**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse involving two residents (Resident #8 and Resident #58) to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours of receiving the allegation. A sample of 18 residents was selected for review. The facility census was 90. Record review of the facility's policy titled, Abuse and Neglect Prevention Standard, showed the following information: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms; -It is the responsibility of all team members to immediately report any act of witnessed, suspected or reported abuse to the administrator or their supervisor. Under the Elder Justice Act, it is every individual's responsibility to ensure that suspected crimes are reported; -All allegations of abuse and/or neglect will be investigated and reported in accordance with the state and federal laws; -Report all alleged violations involving abuse immediately, but no later than two hours after the allegation has been made; -All resident to resident altercations must be reported immediately but no later than two hours after the allegation has been made; -After conducting an internal investigation, you must submit a report of all investigation results to the state within five working days. 1. Record review of Resident #8's face sheet (a brief resident profile sheet) showed the following information: -admission date of 2/28/17; -Diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities), type 1 diabetes mellitus (pancreas produces little or no insulin), heart failure and generalized anxiety (excessive, exaggerated worry about everyday life events for no obvious reason). Record review of the resident's progress note showed the following information: -On 7/20/2021, at 5:30 P.M., Resident #8 was in the hallway with other residents. Staff assisted other residents in rooms. Resident # 8 started yelling, Help me, help me. Staff responded and observed Resident #58 squeezing and twisting Resident # 8's right forearm. Staff assisted both residents to other areas of the hall. Resident #8's right forearm had redness. Resident #8 reported pain to the area. Resident #8 had limited mobility to his/her right lower arm. (Staff did not document notifying DHSS of the allegation of possible abuse.) Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/2/2021, showed the following information: -Severely cognitively impaired; -Required extensive assistance with bed mobility, transfer, locomotion on the unit, and dressing. Record review of the resident's care plan, revised on 11/11/2021, showed the following information; -Activities of daily living skills (ADL - dressing, grooming, bathing, eating, and toileting), self-care performance deficit related to confusion, dementia, fall risk and incontinence; -Cognitive impairment related to diagnosis of dementia; -Unaware of safety needs, unsteadiness, and lack of coordination. Record review of the DHSS records showed no report received from facility staff regarding the alleged possible abuse involving Resident #8 and Resident #58. 2. Record review of Resident #58's face sheet showed the following information: -admission date of 6/17/2019; -Diagnoses included degeneration of brain disease (a progressive nervous system disorder that affects movement) and dementia (a group of symptoms affecting memory, thinking, and social abilities severely enough to affect daily life). Record review of the resident's progress note showed the following information: -On 7/20/2021, at 5:30 P.M., Resident #58 was in the hallway with other residents. Staff assisted other residents in rooms when staff heard Resident #8 yell, help me, help me. Staff went to the hallway and observed Resident #58 holding Resident #8's arm and twisting it. Resident #58 refused to let go. Resident #8 called out in pain. Staff convinced Resident #58 to let go of Resident #8's arm. Staff separated Resident #58 from other residents and staff attempted to calm Resident #8. Staff notified the physician on call of the resident's behavior and of the resident's refusal to take medications this shift. (Staff did not document notifying DHSS of the allegation of possible abuse.) Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -Required extensive assistance with transfer, bed mobility, and (use past tense) wheelchair for ambulation. Record review of the resident's care plan, revised on 11/28/2021, showed the following information: -Experienced cognitive impairment, dementia; -Displayed out-of-character responses due to dementia-related diagnosis. Resident at risk for being verbally aggressive and physically aggressive with cares. Record review of the DHSS records showed staff did not self-report the alleged possible abuse involving Resident #58 and Resident #8. 3. During an interview on 12/2/2021, at 9:00 A.M., Certified Nursing Assistant (CNA) A, said the following: -He/she had received training on abuse and neglect, the types are financial, emotional, verbal and sexual. Resident to resident abuse should be considered abuse; -He/she did not witness the resident to resident altercation between Resident #8 and Resident #58. The incident would be considered abuse and should be reported to the supervisor and the state. 