Based on observation, interview, and record review, the facility failed to assess the use of bed and chair alarms (devices that contain sensors that trigger an alarm when they detect a change in pressure) to determine if utilized as restraints, to complete on-going evaluations for the continued need, and to identify a medical symptom that supported the use of the bed and chair alarms for one resident (Resident #45) out of one sampled resident. The facility census was 63. Review of the facility's policy titled, Safety and Supervision of Residents, revised July 2017, showed: - Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities; - The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices; - Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. 1. Review of Resident #45's medical record showed: - Diagnoses of senile degeneration of the brain (a decline in an individual's memory, behavior, and cognitive abilities), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), atrial fibrillation (an abnormal heart beat), benign prostatic hyperplasia (BPH - enlargement of the prostate causing difficulty in urination), hypertension (high blood pressure), diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), pain, functional dyspepsia (a term used to describe a lingering upset stomach that has no obvious cause), muscle weakness, and need for assistance with personal care; - No documentation of a medical symptom to support the use of the bed and chair alarms; - No documentation of the bed and chair alarms assessed as a restraint or consent for use. Review of the resident's Physician Order Sheet (POS), dated 04/01/25, showed: - An order for a sensory alarm on and checked every shift. Ensure the alarm is working properly and placed under the resident, dated 01/23/25; - The order did not address the medical symptom for the use of the bed and chair alarms. Review of the resident's Progress Notes showed: - On 01/23/25 at 5:46 A.M., the resident was found on the floor; - On 01/24/25 at 12:19 A.M., the resident fell. A pressure alarm was placed on the resident's bed; - On 01/30/25 at 5:46 A.M., the resident's pressure alarm sounded. The resident found on the floor; - On 02/03/25 at 9:49 P.M., the resident had an unwitnessed fall out of the bed; - On 02/10/25 at 2:33 P.M., the resident's alarm went off. The resident was on the floor with his/her head against the nightstand; - On 02/18/25 at 12:16 A.M., the resident found on the floor; - On 02/19/25 at 10:02 P.M., the resident's pressure alarm sounded at 3:00 P.M. The resident was on the floor; - On 03/06/25 at 9:36 P.M., resident had a witnessed fall in his/her room at 9:00 P.M., - On 03/15/25 at 3:52 A.M., the resident's bed alarm sounded at 11:45 P.M., and the resident was found on the floor; - On 03/17/25 at 10:29 P.M., at 10:00 P.M., the resident's alarm sounded and the resident was found on the floor; - On 03/18/25 at 11:51 P.M., the resident had a witnessed fall in the room. The alarm sounded when the resident slipped out of the bed; - On 03/22/25 at 8:36 P.M., at 7:26 P.M., the resident's bed alarm sounded and the resident was found on the floor; - On 03/22/25 at 8:39 P.M., at 8:30 P.M., the resident's bed alarm sounded again. The resident was found on the floor. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 03/19/25, showed: - Cognition severely impaired; - Dependent for eating, lower body dressing, personal hygiene, and putting on/taking off foot ware, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer; - Substantial/maximal assistance for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, roll left and right, sit to lying, lying to sit on side of bed; - Dependent for use of wheelchair for mobility; - Bed, chair, and motion alarms not used. Review of the resident's comprehensive care plan, revised 01/29/25, showed: - Impaired cognitive function/dementia or impaired thought processes related to dementia; - High risk for falls related to confusion, gait/balance problems, poor communication/comprehension, unaware of safety needs; - Potential for pressure ulcer development related to incontinence and requiring assistance with transfers and ambulation; - Bladder incontinence related to dementia; - Interventions include resident uses bed electronic alarm, anticipate and meet the resident's needs, 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 request for assistance. Check as required for incontinence. Observations of the resident showed: - On 04/01/25 at 10:48 A.M., and on 04/04/24 at 1:20 P.M., the resident sat in a recliner in the room. The chair alarm lay over the left arm of the recliner, out of reach of the resident, and the pressure pad under the resident's buttocks. The resident was unable to remove the chair alarm; - On 04/01/25 at 3:43 P.M., the resident lay in bed and a bed alarm hung at the head of the bed attached to a pressure pad under resident's lower back. The resident was unable to remove the bed alarm; - On 04/02/25 at 8:33 A.M., the resident lay in bed with the bed alarm attached to the pressure pad under the resident's lower back. Incontinent care performed and staff did not check the bed alarm at any time while in the room. The resident was unable to remove the bed alarm; - On 04/02/25 at 11:46 P.M., the resident sat in a wheelchair with chair alarm attached to the back of the wheelchair on the handle and a pressure pad under the resident's thighs and buttocks. The chair alarm was out of reach of the resident. The resident was unable to remove the chair alarm. During an interview on 04/04/25 at 1:20 P.M., Resident #45 said he/she didn't know about any alarms and didn't know why he/she would have them. During an interview on 04/04/25 at 1:40 P.M., the MDS Coordinator said the bed and chair alarms the facility used were used for safety for Resident #45 due to multiple falls. During an interview on 04/04/25 at 1:52 P.M., the Director of Nursing (DON) said there was no assessments or a consent for the sensory alarms. The bed and chair alarms were used for safety, as a last resort due to Resident #45 had multiple falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Residents #27 and #45) out of 16 sampled residents. The facility's census was 63. Review of the facility's policy titled, Resident Assessments, revised November 2019, showed: - All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 1. Review of Resident #27's medical record showed: - An admission date of 03/15/25; - Diagnoses of acute kidney failure; - Hospital discharge paperwork, dated 03/15/25, a discharge exam of the resident with a right nephrostomy (a thin, flexible tube inserted into the kidney through an opening in the skin to drain urine directly from the kidney) tube and a urostomy (a surgical procedure that creates an opening in the abdomen to allow urine to exit the body) in place. Review of the resident's admission MDS, dated [DATE],showed: - The resident did not have a nephrostomy. 2. Review of Resident #45's medical record showed: - An admission date of 01/22/25; - Diagnosis of senile degeneration of the brain (a decline in an individual's memory, behavior, and cognitive abilities); - Nurse's Note, dated 01/22/25, the resident under hospice care; - admitted to hospice on 04/01/24; - An order for a sensory alarm (a physical device which can capture and detect the movement of resident) on and checked every shift, ensure alarm is working properly, and placed under resident, dated 01/23/25. Review of the resident's quarterly MDS, dated [DATE], showed: - The resident did not receive hospice care; - The resident did not use an alarm. During an interview on 04/04/25 at 1:30 P.M., the Administrator and the Director of Nursing (DON) said they would expect the MDS assessments to be coded accurately. During an interview on 04/04/25 at 1:40 P.M., the MDS Coordinator said the nephrostomy should be addressed on Resident #27's MDS. Hospice should be addressed on the MDS if a resident was under the care of hospice. If a sensory alarm wasn't being used as a restraint for Resident #45, then the alarm wouldn't be addressed on the MDS. During an interview on 04/04/25 at 1:52 P.M., the Director of Nursing (DON) said alarms should be addressed on the MDS and care plans.

