Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to manage and with in two hours to the Survey Agency (DHSS - Department of Health and Senior Services) when staff failed to report and an allegation of abuse involving one resident (Resident #1) until the following day. The facility census was 101. Review of the facility policy Abuse and Neglect, dated 10/24/22, showed the following:-Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse or neglect, or an injury of unknown origin to the Director of Nursing (DON) or the department supervisor and that individual will notify the Administrator;-Each employee should report to the supervisor and follow-up with the supervisor to confirm it has been addressed. If not, the employee should make direct contact with the Administrator;-Any staff members that witnessed, suspected, or that is reported to, are personally obligated to initiate protection and report to supervisor immediately.1. Review of Resident #1's face sheet (admission information at a glance) showed the following:-admission date of 09/11/23;-Diagnoses included fractured left hip with artificial hip joint, moderate dementia (progressive impairments in memory, thinking, and behavior which affects ability to carry out daily activities) with anxiety, type 2 diabetes mellitus (high blood sugar), chronic kidney disease, urinary tract infection, and chronic obstructive pulmonary disease (COPD - lung disease that blocks air flow and makes it difficult to breathe). Review of the resident's care plan, revised 8/23/25, showed the following:-The resident had impaired cognition/decision making ability and impaired communication related to dementia. The resident exhibited behaviors of delusions;-Explain care and procedures before and during care; -Observe for understand, and repeat information as needed;-Provide consistent caregivers as possible;-Provide simple cues, prompts, and reminders as needed;-Speak name or touch resident so they know they are being addressed;-Allow opportunity to make choices and participate in care;-Do not argue with resident;-Identify causes for behaviors and reduce factors that may provoke behaviors;-Impaired cognition;-Explain care and procedures before and during care;-Observe for changes in cognition;-Observe resident when restless, hungry, thirsty, need to use the bathroom, pain, and provide care needed;-Assist with decisions as needed and offer choices;-Provide cues, prompts, and reminders as needed;-Touch and hugs as appropriate.During interviews on 09/09/25, at 1:34 P.M., and on 09/10/25, at 10:55 A.M., Nurse Aide (NA) E said on 08/31/25, at around 4:30 A.M. to 5:00 A.M., while doing their last rounds before shift change, he/she and Certified Nurse Aide (CNA) G went into the resident's room to provide incontinence care. CNA G turned on the light and asked the resident if they could provide care. When CNA G went to take off the incontinence brief, the resident was startled, and grabbed CNA G's arm and then hit his/her arm. CNA G grabbed the resident's hands and wrists and crossed them on his/her chest to hold him/her down. CNA G had an aggressive mean voice with the resident for hitting him/her. CNA G held the resident's hands across his/her chest for about a minute. NA E didn't know what to say or do. The resident refused to let them change him/her and they left without changing him/her. He/she knows now they should have gone and told the nurse about the resident refusing and being aggressive, and to try to go back later to the resident. He/she said, It didn't cross his/her mind to tell the charge nurse right away. He/she did think about it later and then told NA F the next night on 08/31/25 to 09/01/25. NA F told him/her that he/she should report this. Then NA F went ahead and made the report. He/she was to report to the charge nurse and then make a paper report. NA F told RN A the next day before he/she got off work. He/she did not know the time frame to report an allegation of abuse and neglect and did not know the time frame to report to the state.Review of the resident's progress note dated 09/01/25, at 7:15 P.M., showed there was an allegation of abuse that had been made about the resident. The Staffing Development Coordinator (RN) A and Licensed Practical Nurse (LPN) B assessed the resident, suspended the staff member, and notified the physician, Administrator, and durable power of attorney (DPOA). Review of DHSS records showed the facility self-reported the allegation of physical abuse on 09/01/25, at 7:24 P.M. Review of the facility's written investigation, dated 09/01/25, showed it was reported that CNA G forcibly held down the resident's hands.During an interview on 09/09/25, at 11:25 A.M., CNA D said if he/she noticed any bruising on a resident, he/she would automatically tell the nurse and chart this since the aides do chart skin for redness and bruising and where it's located. If he/she saw abuse, he/she would intervene and go let nurse know. NA E mentioned the event to NA F who was told to report to RN A. NA E was a new nurse aide and said he/she didn't know who to report to. If staff see something like abuse, staff were to tell the nurse who was to report this to the Administrator. They were to report any abuse or neglect within two hours to the state.During interview on 09/09/25, at 12:57 P.M., NA F said he/she worked the night shift on 08/31/25 to 09/01/25 when night NA E told him/her CNA G was mean and aggressive towards the resident when they went to perform incontinence care to the resident. The resident smacked CNA G on his/her arm and CNA G grabbed the resident's hands , crossed them over his/her chest, and forcefully held him/her down by the arms. NA E didn't know to report this to the nurse. NA F told NA E to report this. When NA F got off work, he/she waited to report what NA E told him/her. It was already a day late so he/she thought it was okay to wait until later that day. He/she told RN A, he/she was told this information when he/she came in later that day. NA F was not sure how to report but knew he/she was to report this immediately. It was to be reported to the state within two hours. During an interview on 09/09/25, at 3:58 P.M. Certified Medication Technician (CMT) H said they were to report any abuse to the charge nurse right away and within two hours, and staff to report to the state. During interview on 09/10/25, at 9:15 A.M., LPN I said he/she would report any allegation of abuse and neglect to the DON and Administrator. He/she did not know the time period for reporting to the state.During interview on 09/09/25, at 11:20 A.M., the Activities Director said if there was any abuse such as mental, physical, emotional, verbal, sexual, or financial, staff were to go through the chain of command and go to the charge nurse and report this immediately. This was to be reported to the state within two hours.During interviews on 09/09/25, at 2:45 P.M. and 3:10 P.M., Staffing Development Coordinator (RN A) said NA F texedt him/her that NA E had witnessed CNA G being abusive toward another resident. He/she talked to NA E who said the resident had struck CNA G and CNA G grabbed the resident's arms and pushed them toward his/her own chest while NA E provided incontinence care. RN A contacted the Administrator and then came directly to the facility to go with LPN B night charge nurse to assess the resident with another aide. LPN B They contacted all the nurse aides involved and took them off the schedule. Staff were to contact the DON and Administrator if there was any abuse or neglect allegation. They were to notify staff immediately and have two hours to report to the state.During an interview on 09/10/25, at 10:10 A.M., the Assistant Director of Nursing (ADON) said he/she would expect staff to report immediately any abuse to their charge nurse. During an interview on 09/10/25, at 11:45 A.M., the DON said staff were to report any abuse and neglect immediately and the Administrator had two hours to get the report in to the state. Staff were to call her and not text her. The staff can call her, the ADON, and the Administrator at any time.During an interview on 09/10/25, at 2:20 P.M., the Administrator said she had orientation that discussed Abuse and Neglect and reporting immediately to the charge nurse or the DON, and herself as administrator. Complaint 2604516

Based on observation, interview, and record review, the facility failed to promote and facilitate each resident's right of self-determination through support of resident choice when staff failed to honor resident preferences for showers for three residents (Resident #1, #2, and #3). The facility census was 103.Review of the facility policy titled, Hygiene and Grooming, dated 10/01/10, showed the following:-Good hygiene and grooming help prevent the spread of infection and promote the resident's feeling of self-worth and dignity;-Guidelines for provision of hygiene and grooming services are shower, tub, or complete bed bath, as needed; and hair and scalp shampoo, as needed;-Services may be provided on a varying schedule, when a physician's order or recommendation exists, or when the resident needs services more frequently;-Resident preferences for time of day, type of bath, and frequency of bath should be honored, to the extent possible.1.Review of Resident #1's face sheet showed the following:-admission date of 02/09/24;-Diagnoses included congestive heart failure (CHF - a condition in which the heart doesn't pump blood as efficiently as it should), dependent on oxygen, muscle weakness, unsteadiness on feet, major depression, and general anxiety disorder.Review of the resident's care plan, revised 08/08/25, showed the following:-Required staff assistance with all activities of daily living (ADLs);-Transfers, two-person assist;-Assist to gather items for bathing and assist to bath area as needed;-Two person to assist with bathing;-Assist with hair, brushing teeth/oral care, shaving, and nail care;-Assist with bathing per schedule;-Encourage to wash, rinse, and dry body parts that are within their physical ability to do. Observation and interview on 08/12/25 at1:20 P.M., with the resident showed the following:-The resident lay on his/her bed wearing a night gown with circular stains on the front of the gown;-The resident's hair appeared slightly greasy and uncombed;-The residents said he/she had an issue with the facility not assisting him/her with an adequate number of showers;-The resident said he/she would like to have at least two showers per week, but typically staff assisted the resident with one shower every couple of weeks;-He/she spoke to nursing staff about the issue and spoke to the Social Service Designee (SSD) about the issue as well. The SSD told the resident the facility was working on the shower issue. The SSD told the resident staff documented he/she refused his/her showers in the past, but the resident said that was not accurate. The resident said he/she did not refuse showers. He/she required a considerable amount of assistance to transfer in and out of the shower chair and needed assistance during the shower. During an interview on 08/13/25, at 9:56 A.M., the Shower Aide said the following:-The resident was scheduled to have a shower on the day shift, but he/she required the assistance of two staff and a mechanical lift to transfer in and out of the shower chair;-At times, he/she did not have time or assistance to complete the resident's shower as assigned;-The shower aide reviewed the records and said staff had not assisted the resident with a shower since 08/01/25 per the documentation (12 days prior).Review of the resident's electronic medication record history, dated 07/01/25 to 08/12/25, showed the following:-Showers scheduled once a day on Tuesdays and Fridays;-Staff documented completion of showers by marking as done (completed) on 07/01/25, 07/15/25, and 08/01/15.During an interview on 8/13/25, at 1:40 P.M., the resident said the following:-He/she preferred two showers per week;-If staff do not assist him/her with a shower, he/she starts feeling itchy all over and he/she would get dandruff/dry flaky skin on his/her scalp.2. Review of Resident #2's face sheet showed:-An admission date of 07/20/23;-Diagnoses included schizoaffective disorder(a combination of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may include delusions, hallucinations depressed episodes and manic periods of high energy), post-traumatic stress disorder (PTSD), anxiety, depression, and paranoid personality disorder.Review of the resident's care plan, revised 07/14/25, showed the following:-Required assistance to complete daily activities of care safely;-Allow resident to make choices, when possible;-Bath per schedule.Observation and interview on 08/12/25, at 1:22 P.M., with the resident showed the following:-The resident lay on his/her bed fully dressed and his/her hair appeared greasy;-The resident said he/she had not been assisted with a shower in approximately two weeks;-The resident said he/she was supposed to be assisted by staff with two showers per week;-The resident said he/she thought the reason for not getting a shower was due to the facility pulling the shower aide to work the floor. During an interview on 08/13/25, at 9:56 A.M., the Shower Aide said the following:-He/she thought the evening shift was responsible for assisting the resident with showers;-The SSD and the shower aide just implemented the new shower list during the past week, but prior to that, the evening staff were not competing the assigned showers;-The resident was on the shower aides list of residents that needed a shower;-The shower aide reviewed documentation and said he/she thought the resident had not had a shower in approximately 3 weeks or more.Review of the resident's electronic medical record history, dated 07/01/25 to 08/12/25, showed the following:-Showers scheduled once a day on Mondays and Thursdays;-Staff did not document completion of any showers from 07/01/25 to 07/16/25;-Staff documented resident refused on 07/17/25;-Staff did not document completion of any shower from 07/18/25-08/06/25;-Staff documented resident refused on 08/07/25;-Staff did not document completion of any shower from 08/08/25-08/10/25;-Staff documented resident refused on 08/11/25;-Staff did not document on 08/12/25.During an interview on 08/13/25, at 1:45 P.M., the resident said staff assisted him/her with a shower and changed his/her sheets today (08/13/25) and he/she felt better. If he/she did not get a shower, he/she felt itchy and more tired.3. Review of Resident #3's face sheet showed:-admission date of 12/29/12;-Diagnoses of CHF, morbid obesity, type 2 diabetes mellitus, anxiety, and major depression.Review of the resident's care plan, revised on 07/29/25, showed the following:-Required staff assistance with ADLs related to obesity and limited mobility;-One-to-two-person assistance with bathing as needed;-Encourage the resident to wash, rinse, and dry body parts that are within their physical ability to do;-Required assistance of two staff for use of bed pan for toileting.Review of the resident's electronic medical record, dated 07/01/25 to 08/12/25, showed the following:-Showers scheduled once a day on Tuesdays and Fridays;-Staff documented completion of showers by marking as done (completed) on 07/15/25, 07/23/25, and 08/01/15.Observation and interview on 8/13/25, at 1:50 P.M., with the resident showed the following:-The resident laying on his/her bed; -Resident stated he/she was bed bound, overweight, and got sweaty under his/her skin folds;-The resident's skin became raw and sore, if staff did not assist him/her with a bath;-The resident said he/she liked to have staff assist with a bed bath two times per week, but often had to wait two weeks in between bed baths;-He/she needed a bed bath to keep skin from breaking down;-He/she experienced incontinence of bladder at times and used a bed pan at times;-The resident said he/she began smelling like urine and feces when staff do not assist him/her with a bed bath twice per week;-The resident said his/her head starts itching when his/her head was dirty;-The resident said he/she talked to staff and asked for assistance with bed baths, but staff told the resident they did not have time and were too busy with other responsibilities. 4. During an interview on 08/13/25, at 9:56 A.M., the Shower Aide said the following: -He/she worked as the shower aide in the facility since January 2025;-The facility did not have another shower aide;-He/she generally worked four days per week, seven hours per day;-He/she assisted approximately 10 to 12 residents per day with showers, if no residents refused;-At times, nurses asked him/her to work the floor as an aide due to call-ins or staffing issues and when that happens, he/she was not able to complete assigned showers;-He/she was unsure how often nursing pulled him/her to work the floor as an aide;-Approximately one week ago, the Social Service Designee (SSD) suggested the shower aide change the way in which he/she gave showers;-Every resident room/bed number had two designated shower days and times per week;-In the past, he/she was focused strictly on completing the day shift showers assigned for that day;-He/she was not attempting to catch up on incomplete showers from previous days/evenings;-After working with the SSD, the shower aide was now looking at which residents were not getting showers on other days or shifts and trying to prioritize those that had gone the longest amount of time without a shower;-He/she found some residents were going two to three weeks without a shower;-The SSD had computer access to look back on past resident shower documentation for the past few weeks and found staff were either not completing or not documenting showers;-Evening shift aides were assigned residents showers, but were not completing most of the assigned showers;-Beginning last week, the SSD printed off a list last week of residents that have not had showers in two to three weeks and the shower aide was trying to prioritize showering those residents. We started doing that last week or week before last;-SSD became involved, because SSD and the shower aide noticed more residents were complaining of staff not assisting them with showers;-A majority of the residents complaining were scheduled for showers on the evening shift.-The shower aide said he/she charted the resident refused when he/she ran out of time to give the resident a shower or when nursing pulled him/her to work the floor. The shower documentation did not provide a space to document another reason for not completing the shower and the shower aide said he/she would rather not leave the documentation blank;-On average, he/she was assisting the more independent residents with one shower per week, but he/she generally did not provide showers to the residents requiring more extensive transfer/shower assistance;-In the past, he/she had reported to the charge nurse or previous Director of Nursing (DON) he/she could not complete all the showers, and they would just tell the shower aide okay;-No one was following up with a list of needed showers for the next shift;-Prior to last week no one was auditing showers to ensure staff were completing resident showers.During an interview on 08/13/25, at 1:25 P.M., Nurse Aide (NA) C said the following:-Nursing assigned each aide to work a specific hall for their shift;-For each hall and each shift, there were assigned resident showers. Aides were responsible for assisting with the assigned showers;-He/she did not have adequate time during his/her shift to complete all assigned resident showers due to other resident care responsibilities while working the floor;-He/she said he/she might complete half of the assigned resident showers for the shift on average;-He/she had not notified the nurse of not being able to complete showers.During an interview on 08/13/25, at 2:54 P.M., NA E said the following:-He/she worked the floor as an aide;-Frequently, the aides were unable to complete assigned showers due to lack of time and due to other job responsibilities.During an interview on 08/13/25, at 1:33 P.M., Certified Medication Technician (CMT) D said the following:-Staff were supposed to assist residents with two showers per week;-The aides/shower aide were not completing all the assigned resident showers;-He/she thought the issue was due to staff not encouraging residents enough to take showers;-Staff often just accepted the resident's first refusal and did not re-approach the resident later of notify the nurse of the resident refusals;-The day shift aides frequently did not complete assigned showers;-The Shower Aide frequently did not complete assigned showers. During an interview on 08/13/25, at 11:00 A.M., Licensed Practical Nurse (LPN) A said the following:-The facility had one designated shower aide and then the evening and night shifts aides were assigned showers as well;-He/she was under the impression, the day shift aides were also supposed to do showers, but some days the Shower Aide said he/she and/or the aides were not completing assigned resident showers;-When informed of an issue, he/she would pass a list of residents needing showers to the evening shift staff and ask the evening staff to complete those showers;-He/she thought the evening aides generally completed the provided list of residents needed showers, depending on staffing number and which aides were working that evening;-He/she tried to make sure the aides were documenting showers given or documenting refusals;-If the staff notified him/her of a resident refusal, the nurse would try to encourage the resident to take a shower;-The nurse knew the Shower Aide was sometimes documenting refused when he/she ran out of time or was pulled to the floor, but the shower aide should not document refused unless the resident refused the shower.During an interview on 08/13/25, at 11:20 A.M., LPN B said the following:-Staff were not completing all assigned resident showers;-He/she observed the evening shift only completing a few of the assigned showers;-He/she did not know if the night shift had assigned showers or if they were completing any showers on the night shift;-Some residents complained about not getting showers. He/she was not auditing to see which residents were assisted with showers and which residents were not getting staff assistance with showers. During an interview on 08/13/25, at 11:37 A.M, the SSD said the following:-He/she had worked at the facility for approximately 9 years and used to work as a shower aide several years prior;-Staff were supposed to provide each resident with two showers per week, unless the resident requests a different number of showers;-During resident care plan meetings, some of the residents and/or their family members mentioned concerns with not getting shower assistance or an adequate number of showers. When this occurred, he/she notified nursing of the need to shower those specific residents;-On approximately 08/07/25, he/she observed the Shower Aide did not completing all assigned resident showers. The Shower Aide appeared to be completing a portion of showers for that assigned day. It appeared no staff were assisting residents listed on the evening shift showers list with their showers. When the SSD questioned this, the Shower Aide said he/she was not able to complete all the assigned showers for each day and was not completing any resident showers assigned to the evening shift;-On 08/07/25, the SSD decided to run a report to focus on which residents had not had showers recently;-He/she ran a resident shower report for the past two weeks, 07/24/25 to 08/07/25, to determine which residents had not been assisted with showers and provided the list to the shower aide;-On 08/11/25, he/she notified the interim DON of the issue of staff not assisting residents with an adequate number of showers.During interviews on 08/12/25, at 1:54 P.M., and on 08/13/25, at 2:12 P.M., the DON said the following:-He/she worked as the interim DON of the facility since approximately 07/23/25;-He/she pulled the Shower Aide away from completing resident showers today (08/12/25) and reassigned the shower aide to work as an aide on the floor, due to terminating another aide today;-The facility had one designated shower aide for the building, but if the resident was independent with showers, the aides could also assist with showers;-Unsure how often nursing pulled the Shower Aide to work the floor in the past;-The facility scheduled residents for two showers per week;-The Shower Aide gave approximately 5 to 10 showers per day.-He/she expected staff to provide each resident with two showers per week, unless the resident refused or elected to have a different number of showers per week;-He/she was unsure if anyone was auditing the resident showers on a regular basis to ensure staff were completing the showers;-He/she thought some of the residents complained about not getting showers to the SSD, so the SSD ran a shower report;-A few days ago, the SSD came to the DON with concerns about the staff not assisting residents with showers.-The Shower Aide was not completing all assigned showers and the aides working the floor did not always have time to assist with resident showers;-All residents in the facility required at a minimum supervision for safety while in the shower;-The DON was not aware the Shower Aide documented resident refusals when he/she ran out of time to complete a shower or when pulled to work the floor;-When the Shower Aide was unable to complete assigned list, he/she should give a list of remaining showers to the charge nurse, so the nurse could assign aides to try and complete the showers or so the nurse could document the reason the shower was not given.During an interview on 08/13/25, at 3:00 P.M., the Administrator said the following:-He/she was not aware staff were not assisting residents with showers as scheduled;-All residents should be offered at least two showers per week unless the resident preferred a different number of showers.Complaint #2588293