4. During an interview on 12/2/2021, at 1:09 P.M., CNA H said the following: -He/she would separate residents during an altercation and report to the supervisor. The report goes on up the chain and the State Agency is to be called within two hours. He/she would consider it abuse if residents hurt each other physically. The staff have in-services about abuse frequently. The types of abuse are physical, mental, sexual, and financial. 5. During an interview on 12/2/2021, at 1:13 P.M., CNA I said the following: -If residents have an altercation, staff should separate the residents, makes sure they are safe, and let the supervisor know. The staff gets multiple in-services during the year regarding abuse and neglect. He/she would consider resident physical altercations abuse. Social Services Director is the abuse coordinator. The administrator and DON are contacted. The State Agency is contacted within two hours. 6. During an interview on 12/2/2021, at 1:25 P.M., Housekeeping K, said the following: -If residents are in an altercation, he/she would separate them, make sure they are safe, and get a nurse immediately. The supervisor reports on up the chain and the State Agency should be notified within two hours. 7. During an interview on 12/2/2021, at 9:25 A.M., Certified Medication Technician (CMT) B said the following: -He/she received training on abuse, but not a lot. Types of abuse are verbal, sexual, isolation, and physical. Resident to resident altercations would also be abuse. Abuse should be reported to the charge nurse and the state within two hours. 8. During an interview on 12/2/2021, at 1:19 P.M., Licensed Practical Nurse (LPN) J said the following: -If residents have an altercation, staff should separate them, make sure they are safe, and call the supervisor. The staff gets multiple in-services regarding abuse and neglect throughout the year. He/she would consider it abuse for residents to be in physical altercations with each other. The abuse coordinator is the Social Services Director. 9. During an interview on 12/2/2021, at 9:33 A.M., LPN G, said the following: -He/she receives training at least quarterly on abuse, neglect, exploitation. Types of abuse are neglect, verbal, sexual, isolation and physical. Resident to resident altercations would be abuse; -He/she would report abuse to his/her supervisor, complete an investigation and notify the state within two hours. 10. During an interview on 12/2/2021, at 10:31 A.M., the MDS Coordinator said the following: -He/she received abuse training, at least annually and upon hire. Types of abuse are verbal, physical, emotional, neglect, financial and sexual. Resident to resident altercations would also be considered abuse and all abuse should be reported to supervisor. 11. During an interview on 12/2/2021, at 3:00 P.M., the Social Services Director said the following: -He/she receives abuse and neglect training, and all staff receive it when hired, annually and when there are incidents of abuse; -Types of abuse are neglect, physical, mental, verbal, misappropriation of funds, involuntary seclusion, sexual. Resident to resident would also be considered abuse; -He/she would report suspected abuse to his/her supervisor immediately, the responsible party is also contacted, and the state is notified within two hours; -He/she did not know about the incident between Resident #8 and Resident #58. 12. During an interview on 12/2/2021, at 10:52 A.M., the Director of Nursing (DON) said the following: -Prior to COVID, abuse trainings were held monthly, now there's more paperwork in-services. Training is provided when hired and held at least every two to three months thereafter; -Types of abuse are physical, mental, involuntary seclusion, sexual, neglect, misappropriation. Resident to Resident altercations could be abuse when someone is unsafe; -Staff should report abuse to the DON. If the DON is not available, then staff should report abuse to the supervisor. If after hours, there is an on call nurse available to notify; -Abuse must be reported to the state within two hours, and an investigation started. -The incident between Resident #8 and Resident #58 should be reported to the state within two hours. 13. During an interview on 12/3/2021, at 10:30 A.M., the administrator said the following: -He/she would expect resident to resident altercations to be reported to him/her. -He/she will report these incidents to the state in the future. -The incident between Resident #8 and Resident #58 should have been reported to the state.