Based on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #25) out of one sampled resident. The facility's census was 63. The facility did not provide a policy regarding the baseline care plan. 1. Review of Resident #25's medical record showed: - An admission date of 03/15/25; - Diagnosis of acute kidney failure. Review of the resident's Hospital Discharge paperwork, dated 03/15/25, showed: - A discharge exam of the resident with a right nephrostomy (a thin, flexible tube inserted into the kidney through an opening in the skin to drain urine directly from the kidney) tube and a urostomy (a surgical procedure that creates an opening in the abdomen to allow urine to exit the body) in place upon discharge from the hospital. Review of the resident's Baseline Care Plan, dated 03/15/25, showed: - Did not address the nephrostomy. Observation on 04/01/25 at 10:30 A.M., 04/02/25 at 9:35 A.M., and 04/03/25 at 8:45 A.M., showed the resident with a nephrostomy and an urostomy. During an interview on 04/03/25 at 11:00 A.M., Licensed Practical Nurse (LPN) F said the facility changed the bags to the urostomy and nephrostomy every three days like anything else. They also emptied the bags of the urostomy and nephrostomy every shift or as needed. They monitor the sites as well. During an interview on 04/04/25 at 1:15 P.M., Registered Nurse (RN) E said the facility did have to change the dressing to the nephrostomy site but he/she had never done it. During an interview on 04/04/25 at 1:30 P.M., the Director of Nursing (DON) said the resident had both a urostomy and nephrostomy. The nephrostomy should have been included on the baseline care plan. During an interview on 04/04/25 at 1:40 P.M., the Administrator said it was expected the baseline care plan included the care required by the resident during that initial time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents (Residents #45 and #57) out of three sampled residents receiving hospice (palliative care for the terminally ill with a life expectancy of six months or less) services had a complete hospice coordinated plan of care. The facility census was 63. Review of the facility's policy titled, Hospice Program, revised July 2017, showed: - Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being; - The coordinated care plan will reflect the resident's goals and wishes, as stated in his/her advanced directives and during on-going communication with the resident or representative, including palliative goals and objectives, palliative interventions, and medical treatment and diagnostic tests; - The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including, but not limited to, diagnosis; problem list; symptom management (pain, nausea, vomiting, etc.); bowel and bladder care; nutrition and hydration needs; oral health; skin integrity; spiritual, activity, and psychosocial needs; and mobility and positioning. 1. Review of Resident #45's medical record showed: - admitted to hospice on 04/01/24; - admitted to the facility on hospice on 01/22/25; - No order for hospice services. Review of the resident's Hospice and Facility Coordinated Plan of Care, dated 01/22/25, showed: - Did not address the date of admission to hospice; - Did not address the medical supplies and/or the durable medical equipment (DME - equipment that helps complete daily activities) provided by hospice; - Did not address the specific days of the hospice nurse and the hospice aide visits; - Did not address the care plan interventions or the responsible party. Review of the resident's Comprehensive Care Plan, dated 01/29/25, showed: - Did not address hospice. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be filled out by the facility staff, dated 01/28/25, and the quarterly MDS, dated [DATE], showed: - The resident did not receive hospice services. 2. Review of Resident #57's medical record showed: - admitted to hospice on 10/23/24; - admitted to the facility on hospice on 11/29/24; - No order for hospice services. Review of the resident's Hospice and Facility Coordinated Plan of Care, dated 11/29/24, showed: - Did not address the medical supplies and/or the DME provided by hospice; - Did not address the specific days of the hospice nurse and the hospice aide visits; - Did not address the care plan interventions or the responsible party. Review of the resident's Comprehensive Care Plan, revised date of 03/04/25, showed: - Resident under the care of hospice due to prostate cancer; - Interventions included to notify hospice the company of any changes in condition of the resident and to work closely with hospice staff to effectively meet the needs of the resident. Review of resident #57's quarterly MDS assessment, dated 3/5/25, showed: - The resident received hospice care. During an interview on 04/01/25 at 2:56 P.M., Resident #57 said he/she was currently on hospice. The hospice staff came in to visit a few times a week. During a phone interview on 04/04/25 at 12:44 P.M., the Physician said there should always be an order for hospice. During an interview on 04/04/25 at 1:40 P.M., the MDS Coordinator said if a resident was on hospice, the care plan should address the hospice care and address the resident was under the care of hospice. During an interview on 04/04/25 at 1:52 P.M., the Director of Nursing (DON) said a resident's care plan should identify hospice with interventions. The hospice coordinated plan of care should identify the exact days the hospice nurse and aides were to be in the building, what care would be done, such as showers and cares, and equipment provided. There should be an order for hospice. During an interview on 04/04/25 at 2:15 P.M., the Administrator said hospice was to provide the facility with what they would be doing and how care the care would be provided so the facility could incorporate it into the resident's care plan. There should be an order for hospice. If the resident admitted to the facility already on hospice, it should be already documented the resident was on hospice. He wasn't if an order was required for hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was kept off the floor for three residents (Residents #16, #27, and #117) and to ensure proper drainage position of a urinary catheter drainage bag for one resident (Resident #117) out of three sampled residents. The facility failed to ensure a resident with a urostomy (a surgical procedure that creates an opening in the abdomen to allow urine to exit the body) and a nephrostomy (a thin, flexible tube inserted into the kidney through an opening in the skin to drain urine directly from the kidney) had physician orders for one resident (Resident #27) out of one sampled resident. The facility census was 63. Review of the facility's policy titled, Catheter Care, revised September 2014, showed: - Be sure the catheter tubing and drainage bag are kept off the floor. The facility did not provide a policy regarding catheter devices and/or care. 1. Review of Resident #16's medical record showed: - admitted on [DATE]; - Diagnosis of urinary retention (an inability to empty the bladder of urine). Review of the resident's Physician Order Sheet (POS), dated 04/01/25, showed: - An order to change the suprapubic (a tube that goes into your bladder through the abdominal wall to drain urine from the bladder) 16 French (size of the catheter) catheter monthly every day shift starting on the 28th and ending on the 28th every month and as needed (PRN) for occlusion or leakage, dated 03/03/25; - An order for urinary catheter care every shift and PRN, dated 05/02/22; - An order for an urinary drainage bag, change monthly and PRN one time a day starting on the 20th and ending on the 20th every month, dated 01/22/24. Observation on 04/01/25 at 10:46 A.M., and 1:15 P.M., of the resident showed: - The catheter drainage bag with a privacy cover in place hung from the resident's bed frame and the drainage bag touched the floor. 2. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnosis of acute kidney failure. Review of the resident's POS, dated 04/01/25, showed: - No orders for the urostomy, the nephrostomy, and for the care of the urostomy and the nephrostomy. Review of the resident's Care Plan, dated 04/03/25, showed: - Resident had a nephrostomy and urostomy and required assistance with cleaning and changing of the bags. Review of the resident's admission Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 03/15/25, showed: - The resident had an urostomy; - The resident did not have a nephrostomy. Observations on 04/01/25 11:55 A.M., and 1:10 P.M., showed: - The resident sat in a wheelchair in his/her room with the urostomy and nephrostomy bags touching the floor hanging from under the middle of the wheelchair and without privacy bags. Observation on 04/02/25 at 12:15 P.M., showed: - The resident sat in a wheelchair in his/her room and six inches of the urostomy tubing lay on the floor. During an interview on 04/03/25 at 11:00 A.M., Licensed Practical Nurse (LPN) F said the facility changed the resident's urostomy and nephrostomy bags every three days like anything else. They also emptied the urostomy and nephrostomy bags every shift or as needed. They monitor the sites as well. During an interview on 04/04/25 at 1:15 P.M., Registered Nurse (RN) E said the facility did have to change the dressing to the nephrostomy site but he/she had never done it. 3. Review of Resident #117's medical record showed: - Date of admission [DATE]; - Diagnosis of obstructive and reflux uropathy (a condition where urine flows backward from the bladder into the ureters (the ducts between the kidneys and the bladder) and sometimes the kidneys). Review of the resident's POS, dated April 2025, showed: - An order for a Foley (a flexible tube inserted into the bladder to drain urine) catheter 16 French with a 10 milliliter (ml) balloon, dated 03/28/25; - An order to change the catheter ever 30 days and PRN every day shift starting on the 27th every month related to obstructive and reflux uropathy, dated 03/28/25; - An order to change the urinary catheter drainage bag PRN for bag leaks, dated 02/06/25; - An order to irrigate the urinary catheter with 60 ml of normal saline (salt water) PRN for occlusion or obstruction, dated 02/06/25. Observation on 04/01/25 at 11:20 A.M., and at 1:20 P.M., showed: - The resident lay in bed and the catheter bag and tubing lay on the floor; - The catheter bag not in a privacy cover. Observation on 04/02/25 at 9:37 A.M., of the resident's catheter and incontinent care showed: - Certified Nurse Assistant (CNA) C placed the resident's urinary catheter drainage bag on the foot of the bed; - The drainage bag was not positioned below the resident's bladder to drain. During an interview on 04/02/25 at 12:30 P.M., CNA C said catheter drainage bags should be below the bladder, off the floor, and have a privacy cover. During an interview on 04/03/25 at 2:43 P.M., CNA A said catheter drainage bags should be kept below the bladder, off the floor, and have a privacy cover. During an interview on 04/04/25 at 1:52 P.M., the Director of Nursing (DON) said catheter drainage bags should be placed hanging below the bladder, not touch the floor, and with a privacy cover in place. There should be orders for any catheter devices and/or care that was provided by the facility.