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide an ongoing program of activities to meet the interests of and support the mental and psychosocial well-being for all residents when the facility failed to have an Activity Director, a complete activity program, or activity calendars for the residents including seven residents (Resident #5, Resident #6, Resident #8, Resident #9, Resident #10, Resident #12, and Resident #13) identified as feeling activities were important. The facility census was 102. 1. Review of Resident #8's face sheet showed: -admission date of 11/08/16; -Diagnoses included anoxic brain injury (a condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), major depressive disorder, anxiety disorder, and high blood pressure. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 04/02/24, showed the following: -Cognitively intact; -No behavioral symptoms; -Very important for the resident to do things with groups of people; -Very important for the resident to do his/her favorite activities; -Resident able to ambulate independently. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident remained cognitively intact; -No behavioral symptoms; -Resident able to ambulate independently. Review of the resident's care plan for psychosocial well being, updated on 01/14/25, showed the following: -Activity plan needed; -Deliver mail to resident timely; -Encourage family visits; -Encourage to attend exercise activities; -Encourage to attend religious activity; -Encourage walking outside; -Food related activities of choice; -Resident does not wish to participate in group activities at this time; -Enjoys watching action movies; -Enjoys listening to 90's rock music; -Enjoys reading car magazines; -Enjoys the Discovery channel; -Ice cream socials; -Provide activity calendar; -Required assistance with activities; -Visit with residents, staff, family, and friends. Observation and interview on 02/25/25, at 12:30 P.M., showed the following: -The resident sat on the side of his/her bed; -The resident pointed out an empty plastic sleeve hanging on his/her wall and said the facility was supposed to put an activity calendar in the sleeve each month, but no one was bringing activity calendars to the resident; -The resident said the facility had not had an activity director or a regular program of activities since approximately October 2024; -He/she did not know what activities he/she would like to attend because he/she did not have an activity calendar; -He/she might go to the activities, if the facility offered any; -He/she used enjoy watching movies with other residents. 2. Review of Resident #9's face sheet showed the following: -admission date of 09/27/24; -Diagnoses included dementia, major depressive disorder, history of alcohol use, and high blood pressure. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -No behavioral symptoms; -Very important for the resident to do things with groups of people; -Very important for the resident to do his/her favorite activities; -Resident able to ambulate independently. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident remained cognitively intact; -No behavioral symptoms; -Resident able to ambulate independently. Review of the resident's care plan for psychosocial well being, updated on 01/16/25, showed the following: -Activity plan needed; -Assist in reading mail and writing letters; -Deliver mail timely; -Provide computer access; -Cooking; -Encourage family visits; -Encourage to attend exercise activities; -Encourage to attend religious activity; -Encourage walking outside; -Food related activities of choice -Resident enjoys attending group activities; -Games/bingo/dominos/checkers/puzzles/crossword puzzles; -Movies; -Ice cream socials; -Provide activity calendar; -Place television on; -Provide cards and paper; -Provide reading material; -Put radio on station; -Required assistance with activities; -Visit with residents, staff, family, and friends. During an interview on 02/25/25, at 2:44 P.M., the resident said the following: -The resident did not have an activity calendar. The facility did not have an Activity Director; -One of the resident's does BINGO three times per week, but other than that the facility did not have much else going on; -He/she would like more activities; -He/she listened to music and would more music type activities. 3. Review of Resident #10's face sheet showed: -admission date of 06/13/24; -Diagnoses included alcohol use with alcohol induced persistent dementia, diabetes mellitus type II, schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly and a mood disorder), and traumatic brain injury. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -No behavioral symptoms; -Very important for the resident to do his/her favorite activities; -Resident able to ambulate independently. Review of the resident's care plan for psychosocial well being, updated on 01/14/25, showed the following: -Activity plan needed; -Allow rest breaks between activities; -Assess activity preferences and help plan; -Assist resident to get to chosen activities; -Assist with activities to stay connected with friends; -Provide activities per the capacity of the resident; -Provide opportunities to be outside, when weather permits. Observation of and interview on 02/25/25, at 2:50 P.M., showed the following: -The resident sat talking at a table in the dining room with another resident; -The resident said the facility had not had an Activity Director in several months; -In the past, the AD would go to the dollar store or Wal-Mart for the residents to pick up needed items, such as deodorant and shampoo which the residents paid for. Without an Activity Director, no one went to the store for the residents; -He/she had asked some of the nurses if anyone could go to the store for him/her and they told the resident to ask the office. He/she went to the office and staff said there was no one to go to the store; -One of the facility residents calls out BINGO, but he/she would like more activities. 4. Review of Resident #6's face sheet showed the following: -admission date of 09/21/22; -Diagnoses included Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination), alcoholic cirrhosis of liver (a chronic liver disease caused by excessive alcohol consumption over a prolonged period), and chronic kidney disease, (decreased kidney function, typically indicated by an estimated glomerular filtration rate (eGFR) between 60 and 89, and usually with no noticeable symptoms). Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors; -Very important to listen to music; -Somewhat important to do his/her favorite actives; -Very important to get fresh air when the weather was good. Record review of the residents care plan, for psychosocial well-being, updated 10/14/24, showed the following: -Prevent feelings of isolation from family and friends; -Assist in visits with friends and family in a private location; -Assist to talk privately on the phone; -Assist with activities to stay connected with friends; -Encourage to talk about feelings. During an interview on 02/26/25, at approximately 10:35 A.M., the resident said the following: -He/she was the president of the resident council; -There has only been one meeting in over at least six months; -The last meeting was earlier in February 2025; -There has not been staff around to help set one up; -Residents used to get a calendar every month, so it was easy to know what was planned. Now there are no calendars given and there is no large calendar posted in any hall, for residents to see; -There is no activity director; -One resident does call out bingo, so they can do that a couple times a week; -The only normal activity that is every-other-day is group exercise; -They do have a church come in on some Sunday's, but he/she does not participate; -Some have just given up on activities unless it's doing the exercise and sometimes having popcorn; -He/she said you're out of luck if you really want to do anything. 5. Review of Resident #5's face sheet showed the following: -admission date of 02/09/24. -Diagnoses include hypertensive heart disease with heart failure (a condition where high blood pressure (hypertension) damages the heart muscle over time, leading to an inability of the heart to pump blood effectively), chronic diastolic (congestive) heart failure (a condition where the heart's left ventricle becomes stiff and cannot relax properly, leading to a buildup of fluid in the lungs and other parts of the body due to impaired filling between heartbeats, causing symptoms of congestive heart failure while still maintaining a normal ejection of fraction (the percentage of blood pumped out with each beat)) and spinal stenosis (when the spinal canal and the space around the spinal canal become narrowed). Record review of the resident's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -No behaviors; -Very important to have books, newspapers and magazines to read; -Very important to listen to the music the resident likes; -Very important to keep up with the news; - Somewhat important to do things with groups of people; -Very important to do the resident's favorite activities; -Very important to go outside to get fresh air when the weather is good; -Somewhat important to participate in religious services or practices. Review of the resident's care plan for psychosocial well-being, updated 10/14/24, showed the following: -Prevent feelings of isolation from family and friends; -Assist in visits with friends and family in a private location; -Assist to talk privately on the phone; -Assist with activities to stay connected with friends; -Encourage resident to talk about feelings. During an interview on 02/26/25, at approximately 12:25 P.M., the resident said the following: -He/she could not say when activities had last been offered, but that it has been a long time; -He/she was not sure what activities sound good, but he/she would possibly attend if they were offered; - It is a little boring; -He/she had never been given a calendar that he/she could remember; -He/she would possibly participate if something fun was offered. 6. Record review of Resident #12's face sheet showed the following: -admission date of 11/14/23 -Diagnoses included chronic kidney disease, stage II (mild - decreased kidney function, typically indicated by an estimated glomerular filtration rate (eGFR) between 60 and 89, and usually with no noticeable symptoms); osteonecrosis (a condition where bone tissue dies due to a loss of blood supply), and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -No behaviors; -Very important to have books, newspapers, and magazines to read; -Very important to listen to the music he/she liked; -Very important to be around animals such as pets; -Very important to to keep up with the news; -Very important to do things with groups of people; -Very important to do his/her favorite activities; -Very important to go outside to get fresh air when the weather is good. Record review of the resident's care plan for psychosocial well-being, updated 10/14/24, showed the following: -Assist in visits with friends and family in a private location; -Assist to talk privately on the phone; -Assist with activities to stay connected with friends; -Encourage to talk about feelings. During an interview on 02/27/25, at approximately 11:30 A.M., the resident said the following: -Not anything much is offered for activities; -He/she said, It is boring around here. If they offer anything, you gotta grab it or you're out of luck; -There is bingo sometimes, which he/she does usually attend; -There is church sometimes, but he/she does not attend; -They have popcorn now; -His/her family purchased any items he/she may need, so does not ask any staff. 7. Review of Resident #13's face sheet showed the following: -admission date of 02/07/20; -Diagnoses include chronic kidney disease, stage III; chronic diastolic (congestive) heart failure, and type II diabetes mellitus (a chronic condition characterized by high blood sugar levels (hyperglycemia) due to the body's inability to use insulin effectively or produce enough insulin). Review of the resident's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -No behaviors; -Somewhat important to have books, newspapers and magazines to read; -Very important to be around animals such as pets; -Very important to keep up with the news; -Very important to do his/her favorite activities; -Somewhat important to go outside to get fresh air when the weather is good; -Somewhat important to participate in religious services or practices. Review of the resident's care plan for psychosocial well-being, updated 01/14/25, showed the following: -Deliver mail timely; -Encourage family visits; -Encourage resident to attend exercise; -Encourage resident to walk/wheel outside; -Resident enjoys family visits; -Resident enjoys one on ones with manicures; -Resident enjoys participating in group activities; -Resident enjoys participating in monthly birthday parties; -Resident enjoys playing on his/her tablet and reading the paper from it; -Resident enjoys reading small novels; -Resident enjoys watching love stories; -Resident enjoys watching NCIS, crime, and true crime shows; -Ice cream socials; -Provide activity calendar; -Required assistance with activities During an interview on 02/27/25, at approximately 11:45 A.M., the resident said the following: -His/her family went to Wal-Mart to purchase most of his/her items needed; -He/she had also learned to do Wal-Mart delivery so he/she does not ask staff; -He/she did ask staff several months ago to get something and it seemed to be a big deal, so he/she no longer asks; -It has been months since the facility has had an Activity Director; -He/she did an art class once, a long time ago, and enjoyed that, but they had a Activity Director who set it up; -They no longer have anything fun or that he/she was interested in; -He/she said they would not know if anything were offered, because there is no calendar any longer. 8. During an interview 02/25/25, at 12:53 A.M., Certified Nurse Assistant (CNA) G, who worked in the Special Care Unit, said the following: -The facility did not offer much in the way of activities for the SCU residents; -The staff in the SCU did not generally have much time to provide activities for the residents; -The facility had no Activities Director for several months; -The CNA said the facility had a plastic bowling set in the SCU, but the staff had to be cautious with allowing the residents to use it because it could create a fall risk; -The facility staff did not provide any routine activities to the dementia residents; -The residents in the SCU would benefit from some activities. During an interview on 02/26/25, at 10:01 A.M., Licensed Practical Nurse (LPN) H said the following: -The facility did not currently have an Activity Director; -The facility did not offer activities to the residents residing in the special care unit, and staff did not generally have time to conduct activities with those residents; -A former resident's family member comes on Sunday afternoons and conducts a church service in the main dining room; -The alert and oriented residents complain of boredom; -The facility has a higher number of younger residents and the facility did not have much for these residents to do; -In the past, when the facility had an Activity Director, he/she would make monthly Wal-Mart and dollar store trips for the residents; -Some of the residents have complained there was no one to go to the store for them. During an interview on 02/27/25, at 1:55 P.M., LPN K said the following: -The facility had no Activity Director for approximately the past 6 months, except for one week, a few days ago; -The facility had BINGO and morning exercise three times per week, but other than that, the facility was not offering other activities to the residents; -The residents would like to have more activities; -Residents came to the nurse daily and asked what what was going on in the facility and what activities were happening; -He/she sometimes looked for coloring pages for the residents to complete; -Many of the residents were bored at the facility. During an interview on 02/26/25, at 1:43 P.M., the Financial Specialist Assistant (FSA) said the following: -The residents complained about the lack of activities; -One resident conducted BINGO for the residents and asked about collecting donations for better BINGO prizes; -The only regular activities were resident led BINGO on Monday, Wednesday, and Friday afternoons, and a restorative nursing aide (RNA) led morning exercise class on Monday, Wednesday, and Friday mornings; -The facility did not provide a current activity calendar to the residents; -The residents complained of no activities and the lack of activities led the residents to boredom and were more irritable as a result; -Several of the residents were very upset about not having anyone to go to Wal-Mart or to the dollar store. During an interview on 02/27/25 at 1:19 P.M., the SSD said the following: -The facility did not have an AD; -The only current activities were exercise three times per week and resident led BINGO three times per week; -He/she used to work as the AD at the facility several years ago; -When he/she worked as the AD, he/she would go to the store for residents two times per month, to purchase requested items for individual residents; -Residents enjoyed BINGO, but also would enjoy other activities such as music, corn hole, and trivia games; -The residents would enjoy any activities because currently there was not a lot going on for the residents; -He/she brought up the lack of activities in the morning department head meeting; -The facility administrator was trying to hire an AD. During an interview on 02/26/5, at 12:56 P.M., the facility Nurse Practitioner (NP) I said the following: -He/she was not aware the facility did not have a full-time Activity Director; -Residents would benefit from daily activities; -Activities were important for the residents; -A lack of activities could lead to boredom among the residents. During an interview on 02/26/25, at 1:36 P.M., the Medical Records Nurse (LPN J) said the facility had not had a consistent Activity Director since the end of 2023. Sometimes the residents complained to staff about a lack of activities. During an interview on 02/26/25, at approximately 2:30 P.M., Registered Nurse (RN) E said the following: -The facility was trying to hire an activity director; -Church is on Sunday mornings and some Wednesday evenings; -A resident enjoys calling bingo for everyone. During an interview on 02/25/25, at 10:05 A.M. and 11:20 A.M., and 02/27/25, at 3:10 P.M., the Director of Nursing (DON) said the following: -The facility did not currently have an Activity Director; -The Administrator hired a new AD last month, but he/she worked at the facility for approximately one week and then quit; -Currently, a RNA offered morning group exercise on Monday, Wednesday, and Friday mornings; -One of the facility's residents conducts BINGO on Monday, Wednesday, and Friday afternoons; -He/she encouraged the SSD to reach out to one of the hospice agencies to see about activities and one of the hospice agencies conducted BINGO one time last month; -He/she expects that all department heads take a role in leading some activities for the residents, until an Activity Director was hired; -The DON was unsure who runs purchases for residents, if they need anything; -The facility did not have an activity calendar. During an interview on 02/27/25, at 2:26 P.M., the Administrator said the following: -He had not assigned any current employee to be in charge of resident activities; -The facility did not have a consistent activity program for the residents; -The facility did not have an activity calendar and the residents did not have individual activity calendars; -They do not have the staff to run full-time activities; -All staff have pitched in if a resident needs something bought; -A few residents have made use of choosing deliveries for purchases; -A few residents have expressed they are not happy about the lack of activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to provide appropriate fall follow up assessments, including neurological assessments (evaluation of the functioning of the nervous system, identifying any abnormalities or neurological deficits.) for four residents (Resident #1, Resident #3, Resident #4, and Resident #7) after each resident sustained a fall with potential for head injury. The facility census was 102. Review of the facility policy titled, Incidents and Accidents, dated 11/10/24, showed the following: -The resident environment to remain as free of accident hazards as is possible, however, when an accident occurs, prompt response and reporting occurs; -Examples include falls or resident observed on the floor; -The resident should not be moved unnecessarily until condition has been assessed; -Assess the resident's injury, pain, range of motion, bruising, bleeding, and lacerations -Assess neurological signs as appropriate; -Notify the physician and obtain orders for care, including any indicated diagnostics; -Notify family of accident, status, and orders for care; -Obtain medical care as needed and transfer to emergency room, as needed. Review of the facility policy titled, Change in Medical Condition of Resident/Guest, showed the following: -Keep the physician, who is in charge of medical care, and family member/legal representatives, responsible for health care decisions and other resident/guest representatives informed of the resident/guest medical condition so they may direct the plan of care as needed; -Notification of the physician, legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident condition. Change in the condition is defined as an accident involving the resident/guest which results in injury and has the potential for requiring physician intervention; -Examples of a change in condition may include a fall, new pain, and respiratory distress; -In the event of an emergency, call the physician and family member at the time the event occurs whatever time of day or night; -Document the symptoms and observations associated with the change in condition, the date and time of contact with the physician, and family member or legal representative. Notes also should include comments on the care provided by nursing personnel; -The 24-hour report serves as a reminder to report any change in condition to the upcoming shift; -Further assessment may be warranted with certain permanent changes in condition. 1. Review of Resident # 1's face sheet showed the following: -admission date of 06/28/24; -Diagnoses included of Alzheimer's disease. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 02/05/25, showed the following: -Severe cognitive impairment; -Resident did not reject care; -Exhibited a behavior of daily wandering; -Wandering places the resident at significant risk of getting to a potentially dangerous place; -Two or more non-injury falls since admission; -One injury (except major) fall since admission; -Independent with transfers; -Resident ambulated and did not use a wheelchair. Review of the resident's progress note dated 02/07/25, at 5:35 A.M., showed the following: -Resident was walking in the hall and staff heard a fall. Staff found the resident in the hallway. The resident re-injured a pre-existing skin tear on his/her elbow. Staff cleansed wound cleansed and a dressing and wrap applied. The resident also had a hematoma (closed wound where blood collects and fills a space inside the body) forming on the left side of his/her forehead. The resident denied pain at that time. Review of the resident's fall event report, completed on 02/07/25 at 6:12 A.M., showed a nurse documented the following: -Event date: 02/07/25 at 5:28 A.M.; -Location of fall: Hallway; -What was the resident doing just prior to fall? Walking; -Was fall witnessed? No; -Does resident exhibit or complain of pain related to the fall? No; -Location of injury: Left elbow skin tear and left head hematoma; -Note any injuries to the head, extremities, or trunk: Bump and skin tear; -Range of motion to 4 extremities without pain/limitations; -Level of consciousness: Alert wakefulness-Perceives the environment clearly and responds appropriately to stimuli; -Facial muscle movement: Strong; -Extremity movements: Strong; -Pupil size/response/shape: Both 3 millimeters/round/brisk; -Speech: Clear; -Resident responds to name; -Does not exhibit or complain of dizziness/light headedness, headache, nausea/vomiting, seizure, or other; -No changes in mental status; -Physician notified on 02/07/25 at 6:12 A.M.; -Resident representative not notified; , -Vitals signs (VS) taken. Review of the resident's medical record showed staff did not document any further progress note or fall follow up/neurological assessments on 02/07/25. Review of the resident's medical record showed staff did not document any progress note or fall follow up/neurological assessments on 02/08/25. Review of the resident's progress note, dated 02/09/25 at 9:54 A.M., showed the following: -Does resident have pain: No; -Neuro/Cognitive: Alert, confused, forgetful, oriented to person; -Change in cognitive status: No change; -VS taken. (The nurse did not include documentation of a neurological assessment due to the resident's hematoma.) Review of the resident's progress note, dated 02/09/25 at 10:39 A.M., showed the following: -It was reported to the nurse that the resident received a skin tear to his/her left forearm from a recent fall. Skin assessment completed and observed a skin tear measuring 10.0 centimeters (cm) by 5.0 cm with partial thickness tissue loss with exposed dermis. Nurse was able to approximate part of the tear. Wound bed pink and moist, wound edges rolled and indistinct, peri-wound pink with slight edema (swelling) with moderate amount of serosanguinous (contains or relates to both blood and the liquid part of blood (serum)) drainage. Nurse cleansed area and applied a treatment. Physician orders placed for treatment. (The nurse did not include documentation of neurological checks or assessment of the resident's hematoma.) Review of the resident's medical record showed staff did not document any further progress note/neurological assessment on 02/09/25. Review of a progress note, dated 02/13/25 at 6:43 A.M., showed the resident's physician documented, the following: -Resident was seen on 02/10/25, at the request of nursing staff, for evaluation of closed head injury. Nursing staff reported recent fall that resulted in hematoma to forehead. No loss of consciousness, headache, or vision changes were reported. The resident was awake and alert with baseline confusion. He/she was alert to self only on exam per baseline. The resident resides on the memory care unit and progressive weakness was reported by facility staff. -Review of objective symptoms showed alert/confusion; eyes, ears, and mouth normal; back normal; skin with resolving ecchymosis (bruise) to left side of face; extremities with normal weakness; neurological/psych: and oriented to one; -Closed head injury status post fall with no loss of consciousness reported. Resolving ecchymosis to left face. Continue follow up monitoring per protocol. Review of the resident's progress notes, dated 02/11/25 at 11:28 A.M., showed social services documented a review of the resident's plan of care with the resident's responsible party. The progress note did not mention the fall or any assessment of the resident's neurological status or assessment of the resident's hematoma. Review of the resident's medical record showed nursing staff did not document any fall follow up/neurological assessment on 02/11/25 or 2/12/25. Review of the resident's progress notes until 02/17/25 when the physician saw the resident for unrelated reasons. Observation on 02/21/25, at 12:22 P.M., showed the following: -The resident sat at a dining room table in the Special Care Unit (SCU) eating lunch; -The resident had a large, fading bruise (green in color) covering the left eye lid, the skin below his/her eye, and the left temple area. During an interview on 02/25/25, at 11:08 A.M., Certified Nursing Assistant (CNA) M said the following: -He/she arrived to work one morning approximately two weeks ago and the night shift aide said the resident fell on the night shift; -The night shift reported the resident did not hit his/her head or sustain any injuries; -CNA M went to check on the resident and found the resident had a large dark purple are on the side of his/her head and the resident had blood on his/her hand. The CNA checked the resident and found a bleeding large skin tear on the resident's left arm; -He/she went and reported to one of the day shift nurses. During interviews on 02/26/25, at 10:01 A.M. and 11:15 A.M., Licensed Practical Nurse (LPN) H said the following: -The resident #1 fell during the night and he/she came in to work the following morning; -He/she went to the unit that morning and assessed and dressed the resident's skin tear; -The nurse did not remember the exact circumstance of the resident fall, but he/she did assess the resident, complete neuro checks and place a progress note in the resident's progress notes. 2. Review of Resident #3's face sheet showed: -admission date of 05/27/23; -Diagnoses included hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD - a group of lung disease characterized by a narrowing of the air passageways), atrial fibrillation (an abnormal heart rhythm), and unspecified severe protein-calorie malnutrition. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behavioral symptoms; -No falls since prior assessment; -Used wheelchair for mobility device; -Independent with personal hygiene, toileting hygiene, dressing, and transfers; -Dependent on supplemental oxygen; -Short of breath when lying flat; -Used oxygen therapy. Review of the resident's physician order sheet showed the following: -An order, dated 11/10/24, for staff to apply oxygen at 2 to 4 liters (L) per minute via nasal cannula to maintain the oxygen saturation above 90%. Review of the resident's progress note dated 12/24/25, at 3:28 P.M., showed the following: -The nurse noted the resident to have labored breathing, productive cough, and crackle lung sounds this shift. The nurse notified the physician and obtained orders for a chest X-Ray, Duoneb (an inhaled medication to help open the airways) four times per day for five days, and Rocephin (an antibiotic) 1 gram, intramuscular (IM) injection, give 1 dose now. Rocephin administered and other orders placed at this time. Vitals taken. Review showed staff did not document in the progress notes again until 12/25/24, at 2:01 P.M. Review of the resident's progress note, dated 12/25/24 at 2:01 P.M., showed the following: -The resident stated his/her mattress was off the frame a little on the side he/she got up and down on and he/she went to place his/her hand it, and the mattress gave out from under the resident, and he/she slid of the side of the bed and hit his/her head. The resident reported he/she fell at about 1:00 P.M., but due to current coughing fits, his/her voice was weak, so no one could hear him/her until he/she crawled closer to the door to yell for help. The resident was alert and oriented. Vital signs taken. Approximately 10 to 15 minutes later, the resident was slightly confused, and his/her speech was slurred. The nurse initially sent a text message to the physician group and after re-assessment the nurse called the emergency physician line and sent the resident to the hospital. (The nurse did not document a complete neurological assessment of the resident.) Review of the resident's fall event report, dated 12/25/24 at 2:48 P.M., showed a nurse documented the following: -The resident said his/her mattress was off the frame a little on the side he/she got up and down on and he/she went to place his/her hand, and the mattress gave out from under the resident, and he/she slid of the side of the bed and hit his/her head. The resident reported he/she fell at about 1:00 P.M., but due to current coughing fits, his/her voice was weak, so no one could hear him/her until he/she crawled closer to the door to yell for help. The resident was alert and oriented. Vitals taken. Approximately 10-15 minutes later, the resident was slightly confused, and his/her speech was slurred. The nurse initially sent a text message to the physician group and after re-assessment the nurse called the emergency physician line and sent the resident to the hospital; -No late showing injury. Care plan reviewed and appropriate; -Responsible party notified on 12/25/24 at 1:21 P.M.; -Physician notified on 12/25/24 at 1:30 P.M (The nurse did not document a complete neurological assessment of the resident.) Review of the resident's entry MDS, dated [DATE], showed the resident re-entered the facility from the hospital on [DATE]. Review of the resident's progress notes showed staff did not document a progress note for 12/31/24, 01/01/25, or 01/02/25. Review of the resident's nurse practitioner re-admit note, dated 01/02/25 at 8:00 A.M., showed, in part, the following: -re-admitted to the facility on [DATE]; -Resident seen today for a re-admission at the facility following a hospitalization after a fall with and high blood pressure. Resident was lying in bed and said he/she was feeling much better and blood pressure was stable and denied shortness of breath, chest pain, or dizziness. Resident had not fallen since return from the hospital. Resident was wearing oxygen. Resident denied pain. admission labs ordered and medications and vital signs reviewed. Review of the resident's progress note, dated 01/03/25 at 12:39 A.M., showed a nurse documented an assessment of the resident, but did not address the resident's return from the hospital or any follow up on the hospital findings. 3. Review of Resident #4's face sheet showed: -admission date of 09/04/24; -Diagnoses included chronic kidney disease, dementia, type II diabetes mellitus, and adult failure to thrive. Review of the resident's Quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No behavioral symptoms; -Falls prior to admission or prior assessment, but no falls during this admission; -Required substantial/maximal assistance of staff (staff does greater than half the effort) with toileting hygiene, personal hygiene, showering, and transfers; -Short of breath upon exertion (such as with walking, bathing, or transfers); -Oxygen therapy. Review of the resident's progress note dated 11/15/24, at 4:35 A.M., showed a nurse documented the following: -At 4:00 A.M., the nurse was notified by staff the resident was laying on the floor in his/her room. This nurse observed the resident was laying on the floor next to his/her bed. Resident was laying on his/her left side. The resident's bedside light was on. The nurse assessed the resident and assisted the resident to bed with no noted injuries. Call light placed in reach. Staff educated to place non-slip socks on the resident. The resident physician, responsible party, and hospice were notified. Review of the resident's fall event report dated 11/15/24, at 4:33 A.M., showed a nurse documented the following: -An unwitnessed fall with no injuries in the resident's room; -Was fall witnessed? No; -Does the resident exhibit or complain of pain related to the fall? No; -Range of motion: Without pain/limitation to all extremities; -No rotation, deformity, shortening of extremities noted; -Level of consciousness: Alert wakefulness; -Facial muscle movement: Strong; -Extremity movement: Section left blank; -Bilateral pupils size/response/shape: Section left blank; -Resident responds to name, pain, and environment; -Does the resident exhibit any of the following as a change in mental status of new onset: No changes; -Physician notified on 11/15/24 at 4:14 A.M.; -Resident representative notified on 11/15/24 at 4:14 A.M.; -Vitals taken at 11/15/24, at 4:34 A.M., at 4:41 A.M., at 5:54 A.M., at 5:55 A.M. and at 5:56 A.M. Review of the resident's progress note, dated 11/15/24, at 7:25 A.M., showed social services documented completed current MDS assessments. Social services did not document related to the fall. Review of the resident's progress note dated 11/15/24, at 12:04 P.M., showed a nurse documented the following: -This nurse was at the resident's side from 8:30 A.M. to 10:15 A.M. The resident was going through cards and pictures. Resident asked the nurse a question. Nurse re-oriented the resident to current date and situation. The resident spoke with a relative over the phone. Staff assisted the resident with fluids and protein shake. Nurse assisted the resident to the bathroom. Resident assisted the resident to bed. Resident was notified the call light was in reach. Fall precautions in place. Padding on floor next to bed. Resident's family member visited the resident and at the resident's side at 12:00 P.M. The resident's family member reported the resident ate food and appeared to feel comfortable in bed. The nurse checked on the resident at 12:50 P.M., and resident reported was feeling good at that time. Resident in bed at this time. Frequent room checks and neurological checks are being performed. (Staff did not document subsequent fall follow up/neurological assessment.) Review of the resident's progress notes dated 11/15/24, at 1:30 P.M., showed a nurse documented the following: -This nurse was called into the dining room at approximately 7:30 A.M., by staff. The resident was laying on the floor halfway under the dining room table. Resident states hit head on the edge of the table. Resident noted to have bump to the mid back of his/her head with no complaints of pain to his/her head. Resident complained of pain to his/her mid back. No noted length difference at time of assessment. Physician and hospice notified, and message left for resident's responsible party. Resident noted to be more confused than usual, attempting to collect urine specimen for test. Nurse spoke with hospice and new orders received for Haldol (anti-anxiety medication) 2 milligram dose right now and then two times per day for schizophrenic disorder/restlessness. This nurse administered the first dose. (Staff did not document subsequent neurological assessment and fall follow up.) Review of the resident's fall event report dated 11/15/24, at 1:24 P.M., showed a nurse documented the following: -An unwitnessed fall occurred in the dining room; -What was resident doing just prior to fall? Walking with wheelchair; -Was fall witnessed? No; -Does the resident exhibit or complain of pain related to the fall? Yes, mid back pain. Pain characterized as Moderate pain- Distressing/miserable; -Location of injury: Knot (Bump) to mid back part of the resident's head; -Range of motion painful/limited in lower extremity; -No rotation, deformity, shortening of extremities noted; -Level of consciousness: Alert wakefulness; -Facial muscle movement: Strong; -Extremity movement: Strong to bilateral upper and lower right extremity, weak to lower right extremity; -Bilateral pupils size/response/shape: 3 mm, round, and brisk; -Speech: Clear; -Resident responds to name, pain, and environment; -Does the resident exhibit any of the following as a change in mental status of new onset: Confusion and restlessness; -Physician notified on 11/15/24 at 8:00 A.M.; -Resident representative notified on 11/15/24 at 8:00 A.M.; -Vital signs completed. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/16/24, at 1:42 P.M., showed a nurse documented the following: -Does resident have pain? No -Neuro/cognitive: Alert, confused/forgetful, oriented to person; -Change in cognitive status: Deteriorated (consider significant change); -Respiratory status: Short of breath with exertion; -Vital signs taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/16/24, at 5:47 P.M., showed a nurse documented the following: -Does resident have pain? Yes, relieved with pain medication; -Neuro/cognitive: Alert, confused/forgetful, oriented to person; -Change in cognitive status: No change; -Respiratory status: Short of breath with exertion; -Vital signs taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/17/24, at 2:03 A.M., showed a nurse documented the following: -Does resident have pain? Yes, relieved with pain medication; -Neuro/cognitive: Alert, confused/forgetful, oriented to person, lethargic; -Change in cognitive status: Deteriorated (consider significant change); -Respiratory status: Short of breath with exertion; -Vitals taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/17/24, at 10:16 A.M., showed a nurse documented the following: -Does resident have pain? No; -Neuro/cognitive: Alert; -Change in cognitive status: No change; -Vitals taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress notes dated 11/17/24, at 10:49 A.M., showed a nurse documented the following: -Fall follow-up with no latent injuries observed. No change in activities of daily living (ADLs) or range of motion (ROM). Neuros within normal limits for resident. Vital signs taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/19/24, at 10:16 A.M., showed a nurse documented observed the resident this morning to have quarter-sized, yellow bruise to his/her right upper back, left lower back, and left upper arm. with no signs/symptoms of pain. (Staff did not document subsequent neurological assessment.) 4. Review of Resident #7's face sheet showed: -admission date of 12/03/24; -Diagnoses included dementia, collapsed cervical vertebra (neck), seizures, high blood pressure, and depression. Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No behavioral symptoms; -Used wheelchair for mobility device with assistance of staff to propel; -Fall prior to admission to the facility with no falls since admission. Review of the resident's progress note dated 02/07/24, at 2:33 A.M., (recorded as a late entry on 02/10/25) showed a nurse documented the following: -Resident heard calling for help. Resident stated he/she had to use the bathroom and when he/she attempted to stand, he/she misjudged the edge of the bed and rolled onto the floor. At the time, resident denied injury and/or pain. Review of the resident's fall event report dated 02/07/25, at 4:18 A.M., showed a nurse documented the following: -Unwitnessed fall in the resident's room; -What was resident doing just prior to fall? Sleeping; -Was fall witnessed? No; -Complaint of pain? No; -Location of injury? Not applicable -Range of motion: Without pain or limitation to all extremities; -Position of extremities: No rotation/deformity/shortening noted; -Level of consciousness: Alert/wakefulness; -Facial muscle movement: Strong; -Extremity movement/grasp: all four extremities strong; -Pupil size/response/shape: 3 cm/round/brisk; -Speech: Clear; -Resident responds to name; -Mental status: No changes; -Physician notified on 02/07/25 at 4:30 A.M.; -Responsible party notified on 02/10/25 at 3:00 P.M.; -Vitals taken; -Resident was found on floor adjacent to bed and latent bruising became apparent on day shift 02/07/25. Bruising across left forehead, eye, and brow resolving. Resident denied pain. Pain was resolving. Injury was resolved/healing without complications. Care plan updated. Review of the resident's medical record showed no additional progress notes on 02/07/25. Review of a progress note dated 02/08/25, at 4:33 A.M., showed a nurse documented resident continued fall follow-up without latent injures noted. Neurological checks within normal limits and denied pain or discomfort. (Staff did not document subsequent neurological assessment.) Review of the resident's medical record showed no additional progress notes on 02/08/25. Review of the resident's progress note dated 02/09/25, at 9:37 A.M., showed a nurse documented the following: -Was reported to this nurse that the resident had a fall on 02/07/25 on the overnight shift. No injuries were noted at the time of the fall. Resident remained on fall follow-up. Neurological checks were within normal limits at this time. Resident's pupils are reactive and equal bilaterally, grip strength was equal bilaterally. Bruising noted to the resident's left eye and left upper check area. No other latent injuries noted at this time. Vitals taken. Review of the resident's progress note dated 02/10/25, at 5:07 P.M., showed a nurse documented the following: -Fall follow up from 02/07/25 event. This nurse went to talk to the resident and review the environment. A fall mat was added next to the bed to promote his/her well-being, and an extra blanket was added to pad a couple of knobs that protrude from the bed frame a bit. Discoloration noted across the left side of the resident's forehead, brow, and eye, which appear to be turning yellow/green. When interviewed about the fall, the resident initially said he/she was stuck and could not get up. The resident resided in the SCU and had noted cognitive deficits. The nurse asked the resident a series of questions pertaining to safety and security. The resident stated he/she felt safe in his/her home. The resident mostly replied with word salad, about his/her youth. The resident's tone varied from a whisper to clear and loud. The resident's family member present at bedside during the interaction. Care plan updated. During an interview on 02/25/25, at 11:08 A.M., CNA M said the following: -He/she arrived to work one morning approximately two weeks ago and the night shift aide said the resident fell during the night; -The night shift reported the resident did not hit his/her head; -CNA M went to check the resident and found the resident had a purple area to his/her left eye; -The resident was crying and upset and said his/her face hurt; -He/she went and reported to one of the day shift nurses. During interviews on 02/26/25, at 10:01 A.M. and 11:15 A.M., Licensed Practical Nurse (LPN) H said the following: -He/she worked the day shift on 02/07/25; -The resident's fall occurred on the night shift; -The night nurse passed on information in report on the morning of 02/07/25 about the resident's fall; -The night nurse reported the resident fell overnight and hit his/her head; -The nurse went to the Special Care Unit (SCU) and assessed the resident, conducted neuro checks and made a progress note about the residents left forehead and eye bruise. 