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Record review of Resident #65's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement), high blood pressure, unspecified dementia with behavioral disturbance (mental disorder with loss of the ability to think, remember, learn, make decisions and solve problems), transient ischemic attack (mini stroke), diabetes mellitus (a disease in which the body's ability to respond to the hormone insulin is impaired). Record review of the resident's Pre-Restraining Evaluation (evaluation of need for restraints) dated 1/11/2021, showed the following information: -Oriented to time and place at times; -Gait unsteady; -Balance unstable; -Unstable when making transfers; -Recommendation for positioning rail to be placed with bolster air mattress (a mattress with defined raised edges which help prevent the resident from falling out of bed) to aid in positioning and assist with pain. Record review of the resident's care plan dated 9/15/2021, showed the following information: -Bolster air mattress/right side positioning bar; - Mattress will decrease back pain through the next review; -Assess pain improvement in quarterly MDS; -Restraint review will be completed annually; -Potential for fall related to Parkinson's disease. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Mild depression; -Required extensive assistance, two person assist with bed mobility, transfers, dressing, and toileting; -Required use of wheelchair and walker for mobility; -No restraints. Record review of the current POS did not show an order for positioning bars. Record review of the resident's medical record showed facility staff did not obtain a consent form for bed rails. Record review of the resident's medical record showed the facility staff did not document completion of gap measurements. Observation on 11/30/2021, at 9:51 A.M., showed the resident had a raised grab bar (u-shaped bar measuring approximately 5 inches wide) on the right side of the bed. The resident was not in the bed. During an interview on 12/2/2021, at 11:35 A.M., the resident said he/she does not remember who ordered the side rails and does not remember signing a consent form. He/she sometimes uses the rail to pull him/herself up further in the bed. He/she has not had any accidents or gotten stuck. During an interview on 12/2/2021, at 10:50 A.M., LPN D said he/she did not obtain consent for side rails from the resident. During an interview on 12/2/2021, at 10:25 A.M., the maintenance supervisor said he completed gap measurements for the resident's mattress and grab bar. He did not document the measurements anywhere nor did he document if the measurements were pass/fail. 8. Record review of Resident #80's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included cellulitis of left lower limb (bacterial skin infection), acute posthemorrhagic anemia (condition in which a person quickly loses a large amount of blood quickly), heart disease. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance, two person assist with bed mobility, transfers, and toileting; -Required use of wheelchair and walker for mobility; -No restraints. Record review of the resident's care plan, dated 11/17/2021, showed the following information: -Bed mobility: limited one person assist-right side positioning rail; -Potential risk for falls; -Potential for alteration in comfort related to cellulitis/pain. Record review of the resident's Pre-Restraining Evaluation dated 11/21/2021, showed the following information: -Oriented to time and place; -Poor muscle control; -Engaged in physical and occupational therapy; -Recommendation for right side position rail to assist with bed mobility. Record review of the current POS did not show an order for grab bars. Record review of the resident's medical record showed facility staff did not obtain a consent form for bed rails. Record review of the resident's medical record showed the facility staff did not document completion of gap measurements. Observation on 11/29/2021, at 3:15 P.M., showed the resident had a raised grab bar (u-shaped bar measuring approximately 5 inches wide) on the right side of the bed. The resident was not in the bed. During an interview on 12/2/2021, at 11:45, the resident said he/she did not sign a consent form, did not request the side rail and does not know if his/her family did. Staff came in one day and installed it. It works well for him/her to move in and out of the bed. He/she uses one at home. During an interview on 12/2/2021, at 11:00 A.M., CNA F said he/she has observed the resident use his/her side rails safely. During an interview on 12/2/21, at 10:25 A.M., the maintenance supervisor said he completed gap measurements for the resident's mattress and grab bar. He did not document the measurements anywhere nor did he document if the measurements were pass/fail. 9. During an interview on 12/2/21, at 10:45 A.M., CNA E said he/she does not participate in the process of placing side rails on resident's beds, he/she does not obtain consent forms nor take part in gap measurements. Residents must have the ability to use their arms to move in bed to have side rails. Documentation would be in the chart. 10. During an interview on 12/2/21, at 11:00 A.M., CNA F said he/she only works on the 700 hall. He/she does not know where documents are related to side rails such as consent forms and gap measurements. Side rails are a resident/family preference or ordered by therapy. 