personal hygiene; -Balance not steady for moving from seated to standing, walking, turning while walking, moving on and off toilet, and for surface-to-surface transfers. Review of the resident's form PT (Physical Therapy) Initial Restorative Nursing Program showed the following: -The resident was discharged from therapy on 03/08/23; -Instructions were given by a physical therapy assistant (PTA) for restorative nursing of ambulation as tolerated using front wheeled walker; sit-to-stands x 10; bilateral knee extensions two (repetitions) x 10 with 2-pound (lb.) weights (wts.); and standing/marching 2 x 10. Program to be performed 3 times per week for 90 days; -The instruction sheet was signed by Restorative Nurse Aide (RNA) A on 03/08/23. Review of the resident's form OT (Physical Therapy) Initial Restorative Nursing Program showed the following: -Instructions were given by a certified occupational therapy assistant (COTA) on 03/10/23 for restorative nursing three times a week for 12 weeks. Therapy to included bilateral upper extremities (BUE) bike for 10 minutes or as tolerated and BUE balloon volleyball as tolerated; -The instruction sheet was signed by RNA A on 03/10/23, the Director of Nursing (DON) on 03/14/23, and the physician on 03/15/23. Review of the resident's Physician Order Sheet (POS), current as of 05/11/23, showed an order, dated 03/15/23, for Restorative Nursing Program. The order did not list specifics regarding the Restorative Nursing Program. Review of the resident's progress notes, dated 03/01/23 through 05/11/23, showed staff did not documented activities pertaining to restorative nursing or exercises. Observation on 05/06/23, at 4:05 P.M., showed the resident ambulated slowly out of his/her room using a rolling walker. During an interview on 05/11/23, at 9:54 A.M., RNA A said there was a new restorative therapy order for the resident in March 2023, but the RNA had not been able to work with the resident yet. The RNA said he/she had been pulled to work the floor pretty often for the past two or three months. During an interview on 05/11/23, at 12:10 P.M., the resident said he/she had a history of left knee and back problems. He/she said the facility was supposed to start restorative therapy for strengthening and mobility, which he/she wanted to do, but they had not done so yet. 2. Review of Resident #2's face sheet showed the following information: -admission date of 04/07/23; -Diagnoses included stroke affecting right dominant side and chronic obstructive pulmonary disease (COPD: breathing disorder). Review of the resident's significant change MDS, dated [DATE], showed the following information: -Severely impaired cognition; -Inattention; -Required limited assistance with bed mobility, locomotion using a wheelchair, and bathing; -Required extensive assistance with transfers, walking using a walker, dressing, toileting needs, and personal hygiene; -Balance not steady for moving from seated to standing, walking, moving on and off toilet, and for surface-to-surface transfers; able to stabilize only with human assist. Review of the resident's form PT (Physical Therapy) Initial Restorative Nursing Program showed the following: -On 04/21/23, the resident was discharged from therapy; -Instructions were given by a PTA for restorative nursing including having a partner follow behind with wheelchair during gait training; using gait belt and front wheeled walker to ambulate patient as tolerated with caregiver assistance of two; bilateral hamstring stretches; sit-to-stands at bar x 5; and balloon kicks. Program to be performed three times per week for 90 days; -The instruction sheet was signed by RNA A on 05/10/23. Review of the resident's form OT (Occupational Therapy) Initial Restorative Nursing Program showed the following: -On 04/22/23, the resident was discharged from therapy; -Instructions were given by a COTA for restorative nursing as three times a week for 12 weeks. Therapy included BUE bike as tolerated and BUE balloon volleyball as tolerated; -The instruction sheet was signed by a COTA on 04/23/23 and by RNA A on 04/25/23; Review of the resident's care plan, last updated 04/24/23, showed the following: -Required limited assistance with grooming, hygiene, toileting, bathing, eating, dressing: encourage self-care/participation; -One staff assist with ADLs and evaluate need for restorative nursing care; -Requires safety care related to poor safety awareness, impaired balance, assist with transfers, uses manual wheelchair; -Assist/encourage bed mobility; monitor for falls, unsteady gait, loss of balance or mobility. (Staff did not up date the care plan regarding restorative therapy.) Review of the resident's POS, current as of 05/11/23, showed the staff did not document an order for restorative services. Review of the resident's progress notes, dated 04/21/23 to 05/11/23, showed staff did not document activities pertaining to restorative nursing or exercises. During an interview on 05/11/23, at 9:54 A.M., RNA A said there was an order for restorative nursing for the resident about two weeks prior, but the RNA had not been able to work with the resident yet. The RNA said he/she had been pulled to work the floor pretty often for the past two or three months. Observation on 05/11/23, at 12:20 P.M., showed the resident sat in a wheelchair in his/her room. During the observation, the resident said he/she was supposed to have some therapy or restorative therapy because of his/her balance and difficulty in walking. He/she said he/she thought the therapy would help, but it had not yet started. 3. Review of Resident #3's face sheet showed the following information: -admission date of 12/13/15 with readmission date on 07/05/18; -Diagnoses included osteoarthritis, spondylosis (age-related wear and tear of the spinal disks), and weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognition intact; -Required limited assistance for bed mobility, transfers, dressing, toileting needs, personal hygiene, and bathing; -Required extensive assistance for ambulation using a walker; -Balance not steady for moving from seated to standing, walking, turning while walking, moving on and off toilet, and for surface-to-surface transfers; able to stabilize without human assistance. Review of the resident's POS, current as of 05/11/23, showed an order, dated 12/07/22, for Restorative Nursing Program. The order did not list specifics regarding the Restorative Nursing Program. Review of the resident's form Continuation of Restorative Nursing Program showed the following: -Instructions included active range of motion (AROM) BUE bike x 10 minutes; BUE with 1-pound weights x 10 reps x 2 sets; bilateral lower extremities (BLE) balloon kicks; BLE bike x 5 minutes; sit-to-stands at wall bar x 10. Therapy to continue three times per week for 90 days; -The instruction sheet was signed by RNA A on 01/10/23, the DON on 01/10/23, and the physician on 01/24/23. Review of the resident's progress notes, dated 03/01/23 through 05/11/23, showed staff documented restorative therapy was completed on the following dates: -On 03/01/23; -On 03/10/23 (nine days after last restorative therapy); -On 03/11/23; -On 03/15/23; -On 04/06/23 (22 days after the last restorative therapy); -On 04/07/23; -On 04/11/23; -On 04/17/23 (six days after the last restorative therapy); -On 04/21/23; -On 05/02/23 (11 days after the last restorative therapy); -On 05/05/23; -On 05/06/23; -On 05/09/23. Review of the resident's care plan, last updated 05/03/23, showed the following: -Resident has an ADL self-care performance deficit related to chronic kidney disease and fatigue; -Requires moderate assist by one staff with showering; -Able to transfer self from bed to wheelchair to toilet; -Monitor for changes, any potential for improvement or declines in function; -Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as exercise group; -Resident has chronic pain related to arthritis; -Observe and report decrease in functional abilities, or decrease in range of motion. (Staff did not care plan regarding the initiation or continuation of restorative therapy.) During an interview on 05/11/23, at 9:54 A.M., RNA A said the resident was still supposed to be on continued restorative therapy for maintenance of strength and mobility. Since the decrease in restorative therapy, the resident had told the RNA the resident wasn't sure he/she could even still do the ten minutes on the bike. Observation and interview on 05/11/23, at 12:16 P.M., showed the resident rested in bed. During the observation, the resident said he/she was supposed to work with the RNA several times per week. They had not been doing that regularly for a while because the RNA was getting pulled to work the floor. The resident said he/she really missed the therapy, because it made him/her feel better, stronger, and more energetic. 4. Review of Resident #4's face sheet showed the following information: -admission date of 02/28/22 with a readmission date of 12/14/22; -Diagnoses included chronic ulcer to the back, morbid obesity, and hypertension. Review of the resident's form OT - Restorative Nursing Program showed the following: -On 01/27/23, the resident was discharged from occupational therapy (OT); -Instructions were given by a COTA for restorative nursing three times per week for 12 weeks. Therapy included BUE bike x 10 minutes or as tolerated; BUE balloon volleyball as tolerated; and BUE exercises with 1-pound weights x 1 reps x 2 sets. Review of the resident's form PT - Restorative Nursing Program showed the following: -On 01/29/23, the resident was discharged from physical therapy; -Instructions were given by a PTA for restorative nursing including bilateral hamstring stretches; sit to stands x 5; balloon kicks; and ambulation for as tolerated using gait belt - caregiver assist of two and front wheeled walker. Therapy program to be performed three times per week for 90 days; -The instruction sheet was signed by the PTA on 01/27/23, the RNA on 01/28/23, the DON on 01/31/23, and the nurse practitioner on 02/2/23. Review of the resident's POS, current as of 05/11/23, showed staff did not document an order for restorative therapy. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Required limited assistance with bathing; -Required extensive assistance with bed mobility, transfers, dressing, ambulation using a walker, and locomotion using a wheelchair; -Balance unsteady for moving from seated to standing, walking, turning while walking, moving on and off toilet, and for surface-to-surface transfers; able to stabilize only with assist. Review of the resident's progress notes, dated 03/01/23 through 05/11/23, showed staff provided restorative therapy on the following dates: -On 03/06/23; -On 03/11/23, resident declined; -On 03/15/23, resident declined; -On 03/17/23, resident declined; -On 04/06/23 (20 days after restorative therapy was last offered); -On 04/10/23; -On 05/04/23 (24 days after the last restorative therapy). Review of the resident's care plan, last updated 05/04/23, showed the following: -Resident has and ADL self-care performance deficit related to low back pain and generalized weakness; -Requires moderate assist of one staff for bathing; -Requires two staff to turn and reposition in bed; -Able to transfer with two staff; -PT to evaluate and treat as ordered or as needed; -Resident has high blood pressure; -Educate the resident/family/caregiver about the value of regular exercise; -Assist with ADLs and ambulation as needed. (Staff did not care plan regarding the restorative therapy.) Observation on 05/10/23, at 9:30 A.M., showed two staff assisted the resident to stand from a wheelchair and walk onto a scale. During an interview on 05/10/23, at 3:25 P.M., the resident said he/she was supposed to do restorative therapy three times a week. The therapy wasn't as consistent recently. The therapy was to strengthen his/her arms and legs and improve his/her ability to walk. The resident said he/she thought the therapy helped when it was done. During an interview on 05/11/23, at 9:54 A.M., RNA A said the resident was on continued restorative nursing therapy. The RNA said he/she had received complaints from the resident's family that the resident was not getting his/her restorative therapy because the RNA was pulled to work the floor almost daily for the past three months. 5. Review of Resident #5's face sheet showed the following information: -admission date of 11/01/22; -Diagnoses included COPD and low back pain. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognition intact; -Required limited assistance for bed mobility, transfers, ambulation, dressing, and bathing; -Balance unsteady for moving from seated to standing, walking, turning while walking, moving on and off toilet, and for surface-to-surface transfers; able to stabilize without assistance. Review the resident's form PT - Initial Restorative Nursing Program showed the following: -On 02/07/23, the resident was discharged from physical therapy; -Instructions were given by a PTA for restorative nursing including standing hamstring curls, 2 sets x 10 with 5-pounds, bilateral; standing marching, 2 sets x 10 with 5-pounds bilateral; standing hip abduction 2 sets x 10, bilateral; and seated knee extensions using 5-pounds, 2 sets x 10. Program to be performed three times per week for 90 days; -The instruction sheet was signed by a PTA on 02/07/23 and by RNA A on 02/07/23. Review of the resident's form OT - Initial Restorative Nursing Program showed the following: -On 02/08/23, the resident was discharged from occupational therapy; -Instructions were given by a COTA for restorative nursing for three times per week for 12 weeks. The therapy included standing arm bike x 5 to 10 minutes or as tolerated and BUE exercises using 3-pounds, 2 sets x 10 reps; -The instruction sheet was signed by a COTA on 02/08/23 and by the RNA on 03/01/23. Review of the resident's POS, current as of 05/11/23, showed staff did not document orders pertaining to restorative nursing services. Review of the resident's progress notes, dated 03/01/23 through 05/22/23, showed staff documented completing restorative therapy on 03/01/23. Review of the resident's care plan, last updated 04/27/23, showed the following: -Resident requires safety care related to poor safety awareness; -Encourage bed mobility; -Monitor for falls, unsteady gait, loss of balance or mobility; -Requires monitoring assistance with grooming, hygiene, toileting, bathing, eating, and dressing; -Assist with ADLs and evaluate need for restorative nursing care, (Staff did not document the initiation of restorative therapy.) Observation on 05/06/23, at 4:15 P.M., showed the resident ambulated slowly in the hallway. His/her gait was somewhat unsteady, but he/she did not use an assistive device. During an interview on 05/11/23, at 9:34 A.M., RNA A said there was a new order for restorative therapy for the resident in early March 2023, but the RNA had only been able to work with him/her one or two times. RNA A said he/she had been pulled to work the floor fairly often during the past few months. During an interview on 05/11/23, at 2:25 P.M., the resident said there had not been any restorative therapy lately. The RNA had talked to him/her that day to talk about resuming the therapy. He/she wants to do the therapy to improve his/her movement. 6. Review of Resident #6's face sheet showed the following information: -admission date of 12/04/17 with readmission date of 04/10/19; -Diagnoses included stroke with affect to left non-dominant side, muscle spasm, and contracture. Review of the resident's annual MDS, dated [DATE], showed the following information: -Severely impaired cognition; -Able to eat independently with supervision; -Required extensive assistance for bed mobility and dressing; -Dependent on staff assistance for transfers, locomotion using a wheelchair, and toileting needs; -One sided limitation of range of motion (ROM). Review of the resident's Continuation of Restorative Nursing Program form showed the following: -Instructions included resident to tolerate active assisted range of motion (AAROM) of BUE all planes, 10 to 15 reps x 1 set and AAROM of BLE all planes, 10 to 15 reps x1 set. Therapy to be provided three times per week for 90 days; -The instruction sheet was signed by RNA A on 10/13/2022, by the DON on 10/13/22, and by the physician with no date noted. Review of the resident's POS, current as of 05/11/23, showed an order, dated 12/07/22, for Restorative Nursing Program. (The order did not address the specifics of the program.) Review of the resident's progress notes, dated 03/01/23 through 05/11/23, showed staff provided restorative therapy on the following dates: -On 03/10/23; -On 03/15/23; -On 04/11/23 (26 days after the prior restorative therapy). Review of the resident's care plan, last updated 04/24/23, showed the following: -Resident is high risk for falls related to hemiplegia (one-sided paralysis/weakness, due to stroke)/contractures; -PT to evaluate and treat as ordered or as needed. (Staff did not update care plan for the restorative therapy to be provided.) Observation on 05/06/23, at 4:15 P.M., showed the resident sat in a wheelchair in his/her room. Observation on 05/10/23, at 2:00 P.M., showed the resident required the assistance of two staff to use a mechanical lift to transfer the resident from a wheelchair to a shower chair. The resident's left hand was contracted, but during the transfer he/she did grasp the lift sling with both hands. The resident tried to use his/her arms and hands to help the staff with undressing the resident and bathing him/her. During an interview on 05/11/23, at 9:54 A.M., RNA A said the resident was supposed to be on continued restorative therapy, but the RNA had not worked with him/her recently due to being pulled to work the floor. 7. During an interview on 05/10/23, at 12:50 P.M., the DON said if a resident falls or shows difficulty with movement, the nursing staff will request that the physical therapy department assess the resident. The physical therapist will then make suggestions and get a physician order for restorative therapy for the resident. 8. During an interview on 05/10/23, at 4:01 P.M., the Social Services Director said the RNA had not been doing much restorative therapy lately. The RNA was pulled to work the floor often. 9. During an interview on 05/11/23, at 9:54 A.M., RNA A said when a resident falls or nursing staff think a resident could benefit from restorative therapy, they request an assessment be made by physical therapy. The therapist gets a physician order and gives instructions to the RNA for the restorative therapy. The RNA said he/she was also responsible for completing all residents' daily and weekly weights and assist residents with meals for approximately three hours of each day. 10. During an interview on 05/11/23, at 12:40 P.M., with the Administrator and the DON, they both said the following: -They have a weekly risk meeting where RNA A brings the current list of residents on restorative therapy to discuss; -Restorative therapy will be initiated if a resident is being discharged from physical therapy or if staff feels they could benefit from the restorative therapy; -The physician should sign the restorative therapy request; -The RNA should follow the orders/instructions given by therapy; -If the RNA is not available, staff should complete walk to dine with the residents, as they are able; -The certified nurse aides (CNAs) probably do passive range of motion with many residents, but haven't been told to actually document that; -The facility has had a decrease in staff, and the RNA does get pulled to work the floor. MO00216028

Based on record review and interview, the facility failed to take steps to immediately assess and treat one resident (Resident #1) who spilled hot coffee on him/herself resulting in second degree burns. The facility also failed to complete neurological (neuro) checks (to assess an individual's neurological functions, motor and sensory response, and level of consciousness) after unwitnessed falls according to standards of practice and the facility's policy for three residents (Resident #2, Resident #3, Resident #4). The facility census was 51. 1. Record review of the facility's policy titled, Safety of Water Temperature, revised 2009, showed the following: -Nursing staff will be educated about signs and symptoms of burns (first, second, and third degree) so that injuries can be recognized and treated appropriately; -If a resident is scalded or burned, nursing staff should follow pertinent first aid and physician notification protocols and report injury to his/her direct supervisor. Record review of the Consumer Product Safety Commission Website, undated, showed the following: -Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns. Record review of the resident's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 10/31/22; -Diagnoses include dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), paraplegia (an impairment in motor or sensory function of the lower extremities), type 2 diabetes (is an impairment in the way the body regulates and uses sugar (glucose) as a fuel), polyneuropathy (a condition in which a person's peripheral nerves are damaged. It affects the nerves in the skin, muscles, and organs), hemiplegia and hemiparesis (paralysis of partial or total body function on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and weakness. Record review of the resident's care plan, dated 11/4/22, showed the following: -The resident required assistance with grooming, hygiene, toileting, bathing, eating, and dressing; -All activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) care will be assisted or encouraged for independence until re-evaluated upon comprehensive care plan; -Assist with ADLs and evaluate need for restorative nursing care for independence. Encourage self-care/participation, set-up and monitor; -Monitor for skin issues; -The resident required safety care due to poor safety awareness and severely diminished cognition; -Safety measures will be monitored and managed until further instruction of a comprehensive care plan. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/11/2022, showed the following: -Severe cognitive impairment; -Independent with eating; -Total dependence with transfers and extensive assistance with bed mobility. Record review of the resident's nurses' notes showed the following: -On 12/26/22, at 1:07 P.M., Licensed Practical Nurse (LPN) H noted the resident spilled hot coffee on his/her upper right leg. Resident had an approximately 18 centimeter (cm) by 7 cm burn with large open and scattered blisters to the inner right thigh. Resident said he/she dropped hot coffee on his/her right leg. He/she indicated it did not have a lid on it. The wound nurse, medical director/resident physician, Administrator, DON and dietary all notified of the event; -On 12/26/22, at 2:10 P.M., LPN A noted right anterior (situated in the front of the body or nearer to the head) proximal (situated nearer to the center of the body or the point of attachment) thigh, clean the area with hypochlorous acid (a strong disinfectant in health care and is an excellent cleaning solution for wound care), pat dry with sterile gauze. Apply xeroform (non-adherent primary dressing maintains a moist wound environment) over wound, cover with two abdominal pads and secure with cloth tape. Change dressing daily and as needed. Record review of the resident's care plan, dated 11/4/22, showed the following updates: -On 12/26/22, the resident spilled a cup of hot coffee onto his/her lap causing a burn on his/her left leg. Resident had a 18 cm by 7 cm burn with large open and scattered blisters to the inner right thigh due to diminished cognition and poor safety awareness; -On 12/26/22, the resident will be provided hot beverages with a lid to decrease his/her chances of injury through the next review date; -On 12/26/22, all hot drinks will have a lid to prevent accidental spillage and/or injury to the resident. The resident may need reminders to keep himself/herself safe from injury at times and remind him/her to keep a lid on hot drink. Record review of the resident's Wound Care report, dated 12/26/22, showed the following: -Wound type: blister/ 2nd degree burn -Cause: Resident spilled coffee in his/her lap; -Drainage is light and serous (is thin and clean typical with wound healing); -Surrounding skin is intact; -Intervention was xeroform dressing. Record review of the facility's investigation showed the following: -In a statement, dated 12/26/22, Certified Nurse Aide (CNA) C said he/she did not see the resident spill his/her coffee. He/she witnessed the coffee on the ground and on the resident's thigh. He/she was late coming to the dining room because he/she was putting bath sheets in the computer. He/she was going in and out of the dining room. When he/she got to the dining room he/she started assisting a resident with eating. Then he/she started taking residents out of the dining room; -In a statement, dated 12/26/22, CNA D said he/she walked into the dining room, pushing another resident to the table. The kitchen worker was by the resident and said he/she spilled his/hers coffee. There was coffee on the floor. He/she continued taking the resident to the table and left the dining room. He/she did not hear him/her scream. He/she did not see him/her spill the coffee. During an interview on 1/8/23, at 8:15 A.M., LPN N said the following: -The resident had a cup of coffee in his/her hand and the lid fell off and he/she dropped it on his/her lap; -The resident got a 2nd degree burn that is being treated; -If a resident gets hot liquid on themselves the resident should be assessed as soon as possible. During an interview on 1/8/23, at 9:03 A.M., Dietary Aide (DA) G said the following: -He/she was in the kitchen getting ready to carry drinks out to the assisted dining room before lunch and heard the resident yell, I spilled my damn coffee; -He/she saw that the resident had spilled the coffee on his/her lap from a black thermal cup; -He/she told a female CNA that came into the assisted dining room to bring in a resident that the resident had spilled coffee on himself. He/she was not sure who the CNA was. The CNA just left and did not do anything for the resident; -The resident was left in the dining room and finished his/her meal. The CNA did not check on the resident after that; -The resident was not assessed timely by staff. During an interview on 1/10/23, at 11:40 A.M., LPN A said the following: -The resident has 2nd degree burns on his/her thigh area from spilling hot coffee in his/her lap from the lid coming off his/her thermal cup. He/she thinks the lid malfunctioned. He/she had pants on when he/she was burned. The staff had to lay him/her down to assess the burns; -The resident should have been assessed immediately; -He/she assessed the resident after lunch. He/she would have expected the resident to be assessed right after spilling hot coffee on himself; -The resident has a diagnosis of paraplegia and has lack of sensation in his/her legs. During an interview on 1/10/23, at 12: 17 P.M., CNA C said the following: -He/she assisted laying the resident down after lunch and when they were changing him noticed that he had significant burns that were blistering on his/her thigh/groin area. He/she got LPN A to come look at the wounds. The resident was not acting like he/she was in pain and acted like he/she could not really feel it; -He/she saw he/she had spilled coffee on the floor and his/her leg. Nobody checked the resident right after he/she spilled the coffee on himself/herself to see if it had burned him/her because he/she did not appear to be in any pain. During an interview on 1/10/23, at 12:49 P.M., CNA D said the following: -He/she was taking residents to the dining room. One of the dietary aides told him/her that the resident had spilled coffee. He/she was not made aware that it had spilled on the resident. She assumed it had spilled on the floor; -The resident did not appear to be in any pain; -After the resident had finished lunch he was coming out of the dining room and he/she offered to help him into bed; -When he/she was helping him she noticed his/her pants were wet and when he/she changed him, the resident had blisters on his/her things. The nurse was immediately notified and he/she was assessed. During an interview on 1/10/23, at 2:35 P.M., CNA F said the following: -The resident dropped a cup of coffee on his/her lap; -The resident was not assessed until after he/she finished his breakfast because he did not appear to be in distress. It was not obvious that he/she was burned. During an interview on 1/10/23, at 3:52 P.M., the Dietary Manger (DM) said the following: -The DA G was very upset because staff did not immediately assess the resident and continued bringing residents into the dining room after he/she had told them about the coffee spill; -The nursing staff should have responded to the resident after he spilled coffee on his/herself. During an interview on 1/10/23, at 4:05 P.M., the Medical Director said the following: -He/she was aware that the resident burned him/herself with hot coffee, but was not sure of the severity; -He/she would expect staff to assess him/her as soon as possible after the spill occurred. During an interview on 1/10/23, at 4:30 P.M., the Administrator/DON said the following: -He/she expects the staff to assess residents timely after an accident. The resident should have been assessed as soon as possible after spilling coffee on him/herself. 2. Record review of the facility's Fall Assessment, Fall Risk Assessment, and Fall Care Planning policy, revised 12/28/11, included the following information: -When a fall occurs, the post-fall assessment form will be completed with specific information surrounding the fall, resident's statement if able to provide one, and any precipitating events; - Assessment information will include a physical assessment, vital signs, any signs and symptoms of acute illness and contributing medications. Record review of the facility's Fall Protocol, revised 10/1/15, included the following information: -A nurse must immediately assess resident, checking neurological status and base line vitals must be obtained; -A progress note must be made describing the incident, baseline vitals, neuro checks, notifications and interventions made. -For any instance in which there is a possibility that the head was struck, the Neurological Checklist must be initiated. This consists of baseline vitals and neuro checks, again every 15 minutes for an hour; then every 30 minutes for an hour; every hour for two hours; then once a shift (6a-6p and 6p-6a) for the next three days. Upon completion, this shall be placed in the resident's chart behind the yellow sheet that says, Fall. Review of Saunder's Medical-Surgical Nursing, 4th edition, 2002, showed that neurological assessments (neuro checks) can detect early signs of central nervous system (brain) deterioration and are commonly done after a person sustains a head injury to detect complications. One of the most serious types of head injuries is a subdural hematoma, which consists of a collection of blood on the surface of the brain and is an emergency condition. The purpose of performing neurological assessments is to establish a baseline upon which subsequent assessments can be compared and changes in neurological status can be determined. 3. Record review of Resident #4's face sheet showed the following: -admission date of 10/31/17; -Diagnoses included dementia, altered mental status, and osteoarthritis (a degenerative joint disease that can affect the many tissues of the joint). Record review of the resident's incident report dated 1/4/23, at 11:15 P.M., showed a nurse documented the following: -Unwitnessed (fall) in the resident's room; -Resident sat next to the bed, on the floor, with his/her back against the bed. No injuries or redness observed. -Per resident, slid down off the side of the bed; -Immediate action taken: Vital signs taken. Two staff assisted the resident to bed, no injuries, able to move all extremities. The resident requested something for pain after staff assisted him/her to bed. Record review of the resident's incident report dated 1/4/23, at 11:38 P.M., showed a nurse documented the following: -Unwitnessed (fall) in the resident's room; -Resident sitting on the floor next to his/her bed. Staff completed an assessment, no injury or redness found. The resident said he/she slid off the bed. Gripper socks in place. -The resident said she slid off the bed onto the floor. Record review of the resident's progress notes, showed a nurse documented the following: -On 1/4/23, at 11:56 P.M., per the resident, he/she slid off the bed onto the floor next to his/her bed. No injuries noted and no redness. Staff moved the call light over by the resident as it was by his/her roommate. The resident has used his/her call light multiple times, so far. The resident complained of all over pain. Per orders, staff administered Tylenol to the resident. The resident was able to move all extremities without signs or symptoms of pain or discomfort. Call light within reach; -On 1/5/23, at 2:43 A.M., the resident was resting in bed with his/her eyes closed. Respirations even and nonlabored. No signs and symptoms of distress. The resident laid on his/her right side facing the hallway with his/her legs were curled and bent. No signs or symptoms of pain or discomfort. Call light within reach at that time;. -On 1/6/23, at 1:35 P.M. (fall follow up), no adverse effects from being observed on the floor on 1/4/23 noted so far this shift. Range of motion within normal limits to all extremities for resident's abilities. Neuro checks within normal limits to the resident's baseline. No complaints of voiced or signs and symptoms of distress noted at this time; -On 1/7/23, at 7:46 A.M. (fall follow up), no adverse effects from being observed on the floor on 1/4/23 noted so far this shift. Range of motion within normal limits to all extremities for resident's abilities. Neuro checks within normal limits to the resident's baseline. No complaints of voiced or signs and symptoms of distress noted at this time; -On 1/8/23, at 1:42 A.M. (fall follow up), the resident was without any complaints of pain or injury. No signs or symptoms of pain or injury noted. Record review of the resident's electronic medical record showed staff documented neurological assessments completed at the following times/dates: -On 1/5/23, at 10:10 A.M.; -On 1/6/23, at 4:38 P.M.; -On 1/7/23, at 4:38 P.M. (Staff did not document neurological assessments per policy: every 15 minutes for an hour, then every 30 minutes for an hour, every hour for two hours, then once a shift (6a-6p and 6p-6a) for the next three days.) Record review of the resident's progress notes dated 1/15/23, at 10:43 A.M., showed a nurse documented the following: -Staff called nurse to the resident's room stating the resident was on the floor. Upon entering the resident's room, he/she was sitting upright in the floor with his/her back leaned against the bottom of his/her recliner chair with his/her legs out in front of him/her. The resident and his/her spouse said the resident tried to get up on his/her own and slid down his/her chair. The resident denied hitting his/her head. He/she denied any pain, discomfort or injury related to the fall. A skin assessment was completed and showed no redness, bruising, or injury. The resident was able to participate in getting up from the floor, staff assisted. No leg shortening or increased weakness noted. The resident transfer/gait remained at baseline. Neuros initiated and intact. Staff notified the DON, and continued the plan of care. Record review of the resident's incident report dated 1/15/23, at 11:27 P.M., showed a nurse documented the following: -Unwitnessed (fall) in the resident's room; -Resident laying in the floor next to the bed with clothes on, resident's wheelchair was behind him/her. Resident heard at the nurse's station yelling for help. He resident said he/she did not know what happened; -Complete body assessment. The resident complained of pain laying on the floor. When staff assisted the resident off the floor, staff observed a small bruise on the resident's tailbone area; -Injuries observed at the time of the incident: No injuries observed at the time of the incident. -Injuries post incident: Bruise to sacrum (a large, flat triangular shaped bone nested between the hipbones and positioned below the last lumbar vertebra (L5)). Record review of the resident's progress notes showed a nurse documented the following: -On 1/15/23, at 11:35 P.M., staff heard yelling from the hallway, when they entered the resident's room; the resident was laying on the floor with his/her wheelchair behind him/her. The resident was dressed in regular clothing and said he/she did not know what he/she was doing. Staff said the resident was dressed in his/her nightclothes when they assisted the resident to bed. The nurse completed an assessment while the resident laid on the floor. No injuries were noted at that time. When staff assisted the resident to a standing position, staff observed a small bruise on the top of the resident's tailbone area. Staff took the resident to the nurse's station for observation. Staff notified the resident's responsible party and faxed the physician. -On 1/16/23, at 12:26 A.M., staff brought the resident's recliner out by the nurse's station, placed resident in it at this time. Resident appears comfortable, resting with eyes close. No signs or symptoms of distress noted. -On 1/16/23, at 8:36 A.M., no adverse effects from being observed on the floor on 1/15/23 noted so far this shift. Range of motion within normal limits to all extremities for resident's abilities. Neuro checks within normal limits to the resident's baseline. No complaints of voiced or signs and symptoms of distress noted at this time. Record review of the resident's electronic medical record showed staff documented neurological assessments completed at the following dates/times: -On 1/15/23, at 11:40 A.M.; -On 1/16/23, at 10:28 A.M.; -On 1/17/23, at 8:08 A.M. (Staff did not document neurological assessments per policy: every 15 minutes for an hour, then every 30 minutes for an hour, every hour for two hours, then once a shift (6a-6p and 6p-6a) for the next three days.) 4. Record review of Resident #2's face sheet showed the following: -admission date of 10/18/22; -Diagnoses included dementia, anxiety, and osteoarthritis. Record review of the resident's progress notes, showed the following: -On 11/1/22, at 1:05 P.M., showed a nurse documented the resident was found on the floor of his/her bathroom. The resident was assessed and no injuries were found. Vital signs were stable and the resident denied any pain. The resident was assisted back into his/her bed and educated about the importance of using the call light. The resident said he/she understood; -On 11/3/22, at 12:21 P.M. (Fall Follow Up), No adverse effects from being observed on the floor on 11/1/22 noted so far. Range of motion within normal limits to all extremities. Neuro checks within normal limits to the resident's baseline. No complaints of voiced or signs and symptoms of distress noted at this time. Record review of the resident's electronic medical record showed staff documented the following neurological assessments: -On 11/2/22, at 12:17 P.M. (Staff did not document neurological assessments per policy: every 15 minutes for an hour, then every 30 minutes for an hour, every hour for two hours, then once a shift (6a-6p and 6p-6a) for the next three days.) Record review of the resident's progress notes showed the following: -On 11/20/22, at 12:15 A.M., a nurse documented the resident was found on his/her knees kneeling on the side of the bed leaning on both elbows. The resident was alert and oriented, neuro checks were within normal limits, he/she denied pain or discomfort, and moved all extremities well. Staff assisted the resident back to bed; -On 11/20/22, at 12:30 P.M. (communication with physician), the resident was found on his/her knees next to his/her bed leaning on both elbows. No signs of injury noted, moves all extremities well. Background: the resident removes his/her nasal cannula and his/her oxygen saturation drops in the 70s and 80s. Reminded the resident to wear his/her nasal cannula. Record review of the resident's electronic medical record showed staff documented the following neurological assessments: -On 11/20/22, at 12:25 P.M.; -On 11/23/22, at 1:05 A.M. (Staff did not document neurological assessments per policy: every 15 minutes for an hour, then every 30 minutes for an hour, every hour for two hours, then once a shift (6a-6p and 6p-6a) for the next three days.) Record review of the resident's progress notes showed a nurse documented the following: On 1/1/23, at 4:01 P.M., the resident was observed sitting on his/her bottom at his/her bedside. He/she wore gripper socks and the room's light was on. The resident's feet were tangled in his/her Oxygen tubing from the concentrator and wheelchair at his/her feet. The resident said he/she was sitting on his/her bed reaching for the concentrator when he/she slid off the bed and landed on his/her bottom. No injuries noted and the resident denied pain. Range of motion to all extremities, neuro checks within normal limits per the resident's baseline. Two staff assisted the resident to bed; -On 1/2/23, at 9:15 A.M. (fall follow up), no adverse effects from being observed on the floor on 1/1/23 noted so far this shift. Range of motion within normal limits to all extremities for resident's abilities. Neuro checks within normal limits to resident's baseline. No complaints or signs and symptoms of distress noted at this time. -On 1/3/23, at 12:20 A.M. (fall follow up), the resident denies any injury from the previous fall; -On 1/3/23, at 8:44 A.M. (fall follow up), no adverse effects from being observed on the floor on 1/1/23 noted so far this shift. Range of motion within normal limits to all extremities for resident's abilities. Neuro checks within normal limits to resident's baseline. No complaints or signs and symptoms of distress noted at this time; -On 1/5/23, at 2:59 A.M., the resident continues on observation for fall follow up. No signs or symptoms of pain or discomfort. Call light within reach. Record review of the resident's incident report dated 1/1/23, at 5:45 P.M., showed a nurse documented the following: -Unwitnessed (fall) in the resident's room; -Resident found sitting on his/her bottom by bedside. -Per resident, he/she was sitting on the bed and slid off. It does not hurt; -Immediate action taken: Assessed for injuries, assisted up from the floor, neuro checks initiated. Record review of the resident's electronic medical record showed staff documented the following neurological assessments: -On 1/1/23, at 5:45 P.M.; -On 1/1/23, at 6:00 P.M.; -On 1/1/23, at 6:15 P.M.; -On 1/2/23, at 9:45 A.M.; -On 1/2/23, at 9:45 P.M.; -On 1/3/23, at 9:45 A.M.; -On 1/3/23, at 9:45 P.M.; -On 1/4/23, at 9:06 A.M. (Staff did not document neurological assessments per policy: every 15 minutes for an hour, then every 30 minutes for an hour, every hour for two hours, then once a shift (6a-6p and 6p-6a) for the next three days.) 5. Record review of Resident #3's face sheet showed the following: -admission date of 6/6/20; -Diagnoses included dementia, osteoarthritis of the knee, abnormalities of gait and mobility, and weakness. Record review of the resident's incident report dated 1/10/23, at 12:40 P.M., showed a nurse documented the following: -Unwitnessed (fall) in the resident's room; -This nurse was summoned to the resident's room where a CNA found the resident lying on the floor in a relaxed fetal position on his/her left side between him/her and roommate's bed. The resident had his/her feet pointed toward his/her bed and his/her head was toward his/her roommate's bed. The assessment yielded no malformation or change of strength to extremities. The resident voiced no discomfort to the event; -Resident description: The resident said he/she was moving his/her call light from the top of his/her bed when he/she reached too far and slid out of his/her wheelchair; -Immediate action taken: Educated the resident to call for help. Requested Hospice to bring a lower wheelchair as the current one is not at proper height for the resident. -Injury noted to the top of the resident's scalp (the nurse documented no further information such as injury type). Record review of the resident's progress notes showed a nurse documented the following: -On 1/10/23, at 12:47 P.M., the resident was found on the floor between his/her bed and his/her roommate's bed, with his/her head near the roommate's bed. The resident was lying in a relaxed fetal position on his/her left side. The assessment yielded no malformation or loss of strength to his/her extremities. The resident voiced no pain with the event. No first aid needed at that time; -On 1/11/23, at 2:28 A.M. (fall follow up), the resident remained on fall follow up, no injuries noted or reported. The resident denied pain and discomfort so far this shift, call light in reach; -On 1/11/23, 7:17 A.M. (fall follow up), no adverse effects from being observed on the floor on 1/10/23 noted so far this shift. Range of motion within normal limits to all extremities for resident's abilities. Neuro checks within normal limits to resident's baseline. No complaints or signs and symptoms of distress noted at this time; -On 1/12/23, at 9:47 A.M. (fall follow up), no adverse effects from being observed on the floor on 1/10/23 noted so far this shift. No obvious injuries noted. Range of motion remained within normal limits to all extremities for resident's abilities. Neuro checks within normal limits to resident's baseline. No complaints or signs and symptoms of distress noted at this time. Record review of the resident's electronic medical record showed staff documented the following neurological assessments: -On 1/10/23, at 12:40 P.M.; -On 1/11/23, at 12:48 P.M.; -On 1/12/23, at 12:48 A.M.; -On 1/12/23, at 6:25 A.M.; -On 1/13/23, at 1:32 A.M. (Staff did not document neurological assessments per policy: every 15 minutes for an hour, then every 30 minutes for an hour, every hour for two hours, then once a shift (6a-6p and 6p-6a) for the next three days.) 6. During interviews conducted on 1/16/23, at 11:27 A.M. and 1:30 P.M., and on 1/17/23, at 11:34 A.M., LPN N said the following: -If a resident fell, he/she would assess the resident for injury, if none, staff would transfer the resident off the floor to either his/her wheelchair or his/her bed; -After a fall, staff monitor the resident every shift for 3 days. If the resident had a unwitnessed fall or the resident hit his/her head, staff conducted neuro checks every 15 minutes x 4, every 30 minutes x 4, every hour x 4 then every shift for 72 hours; -When the nurse starts an incident report, the times of the neuro checks self-populate in the electronic medical record. -Staff used to document the neuro checks on paper, but for the last month or so, staff completes them in the resident's electronic medical record. 7. During an interview on 1/16/23, at 12:41 P.M., Certified Medication Tech (CMT) P said the following: -If a resident fell, he/she would call for help, the nurse would complete a head-to-toe assessment then, when it was safe to move the resident, staff would assist the resident either to his/her bed or wheelchair. -If staff did not witness a fall, staff conducted neuro checks every 15 minutes for 1 hour, every 30 minutes for 1 hour, every hour for 4 hours then every shift. The CMT said he/she did not know if that was this facility's neuro check protocol, but that is what other facilities did. 8. During interviews on 1/17/23, at 10:07 A.M. and 12:00 P.M., CNA Q said the following: -If a resident fell, staff notified the nurse who conducted an assessment. If the fall was unwitnessed, staff performed neuro checks then gave the documented neuro checks to the ward clerk to file. However, recently, staff had not placed the neuro checks in the ward clerk's box. He/she knew they could document neuro checks in the electronic medical record, but he/she did not know how to access them. -The CNAs documented the resident's vital signs on a piece of paper and gave it to the nurse. He/she did not know what the nurse did with the resident's vital sign paper after the aides gave it to him/her. 9. During an interview conducted on 1/17/23, at 10:52 A.M., the MDS coordinator said the following: -When a resident falls, staff called for the nurse (if the nurse was not present). The nurse assesses the resident then transfers the resident off the floor. The nurse should then complete an incident (fall) report, make a note in the resident's electronic medical record and notify the DON, resident's family and physician. -If the resident had an unwitnessed fall, staff completed neuro checks every 15 minutes x 4, every 30 minutes x 2, every hour x 2 then continue follow-up for 72 hours. MO00212244 and MO00212635