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #117) out of two sampled residents, wound care for one resident (Resident #13) outside the sample of two sampled residents, and incontinent care for one resident (Resident #45) out of three sampled residents. The facility failed to utilize proper sterile technique for accessing a venous port (a medical device surgically placed under the skin in the chest area, providing access to a large vein for administering medications, fluids, or drawing blood) for one resident (Resident #27) out of one sampled resident. The facility census was 63. Review of the facility's policy titled, Catheter Care, Urinary, revised September 2014, showed: - The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; - Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag; - Wash and dry your hands thoroughly; - Put on gloves; - Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site to approximately four inches outward; - Discard the disposable items into designated containers. Remove gloves and discard into designated container; - Wash and dry your hands thoroughly. Review of the facility's policy titled, Perineal Care, revised February 2018, showed: - Wash and dry your hands thoroughly; - Put on gloves; - Obtain pre-moistened washcloths or wet washcloth and apply soap or skin cleansing agent; - Wash perineal (the thin layer of skin between the genitals and anus) area starting with the urethra and working outward; - If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches; - Wash and rinse the rectal area thoroughly; - Discard disposable items into designated containers; - Remove gloves and discard into designated container; - Wash and dry your hands thoroughly. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2019, showed: - This facility considers hand hygiene the primary means to prevent the spread of infections; - Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visibly soiled; - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty; before and after direct contact with residents; before performing any non-surgical invasive procedures; before and after handling an invasive device (e.g., urinary catheters, IV access sites); before putting on sterile gloves; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment, etc.; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; after removing gloves; before and after entering isolation precaution settings; - Hand hygiene is the final step after removing and disposing of personal protective equipment (PPE); - The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility's policy titled, Implanted Venous Port- Accessing, dated April 2016, showed: - Wash hands and assemble equipment on a clean surface near the resident; - Place a mask on yourself and on the resident; - Apply non-sterile gloves; - Palpate (examine by touch) the port, remove the gloves, wash hands, and open the dressing kit to prepare a sterile field; - Apply sterile gloves; - Flush air out of the non-coring needle and prime the tubing; - Clean the port area with antiseptic cleaning solution and air dry; - With the non-dominant hand palpate the port, hold the port steady, and insert the needle into the center of the port; - Check for blood return, flush, clamp tubing, and cover with sterile dressing. 1. Observation on 04/02/25 at 9:37 A.M., of Resident #117's catheter and incontinent care showed: - Enhanced Barrier Precautions (EBP) signage on the door frame; - Certified Nursing Assistant (CNA) C and CNA D put on gowns, did not perform hand hygiene, put on gloves, and entered the resident's room; - CNA C cleaned the catheter from the insertion site down the tubing with a wipe, moved back to the insertion site, did not use a clean area of the wipe, and wiped down the catheter again; - CNA C wiped from the insertion site down the catheter with a clean wipe, did not change gloves, did not perform hand hygiene, touched the catheter tubing and the catheter drainage bag to remove the resident's pants, assisted CNA D to put the resident's legs through a clean brief, touched the catheter tubing, and placed the catheter drainage bag on the foot of the bed; - CNA D tucked the brief soiled with fecal material between the resident's legs; did not change gloves; did not perform hand hygiene; assisted CNA C with the removal of the resident's pants and placed the resident's legs through a clean brief; removed the gloves; did not perform hand hygiene; touched the resident's cell phone, the bed side table, and the call light; removed the gown; and performed hand hygiene; - CNA C did not change gloves, did not perform hand hygiene, touched the perineal cleanser bottle, touched the wipe package, removed a wipe from the package, cleaned the fecal material from the resident's buttocks, did not change gloves, did not perform hand hygiene, touched the resident's shirt and bare leg to turn the resident, touched the wipe package, touched the trash bag, moved the catheter drainage bag from the foot of the bed to the bed frame, and touched the perineal cleanser bottle; - CNA C removed the gloves and gown and performed hand hygiene. During an interview on 04/02/25 at 12:30 P.M., CNA C said for catheter care should only wipe one time per wipe. For catheter or incontinent care, should perform hand hygiene, put gloves on, clean the resident, perform hand hygiene and change gloves, put on a clean brief, and wash hands when done. The catheter drainage bag should be below the bladder and off the floor with a privacy cover. 2. Observation on 04/02/25 at 8:33 A.M., of Resident #45's incontinent care showed: - CNA A and CNA B entered the room, performed hand hygiene, and put on gloves; - CNA A cleaned the resident's perineal area and did not use a clean area of the wipe for each swipe; - CNA A did not change gloves, did not perform hand hygiene, touched the resident's drawer handle, retrieved a clean brief, and touched the resident's bare right thigh; - CNA B touched the resident's perineal area, did not change gloves, did not perform hand hygiene, touched the resident's shirt, and assisted CNA A to turn the resident to the left side; - CNA A did not change gloves, did not perform hand hygiene, picked up the perineal cleanser bottle, retrieved a wipe from the package, wiped the resident's buttocks, did not change gloves, did not perform hand hygiene, closed the wipe package, picked up the perineal cleanser bottle, and sat it on the side table; - CNA A did not change gloves; did not perform hand hygiene; touched the resident's pillow and bed covers; removed a trash bag from his/her pocket and put it in the trash can; touched the resident's wheelchair handles, fall mat, call light, light switch by the sink, light switch by the door, and the door handle; exited the resident's room and walked down the hall to the common area; touched another resident's wheelchair handles; and pushed another resident in the wheelchair to their room, touched the light switch in the other resident's room, and performed hand hygiene; - CNA B removed the gloves, removed the trash bag from the trash can, walked the trash bag to the soiled utility, touched the doorknob, and performed hand hygiene. During an interview on 04/03/25 at 2:43 P.M., CNA A said for incontinent care, should wash hands and put on gloves, change gloves and do hand hygiene when moving from dirty to clean care, and perform hand hygiene after care was done before leaving the room. Should wipe front to back and use a new wipe with each swipe. If the foreskin was pulled back, it should be put back in place. Should sanitize hands between residents. When performing catheter care, should wear a gown and gloves, and clean away from insertion site using one wipe with each swipe, and the catheter should stay below the bladder and off the floor with a privacy cover. 3. Observation on 04/03/25 at 9:23 A.M., of Resident #117's wound care treatment showed: - EBP signage on the door frame; - The Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Registered nurse (RN) put on a gown, performed hand hygiene, and put on gloves; - The MDS RN entered the room, sat the supplies on a clean towel on the bedside table, and placed a clean cloth under the resident's left heel; - The MDS RN removed the dressing from the left heel, did not change gloves, did not perform hand hygiene, cleaned the heel wound with the wound cleanser soaked gauze; - The MDS RN didn't change gloves, didn't perform hand hygiene, removed the dressing from the nipple area wound, did not change gloves, did not perform hand hygiene, and removed the dressing from the wound under the breast area; - The MDS RN removed the gloves, performed hand hygiene, and put on new gloves; - The MDS RN applied calcium alginate (a natural, highly absorbent wound dressing derived from brown seaweed) with silver, and covered with a bordered gauze adhesive island dressing to the left heel; - The MDS RN did not change gloves, did not perform hand hygiene, opened the packaging for the breast dressings, applied Xeroform gauze (type of wound dressing used to cover and protect wounds), and covered with a bordered gauze adhesive island dressing to the nipple area wound; - The MDS RN removed the gown and gloves, did not perform hand hygiene, exited the room, obtained gauze from the treatment cart, entered the room, performed hand hygiene, and put on a gown and gloves; - The MDS RN cleaned the blood that oozed from the nipple area wound; - The MDS RN did not change gloves, did not perform hand hygiene, applied calcium alginate with silver, and covered with a bordered gauze adhesive island dressing to the under the breast wound; - The MDS RN did not change gloves, did not perform hand hygiene, put on the resident's left sock and shoe, removed the gloves, did not perform hand hygiene, removed the right sock, performed hand hygiene, and put on gloves; - The MDS RN applied skin prep (barrier film that protects the skin) to the resident's right heel, did not change gloves, did not perform hand hygiene, and put on the resident's right sock and shoe; - The MDS RN removed the gown and gloves, and performed hand hygiene. 4. Observation on 04/02/25 at 9:55 A.M., of Resident #27's venous port access procedure showed: - EBP signage on the door frame; - The Director of Nursing (DON) put on a gown, performed hand hygiene, and put on gloves; - The DON entered the room and sat the supplies on a clean towel on the bedside table, - The DON opened the packages and left the contents inside the packages; - The DON and the resident did not wear face masks; - The DON did not put on sterile gloves; - The DON performed the venous port access procedure. During an interview on 04/04/25 at 1:40 P.M., the DON said accessing the port should be a sterile procedure and with a mask worn by the staff. If the resident could tolerate wearing a mask, the resident should wear one also. During an interview on 04/04/25 at 1:52 P.M., the DON said the catheter drainage bag should be placed hanging below the bladder, not touching the floor, with a privacy bag in place, it should not be placed on top of the bed. Should perform hand hygiene and change gloves when going from dirty to clean care, and when moving between different wound sites. For catheter care, a gown and gloves should be worn; wash hands going in; put on gloves; perform the peri care; pull back the foreskin if needed and clean the penile head; discard the wipe; clean the shaft, groin and scrotum using a clean wipe to clean each area; use a clean wipe to clean the catheter from the insertion site; wipe downward, and discard the wipe after each wipe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 66. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary and orderly environment. Observations made on 1/10/24 at 8:40 A.M. of the 100 hall showed: - One, two foot (ft.) by two ft. ceiling tile missing near the nurses' station; - One, ten inch (in.) x four ft. ceiling tile near room [ROOM NUMBER] with a linear brown stain approximately two in. x two ft.; - One, ten in. x four ft. ceiling tile near room [ROOM NUMBER] with a small brown circle; - One, two ft. x four ft. ceiling tile with small area of discoloration next to the metal tract near the hall light near room [ROOM NUMBER]. Observation made on 01/10/24 at 9:00 A.M. of room [ROOM NUMBER] showed several areas of exposed sheetrock and peeled paint on the wall, near the bed on the left side of the room. Observations made on 01/10/24 at 9:16 A.M. of the [NAME] Hall shower room, next to soiled utility room, showed: - Dust and debris on the ceiling vent in front of shower; - Three black tape-like strips peeling on the floor in front of shower; - Five black tape-like strips peeling on the floor in front of the toilet; - A 36 in. x 36 in. area of peeling tile on the floor next to a locked cabinet; - Several areas with exposed sheetrock and peeled paint on the left-side divider wall above the ceramic tile next to shower. During an interview on 01/10/24 at 9:36 A.M., Housekeeper A said there is a maintenance request form staff fill out to address areas of concerns. He/she had not seen any areas of exposed sheetrock, peeled paint, peeled floor tape or any other environmental concerns. He/she does not really pay attention to things while doing routine cleaning and sometimes will verbally tell maintenance of any issues. During an interview on 01/10/24 at 10:03 A.M., Shower Aid B said he/she had not reported anything to maintenance, but notified the charge nurse of environmental concerns. He/she is aware of the issues in the shower room, but had not notified anyone yet. During an interview on 01/10/24 at 10:16 A.M., Housekeeper C said he/she had not reported anything to maintenance recently. If he/she does have an environmental concerns a maintenance request form should be filled out and placed in the maintenance file to be addressed. During an interview on 01/10/24 at 10:34 A.M., the Maintenance Supervisor (MS) said staff verbally tell him of any needed repairs. It does make it hard to keep up because some things he/she can't remember. Once an area of concern is completed, the request form is signed and thrown away. MS does not keep copies of the maintenance request forms. During an interview on 01/11/24 at 10:23 A.M., the Administrator said he would expect staff to write down any environmental concerns on a maintenance request form to be addressed in a timely manner instead of verbally informing the maintenance department. This would allow the maintenance department to stay on top of environmental issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate incontinent care was provided to prevent possible infection when staff failed to provide peri-care for two residents (Resident #1 and Resident #2) who were incontinent of urine and failed to completely clean one resident (Resident #3) who was incontinent of urine and bowel. The facility census was 65. Review of the facility's policy titled Perineal Care, dated February 2018, showed the purpose of perineal care was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following: -admission date of 08/22/22; -Diagnoses included nontraumatic subarachnoid hemorrhage (stroke), muscle weakness, hypertension (high blood pressure), anxiety, and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/29/23, showed the following: -Severe cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised 09/04/23, showed the following: -Provide resident with supportive care and services; -Keep skin clean and dry to prevent skin breakdown. Observation on 09/08/23, at 5:45 A.M., showed the following: -CNA A entered the resident's room and donned gloves without performing hand hygiene; -CNA A removed the resident's wet brief; -CNA A placed a new brief on resident. The CNA did not perform perineal care or cleaning the resident's body contaminated with urine. 2. Review of Resident #2's face sheet showed the following: -admission date of 01/20/23; -Diagnoses included cerebral infarction (stroke), Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), atrial fibrillation (irregular, often rapid heart rate), anemia (lack of blood), and hypokalemia (low potassium). Review of the resident's care plan, revised on 02/03/23, showed the following: -Provide resident with supportive care and services; -Keep skin clean and dry to prevent skin breakdown. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder. Observation on 09/08/23, at 5:50 A.M., showed the following information: -CNA A entered the resident's room and donned gloves without performing hand hygiene; -CNA A removed wet brief from the resident and dropped it on a mat on the floor; -CNA A placed a new brief on resident. The CNA did not perform perineal care or cleanse the resident's body contaminated with urine. 3. Review of Resident #3's face sheet (a brief resident profile sheet) showed the following: -admission date of 06/10/22; -Diagnoses included hypertensive heart disease (high blood pressure) with heart failure (heart cannot pump blood adequately), peripheral vascular disease (narrowed blood vessels reduce blood flow to arms and legs), unsteadiness on feet, and dysphagia (difficulty swallowing). Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised on 06/23/23, showed the following: -Staff to wear personal protective equipment when providing cares. Observation on 09/08/23, at 5:52 A.M., showed the following: -CNA A entered the resident's room; -CNA A donned gloves; -CNA A pulled back the resident's blanket and a wet and brown ring colored area from the right side of his/her lower back to across the left side of his/her lower back and down to the thigh area was visible; -CNA A removed a wet and soiled brief from the resident, cleaned his/her buttocks with one swipe of a wet wipe and placed the soiled brief and wipe in the trash; -CNA A left the room without performing perineal care or cleaning the resident's body contaminated with urine. 4. During an interview on 09/08/23, at 6:40 A.M., CNA A said staff should check residents for incontinence every two hours. Staff should clean all parts of the body that had contact with urine and or feces. 5. During an interview on 09/08/23, at 9:30 A.M., CNA B said staff should provide peri-care to residents that have been incontinent. 6. During an interview on 09/08/23, at 9:32 A.M., CNA C said staff should provide peri-care to residents that have been incontinent. Staff should use wet wipes and wipe from front to back. 7. During an interview on 09/08/23, at 10:20 A.M., Licensed Practical Nurse (LPN) D said that staff should provide peri-care to residents that have been incontinent of urine and or stool. Staff should clean from front to back with a warm wet washcloth or use the perineal spray to clean the resident. 8. During an interview on 09/08/23, at 10:28 A.M., the Registered Nurse (RN) E said staff should provide peri-care to residents that have been incontinent of urine and or stool. Staff should clean from front to back with a wet wipe and then allow time to dry before replacing brief. 9. During an interview on 09/08/23, at 10:38 A.M., the Director of Nursing (DON) said he/she expects staff to perform peri-care on residents that have been incontinent of urine or stool. Staff should clean the resident from front to back and allow time to dry before replacing brief. 10. During an interview on 09/08/23, at 11:55 A.M., the Administrator said he/she expects staff to clean the resident during incontinent cares if the resident is wet or soiled. MO00220362

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when staff failed to complete appropriate hand hygiene while assisting three residents (Resident #1, Resident #2 and Resident #3) with cares. The facility census was 65. Review of the facility policy titled Handwashing/Hand Hygiene, undated, showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; -Use an alcohol-based hand rub before and after direct contact with residents; -Use an alcohol-based hand rub before donning gloves; -Use an alcohol-based hand rub before moving from a contaminated body site to a clean body site during resident care; -Use an alcohol-based hand rub after contact with bodily fluids; -Use an alcohol-based hand rub after removing gloves; -Hand hygiene is the final step after removing and disposing of personal protective equipment. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following: -admission date of 08/22/22; -Diagnoses included nontraumatic subarachnoid hemorrhage (stroke), muscle weakness, hypertension (high blood pressure), anxiety, and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/29/23, showed the following: -Severe cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised 09/04/23, showed the following information: -Provide resident with supportive care and services; -Keep skin clean and dry to prevent skin breakdown. Observations on 09/08/23, at 5:45 A.M., showed the following information: -Certified Nursing Assistant (CNA) A entered the resident's room, donned gloves, removed the resident's wet brief, and placed a new brief on the resident without completing hand hygiene; -With the same contaminated gloves, the CNA then placed the call light, that was attached to a small stuffed animal, back in the resident's hands; -With the same contaminated gloves the CNA patted the resident on the head with his/her gloved hand; -The CNA then removed his/her gloves, gathered trash, and left the room without completing hand hygiene. 2. Review of Resident #2's face sheet showed the following: -admission date of 01/20/23; -Diagnoses included cerebral infarction (stroke), Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), atrial fibrillation (irregular, often rapid heart rate), anemia (lack of blood), and hypokalemia (low potassium). Review of the resident's care plan, revised on 02/03/23, showed the following: -Provide resident with supportive care and services; -Keep skin clean and dry to prevent skin breakdown. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder. Observations on 09/08/23, at 5:50 A.M., showed the following: -CNA A entered the resident's room, donned gloves, removed the resident's wet brief, and placed a new brief on the resident without completing hand hygiene; -The CNA dropped the wet brief on a mat on the floor; -With the same contaminated gloves, the CNA off the call light; -The CNA removed his/her gloves, did not perform hand hygiene, and assisted the resident with a drink of water by holding the cup to the resident's mouth; -The CNA gathered the wet brief from the floor, along with the resident's trash, and left the room without completing hand hygiene. 3. Review of Resident #3's face sheet (a brief resident profile sheet) showed the following information: -admission date of 06/10/22; -Diagnoses included hypertensive heart disease (high blood pressure) with heart failure (heart cannot pump blood adequately), peripheral vascular disease (narrowed blood vessels reduce blood flow to arms and legs), unsteadiness on feet, and dysphagia (difficulty swallowing). Review of the resident's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised on 06/23/23, showed the following information: -Staff to wear personal protective equipment when providing cares. Observations on 09/08/23, at 5:52 A.M., showed the following: -CNA A entered the resident's room; -CNA A entered the resident's room, donned gloves, removed the resident's wet/soiled brief, provided peri-care, and placed the soiled brief and wipe in the trash without completing hand hygiene; -With the same contaminated gloves, the CNA removed a clean gown from the resident's closet and assisted the resident with removing his/her soiled gown and replaced it with a clean gown; -With the same contaminated gloves, the CNA A applied deodorant to the resident's armpits; -The CNA removed his/her gloves, did not perform hand hygiene, and assisted the resident with a drink of water by holding the cup to the resident's mouth; -CNA A left the room to gather bed linens. 3. During an interview on 09/08/23, at 6:40 A.M., CNA A said staff should perform hand hygiene after every resident. Staff should perform hand hygiene before donning gloves. Gloves should be changed between dirty and clean process only if gloves become soiled. 4. During an interview on 09/08/23, at 9:30 A.M., CNA B said staff should perform hand hygiene when entering and exiting a resident room. 5. During an interview on 09/08/23, at 9:32 A.M., CNA C said staff should perform hand hygiene when entering and exiting a resident room. Gloves should be changed while performing incontinent cares if gloves become visibly dirty. 6. During an interview on 09/08/23, at 10:20 A.M., Licensed Practical Nurse (LPN) D said staff should perform hand hygiene before putting on gloves and after removing gloves. Gloves should be removed and hand hygiene performed after incontinence cares is given and brief is removed. Staff should wash hands and put on clean gloves prior to cleaning resident. Staff should remove gloves and wash hands again prior to placing clean brief on resident. Staff should remove gloves and wash hands prior to leaving resident's room. 7. During an interview on 09/08/23, at 10:28 A.M., Registered Nurse (RN) E said staff should wash hands and put on gloves, provide incontinent cares including cleaning the resident. Staff should remove gloves and wash hands, place brief, remove gloves and wash hands again before leaving the resident's room. 8. During an interview on 09/08/23, at 10:38 A.M., the Director of Nursing (DON) said he/she expects staff to wash their hands before putting on gloves and after taking off gloves. Gloves should be changed after incontinent cares are performed. It is never acceptable to provide incontinent cares to a resident and then touch things in the room such as call light or pat resident on the head with dirty gloved hand. 9. During an interview on 09/08/23, at 11:55 A.M., the Administrator said he/she expects staff to do good infection control. Staff should wash hands when entering a resident's room, put on gloves, perform incontinent cares, remove gloves then use hand hygiene. MO00220362

Based on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a dignity bag for one resident's (Resident #23) catheter (sterile tube inserted into the bladder to drain urine) bag. The facility census was 67. Record review of the facility's policy titled' Dignity, dated February 2021, showed the following: -Residents are treated with dignity and respect at all times; -Demeaning practices and standards of care that compromise dignity are prohibited; -Staff are expected to promote dignity and assist residents to keep urinary catheters (a sterile tube inserted in the bladder to drain urine) bags covered. 1. Record review of Resident #23's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 11/20/18; -Diagnoses included obstructive uropathy (obstruction of normal urine flow) with suprapubic catheter (a tube inserted directed through the abdomen into the bladder to drain urine), and contractures (permanent shortening of the muscle, tendon, or scare tissue causing distortion) of the right and left knees. Record review of the resident's quarterly Minimum Date Set (MDS - a federally mandated assessment instrument completed by facility staff, dated 02/07/22, showed the following: -Cognitively intact; -Extensive staff assistance required for dressing, toileting, and hygiene; -Indwelling catheter. Record review of the resident's care plan dated 2/19/20 did not give direction to staff for interventions related to the catheter bag. Observations on 04/19/22 at 9:15 A.M., showed the resident in his/her wheelchair at the nurse's station. The residents' pants leg raised to the mid-calf area. A catheter leg bag, laid on the resident's right ankle, showing amber colored urine. Observations on 04/20/22 at 8:32 A.M., showed the resident in his/her wheelchair at the nurse's station. A nurse passed the resident pushing a medication cart. The resident's catheter leg bag was fully visible laying near his/her right ankle. The catheter bag was approximately half full of amber-colored urine. Observations on 04/20/22 at 12:25 P.M., showed the resident in his/her wheelchair at the nurse's station eating lunch. The residents catheter leg bag laid fully visible on the resident's right ankle area. The catheter bag was approximately half full of amber-colored urine. A Certified Nurse Assistant (CNA) stood along side of the resident and spoke to him/her about lunch. The CNA did not adjust the resident's clothing to cover the bag. Observations on 04/20/22 at 2:34 P.M., showed the resident in his/her wheelchair at the nurse's station. The resident's catheter leg bag was fully visible on the resident's right ankle area with dark amber-colored urine. Observations on 04/21/22 at 8:00 A.M., showed the resident in his/her wheelchair at the nurse's station. The resident's catheter leg bag laid atop his/her right shoe. The leg bag was approximately one-fourth full of cloudy amber-colored urine. Observations on 04/21/22 at 1:07 P.M., showed the resident in his/her wheelchair at the nurse's station. The resident's catheter leg bag, fully visible, hanging between the wheelchair foot pedals. The catheter tubing was stretched taunt (tight). The leg bag straps laid on the floor. During an interview on 04/21/22 at 1:12 P.M., CNA F said catheter care is provided anytime care is provided to the resident. Catheter leg bags should be secured to the resident's lower leg and should be covered by the resident's clothing. During an interview on 04/02/22 at 1:17 P.M., Licensed Practical Nurse (LPN) G said the following: -Catheter leg bags should be secured to the resident's leg; -Staff should monitor for correct placement and adjust as necessary; -Catheter leg bags should be covered. Observations and interview on 04/21/22 at 1:25 P.M., showed LPN G checked the resident's catheter leg bag placement. The leg bag was fully visible hanging between the resident's wheelchair pedals. The LPN said the leg bag should be secured to the resident's leg and the bag should be covered with the resident's clothing. During an interview on 04/21/22 at 1:36 P.M., the MDS Coordinator said catheter care and monitoring of the catheter should be addressed in the resident's care plan. During an interview on 04/22/22 at 8:35 A.M., the Director of Nursing (DON) and Administrator said they expected staff to ensure catheter bags were secured and covered. The staff should monitor the catheter bags and adjust as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff developed, reviewed, and revised one resident's (Resident #11) comprehensive care plan to include wandering and elopement behaviors. The facility census was 67. Record review of the facility's policy titled care plan, dated 2001, revised 2006, showed the following information: -The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; -Completed care plans are placed in the resident's chart; -Certified Nurse's Aides/CNA's, are responsible for reporting to the nurse supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved; -Other facility staff noting a change in the resident's condition must also report those changes to the nurse supervisor and/or the MDS assessment coordinator; -Changes in the resident's condition must be reported to the MDS assessment coordinator so that a review of the resident's assessment and care plan can be made; -Documentation must be consistent with the resident's care plan. Record review of the facility's policy titled, wandering and elopements, dated 2001, and revised March 2019, showed the following information: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; -If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 1. Record review of Resident #11's face sheet (a document that provides resident information at a quick glance) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included, adjustment disorder with mixed anxiety and depressed mood (feeling hopeless or sadder than would be expected after a stressful event), generalized anxiety disorder (excessive or unrealistic worry about everyday life events for no obvious reason), primary insomnia (inability to sleep), vascular dementia with behavioral disturbance (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain). Record review of Resident #11's care plan, dated 11/02/2021, showed the following information; -Exhibited periods of disorganized thinking: disorganized speech. -Allow him/her adequate time to express self; complete word or sentence if he/she is unable to do so. -Assess potential cause (s) for deterioration (lack of sleep, medication change, illness, and change in routine/activities); -Diagnosis of anxiety disorder with physical manifestations of anxiety. -Assess and record behaviors. -Determine pattern of behavior (time of day, precipitating factors/situations), -Discuss with physician and team a trial period of antianxiety medication therapy. -Assess changes in mental status. -Staff did not address the resident's wandering or elopement behaviors in the care plan. Record review of the resident's re-hospitalization risk assessment, dated 11/2/2021, showed the following information: -The resident exhibited early evening confusion (sundowning); -The resident had a history of elopement/wandering off, getting lost, etc.; -The resident's risk assessment score was 25; -If the score is 5 or greater, refer to elopement precautions and initiate elopement precautions, when appropriate. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 11/5/2021, showed the following information: -Severely impaired cognition; -No wandering behaviors; -Required extensive assistance for transfers and locomotion; -The resident used a wheelchair mobility device. Record review of Resident #11's progress notes showed the following information: - On 12/29/2021, resident not found in the facility, staff received a call stating the resident was at a house across the street from the facility. Staff notified the nurse the resident was at the brick apartments across the road. When the nurse ran over to the apartments, he/she found the resident standing and about to fall; Staff escorted the resident back to the facility in a wheelchair. Resident had gone looking for his/her car. When staff asked him/her where he/she was going, he/she said to hell. Unclear which door he/she went out. Staff notified the resident's guardian of the elopement and staff placed the resident on 15 minute checks; -After the incident on 12/29/2021, the resident was at the nurse's station and said he/she would not go outside again, but the next minute, the resident said he/she wanted to go home; -On 12/30/2021, the resident had increased anxiety. The resident wandered and talked about leaving. The resident put on his/her coat and said he/she had to leave. Staff will continue 15 minute checks; -On 1/4/2022, the resident cursed at staff when attempting to go into other residents' rooms; -On 1/7/2022, the resident wandered into female rooms. Resident up and down the halls, wandering. -On 1/9/2022, the resident wandered during first shift, walking around the nurse's station and day room; -On 1/10/2022, the resident wandered during first shift, walking around the nurse's station and day room. Resident up with occasional roaming. The resident would go to court yard door, look out, and come up to the nurse's station and ask about leaving. Will continue to monitor closely; Record review of the resident's care plan showed staff did not update the care plan to reflect the wandering behaviors and elopement incident on 12/29/2021. Record review of the resident's restorative quarterly assessment, 1/27/2022, showed staff assessed the resident as not at risk for elopement. Record review of the elopement risk assessment, dated 1/27/2022, showed the following information: -Diagnoses of dementia and depression; -The resident is cognitively impaired with poor decision-making skills; -The resident did not have a history of elopement; -The resident had verbalized the intent to leave the facility; -The resident wandered and was seeking to find spouse or family; -The resident wandered aimlessly. - The resident's elopement risk score was 4, due to four yes responses; - If the assessment indicated yes to any question, consider initiating a care plan or service plan for elopement risk. Record review of the resident's care plan showed staff did not update the care plan or service plan to address the resident's wandering behaviors or elopement risk. Record review of Resident #11's progress notes showed the following information: -On 3/14/2022, the resident had been angry with staff. The resident told staff they can't tell him/her what to do. He/she wandered and staff tried to toilet him/her. The resident pulled down his/her pants, tore his/her incontinent brief apart, and had a bowel movement in the recliner in the common TV area; -On 3/29/2022, the resident gathered some of his/her clothes and walked the hallway with them. The resident said he/she was leaving. The resident had been wandering since he/she got back up. Record review of Resident #11's quarterly MDS, dated [DATE], showed the following information: -Severely impaired cognition; -Disorganized thinking occurred in two of the seven days of the lookback period; -Wandering behavior of this type occurred one to three days of the seven day lookback period; -Required extensive assistance for dressing, toilet use, and personal hygiene; -Locomotion on unit, supervision only; -No mobility device; -Dementia; -The resident had a legal guardian. Record review of the resident's care plan showed staff did not update the resident's care plan to reflect the wandering behaviors or elopement risk. During an interview and observation on 4/18/2022, at 11:11 A.M., Resident #11 showed the following: -Resident sat in the dining area at the end of the hall; -Resident verbalized, but difficult to understand the resident's words; -Resident unable to answer some questions appropriately. During an interview on 4/22/2022, at 8:52 A.M., Certified Nursing Assistant (CNA) J said the following: -Not aware of any residents at risk for elopement; -Staff look at care plans to know which residents are at risk for elopement; -Resident #11 does wander to the door in the courtyard; -Resident #11 has not eloped on his/her shift; -If residents attempt to open the doors, there are door alarms that sound; -If residents are elopement risk, they keep the residents in sight more and redirect the resident with activities. During an interview on 4/22/2022, at 9:03 A.M., CNA K said the following: -No residents have eloped on his/her side of the building; -If residents are wandering or exit seeking, staff should redirect them; -He/she has worked with Resident #11 in the past, he/she did not wander; -Staff look at charting to see which residents are elopement risks, or other staff make him/her aware of residents at risk for elopement. During an interview on 4/22/2022, at 8:45 A.M., CNA I said staff look at care plans to know which residents may be an elopement risk. He/she did not work with Resident #11. During an interview on 4/22/2022, at 9:32 A.M., Licensed Practical Nurse (LPN) G said the following: -Resident #11 is not as bad about wandering since he/she got sick and went to the hospital; -Resident #11 will ask where his/her truck is at; -Resident #11 doesn't usually show behaviors during the day, but more so in the evening. -Staff will document if residents are wandering and this will be shared at shift change. -The careplan would also have a resident's elopement status. During an interview on 4/22/2022, at 9:08 A.M., LPN C said the following: -Not aware of any residents at risk for elopement; -If a resident is at risk for elopement, it would be on the resident's care plan and would pop up in their system; -Residents at risk for elopement may have chair alarms, or one on one; -He/she does not work with Resident #11. During an interview on 4/22/2022, at 9:17 A.M., the MDS/care plan coordinator said the following: -If a resident is an elopement risk, they would be on 15 minutes checks; -Staff know which residents are elopement risk as there's a book at the nurse's station; -If a resident is an elopement risk, this would be on his/her care plan; -Resident #11 did not score high enough on the elopement assessment; -Resident #11 is not considered an elopement risk; -Resident #11 is confused and walks a lot, also has sundowners; -He/she did not know if Resident #11 had eloped in the past. During an interview on 4/22/2022, at 9:35 A.M., the Director of Nursing (DON) said the following: -If an elopement has occurred more than one time, it would be in the resident's care plan; -When residents are admitted , they will have an elopement risk assessment completed by the DON; -If residents tend to wander, staff will watch to figure out these behaviors; -If a resident has cognitive decline, they may need to be put on 15 minute checks; -Resident 11 is not an elopement risk, he wanders and pilfers. During an interview on 4/22/2022, at 9:27 A.M., the administrator said the following: -MDS assessment process drives the care plan; -Elopement risks are also completed on residents, if it's determined the resident is at risk, this would be in the care plan; -If eloped in the past, but doesn't get off the facility property, or stays in sight of facility staff, this would not be considered an elopement; -In his/her recollection, Resident #11 went out the end door, and across the street, but he/she was in sight at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement physician orders of Two-Cal (a liquid dietary supplement) and calcium for one resident (Resident #46), who had a history of weight loss. The facility census was 67. Record review of the facility's policy, titled nutrition (impaired)/unplanned weight loss-clinical protocol, dated September 2017, showed the following information: -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff and physician will define the individual's current nutritional status and identify individuals with anorexia (lack or loss of appetite for food), weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss; -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake; -The physician will authorize appropriate interventions as indicated. Record review of the facility policy, titled administering medications, dated April 2019, showed the following information: -Medications are to be administered in a safe and timely manner, and as prescribed. 1. Record review of Resident #46's face sheet (a brief resident profile sheet) showed the following information: -The resident admitted to the facility on [DATE]; -His/her diagnoses included a right hip fracture, right humerus (the bone in the upper arm between the elbow and shoulder) fracture, Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #46's Weight Report showed the following information: -On 3/3/2022, Resident #46 weighed 140 pounds; -On 3/5/2022, Resident #46 weighed 140.8 pounds. Record review of Resident #46's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 3/9/2022, showed the following information: -The resident was moderately cognitively impaired; -He/she needed setup help with eating. Record review of Resident #46's care plan, dated 3/11/2022, showed the facility did not address the resident's weight loss on the care plan. Record review of Resident #46's Registered Dietitian Nutritional Assessment showed the following information: -On 3/11/2022, the Registered Dietitian documented the resident was newly admitted and had two fractures with an open area on the coccyx (tailbone). Nutritional needs were elevated and the hospital records referred to his/her appetite and intake as not being very good, despite encouragement. Recommend continuing regular diet, adding fortified foods at all meals, Two-Cal with medication passes, and continue efforts to learn and honor his/her food preferences. Due to his/her arm fracture, he/she will need assist with set up, and may need assist with feeding. Suggest we add calcium + vitamin D in view of his/her fractures. Record review of Resident #46's clinical notes report showed the following information: -On 3/11/2022, at 9:32 A.M., the Registered Dietitian documented she recommended the facility