5. During interviews on 02/26/25, at 10:01 A.M. and 11:15 A.M., Licensed Practical Nurse (LPN) H said the following: -After a resident fall, the nurse should assess the resident for any injury, check the resident's range of motion (ROM) and assess for pain; -If a resident falls and hits his/her head or if it is an unwitnessed fall and the resident is not able to remember whether or not he/she hit his/her head, the nurse should complete neurological checks; -Neurological checks are to be completed per policy, which is every 15 minutes for the first hour then every 30 minutes for an hour the every hour for a set number of hours, LPN H was unsure exactly, but said the neuro checks were generally performed for 48 to 72 hours in total, to ensure the resident did not have a head injury; -The nurse said the facility used to have a paper form to record the neuro checks on, but several months back, the facility started using an electronic health record system, and there was no place to record the neuro checks, so he/she conducted the neuro checks, but did not record them, but rather made a progress note; -After assessment of the resident for injury, the nurse should notify the resident's physician and the resident's responsible party, the nurse should then document the assessment in the progress note. During an interview on 02/25/25, at 11:50 A.M., LPN N said the following: -After a resident fall, the nurse should complete a head to toe skin assessment on the resident and complete neuro checks, if there is a possibility of head injuries; -The nurse should notify the physician and the resident's responsible party of the fall and any injuries; -The nurse would continue neuro checks and vital signs. He/she was unsure where to record neurological checks; -He/she completed neuro checks after a resident fall, if they hit their head, but he/she was not documenting the checks; -The nurse should continue to assess the resident's pain, skin, and check ROM to the resident's extremities as part of the fall follow up every shift for three days and should document in the progress notes; -The neuro check included assessing the resident's vital signs, handgrips, and pupil reactions. During an interview on 02/26/25, at 2:05 P.M., LPN J said the following: -If a resident fell and hit his/her head or if staff were unsure if the resident hit his/her head, the staff should assess the resident's vital signs and neuro checks; -The facility had a paper to document vital signs on, but no paper to specifically record neuro checks which included hand grips and no where to document that pupils and equal and reactive to light (PEARL); -Neuro checks should be completed every 15 minutes times 4, then every 30 minutes times 4, then every hour times 4, then every 4 hours times for, then every 8 hours times four; -After each fall, the nurse should assess the resident every shift for three days following the fall and document the assessment in the progress notes. During an interview on 02/26/25, at 1:55 P.M., LPN K said the following: -If a resident falls, the nurse should chart a head to toe assessment, any injuries and the resident's vital signs in the progress notes; -If the resident hit his/her head or if it is unknown if the resident hit his/her head, the nurse should complete neuro checks; -The nurse should document the follow up assessments every shift for three days; -The nurse should complete neuro checks per protocol every shift for three days; -LPN K said the nurses documentation after falls was not the best, but the nurses were working on improving their documentation. During an interview on 02/26/25, at 2:30 P.M., Registered Nurse (RN) E said the following: -Nurses should assess the residents for injuries after each fall and document on the resident in the progress notes every shift for three days; -RN E said the nurses should do a better job documenting on residents after falls; -If the resident had a head injury or if the fall was unwitnessed, the nurse should conduct neuro checks every 15 minutes times 4, then every 30 minutes times 4, then every 1 hour times 4, then every 4 hours for the remainder of the 72 hours following the fall; -Neuro checks include assessing the resident's PEARL, reflexes, and grips; -The nurse sh[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents maintained acceptable parameter of nutritional status when staff failed to implement and document recommended, care planned, or ordered, weekly resident weights for three residents (Resident #1, Resident #2, and Resident #3) and failed to provide meal assistance to two residents (Resident #1 and #2). The three resident has been identified as having weight loss. The facility census was 102. Review of the facility policy titled, Weight Management, dated 10/01/10, showed the following: -Purpose was the maintenance of adequate nutrition and hydration is necessary for the resident to maintain health and prevent complications such as malnutrition and pressure sores; -Residents should be weighed monthly unless there is a problem that warrants a deviation from that routine; -Suggested weight schedule of weigh newly admitted residents weekly for four weeks, weigh residents with weight loss weekly, and all other residents monthly; -The newly recorded resident weight should be compared to the previous weight. A significant change in weight is defined, by federal regulations, as 5% change in weight in one month (30 days), 7.5% change in weight in three months (90 days), and/or 10% change in weight in six months (180 days); -Though a weight change may not occur, the resident may be identified as below ideal body weight by the Dietary Manager (DM); -The physician should be informed of a significant change in weight and may order nutritional interventions. The physician should be encouraged to document the diagnosis of clinical conditions that may be contributing to the weight loss. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed. If the interdisciplinary care team desires to explore specific meal consumption information for a resident. Either the DM or the Registered Dietitian (RD) should be consulted to assist with interventions, actions are recorded in the dietary progress notes. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. The interdisciplinary plan of care communicates care instructions to staff. Review of the facility policy titled, Feeding the Impaired Resident, dated 10/01/10, showed the following: -Residents are assisted, as needed, to consume each meal so adequate nutrition is provided; -Residents should eat in the location of their preference and should be provided with a pleasant dining environment, regardless of the location; -Remove dome lid from the tray, and check to be sure everything is included on the meal tray that is required by the diet cart and the resident's preference; -Arrange dishes and silverware so the resident can reach them easily; -Open all cartons and give the napkin to the resident. Use clothing protectors as needed; -Ask the resident regarding the use of condiments such as salt, pepper, sugar, ketchup, and apply as desired; -Alternate food, readily available food, or supplements, should be offered consistent with the diet order, if the resident consumes less than half of the meal. 1. Review of Resident # 1's face sheet showed an admission date of 06/28/24 and diagnoses included of Alzheimer's disease. Review of the resident's weight record showed the following resident weights: -On 06/28/24, weight of 172.6 pounds (lbs); -On 07/25/24, weight of 171.0 lbs (a loss of 1.6 lbs); -On 08/09/24, weight of 169.0 lbs (a loss of 2 lbs); -On 09/09/24, weight of 168.0 lbs (a loss of 1 lb); -On 09/26/24. weight of 159.0 lbs (a loss of 9 lbs). Review of the resident's October 2024 Physician Order Sheet (POS) showed the following: -An order, dated 10/07/24, for Ensure (food supplement) two times per day at 8:00 A.M. and 1:00 P.M.; -An order, dated 10/08/24, for a regular, mechanical soft diet. Review of the resident's Registered Dietitian (RD) progress note, dated 10/09/24, showed recommendation of weekly weights to monitor the resident's weight loss. Review of the resident's weight record showed the following: -On 10/15/24, weight of 157. 0 lbs (a loss of two pounds). Staff did not document additional weights for October 2024; -Staff did not document weights for November 2024 or December 2024; -On 01/10/25, weight of 156.4 lbs (a loss of .6 lbs). Staff did not document additional weights for January 2025. Review of the resident's January 2025 POS showed an order, dated 01/29/25, to admit the resident to hospice services. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 02/05/25, showed the following: -Severe cognitive impairment; -Diagnoses included lipodystrophy (an abnormal loss of body fat with an unknown cause); -Received mechanical altered diet; -Resident did not reject care; -Required assistance of staff with meal set up or clean up; -Resident did not have a significant weight change. -Weight 156.0 pounds (a .4 lb loss). Review of the resident's care plan, updated on 02/19/25, showed the following: -Potential for weight loss; -Ice cream with lunch and dinner, ensure two times per day; -Mechanical soft diet; -Allow sufficient time to eat; -Assess for serving smaller portions more frequently; -Maintain a list of food likes and dislikes; -Medication review to determine if medications are contributing to decreased meal consumption; -Monitor intake and output; -Offer food alternatives when appropriate for any meal; -Provide snacks between meals; -Provide a quiet dining environment; -Provide socialization opportunities during meals, provide verbal encouragement/cueing, refer to RD for evaluation of current nutritional status. Review of the resident's weight record showed the following: -On 02/21/25, weight of 151.8. lbs; -The February 2025 weight represented a significant weight loss over the last 6 months. The recorded resident weight dropped from 169 lbs in August 2024 to 151.8 lbs in February 2025, a loss of 17.2 lbs or a 10 % loss. Observation on 02/21/25, at 12:22 P.M., in the special care unit (SCU), showed the following: -The resident sat at a dining room table in the SCU; -Facility staff served lunch to the resident; -Staff served the resident a one cup sized bowl containing chili, a small dessert cup of canned sliced peaches, and a Magic Cup (a 4 ounce pudding consistency dessert cup containing 290 calories and 9 grams of protein) for lunch; -Staff did not serve residents a baked potato as listed on the menu; -Staff served a glass of water to the resident and no other beverages; -The resident appeared able to feed him/herself. Observation on 02/26/25, in the SCU, showed the following: -At 12:00 P.M., the resident sat at a dining room table and one of the nurse assistants brought the resident a lunch tray and placed the tray on the table; -Part of the meal was a side salad and a packet of ranch dressing; -The staff member walked away without assisting the resident in opening his/her packet of dressing; -The resident attempted to open the packet using his/her fingers and teeth. The resident struggled for several minutes attempting to open the dressing packet, with no success; -At approximately 12:10 P.M., the NA re-approached the resident and asked if the resident if he/she was going to eat, but the resident did not reply. The NA did not offer to assist the resident with his/her salad dressing; -At approximately 12:20 P.M., the NA brought the resident a Magic Cup (in a plastic container with a thick paper lid in place) and walked away; -The resident attempted to open the Magic Cup, but could not remove the lid; -At approximately 12:30 P.M., the NA assisted the resident in removing the Magic Cup lid. 2. Review of Resident #2's face sheet showed: -admission date of 01/02/24; -Diagnoses included dementia, depression, reduced mobility, and muscle weakness. Review of the resident's weight record showed the following resident weights; -On 07/25/24, weight of 160.0 lbs; -On 08/15/24, weight of 163.0 lbs; -On 09/09/24, weight of 158.0 lbs (a five pound loss); -On 10/15/24, weight of 152 0 lbs (a six pound loss). Review of the RD note, dated 10/30/24, showed the resident had a six pound weight loss in the last month. This was not significant, but lower than ideal body weight (IBW). Resident intake less than 50%. RD recommended adding weekly weights and house shakes twice per day. Review of the resident's physician orders, dated 11/07/24, showed the current diet order of regular, mechanical soft diet, high carbohydrate/calorie, assist with meals as needed, and offer puree foods to maximize caloric intake. Review of the resident's weight record showed the following resident weights; -On 11/11/24, weight of 148. 0 lbs; -Staff did not record weights for December 2024; -On 01/10/25, weight of 143.0 lbs (a five pound weight loss). Review of the resident's progress note dated 01/13/25, at 2:25 P.M., showed the following: -Resident reviewed for weight loss; -Resident had lost a significant amount of weight in the last 6 months. Staff will notify the physician and responsible party. New interventions placed in care plan or house shakes at every meal; -Will weigh weekly until stable. Review of the resident's weight record showed on 01/15/25 a weight of 144.8 lbs. Staff did not document any further weights in January 2025. Review of the resident's potential for weight loss care plan, updated 01/15/25, showed the following: -Fortified pudding with meals; -House shakes with meals; -Mechanical soft diet; -Sit at the assisted table for help as needed; -Allow sufficient time to eat; -Maintain list of food likes and dislikes; -Monitor intake and output; -Offer food alternatives when appropriate for any meal; -Provide quiet dining environment; -Provide verbal encouragement/cueing. Review of the resident's quarterly MDS, dated [DATE], showed the following: -admission date of 01/02/24; -Severe cognitive impairment; -Exhibits a behavior of daily wandering; -Weight of 145 pounds; -No weight loss or gain. Review of the resident's weight record showed staff did not document resident weight from 02/01/25 to 02/21/25. Observation on 02/21/25, at 12:22 P.M., in the SCU showed the following: -The resident sat at a dining room table in the SCU; -Facility staff served lunch to the resident; -Staff served the resident a one cup sized bowl containing chili, a small dessert cup of canned sliced peaches, and a Magic Cup for lunch; -Staff did not serve residents a baked potato as listed on the menu; -Staff served a chocolate shake and a glass of water to the resident; -The resident appeared able to feed him/herself. Review of the resident's physician orders showed an order, dated 02/24/25, for weekly weights. Observation on 02/26/25, at 12:00 P.M., in the SCU showed the following: -The resident sat at a dining room table and one of the nurse assistants brought the resident a lunch tray and placed the tray on the table; -Part of the meal was a side salad and a packet of ranch dressing; -The staff member walked away without assisting the resident in opening his/her packet of dressing; -The resident did not eat the salad or attempt to open the dressing packet. 3. Review of Resident #3's face sheet showed: -admission date of 05/27/23; -Diagnoses of unspecified severe protein-calorie malnutrition. Review of the resident's weight record showed on 08/09/24 the resident weighed 115 lbs. The facility did not provide any addition weights for 08/2024. Review of the resident's nurse practitioner (NP) progress note, dated 09/09/24, showed the following: -The resident was seen this day for weight loss review. The resident's current weight of 105 pounds and a previous month's weight was 115 pounds. This was a 10-pound weight loss in one month. Discussed with the resident who feels he/she was eating well. The resident was feeling well and continued to drink shakes. It is thought this could be an erroneous weight. Will have staff reweigh the resident and will then re-evaluate; -Continue protein shakes to three times per day. Review of the resident's record showed staff did not provide resident weight for 09/2024. Review of the resident's RD note, dated 10/08/24, showed the following: -Follow up to weight change; -Recommend weekly weights; -On supplement between meals; -Recommend fortified foods to meals. Review of the resident's record showed staff did not provide resident weight for 10/2024. Review of the resident's physician order sheet showed an order, dated 11/22/24, for Ensure plus 237 milliliters (mL) twice daily between meals. Review of the resident's record showed staff did not provide resident weight for 11/2024. Review of the resident's physician order sheet showed an order, dated 12/31/24, for a regular diet. Review of the resident's 5-day MDS, dated [DATE], showed the following: -Re-entered the facility on 12/31/24; -Cognitively intact; -Diagnosis of malnutrition; -Independent with eating; -Weight of 106 pounds. Review of the resident's record showed staff did not provide resident weight for 12/2024. Review of the resident's nurse practitioner progress note, dated 01/09/25, showed the following: -Resident weight listed as 105 pounds; -Severe protein-calorie malnutrition; -Protein shakes two times per day. Review of the resident's potential for weight loss care plan, updated on 01/14/25, showed the following: -Provide ensure with breakfast and supper; -Assess for serving smaller portions more frequently; -Maintain list of food likes and dislikes; -Medication review to determine if medications are contributing to decreased meal consumption; -Monitor intake and output; -Offer food alternatives when appropriate for any meal; -Provide quiet dining environment; -Provide socialization opportunities during meals; -Provide verbal encouragement /cueing; -Refer to RD for evaluation of current nutritional status. Review of the resident's record showed staff did not provide resident weight for 01/2025. Review of the resident's NP progress note, dated 02/14/25, showed the following: -Weight of 105 pounds; -Severe protein calorie malnutrition; -Protein shakes twice per day. Review of the resident's weight record, dated 02/24/24, showed a weight of 100 pounds. (This represented a significant weight loss of 15 pounds in 6 months from 115 lbs on 08/09/24 to 100 lbs on 02/24/25.) 4. During an interview on 02/26/25, at 3:45 P.M., the Restorative Nurse Aide (RNA) said the following: -He/she was responsible for weekly and monthly weights and some of the aides help with the weights at times; -The facility used to have weekly weight meetings, but had not had them for at least a couple of months; -He/she was not always able to obtain all the resident weights due to working the floor as an aide and having other responsibilities. During an interview on 02/26/25, at 2:54 P.M., the DM said the following: -Prior to 02/21/25, he/she was unsure which residents had weight loss; -On 02/21/25, the corporate nurse and the RD told the DM how to view and print and resident weight loss report; -The RD did not tell the DM which residents needed weekly weights; -The RD recommendations for weekly weights go to the nursing department; -The RNA was responsible for obtaining the weekly and monthly weights and recording the weights; -The facility did not have any weight meetings during December 2024 because the RD was filling in as a DM at another facility; -Prior to that, in November of 2024, the facility was conducting weekly weight loss meetings; -He/she asked the Director of Nursing (DON) about weekly weight meetings and the DON told the DM he/she would look into it, but the meetings did not occur; -In December 2024, he/she asked for the December weights and nursing said the RNA did not obtain the December 2024 weights due to the RNA having to work the floor as an aide. During an interview on 02/26/25, at 4:15 P.M., the RD said the following: -In the past, he/she visited the facility weekly, but he/she had not been to the facility up until 02/21/25 in approximately one month due to responsibilities at another facility; -In the past the facility had weekly weight meetings, and he/she was unaware the weekly weight meetings had stopped occurring; -In January 2025, the Quality Assurance (QA) Nurse reviewed the resident weights and informed the RD there were gaps in the resident weights and gave the RD a list of residents that the facility was adding to the weekly weight list due to weight loss; -The RD said obtaining weights as recommended and having weekly weight loss meetings were important and could help prevent significant resident weight loss; -The nursing department was responsible for obtaining resident weights; -When he/she or the QA Nurse make recommendations to nursing for interventions to help with weight loss, such as weighing a resident weekly, nursing should notify the resident's physician or nurse practitioner and obtain an order for the recommended interventions. -The RNA should be obtaining weekly weights. During interviews on 02/25/25, at 10:05 A.M., and on 02/27/25, at 3:12 P.M., the DON said the following: -The facility had a weight meeting on 02/24/25 to discuss residents with weight loss; -The DON, the Registered Nurse (RN) Unit Manager, the DM, the Regional Nurse, and the RNA attended; -Based on the meeting he/she was made aware there were residents that had been identified with weight loss, that should have been on the weekly weight loss list, but staff were not weighing these residents weekly; -He/she found out at the meeting on 02/24/25, that staff did not complete the monthly resident weights in December 2024; -The RNA was responsible for weekly and monthly weights; -The RNA said he/she had not been able to complete all the assigned weights due to being pulled from his/her position as the RNA to work as an aide on the floor; -The facility's previous weight meeting was on 01/16/25 with the corporate nurse; -He/she said the DM should review the recommendations from the RD and should notify the nursing department of any recommendations, and should notify the DON of the recommendations; -Weekly weights need to be reviewed and interventions put in place. During an interview on 02/27/25, at 2:26 P.M., the Administrator said the following: -In the past, the RD came to the facility and reviews weights one time weekly and made recommendations; -There was a gap of approximately the past month, the RD did not come to the facility, due to working at another facility; -The RD communicated directly with the DM; -Generally, all department heads review the weekly RD recommendation report; -Nursing was responsible for obtaining and recording the weekly and monthly resident weights; -The RNA generally obtained the weights, he was not notified the RNA did not have time to obtain the resident weights; -He/she expected the nursing staff to assist the residents at meal time with opening packages and assisting with eating as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to serve appetizing and palatable meals when kitchen staff overcooked and under seasoned foods served to residents, including two residents (Resident #6 and #5) who would not eat food/meals at times due to the poor palatability. The facility had a census of 102. Review of the facility policy, Hot and Cold Food Holding, dated 05/25/12, showed the following: -Purpose was to ensure optimal quality of foods held prior to and during meal service; -Foods should not be held on the steam table longer than 30 minutes prior to start. Review of the facility policy, Food Taste Test, dated 01/2002, showed the following: -Foods with a distinctively good taste and appearance help promote the resident/guest(s) dietary intake; -Foods should be tasted prior to meal service to test the quality of the food; -Check the food for appearance (appealing, appetizing, garnished properly, colorful); -Check for flavor, seasoning, texture and that hot foods are hot and cold foods are cold. 1. Review of Resident Council Meeting Notes, dated 2/11/25, showed residents said food was cooked too hard and was hard to eat. 2. Observation on 02/25/25, at approximately 9:30 A.M., showed the following: -A large pot of peas and carrots were boiling, on top of the stove; -A large pot of frozen, mixed vegetables, were boiling, on top of the stove. Observation on 02/25/25, at approximately 12:15 P.M., showed the following: -The rice was hard, making it difficult to chew; -The egg roll was hard and was difficult to eat. It was hard to bite into and was chewy; -The stir-fried vegetables had standing water on the plate around them and were very mushy. 3. Observation on 02/26/25, at approximately 9:40 A.M., showed the following: -The spaghetti pasta noodles, for the lunch meal, were on the stove, boiling; -Spaghetti sauce was on the steam table, warming up for serve-out, for the lunch meal. Observation on 02/26/25, at approximately 10:15 A.M., showed the spaghetti pasta noodles were on the steam table, being warmed until serve out at the lunch meal. Observation on 02/26/25, at approximately 12:35 P.M., showed the following: -The spaghetti pasta noodles were very mushy; -The spaghetti sauce was very plain, with very little or no seasoning. 4. Review of Resident #6's face sheet showed the following: -admission date of 09/21/22; -Diagnoses included Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination), and chronic kidney disease, (decreased kidney function, typically indicated by an estimated glomerular filtration rate (eGFR) between 60 and 89, and usually with no noticeable symptoms). Review of the resident's care plan for nutritional status of potential weight loss/goal to prevent, updated 10/14/24, showed the following: -Allow sufficient time to feed/eat; -Maintain list of food likes and dislikes. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/10/25, showed the following information: -admission date of 09/21/22; -Cognitively intact; -No behaviors; -Independent with eating. During an interview on 02/25/25, at approximately 9:50 A.M., the resident said the following: -The food was never good. Most days it tastes really bad; -The chili that was served on 03/21/25 was plain; -The cooks don't use seasoning, so food is always plain; -Meats are usually too hard, but the pork chops are especially hard to eat; -There is an alternate, but it is just as bad; -He/she thinks they are served leftovers for the alternate. 5. Record review of Resident #5's face sheet showed the following: -admitted to the facility on [DATE]. -Diagnoses include hypertensive heart disease with heart failure (a condition where high blood pressure (hypertension) damages the heart muscle over time, leading to an inability of the heart to pump blood effectively), chronic diastolic (congestive) heart failure ( a condition where the heart ' s left ventricle becomes stiff and cannot relax properly, leading to a buildup of fluid in the lungs and other parts of the body due to impaired filling between heartbeats, causing symptoms of congestive heart failure while still maintaining a normal ejection of fraction (the percentage of blood pumped out with each beat) and spinal stenosis (when the spinal canal and the space around the spinal canal become narrowed). Review of the resident's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -No behaviors; -Independent with eating. Review of the resident's care plan for nutritional status of potential weight loss/goal to prevent, updated 02/24/25, showed the following: -Resident was not a breakfast eater and preferred to sleep in then asks for a drink when he/she wakes; -Allow sufficient time to feed/eat; -Assess for serving smaller portions more frequently; -Maintain list of food likes and dislikes; -Medication review to determine if medications contribute to decreased meal consumption; -Monitor intake/output. During an interview on 02/25/25, at approximately 1:45 P.M., the resident said the following: -He/she felt like there was enough to eat, but it was usually gross; -He/she was offered a ham and cheese sandwich, but by the time it was offered, he/she was so frustrated, he/she declined; -He/she had a snack of crackers instead of lunch. He/she does this a lot of the time; -Today, the rice and chicken went uneaten, because it was too hard; -All of the meat patties that are served are terrible because they are too hard to eat. 6. During an interview on 02/26/25, at approximately 1:35 P.M., [NAME] B said the following: -Some residents complain the food was just too bad to eat; -He/she makes up plenty of extra sandwiches every evening he/she works, so residents can have something else to eat in the evening; -He/she had let the Dietary Manager (DM) know his/her concerns. During an interview on 02/26/25, at approximately 2:00 P.M., [NAME] D said the following: -He/she had constant comments about how horrible the food was; -Residents ask for more seasoning, other than pepper; -He/she had let the DM know that residents complain about the taste of food. During an interview on 02/26/25, at approximately 3:15 P.M., the DM said the following: -The cooks tend to overcook items; -He/she was unsure why the cooks overcook items, because he/she has discussed this with them; -He/she has not reviewed any resident council meeting notes. During an interview on 02/26/25, at approximately 4:10 P.M., the Regional DM said the following: -Frozen vegetables should never be started too early, as they only need to be heated; -Nothing should be on the steam table for longer than 30 minutes prior to serve-out; -He/she has not reviewed any resident council meeting notes. During an interview on 02/25/25, at approximately 2:40 P.M., Registered Nurse (RN) F said the following: -Residents do often complain about the food that is served; -The biggest complaint is that it taste bad; -Some of them will say they just can't eat it; -He/she and other staff will offer the resident something else to eat; -Sometimes the resident will choose the alternate, or something else; -If they decide not to eat lunch, they may have a snack or wait until dinner; -If it's dinner, they are strongly encouraged to eat something else and are offered many choices. During an interview on 02/27/25, at approximately 1:20 P.M., the Social Services Director (SSD) said the following: -Food was hit and miss; -It can be pretty good on most days, but if it's bad, it's really bad; -The meat is often really tough. He/she will not eat the meat because it's often too tough to chew, especially pork chops. During interviewed on 02/25/25, at approximately 10:10 A.M., and on 02/27/25, at approximately 3:10 P.M., the Director of Nursing (DON) said the following: -He/she would expect an alternate to be offered, if residents are not eating the food they are given; -Residents have said, here or there, that the food does not taste good, but has not been enough to go to the team about anything; -He/she has not gone to the DM about any food issues; -He/she has never eaten the food. During an interview on 02/27/25, at approximately 2:25 P.M., the Administrator said the following: -He/she had not had any real complaints of bad food; -If someone has a complaint, he/she expected staff to address it at that very moment and get the resident something they want to eat; -He/she would expect the DM to be notified immediately of any food concerns; -He/she would expect the DM to discuss food issues with residents immediately and to make all necessary changes, right away.

Based on observation, interview, and record review, the facility failed to provide each resident with a nourishing, well-balanced diet that met the daily nutritional needs of the residents when the facility failed to prepare and serve meals for the residents per the facility approved menu and failed to make an nutritionally adequate substitutions to the menu. The facility census was 102. Review showed the facility did not provide a policy regarding serving sizes or nutritional values. 1. Review of the facility's February 2025 Dietary Menu showed staff were to serve the following on 02/21/25, at lunch, to the residents: -Chili, 6 ounces (oz); -Baked potato, 1 each.; -Crackers, 2 packages; -Spiced peaches, 4 oz.; -Iced tea, 8 oz.; -Water, 8 oz. Observation on 02/21/25, at 12:08 P.M., showed the following: -The surveyor requested a test tray of a resident meal; -Staff delivered two test trays to the surveyors; -Each tray contained a bowl of chili and no additional food items. Observation on 02/21/25, at 12:22 P.M., in the special care unit (SCU) showed the following: -Facility staff served lunch to the residents in the special care unit (SCU) dining room; -Staff served the residents chili in an approximate one cup sized bowl containing chili and a small dessert cup of sliced peaches for lunch; -Staff did not serve residents a baked potato or crackers, as listed on the menu. Observation and interview on 02/21/25, at 12:45 P.M., with Resident #5 said the following: -Staff did not give him/her all the food on the menu for today; -He/she was missing the baked potato, margarine, sour cream, and crackers -At times, staff only served half of the meal on the menu; -Observation showed the resident's tray contained a bowl of chili and a cup of sliced peaches. Observations and interview on 02/21/25, at 1:04 P.M., with Resident #14 said the following: -He/she did not get the full lunch meal; -Staff did not serve the baked potato with margarine and sour cream, or any crackers; -Staff did not bring him/her any iced tea; -Observation showed the resident's tray contained a bowl of chili and a cup of sliced peaches. Observation on 02/21/25, at 1:27 P.M., of the main dining room showed the following: -A table of 5 residents sat, eating lunch; -All residents had a bowl of chili and a cup of peaches; -None of the 5 residents had a baked potato, as listed on the menu. During interviews on 02/21/25, at 1:04 P.M. and at 1:45 P.M , Dietary Aide (DA) L said the following: -He/she assisted with resident lunch service; -As he/she was loading the resident food carts for the halls, he/she observed the meal ticket listed a baked potato with sour cream, but the resident meals did not include a baked potato; -He/she asked the cook about the absence of a baked potato on the resident trays and the cook said the facility did not have any potatoes to bake for the residents; -The cook told the DA, he/she was directed by the Dietary Manager (DM) to substitute Fritos for the baked potato; -The cook placed a layer of Fritos under the chili in the bowls and the sprinkled cheese on the top; -The DA said the facility frequently did not have available the menu listed foods and the cook had to make substitutions. During an interview on 02/21/25, at 1:10 P.M., [NAME] D said the following: -Earlier in the A.M., he/she checked the menu for today's lunch and the menu listed a baked potato; -The [NAME] looked in the food storage area and found no potatoes; -He/she then asked the DM what to do and the DM said to substitute Frito chili pie; -He/she did not think the Fritos were an adequate substitution for the potato; -He/she placed a handful (approximately 2 layers of Fritos) in the bottom of each bowl. He/she did not measure the amount of Fritos; -He/she then placed chili on top of the Fritos. He/she did not measure the amount of chili, but rather used the bowl as the measurement, he/she then sprinkled shredded cheese on top; -He/she used canned peaches for dessert as per the menu; -The facility did not always have the items listed on the menu, he/she had to make substitutions fairly often; -When he/she asked the DM about why the facility did not have the listed foods, the DM said he/she was not able to purchase due to facility budget restrictions or because he/she was not aware the facility was out of a certain food item; -At times, the kitchen was shorting the residents on the amount of calories in a day, due to not having the menu listed foods of not having a sufficient amount of the listed foods; -Some of the residents complain about the substitutions or the lack of food; -He/she and a couple of the other kitchen staff went to the Administrator about the issues in the kitchen. During an interview on 02/26/25, at approximately 1:35 P.M., [NAME] B said the following: -The chili meal was way too small; -He/she was unsure why they did not have potatoes to serve the residents because he/she knew the night before and let the DM know; -He/she said the DM went to the store and bought Fritos instead of potatoes; -They put the Fritos in the bowl, under the chili; -He/she was aware this actually took away from what already looked to be a small amount of chili; -He/she had gotten used to residents complaining in the evening that they are hungry. He/she makes up plenty of sandwiches and snacks for every night. During an interview on 02/25/25, at approximately 9:50 A.M., Resident #6 said the kitchen only serves out small amounts of food. He/she felt residents should already get enough in the first place, that no one should have to ask for more During an interview on 02/25/25, at approximately 10:00 A.M., Resident #11 said the following: -The amount of food given is small every time; -The chili was always a small amount like that; -He/she was unsure why the amounts are usually small. During an interview on 02/25/25, at approximately 12:30 P.M., the Restorative Nursing Aide (RNA), said the there have been a few times that residents have told him/her, following a meal, that they were still hungry. During an interview on 02/26/25, at approximately 3:15 P.M., the Dietary Manger (DM) said the following: -He/she does have a monthly budget that he/she is supposed to stay within each month; -He/she will run to the local grocery store, if the facility needs a certain food item, and it was not provided by their supplier; -He/she had to substitute potatoes because they had ran out; -He/she did go to the grocery store and purchased Fritos, due to not having time to cook baked potatoes; -He/she did not think to purchase or serve anything else; -The DM orders items, according to the menu, on a weekly basis; -None of the residents or staff have complained to him/her that there is not enough food being served. During an interview on 02/26/25, at approximately 4:10 P.M., the Registered Dietician (RD) said the following: -Staff should have served something more substantive, such as another starch or vegetable, to ensure the residents had enough to eat; -He/she would expect there to be plenty of food for all of the residents. During an interview on 02/25/25, at approximately 10:10 A.M., the Director of Nursing (DON) said he/she has not seen any problems with the amounts of food residents receive. If he/she were to have an issues with food, they would go to the dietary manager (DM), first to discuss any concerns. During an interview on 02/27/25, at 2:25 P.M., the Administrator said the following: -He/she said the DM would be expected to get an appropriate substitute; -If the DM was unsure what that would be, or what he/she should do, the administrator expected the DM to contact the RD for guidance. MO00249859 .

Based on observation, interview, and record review, the facility staff failed to ensure food was protected from potential contamination at all times when staff failed to keep non-food contact services clean and free from debris. The facility census was 102. Review of the facility's policy titled Sanitation Principles, dated 02/01/02, showed the following information: -The purpose of the policy was to prevent the spread of bacteria that may cause food borne illnesses; -Food service areas should be maintained in a clean and sanitary manner; -The current Food Code should be utilized as guidelines for the department; -Utensils, counters, shelves, and equipment should be kept clean; -Cleaning schedule should developed and posted by the Food Service Manager (FNS) for the routine cleaning of all kitchen surfaces, equipment and utensils. Review of the Food and Drug Administration (FDA) 2022 Food Code showed non-food contact surfaces of facilities, equipment, and utensils used in the operation of the establishment must be cleaned and sanitized as frequently as necessary to prevent the creation of unsanitary conditions or the adulteration of product. 1. Observation on 02/25/25, beginning at 9:30 A.M., of the kitchen showed the following: -Ceiling vents over the serve-out/steam table, had a build-up of a grease and dust covering the surface; -White pipes running across the ceiling, were discolored and had a build-up of a grease and dust covering the surface; -The convection oven top and knobs had a build-up of a grease and dust mixture covering the surface; -The Vulcan stove knobs had a build-up of a grease and dust mixture, covering the surface; -The back of the Vulcan stove had a build-up of a grease and dust mixture, covering the entire surface and the metal pipe going up into the ceiling; -The walk-in freezer had spots of a silvery-white build-up, that was spread across the ceiling and walls. During an interview on 02/25/25, beginning at approximately 11:30 A.M., the Maintenance Director said the kitchen staff are responsible for all cleaning duties in the kitchen. He/she will do maintenance on the walk-ins as needed. During an interview on 02/26/25, at approximately 3:15 P.M., the Dietary Manager (DM) said if there was a mess, staff were expected to clean it up and he/she has not seen a cleaning policy. During an interview on 02/27/25, at 3:10 P.M., the Director of Nursing (DON) said he/she would expect kitchen staff to keep the kitchen clean. During an interview on 02/27/25, at 2:25 P.M., the Administrator said he/she would expect deep cleaning to be done at least once a week. He/she was unsure why some of the kitchen surfaces are not clean at this time. MO00249859

Based on observation, interview, and record review, the facility staff failed to ensure the baseboards, walls, and windows were clean and free of dirt. The facility census was 102. Review of the facility's policy titled Sanitation Principles, dated 02/01/02, showed the following information: -The purpose of the policy was to prevent the spread of bacteria that may cause food borne illnesses; -Food service areas should be maintained in a clean and sanitary manner; -The current Food Code should be utilized as guidelines for the department; -Utensils, counters, shelves, and equipment should be kept clean; -Cleaning schedule should developed and posted by the Food Service Manage (FNS) for the routine cleaning of all kitchen surfaces, equipment and utensils. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the non-food contact surfaces of facilities, equipment, and utensils used in the operation of the establishment must be cleaned and sanitized as frequently as necessary to prevent the creation of unsanitary conditions or the adulteration of product. 1. Observation on 02/25/25, beginning at 9:30 A.M., of the kitchen showed the following: -The 4-light switch plate, the fire extinguisher, and panel box, all together on a small wall between the stove and dishwashing area, had a build-up of a grease and dust mixture, covering the surface; -The window over the sink was dirty and it was difficult to see out. There were cobwebs, visibly moving with any air, in both of the top corners; -The corner and floorboards between the sink and convection oven were dirty with particles of food and debris. During an interview on 02/25/25, beginning at approximately 11:30 A.M., the Maintenance Director said the kitchen staff are responsible for all cleaning duties in the kitchen. He/she will do maintenance on the walk-ins as needed. During an interview on 02/26/25, at 10:15 A.M., the Regional Dietary Manager said he/she had spoken to the Dietary Manager (DM) before about the cleaning schedule and that is should probably be posted. During an interview on 02/26/25, at 10:45 A.M. and 3:15 P.M., the DM said the following: -He/she did not feel a cleaning scheduled needed to be posted; -He/she does not think staff forget to clean the kitchen, when they are unable to see the cleaning schedule; -Having a cleaning schedule would not impact how clean the kitchen was or was not; -If there is a mess, staff are expected to clean it up; -Staff know to do this and do not have to be told. During an interview on 02/27/25, at 3:10 P.M., the Director of Nursing (DON) said he/she would expect kitchen staff to keep the kitchen clean for resident's safety and to keep out rodents. During an interview on 02/27/25, at 2:25 P.M., the Administrator said the following: -He/she would expect deep cleaning to be done at least once a week; -If staff would stay on top of the cleaning, it would get better and be easier to keep it clean. -He/she was unsure why some of the kitchen surfaces are not clean at this time. MO00249859

Based on observation and record review, the facility failed to maintain an effective infection control program when staff failed to administer the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test for four sampled staff members (Dietary Aide B, Nurse Aide (NA) C, Licensed Practical Nurse (LPN) D and LPN E). The facility census was 108. Review of the facility's policy titled Infection Prevention and Control Manual, dated 09/01/17, showed the following: -Purpose to prevent the spread of tuberculosis in resident/guest(s) and employees; -Employees are screened for TB at the time of employment; -The Infection Preventions (IP)/designee is designated to monitor and coordinate compliance with TB screening and management per state/regional/community data/recommendations per applicable Federal and State Laws. Review of the facility's policy titled Infection Prevention and Control Manual, dated 11/14/16, showed the following: -Purpose to prevent the spread of TB through early detection of the disease in residents/guests and employees; -Method One - Apply first test and read results in seven days. If result is negative (0-9 millimeters (mm) induration not redness) apply second test the same day. Read results of second test in 72 hours and use results of second test as the baseline; -Method Two - Apply first test and read results in 72 hours. If the result is negative (0-9 mm induration) apply second test one to three weeks later. Read results of second test in 72 hours and use results of second test as the baseline; -Residents/guests or staff members with tests showing conversion should be reported to county health department. Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities showed the following: -All new long term care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD (a skin test) two-step tuberculin test within one month prior to starting employment in the facility; -If the initial test is zero to nine millimeters (0–9 mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years; -It is the responsibility of each facility to maintain a documentation of each employee ' s and volunteer ' s tuberculin status. 1. Review of Dietary Aide B's personnel record showed the following information: -Hire date of 01/10/24; -Staff did not document administering the first or second step TB skin test. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said staff did not complete the first and second TB skin test. During an interview on 02/07/24, at 1:20 P.M., the Administrator said staff did not complete the employee's first and second step TB skin test. 2. Review of NA C's personnel record showed the following information: -Hire date of 01/16/24; -Staff did not document administering the first or second step TB skin test. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said staff did not complete the first and second TB skin test. During an interview on 02/07/24, at 1:20 P.M., the Administrator said staff did not complete the employee's first and second step TB skin test. 3. Review of LPN D's personnel record showed the following information: -Hire date of 01/23/24; -Staff did not document administering the first or second step TB skin test. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said staff did not complete the first and second TB skin test. During an interview on 02/07/24, at 1:20 P.M., the Administrator said staff did not complete the employee's first and second step TB skin test. 4. Review of LPN E's personnel record showed the following information: -Hire date of 01/04/22; -Staff did not document administering the first or second step TB skin test. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said staff did not complete the first and second TB skin test. During an interview on 02/07/24, at 1:20 P.M., the Administrator said staff did not complete the employee's first and second step TB skin test. 5. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said the following: -He/She is the current staff development coordinator and responsible for monitoring the employee TB skin tests; -Nurses administer the first TB skin test on an employee's first day of hire; -Nurses read the new employee's first step TB skin test; -The nurse administers the second TB skin test when the employee returns within a week or two; -He/she monitors the TB skin tests multiple times per month to determine if completed; -He/she worked the floor as a charge nurse the month of January and did not discover these TB skin tests not completed. 6. During interviews on 02/07/24, at 1:20 P.M., and on 02/08/24, at 2:24 P.M., the Administrator said the following: -A charge nurse quit and LPN A worked the floor full time since 01/01/24; -The TB skin tests for the employees fell through the cracks; -The DON is interim and the nurse consultant; -The interim DON has been at the facility for a week; -The interim DON is the IP. 7. During an interview on 02/07/24, at 2:07 P.M., the Director of Nursing (DON)/IP said the following: -She is the interim DON at the facility; -She did not know for sure who is responsible for monitoring employee TB skin tests, she thinks may be the staff development coordinator; -Staff should administer first step TB skin test on employees before they work the floor and document; -She expects employee TB skin tests to be completed timely.