11. During an interview on 12/02/2021, at 2:35 P.M., CNA J said if a resident or family member requests an enabler for a resident, a request should be put in for the physician to approve the device. Once the physician approved the enabler, then a work order should be placed for maintenance to put the enabler on the bed. He/she did not know what other paperwork was required for the enablers since this would be the nurse or maintenance's responsibility. 12. During an interview on 12/02/21, at 9:25 A.M., Certified Medication Technician (CMT B) said the following: -Side rails require a physician's order; -Keeps residents from rolling out of bed. 13. During an interview on 12/02/2021, at 2:40 P.M., LPN K said the facility did not use side rails and only used the enablers (turn rails). He/she calls the enablers grab bars. If a resident or family member request the enabler, the nurse would put in a request for the enabler and get a physician's order from the physician for the enabler. Once an order is obtained, then the nurse should put a work order in for maintenance to apply the enabler. He/she did not know what paperwork should be completed for the enablers and would have to ask a nurse who had been there longer. 14. During an interview on 12/2/21, at 10:50 A.M., LPN D said he/she has obtained consents from residents for side rails. Therapy recommends side rails and maintenance installs them. Consents would be scanned into the chart now that the facility is paperless. He/she doesn't deal with gap measurements and are not sure where they are located. 15. During an interview on 12/02/21, at 9:39 A.M., the MDS Coordinator, said the following: -Residents request side rails and these usually come through therapy. -This request is discussed with therapy, nurses, and those part of the medical team. -He/she puts the request in the Tell's system (a work order system for maintenance where staff should report issues that maintenance needs to repair, clean, or respond to) and a work order is created. -The Pre- Restraining Evaluation form is completed through this process and thereafter annually. -Every quarterly care plan they review the need for the side rails. -Residents sometimes request side rails as it makes them feel safer. 16. During an interview on 12/01/21, at 12:05 P.M., the Director of Nursing (DON) said they do not have consents for the side rails because they're considered enablers and not restraints. The side rails are placed at the resident's request. Once requested from the resident, the nurse and MDS coordinator complete their assessment and the maintenance department does their process after that. The maintenance department completes monthly checks of the side rails. 17. During an interview on 12/01/21, at 1:53 P.M., the maintenance supervisor said he/she measures the gaps between the side rails and mattresses. The measurements are not documented unless the computer systems tells him/her to document. The system has not prompted the need to document so the gap measurements are not documented. The measurements could be documented if this is required. 18. During an interview on 12/2/2021, at 3:10 P.M., the administrator said he believed the facility had assessed the turn rails prior to them being installed on the bed. Staff complete a risk versus benefits assessment. Maintenance completes the gap measurements prior to putting the turn rail on but he did not know maintenance did not record the measurements. He did not know there had to be a consent. Based on observation, interview, and record review, the facility staff failed to document completion of measurements to ensure there were no gaps that could potentially cause injury or entrapment and failed to obtain signed consent for the use of side rails for eight residents (Resident #5, #12, #36, #65, #71, #73, #76, and #80) out of a sample selection of 18 residents. The facility census was 90. Record review of the facility's policy titled, Restrictive Device Determination Guideline, showed the following information: -Prior to the initiation of any potentially restraining device being implemented, a designated member of the nursing team, with interdisciplinary Team involvement, will complete the Pre-Restraining Evaluation and request therapy screen and/or evaluation; -Alternatives to these devices will be considered; -If the resident can remove, release or freely move about, the device is not restrictive and not determined to be a restraint; -The interdisciplinary team will complete the summary of the evaluation and will carry interventions to the activity of daily living section of the resident's comprehensive care plan; -If the device is considered to be a restraint, the nurse will initially obtain and review the informed consent for use of restraints with the resident/responsible party, discussing the benefits and potential risks; -Assist Bar Sizing and Use Guidelines: Zone 1: within the rail, <120 mm (<4 ¾) Zone 2: Under the rail, between rail supports or next to a single rail support, <120mm (<4 ¾) Zone 3: Between rail and mattress, <120 mm (<4 ¾) Zone 4: Under the rail, at the ends of the rail, (60 mm (<2 3/8) AND >60 angle) -Measurements for assist bars need to be documented on the Pre-Restraining Evaluation and then quarterly and as needed (PRN) on the Physical Restraint Elimination Review; -Evaluate the need for assist bars. If not needed, please remove them; -The need for assist bars should be assessed and documented at least quarterly in conjunction with the resident's care planning/MDS cycle. This can be completed during a therapy screen, or by the nurse that is responsible for overseeing restorative. 