staff add fortified foods, Two-Cal with medication passes, and Calcium+ Vitamin D for healing. -On 3/25/2022, at 10:41 A.M., facility staff documented the physician reviewed the Registered Dietitian recommendations with agreement to the following changes: 1. Add fortified foods to current regular diet, 2. Add Two-Cal with medication passes, 3. Learn and honor food preferences to help with eating, 4.Add calcium plus vitamin D related to fractures. Facility staff documented the orders were updated. Record review of Resident #46's physician order sheet (POS), dated March 2022, showed facility staff failed to document the order for Two-Cal and Calcium. Record review of Resident #46's medication administration record (MAR), dated March 2022, showed facility staff failed to document the order for Two-Cal or Calcium. Record review of Resident #46's weight report showed the following information: -On 4/1/2022, Resident #46 weighted 127 pounds; which is a loss of 9.29 % in one month. Record review of Resident #46's care plan showed the facility did not update the care plan to address the resident's weight loss on 4/1/2022. Record review of Resident #46's POS, dated April, 2022 showed facility staff failed to document the order for Two-Cal and Calcium. Record review of Resident #46's MAR, dated April, 2022 showed facility staff failed to document the order for Two-Cal or Calcium. During an interview on 4/21/2022, at 8:45 A.M., Resident #46 said he/she eats until he/she is full, but a couple hours later he/she is hungry. He/she is not getting any shakes between meals. During an interview on 4/21/2022, at 12:45 P.M., Licensed Practical Nurse (LPN) C said when a resident has weight loss, they usually get reweighed, and added to the physician's list. The physician will add interventions and they usually include things like Two-Cal. He/she is not aware of Resident #46 having weight loss or getting Two-Cal. The Director of Nursing (DON) is responsible for adding orders to the resident's chart after the physicians' complete their rounds. During an interview on 4/21/2022, at 1:00 P.M., Certified Medication Technician (CMT) D, said when a resident has weight loss, staff should start encouraging the resident to eat, and offering alternatives to the resident. The dietary department is notified, the family is notified, and the physician is notified, and many times, Two-Cal and Mighty shakes are added. Fortified foods are often added as well. The DON or medical records person is responsible for adding new orders to the resident's chart. If the orders aren't added, the staff is not aware to do the medication pass. Orders should always be added if they are given. During interview on 4/21/2022, at 1:10 P.M., and 4/22/2022, at 9:18 A.M., Registered Nurse (RN) E/MDS/Care Plan Coordinator, said several residents receive Two-Cal, but Resident #46 does not. Staff should implement dining assist if needed, offer snacks, fortified foods, etc. Staff involves the physician, the Registered Dietician, and the Dietary director to keep the residents from having weight loss. The DON is responsible for entering in new medication orders after completing rounds with the physician. He/she did not see where the order had been entered after it was suggested by the Dietitian and approved by the physician. Medication orders should be entered after approved by the physician. If a resident has weight loss, it should be documented on the care plan. If the weight loss does not get addressed in Quality Measure meetings, it may not be addressed until quarterly meetings. During an interview on 4/21/2022, at 2:30 P.M., the DON said she or the medical records staff is responsible for putting in new physician orders. The shower aide is responsible for weighing the residents and if a resident displays a weight loss, the aide will reweigh them in a couple days, and if the loss is still present, the provider is notified. Interventions are put in place to prevent weight loss, such as snacks, Two-Cal, encouraging eating, and Registered Dietitian (RD) consults. The physician did order vitamins, Two-Cal, and a fortified diet for Resident #46 and it just got missed. She got part of it put in but the Two-Cal and calcium just got missed. During an interview on 4/22/2022, at 9:29 A.M., the administrator said he expects staff to enter physician orders when written if they are reasonable orders. If the orders need clarification, they may need to call the physician back. If a resident has weight loss, staff should encourage the resident to eat, offer snacks, Two-Cal, Mighty Shakes (a high calorie, high protein nutritional shake), get with the physician and RD for evaluation, and go from there. When Resident #46 came from the apartments, he/she did not want to eat, then his/her family came and stayed with the resident for several days, and the resident's eating improved greatly. The resident always tells him he is feeding him/her too much.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #15's face sheet (a brief resident profile sheet) showed the following information: -The resident admitted to the facility on [DATE]; -His/her diagnoses included multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves, causing a disruption in communication between the brain and the body), chronic pain, anxiety, and reduced mobility. Record review of Resident #15's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 1/31/2022, showed the following information: -The resident was cognitively intact; -He/she was totally dependent on staff for transfers and bed mobility; -He/she had upper extremity impairment on both sides. Record review of Resident #15's current POS, showed no physician order for side rails. Record review of Resident #15's medical record showed facility staff did not obtain gap measurements for the side rails for 2020 or 2021. Observation on 4/20/2022, at 8:47 A.M., showed Resident #15 rested in bed. The bed had a quarter rail on the left side of the bed in the raised position. 4. Record review of Resident #46's face sheet showed the following information: -The resident admitted to the facility on [DATE]; -His/her diagnoses included a right hip fracture, right humerus (the bone in the upper arm between the elbow and shoulder) fracture, Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #46's admission MDS, dated [DATE], showed the following information: -The resident was moderately cognitively impaired; -He/she needed setup help with eating. Record review of Resident #46's care plan, dated 3/11/2022, showed the facility staff did not address the resident's side rails on the care plan. Record review of Resident #46's current POS showed the facility staff did not obtain a physician order for the side rails. Record review of Resident #46's medical record showed facility staff did not obtain gap measurements for the side rails. Observation on 4/19/2022, at 2:00 P.M., showed the resident rested in bed. The bed had a quarter rail in the raised position on the left side of the resident's bed. The rail was positioned in middle of the bed. 5. During an interview on 4/22/2022, at 10:50 A.M., the MDS/Care Plan coordinator said side rails should be on a resident's care plan if the resident has them. 6. During an interview on 4/22/2022, 10:11 A.M., the administrator and DON said maintenance had been completing side rail assessments and the former DON took control of the process. Maintenance completed the measurements. Now, anyone who has side rails gets assessments and therapy is completing the measurements. That new process started about 3 weeks ago. They are completing them with their quarterly assessments. Based on observation, interview, and record review, the facility failed to complete a risk/versus benefit review for one resident's side rails (Resident #51), and failed to document alternatives attempted prior to bed rail use for two residents (Resident #51 and #17); failed to complete bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for four residents (Residents #51, #17, #15, #46); failed to obtain physician order for the use of side rails for two residents (Resident #15 and #46), failed to obtain documented consent for use of side rails for two residents (Resident #51 and #17), and failed to address the use of bed rails in the residents' care plans for one resident (Resident #46). The facility census was 67. Record review of the facility's policy for the use of bed rails, from Med-Pass, 2001 and last revised 2017, showed the following information: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical condition, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risk and problems including potential entrapment risk: -Review that gaps within the bed system are within dimensions established within the Food and Drug Administration (FDA-note the review shall consider situations that could be caused by the resident's weight, movement, or bed position); -Ensure that the bed system components are worn and need to be replaced, components meet manufacturer specifications; -Ensure the bed rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., altered mental status, restlessness, etc.); -Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.); -The maintenance department shall provide a copy of inspections to the administrator and report results to the Quality Assurance (QA) committee for appropriate action. Copies of the inspection results and QA committee recommendations shall be maintained by the administrator and/or safety committee; -The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment; -If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative; -The staff shall obtain consent for the use of side rails from the resident or resident's legal representative prior to their use; -After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed); -Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; -Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; -When using side rails for any reason, the staff shall take measurements to reduce the related risk; -Side rails shall not be used as protective restraints. Should a protective restraint be used, our facility's protocol for the use of restraints shall be followed; -The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals; -The staff shall report to the director of nursing (DON) and administrator any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The administrator shall ensure that reports are made to the FDA or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. Record review of the guidance for industry and Food and Drug Administration (FDA) staff, Hospital Bed System Dimensional And Assessment Guidance To Reduce Entrapment, issued on 3/10/2006, from the FDA, Center for Devices and Radiological Health, showed the following information: -The term medical bed and hospital bed are used interchangeably and include adult medical beds with side rails; -Evaluating the dimensional limits of the gaps in hospital beds may be one component of a bed safety program which includes a comprehensive plan for patient and bed assessment; -Bed safety programs may also include plans