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to keep the environment as free of accident hazards as possible, when staff did not have a process in place to monitor hot water temperatures, failed to have supervision present when hot liquids were being served, and failed assess all residents for their ability to drink hot liquids safely, resulting in one resident (Resident #1) receiving second degree burns on his/her legs from spilled coffee. The facility also failed to complete fall risk assessments timely; failed to follow, update, develop, and ensure the accuracy of care plans; failed to implement new interventions in attempt to prevent falls consistent with the residents' physical and cognitive abilities; and failed to ensure staff were aware of high risk fall residents and current interventions for three residents (Resident #2, Resident #3, Resident #4). The facility census was 51. 1. Record review of the facility's policy titled, Safety of Water Temperature, revised 2009, showed the following: -Direct-care staff shall be informed of risk factors for scalding/burns that are more common in the elderly including, decreased skin thickness, decreased skin sensitivity peripheral neuropathy (a result of damage to the nerves located outside of the brain and spinal cord that often causes weakness, numbness and pain, usually in the hands and feet), reduced reaction time, decreased cognition, decreased mobility and decreased communication: -Nursing staff will be educated about signs and symptoms of burns (first, second, and third degree) so that injuries can be recognized and treated appropriately; -If a resident is scalded or burned, nursing staff should follow pertinent first aid and physician notification protocols and report injury to his/her direct supervisor. Record review of the facility's policy titled, Safety of Hot Liquids, revised 2014, showed the following: -Residents will be evaluated for safety concerns and potential injury from hot liquids upon admission, readmission, and on change of condition. Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury; -The potential for burns from hot liquids is considered an ongoing concern among residents with weakness, motor skill and balance issues, impaired cognition, and nerve and musculoskeletal conditions; -Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal; -Resident's who prefer hot beverages with meals (ie coffee, tea, soups etc) will not be restricted from these options. Instead, staff will conduct regular hot liquids safety evaluations as indicated, and document the risk factors for scalding and burns in the care plan; -Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk of burn; -Interventions include maintain hot liquids serving temperature at no more than 180 degrees Fahrenheit (F), serving hot beverages in a cup with a lid, encourage residents to sit at a table while drinking or eating hot liquids, providing lap protective covering or clothing to protect the skin from accidental spills and staff supervision or assistance with hot beverages; -Food services staff will monitor and maintain foods temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Record review of the Consumer Product Safety Commission Website, undated, showed the following: -Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns. Record review of the facility's policy titled, Accidents and incidents-Investigating and Reporting, revised 7/29/22, showed the following: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises shall be investigated and reported to the administrator; -A nurse supervisor/charge nurse and/or the department director supervisor shall promptly initiate and document an investigation of the accident or incident; -The following data shall be included, date and time of the accident, nature of the injury, the circumstances surrounding the accident or incident, the injured person's account of the accident, and name of witnesses and their accounts of the accident, the notification of the injured person's physician as well as the time the physician responded and their instructions, date/ time the next of kin was notified, the condition of the injured person, including vital signs, the disposition of the injured, a corrective action taken, follow-up information, other pertinent data as necessary and required and the signature of the person completing the report; -The nurse supervisor/ charge nurse and/or the department director or supervisor shall complete a report of incident/accident form and submit the original to the director of nursing services within 24 hours of the incident or accident; -The director of nursing (DON) shall ensure that the administrator receives a copy of the report of incident/accident form for each occurrence; -Incident/accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual vulnerabilities. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 10/31/22; -Diagnoses include dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), paraplegia (an impairment in motor or sensory function of the lower extremities), type 2 diabetes (is an impairment in the way the body regulates and uses sugar (glucose) as a fuel), polyneuropathy (a condition in which a person's peripheral nerves are damaged. It affects the nerves in the skin, muscles, and organs), hemiplegia and hemiparesis (paralysis of partial or total body function on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and weakness. Record review of the resident's care plan, dated 11/4/22, showed the following: -The resident required assistance with grooming, hygiene, toileting, bathing, eating, and dressing; -All activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) care will be assisted or encouraged for independence until re-evaluated upon comprehensive care plan; -Assist with ADLs and evaluate need for restorative nursing care for independence. Encourage self-care/participation, set-up and monitor; -Monitor for skin issues; -The resident required safety care due to poor safety awareness and severely diminished cognition; -Safety measures will be monitored and managed until further instruction of a comprehensive care plan. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/11/2022, showed the following: -Severe cognitive impairment; -Independent with eating; -Total dependence with transfers and extensive assistance with bed mobility. Record review showed the facility did not have an assessment of safety with hot liquids in the resident's record. Record review of the resident's nurses' notes showed the following: -On 12/26/22, at 1:07 P.M., Licensed Practical Nurse (LPN) H noted the resident spilled hot coffee on his/her upper right leg. Resident had an approximately 18 centimeter (cm) by 7 cm burn with large open and scattered blisters to the inner right thigh. Resident said he/she dropped hot coffee on his/her right leg. He/she indicated it did not have a lid on it. The wound nurse, medical director/resident physician, Administrator, DON and dietary all notified of the event; -On 12/26/22, at 2:10 P.M., LPN A noted right anterior (situated in the front of the body or nearer to the head) proximal (situated nearer to the center of the body or the point of attachment) thigh, clean the area with hypochlorous acid (a strong disinfectant in health care and is an excellent cleaning solution for wound care), pat dry with sterile gauze. Apply xeroform (non-adherent primary dressing maintains a moist wound environment) over wound, cover with two abdominal pads and secure with cloth tape. Change dressing daily and as needed. Record review of the resident's care plan, dated 11/4/22, showed the following updates: -On 12/26/22, the resident spilled a cup of hot coffee onto his/her lap causing a burn on his/her left leg. Resident had a 18 cm by 7 cm burn with large open and scattered blisters to the inner right thigh due to diminished cognition and poor safety awareness; -On 12/26/22, the resident will be provided hot beverages with a lid to decrease his/her chances of injury through the next review date; -On 12/26/22, all hot drinks will have a lid to prevent accidental spillage and/or injury to the resident. The resident may need reminders to keep himself/herself safe from injury at times and remind him/her to keep a lid on hot drink. Record review of the resident's Wound Care report, dated 12/26/22, showed the following: -Wound type: blister/ 2nd degree burn -Cause: Resident spilled coffee in his/her lap; -Drainage is light and serous (is thin and clean typical with wound healing); -Surrounding skin is intact; -Intervention was xeroform dressing. Record review of the resident's December 2022 Treatment Administration Record (TAR) showed the following: -An order, dated 12/27/22, for right anterior proximal thigh. Staff to clean the area with hypochlorous acid, pat dry with sterile gauze, and apply xeroform over wound. Cover with two abdominal pads and secure with cloth tape. Change dressing daily and as needed until wound is resolved. Record review of the resident's initial wound/assessment, dated 12/29/22, showed the following: -Type of wound: Boil/cyst and other; -Wound acquired in house; -Surrounding skin intact and red; -Treatment: Blisters popped, cleaned, and covered with xeroform (dressing and secured with abdominal pad and cloth tape, order for daily dressing change added to treat administration record; -Physician notified on 12/26/22 at 12:00 P.M.; -Responsible party notified on 12/26/22 at 12:00 P.M.: -Administrator, DON, and wound nurse notified; -Description of the wound: wound base pink, slough (is considered the by-product of the inflammatory phase of wound healing present), light drainage, and serous drainage. Record review of the facility's investigation showed the following: -In a statement, dated 12/26/22, Certified Nurse Aide (CNA) C said he/she did not see the resident spill his/her coffee. He/she witnessed the coffee on the ground and on the resident's thigh. He/she was late coming to the dining room because he/she was putting bath sheets in the computer. He/she was going in and out of the dining room. When he/she got to the dining room he/she started assisting a resident with eating. Then he/she started taking residents out of the dining room; -In a statement, dated 12/26/22, CNA D said he/she walked into the dining room, pushing another resident to the table. The kitchen worker was by the resident and said he/she spilled his/hers coffee. There was coffee on the floor. He/she continued taking the resident to the table and left the dining room. He/she did not hear him/her scream. He/she did not see him/her spill the coffee; -The facility did not provide any additional information regarding the investigation, including measuring of beverage temperatures to ensure they were not too hot. Observations on 1/8/23, at 7:36 A.M., showed the temperature of coffee served from the coffee machine measured in the kitchen measured 173.4 degrees F. Observations on 1/8/23, at 8:01 A.M., showed the temperature of coffee from the pitcher in the assisted dining room measured 168.4 degrees F. Observations on 1/8/23, at 8:59 A.M., showed the Dietary Manager checked the temperature of the coffee after breakfast in the coffee machine. The coffee measured 167 degrees F. During an interview on 1/8/23, at 8:15 A.M., LPN N said the following: -He/she believes there was investigation completed after the resident burned himself; -The resident had a cup of coffee in his/her hand and the lid fell off and he/she dropped it on his/her lap; -The residents are not allowed to get coffee on their own; -He/she is having the aides on his rotation put ice in the coffee cups due to the coffee being hot. No other residents have been burned; -The resident got a 2nd degree burn that is being treated. During an interview on 1/8/23, at 9:03 A.M., Dietary Aide (DA) G said the following: -He/she was in the kitchen getting ready to carry drinks out to the assisted dining room before lunch and heard the resident yell, I spilled my damn coffee; -He/she saw that the resident had spilled the coffee on his/her lap from a black thermal cup; -He/she told a female CNA that came into the assisted dining room to bring in a resident that the resident had spilled coffee on himself; -There was no staff in the dining room when the resident spilled his/her coffee. He/she is not sure who gave the resident the coffee. During an interview on 1/8/23, at 10:02 A.M., the resident said the following: -He/she was sitting at the table in the assisted dining room and he/she spilled his/her coffee on his/her lap; -He yelled because he was upset that he spilled his coffee; -He/she has to sip the coffee because it is too hot; -He has burns on his/her legs. During an interview on 1/10/23, at 11:40 A.M., LPN A said the following: -The resident has 2nd degree burns on his/her thigh area from spilling hot coffee in his/her lap from the lid coming off his/her thermal cup. He/she thinks the lid malfunctioned. He/she had pants on when he/she was burned. The staff had to lay him/her down to assess the burns; -He/she would expect that the resident would be supervised when he/she has hot coffee. During an interview on 1/10/23, at 12:10 P.M., CNA B said the following: -He/she has been adding ice to the coffee given to residents due to it being very hot. It comes out of the machine really hot and it could burn residents. The residents in the assisted dining should be monitored when they have hot drinks that could burn them. During an interview on 1/10/23, at 12: 17 P.M., CNA C said the following: -He/she assisted laying the resident down after lunch and when they were changing him noticed that he had significant burns that were blistering on his/her thigh/groin area. He/she got LPN A to come look at the wounds. The resident was not acting like he/she was in pain and acted like he/she could not really feel it; -He/she is not sure who gave the resident the coffee, but it was obviously way too hot. After this incident he/she has started putting ice in the coffee to prevent burns. He/she she saw other aides doing it. During an interview on 1/10/23, at 12:49 P.M., CNA D said the following: -He/she was taking residents to the dining room. One of the dietary aides told him/her that the resident had spilled coffee. He/she was not made aware that it had spilled on the resident. She assumed it had spilled on the floor; -The resident did not appear to be in any pain. During an interview on 1/10/23, at 2:34 P.M., CNA E said the following: -There is always supposed to be at least one staff in the assisted dining room prior to serving coffee because the coffee is very hot. Some of the staff are putting ice in the coffee now. During an interview on 1/10/23, at 2:29 P.M., the MDS Coordinator said the following: -The resident care plans should be updated timely; -Resident wounds and burns should be included on the care plan; -He/she has not worked there very long and is still trying to get caught up. During an interview on 1/10/23, at 2:35 P.M., CNA F said the following: -The resident dropped a cup of coffee on his/her lap; -He/she has been putting ice in the resident's coffee since that incident because the coffee is too hot, another aide told him/her to start doing it; -The staff have not been educated regarding the safety of residents and hot coffee; -The residents are now not supposed to be left with hot drinks in the assisted dining room without nursing staff present; -He/she thinks a dietary aide gave the hot coffee to the resident prior to nursing staff being in the dining room to provide supervision. During an interview on 1/10/23, at 3:52 P.M., the DM said the following: -The coffee machine does not get calibrated and they do not check the temperature of the coffee or hot water that comes out of it; -He/she is not sure what the policy say's regarding the temperature of hot liquids/coffee; -There should have been staff in the assisted dining room supervising the residents and the resident should have been assessed right after it happened because the coffee is very hot; -There should be staff in the assisted dining room at all times if food or drinks are served. During an interview on 1/10/23, at 4:05 P.M., the Medical Director said the following: -He/she was aware that the resident burned him/herself with hot coffee, but was not sure of the severity; -The resident has some confusion and he/she would expect that the resident would be supervised with liquids that are hot enough to burn him/her. During an interview on 1/10/23, at 4:30 P.M., the Administrator/DON said the following: -The previous administrator started an investigation. He/she is not sure if he/she finished it; -He/she is not sure if the temperature of the coffee was being checked. The facility should follow their policy; -Residents in the assisted dining room are to be monitored if food or drinks have been served; -There is now always someone in the assisted dining room if food or drink is being served. The resident is using a new cup with working lid. 2. Record review of the facility's Fall Assessment, Fall Risk Assessment, and Fall Care Planning Policy, revised 12/28/11, showed the following information: -Purpose to identify residents who are risk for falls; to identify events leading up to falls that do occur; identify any patterns to falls; and to implement interventions or reduce incidence of additional falls; -Residents will be assessed for fall risk upon admission using the fall risk assessment, annually, for any change in condition, and as needed using the facility's fall risk assessment; -Areas assessed include fall history, age, balance, mental status, sensory deficits, medications, illness, continence pattern, activity level, and any contributing factors. A resident is considered high risk if the admission assessment is 14 or greater; -If resident is a fall risk, door signage will be used as an identifier for staff. Upon admission, fall risk assessment completion, or post fall, charge nurse is to assess for interventions and implement as needed. Charge nurse will communicate interventions placed to the registered nurse (RN) supervisor; -When a fall occurs, the post-fall assessment form will be completed with specific information surrounding the fall, resident's statement if able to provide one, and any precipitating events; -Assessment information will include a physical assessment, vital signs, any signs and symptoms of acute illness and contributing medications; -Family, physicians, administration and director of nursing (DON) notification of fall is to be documented along with follow up; -After the resident has been assessed and potential causes for the fall have been identified, specific interventions will be identified on the care plan; -Interventions may include environmental management, behavioral management, toileting and incontinence issues, medication reduction/management, and acute illness identification and treatment. Record review of the facility's Fall Protocol, revised 10/1/15, showed the following information: -A fall report shall be filled out by the nurse. This report can be found at the nurses' station in a blue Fall Protocol folder in the box labeled Incident. This includes the following forms: Incident Report and Post Fall Assessment. Both forms must be filled out completely. A progress note must be made describing the incident, baseline vitals, neuro checks, notifications, and interventions made. 3. Record review of Resident #4's face sheet showed the following: -admission date of 10/31/17; -Diagnoses included dementia, altered mental status, and osteoarthritis (a degenerative joint disease that can affect the many tissues of the joint). Record review of the resident's January 2023 Medication Review Report showed the following: -An order, dated 5/29/21, for a pressure alarm when the resident is in bed or wheelchair per the family's request. Record review of the resident's fall care plan, initiated on 8/18/22, showed the following information: -The resident is high risk for falls related to confusion, gait/balance problems, and vision/hearing problems; -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as chair exercise group and walking in the courtyard; -Ensure the resident is wearing appropriate footwear for example, non-skid lace-free shoes, non-skid socks when walking or mobilizing in the wheelchair; -Follow facility fall protocol; -The resident needs a safe environment with: even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, use walker or wheelchair for mobility, ensure high use personal items such as drinks, glasses, phone, television remote (staff did not finish this sentence). Record review of the resident's significant change MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Adequate vision; -Used corrective lenses for vision; -Adequate hearing; -Dependent on staff for bed mobility, transfers, and toilet use; -Moving from seated to standing: Not steady, only able to stabilize with human assist; -Surface to surface transfer: Not steady, only able to stabilize with human assist; -Used a wheelchair for mobility; -No falls prior assessment; -Used opioids (a class of drugs used mostly to treat moderate to severe pain but can also have serious risks and side effects) four out of seven days. Record review of the resident's January 2023 Medication Review Report showed the following: -An order, dated 11/1/22, for a physical therapy (PT) evaluation and treatment when hospice services are discontinued. Record review of the resident's quarterly Morse Fall Scale, dated 11/30/22, showed the following information: -Fall risk based upon fall risk factors and it is more than a total score. Determine fall risk factors and target interventions to reduce risks. Complete on admission, quarterly, at change of condition, and after a fall; -Fall risk score = 105 (high risk for falling); -History of falls; -Had more than one diagnosis; -Used furniture for support; -Impaired gait (a person's manner of walking-difficulty rising from chair, uses chair arms to get up, bounces to rise; keeps head down when walking, watches the ground; grasps furniture, person or aid when walking. Could not walk unassisted); -Resident overestimates or forgets limits. Record review of the resident's incident report dated 1/4/23, at 11:15 P.M., showed a nurse documented the following: -Unwitnessed (fall) in the resident's room; -Resident sat next to the bed, on the floor, with his/her back against the bed. No injuries or redness observed; -Per resident, slid down off the side of the bed; -Vital signs taken. Two staff assisted the resident to bed. Resident had no injuries and was able to move all extremities. The resident requested something for pain after staff assisted him/her to bed; -No injuries at the time of the incident; -Pain level rated a 3; -Ambulatory with assistance; -Resident alert and oriented to person and place; -Staff moved the call light closer to the resident, as it was by his/her roommate. The resident has pushed the call light since staff moved it. Staff was in the room multiple times since the incident; -Predisposing environmental factors: Clutter, crowding, furniture; -Predisposing physiological factors: Incontinent, gait imbalance; -Predisposing situational factors: Recent room change (the resident lived in the same room since admission); -Other info: Room is very cluttered, beds, wheelchairs, walkers, regular chairs, books, etc. Record review of the resident's incident report dated 1/4/23, at 11:38 P.M., showed a nurse documented the following: -Unwitnessed (fall) in the resident's room; -Nursing description: Resident sitting on the floor next to his/her bed. Staff completed an assessment, no injury or redness found. The resident said he/she slid off the bed. Gripper socks in place; -The resident said he/she slid off the bed onto the floor; -Immediate action taken: (nothing documented) -No injuries at the time of the incident; -Pain level rated a 5. -Ambulatory with assistance; -Resident alert and oriented to person and place; -Predisposing environmental factors: Clutter, furniture; -Predisposing physiological factors: None; -Predisposing situational factors: (nothing documented); -Other info: After assessment completed, resident complained of pain all over. Record review of the resident's progress notes showed a nurse documented the following: -On 1/4/23, at 11:56 P.M., per the resident, he/she slid off the bed onto the floor next to his/her bed. No injuries noted and no redness. Staff moved the call light over by the resident as it was by his/her roommate. The resident has used his/her call light multiple times, so far. The resident complained of all over pain. Per orders, staff administered Tylenol to the resident. The resident was able to move all extremities without signs or symptoms of pain or discomfort. Call light within reach. Record review of the resident's care plan showed staff did not update the care plan to reflect the 1/4/23 falls or any new interventions. Record review of the resident's progress notes dated 1/15/23, at 10:43 A.M., showed a nurse documented the following: -Staff called nurse to the resident's room stating the resident was on the floor. Upon entering the resident's room, he/she was sitting upright in the floor with his/her back leaned against the bottom of his/her recliner chair with his/her legs out in front of him/her. The resident and his/her roommate said the resident tried to get up on his/her own and slid down his/her chair. The resident denied hitting his/her head. He/she denied any pain, discomfort or injury related to the fall. A skin assessment was completed and showed no redness, bruising, or injury. The resident was able to participate in getting up from the floor, staff assisted. No leg shortening or increased weakness noted. The resident transfer/gait remained at baseline. Staff notified the DON, and continued the plan of care. Record review showed the facility staff did not provide the incident report (investigation) related to the resident's fall on 1/15/23, at 10:43 A.M. Record review of the resident's incident report dated 1/15/23, at 11:27 P.M., showed a nurse documented the following: -Unwitnessed (fall) in the resident's room; -Resident laying in the floor next to the bed with clothes on. Resident's wheelchair was behind him/her. Resident heard at the nurses' station yelling for help. The resident said he/she did not know what happened. -Completed body assessment. The resident complained of pain laying on the floor. When staff assisted the resident off the floor, staff observed a small bruise on the resident's tailbone area. -No injuries observed at the time of the incident. -Wheelchair bound; -Resident alert and oriented to person; -Injuries post incident: Bruise to sacrum (a large, flat triangular shaped bone nested between the hipbones and positioned below the last lumbar vertebra (L5)); -Predisposing environmental factors: Clutter, crowding, furniture, poor lighting; -Predisposing physiological factors: Confused, gait imbalance, impaired memory, weakness/fainted; -Predisposing situational factors: (staff did not complete this section); -Other info: Residents room is very cluttered. Unable to get the resident's wheelchair to his/her side of the bed for safe transfers from bed to wheelchair or wheelchair to bed. Record review of the resident's progress notes showed a nurse documented the following: -On 1/15/23, at 11:35 P.M., staff heard yelling from the hallway. When they entered the resident's room, the resident was laying on the floor with his/her wheelchair behind him/her. The resident was dressed in regular clothing and said he/she did not know what he/she was doing. Staff said the resident was dressed in his/her nightclothes when they assisted the resident to bed. The nurse completed an assessment while the resident laid on the floor. No injuries were noted at that time. When staff assisted the resident to a standing position, staff observed a small bruise on the top of the resident's tailbone area. Staff took the resident to the nurse's station for observation. Staff notified the resident's responsible party and faxed the physician; -On 1/16/23, at 12:26 A.M., staff brought the resident's recliner out by the nurses' station, placed resident in it at this time. Resident appears comfortable, resting with eyes close. No signs or symptoms of distress noted; -On 1/16/23, at 8:36 A.M., no adverse effects from being observed on the floor on 1/15/23 noted so far this shift. Range of motion within normal limits to all extremities for resident's abilities. No complaints of voiced or signs and symptoms of distress noted at this time. Record review of the resident's fall care plan, updated 1/16/23, showed the following information: -The resident had an actual fall with no injury related to poor balance, poor communication/comprehension, unsteady gait and poor safety awareness. -Continue interventions on the at risk plan (care plan dated 8/18/22); -Provide activities that promote exercise and strength building where possible. Provide one-on-one activities if bedbound; -Try to anticipate the resident's needs with prompted toileting. During an interview conducted on 1/16/23, at 11:10 A.M., CNA O said the following: -The resident was confused at times and a high risk for falls; -His/her fall interventions included checking on the resident every time he/she (the CNA) walked by the room, and at least, every two hours; -The resident did not have a chair or bed alarm; -The resident usually used his/her call light when he/she needed assistance. He/she did not walk but sometimes he/she transferred himself/herself, unassisted, to the bathroom; -On 1/15/23, the resident had two falls, one on the day shift and one during the night shift. The CNA was working when the resident fell the first time. Another resident told the CNA, the resident fell. The CNA found the resident on the floor between his/her recliner and wheelchair. The resident said he/she did not know what he/she was doing. The nurse assessed the resident and found no apparent injury however, the resident complained of back pain.