1. Record review of Resident #71's face sheet (basic resident information sheet) showed the following information: -admitted to the facility on [DATE]; -Diagnoses includes unspecified sequelae of the other cerebrovascular disease (stroke-when blood flow to part of the brain is blocked), vascular dementia without behavioral disturbances (decline in thinking skills), pain in left and right shoulders, major depression (persistent feeling of sadness, and loss of interest). Record review of the resident's Pre-Restraining Evaluation, dated 5/21/2021, showed the following information: -Oriented to time and place; -Disoriented/confused; -Wheelchair mobility; -Bed alarm, and chair alarm. -Resident evaluated for bilateral turn rails, and alarm at all times. Record review of the resident's care plan, revised on 8/24/2021, showed the following information: -Experienced cognitive impairment, dementia. -At risk for falls related to impaired gait/balance and weakness; -Quarterly review of turn rails/bolster mattress; -Pre-restraining evaluation/enabler complete; -Use turn rail to assist with repositioning and will be removed when possible. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 11/21/2021, showed the following information: -Memory problems, modified independence; -Fall risk; -Required extensive assistance, two person assist with bed mobility, transfer, and mobility; -Bed rails not used. Record review of the current physician order sheet (POS) did not show an order for side rails. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that could potentially cause injury or entrapment. Record review of the resident's medical record showed the facility did not obtain written consent from the resident, or resident representative, prior to placing the side rails. Observation on 11/29/2021, at 9:11 A.M., showed Resident #71's bed had quarter side rails on both sides, in the raised position. Resident sat in his/her wheelchair. Observation on 11/30/2021, at 7:45 A.M., showed quarter side rails on both sides of the bed, in the raised position, and the resident rested in the bed. Observation on 11/30/2021, at 12:05 P.M., showed quarter side rails on both sides of the bed, in the raised position, and the resident rested in bed. During an interview on 12/2/2021, at 9:00 A.M., Certified Nurse's Aide (CNA) A said the following: -A resident that's had a stroke and paralysis, would use the side rail to reposition and be more independent; -Resident # 71 doesn't use the side rail as much as he/she used to; but, he/she does still use the rail to assist with turning in bed. During an interview on 12/2/2021, at 9:39 A.M., the MDS Coordinator, said he/she is unsure how Resident # 71, came to have sides rails as he/she does not assess residents on that hall. The other MDS coordinator that assesses this resident's hall, had not been at the facility long and would not have completed the evaluation for the use of side rails for this resident. During an interview on 12/2/2021, at 10:20 A.M., the maintenance supervisor said he does not have documented gap measurements for Resident # 71's side rails. 5. Record review of Resident #12's face sheet showed the following information: -The resident admitted to the facility on [DATE]; -Diagnoses included a traumatic subdural hemorrhage with loss of consciousness (stroke), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), congestive heart failure (CHF-a condition in which the heart doesn't pump blood as well as it should), anxiety, depression, and chronic kidney disease, stage 3 (moderate kidney damage). Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -The resident did not use bed rails. Record review of the resident's current care plan, showed the following interventions initiated on 12/17/2020: -Total assist with bed mobility; -Turn rails on bed. The resident's medical record did not have a consent form for bed rails or documented gap measurements, Observations on 11/29/2021, at 3:15 P.M., showed the resident resting in bed with bilateral (on both sides) grab bars in the up position. Observations on 12/1/2021, at 2:00 P.M., showed the resident resting in bed with bilateral grab bars in the up position. Observations on 12/2/2021, at 8:58 A.M., showed the resident resting in bed with bilateral grab bars in the up position. Observations on 12/3/2021, at 8:25 A.M., showed the resident resting in bed with bilateral grab bars in the up position. During an interview on 12/2/2021, at 1:09 P.M., CNA H said Resident #12 uses his/her grab bars for positioning only. A staff member comes and measures the bars frequently. The aide believes it may be monthly. He/she is not sure where the measurements are documented. 