for reassessment of hospital bed systems; -Reassessment may be appropriate when there is reason to believe that some components are worn, such as rails wobble, rails have been damaged, mattresses are softer and could cause increased spaces within the bed system; when accessories such as mattress overlays or positioning poles are added or removed; when components in the bed system are changed or replaced, such as new bed rails or mattresses; -Bed rails are rigid bars that are attached to the bed and are available in a variety of sizes and configurations from full length to half, one-quarter, and one-eighth length and are used as restraints, reminders, or as assistive devices; -Zone 1 is the measurement within the rail, any open space within the perimeter of the rail, a loosened bar or rail can change the size of the space; -Zone 2 is the gap under the rail between a mattress compressed by the weight of a patient's head and the bottom edge of the rail at a location between the rail supports or next to a side rail support. Factors to consider are the mattress compressibility which may change over time due to wear, the lateral shift of the mattress or rail, and any degree of play from loosened rails or rail supports. A restless patient may enlarge the space by compressing the mattress beyond the specified dimensional limit. This space may also change with different rail height positions and as the head or foot sections are raised or lowered; -Zone 3 is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head; -Zone 4 is the gap that forms between the mattresses compressed by the patient and the lowermost portion of the rail, at the end of the rail. Factors that may increase the gap size are mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails; -General testing considerations include for ease of mattress movement and measurement, and general safety, the patient should not be in the bed during the measurement procedures. 1. Record review of Resident #51's current physician order sheet (POS) showed an order for half side rails on the bed for positioning/not a restraint, dated 8/18/2014. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 4/4/2022, showed the following information: -admitted to the facility on [DATE]; -Cognitively intact; -Diagnoses included diabetes, hereditary motor and sensory neuropathy (progressive disease of the nerves and weakness and numbness in the legs and arms), muscular dystrophy (a hereditary condition marked by progressive weakening and wasting of the muscles), high blood pressure, progressive muscular atrophy (an inherited form of motor neuron disease that effects the lower motor neurons in the brain stem and spinal cord); -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting; -No history of falls; -Bed rails not used. Record review of the resident's care plan, last updated 3/18/2022, showed the resident used half side rails to assist with bed mobility and positioning and the resident requested to continue the use of the half side rails when in bed for positioning and bed mobility. The bed rails were not a restraint per the care plan team. Observation on 4/19/2022, at 9:25 A.M., showed half side rails on both sides of the bed in the raised position. During an interview, on 4/19/2022, at 11:33 A.M., the resident said he/she used the side rails to assist him/her with repositioning in bed. Record review of the resident's electronic medical record showed the following information: -No paper or electronic record of when the resident signed a consent for the use of side rails for positioning; -No risk versus benefits assessment for the use of the side rails; -No alternatives documented prior to the use of the side rails; -Bed gap measurements completed on 3/1/2019. There was no documentation of annual side rail measurements for 2020 or 2021. 2. Record review of Resident #17's current POS showed a physician's order, dated 7/22/2018, for bilateral half side rails when in bed per resident request to assist with bed positioning and a feeling of security. The half side rails were not a restraint. Record review of the resident's annual MDS, dated [DATE], showed the following information: -admitted to the facility on [DATE]; -Cognitively intact; -Diagnoses included multiple sclerosis ( a progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord), anxiety disorder, cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), muscle weakness, polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body) and need for assistance with personal cares; -No history of falls since prior assessment; -Bed rails not used. Record review of the resident's care plan, annual review (date of annual review not listed), initial date of 5/10/2018 to present), showed the following information: -The resident's preferred use of side rails. Up on both/one side for safety and assistance with repositioning. -The resident and family have been educated on the risk of side rails and communicated understanding. -Followed Primaris Device Decision Guide and considered not a restraint. Record review of the resident's electronic health record showed the following information: -A side rail assessment, dated 2/22/2022 for the use of bilateral side rails for positioning; -No signed consent for the use of bed rails; -Resident and family educated on the risk versus benefits of the use of side rails on 2/22/2022; -No alternatives documented prior to the use of side rails. -No documentation of side rail gap measurements since side rails installed on 2/22/2022. Observations on 4/19/2022, at 9:25 A.M., showed half side rails on the bed in the raised position. The resident was not in his/her bed. During an interview on 4/19/2022, at 1:52 P.M., the resident said he/she used the bed rails for positioning in bed.

Based on record review, observation, and interview, the facility failed to store and prepare food in accordance with professional standards of practice and protect food from possible contamination when staff did not maintain clean surfaces, stored a scoop in the dry food storage bin, and staff did not wear proper facial hair or hair coverings. The facility census was 67. 1. Record review of the 2013 Missouri Food Code showed the following information: -Chapter 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils showed; (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch; (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Chapter 4-101.19 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material; -Chapter 4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; -Chapter 6-501.12, Paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean. Record review of the facility policy, dated 2020, on cleaning rotation showed the following information: -Equipment and utensils will be cleaned and sanitized according to the following guidelines, or manufacturer's instructions; -Items cleaned daily; stove top, grill, steam table, exterior of large appliances; -Items cleaned monthly; walls; -Items cleaned annually; ceilings. Observation of the kitchen on 4/18/2022, beginning at 10:35 A.M., showed the following: -Pot rack that held tongs, pans and cutting boards, had a thick layer of fuzzy lint around the top; -Kitchen wall as you enter from the dining area had dried splatters from liquid and/or food; -Fuzzy lint on the vent in the dishwasher room; -Fuzzy lint on the fan, located on the wall in the dishwasher room; -Fuzzy lint on the vents over the counter and sink area; -Dry food container that contained oatmeal with a plastic spoon, down in the oatmeal, with approximately 3 inches of the handle visible; -The outside of the oven had a brown liquid substance on the front, and clear liquid substances on the sides and back of the oven. The outside front of the oven, located under the oven doors had black/brown burnt, food particles. Observations of the kitchen on 4/20/2022, beginning at 11:30 A.M., showed the following: -Scoop down in the dried oatmeal, with approximately three inches of the handle visible; -Two of the steamtable compartments had three spots of mostly burnt food, covering about 1/4 of the compartment. Record review of the cleaning schedules for the week of April 17th through April 23rd, 2022 showed the following information: -Staff checkmarked that the walls in the dish room had been cleaned on Monday, Tuesday, Wednesday, Thursday and Sunday; -Staff checkmarked that oven 1 and 2 had been cleaned Tuesday, Wednesday and Thursday; -Staff checkmarked that the steamer had been deep cleaned on Monday, Tuesday, Wednesday, Thursday and Sunday; -Staff checkmarked that the steam table had been cleaned on Tuesday, Wednesday and Thursday. During an interview on 4/21/2022, at 1:15 P.M., Dietary aide A said the following: -Kitchen staff have a cleaning schedule and they are assigned certain duties; -Scoops should not be left in dry food containers; -Kitchen staff are required to clean the hanging pot rack holder; -Maintenance is responsible for cleaning the ceiling vents and fans in the kitchen During an interview on 4/21/2022, at 1:21 P.M., Dietary Aide B said the following: -Kitchen staff have a cleaning schedule. Dietary Aide A cleans one half of the kitchen and Dietary Aide B cleans the other half of the kitchen; -Kitchen staff are responsible for cleaning the hanging pan holders and the appliances; -He/she did not know if scoops should be left in dry food containers; -Maintenance is responsible for cleaning the ceiling vents and fans. During an interview on 4/21/2022, at 1:30 P.M., the dietary manager said the following: -The kitchen has different cleaning schedules for each area, they're visible on the walls/windows in each section; -Scoops should be removed after using them and not left in the dry food containers; -The hanging pan holder should be cleaned by kitchen staff; -Staff are required to clean the oven weekly; -Staff are required to clean the walls in the dish room daily; -Staff are required to clean the steamtable weekly. 2. Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following: -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. Record review of the facility policy, dated 2020, on hair restraints showed the following information: -Hair restraints shall be worn by all dining services staff when in food production areas, dishwashing areas, or when serving food; -Staff shall wear hair restraints in all food production, dishwashing and serving areas; -Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. During an observation and interview on 4/21/2022, at 1:15 P.M., in the kitchen showed the following: -Dietary Aide A transferred pudding from a can into small cups; -He/she did not wear a facial hair cover or hair covering; -He/she said kitchen staff are required to wear hair nets, he/she forgot; -He/she had asked about beard nets, but didn't know for sure where they were located; -The kitchen staff are required to wear hair nets when in the kitchen. During an interview on 4/22/2022, at 9:59 A.M., the administrator said the following; -Staff should be wearing hairnets in the kitchen; -Maintenance is supposed to be cleaning the vents in the ceiling.