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program that provided a safe and sanitary environment for all residents related to Coronavirus Disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)), when staff failed to wear face coverings properly while working with residents. The facility census was 51. Record review of the updated guidance for healthcare workers from the Centers for Disease Control and Prevention (CDC) titled Infection Control Guidance, updated on 09/22/2022, showed the following: -Implement source control refers to use of well-fitting cloth masks, face masks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; -When SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. Record review showed the facility did not provide a policy that addressed masking. Record review of the COVID Data Tracker, on the CDC website, showed the facility's county had a high community transmission rate on 1/8/23. 1. During an observation on 1/8/23 at 5:15 A.M., Certified Nurse Aide (CNA) L wheeled a resident in his/her wheelchair. The CNA was not wearing a mask. During an observation on 1/8/23 at 5:21 A.M., CNA J was working on the locked unit and in contact with residents. The CNA was observed going into resident rooms with residents in the room. The CNA was not wearing a mask. During an interview on 1/8/23 at 5:21 A.M., CNA J said the following: -The staff were told by the previous Administrator they did not have to wear masks unless there was someone positive in the building. There were no positive residents; -He/she has been completing care for the residents without a mask. He/she has been caring for seven residents on the unit. During an observation on 1/8/23 at 5:24 A.M., Licensed Practical Nurse (LPN) M was observed coming out of a resident room without wearing a mask. During an interview on 1/8/23 at 5:49 A.M., CNA L said the following: -He/she is not sure why they stopped wearing masks, but the staff was told they didn't have to anymore sometime last week. During an observation on 1/8/23 at 6:03 A.M., CNA I entered a residents' rooms and assisted them with transferring out of bed. The CNA was not wearing a mask. During an interview on 1/10/23 at 11:40 A.M., LPN A said the following: -The previous Administrator said the staff no longer had to wear masks unless there was an outbreak; -They stopped wearing masks sometime last week. During an interview on 1/8/23 at 6:41 A.M., the Assistant Director of Nursing (ADON) said the following: -The previous Administrator said the staff no longer had to wear masks according to the CDC and CMS (Centers for Medicare and Medicaid Services). They stopped wearing masks sometime last week. During an interview on 1/8/23 at 10:10 A.M., the Director of Nursing (DON) said the following: -The previous Administrator said they no longer needed to wear masks. He/she did not believe this was correct, but he/she was not sure. MO00212244

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to utilize acceptable infection control practices while performing pressure ulcer care, failed to obtain treatment orders timely for new wounds, failed to care plan and implement pressure ulcer precautions, and failed to complete accurate and complete tracking of wounds for two residents (Resident #18 and #199). The facility census was 49. Record review of the U.S. Department of Health and Human Services Clinical Practice Guidelines, Number 15, Treatment of Pressure Ulcers, showed the following: -Assess the pressure ulcer initially for location, stage, size, tracts, exudate (any fluid that has been forced out of the tissue in response to disease or injury), and presence or absence of granulation tissue (formation of new tissue, usually pink to red in color) and epithelialization (healing outer layer of a body's surface over a denuded (loss of surface layer of skin) surface; -To monitor progress or deterioration, the examiner must accurately measure the length, width, and depth of the ulcer; -Reassess pressure ulcers at least weekly; -Indicators of a deteriorating pressure ulcer include increases in exudate and wound edema (swelling or puffiness from fluid), loss of granulation tissue, and a purulent (containing pus) discharge; -A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. Record review of the facility's policy titled Skin Treatment Policy/Skin Team, dated 3/3/16, showed the following: -Resident's will be assessed on admission and monitored weekly for any development of pressure issues; -Nursing staff will perform bi-weekly skin assessments; -Certified nurse aides (CNA) will check each resident at the time of bath to ensure all areas of skin concerns/breakdown are identified; -Assessments will be documented at least weekly and will continue for three weeks once the wound is resolved. 1. Record review of Resident #18's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 2/6/12; -Diagnoses included Alzheimer's (memory loss and other cognitive abilities serious enough to interfere with daily life) disease, Parkinson's disease (a disorder of the central nervous system which affects movement), and pain. Record review of the resident's Braden Scale (a predicting pressure ulcer risk tool), dated 10/31/19, showed staff identified the resident at high risk for developing pressure ulcers. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/12/19, showed the following: -Severely impaired cognition; -Total assistance of two staff required for bed mobility, transfers, toileting, and hygiene; -Incontinent of bladder and bowel; -Identified risk for pressure ulcer development; -No unhealed pressure ulcers; -Hospice services. Record review of the resident's care plan, revised date 11/12/19, showed the following: -Monitor pressure points with bathing and routine cares for new wounds; -Barrier cream to coccyx and buttocks for prevention of skin breakdown; -Turn and reposition resident every two hours; -Protect the resident's heels with heel protectors and pillows while in bed. Record review of the resident's initial wound assessment, dated 12/25/19, showed the following: -Left heel wound measured 1.2 centimeters (cm) length by 0.8 cm width; -Acquired in-house; -Possible deep tissue injury (DTI - a pressure related injury to subcutaneous tissues under intact skin); -Odor present after cleaning. Record review of the residents' nurse's progress note, dated 12/25/19, showed staff identified a new wound to the resident's left heel, which was purple in color and noted to continue to apply skin prep to the left heel. Record review of the residents' nurse's progress note, dated 1/9/20, showed staff identified a new wound to the resident's left buttock and noted the area was open and measured 1.5 cm by 1.0 cm. Record review of the facility's multi-resident weekly wound tracking record, dated December 2019, showed staff did not document an assessment for the resident. Record review of the facility's multi-resident weekly wound tracking record, dated January 2020, showed staff did not document an assessment for the resident. Observation and interview on 1/13/20, at 10:05 A.M., showed staff assisted the resident onto his/her right side. The resident had a right buttock open pressure ulcer, dime-sized and deep red/purple in color. The area was open with no treatment or dressing present. CNA F said the resident has had the wound for about a week. Registered Nurse (RN) E said he/she was not sure when the wound was identified and was not aware of the type of treatment which was initiated. Record review of the resident's Treatment Administration Record (TAR), dated January 2020, showed staff did not document a pressure ulcer treatment on the resident's left buttock from 1/9/20 through 1/13/20 (five days after the wound was identified). Record review of the resident's physician order, dated 1/14/20, showed direction for staff to clean the resident's left buttock pressure ulcer with hypochlorous acid (mixture of chlorine and water), apply hydrogel (a gel based wound care dressing), and cover with a silicone border dressing once a day. Observation and interview on 1/16/20, at 9:30 A.M., showed RN E prepared to provide the resident's pressure ulcer care. RN E washed his/hands and donned gloves. The right buttock pressure ulcer was open without a dressing. RN E said he/she is not sure why there was no dressing covering the wound. He/she said the wound was identified on 1/9/20. The right buttock pressure ulcer measured 1.25 cm by 1.0 cm with a deep red/purple wound bed. The surrounding skin was red in color. RN E cleaned the wound bed with wound cleanser and gauze. The RN used the same gauze to clean in a back and forth motion over the wound numerous times in a scrubbing manner. The RN performed hand hygiene and applied hydrogel to the wound bed and covered the wound with a foam dressing. The residents' heels rested directly on the mattress of the bed. Two heel protectors laid in the resident's wheel chair. RN E said the resident does not have a pressure relief mattress. The RN did not change gloves and cleaned the scabbed area to the resident's right heel (1.0 cm by 1.0 cm) with wound cleanser and a gauze. The RN cleaned across the wound multiple times using the same gauze in a back and forth scrubbing motion then applied skin prep (a liquid protective film). RN E said when a new pressure wound is identified it should be assessed, measured and a treatment should be started immediately. Observation on 1/17/20, at 9:12 A.M., showed the resident lying in bed on his/her back and his/her feet rested directly on the mattress. Observation on 1/21/20, at 8:32 A.M., showed the resident lying in bed on his/her back. A pillow was at foot of the bed and both of the resident's feet laid directly on the mattress. During an interview on 1/21/20, at 8:54 A.M., CNA B said the resident is at risk for pressure ulcers and should have his/her heels floated or pressure relief boots on and be turned frequently. The CNA said the resident does not have current wounds. During an interview on 1/21/20 Licensed Practical Nurse (LPN) C said the resident does not have any pressure wounds. The LPN said all wounds should be addressed in the resident's care plan. 2. Record review of Resident #199's face sheet showed the following: -admission dated 1/4/20; -Diagnoses included peritoneal abscess (a pocket of infected fluid inside the lining of the abdominal cavity), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and morbid obesity. Record review of the resident's admission nursing assessment, dated 1/4/20, showed staff documented the following: -A nickel-sized dark red area to the resident's outer right heel; -Skin to buttocks intact; -Pain related to right heel wound. Record review of the resident's Braden scale showed staff did not identify the resident at risk for developing pressure ulcers. Record review of the resident's initial wound assessment, dated 1/5/20, showed the staff documented the resident had a right heel abrasion and measured 2.0 cm by 2.5 cm. Record review of the resident's history and physical, dated 1/7/20, showed the resident's physician documented the resident had a blister to the right heel. Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Limited staff assistance required for bed mobility and transfers; -No risk for pressure ulcer injuries; -No unhealed pressure ulcers. Record review of the resident's care plan, dated 1/10/20, showed direction to staff for the following: -Assist the resident with turning and repositioning in bed; -Float heels in bed; -Apply skin prep to the resident's right heel. Record review of the resident's POS showed the following: -An order, dated 1/6/20, with directions for staff to apply skin prep to the right heel two times daily: -An order, dated 1/16/20, with directions for staff to apply skin prep to bilateral buttocks two times daily. Record review of the resident's weekly wound tracking showed the following: -On 1/9/20, staff documented a 1.0 cm by 1.2 cm abrasion to the right heel. The staff did not document a description of the wound. Staff did not document an assessment of the residents buttocks; -On 1/15, staff documented a 1.0 cm by 1.2 cm abrasion to the right heel. The staff did not document a description of the wound. Staff did not document an assessment of the resident's buttocks. During an interview on 1/13/20, at 3:22 P.M., the resident said he/she had a nickel size pressure ulcer on his/her right heel and also has two open areas on his buttocks. He/she said staff are putting something on his heel. He/she has told staff about the areas on his/her buttocks, but staff have not looked at them or started any treatment. Observation and interview on 1/15/20, at 2:00 P.M., showed the resident lying in bed with heels resting directly on mattress. No pressure relief mattress on bed. The resident said he/she wishes staff would come in and help with turning at least every two hours. It is often four hours or more until staff assist him. Observation and interview on 1/16/20 showed RN E entered the resident's room to provide wound care. RN E performed hand hygiene and donned gloves. The RN rolled the resident onto the left side. Denuded skin (loss of outer layer of skin) with cracks in the epidermis (outer layer of skin) was observed on both sides of the intergluteal cleft (grove between the buttocks). The RN said she was unaware the resident had wounds on his buttocks. The RN said he/she observed some areas his buttocks on 1/15/20. Treatment was not started at time the wounds was identified. The RN removed gloves and performed hand hygiene and positioned the resident's right foot and exposed a 1.5 cm by 2.0 cm wound to the right outer heel, deep purple in color, without open skin. The surrounding skin was boggy (spongy). The RN cleaned the area with wound cleanser and gauze going back and forth across the wound numerous times in a scrubbing type method and applied skin prep to the area. The resident said his/her buttocks are very tender and the right heel is painful. He/she said his/her feet won't stay on the pillow, they keep sliding off and the resident is unable to place heels back on the pillow without assistance. The resident said the heel was painful. Observation on 1/17/20, at 9:15 A.M., showed the resident slid down in the bed with both heels against the foot board of the bed. Certified Medication Technician (CMT) G was at the resident's door, speaking with the resident and did not offer assistance for positioning. During an interview on 1/21/20, at 8:54 A.M., CNA B said staff do not turn and reposition the resident. The resident is independent and does not require assistance. The resident does have a wound on his heel. During an interview on 1/21/20, at 10:15 A.M., LPN C said the resident does not have any wounds at this time. 3. During an interview on 1/21/20, at 8:54 A.M., CNA B said if a new wound is observed, the nurse should be notified to assess the wound and start treatment. If a dressing has fell off, the nurse should be notified to replace the dressing. Nurses tell the CNAs if a resident has wounds. He/she said CNA's do not look at the resident's care plan for interventions/approaches. 4. During an interview on 1/21/20, at 10:15 A.M., LPN C said nurses look at the TAR to know the resident's with pressure ulcers. Nurses report to CNAs what interventions are needed for the residents. CNA's should notify the nurse if a new wound is found or a dressing needs to be replaced. New wounds should be assessed and treatment started immediately and information regarding the wound should be documented on an initial wound assessment. A copy of the wound assessment is provided to the wound nurse so the resident can be added to the weekly wound tracking. 5. During an interview on 1/21/20, at 10:50 A.M., the Assistant Director of Nursing (ADON) said the following: -New wounds should be assessed with a full description of the wound to include measurements; -Treatment should be started on new wounds immediately when identified; -New wounds should be documented in the nurses' notes and on the wound assessment; -The wound nurse should review the treatment and begin weekly wound assessments to include measurements, color, odor, drainage and status of wound; -The resident should remain on weekly assessments until the wound is resolved; -Staff should follow infection control guidelines when performing wound care. 6. During an interview on 1/21/20, at 11:40 A.M., the administrator said she expects for weekly skin inspections to be completed and documented on all residents. If a wound is identified a full assessment should be completed and treatment started at the time. She expects the wound nurse to assess residents with wounds weekly and document on the weekly wound tracking to include a full assessment and measurements of the wound. All active wounds should be identified in the residents care plan with individualized interventions. She expects staff to follow the interventions set in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to compete a side rail assessment, to include a risk/benefit review ad alternatives attempted prior to use, and failed to obtain informed consent for side rails for two residents (Residents #13 and #199). The facility census was 49. Record review of the facility's policy titled Side Rail Policy, dated 3/2015, showed the following: -Use of side rails can create accidents/falls with greater impact than if side rails were not used; -The facility will assess resident to eliminate unnecessary use of side rails; -Risks to side rails will be identified; -Alternatives to side rails will be considered; -The resident has the right to make choices regarding side rails; -An assessment will be completed at least quarterly to as assess the need for use of side rails. 1. Record review of Resident #199's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 1/4/20; -Diagnoses included peritoneal abscess (a pocket of infected fluid inside the lining of the abdominal (belly), cavity), chronic kidney disease, and morbid obesity. Record review of the resident's nursing admission assessment, dated 1/4/20, showed the following: -Half side rails on both sides of bed used for mobility; -Consent not received for bilateral side rails. Record review of the resident's physician order sheet (POS) showed an order, dated 1/4/20, with directions that the resident may have bilateral one-half side rails for increased mobility. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/10/20, showed the following: -Cognitively intact; -Required limited assistance from staff for bed mobility and transfers. Record review of the resident's care plan, dated 1/10/20, showed the resident uses upper one-half side rails to assist with boundary markers and mobility. Observation on 1/17/20, at 9:15 A.M., showed the resident in bed, with one-half side rails in the up position on both sides of his/her bed. Observation on 1/21/20, at 840 A.M., showed the resident was not in his/her room. One half side rails were in the up position on both sides of the bed. The mattress on the bed shifted slightly side-to-side at the lower end of the side rails and shifted approximately 3 inches at the upper end of the rails exposing the bed frame underneath the mattress. Record review of the resident's medical record showed staff failed to document the following: -An assessment for the use of possible alternates prior to the use of side rails; -An assessment for the risk versus benefits of side rail use; -An informed consent for the use of side rails prior to installation; -Initial and ongoing assessment and inspections of the bed frame and rails to ensure the side rails were appropriate for use. During an interview on 1/21/2020, at 8:54 A.M., Certified Nurse Aide (CNA) B said the resident is independent with mobility and transfers. The resident does not require side rails. 2. Record review of Resident #13's face sheet showed the following: -admission date of 4/5/18; -Diagnoses included fistula of the intestine (abnormal opening in the digestive tract), schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms such as hallucinations (a perception not actually there) or delusions (altered reality) and mood disorder (mood swings ranging from depressive lows to manic highs)), and restless leg syndrome. Record review of the resident's POS showed an order, dated 12/01/18, with directions that the resident may use bilateral one-half side rails for increased mobility. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required limited staff assistance for bed mobility. Record review of the resident's care plan, dated 1/16/20, showed the following: -Amount of physical assistance required depends on the resident's changing mental status; -Upper one-half side rails on both sides of the bed for boundary markers and bed mobility. Observation and interview on 1/14/20, at 10:00 A.M., showed the one-half side rails on both sides of the resident's bed. The resident said he/she has always had side rails. He/she said staff did not talk to her about side rails. Observation on 1/21/20, at 8:34 A.M., showed the resident was not in his/her room. One-half side rails on both sides on the bed was in the up position. When the mattress was pushed lightly the mattress slid side-to-side showing an approximate 2 inch gap exposing the bed frame under the mattress. During an interview on 1/21/20, at 8:54 A.M., CNA B said the resident is independent with mobility and transfers. The resident did not require side rails. 3. During an interview on 1/17/20, at 10:20 A.M., Licensed Practical Nurse (LPN) A said side rail assessments are not included in the admission process. He/she said charge nurses are not required to complete side rail assessments. 4. During an interview on 1/21/20, at 8:54 A.M., CNA B said if a resident has side rails on their bed the staff will pull them up when the resident is in bed. 5. During an interview on 1/21/20, at 10:15 A.M., LPN C said residents are not assessed for side rails needs. If side rails are needed the nurse will call the physician and get an order. Alternative methods are not tried prior to side rail use. The resident's do not sign a consent for side rail use. 6. During an interview on 1/21/20, at 10:50 A.M., the Assistant Director of Nursing (ADON) said the following: -The facility does not completed side rail assessments for any resident; -Staff will obtain a physician order if side rails are needed; -The facility does not provide education to the resident on risk and benefits of side rails; -The resident is not asked to sign a consent for side rails; -Safety inspection including bed measurements are not completed by facility staff. 7. During an interview on 1/21/20, at 11:40 A.M., the Administrator said she expects staff to complete side rail assessments on all residents prior to use. Alternatives should be attempted prior to use the alternatives tried should be documented in the residents' medical record. All residents should be education on the risks and benefits of side rails and a consent to use should be signed by the resident or the resident's responsible party. A safety inspection to include measurements of the bed and mattress should be completed prior to side rail use. She was unaware that staff failed to complete side rail assessments and safety inspections.