6. Record review of Resident #36's face sheet showed the following information: -The resident admitted to the facility on [DATE]; -His/her diagnoses included a right femur (the thigh bone) fracture, dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning), and rheumatoid arthritis (a chronic inflammatory disorder affecting many joints). Record review of the resident's admission MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -The resident did not use bed rails. Record review of the resident's current care plan, showed the following interventions, dated 10/15/2021: -Extensive two person assistance for bed mobility; -Bilateral turn rails on the bed. The resident's medical record did not have a consent form for the turn rails or documented gap measurements. Observations on 11/30/2021, at 2:49 P.M., showed the bilateral grab bars in the up position. The resident rested in the recliner next to the bed. Observations on 12/1/2021, at 12:28 P.M., showed the resident up in his/her wheelchair. The bilateral grab bars were in the up position on the bed. Observations on 12/2/2021, at 9:03 A.M., showed the resident resting in the recliner. The bilateral grab bars were in the up position on the bed. Observations on 12/3/2021, at 8:24 A.M., showed the bilateral grab bars in the up position on the bed. The resident was not in the room at the time. During an interview on 12/2/2021, at 12:20 P.M., LPN J said Resident #36 uses his/her grab bars for positioning only. He/she uses them to turn and was assessed by the MDS coordinator. He/she thinks the resident's family signed a consent form, but is not sure. Maintenance installed the bars and comes monthly and makes sure they fit properly. The rails are never used to keep a resident in bed. 2. Record review of Resident #5's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included dementia, muscle weakness, and stroke. Record review of the resident's significant change (major decline or improvement in the resident's status) MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required extensive staff assistance of two staff for bed mobility, transfer, dressing, and toilet use; -Bed rails not used. Record review of the resident's care plan, dated 4/17/2017 and last revised on 11/11/2021, showed the following information: -The resident had self-care deficits with activities of daily living (ADLs) to include bed mobility, transfers, dressing, mobility, hygiene, and toileting, related to disease process; -One turn rail on bed to assist with repositioning; -Experienced cognitive impairment related to dementia. Observation on 11/29/2021, at 10:20 A.M., showed the resident up in his/her wheelchair in his/her room. The resident had one turn rail (grab bar) to the left side of his/her bed. The turn rail was in the raised position. Observation on 11/29/2021, at 2:56 P.M., showed the resident in bed with one turn rail (grab bar) to the left side of his/her bed. The turn rail was in the raised position. Record review of the resident's November 2021 POS showed no physician order for the turn rail (grab bar). Record review of the resident's medical record showed the following: -A pre-restraint evaluation and risk versus benefits, dated 8/23/2021, for the turn rail; -No consent for the turn rail; -No gap measurements for the turn rail. During an interview on 12/2/2021, at 2:35 P.M., CNA J said the facility does not use side rails, just enablers (turn rails). He/she has seen Resident #5 use the enabler to assist when staff reposition the resident to his/her wheel chair. During an interview on 12/2/2021, at 2:40 P.M., Licensed Practical Nurse (LPN) K said the facility did not use side rails and only used the enablers (turn rails). He/she calls the enablers grab bars. He/she has not seen Resident #5 use the enabler to reposition. 3. Record review of Resident #73's face sheet showed the following information: -admitted to facility on 5/7/2021; -Diagnoses included emphysema (disease that involves the gradual damage of lung tissue), chronic kidney disease stage three (level of kidney damage that cuts kidney function to about half), muscle weakness, need for assistance with personal cares, and history of falls. Record review of the resident's care plan, dated 5/20/2021, showed the following information: -Self-care performance deficit related to being a fall risk; -Required extensive assistance of two staff for bed mobility, dressing, transfers, and toileting; -Turn rails to bed for repositioning. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required extensive assistance of two staff for transfers, dressing, toileting, and hygiene; -No bed rails used. Observation on 11/29/2021, at approximately 10:40 A.M., showed the resident asleep in his/her wheel chair in his/her room. The resident had turn rails (grab bars) on both sides of the bed. Both turn rails were in the raised position. Observation on 11/29/2021, at 1:42 P.M., showed the resident was not in his/her room. The resident had enablers (grab bars) on both sides of his/her bed. Both side rails were in the raised position. Record review of the resident's November 2021 POS showed no physician order for turn rails. Record review of the resident's medical record showed the following information: -A pre-restraint evaluation and risk versus benefits, dated 8/18/2021, for the two turn rails; -No consent for the turn rails; -No gap measurements for the turn rails. During an interview on 12/2/2021, at 2:35 P.M., CNA J said he/she has seen Res #73 use the enabler (turn rail) to assist when staff reposition. During an interview on 12/2/2021, at 2:40 P.M., LPN K said he/she saw Res #73 use the enabler to reposition last night. 