Based on observations, record review, and interview, the facility failed to ensure food was prepared and served in accordance with professional standards when one counter area in the kitchen was broken and had a porous surface and when one staff member was observed to handle ready to eat food with bare hands while assisting one supplemental resident (Resident #89) with their meal. 1. Review of the United States Food and Drug Administration (FDA) 2022 Food Code showed multi-use food-contact surfaces shall be smooth, free of breaks, cracks, chips, pits, and similar imperfection. Observations during the initial kitchen tour on 01/29/24, at 9:18 A.M., showed the following: -A large section (over a foot in length) of a prep area counter edge was observed to have an exposed porous surface. The surface of the counter had multiple small rough divots on the surface. During an interview on 01/29/24, at 9:18 A.M., the Dietary Manager (DM), who had worked at the facility for three months, said the counter had been broken before her time. During an interview on 01/29/24, at 9:18 A.M., Dietary Staff (DS) 1, who had worked at the facility about a year, said the counter had been like that as long as he/she had worked at the facility. During an interview on 02/01/24, at 5:06 P.M., the DM stated she had spoken with maintenance about the counter and the surface was not repairable. 2. Review of the facility policy titled, Food Preparation Guidelines, section Food Preparation and Handling, dated 08/10/18 showed food should be protected from contamination, while being served to resident/guest(s). To prevent growth of pathogenic organisms, staff should wear gloves when handling foods. During observation of the lunch meal in the main dining room on 01/29/24, from 1:15 P.M. to 1:22 P.M., Restorative Nurse Aide (RNA) 1 assisted Resident #89 with his/her peanut butter and jelly sandwich. The RNA picked up and held the sandwich for the resident with his/her bare hands. During an interview on 01/30/24, at 1:28 P.M., RNA 1 said he/she did not typically wear gloves in the dining room and was unaware that resident food should not be handled with bare hands.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure that alternatives to bed rails were attempted prior to the use of bed rails, failed to document reasons for failure of alternatives, and failed to advise residents and/or resident representatives (RR) of the risks and/or benefits of rail use with informed consent signed prior to the installation of bed rails for three of three residents (Resident #24, #34, and #54) reviewed for bed rail use. Review of the facility policy titled, Resident Beds and Bed Safety Rails Program, effective 10/28/19, showed the policy did not address the assessment items, attempted alternatives with documented reasons for failure, and getting an informed signed consent prior to the installation of the bed rails. 1. Review of Resident #24's Face Sheet showed the following: -admission date of 01/15/21 with readmission date of 01/16/24; -Diagnoses included aphasia (loss of ability to understand or express speech) following a cerebral infarction (stroke), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), adult failure to thrive, and Alzheimer's disease. Review of the resident's electronic medical record (EMR) showed staff did not have signed informed consent explaining the risks and benefits of the use of side rails or documentation to show what alternatives to side rails had been attempted prior to the use of side rails or why the alternatives had failed. Review of the resident's form titled Physical Restraint Record of Informed Consent, showed the following: -The form was signed by the resident's representative on 01/14/21; -Restraints have been found in some cases to increase falls or other accidents such as strangulation, entrapment; -Restraints can reduce independence, functional capacity and quality of life. -The form did not address the use of side rails as a potential restraint. Observation on 01/29/24, at 12:07 P.M., showed the resident was asleep in bed with bilateral upper bed rails. 2. Review of Resident #34's Face Sheet showed the following: -admission date of 03/06/19 with readmission date of 03/25/19; -Diagnoses included post traumatic stress disorder (PTSD - makes one feel stressed and afraid after the danger is over), psychosis, muscle spasm, muscle weakness, panic disorder, hemiplegia (paralysis of one side of the body), history of TIA (transient ischemic attack - mini-stroke) and cerebral infarct (stroke), and restless leg (in ability to keep legs still). Review of the resident's EMR showed staff did not have signed informed consent explaining the risks and benefits of the use of side rails or documentation to show what alternatives to side rails had been attempted prior to the use of side rails or why the alternatives had failed. Review of the resident's form titled Physical Restraint Record of Informed Consent, showed the following: -The form was signed by the resident's representative on 08/06/18; -Restraints have been found in some cases to increase falls or other accidents such as strangulation, entrapment; -Restraints can reduce independence, functional capacity and quality of life; -The form did not address the use of side rails as a potential restraint. During an interview and observation on 01/30/24, at 10:33 A.M., the resident was observed to have bed rails. When asked if the facility had advised him of the risks and benefits of bed rail, the resident said he/she could not remember. 3. Review of Resident #54's Face Sheet showed the following: -admission date of 05/17/23 with readmission date of 10/02/23; -Medical diagnoses included anxiety, hip pain, and insomnia. Review of the resident's EMR showed staff did not document signed informed consent explaining the risks and benefits of the use of side rails or showing what alternatives to side rails had been attempted prior to the use of side rails or why the alternatives had failed. Review of the resident's form titled Physical Restraint Record of Informed Consent, showed the following: -Form signed by the resident 04/25/23; -Restraints have been found in some cases to increase falls or other accidents such as strangulation, entrapment; -Restraints can reduce independence, functional capacity and quality of life. -The form did not address the use of side rails as a potential restraint. During an interview and observation on 01/29/24, at 5:06 P.M., the resident was noted to have bed rails. When asked if he/she had been advised of the risks and benefits of the rails, the resident responded that he/she had not. 4. During an interview on 02/01/24, at 12:46 P.M., Regional Nurse Consultant (RNC) said the physical restraint consent was signed at admission if there were rails on the bed. The bed rails were not used as restraints since they are not full side rails. 5. During an interview on 02/01/24, at 3:12 P.M., the Administrator confirmed the informed consent for restraints was being signed at admission prior to alternatives to side rails being attempted and side rails being installed.

Based on observation, interview, and record review, the facility failed to ensure foods were served at palatable temperatures for four supplemental residents (Resident #75, #17, #6 and #4) when hot food was not hot at the point of service for hall trays. Review of the facility policy titled, Food Preparation Guidelines, section Food Preparation and Handling, dated 08/10/18, showed the following: -Food should be palatable, attractive, and at the proper temperature, as determined by the type of food, to ensure resident/guest(s) satisfaction. 1. Review of the resident council minutes, dated 12/28/23, showed the residents expressed concerns with the temperature of food on hall trays. A resolution was not indicated in the minutes. It was noted the Dietary Manager was present during the meeting. During an interview on 01/29/24, at 12:37 P.M., Resident #75 said the food was lousy. During an interview on 01/29/24, at 12:37 P.M., Resident #17 said the food was not served hot. During an interview on 01/29/24, at 2:53 P.M., Resident #6 said the food sucks and said hot foods were cold at times. During an interview on 01/29/24, at 5:02 P.M., Resident #4 said the food was bland. Review of the Production Counts - Lunch-Hot Foods, dated 01/31/24, showed the following prior to the start of meal service: -The chicken soft tacos measured 163 degrees Fahrenheit (F); -The rice measured 170 degrees F. Observation and interview on 01/31/24, beginning at 12:36 PM, showed the following: -Plates were observed in a plate warmer. The plates felt warm. There were dome lids with no insulated bases for the hall trays; -At 12:41 P.M., dietary staff removed a large stack of plates from the warmer and set them on the counter to plate food; -At 12:52 PM, the last plate that had been removed from the warmer was plated, after sitting on the counter for 11 minutes; -At 12:56 P.M., the last hall cart exited the dining room with a test tray; -At 1:03 PM, the last tray was served from the hall cart and was tasted with Dietary Manager (DM). The plate consisted of a soft chicken taco which temped at 110 degrees F. The chicken taco was lukewarm to taste. The rice was temped at 110 degrees F and was cool to taste; -The DM said she has received complaints of cold food from residents, usually residents who where towards the ends of the halls; -The previous dietary manager had ordered heated bases, but they did not fit the plates the facility had; -The food should be hot if it was served quickly enough; -The plates near the bottom of the plate warmer were often hot enough she could not pick them up barehanded however plates near the top did not get as hot. MO00229656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure bed frames and bed rails, if present, were inspected and maintained per the Manufacturer's Instructions for Use (MIFU) to minimize the risks of bed malfunction or resident injury. This failure had the potential to affect 109 of 109 residents that used a bed. Review showed the facility did not provide a policy regarding maintenance of bed/bed rails. 1. Review of the form Resident Beds: Annual Maintenance - Resident Beds/Wheelchairs, showed the following; -OEM [Original Equipment Manufacturer] PM [Preventative Maintenance] Recommendations -Lubricated bed adjusting mechanisms; -Make sure wheels, castors, and locks are operable; -Check all electrical components/wiring for safety and proper operation; -Check all components for beds/wheelchairs for wear and tear; -Check all bed components for compatibility to verify that there is no risk of entrapment - per OEM recommendations; -Conduct user training with all users. Review of bed inspection reports, dated November 2023 and January 2024, showed the following; -The reports had 17 beds listed; -Four of the beds were labeled Main Building and did not have room numbers listed. Review of an audit of all beds currently in use, and provided by the Administrator, on 02/01/24, at 12:25 P.M., showed the following: -38 manual (drive) beds -36 Joerns beds; -13 Invacare beds; -15 Zenith/Basic American/Graham-Field beds; -2 [NAME] Maxi beds; -1 MC Advantage; -2 beds without manufacturer tags; -3 beds supplied by Hospice providers. Review of the MIFUs for the beds showed showed the recommended inspection / maintenance as follows: -[NAME] Maxi Rest Bariatric Bed - once per year; -Zenith II - at six months and 12 months; -[NAME] Maxi Rest Bariatric - at three months, six months, and 12 months; -[NAME] 4748 model - at two weeks then every six months; -Zenith 7000 at three months and six months; -Joerns Bed Frames Easy Care - monthly; -Drive Bed Frame - between users; -MC Advantage -- every six months. During an interview on 02/01/24, at 3:10 P.M., the Administrator said the company has the inspections in computer system. Bed inspection/maintenance records should match the MIFUs.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical and emotional abuse by facility staff when one staff member (Licensed Practical Nurse (LPN) A) administered an injectable medication against the resident's wishes for one resident (Resident #1). The facility had a census of 102. The Administrator and the Director of Nursing (DON) were notified on 06/12/23 of the Past Non-Compliance which occurred on 06/11/23, at approximately 2:00 P.M. Facility staff started an investigation, educated the staff members involved, began in-servicing of all facility staff as they began their shifts, and began monitoring charts and interviewing residents weekly to ensure no other incidents occur. Facility staff notified Department of Health and Senior Services (DHSS) of the noncompliance on 06/14/23. The noncompliance was corrected on 06/14/23. Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, dated 05/01/23, showed the following information: -All of our residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraints not required to treat the resident's medical symptoms; -The facility's policy strictly prohibits the abuse, neglect, exploitation, and involuntary seclusion of residents; -This policy includes abuse by any other person, including, but not limited to any member of the facility staff, physicians, physician assistants, dentist, beauticians, staff of governmental agencies, family members of the resident, visitors, the residents legal guardian, other residents, intruders, volunteers; -The definition of abuse encompasses a broad scope of behavior. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. In addition, abuse includes depriving the resident of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being irrespective of any mental or physical condition. Any act considered abusive towards an alert and orientated resident should be considered abusive to the cognitively impaired or non-responsive. Willful means the individual must have acted deliberately (not inadvertently or accidentally), not that the individual must have intended to inflict injury or harm. Review of the facility policy titled Resident Grievances,, dated 11/28/16, showed the following information: -The resident has a right to voice grievances without discrimination or reprisal; -Reports of suspected abuse, neglect or exploitation are handled according to the Abuse policy. 1. Review of Resident #1's face sheet showed the following information: -admission date of 01/10/23; -Diagnoses included anxiety disorder, cognitive communication deficit, occlusion (blockage of blood flow) and stenosis (decrease of blood flow) of right carotid artery (major artery that carries blood from the heart to the head), personal history of TIA (transient ischemic attack - mini-stroke causing minor and temporary symptoms), cerebral infarction (stroke) without residual deficit, ataxia (Impaired balance or coordination), and history of falling. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/07/23, showed the following: -Cognitively intact; -Independent with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene; -Wheelchair used for mobility. Review of the resident's care plan, dated 01/23/23, showed the following information: -Resident had potential for mood state/psychosocial well-being related to change of environment; -Staff should observe for changes in mood; -Staff should provide support and reassurance as needed; -Staff should encourage/allow to voice feelings or concerns; -Staff should address complaints, concerns timely; -Resident may become agitated and make accusations of belongings being taken when the trash is emptied; -Resident will fixate often and can be verbally aggressive, and is paranoid at times; -Resident had history of obsessive over medication regimen and likes medication late at night when he/she asked for them; -Resident room is untidy and usually full of clutter. The resident can become irate when things are touched or thinks they have been touched or moved or the trash thrown away and project accusation on others; -Staff will talk in calm voice when behavior is disruptive; -Staff should refer to social services for evaluation; -Staff should provide resident with frequent reminders and encouragement to clean room, resident becomes upset when items are arrange. (Staff did not care plan the use of as needed medications to address behaviors or outbursts.) Review of the resident's physician order sheet, current as of 06/15/23, showed the following: -An order, dated 06/11/23, for haloperidol (drug used in the treatment of psychotic conditions), 5 milligrams (mg)/milliliter (ml), administer one ml every four hours as needed for agitation. Review of the resident's electronic medical record showed the following in the nursing progress notes: -On 06/11/23, at 10:12 A.M., staff documented the nurse heard resident yelling down the hallway and observed the resident yelling at family members of another resident. The nurse intervened and asked the resident what was going on. The resident stated he/she shit in my toilet and it is clogged and now he/she need to unclog it. The nurse told the resident it was not appropriate to yell at family members and if he/she needed help he/she needs to ask staff. The nurse then used a plunger to unclog toilet. No further issues noted at that time; -On 6/11/23, at 2:09 P.M., staff documented the nurse attempted to redirect the resident after the resident began yelling at another resident's family. The resident went back to his/her room for a couple of minutes, then came back out and started towards the other resident's family again and continued yelling at them. The nurse asked the resident what was wrong and the resident said someone stole my things and I'm banning everyone from my room. The nurse told the resident that it was not appropriate to yell at family members and that he/she had a roommate who required care so staff will not bother him/her if appropriate, but will need to go and check on the resident's roommate. The resident continued to yell and stated none of you are allowed to go into my room and I will be reporting you to the state and the Administrator. Staff notified the provider who gave orders to administer as needed Haldol (haloperidol) injection. The resident tolerated the injection well without signs or symptoms of adverse reactions. Review of the resident's electronic medical record showed the following in the nursing progress notes: -On 06/14/23, at 9:49 A.M., Social Service Director (SSD) assessed the resident as cognitively intact; -On 06/14/23, at 10:38 A.M., the Corporate Nurse documented that a head to toe body audit was completed on the resident. The resident had small circular bruise to left hip consistent with Intra-muscular (IM - technique used to deliver a medication deep into the muscles) injection. The resident stated it was not painful. During an interview on 06/15/23, at 10:50 A.M., with Corporate Nurse, she said that the resident went to the Administrator on 06/12/23 to advise that he/she did not feel well and that he/she did not want the injection from the Licensed Practical Nurse (LPN) A on 06/11/23. Review of the facility investigation showed the following: -On 06/12/23, the resident notified the Administrator that he/she received an injection against his/her wishes; -On 06/14/23, regional staff became aware of the incident and instructed the Administrator to report the event to the State and initiate an investigation; -The investigation revealed that LPN A, LPN B, and Certified Nurse Aide (CNA) C knew the resident did not want the injection, but it was administered; -The resident stated he/she did state multiple times that he/she did not want the injection, but did not resist when administered. Review of the resident's physician order sheet, current as of 06/15/23, showed the following: -An order, dated 06/15/23, to discontinue haloperidol 5 mg/ml; -An order, dated 06/15/23, for referral for psychiatric consult. During an interview on 06/15/23, at 1:00 P.M., LPN A said that on the morning of 06/11/23 he/she had heard yelling down the hall and when to see what was going on. The resident was yelling at another