Based on interview and record review, the facility failed to respond, address and provide feedback regarding concerns expressed by multiple residents attending the resident council meetings. The facility census was 49. 1. During the Resident Council interview on 1/14/20 at 1:00 P.M., 8 residents attended the meeting and shared the following concerns: -During resident council meetings, the activity director (AD) took notes of the residents' concerns and gave the notes to the department heads; -At each meeting, the AD did not review the concerns from the previous month; -Staff did not resolve issues brought up in resident council, and staff gave no real rationale for not responding to requests. Sometimes the staff gave them was they would go over it or they were working on it. -Concerns included: Staff served meals late, food was cold; and the residents did not always get the food they ordered, or the staff mixed up their orders; -Other concerns included call lights, staffing, and laundry; -Without staff responses nothing gets changed making resident council was a waste of time. 2. Review of the Resident Council Meeting Minutes dated 10/3/19, showed the following: -Five residents in attendance; -No documentation or follow-up on the old news related to the concerns voiced by residents from the previous month; -Nursing: Staff did not give the residents time in the morning to get ready before taking them to the dining room. Residents were tired of staff telling them they were busy and behind in their work, but are seen standing around talking to one another, talking across the room, and gathering in the corner to talk about the money they won; one resident asked for his/her wheelchair to be washed and and said staff only cleaned his/her wheelchair one time since his/her admission. -Dietary: Staff mixed up the residents' orders, and they did not get the meal they ordered. Meals were not served on time. -Housekeeping: Staff still threw away residents' belongings; -Maintenance: One resident needed his/her wheelchair brakes tightened and another resident needed a call light installed near his/her sink; 3. Review of the Resident Council Meeting Minutes dated 11/7/19, showed the following: -Nine residents in attendance; -No follow-up or review on the old news related to the concerns voiced by residents from the previous month; -Nursing: Staff still turned off the residents' call lights and said they would be right back but never returned. Some of the staff told the residents their personal problems, the residents wanted to help but could not. -Dietary: Staff served hamburgers that were too big and too hard to eat. Supper was not served on time and often the food was cold. The ham and beans served the other day were not good; -Housekeeping: Staff still threw away residents belongings. One resident asked that staff not touch his/her table, the counter by the sink or stuff on his/her bed; The residents wanted their rooms cleaned more than once a day and they were not happy with how the staff are cleaning room floors; -Maintenance: One resident needed his/her wheelchair brakes tightened and another resident needed a call light installed near his/her his/her sink; 4. Review of the Resident Council Meeting Minutes dated 12/9/19, showed the following: -Eleven residents in attendance; -No follow-up or review on the old news related to the concerns voiced by residents from the previous month; -Nursing: Staff still turned off the residents' call lights and did not return to assist the residents; Staff still rushed the resident to breakfast, the residents wanted time to get their belongings together; -Dietary: Food was still served out cold; -Housekeeping: Residents agreed staff did a better job cleaning the floors; -Maintenance: One resident needed a remote for his/her television. 5. Review of the Resident Council Meeting Minutes dated 1/2/20, showed the following: - Ten residents in attendance; -No follow-up or review on the old news related to the concerns voiced by residents from the previous month; -Nursing: Staff still turned off the residents call lights and did not return to assist the residents; Staff still rushed the residents to breakfast, the residents wanted time to get their belongings together; -Dietary: Food was still served out cold; -Housekeeping: Residents agreed staff did a better job on the floors; -Maintenance: One resident needed a remote for his/her television. 6. During an interview on 1/21/20 at 3:15 P.M., the AD said the residents met one time a monthly, usually the first Thursday of the month, for resident council. The residents complained about the food, call lights, laundry and other issues. The AD documented the residents' concerns on the council minutes and gave each department head a copy. The AD did not know what the department heads did with the information she provided. She did not ask each department head their plan to resolve or address the residents' concerns. The AD did not review the previous months concerns during the resident council meeting. She did not know what old news was. The department heads did not attend any of the council meetings. As far as she knew, no one follow-up on the residents' concerns. During an interview on 1/21/20 at 2:35 P.M., the Administrator said the AD provided each department head a written summary of residents' concerns during the morning meeting. The department heads should review, and address and/or resolve the residents' concerns. The AD should review the old news from the previous month during the resident council meeting to find out of their were any improvements since their last meeting. The AD should follow-up on all concerns and complaints brought by the resident council or individual residents. The AD should document if the residents' concerns were not resolved.

Based on observation and interview the facility failed to post the required abuse/neglect hotline information in a prominent location for residents, visitors, and staff to review. The facility census was 49. 1. Observation on 1/21/20 at 1:05 P.M., showed the facility posted the Department of Health and Senior Services (DHSS) Abuse and Neglect Hotline information on the top left corner of a bulletin board located behind a water fountain in the main lobby. The posting measured approximately 8 inches x 10 inches, and was written in fine print which may not be visible to all residents and visitors. The facility did not have the DHSS Abuse and Neglect Hotline information posted in any other area of the facility. During the Resident Council interview on 1/14/20 at 1:00 P.M., eight council members said they did not know where or if there was information related to the DHSS Abuse and Neglect Hotline posted in the facility. During an interview on 1/21/20 2:35 P.M., the Administrator said the State agency information should be posted where all residents, family and visitors could easily see and access it. The administrator thought the only place the hotline information was posted, was on the bulletin board, in the front lobby, near the water fountain. This location might make it hard for a short resident or a resident sitting in a wheelchair to view the information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an ongoing program of meaningful activities based on their interests and abilities for four residents (Resident #8, #20, #28 and #43) residing in the Special Care Unit (SCU) out of a selected sample of 14 residents. The facility's census was 49. Record review of the facility's policy titled, Resident Activities showed the following: -A staff member is hired or designated as the Activity Director (AD) by the administrator; -This facility will provide an on-going program of meaningful activities appropriate to the needs and interests of the residents and designated to promote opportunities for engaging in normal pursuits of daily living including religious activities of their choice, if any; -Activities will be planned on a monthly basis and posted in an area easily accessible to all residents; -Individual activities as well as group activities will be provided; -The opportunity to participate in religious activities will be provided for each resident; -The activity program is designed to promote the physical, social and mental well-being of the resident; -The activity program designee will be responsible for developing the resident's activity plan of care and make quarterly summaries on the resident; -The AD will identify the resident's interests and the needs as they relate to the activities; -Quarterly progress notes will be done on each resident. Progress notes will be done as needed as well; -These progress notes will include the activities in which the resident has participated, the resident's needs related to activities and changes in the resident's patterns of response to activities. Record review of the facility's job description for the Activity Director, undated, showed the following: -AD assist the residents to participate in planned group and individual activities; -The AD will offer the needed encouragement and physical assistance that will allow each resident to participate and achieve their goals in group and individual activities as outlined in their care plan. 1. Record review of Resident #8's medical record showed the following information: -admitted to the facility on [DATE]; -Diagnoses included dementia with behavior disturbance, anxiety, depression, and pain. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/19, showed the following information: -Severe cognitive impairment; -No behaviors; -Used a wheelchair for mobility. Record review of the resident's care plan, updated 10/28/19, showed the following: -Activity deficit due to difficulty self initiating participation; -Objective: Would be content with the use of leisure time; -Liked to garden and would enjoy being outside weather permitting. -Enjoyed the balloon toss, some cooking events, having nails done, music programs, church, and watching television; -Enjoyed looking at magazines related to gardens, art or needlework; -Liked hand massages; -Liked to visit with others. Record review of the resident's November 2019, December 2019, and January 2020 Activity Participation notes showed staff documented the following: -On 11/11/19, at 1:28 P.M., assisted with coloring and visited with the resident; -On 11/20/19, at 3:40 P.M., one-on-one (1:1) activity with the resident (staff did not specify the one-on-one activity); -On 12/18/19, at 12:39 P.M., the activity assistant gave the resident a hand massage and visited with him/her; -On 12/24/19, at 1:43 P.M., the activity assistant visited with the resident; -On 1/9/20, at 12:43 P.M., the activity assistant gave the resident a hand massage and visited with him/her. An observation (in the SCU) on 1/15/20, at 2:16 P.M., showed the following: -According to the calendar, the 2:00 P.M. scheduled activity was a movie; -The resident sat in his/her wheelchair, in the dining room, with his/her eyes closed; -Staff did not attempt to engage the resident in any activity. An observation (in the SCU) on 1/15/20, starting at 10:17 A.M., showed the following: -According to the calendar, the 10:00 A.M. scheduled activity was a memory game; -At 10:17 A.M., the resident sat in his/her wheelchair, in the dining room, with his/her eyes closed; -At 10:23 A.M., the AD entered the SCU and placed a memory game box on a table and sat down near the resident. The AD took the memory cards out of the game box and placed them on the table. The AD left the dining room to ask another resident if he/she wanted to join him/her in the memory game. The AD returned to the dining room and sat at the table with Resident #8 and one other resident. Resident #8 continued to sit in his/her wheelchair with his/her eyes closed; -The AD did not attempt to engage the resident in this scheduled activity; -At 11:00 A.M., the AD had left the SCU. An observation (in the SCU) on 1/16/20, from 9:45 A.M. to 11:15 A.M., showed the following: -According to the calendar, the 10:00 A.M. scheduled activity was hand massage; -The resident sat in his/her wheelchair in the dining room; -Staff did not assist or engage the resident in any activity. An observation (in the SCU) on 1/16/20, at 1:53 P.M., showed the following: -According to the calendar, the 2:00 P.M. scheduled activity was Bingo; -The resident sat in his/her wheelchair in the dining room; -No staff initiated the Bingo game; -Staff took three residents to the main dining room for a music activity. Staff did not ask Resident #8 if he/she wanted to attend the activity. Record review of the resident's January 2020 Activity Participation notes showed staff documented the following: -On 1/20/20, at 3:28 P.M., the activity assistant and resident looked at picture book; -On 1/21/20, at 11:29 A.M., staff took the resident to a music activity in the common area (outside of the SCU), the resident was in tears. 2. Record review of Resident #20's medical record showed the following information: -admitted to the facility on [DATE]; -Diagnoses included dementia without behavior disturbance, mood disorder, depression, cognitive communication deficit, and disorientation anxiety. Record review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Used a wheelchair for mobility. Record review of the resident's care plan, updated on 11/13/19, showed the following: -The resident required assistance from staff with leisure activities; -Objective: The resident would indicate satisfaction with use of leisure time; -One-on-one interactions with staff during care and during the day; -Resident loved to visit with others; -Enjoyed watching television, music programs and loved to sing; -May enjoy watching religious programs; -Enjoyed interactions with the dogs who visited the facility; -Liked his/her nails done. Record review of the resident's November 2019, December 2019, and January 2020 Activity Participation notes showed staff documented the following: -On 11/8/19 at 8:54 A.M., staff performed one-on-one activities with the resident. The resident was in bed most of the time. The resident enjoyed the therapy ponies brought to his/her room, and a visitor would play the fiddle for the resident in his/her room. Family sent the resident packages and activities staff helped the resident with his/her mail. The resident enjoyed watching television. Staff propelled the resident in his/her wheelchair; -On 11/11/19, at 1:31 P.M., visited 1:1 with the resident; -On 11/20/19, at 3:30 P.M., 1:1 activity with the resident; -On 12/5/19, at 11:10 A.M., AD and [NAME] went to the resident's room and played music, prayed and sang with him/her; -On 12/18/19, at 12:47 P.M., 1:1 hand massage and visited with the resident; -On 12/24/19, at 1:47 P.M., visited 1:1 with resident; -On 12/26/19, at 3:56 P.M., 1:1 activity with the activity assistant and volunteer entertainer in the resident's room; -On 1/9/20, at 12:46 P.M., 1:1 hand massage and visited with the resident; -On 1/14/20, at 11:32 A.M., 1:1 activity with the resident. During an interview on 1/14/20 at 10:00 A.M., Certified Nurse Aide (CNA) K said the resident did not leave his/her room. An observation and interview on 1/15/20, at 11:20 AM, showed the following: -The resident laid in bed. -He/she said there were no activities to really speak of in the SCU and he/she got really bored. The residents in the SCU would like something to do besides lay in their beds, walk the halls, or sit in the common/television/dining room. He/she liked music, but nobody ever came in and did any activities with him/her. When he/she felt better, he/she would like someone to come in and visit with him/her and maybe go out to a music activity. He/she would like for someone to come in to talk to him/her every so often. During an observation on 1/15/20, at 2:16 PM in the SCU showed the following: -According to the calendar, the 2:00 P.M. scheduled activity was a movie; -The resident laid in bed, awake; -Staff did not encourage or engage the resident in any activity. An observation (in the SCU) on 1/16/20, from 9:45 A.M. to 11:15 A.M., showed the following: -According to the calendar, the 10:00 A.M. scheduled activity was hand massage; -The resident was in his/her room; -Staff did not attempt to engage the resident in the activity. An observation (in the SCU) on 1/16/20, at 1:53 P.M., showed the following: -According to the calendar, the 2:00 P.M. scheduled activity was Bingo; -The resident was in his/her room; -Staff took three residents to the main dining room for a music activity. Staff did not ask Resident #20 if he/she wanted to attend the activity. Record review of the resident's Activity Participation note dated 1/20/20, at 3:31 P.M., showed staff gave the resident a hand massage and visited with him/her. 3. Record review of Resident #28's medical record showed the following information: -admitted to the facility on [DATE]; -Diagnoses included dementia, psychotic disorder with delusions (a firm and fixed belief based on inadequate grounds not amenable to rational argument or evidence to contrary), adult failure to thrive, depression, and pain. Record review of the resident's care plan, last reviewed on 10/28/19 , showed the following: -The resident had multiple declining health issues and was on hospice services; -Care would be directed with comfort as the main goal; -The resident spent the majority of his/her time dozing in his/her chair; -The resident enjoyed watching television and needed assistance with changing the channels as needed; -The resident enjoyed music; -May enjoy sitting in the garden/area outside weather permitting; -Enjoyed talking on the phone to family. Record review of the resident's annual MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Liked listening to music; -Used a wheelchair for mobility; -No behaviors. Record review of the resident's November 2019, December 2019, and January 2020 Activity Participation notes showed the following: -On 11/08/19, at 2:08 P.M., staff lotioned the resident's hands; -On 11/20/19, at 3:32 P.M., 1:1 activity with the resident; -On 11/21/19, at 1:40 P.M., staff documented resident was low functioning. Activity staff did 1:1 activities with the resident. The resident listened to music, did the balloon toss, colored, and enjoyed the therapy ponies. Staff propelled the resident in his/her wheelchair; -On 12/24/19, at 1:46 P.M., Activity Assistant performed a 1:1 with the resident by talking to resident; -On 1/09/20, at 12:47 P.M., 1:1 hand massage and talked with the resident; -On 1/14/20, at 11:39 A.M., activity assistant attempted a 1:1 activity but the resident was not receptive. An observation (in the SCU) on 1/15/20, at 2:16 P.M., showed the following: -According to the calendar, the 2:00 P.M. scheduled activity was a movie; -The resident sat in his/her wheelchair in the dining room, with his/her eyes closed; -Staff did not attempt to engage the resident in the activity. An observation (in the SCU) on 1/16/20, from 9:45 A.M. to 11:15 A.M., showed the following: -According to the calendar, the 10:00 A.M. scheduled activity was hand massage; -The resident laid in bed with his/her eyes closed; -Staff did not attempt to engage the resident in the activity. An observation (in the SCU) on 1/16/20, at 1:53 P.M., showed the following: -According to the calendar, the 2:00 P.M. scheduled activity was Bingo; -The resident laid in his/her bed; -Staff took three residents to the main dining room for a music activity. Staff did not ask the resident if he/she wanted to attend the activity. Record review of the resident's Activity Participation notes dated 1/20/20, at 3:33 P.M., showed the activity assistant documented she attempted to engage the resident in a 1:1 activity but resident would not respond. 4. Record review of Resident #43's medical record showed the following information: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease, dementia with behavior disturbance, hearing loss,major depressive disorder, anxiety, and depression. Record review of the resident's care plan, updated 1/15/20, showed the following: -Due to a persistent decline in multiple health issues the resident was admitted to hospice services on 1/15/20; -All care would be directed with comfort as a main goal; -Participated in more passive activities; -May enjoy looking through sewing, crocheting, and crafting magazines; -The resident enjoyed television, music programs and nail care. Record review of the resident's significant change MDS, dated [DATE], showed the following information: -Severely impaired cognitive skills; -Used a wheelchair for mobility; -No behaviors. Record review of the resident's November 2019, December 2019, and January 2020 Activity Participation notes showed the following: -On 11/8/19 at 1:46 P.M., (quarterly care plan meeting) the resident watched television and visited with his/her roommate. Family visited with the resident and painted his/her nails. The resident gets his/her hair done weekly at the facility beauty shop. The resident enjoyed the therapy ponies and staff conducted 1:1 activities with the resident; -On 11/11/19, at 1:44 P.M., 1:1 activity with the resident; -On 11/20/19, at 1:40 P.M., 1:1 activity with the resident; -On 12/18/19, at 12:42 P.M., 1:1 hand massage and visited with the resident; -On 12/24/19, at 1:58 P.M., 1:1 visit with the resident; -On 1/2/20, at 4:10 P.M., the AD and activity assistant brought the resident a cupcake and a balloon, and sang to the resident for his/her birthday. An observation (in the SCU) on 1/15/20, at 2:16 P.M., showed the following: -According to the calendar, the 2:00 P.M. scheduled activity was a movie; -Resident sat in his/her wheelchair, in common television area, with his/her eyes closed; -Staff did not encourage or engage the resident in the activity. An observation (in the SCU) on 1/16/20, from 9:45 A.M. to 11:15 A.M., showed the following: -According to the calendar, the 10:00 A.M. scheduled activity was hand massage; -Staff were assisting the resident in the shower during this activity. An observation (in the SCU) on 1/16/20, at 1:53 P.M., showed the following: -According to the calendar, the 2:00 P.M. scheduled activity was Bingo; -The resident was in his/her room; -Staff took three residents to the main dining room for a music activity. Staff did not ask Resident #43 if he/she wanted to attend the activity. 5. Record review of facility's January 2020 activity calendar showed the following: -On 1/13/20, Picture Books at 10:00 A.M., and Balloon Toss at 2:00 P.M.; -On 1/14/20, Dominoes at 10:00 A.M., and Story X at 2:00 P.M.; -On 1/15/20, Memory Game at 10:00 A.M., and Movie at 2:00 P.M.; -On 1/16/20, Hand Massage at 10:00 A.M., and Bingo at 2:00 P.M.; -On 1/17/20, Crafts at 10:00 A.M., and Music with [NAME] at 2:00 P.M.; -On 1/21/20, Dominoes at 10:00 A.M., and Story X at 2:00 P.M. 6. An observation on 1/14/20, at 10:00 A.M., showed the following: -According to the calendar, the 10:00 A.M. scheduled activity was a dominoes; -One resident sat in the SCU dining room, where staff usually conducted activities; -Dominoes were not set-up; -No activity staff were present. 7. During an interview on 1/14/20, at 10:00 A.M., Certified Medication Technician (CMT) H said staff who worked in the SCU did not follow the posted activity calendar. The posted calendar was mainly for resident in the main facility. 8. During an interview on 1/14/20, at 10:00 A.M., Certified Nurse Aide (CNA) K said the following: -The activity assistant did not go to the SCU everyday, maybe a couple times a week. -The residents did not like the activities listed on the calendar. They would not play Bingo, dominoes or do puzzles; -The eight residents in the SCU did not want to be bothered with activities; they just did their own thing; -Staff did not follow the posted activity calendar. Staff used to play dominoes with the residents, but now the residents will not participate; -Sometimes, a church group would play music for the residents on the SCU, but after two songs the residents wanted them to leave, the same thing happened with the violin players who came every so often; -There were no scheduled 1:1 activities with any residents in the SCU. Staff performed 1:1 activities, all day, when they interacted with the residents during cares and meals. 9. During an interview on 1/15/20, at 2:36 P.M., CNA J said if the facility had a more scheduled activity program, the residents may benefit, but the residents on the SCU did not want to do anything. The activity staff did not come back to the SCU for any activities. They posted an activity calendar which was a guide to which activities staff could do with the residents. The calendar gave staff ideas of activities they could try. The staff did not do all the activities on the calendar. Staff did not assist the residents with two activities a day. 10. During an interview on 1/16/20, at 4:02 P.M., the activity assistant said: -She became the activity assistant in the fall of 2019; -This week she was in orientation and had not been in the SCU everyday; -They were working on making the activities better for the residents on the SCU; -The facility had two activities staff, the AD and the activity assistant; -Most of the residents who resided in the SCU required 1:1 activities. When she performed 1:1 activities with the residents, she would usually spend 30 minutes with each resident; -Staff did not usually follow the posted activity calendar because most of the residents who resided in the SCU at this time, did not really want to participate in activities; -The residents could not participate in the Bingo activity or many other activities posted on the calendar. During an interview on 1/21/20, at 3:15 P.M., the Activity Director said: -All of the residents should participate in activities daily; -The activity staff posted a monthly calendar in the SCU with activities scheduled at 10:00 A.M., and at 2:00 P.M.; -When she did not have an activity assistant, she could not complete all of the activities in the facility; -The SCU suffered, because she was unable to spend a lot of quality time with the residents; -She depended on the CNAs to assist with the activities in the SCU. -The residents should get at least one activity a day; -The assistant did most of the 1:1 activities with the residents in the SCU; -The assistant went to the SCU and completed activities most days; -Staff did not conduct activities in the SCU twice a day; -The AD would go to the SCU when the assistant could not; -The assistant worked every other weekend; -The residents who resided in the SCU, at this time, did not really want to participate in very many of the activities they offered; -On the weekends there was a movie and church on Sunday; -The AD knew there was a problem with the activities in the SCU and they have talked about how to improve this concern. During an interview on 1/21/20, at 2:35 P.M., the Administrator said the AD and the activity assistant should plan and assist residents with appropriate activities, including the residents who resided in the SCU.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation systems in proper working condition when 13 residents' bathrooms did not have functioning exhaust vents. The facility had census was 49. 1. Observation on 1/13/2020, beginning at 8:30 A.M., showed the exhaust ventilation system in the following resident rooms did not have functioning exhaust ventilation system when tested: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]. During an interview on 1/13/2020, at approximately 1:00 P.M., the Maintenance Supervisor (MS) said he did not know the residents' bathroom exhaust systems did not work The exhaust systems worked off of fans located on the roof.