4. Record review of Resident #76's face sheet showed the following information: -admitted to facility on 2/20/2019; -Diagnoses included dementia, palliative care (comfort care), and history of falls. Record review of the resident's care plan, dated 5/21/2021, showed the following information; -ADL self-care performance deficit related to weakness and Alzheimer's disease; -Supervision of one staff for bed mobility, transfers, dressing, and hygiene; -Turn rail on one side for repositioning. Record review of the resident's annual MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Required supervision of one staff for bed mobility, transfers, dressing, and toileting; -Bed rails not used. Observation on 11/29/2021, at 10:35 A.M., showed the resident in bed asleep. The resident had one turn rail (grab bar) on one side of the bed. The turn rail was in the raised position. Observation on 11/29/2021, at 3:25 P.M., showed the resident was not in his/her room. The resident had one turn rail (grab bar) to one side of the bed. The turn rail was in the raised position. Record review of the resident's November 2021 POS showed no physician order for the turn rail (grab bar). Record review of the resident's medical record showed the following information: -A pre-restraint evaluation and risk versus benefits, dated 5/21/2021, for one turn rail; -No consent for the turn rail; -No gap measurements for the turn rail. During an interview on 12/2/2021, at 2:35 P.M., CNA J said Resident #76 was independent and used the turn rail for repositioning and to get out of bed. During an interview on 12/2/2021, at 2:40 P.M., LPN K said he/she had seen Resident #76 use the enabler to get to a sitting position in bed and to get out of bed.

Based on observation, interview, and record review, the facility failed to maintain the ice machine in a clean manner when the ice reflector shield in the ice machine located in the kitchen had a build-up of a black substance that appeared to be mold on the ice reflector shield, failed to ensure the air cooling vent in the walk in freezer was free of lint which could blow on to food stored in the walk-in freezer, and failed to ensure two fluorescent light fixtures in the dry storage pantry had covers and one cover for a fluorescent light fixture was broken. If the light bulbs were to shatter or break, food stored in the dry pantry could be contaminated by broken glass. The facility census was 90. The facility did not have a policy for the kitchen cleanliness. Record review of the Missouri 2013 Food code, showed the following information: -The purpose of this Code is to safeguard public health and provide to consumers food that is safe, unadulterated, and honestly presented; -(2) Bears or contains any added poisonous or added deleterious substance which is unsafe; (3) Consists, in whole or in part, of any diseased, contaminated, filthy, putrid, or decomposed substance, or if it is otherwise unfit for food; or (4) Has been produced, prepared, packed, or held under unsanitary conditions whereby it may have become contaminated with filth or whereby it may have been rendered diseased, unwholesome, or injurious to health. 1. Observation on 11/29/2021, beginning at 9:29 A.M., showed the ice machine, located in the kitchen near the entrance to the kitchen, ice reflector shield in the interior portion of the ice machine, had a black substance across the ice reflector shield which appeared to be mold. Observation on 12/1/2021, beginning at 10:54 A.M., showed the ice reflector shield had been cleaned and the black substance had been removed from the ice reflector shield. During an interview on 12/2/2021, at 9:16 A.M., Dietary Staff (DS) C said he/she thought maintenance checked and cleaned the ice machine reflector shield monthly. He/he did not know dietary staff should monitor for cleanliness of the interior of the ice machine or the ice reflector shield and report this to maintenance if the ice machine or ice reflector shield was dirty. During an interview on 12/2/2021, at 9:22 A.M., DS D said the maintenance staff clean the ice machine. He/she did not know how often maintenance cleaned the ice machine and the ice reflector shield. During an interview on 12/2/2021, at 9:32 A.M., the Dietary Manager (DM) said maintenance is responsible for cleaning the ice machine and the ice reflector shield on a monthly basis. If she saw the ice reflector shield had a build-up of a black substance on the ice reflector shield in between cleanings, she would put a work order in for maintenance to clean it. During an interview on 12/2/2021, at 10:14 A.M., the Maintenance Director (MD) said