resident's family. He/she said that the resident was able to be redirected. Then at about 2:00 P.M., the resident was yelling at the same family and trying to corner them as they tried to leave. The staff redirected the resident to his/her room. The nurse contacted the physician on call and received an order for Haldol injection. The resident self-propelled his/her wheelchair to his/her room, the nurse explained the injection, and the resident said why, why. The resident kept asking why, but did not say do not do this. The nurse did not contact the resident's family regarding the Haldol order. The nurse said that he/she was not aware the resident refused the injection. The resident only said why, and the nurse provided education to the resident that the provider ordered for agitation. During an interview on 06/16/23, at 10:55 A.M., Certified Nurse Aide (CNA) C said that he/she had graduated from nursing school and LPN A and B said that he/she could observe an injection being provided to a resident. He/she said when he/she entered the room the resident was coming out of their bathroom in his/her wheelchair. He/she said that the resident initially said he/she did not want a shot. The aide said that the nurse explained the reason to the resident and the resident was assisted to standing by the nurses and they pulled down the resident pants and administered the shot. During an interview on 06/15/23, at 3:25 P.M., the Administrator said that that on 06/12/23, before lunch, the resident came to his/her office. The resident was having difficulty getting his/her wheelchair into the office and was bent in half. The Administrator got up and asked the resident if he/she was okay. The resident said that he/she did not feel good. The Administrator went to get the nurse, LPN A, to come to the office. LPN A put a pulse oximeter on the resident's finger and said that it was probably because of the shot. The Administrator asked, What shot? The nurse said Haldol. The resident then starting yelling and said I told you I did not want the shot. I told you I was going to tell the Administrator and call the State. After 1:00 P.M., the Administrator called the DON and asked why the resident was given a Haldol shot, the DON did not know that the resident was given that shot. And said why was he/she given Haldol for screaming. The Administrator said that she called the Corporate Administrator and asked what should be done regarding the resident refusing Haldol. The Corporate Administrator said that we should do an investigation and education regarding the resident right to refuse any medication or treatment. She said that she spoke with LPN A about resident rights to refuse medications, that when they say no, it is no and when a resident is yelling or pointing a finger at somebody, the nurse should get other staff to redirect with coffee, snack, or word search. And if not enough staff the nurse can contact the DON, Assistant Director of Nursing (ADON), or the Administrator any time and one of them will come into the facility. The Administrator said that she expects staff to call the DON, ADON, or the Administrator immediately if there are any concerns or questions of abuse allegations. During an interview on 06/15/23, at 12:40 P.M., Housekeeping D he/she would report if he/she saw any staff forcing a resident to do something against their will, as that could be abuse. During an interview on 06/15/23, at 2:25 P.M., CNA E said he/she said that she would report any allegations of abuse and forcing a resident that refused to do something could be abuse. During an interview on 06/15/23, at 2:30 P.M., Nurse Aide (NA) F said that staff should not force residents against their will. During an interview on 06/15/23, at 2:40 P.M., Certified Medication Tech (CMT) G said said that residents have the right to refuse care, including medications During an interview on 06/15/23, at 3:00 P.M., the SSD said he/she would immediately report any concerns to the DON or Administrator, but can call the Corporate office directly if needed. He/she had heard about the incident and said that residents have the right to refuse. Staff should not make that choice for residents. During an interview on 06/15/23., at 3:10 P.M., the ADON said she became aware of the incident after the DON notified her. She felt that refusing a resident choice was abuse. During an interview on 06/15/23, at 3:15 P.M., the DON said the residents have the right specifically to refuse medication and, refuse any treatment. right to be free from misappropriation. The DON said she became aware of the incident after the resident went to the Administrator. She considered forcing a resident against their will to receive medication abuse. During an interview on 06/16/23., at 10:30 A.M., the Corporate Administrator said that he is familiar with the resident from this facility and previous facility. He said the resident would frequently refuse medications and choose which ones he/she wanted to take. He said that the Administrator called him on 06/12/23 regarding the resident being given Haldol after he/she refused. He expects staff to report allegations of abuse immediately. He said abuse could include forcing a resident to have an injection. MO00219982

Based on interview and record review, the facility failed to report an allegation of abuse made by one resident (Resident #1) against staff member to the Department of Health and Senior Services (DHSS) within in two hours of staff being made aware of the allegation. The facility had a census of 102. The Administrator and the Director of Nursing (DON) were notified on 06/12/23 of the Past Non-Compliance which occurred on 06/11/23, at approximately 2:00 P.M. Facility staff started an investigation, educated the staff members involved, began in-servicing of all facility staff as they began their shifts, and began monitoring charts and interviewing residents weekly to ensure no other incidents occur. Facility staff notified Department of Health and Senior Services (DHSS) of the noncompliance on 06/14/23. The noncompliance was corrected on 06/14/23. Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, dated 05/01/23, showed the following information: -Certain incidents and accident involving residents must also be reported to the appropriate state agencies; -The facility's policy strictly prohibits the abuse, neglect, exploitation, and involuntary seclusion of residents; -This policy includes abuse by any other person, including, but not limited to any member of the facility staff, physicians, physician assistants, dentist, beauticians, staff of governmental agencies, family members of the resident, visitors, the residents legal guardian, other residents, intruders, volunteers; -Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse or neglect, an injury of unknown origin, exploitation or misappropriation of resident property to the Administrator, Director of Nursing (DON), or the Department Supervisor. If the report is made to the DON or the Department Supervisor, that individual will notify the Administrator. Each employee should report to the Supervisor. Each employee should follow-up with the Supervisor to confirm it has been addressed. If not, the employee should make direct contact with the Administrator; -The facility will report all instances of alleged or suspected abuse, including verbal and mental abuse, neglect, suspicious injuries of unknown origin, exploitation and misappropriation of resident property Investigating and reporting steps include: -Notify the Administrator of any unusual situation in the facility, whether reportable or not immediately -The Administrator/Designee will report to the State Agency and all other required agencies, per regulation. All allegations of abuse and instances that results in serious bodily injury must be reported within 2 hours. Review of the facility policy, dated 11/28/16, titled Resident Grievances, showed the following information: -The resident has a right to voice grievances without discrimination or reprisal; -Reports of suspected abuse, neglect or exploitation are handled according to the Abuse policy. 1. Review of Resident #1's face sheet showed the following information: -admission date of 01/10/23; -Diagnoses included anxiety disorder, cognitive communication deficit, occlusion (blockage of blood flow) and stenosis (decrease of blood flow) of right carotid artery (major artery that carries blood from the heart to the head), personal history of TIA (transient ischemic attack - mini-stroke causing minor and temporary symptoms), cerebral infarction (stroke) without residual deficit, ataxia (Impaired balance or coordination), and history of falling. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/07/23, showed the following: -Cognitively intact; -Independent with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene; -Wheelchair used for mobility. Review of the resident's care plan, dated 01/23/23, showed the following information: -Resident had potential for mood state/psychosocial well-being related to change of environment; -Staff should observe for changes in mood; -Staff should provide support and reassurance as needed; -Staff should encourage/allow to voice feelings or concerns; -Staff should address complaints, concerns timely; -Resident may become agitated and make accusations of belongings being taken when the trash is emptied; -Resident will fixate often and can be verbally aggressive, and is paranoid at times; -Resident had history of obsessive over medication regimen and likes medication late at night when he/she asked for them; -Resident room is untidy and usually full of clutter. The resident can become irate when things are touched or thinks they have been touched or moved or the trash thrown away and project accusation on others; -Staff will talk in calm voice when behavior is disruptive; -Staff should refer to social services for evaluation; -Staff should provide resident with frequent reminders and encouragement to clean room, resident becomes upset when items are arrange. Review of the resident's physician order sheet, current as of 06/15/23, showed the following: -An order, dated 06/11/23, for haloperidol (drug used in the treatment of psychotic conditions), 5 milligrams (mg)/milliliter (ml), administer one ml every four hours as needed for agitation. Review of the resident's electronic medical record showed the following in the nursing progress notes: -On 06/11/23, at 10:12 A.M., staff documented the nurse heard resident yelling down the hallway and observed the resident yelling at family members of another resident. The nurse intervened and asked the resident what was going on. The resident stated he/she shit in my toilet and it is clogged and now he/she need to unclog it. The nurse told the resident it was not appropriate to yell at family members and if he/she needed help he/she needs to ask staff. The nurse then used a plunger to unclog toilet. No further issues noted at that time; -On 6/11/23, at 2:09 P.M., staff documented the nurse attempted to redirect the resident after the resident began yelling at another resident's family. The resident went back to his/her room for a couple of minutes, then came back out and started towards the other resident's family again and continued yelling at them. The nurse asked the resident what was wrong and the resident said someone stole my things and I'm banning everyone from my room. The nurse told the resident that it was not appropriate to yell at family members and that he/she had a roommate who required care so staff will not bother him/her if appropriate, but will need to go and check on the resident's roommate. The resident continued to yell and stated none of you are allowed to go into my room and I will be reporting you to the state and the Administrator. Staff notified the provider who gave orders to administer as needed Haldol (haloperidol) injection. The resident tolerated the injection well without signs or symptoms of adverse reactions. During an interview on 06/15/23, at 10:50 A.M., with Corporate Nurse, she said that the resident went to the Administrator on 06/12/23 to advise that he/she did not feel well and that he/she did not want the injection from the Licensed Practical Nurse (LPN) A on 06/11/23. Review of the facility investigation showed the following: -On 6/12/23, the resident notified the Administrator that he/she received an injection against his/her wishes; -The Administrator instructed the DON to re-educate staff regarding resident rights; -On 06/14/23, regional staff became aware of the incident and instructed the Administrator to report the event to the State and initiate an investigation; -The investigation revealed that LPN A, LPN B, and Certified Nurse Aide (CNA) C knew the resident did not want the injection but it was administered; -The resident stated he/she did state multiple times that he/she did not want the injection but did not resist when administered. Review DHSS records showed the facility self-reported the allegation of abuse on 06/14/23 (three days after the event occurred and two days after the resident reported the allegation to the administrator). During an interview on 06/15/23, at 1:00 P.M., LPN A said that on the morning of 06/11/23 he/she had heard yelling down the hall and when to see what was going on. He/she said that Resident #1 was yelling at another resident's family. He/she said that the resident was able to be redirected. Then at about 2:00 P.M., the resident was yelling at the same family and trying to corner them as they tried to leave. The staff redirected the resident to his/her room. The nurse contacted the physician on call and received an order for Haldol injection. The resident self-propelled his/her wheelchair to his/her room, the nurse explained the injection and the resident said why, why. The resident kept asking why but did not say do not do this. The nurse said that the facility expects that any health changes are put into the resident chart and notify the DON and provider. The nurse did not contact the resident's family regarding the Haldol order. The nurse said that he/she was not aware the resident refused the injection, the resident only said why, and the nurse provided education to the resident that the provider ordered for agitation. During an interview on 06/15/23, at 2:25 P.M., CNA E said staff should notify the nurse and can report to the Administrator of allegations of abuse. During an interview on 06/15/23, at 2:30 P.M., Nurse Aide (NA) F said that if he/she saw any resident being treated improperly he/she should report immediately to the charge nurse, DON, or Administrator. During an interview on 06/15/23, at 2:45 P.M., Registered Nurse (RN) H said that if staff see something or feel something is inappropriate they should report to the Assistant Director of Nursing (ADON) or DON. During an interview on 06/15/23, at 3:00 P.M., the SSD said he/she would immediately report any concerns to the DON or Administrator, but can call the Corporate office directly if needed. During an interview on 06/15/23., at 3:10 P.M., the ADON said the management staff should contact the State Hotline for allegation of abuse within two hours. During an interview on 06/15/23, at 3:15 P.M., the DON said staff should immediately notify the charge nurse, ADON, DON, or Administrator of any allegation of abuse, neglect, misappropriation, or resident denied rights. MO00219982

Based on interview and record review, the facility failed to ensure one resident's (Resident #346) records accurately and consistently indicated the resident's wishes regarding his/her code status (the level of medical interventions a resident wishes to have if their heart or breathing stops). The facility census was 102. Record review of the facility's Advanced Directive Policy, dated 10/1/2010, showed the following: -When a Do Not Resuscitate (DNR- a status that means a resident does not want his/her life to be saved in the event that his/her heart or breathing stops) order is decided upon, the DNR order must be entered into the resident's medical record. 1. Record review of Resident #346's face sheet showed an admission date of 10/4/2021. Record review of the resident's medical record showed a signed DNR form (purple sheet) in the paper chart. Record review of the resident's medical record showed no physician's order for code status in the online chart or in the paper chart. Record review of the resident's progress notes and care plan showed staff did not document the resident's code status. During an interview on 10/25/2021, at 10:29 A.M., Licensed Practical Nurse (LPN) A said the following: -He/she didn't see any DNR in the electronic record, so the resident must be a full code; -If the resident coded (the resident's heart or breathing stopped), he/she would check the resident's paper chart to be sure of the resident's DNR status before coding the resident; -He/she said the resident did have a DNR according to the paper chart; -The Director of Nursing (DON) and Assistant Director of Nursing (ADON) used to enter the code status into the computer, but now Registered Nurse (RN) C and Medical Records, who's currently working from home, can do them too; -A full code status is not listed; -For DNRs, nurses enter the code status order by doctor and the date of the doctor's signature, plus the nurse's signature who is entering the code status into the computer. During an interview on 10/21/21, at 11:33 A.M., Registered Nurse (RN) B said if a resident is a full code it is not shown in the online charting system or the paper charting system. It only shows up in the online system if the resident is a DNR, under the e-chart, in the Physician Order Sheet section. Also, DNRs have a purple copy in the paper chart. During an interview on 10/25/2021, at 9:57 A.M., RN C said on each hall there is a portable computer on wheels, and when staff look under the physician order sheet, and select order type, the advanced directives show up at the top of the physician order sheet. If the computer systems are down the written DNR order is in the front of the paper chart. If someone has a change in condition staff look up code status before sending the resident to the emergency room. Full code status is not marked in either the online or paper chart. If there is no DNR order then staff know the resident is a full code. During an interview on 10/25/2021, at 10:40 A.M., Certified Nurse Aide (CNA) D said resident code status is not available on the aide charting screen in the computer. The aides have to notify the nurse if they find a resident unresponsive. During an interview on 10/25/21, at 10:45 A.M., CNA W said resident code status was somewhere at the nurses' station, but he/she had not had to look for it. During an interview on 10/26/21, at 9:45 A.M., CNA J said that he/she would contact the nurse if there was a change in resident status and the nurse would know the resident's code status. During an interview on 10/26/2021, at 10:45 A.M., LPN A said that resident code status should be in the physician's order in the electronic medical record and it should be located in the front of the resident's paper charts. The chart should include do not resuscitate and full code status of all residents. If code status is not found in the chart then staff assume the resident is a full code. During an interview on 10/26/2021, at 1:27 P.M., the MDS Coordinator said if a resident wanted a DNR code status there was a sheet in the front of the hard chart, and if there was not a DNR sheet the resident was a full code. During an interview on 10/25/2021, at 12:46 P.M., the Director of Nursing (DON) said charge nurses check for code status and they verify it via the physician order sheet in the electronic medical record. Aides report change in condition to the charge nurse, and then the nurse looks up the code status. Any nurse can put in a DNR order. Full codes are not documented anywhere. During an interview on 10/25/2021, at 2:09 P.M., the Administrator said he was not familiar with the advanced directives. He/she said the staff do audits on them.