Based on observation and interview, the facility failed to prevent possible cross contamination of the residents' food during preparation and service when staff did not properly store and label food to prevent contamination or spoilage; did not perform proper food handling techniques; did not properly store clean dishware; and did not provide a require air gap for the drainage of the ice machine. The facility had a census of 49. 1. Record review of facility's policy on food storage, dated 10/26/12, showed the following: -Facility staff to label all food items held for more than 24 hours; -The label must include the name of the food and the date it should be consumed or discarded; -Facility staff to wrap food properly and never leave any food item uncovered or unlabeled. Observations starting on 1/13/20, at 9:40 A.M., in the dry storage area of the kitchen showed the following: -A large 25 pound bag of sugar cookie mix open and rolled shut (not sealed or covered). The sugar cookie mix did not have an open or use by date; -One 16 ounce bag of Cream Soup base open and sealed in Ziplock bag. The soup based did not have an open or use by date on the bag; -One bulk sugar container with a 1/2 cup scoop stored in with the product (sugar); -One open box of Cream of Wheat on shelf, unsealed; -Eleven various dry spice containers open and sitting on a metal shelf, not in use. Observations starting on 1/16/20, at 10:42 A.M., showed the following: -Cream of Wheat and box of quick oats open and unsealed on shelf; -Small scoop in bulk sugar container; -Scoop also in unlabeled bulk storage container storage; -Sugar cookie mix open and unsealed, undated. During an interview on 1/21/20, at 4:25 P.M., the Dietary Manager (DM) said food should be sealed and dated if it is open. Staff should date all food upon receipt. Staff should keep food fully sealed. Staff should label food when it was opened. Scoops should not be stored in the product (food) in bulk storage. The scoop should be used for one cooking task, then washed. 2. Record review of the Missouri Food Code showed the following: -In order to prevent backflow, a direct connection may not exist between the sewage system and a drain originating from equipment in which food is placed; -A backflow prevention device or an air gap must be in place to prevent wastewater backsiphonage. Observations starting on 1/13/20, at 11:40 P.M., showed the ice machine in a separate room outside of kitchen. The drain pipe of the ice machine lead directly into the floor drain and was touching the sides of floor drain. There was a buildup of dark, slimy substance around the end of the drain. Observations on 1/16/20, at 9:53 A.M., showed the ice machine drain had heavy soiling of dark material around end of conduit. The drain conduit was leading into a raised cup floor drain (the ice machine drain was partially inserted into the floor drain). During an interview on 1/21/20, at 4:25 P.M., the dietary manager said she was not aware of the process for cleaning or maintaining the ice machine. She said there is some buildup on the end of the drainpipe and was not sure when it was last cleaned. The dietary manager was not aware of the necessity for a gap between the drain pipe of the ice machine and the drain in the floor. 3. Record review of the Missouri Food Code showed the following information: -Except when washing fruits and vegetables, food employees mat not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. Record review of the facility's policy named Hand Washing/Hand Hygiene, dated 3/3/16, showed the following: -Facility staff should prevent the transmission of pathogens to residents by performing hand hygiene before and after resident contact, before and after food preparation or serving food, and any time there is a chance of cross contamination. Observations starting on 1/13/20, at 11:28 A.M., in the assisted dining room showed Certified Nurse Aide (CNA) D had a tray with two covered plates. He/she put one plate on small table in front if one resident. The CNA took off the cover and handed sandwich to the resident. The CNA did not use gloves and did not perform hand hygiene before or after he/she handed the sandwich to the resident. During an interview with the administrator on 1/21/20, at 2:34 P.M., she said she expects the dietary manager to monitor the assisted dining on a regular basis. The dietary manager should observe the dining room for appropriate assisting of residents, including performing appropriate hand hygiene. During an interview on 1/21/20, at 4:25 P.M., the DM said she had not yet made any observations of meal service in the assisted dining room. The dietary manager said all staff should change gloves and staff should wash hands between assisting different residents with eating. 4. Record review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. - Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Observations starting on 1/13/20, at 9:40 A.M., showed moisture trapped between 10 cups (6 ounce) stored stacked and stored in the dishwash room (potentially creating a warm, moist environment that could allow bacteria to grow). Observations starting on 1/16/20, at 10:42 A.M., showed there was significant moisture droplets in eight cups (6 ounce) and five cups (12 ounce) stored in dish room. Two coffee carafes also had moisture buildup inside. During an interview on 1/21/20, at 4:25 P.M., the dietary manager said all dishes should be stored dry. All washed dish items should be air-dried and not wiped down.

Based on interview and record review, the facility failed to report an allegation of abuse involving (Resident #17 and Resident #35) and failed to report an allegation of abuse involving (Resident #17 and Resident #14) to the Department of Health and Senior Services (DHSS) within two hours of receiving the allegation. A sample of 13 residents was selected out of a facility census of 50. Record review of the facility's abuse reporting policy, dated 3/01/18, showed the following information: -If a suspicion of abuse or an allegation resulting in serious bodily injury has been formed at least one law enforcement agency as well as the State Survey Agency must be notified immediately and no later than two hours after forming the suspicion. The facility must ensure that all allegations of mistreatment, neglect, allegation of abuse, injuries of unknown source and misappropriation of resident property are immediately reported to the facility administrator and to other officials in accordance with State law; -All other must be reported within 24 hours if the events that cause reasonable suspicion is not abuse or do not result in serious bodily injury to a resident; -A completed copy of the Resident Abuse Reporting Form and written statements from witnesses, if any will be provided to the administrator within 24 hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of the investigation will be provided to the administrator or his/her designated representative and to other officials in accordance with State law (including the State Survey and Certification Agency) as soon as possible and at least within five working days of the occurrence of such incidents, and if the alleged violation is verified, corrective actions must be taken. 1. Record review of Resident #17's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of 6/08/17; -Diagnoses included dementia with behavioral disturbances (a group of thinking and social symptoms that interfere with daily functioning and anxiety disorder. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 8/25/18, showed the following information: -Severe cognitive impairment; -Behaviors of rejection of care 1-3 days out of 7; -Inattention and disorganized thinking fluctuates; -No wandering or physical/verbal behaviors to others or self; -No change in mental status. Record review of the nurses' notes showed the following information: -On 9/24/18, at 10:46 P.M., the resident's roommate (Resident #14) was in the room looking through his/her own dresser drawer and all of a sudden Resident #17 grabbed the other resident's wheel chair handles and ran down the hallway with the other resident, and forcefully pushed the resident and the wheel chair into the day room. The roommate did not sustain any injuries. Resident #17 then proceeded to throw water onto the roommate and staff. Resident #17 then went to his/her room and staff closed the door leaving it open a crack in an attempt to help the resident calm down. The resident continued to throw water onto the staff through the crack in the door. The nurse went to assess Resident #17 and the resident refused to even talk to the nurse. Staff notified hospice and the on-call nurse telephoned back. Staff relayed the situation to the hospice nurse and staff obtained an order for a dose of Ativan (anxiety medication) intramuscular (IM). Staff requested the Ativan because the resident continued to throw water and chocolate milk at staff and spit at staff. It was clear the resident would refuse to take any medications by mouth. The hospice nurse said he/she would call the physician and request the order asked for. Staff will await a return call from the hospice nurse; -On 9/24/18, at 11:20 P.M., the hospice nurse called back and said the physician had given a new order for Ativan 0.5 milliliter (ml) IM every four hours as needed for anxiety. Staff pulled the initial dose from the e-kit and administered it per physician orders at 11:15 P.M. Staff will continue to observe. Record review of DHSS records showed the facility staff did not notify DHSS of the alleged abuse. 2. Record review of Resident #17's nurses' notes, dated 9/29/18, at 1:56 P.M., showed on 9/28/18, at 7:30 P.M., a certified nurse's assistant (CNA) called the nurse back to the special care unit (SCU). The CNA reported this resident and another resident (the other resident's name not mentioned in this nurse's note) had been physically fighting. The CNA had been able to break them up and had separated the residents. Both residents were checked out for injuries and no new injuries were found. Resident #17 already had a large bruise on his/her right hand. The resident could move all extremities on his/her own and was up unassisted. The nurse instructed the CNA to keep the residents apart if possible. The nurse left a message for the resident's family and notified the nurse on-call who said he/she would report the incident to the administrator. The nurse was instructed to call the family and document the incident. Record review of DHSS records showed the facility staff did not notify DHSS of the alleged abuse. 3. During an interview on 11/29/18, at 8:42 A.M., the administrator agreed both of the incidents with Resident #17 on 9/24/18 and 9/28/18 should have been reported to DHSS. 4. During an interview on 11/29/18, at 9:11 A.M., CNA C said if residents get in a physical fight staff should separate the residents and report it immediately to the charge nurse. He/she had never seen Resident #17 get physically aggressive with any other resident. He/she had not heard of the incident when Resident #17 forcefully wheeled another the resident down the hallway and threw water on the resident or the incident when the resident had gotten into a physical altercation with another resident. The CNA said both of these incidents should have been reported to the nurse who would then report to the administrator, nurse on call, or director of nursing (DON). 5. During an interview on 11/29/18, at 9:48 A.M., Registered Nurse (RN) D said he/she may have heard in report about Resident #17 forcibly wheeling another resident down the hallway and throwing water on the resident. He/she did not work at the time of this incident. The incident had been reported to him/her by the licensed practical nurse (LPN) on duty regarding the resident getting into a physical altercation with another resident. The other resident was Resident #35. The LPN did report a physical altercation; but, RN C could not remember if it was slapping or which resident initiated the altercation. He/she told the other nurse to notify both families. Neither of the residents had any injuries. He/she did not know if the other nurse had reported the incident to DHSS. 6. During a telephone interview on 11/29/18, at 10:28 A.M., LPN E said if there was a resident to resident altercation, staff should report to the on-call nurse. A CNA reported to him/her a physical altercation had occurred between Resident #17 and Resident #35. He/she assessed Resident #17 and there were no injuries. Resident #35 refused to be assessed; but, the LPN did not see any injuries. He/she notified the on-call nurse (RN D) and the LPN was directed to notify families and document the incident. The RN told LPN E, he/she would report the incident to the administrator. The LPN could not remember which CNA had reported the incident to him/her. He/she had not been instructed to report the resident to resident altercation to DHSS. He/she believed Resident #17 started the physical altercation due to his/her tendency of wandering into other resident rooms. He/she did not realize all resident to resident altercations must be reported to DHSS. 7. During an interview on 11/30/18, at 8:10 A.M., RN F said the incident where Resident #17 forcefully wheeled his/her roommate down the hall into the dayroom and threw water onto the other resident had been reported to him/her by a CNA. He/she did not witness the incident. The CNA said the roommate had been in his/her room going through his/her dresser when Resident #17 jumped up and grabbed the handles of the roommate's wheel chair and ran out of the room with the other resident in the wheel chair and down the hallway to the dayroom. When Resident #17 got to the dayroom, he/she forcefully pushed the wheel chair into the dayroom and started running back down the hall and threw water on the CNA. The resident then went to his/her room and the CNA closed the door and left the door cracked to allow Resident #17 time to calm down. The resident did not calm down right away and continued to throw chocolate milk and water on the CNA through the crack in the door. A nurse assessed the roommate and there were no injuries. The resident did not appear to be nervous or upset. The nurse then assessed Resident #17 who was still at a high level of anxiety and aggression. The RN notified the physician who ordered Ativan IM as needed. The RN gave the ordered Ativan. He/she said Resident #17 had a history of being aggressive to staff and residents and poses a danger to self and others at times. The resident had never hurt another resident that he/she was aware of. Resident to resident altercations should be reported. He/she passed this information on to other staff at report and informed the DON of the incident. Resident to resident altercations should be reported in two hours and then the DON or administrator would take over. 8. During an interview on 11/30/18, beginning at 3:45 P.M., the administrator said the resident to resident altercations of abuse had not been reported to DHSS. Complaint# MO00148499

Based on interview and record review, the facility failed to complete timely and thorough investigations of allegations of abuse involving one resident (Resident #17). A sample of 13 residents was selected for review out of a facility census of 50. Record review of the facility's abuse reporting policy, dated 3/01/18, showed the following information: -Abuse investigation-it is the policy of the facility that reports of abuse be promptly and thoroughly investigated; -When an incident or suspected incident of abuse is reported, the administrator will appoint a representative to investigate the incident. The social service designee or social service director will be the primary representative; -The administrator will provide to the person in charge of the investigation a copy of the resident abuse reporting form and any supporting documents relative to the investigation; -The representative's investigation shall consist of: -A review of the completed resident abuse form; -An interview with the person(s) reporting the incident; -Interviews with any witnesses to the incident; -An interview with the resident; -A review of the resident's medical record; -An interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident; -Interview with the resident's roommate, family members and visitors; -A review of circumstances surrounding the incident; -The person in charge of the investigation will consult with the administrator daily concerning the progress of the investigation; -The results of the representative's investigation will be recorded on the resident abuse investigation report form; -An immediate investigation will be made and a copy of the findings of such investigation will be provided to the administrator and/or his/her designated representative and to other officials in accordance with State law (including the State Survey and Certification Agency) as soon as possible and at least within five working days of the occurrence of such incidents; and if the alleged violation is verified, appropriate corrective action must be taken; -The administrator and/or his designated representative will inform the resident and his/her representative of the findings of the investigation and the corrective action taken, if any were required; -A completed copy of the resident abuse reporting form and written statements from witnesses, if any, will be provided to the administrator within 24 hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of the investigation will be provided to the administrator or his/her designated representative and to other officials in accordance with State law (including the State Survey and Certification Agency) as soon as possible and at least within five working days of the occurrence of such incidents, and if the alleged violation is verified corrective actions must be taken. 1. Record review of Resident #17's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of 6/08/17; -Diagnoses included dementia with behavioral disturbances (a group of thinking and social symptoms that interfere with daily functioning and anxiety disorder. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 8/25/18, showed the following information: -Severe cognitive impairment; -Behaviors of rejection of care 1-3 days out of 7; -Inattention and disorganized thinking fluctuates; -No wandering or physical/verbal behaviors to others or self; -No change in mental status. Record review of the nurse's note dated 9/24/18, at 10:46 P.M., showed the resident's roommate (Resident #14) was in his/her room looking through his/her own dresser drawer and all of a sudden Resident #17 grabbed the other resident's wheel chair handles and ran down the hallway with the other resident, and forcefully pushed the resident and the wheel chair into the day room. The roommate did not sustain any injuries. Resident #17 then proceeded to throw water onto the roommate and staff. Resident #17 then went to his/her room and staff closed the door leaving it open a crack in an attempt to help the resident calm down. The resident continued to throw water onto the staff through the crack in the door. The nurse went to assess Resident #17 and the resident refused to even talk to the nurse. Hospice was notified and the on-call nurse telephoned back. Staff relayed the situation to the hospice nurse and obtained an order for a dose of Ativan (anxiety medication) IM (intramuscular). Staff requested the Ativan because the resident continued to throw water and chocolate milk at staff and spit at staff. It was clear the resident would refuse to take any medications by mouth. The hospice nurse said he/she would call the physician and request the order asked for. Staff will await a return call from the Hospice nurse; -On 9/24/18, at 11:20 P.M., the hospice nurse called back and stated the physician had given a new order for Ativan 0.5 milliliter (ml) IM every four hours as needed for anxiety. Staff pulled the initial dose from the e-kit and administered it per physician orders at 11:15 P.M. Staff will continue to observe. Record review of the facility's records showed staff did not document an investigation into the allegation of abuse. Record review of DHSS records showed the facility staff did not send a completed investigation to DHSS within the required five working days. 2. Record review of Resident #17's nurses' notes, dated 9/29/18, at 1:56 P.M., showed on 9/28/18, at 7:30 P.M., a certified nurse's assistant (CNA) called the nurse back to the special care unit (SCU). The CNA reported this resident and another resident (the other resident's name not mentioned in this nurse's note) had been physically fighting. The CNA had been able to break them up and had separated the residents. Staff checked both residents out for injuries and found no new injuries. Resident #17 already had a large bruise on his/her right hand. The resident could move all extremities on his/her own and was up unassisted. The nurse instructed the CNA to keep the residents apart if possible. The nurse left a message for the resident's family and notified the nurse on-call who said he/she would report the incident to the administrator. The nurse was instructed to call the family and document the incident. Record review of the facility's records showed staff did not document an investigation into the allegation of abuse. Record review of DHSS records showed the facility staff did not send a completed investigation to DHSS within the required five working days. 3. During an interview on 11/29/18, at 8:42 A.M., the surveyor asked the administrator if she had an investigation of the incident with Resident #17 for 9/24/18 and 9/28/18. The administrator said she had been out sick at this time and would see if the director of nursing (DON) handled this. The administrator agreed both of these incidents should have been reported to DHSS and the facility should have completed an investigation of the alleged abuse. 