if there was an issue in the kitchen, maintenance needed to clean or fix, dietary staff should put in a work order in Tels (a work order system for maintenance where staff should report issues that maintenance needs to repair or clean) so maintenance could clean or fix it. Maintenance cleans the ice machine and the ice reflector shield monthly and it was on the maintenance monthly check list. Dietary staff see the ice machine daily and would know if it needed to be cleaned in between the monthly scheduled cleanings. If it is dirty prior to the next month cleaning, the dietary staff should report this so maintenance can clean it. 2. Observation on 11/29/2021, beginning at 9:29 A.M., showed two fluorescent light fixtures in the dry pantry area that had missing covers. Stored beneath the fluorescent light fixtures that had missing covers were boxes of uncovered uncooked sweet potatoes, russet potatoes, and golden russet potatoes. One fluorescent light fixture cover near the walk in freezer and walk-in cooler had a cracked and broken surface. Observation on 12/1/2021, at 10:54 A.M., showed the covers for the two fluorescent light fixtures in the dry pantry area were still missing and the fluorescent light cover fixture near walk-in cooler and walk-in freezer was still broken. During an interview on 12/2/2021, at 9:16 A.M., DS C said he/she would put in a work order through Tels to notify maintenance of missing or broken light fixture covers. He/she had not noticed the fluorescent light fixtures in the dry pantry area were missing or that the light fixture cover near the walk-ins was broken. During an interview on 12/2/2021, at 9:23 A.M., DS D said if he/she saw a fluorescent light fixture in the kitchen had missing light covers or a broken light cover, he/she should put in a Tels order for maintenance so they could replace the covers on the light fixtures. He/she had not noticed the fluorescent light fixtures in the dry pantry did not have covers and had not noticed the fluorescent light fixture near the walk-ins was broken. During an interview on 12/2/2021, at 9:32 A.M., the DM said if light fixtures in the kitchen were missing covers or if covers for light fixtures were broken, staff should report this to maintenance so maintenance could replace the light covers. He/she had not noticed the fluorescent light fixtures in the dry pantry were missing covers or the cover for the fluorescent light fixture near the walk-ins was broken. When she or her dietary staff find missing or broken light covers, they should put in a work order with Tels so the maintenance staff know to replace these covers. During an interview on 12/2/2021, at 10:14 A.M., the Maintenance Director said he had been told about the broken and missing light covers in the kitchen approximately five minutes ago. He had covers for the fluorescent light fixtures that were missing or broken and he would change them. Staff should put in a work order for anything in the kitchen that needs to be repaired so he is aware of of it. 3. Observation on 11/29/2021, beginning at 9:29 A.M., showed the air exchange vent in the walk-in freezer had a build-up of lint that had the potential to blow onto the surfaces of food packaging container and when staff opened the containers to prepare the food the lint had the potential to contaminate the food. Stored underneath the air exchange vent in the walk-in freezer was a box of uncovered onions. The lint had the potential to be blown into the box of unions and contaminate the food. Observation on 12/1/2021, beginning at 10:54 A.M., showed the air exchange vent in the walk-in freezer remained dirty with a build-up of lint. During an interview on 12/2/2021, at 9:16 A.M., DS C said he/she did not know to look to see if the air exchange vent in the walk-in freezer was dirty and to report this to maintenance. During an interview on 12/2/2021, at 9:23 A.M., DS D said he/she did not know the air exchange vent in the walk-in freezer had a build-up of lint. This should be reported to maintenance to clean. During an interview on 12/2/2021, at 9:32 A.M., the DM said he/she did not know the air exchange vent in the walk-in cooler or freezer could get dirty. He/she would put in a work order for maintenance to clean this since it has a motor. During an interview on 12/2/2021, at 10:14 A.M., the Maintenance Director said the cooling fans (air exchange vents) were visually inspected monthly and cleaned as needed. 4. During an interview on 12/2/2021, at 10:14 A.M., the Maintenance Director said if there was something in the kitchen, maintenance needed to fix or repair, dietary staff should put in a work order in Tels so maintenance knew of the issue and could fix it. 5. During an interview on 12/02/2021, at 09:45 A.M., the administrator said he knows maintenance cleans the ice reflector shield monthly so the facility may need to replace this part. He did not know there were missing covers for fluorescent light fixtures or that one in the kitchen was broken and he would make sure these were replaced. He would make sure the air exchange vent in the walk-in freezer was cleaned.