4. During an interview on 11/29/18, at 9:11 A.M., CNA C said if residents get in a physical fight staff should separate the residents and report it immediately to the charge nurse. He/she had never seen Resident #17 get physically aggressive with any other resident. He/she had not heard of the incident when Resident #17 forcefully wheeled another resident down the hallway and threw water on the resident or the incident when the resident had gotten into a physical altercation with another resident. The CNA said both of these incidents should have been reported to the nurse who would then report to the administrator, nurse on call, or DON. The administrator, DON, or charge nurse would be responsible for completing the investigation. 5. During an interview on 11/29/18, at 9:48 A.M., Registered Nurse (RN) D said he/she may have heard in report about Resident #17 forcibly wheeling another resident down the hallway and throwing water on the resident. He/she did not work at the time of this incident. The incident had been reported to him/her by the licensed practical nurse (LPN) on duty regarding the resident getting into a physical altercation with another resident. The other resident was Resident #35. The LPN did report a physical altercation; but, RN C could not remember if it was slapping or which resident initiated the altercation. He/she told the other nurse to notify both families. Neither of the residents had any injuries. He/she did not know if the other nurse had reported the incident to DHSS. The administrator, DON, or charge nurse on-call would be responsible for completing an investigation. 6. During a telephone interview on 11/29/18, at 10:28 A.M., LPN E said if there was a resident to resident altercation staff should report to the on-call nurse. A CNA reported to him/her a physical altercation occurred between Resident #17 and Resident #35. He/she assessed Resident #17 and there were no injuries. Resident #38 refused to be assessed; but, the LPN did not see any injuries. LPN E notified the on-call nurse (RN D) and the LPN was directed to notify families and document the incident. The RN told LPN E he/she would report the incident to the administrator. The LPN could not remember which CNA had reported the incident to him/her. He/she had not been instructed to report the resident to resident altercation to DHSS. He/she believed Resident #17 started the physical altercation due to his/her tendency of wandering into other resident rooms. He/she did not realize all resident to resident altercations must be reported to DHSS and a thorough investigation was required for any allegation of abuse, including resident to resident altercations. 7. During an interview on 11/30/18, at 8:10 A.M., RN F said the incident where Resident #17 forcefully wheeled his/her roommate down the hall into the dayroom and threw water onto the other resident had been reported to him/her by a CNA. He/she did not witness the incident. The CNA said the roommate had been in his/her room going through his/her dresser when Resident #17 jumped up and grabbed the handles of the roommate's wheel chair and ran out of the room with the other resident in the wheel chair and down the hallway to the dayroom. When Resident #17 got to the dayroom, he/she forcefully pushed the wheel chair into the dayroom and started running back down the hall and threw water on the CNA. The resident then went to his/her room and the CNA closed the door and left the door cracked to allow Resident #17 time to calm down. The resident did not calm down right away and continued to throw chocolate milk and water on the CNA through the crack in the door. A nurse assessed the roommate and there were no injuries. The resident did not appear to be nervous or upset. The nurse then assessed Resident #17 who was still at a high level of anxiety and aggression. The RN notified the physician who ordered Ativan IM as needed. RN F gave the ordered Ativan. Resident #17 had a history of being aggressive to staff and residents and poses a danger to self and others at times. The resident had never hurt another resident that he/she was aware of. Resident to resident altercations should be reported. He/she passed this information on to other staff at report and informed the DON of the incident. Resident to resident altercations should be reported in two hours and then the DON or administrator would take over and complete an investigation. 8. During an interview on 11/13/18, beginning at 3:45 P.M., the administrator said she did not have an investigation for either of the resident to resident altercations. Complaint# MO00148499

Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for the transfer, and failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification, for two residents (Resident #38 and #41) out of 13 sampled residents. The facility census was 50. Record review of the facility policy and procedure titled, transfer and receiving, dated 4/26/00, showed the following information: -The facility maintains an effective transfer agreement with the local hospitals and other facilities to assure the continuing care of the residents; -A resident will be considered transferred if he/she is admitted to a hospital or other health care setting and the resident's space in the facility is reserved by the resident and/or personal representative; -At the time of notification of the transfer of the resident, inquiry will be made by the nursing staff or business office, to the resident and/or personal representative concerning reserving the room of the resident; -Financial arrangements to reserve the room should be made between the resident and/or personal representative and the business office of this facility within 24 hours after the transfer; -If the business office is not open during this 24 hour period, the resident and/or personal representative should make arrangements with the nurse in-charge to reserve the resident's room; -The administrator is responsible to see that all charge personnel are aware of the facility's room reservation procedures; -The facility shall have a Bed Hold Policy which sets forth the federal requirements regarding notifying residents and/or personal representative of residents' right to hold rooms; -Any transfer of a resident within this facility should be fully documented by the nursing personnel and/or social services. -The summary should include: -Reason for transfer; -Time of transfer; -Location of resident before and after transfer (room number, wing, and location of bed); -Disposition of personal effects; -Consultation with resident and/or personal representative; -Notification of residents' roommate and legal representative or interested family member; -Resident's response to transfer; -This facility will ensure that an interchange of medical and other pertinent information useful in the care and treatment of the resident at the time of the transfer from this facility; -Residents transferred from the facility will be accompanied by a copy of the history and transfer forms which include the physical exam report, nursing summary, and report of physician's orders prescribed; -No medications are sent with the resident unless the facility has physician's orders prescribed; -The administrator or his/her designee will notify all organizations, agencies, or groups working with the resident of the transfer; -A reasonable effort will be made to arrange for services to assure continuity of care in meeting the resident's needs through other resources, which will be summarized in a discharge plan; -The transfer policy/procedure did not direct staff to send a written notice to the resident, resident representative, or ombudsman of the resident's transfer to the hospital. 1. Record review of Resident #38's nurses' notes showed the following information: -On 9/14/18, at 4:32 P.M., the resident had a change of condition and spiked a temperature of 102.2 this afternoon and had decreased level of consciousness. This nurse notified the emergency medical services (EMS) and the resident left the facility at 4:30 P.M. The nurse documented the resident's vitals as temperature 102.2, pulse 124, respirations 22, oxygen saturation level of 86% on room air, and blood pressure of 160/90. Oxygen applied at two liters per nasal cannula and his/her oxygen saturation levels went up to 92%. Some facial drooping on the right side and the resident's grips were weak on the right side. The resident noted to have coughing with meals and emesis after meals. The nurse notified the resident's guardian, physician, director of nursing (DON), and administrator. The resident went to the hospital; -On 9/18/18, at 7:20 P.M., the resident returned to the facility via ambulance accompanied by ambulance attendants. Record review of the resident's medical record did not show any letter sent to the responsible party or to the ombudsman regarding the transfer on 9/14/18. 2. Record review of Resident #41's nurses' notes showed the following information: -On 9/24/18, at 1:54 P.M., the nurse assessed the resident due to a concerning statement from a certified medication technician (CMT). He/she said the resident was difficult to arouse, did not eat lunch, and would not take his/her medications. Upon assessment, the resident's pupils were unequal with the right being smaller than the left and right eye slower to respond than the left. The resident was also difficult to arouse and would not respond to commands. He/she was also having difficulty speaking. This nurse called the resident's family who said it was fine to send the resident out. The nurse faxed the physician and EMS arrived and took the resident at 1:50 P.M., to the hospital; -On 9/24/18, at 7:40 P.M., the resident returned from the hospital emergency room at 7:30 P.M. accompanied by two emergency services technicians (EMT). Record review of the resident's medical record did not show any letter sent to the responsible party or to the ombudsman regarding the transfer on 9/24/18. During a telephone interview on 11/28/18, at 8:57 A.M., the resident's family member said he/she had been notified of the hospital stay in September by telephone. He/she had not been given a written notice of the transfer to the hospital. 3. During an interview on 11/28/18, at 10:41 A.M., the administrator said whether written notices were sent to family or the ombudsman regarding a resident sent to the hospital would be a social service question. 4. During an interview on 11/28/18, at 10:42 A.M., the Social Service/Business Office Manager (SS/BOM) A said the social service staff send a report at the end of each month to the ombudsman of which residents had been sent to the hospital. The social service staff had only been able to find a copy of the report sent to the ombudsman for August 2018. He/she did not know if social services had sent written notices to the resident or residents' representatives regarding the residents who had been sent to the hospital. 5. During an interview on 11/28/18, at 10:44 A.M., Social Service Director (SSD) B said he/she sent a notice at the end of each month to the ombudsman of the residents who had been sent to the hospital. He/she could not find a copy of the reports that had been sent to the ombudsman. He/she did not send written notices to the resident or resident's representative. 6. During an interview on 11/28/18, at 4:00 P.M., the administrator said he/she did not know that the resident or resident representative had to be given a written notice that the resident had been sent to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #10's face sheet showed the resident admitted to the facility on [DATE], with a diagnosis of type 2 diabetes mellitus without control. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/13/18, showed the following information: -Diagnoses included diabetes mellitis; -The resident received insulin injections during the last 7 days of the 7 day assessment lookback period. Record review of the resident's care plan, updated 11/16/18, showed the following information: -The resident was an insulin dependent diabetic and chooses not to stick to the recommended diet; -The staff will continue to encourage dietary compliance and the provider will be notified of symptomatic blood glucose levels; -Interventions included accucheks before meals (AC), at bedtime (HS), and as needed (PRN), notify the provider if emergency blood glucose protocols are used and if blood glucose levels are above range for notification, monitor for signs and symptoms the resident's blood sugar is too high or too low. Record review of the resident's November 2018 POS showed the following orders: -3/8/18, Accucheks AC and HS; -3/8/18, Novolog (an insulin used for diabetes that quickly absorbs in the bloodstream) 10 units subcutaneous (SQ) injection before meals; -3/8/18, Novolog SQ injection per sliding scale before meals. If blood glucose is less than 60, call the medical director (MD). If blood glucose is greater than 340, give 16 units and call the MD; -3/8/18, Tradjenta (an oral medication that aides in treating type 2 diabetes mellitis) 5 milligrams (mg) by mouth once a day; -7/3/18, Tresiba (a long-acting insulin used to control high blood glucose) FlexTouch insulin pen 48 units SQ at HS. Record review of the resident's August 2018 medication administration record (MAR) and nurses' notes showed on 8/23/18, at 11:27 A.M., the resident had a blood glucose level of 355. Staff administered insulin, but did not notify the physician. Record review of the resident's September 2018 MAR and nurses' notes showed the following information: -On 9/3/18, at 4:07 P.M., the resident had a blood glucose level of 381. Staff administered insulin, but did not notify the physician; -On 9/6/18, at 7:02 P.M., the resident had a blood glucose level of 490. Staff administered the insulin and the nurse called the physician and awaited phone call. No response from the physician documented; -On 9/9/18, at 12:19 P.M., the resident had a blood glucose level of 355. The CMT administered insulin and notified the nurse, but the nurse did not notify the physician. Record review of the resident's October 2018 MAR and nurses' notes showed on 10/7/18, at 11:53 A.M., the resident had a blood glucose level of 399. Staff administered the insulin, but did not notify the physician. Record review of the resident's November 2018 MAR showed the following information: -On 11/27/18, at 12:16 P.M., the resident had a blood glucose level of 402. The CMT administered insulin and notified the charge nurse. The nurse did not notify the physician; -On 11/27/18, at 4:06 P.M., the resident had a blood glucose level of 378. Staff administered the insulin, but did not notify the physician. During an interview on 11/30/18, at 10:23 A.M., the Director of Nursing (DON) said Resident #10's blood glucose level fluctuates due to noncompliance and his/her blood glucose sometimes is high if he/she has a urinary tract infection. 3. During an interview on 11/29/18, at 11:38 A.M., CMT H said if an accuchek is out of range, the CMT should notify the charge nurse immediately and recheck a different finger. If the resident's blood glucose was low, he/she would hold the insulin, give the resident some juice or a snack, notify the nurse immediately, and recheck the resident's blood glucose in 30 minutes. He/she would notify the charge nurse if a resident's blood glucose level was above 250. He/she would notify the nurse before administering the insulin to see if the physician's order is changed. The nurse documents actions taken on the MAR. 4. During an interview on 11/30/18, at 12:41 P.M., CMT I said if a resident's blood glucose was out of range, he/she would report it to the nursing supervisor, and recheck the resident's blood glucose in 30 minutes. If the resident's blood glucose was too low, he/she would give the resident orange juice and if it came up, report to the nurse and follow their instructions. 5. During an interview on 11/30/18, at 12:45 P.M., LPN G said if there was an order for contacting the physician for a high blood glucose, then contact the physcian first, before administering the insulin. The physician should be notified any time a resident has a blood glucose out of range per the physician's orders. 6. During an interview on 11/30/18, at 10:23 A.M., the DON said the CMTs are all certified to administer insulin. If a CMT is hired and is not insulin certified, then they are certified by a certified instructor in the facility. The DON said if a resident's blood glucose is out of range, the CMT should first recheck the resident's blood glucose using a different finger. If the resident's blood glucose is still high and the order states to call the physician if over a certain number, then the CMT should notify the charge nurse. The charge nurse should assess the resident for signs and symptoms of hyperglycemia and notify the physician to see if he wants to change the orders. All orders read to go ahead and administer the insulin if it's high and then call the physician. If a resident's blood glucose level is low, then the CMT should hold the insulin and notify the nurse. The nurse should give the resident a sugar-containing substance, recheck the resident's blood glucose level in 30 minutes, and notify the physician even if it is within normal range at the recheck. The nurse can contact the physician by telephone or fax if it is indicated on certain residents. The nurse would place a telephone order if the physician changes the orders. The nurse should also document the new order and notification of the physician in the nurses' notes. The CMT can make a note in the MAR, but they don't always do it. The DON said she would expect the CMT to report a high blood glucose level to the nurse for any resident. The nurse should report high and low blood glucose levels to the physician as the order states. Based on interview and record review, the facility failed to notify the physician of high and low blood glucose levels at the time of insulin administration for two diabetic residents (Resident #10 and Resident #38) as directed by nursing standards of practice, facility policy, and/or physician orders out of a sample selection of 13 residents. The facility census was 50. Record review of the facility's policy titled, Insulin Injection, dated 12/26/16, showed the following information: -Staff should assess the physician's order for insulin and assess glucose levels; -Staff should document date and time, type and dosage, and route and exact location of the injection site; -Staff should implement the facility's hypoglycemia protocol if a resident's blood glucose is less than 90. Record review of the facility's policy titled, Treatment of Hypoglycemia, dated 12/26/16, showed the following information: -Any residents that have accucheks (blood glucose level testing) ordered will be on the daily accucheks list; -Blood glucose level below 90 per accuchek machine will be repeated once to verify accuracy; -Upon receiving notification of a low blood glucose level, the charge nurse will begin implementation to correct the level with appropriate nutritional supplement. If the resident is alert and able to take fluids by mouth, give 6 ounces of milk or juice with two sugar packets; -Intramuscular (IM) glucagon (a solution containing glucose that raises the blood glucose level) is available if the physician has given orders for administration. If the resident is unresponsive or unable to take fluids by mouth, the physician should be notified immediately. If the physician is not immediately available, emergency services will be contacted for immediate assistance; -In situations where the resident is responding to oral treatment, the charge nurse will notify the primary care provider of the occurrence, treatment, and outcomes as soon as possible; -Follow up accucheks will be taken at 30 minute intervals until the resident reaches a level of 100 or above. After reaching 100, two more additional readings will be taken at 30 minute intervals; -There should be complete charting in the nurses' notes of low blood glucose, actions completed, and response, including all accucheks and the time at which they were taken; -The registered nurse (RN) supervisor should be notified of occurrence so that follow up documentation can be assured. 1. Record review of Resident #38's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -Date of admission 7/28/16, and most recent re-admission date of 9/18/18; -Diagnoses included diabetes, dementia with behavioral disturbances, and adult failure to thrive; -Hospice. Record review of the resident's care plan, last updated 10/10/18, showed the following information: -At risk for multiple declining health issues and is currently on hospice; -Diabetic puree diet with pudding thickened liquids. No straws; -Monitor to ensure the resident does not get food and fluids from other residents that are not on his/her diet; -Dined in the assisted dining room and required assistance of one staff to eat; -Accu cheks before meals, at bed time, and as needed; -Routine and sliding scale insulin as ordered; -Watch for increased confusion, cold or clammy skin, increased heart rate, anxiety, tremors, faintness, dizziness, nausea, thirst, changes in appetite, and increased urination as these may be signs of high or low blood glucose. Record review of the resident's November 2018 physician order sheet (POS) showed the following information: -Novolog (rapid acting insulin) Flex Pen U-100 Insulin (insulin aspart u-100) per sliding scale as follows: -If blood glucose level is 200 to 249, give two units; -If blood glucose level is 250-299, give three units; -If blood glucose level is 300-349, give four units; -If blood glucose level is 350-399, give five units; -If blood glucose level is greater than 399, give six units subcutaneous (under the skin); -The order did not give parameters for staff to report if blood glucose was out of range; -Tresiba (long acting insulin) FlexTouch U-100 (insulin degludec) insulin pen, give 60 units subcutaneous in the morning at 9:00 A.M.; -Glucagon (a hormone that raises the level of glucose (a type of sugar) in the blood) one milligram (mg) injection as needed for low blood glucose if resident unable to take anything by mouth; -Accu cheks before meals and at bed time. Record review of the resident's nurse's note, dated 10/22/18, at 8:25 A.M., showed the resident's blood glucose level was 53. The resident drank a glass of orange juice with two sugars in it and ate 100% of his/her breakfast. At 8:00 A.M., the resident's blood glucose level was 71. At 8:20 A.M., the resident's blood glucose level had come up to 111. Staff did not document they had notified the physician of the resident's low blood glucose levels. Record review of a nurse's note, dated 10/25/18, at 5:48 A.M., showed at 5:30 A.M., the resident's blood glucose was 48. The nurse had the certified nurse's aide (CNA) give the resident a thickened orange juice with sugar in it. The resident took the orange juice and this information was passed on to the day shift nurse and the certified medication technician (CMT) that the resident's blood glucose would need to be rechecked soon to see if there were improvements. Staff documented the resident's blood glucose had been rechecked on 10/25/18, at 7:27 A.M., and his/her blood level was 148 at this time. Staff did not document the physician had been notified of the resident's low blood glucose. Record review of a nurse's note, dated 10/26/18, at 8:30 A.M., showed the resident's blood glucose level dropped to 42 this morning. The resident was not taking anything by mouth. Staff notified the the physician at 7:40 A.M. The physician gave an order to decrease the resident's Tresiba to 60 units daily and also added an as needed glucagon injection order if the resident's blood glucose levels dropped low again and he/she was unable to take anything by mouth. The resident did start drinking and at 8:30 A.M., his/her blood glucose came up to 85. Staff will continue to monitor. Record review of a nurse's note, dated 10/27/18, at 5:00 A.M., showed the resident's fasting blood glucose level was 42 and the only symptom noted was that he/she had increased lethargy. Staff offered the resident yogurt and ice cream and with staff assistance the resident consumed both items. Staff will continue to monitor the resident and recheck his/her blood glucose in 30 minutes. Staff rechecked the resident's blood glucose level at 5:39 A.M., and the resident's blood glucose level was now 97. Staff did not document the physician had been notified of the resident's low blood glucose. Record review of the resident's insulin administration record, dated 11/29/18, showed the following information: -At 7:00 A.M., the resident's blood glucose level was 76; -At 11:00 A.M., the resident's blood glucose level was 420; -At 8:00 P.M., the resident's blood glucose level was 252; -Staff did not document notification to the physician of the blood glucose level being over 400. During an interview on 11/30/18, at 10:23 A.M., the Director of Nursing (DON) said Resident #38's blood glucose level runs high sometimes and the nurse should report the blood glucose level to the physician if it is above the level stated on the insulin sliding scale orders.

Observation and interview on 11/27/18, at 10:20 A.M., showed Registered Nurse (RN) K entered the resident's room, washed his/her hands, and applied clean gloves. RN K removed the soiled dressing on the left calf. RN K measured the resident's left calf abrasion at 1.8 centimeters (cm) x 0.5 cm and described the wound bed as slightly reddened and scabbed with the peri wound (area around the wound) measuring 3.5 cm x 1.5 cm. RN K did not cleanse the wound, wash his/her hands, or change his/her gloves before he/she covered the wound with Duoderm. RN K did not wash his/her hands or change his/her gloves. RN K measured the right posterior upper calf abrasion at 5 cm x 1 cm and described the wound as scabbed and reddened. RN K did not cleanse the wound, wash his/her hands, or change his/her gloves. RN K placed a Duoderm dressing on the resident's right calf. RN K did not wash his/her hands or change gloves before he/she removed the soiled dressing on the resident's left shin and cleansed the wound with wound cleanser. RN K measured the wound at 1.5 cm x 0.5 cm wound base with yellow slough (dead tissue) and the peri wound at 4 cm x 2 cm. RN K did not wash his/her hands or change his/her gloves. RN K applied skin prep around the wound and placed a Duoderm dressing on the wound. RN K did not wash his/her hands or change gloves. RN K removed the soiled dressing on the resident's coccyx. RN K did not wash his/her hands or change gloves. RN K described the wound as follows: left coccyx 2.4 cm x 2.5 cm, 5% at 1 o'clock, clean and pink purple color with 1.8 cm x 1 cm unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) and the right coccyx, 1.2 cm x 0.8 cm, clean and pink color, Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) with no measurable depth. RN K cleansed the wound with gauze soaked with wound cleanser, applied skin prep around the wound, and placed a bordered foam dressing on the wound. RN K removed his/her gloves and washed his/her hands. During an interview on 11/27/18, at 11:29 A.M., RN K said the Director of Nursing (DON) conducts infection control inservices. Staff should wash his/her hands and apply clean gloves when he/she enters the room, when his/her gloves become soiled, and when going from a clean area to a dirty area, and before he/she leaves the room. When the nurse performs dressing changes using a clean technique, he/she should wash his/her hands when entering a resident's room and after removing the old dressing. The nurse should work from the cleanest wound to the worst wound. The nurse should change his/her gloves when going from one wound to another. He/she didn't change his/her gloves between Resident #38's two closed wounds because they were scabbed over. During an interview on 11/30/18, at 10:45 A.M., the DON said the nurses do all wound care. The wound care program is being led by the wound nurse, RN K and he/she assesses the identified wounds weekly. If a resident has multiple wound treatments, the nurse should start from the cleanest wound and work to the dirtiest. The nurse should wash his/her hands, don gloves, clean the first wound, wash his/her hands and glove, then apply the treatment. When the nurse moves to the next wound, he/she should wash his/her hands, apply clean gloves, and follow the same process. It is important for the nurse to wash his/her hands and apply clean gloves after cleaning a wound and before placing the dressing so he/she is not contaminating the wound. The nurse should clean any wound the nurse is treating with a dressing. Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to handwashing when staff failed to wash hands and change gloves during wound care for one resident (Resident #38). A sample of 13 residents was selected for review out of a facility census of 50. Record review of the Center for Disease Control's (CDC) Guideline for Hand Hygiene in Healthcare Settings, dated 2002, volume 51 showed the following information: -The hands are the most common mode of transmitting pathogens (microorganisms); -Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance (infections caused by microorganisms that are resistant to antibiotics) in healthcare settings; -Hand hygiene reduces the number of healthcare associated infections; -There is substantial evidence that hand hygiene reduces the incidence of infections. Record review of Brunner and Suddarth's textbook of Medical-Surgical Nursing, ninth edition, Guidelines for Standard Precautions, showed staff should do the following: -Wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites; -Change gloves between tasks and procedures on the same patient after contact with materials that may contain a high concentration of microorganisms; -Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient. Record review of the facility's (undated) policy titled, Infection Control Guidelines for Long Term Care Facilities: Body Substance Precautions, showed the following information: -The Body Substance Precautions System should be followed by all personnel at all times regardless of the resident's diagnosis; -The Body Substance Precautions System includes wearing gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash; -Gloves must be changed between residents and between contacts with different body sites of the same resident. Record review of the facility's policy titled, Handwashing/Hand Hygiene and Sanitizing Gels, dated 3/3/16, showed the following information: -The goal is to prevent the transmission of pathogens to residents by performing hand hygiene at key times in resident care to prevent this transmission; -Hands are to be washed after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); -Hands are to be washed after touching wounds; -Hands are to be washed after contact with any body fluids, excretions, or secretions; -Hands are to be washed before and after donning gloves; -Hands are to be washed any time there is a possibility of cross contamination. Record review of the facility's policy titled, Wound Care Procedure, dated 12/26/16, showed the following information: -Wash hands and don gloves before contact with the resident, after removing soiled dressings, after cleansing the wound, and before applying the clean dressing; -If at any time during the procedure, gloves become soiled or contaminated, hands must be washed and new gloves must be applied. 1. Record review of Resident #38's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -Date of admission 7/28/16 with most recent admission date of 9/18/18; -Diagnoses included peripheral vascular disease (PVD- a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm. This can happen in your arteries or veins. PVD typically causes pain and fatigue, often in your legs) and adult failure to thrive. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 10/10/18, showed the following information: -Severe cognitive impairment; -Required extensive staff assistance of two staff for bed mobility, dressing, and bathing; -Required total assistance of two staff for transfers, toileting, and hygiene; -Indwelling catheter and incontinent of bowel; -At risk for pressure ulcers. No current pressure ulcers; -Hospice. Record review of the resident's physician order sheet (POS), dated November 2018, showed the following information: -Apply house barrier cream to buttocks as needed after incontinent episodes with a start date of 9/18/18; -Monitor abrasions to the top of the left foot and posterior (near the rear or hind end) proximal (something that is situated closest to the attachment or point of origin) left lower leg for signs of open areas or abrasions, dated 10/23/18; -Cleanse left shin and left and right posterior lower leg with hypochlorous acid ( a weak acid that forms when chlorine dissolves in water and is highly active against all bacterial, viral, and fungal human pathogens) and apply skin prep (a liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes and films) to intact skin around the wounds. Apply Duoderm ( a brand name for a commonly used hydrocolloid dressing-moisture retentive wound dressing used to treat pressure ulcers) to all three wounds and change every seven days until healed, dated 11/19/18; -Cleanse the coccyx with hypochlorous acid, apply Mepilex ( an absorbent foam dressing that minimizes trauma and pain to the wound and during dressing changes and is used for wound exudate (drainage)) every three days and as needed, dated 11/25/18.

3. Record review of Resident #1's EHR showed the following information: -The facility admitted the resident on 6/11/18 with the most recent admission date of 7/20/18; -The resident's diagnoses included acute osteomyelitis (infection of the bone), type 2 diabetes mellitus, heart disease, and congestive heart failure. Record review of the resident's paper medical record showed a DNR request signed by the DPOA and the physician on 7/24/18. Record review of the resident's paper medical record face sheet showed the resident as a full code. Record review of the November 2018 POS in the resident's paper medical record showed the resident as a full code. Record review of the resident's EHR face sheet showed the resident's code status as DNR. Record review of the resident's care plan, last reviewed on 11/23/18, showed the resident as a DNR code status. 4. Record review of Resident #29's EHR showed the following information: -The facility admitted the resident on 9/13/16; -The resident's diagnoses included chronic pain, high blood pressure, heart failure, respiratory disease, and Stage 4 chronic kidney disease. Record review of the resident's paper medical record showed the resident signed a full code request on 11/21/18. Record review of the resident's face sheet in the paper medical record showed the resident as a full code. Record review of the resident's care plan, last reviewed on 10/4/18, showed the resident as a DNR. Record review of the November 2018 POS in the paper medical record showed the resident as a DNR. 5. During an interview on 11/29/18, at 10:15 A.M., Certified Medication Technician (CMT) J said he/she prints out an updated POS and places it in the paper medical record when he/she is verbally notified by SS B that a resident has changed their code status. 6. During an interview on 11/30/18, at 12:46 P.M., CMT I said if a resident were to code, he/she would check the resident's paper medication administration record (MAR) and face sheet to see if the resident was a full code. 7. During an interview on 11/29/18, at 9:55 A.M., Social Services (SS) B said he/she reviews the resident's code status and advance directives when a resident is admitted , wants to change their code status, and with their annual MDS. He/she completes the code status request form with the resident and/or durable power of attorney (DPOA) and the physician signs off on DNRs. If a resident wants to change their code status, then he/she updates the code status request form with the resident's and the physician's signature, and updates the face sheet in the computer and hard chart. CMT J updates the physician order sheet and prints it out for the hard chart. All code status areas of the hard chart and electronic medical record should match and reflect the wishes of the resident or the DPOA. 8. During an interview on 11/30/18, at 12:45 P.M., Licensed Practical Nurse (LPN) G said if a resident were to code, he/she would check the resident's paper chart to see if they are a DNR or full code. If the resident had a DNR, then he/she would check the DNR for the physician's signature. 9. During an interview on 11/30/18, at 10:36 A.M., the DON said all new admissions are full code unless they have an out of hospital DNR signed by a physician. If they desire to be a DNR, SS B reviews code status with all new admissions. All DNRs have to be signed by the physician to be active. If they are not signed by the physician, then the resident is considered a full code status. SS B updates the face sheet in the computer and should put an updated copy of the face sheet in the paper chart. CMT J should print out the updated POS and place it in the chart. There is a lack of communication between SS B and CMT J. If a resident codes (stops breathing, lack of heart beat), the staff look in the hard chart at the code status sheet in the front of the chart and make sure it is signed by the physician. The code status should match in all parts of the resident's electronic and paper medical record. Based on record review and interview, the facility failed to ensure the resident's code status was accessible to staff in the event of an emergency when the residents' code status information did not match throughout the electronic health record (EHR) and paper medical records for four residents (Resident #35, #38, #1, and #29) out of a sample of 13 residents. The facility census was 50. Record review of the facility's policy titled, Advanced Directive, dated 1/24/16, showed the following information: -The facility will assist residents in their healthcare decision making and to assure the legal rights of both capacitated and incapacitated residents will be protected and applied; -It is the resident's or legal surrogate's responsibility to provide the facility with copies of advance directives currently in place; -The facility will follow the directions given by each resident with regard to accepting or refusing medical or surgical treatment to the extent permitted by law; -If an incapacitated resident did not execute an advance directive while competent, the facility will consult the appropriate person in the following succession: court appointed guardian, spouse, adult children, parents, and adult siblings. The facility may petition for a court appointed guardian for a resident without advance directives. In the instance where there are equal durable power of attorney for health care that are conflicting in opinion, the facility may also consider petitioning for a court appointed guardian; -Residents may revoke any advance directive by notifying their attending physician, nurse, or social worker; -The procedure for advance directives showed the education and information would be provided by social service staff. At the time of admission, the resident/designee will be provided written information concerning the resident's rights under state law to make decisions concerning health care including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. The advance directive will be reviewed annually for desired changes or to allow capable residents to formulate an advance directive if not previously done. Review will be documented on the Resident Care Plan Quarterly by Department form; -The social worker or designee shall document in the medical record whether the resident has executed any advance directive, and copies of each shall be made a part of the permanent medical record which is filed under the advance directive tab in the chart; -Forms of advance directives are as follows: -Living Wills/Healthcare Directive; -Durable Power of Attorney for Healthcare; -Any other signed and dated written document that expresses the individual's health care treatment decisions; -Per state law, the resident must sign the document and have it witnessed by two individuals who are not related to them nor have financial connections to the resident. The Durable Power Of Attorney (DPOA) must also be notarized; -If the resident has a advance directive from another state, consultation may be sought; -In the event a resident desires to complete an advance directive, social services shall be notified to assist if needed. When a DPOA for healthcare is completed with the assistance of social services, a copy will be sent to all agents; -The charge nurse, or designee, shall forward a copy of any advance directive, along with any routing transfer information, when a resident is transferred; -A capacitated resident has the right to change or revoke their advance directive at any time, in accordance with state law; -If any staff member, contractual service or in-house provider is unwilling to honor any advance directive, the administrator or director of nursing (DON) shall be notified immediately; -The advance directive goes into effect when the resident becomes incapacitated, or as indicated, or when the resident is unable to make or communicate a decision. If verification of incapacity is required, the primary physician must document that the resident is incapacitated in order for the DPOA for Healthcare to take effect, If the advance directive requires two physicians' statements, the facility will assist by coordinating an appointment with another physician. Any cost will be at the resident's expense. 1. Record review of Resident #35's EHR showed the following information: -admission date of 8/09/18; -Diagnoses included dementia (decline in memory or thinking and social symptoms that interfere with daily functioning) with behavioral disturbances, anxiety disorder, high blood pressure, and heart disease. Record review of the resident's EHR face sheet (a document that gives a resident's information at a quick glance) showed staff documented the resident's code status as do not resuscitate (DNR, legal order to withhold cardiopulmonary resuscitation in case a resident's heart were to stop or to stop breathing). Record review of the EHR November 2018 physician order sheet (POS) did not show the resident's code status. Record review of the resident's face sheet in the paper medical record showed staff documented the resident as a full code (provide cardiopulmonary resuscitation in the case a resident's heart stopped beating or breathing stopped). Record review of the November 2018 POS in the paper medical record showed the resident as a full code. 2. Record review of Resident #38's EHR showed the following information: -admission date of 7/28/16 with the most recent admission date of 9/18/18; -Diagnoses included respiratory disease, diabetes, major depressive disorder, psychotic disorder with delusions, dementia with behaviors, and adult failure to thrive. Record review of the resident's EHR face sheet showed staff documented the resident's code status as DNR. Record review of the EHR POS showed the resident as DNR. Record review of the resident's face sheet in the paper medical record showed staff documented the resident as a full code. Record review of the November 2018 POS in the paper medical record showed the resident as a full code. Record review of a nurse's note, dated 10/04/18, at 11:55 A.M., showed the nurse contacted the guardian public administrator's office and spoke to a staff member at the public administrator's office regarding the resident's condition and possibly placing the resident on Hospice services. The public administrator was not in the office but the staff person would pull his/her file and talk to the public administrator when he/she was back tomorrow. The facility staff also spoke to the staff person about changing the resident to a DNR. The facility staff documented they would wait to contact the resident's physician regarding his/her code status until they had spoken to the public administrator.