Based on interview, record review, and observation, the facility staff failed to perform an initial wound assessment, delayed obtaining a wound treatment, and did not perform weekly wound assessments following an accidental burn for one resident (Resident #51). The facility census was 102. Record review of the facility's policy titled Incidents and Accidents, dated 11/10/2014, showed the following: -Examples of incidents include but are not limited to falls, burns, medication errors, skin tears, bruises, altercations or unusual combative behavior, attempted elopements, treatment errors, equipment malfunctioning causing injury to residents, adverse reaction to diet or medication, and smoking infractions; -Staff should notify the resident's physician and obtain orders for care, including any indicated diagnostics (x-rays, laboratory orders); -Staff should obtain medical care as needed and transfer to the emergency room as needed. Record review of the facility's policy titled Dressings-Clean, dated 12/20/2016, showed the following: -Physician's orders should specify the type of the wound, the frequency of the dressing change, the type of the dressing used, and the products used. (The policy did not address documentation of the wound assessments. No wound policy or skin assessment policy was provided.) 1. Record review of Resident #51's face sheet (a brief resident profile sheet) showed the following: -admission date of 11/14/2016; -Diagnoses included schizoaffective disorder (a mental illness characterized by symptoms such as hallucinations or delusions, and mania and depression), dementia (a group conditions characterized by impairment of a least two brain functions, such as memory loss and judgement), and history of a cerebral infarction (stroke). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 9/1/2021, showed the following: -The resident was severely cognitively impaired; -He/she required substantial assistance with eating where the helper did more than half of the feeding effort; -The resident did not have any scheduled pain medication or receive any as needed pain medication; -He/she did not have any skin conditions. Record review of the resident's progress notes showed the following: -On 9/5/2021, at 6:15 P.M., facility staff documented the resident spilled food onto him/herself. Redness was noted to the resident's chest. Staff noted no other apparent injuries at that time. Staff notified the resident's responsible party and physician; -On 9/6/2021, at 11:20 A.M., facility staff documented the resident had redness and blisters to his/her chest. Record review of the resident's medical record showed facility staff did not complete an initial full wound assessment or begin a wound treatment after identifying the wound. Record review of the resident's physician orders (POS) showed the following: -An order, dated 9/7/2021 (Two days after the wound was initially identified.), to clean the resident's chest daily with normal saline, pat dry, and apply a thin layer of Silvadene cream (a cream used to prevent infections in patients with burns) daily until resolved. Record review of the resident's Treatment Administration Record (TAR) showed the following: -An order, dated 9/7/2021, to clean the resident's chest daily with normal saline, pat dry, and apply a thin layer of Silvadene cream daily until resolved. Record review of the resident's departmental notes showed the following: -On 9/7/2021, at 9:38 A.M., hydrocodone (a pain medication used to treat moderate to severe pain) 7.5/325 was administered for signs and symptoms of pain. The resident was yelling out. Record review of the resident's departmental notes dated 9/8/2021, at 6:42 P.M., showed had redness with fluid filled blister to the chest with no signs or symptoms of infection noted at this time. (Staff did not document a full assessment of wound.) Record review of the resident's chart showed facility staff did not contact the physician regarding the severity of the burn or possible pain from the wound. Record review of the resident's departmental notes dated 9/11/2021, at 9:51 A.M., showed the resident presented with multiple areas of redness on his/her chest, one non-fluid filled blister, and two open blisters noted on observation. No signs or symptoms of infection were present. Staff cleaned the area was with normal saline and the treatment was performed per the physician's order. (Staff did not document a full assessment of wound.) Record review of the resident's POS showed the following: -An order, dated 9/14/2021, to clean the resident's burn site on the mid chest daily with Vashe (a wound cleanser), apply Silvadene cream, cover with a non-adhesive pad and dry dressing, and observe the area daily. Record review of the resident's TAR showed the following: -An order, dated 9/14/2021, to clean the resident's burn site on the mid chest daily with Vashe, apply Silvadene cream, cover with a non-adhesive pad and dry dressing, and observe the area daily. Record review of the resident's departmental notes dated 9/14/2021, at 5:09 A.M., showed the resident continued on incident follow up with some pinkish/red discoloration to his/her chest and three to four blisters which appeared to be crusting over without drainage. No signs or symptoms of pain were observed. The resident had no grimacing, guarding, or crying. (Staff did not document a full assessment of wound.) Record review of the resident's current care plan showed the following: -An intervention, dated 9/14/2021, instructed staff to perform wound care as ordered; -An intervention, dated 9/14/2021, instructed staff to assess resident's skin daily with routine care. Record review of the resident's departmental notes dated 9/15/2021, at 5:31 A.M., showed the blisters to the resident's mid chest and abdomen were still present. There was no oozing or inflammation seen in this area. Scabbing was seen on the mid chest, although the blisters had popped on the lower abdomen and the area remained reddened. A loose dressing with triple antibiotic ointment was applied to both areas to prevent infection. (Staff did not document a full assessment of wound.) Record review of the resident's departmental notes dated 9/18/2021, at 3:04 P.M., showed facility staff documented the resident had redness around the burn and drainage on the dressing. (Staff did not document a full assessment of wound.) Record review of the resident's POS showed the following: -An order, dated 9/22/2021, to clean the resident's burn site with normal saline, apply Xeroform (a fine mesh gauze embedded with petroleum jelly), cover with a non-adhesive pad, and a dry dressing. Record review of the resident's TAR showed the following: -An order, dated 9/22/2021, to clean the resident's burn site with normal saline, apply Xeroform cover with a non-adhesive pad and a dry dressing. Record review of the resident's departmental notes dated 9/23/2021, at 2:43 A.M., showed the resident's wounds had no warmth, redness, or drainage noted. No signs or symptoms of discomfort were noted. (Staff did not document a full assessment of wound.) Record review of the resident's departmental notes dated 9/30/2021, at 3:05 P.M., showed the resident's wounds had no warmth, redness, or drainage, and the resident did not show signs of discomfort. (Staff did not document a full assessment of wound.) Record review of the resident's POS showed the following: -An order, dated 10/7/2021, to clean the resident's burn with Vashe, apply skin prep (a protective film to help reduce friction during the removal of tapes and films) to the peri-wound (the area around the wound), apply Santyl (a medication that removes dead tissue from wounds so they can begin to heal) to the wound bed (the bottom of the wound), cover with Xeroform gauze, and a dry dressing. Observe the area daily. Record review of the resident's TAR showed the following: -An order, dated 10/7/2021, to clean the resident's burn with Vashe, apply skin prep to the peri-wound (the area around the wound), apply Santyl to the wound bed, cover with Xeroform gauze, and a dry dressing. Observe the area daily. Record review of the resident's departmental notes dated 10/7/2021, at 11:09 P.M., showed the resident continued on incident follow up to the chest. No warmth or redness was noted to the sites. He/she continued with wound care. The dressings were intact to the affected areas. He/she had no signs or symptoms of pain or discomfort. (Staff did not document a full assessment of wound.) Record review of the resident's POS showed the following: -An order, dated 10/12/2021, to cleanse with Vashe, apply skin prep to the peri-wound area, cover with Xeroform gauze and a dry dressing daily. Record review of the resident's TAR showed the following: -An order, dated 10/12/2021, to cleanse with Vashe, apply skin prep to the peri-wound area, cover with Xeroform gauze and a dry dressing daily. Record review of the resident's departmental notes dated 10/14/2021, at 6:27 P.M., showed an aide notified the nurse the resident had spilled hot food on his/her chest. The resident was cleaned up and his/her skin was assessed. He/she had redness and was developing blisters on the sensitive skin from the previous burn. The area was cleaned with Vashe (a wound cleanser), skin prep (a protective film to help reduce friction during the removal of tapes and films) was applied, and the area was left open to air. Staff notified the physician and responsible party. (Staff did not document a full assessment of wound.) Record review of the resident's POS showed the following: -An order, dated 10/18/2021, to cleanse the burn to the abdominal area with Vashe, apply skin prep to the peri-wound, apply Silvadene cream to the wound bed, and cover with a dry dressing. Observe the area daily; -An order, dated 10/18/2021, to cleanse the burn to the mid-chest with Vashe, apply skin prep to the peri-wound, apply Silvadene cream to the wound bed, and cover with a dry dressing; -An order, dated 10/18/2021, to cleanse the burn to the upper chest with Vashe, apply skin prep to the peri-wound, apply Silvadene cream to the wound bed, and cover with a dry dressing. Record review of the resident's departmental notes dated 10/19/2021, at 5:19 P.M., showed burn to mid chest showed deterioration this week. The wound bed (bottom of the wound) showed slough tissue (dead tissue). No drainage was seen. The edges were distinct and intact. The peri-wound (area surrounding the wound) was pink and firm. During an interview on 10/19/21, at 3:35 P.M., Licensed Practical Nurse (LPN) A said the resident still had some blisters from the first wound and the wound nurse said it was showing signs of infection. The second wound showed some blisters, so LPN A did the same treatment on it. During an interview on 10/20/2021, at 12:47 P.M., the Medical Director said he was probably made aware of the first burn. During an interview on 10/22/2021, at 2:30 P.M., the resident's PCP said he had not seen the resident's burn. He was notified several days after the first burn and was told it was likely a second degree burn. He rounded several weeks after the first burn and did not look at the wound because he was told it was essentially healed. He received a call probably about a month later that the resident had another burn, and staff did not give a good description. He said he asked about the surface area of the burn because sometimes a patient would require intravenous (IV-through the veins) fluids. He said this wound does not look like he/she would need fluids. If an incident occurs he expects to be immediately contacted to determine if he can get to the facility to round or if the resident should be sent out to the emergency room. During an interview on 10/26/2021, at 12:26 P.M., Certified Nurse Aide (CNA) D said he/she reports injuries to the charge nurse who assesses the resident and notifies the wound nurse, who then does another assessment and treats the wound per order. The charge nurse is responsible for calling the doctor. The charge nurse does an initial skin assessment, followed by the wound nurse. Wound assessments are done weekly by the wound nurse, but if wound nurse isn't working, the charge nurse does the wound assessment. The wound assessment is documented in the wound assessment charting in the computer and also documented on the care plan. During an interview on 10/26/2021, at 12:51 P.M., CNA E said he/she reports wounds and injuries to the charge nurse, and, depending on the injury, he/she may assist the nurse in caring for the injured resident. The charge nurse calls the physician, and either the charge nurse or wound care nurse can do the skin assessment for the injury. Wound assessments are done once a week and as needed by the wound nurse, and in the wound nurse's absence, the charge nurse does the wound assessment, CNAs can also document skin issues as yes or no in CNA online charting, then it flags the wound care nurse so she can come talk to the aides about the skin issue. CNA E was unsure about where wound assessments were documented. During an interview on 10/26/21, at 1:01 P.M., LPN K said if a resident has an injury or new wound, nursing will assess the injury, apply appropriate dressings, and then the charge nurse notifies the wound nurse. The charge nurse is also to enter an as needed order to observe and change the dressing. He/she was not involved with the resident who was burned when it happened, but has taken care of him/her since. If it was an open burn wound, the charge nurse would call the physician for orders. The initial skin assessment is done by the charge nurse, then the charge notifies the wound nurse of the treatment. The wounds are visualized once or twice a week during the ordered dressing change, and measurements are done weekly. The wound assessments are documented in the online chart. During an interview on 10/26/21, at 1:32 P.M., Registered Nurse (RN) C said if a resident had an injury or new wound he/she would do an incident report and include an assessment of the size and description of the injury. He/she would call the DON. The charge nurse is responsible for calling the physician, and also doing the initial skin assessment. The day of the second burn for the resident, he/she went to assess him/her and there was no open areas, there was just some redness and blistering so the staff applied Silvadene cream, and waited to hear back from the physician. Wound assessments are done weekly, including measurements. The wound nurse also assesses wounds anytime she does a treatment. In the period of time that the resident had his/her first burn, the facility did not have a wound nurse, so the DON, Assistant Director of Nursing (ADON), and Administrator, who was also an RN, were doing the wound assessments. Wound assessments are documented in the progress notes as well in the wound assessment module on the computer. During an interview on 10/27/21, at 9:12 A.M., RN BB (the wound nurse) said if staff finds a new wound they can put it in the new wound assessment book that is reviewed every morning, tell the charge nurse, or tell her in person. If it is an emergent wound, staff should go get her. She will do the initial assessment, start a treatment, and fax or call the doctor. The charge nurse usually takes care of notifying the physician. The resident's family is notified of the injury. If the wound nurse is not available, the charge nurse is responsible for the assessment and treatment. Dressings should always be done according to physicians' orders. Wound measurements should be done weekly. The RN said the facility staff do not measure non-pressure wounds. Measurements are only taken if the wound is a pressure ulcer, a diabetic ulcer (an open sore or ulcer commonly located on the bottom of a foot and usually caused by the lack of feeling in the foot of a diabetic person), or a venous ulcer (a wound on a leg or ankle caused by a damaged vein or artery). During an interview on 10/27/21, at 8:26 A.M., the DON said non-pressure wounds are not tracked unless they are surgical, diabetic, or venous or arterial ulcers. Staff should chart a description of a wound in the nurses' notes. In a burn, the site itself would not change in size, but she would expect staff to assess the size and document every shift. The charge nurse would be responsible every shift to observe the wound. The wound nurse would assess weekly. Either nurse could contact the physician if there was a deterioration. Staff should have documented an assessment of the resident's burn before they did. A skin assessment policy was not provided. During an interview on 10/27/21, at 8:56 A.M., the Administrator said if staff report a new wound, he expects them to do immediate first aid, and the nurse to do an assessment. The nurse should contact the doctor for orders and the nurse will follow the orders. The tracking should be done as the doctor orders, either twice weekly or weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when two residents (Resident #71 and Resident #247) were left exposed in view of other residents and staff and when the facility failed to provide a dignity bag for one resident (Resident #146) with a catheter (a sterile tube used to drain urine). The facility census 102. Record review of the facility's policy, titled Federal Rights of Residents/Guests, dated 11/28/2016, showed the following: - The resident/guest has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; - The resident/guest has the right to personal privacy and confidentiality of his or her personal and medical records; - A facility must treat each resident/guest with dignity and respect and care for each resident/guest in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident/guest(s) individuality. 2. Record review of Resident #71's face sheet (a brief resident profile sheet) showed the following: -admission date of 2/25/2021; -Diagnoses included borderline personality disorder (disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships); metabolic encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood, it can lead to personality changes); and vascular dementia (common form of dementia caused by an impaired supply of blood to the brain). Record review of the resident's care plan, dated 7/1/21, showed the following: -Unable to perform self-care, requires total assistance related to decline, on end of life care; -Dress in appropriate clothing and foot wear; -Assist with dressing; -Assist with hair; -Transfer requires two staff with mechanical lift. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Totally dependent on staff for activities of daily living; -Two person assist to complete activities of daily living such as bathing, grooming, repositioning, transfers; -One person assist for eating; -Indwelling catheter (a tube place in bladder to drain urine). Observations on 10/18/2021, at 12:03 P.M., showed the following: -The resident in the dining room in a tall back wheelchair with the chair legs in the elevated position, the wheelchair was the first chair in the dining room closest to the nurse station; -The resident had on a long sleeved shirt, incontinent brief, and a white sheet; -The resident had slipped down in the chair and was not sitting upright; -The resident had kicked the sheet off his/her right leg; -The resident's right leg, thigh, and right hip was visible to all residents and staff in the dining room; -The resident's incontinent brief and catheter tubing were visible; -The resident had both legs hanging off the left side of the wheelchair; -Eighteen residents were seated in the dining room; -Several staff entered and exited the dining room, while preparing the residents for lunch, and walked by the resident with his/her legs exposed. No one stopped to assist the resident and cover him/her. Observation on 10/22/2021, at 11:58 A.M., showed the resident was seated in a wheelchair in the dining room and had pushed off his/her sheet. The resident's legs, incontinent brief, and catheter tubing were exposed to all residents and staff in the dining room. During an interview on 10/26/2021, at 9:45 A.M., Certified Nurse Aide (CNA) J said all residents should have a shirt and pants on when they are in the common area. If the resident was cold they should be covered by a blanket as well. He/she did not know why the resident did not have pants on while in the dining room. During an interview on 10/26/2021, at 10:45 A.M., Licensed Practical Nurse (LPN) A said residents should be dressed in their regular clothing when in the common areas. This included something on their feet. There are some residents that want to wear a house gown, but they have to at least be fully covered. The residents should not be in the dining room with only an incontinent brief, shirt, and sheet covering their legs. The resident can be difficult, but he/she has had pants on in the past. He/she did not know why the staff did not put pants on the resident this week. During an interview on 10/26/2021, at 1:20 P.M., the DON said it would not be appropriate for a resident to have no pants on, with a sheet that was pushed off, allowing legs, brief, and catheter to be visible in the dining room. During an interview on 10/26/2021, at 1:27 P.M., the Social Services Director (SSD) said it would not be appropriate for a resident to have a visible brief and catheter in the dining room. He/she said the resident does fight cares at time and maybe that is why the staff do not put pants on the resident. He/she had not thought about putting a resident's preference for dressing and dignity in the care plan. During an interview on 10/27/2021, at 9:08 A.M., the Administrator said if a resident only had a sheet over their legs with no pants on in the dining room, the staff should ensure they remain covered the best they can. 1. Record review of Resident #247's face sheet showed the following: -admission date of 10/10/2021; -His/her diagnoses included dementia, chronic kidney disease stage 3 (moderate kidney damage), and a trimalleol fracture (ankle break). Record review of the resident's current care plan showed the following: -An intervention, dated 10/10/2021, that instructed staff to provide an environment that respected privacy. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 10/15/2021, showed the following: -Severely cognitively impaired; -Required two persons to assist with bed mobility, transfers, and dressing; -Dependent on staff for upper body dressing, and lower body dressing has not been attempted due to medical safety reasons. Observation on 10/19/2021, at 12:20 P.M., showed the resident rested in his/her bed nude, with no screen or curtain pulled, and the door to the hallway wide open. The resident's bed was positioned where any resident or staff member walking down the hall could see the resident. Observation on 10/22/2021, at 8:58 A.M., showed the resident rested in his/her bed nude with the door wide open. The resident's roommate was present in the room seated in his/her wheelchair next to the resident's bed in view of the resident. During an interview on 10/27/2021, at 8:26 A.M., the Director of Nursing (DON) said residents with beds close to the door should be kept covered all times, or staff should close the door to provide dignity. During an interview on 10/27/2021, at 8:56 A.M., the Administrator said if a resident likes to keep themselves undressed, they should be kept covered as best they can and given privacy. 3. Record review of Resident #146's face sheet showed the following information: -admission date of 10/13/2021; -Diagnoses included benign prostatic hyperplasia with lower urinary tract infection (BPH-age associated prostate gland enlargement that can cause urination difficulty) and dementia with behaviors; -Foley catheter (an indwelling catheter). Observation on 10/19/2021, at 8:44 AM, showed the resident in full personal protective equipment (PPE) exiting the facility for a doctor's appointment. The resident had a clear catheter bag (bag that hold urine) hooked on the side of his/her walker. The catheter bag was not covered or in a privacy/dignity bag. A small amount of yellow urine was observed in the catheter bag. During an interview on 10/25/2021, at 11:25 A.M., CNA T said residents should be treated with dignity and respect. Catheters should have a dignity/privacy bag cover, but said the facility has not had the covers for years. He/she said when he/she asked the charge nurse and social service director for privacy bags he/she was told they did not have any. A resident not having a privacy cover for his/her catheter is a dignity concern. During an interview on 10/25/2021, at 11:34 A.M., CNA E said residents should be treated with dignity and respect. If a resident did not have a dignity bag or privacy cover for a catheter when going out of the facility on an appointment this is a dignity concern. If he/she saw resident without, he/she would get a privacy or dignity bag for the residents catheter. During an interview on 10/25/2021, at 11:49 A.M., LPN K said if a resident does not have a dignity bag for his/her catheter it is a dignity issue. The facility tried to use leg bags for catheters if possible, but if this is not possible staff should use a privacy bag for the catheter. During an interview on 10/26/2021, at 10:27 AM Certified Medication Technician (CMT) X said catheters should be in privacy bag when a resident leaves their room or if the catheter bag is visible from the hall. A resident should never be sent on an appointment without a privacy bag for a catheter. The CMT said they have privacy bags and staff just have to ask the nurse for one. During an interview on 10/26/2021, at 1:42 P.M., Registered Nurse (RN) MDS/Care Plan Coordinator said all residents that have catheters should have a dignity/privacy bag for their catheter and should not be sent out to an appointment without the dignity/privacy bag. This would be consider a dignity issue. He/she said dignity/privacy bags are not care planned and staff should know to use a dignity/privacy bag for catheters. During an interview 10/25/2021, at 12:19 P.M., the DON said catheters should have privacy/dignity bags when a resident leaves his/her room. If the resident did not have a privacy or dignity bag she would consider this a dignity issue. During an interview on 10/25/2021, at 2:00 P.M., the administrator said he was made aware last Monday during rounds the facility did not have privacy bags for catheters. The facility was able to obtain some from a sister facility. If a privacy bag is not used for a catheter when a resident leaves his/her room, he would consider this a dignity issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to maintain a clean, comfortable, homelike environment on the special care unit (SCU-a locked memory care unit) when P-TACs (filter for air conditioners) were lying on the ground and were fuzzy and dirty, fluorescent light fixtures were missing covers; and on 400 hall the fluorescent lights were dirty with dead bugs. The facility census was 102. Record review showed the facility did not provide a policy regarding maintaining the cleanliness of the home. 1. Observation on 10/19/2021, at 9:23 A.M., of the SCU showed the following P-TAC filters for the air conditioning units lying on the floor underneath the air conditioner units. The filters were dirty with fuzzy lint and dust: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -SCU dining room; -SCU television/common area. Observation on 10/22/2021, beginning at 11:20 A.M., of the SCU showed the following P-TAC filters for the air conditioning units lying on the floor underneath the air conditioner units. The filters were dirty with fuzzy lint and dust: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -SCU dining room; -SCU television/common area. During an interview on 10/19/2021, at 9:27 A.M., Resident #27 said the filters are always on the floor underneath the air conditioner. During an interview on 10/22/2021, at 12:00 P.M., the Maintenance Director said he/she knew some of the P-TACs for the air conditioners on the SCU were on the floor, dirty, and needed to be cleaned. He/she cleans them and puts them back on the air conditioning units. A resident on the SCU yanks them out or bangs on the air conditioning units until the P-TAC filters fall out. He/she is in the process of replacing the air conditioning units, because the air conditioning units were so old he/she could no longer find parts for them. During an interview on 10/22/2021, at 12:31 P.M., Nurse Aide (NA) F said the filters for the air conditioners come off because one resident messes with them. He/she said the staff on the SCU report to maintenance the filters are lying on the floor when the resident removes them. He/she said maintenance comes and cleans them and puts them back in when staff report this. During an interview on 10/26/2021, at 8:55 A.M., the Laundry/Housekeeping Supervisor said the P-TAC filters for the air conditioning units on the SCU are found on the floor at times. The staff who work on the SCU or housekeeping staff should report this to the maintenance person so he/she can clean the P-TAC filters and replace them or put them back in. During an interview on 10/26/2021, at 10:10 A.M., the Administrator said the P-TAC filters for the air conditioning units on the SCU should be reported to maintenance so he can put in a work order and repair or replace them as needed. 2. Observation on 10/20/2021, at 8:20 A.M., showed two fluorescent light fixtures on the 400 hall, near the exit where employees go out to smoke, dirty with dead bugs. The fluorescent light fixtures had too many bugs in them to count. The bugs appeared to be dead gnats. Observation on 10/22/2021, at 11:30 A.M., showed the two fluorescent light fixtures on the 400 hall, near the exit where employees go out to smoke, remained dirty with dead bugs. Observation on 10/25/2021, at 8:30 A.M., showed the two fluorescent light fixtures on the 400 hall, near the exit where employees go out to smoke, remained dirty with dead bugs. During an interview on 10/22/2021, at 12:31 P.M., NA F said if staff saw the light fixture covers were dirty, the staff should report this to maintenance or housekeeping so they can be cleaned. During an interview on 10/26/2021, at 8:55 A.M., the Housekeeping/Laundry Supervisor said light fixtures are deep cleaned monthly and maintenance is responsible for cleaning the inside of the fluorescent light covers. During an interview on 10/26/2021, at 10:10 A.M., the Administrator said the fluorescent light fixtures should be cleaned as needed and should be observed on environmental rounds by housekeeping and maintenance. If the light cover is dirty they should be cleaned. 3. Observation on 10/18/2021, at 12:15 P.M., of the SCU television room showed a fluorescent light fixture cover missing. Observation on 10/22/2021, at 12:30 P.M., of the SCU television room showed a fluorescent light fixture cover missing. During an interview on 10/22/2021, at 12:31 P.M., NA F said he/she had not noticed a cover for a fluorescent light fixture in the SCU television room was missing. He/she knew maintenance had fixed a few light covers for the fluorescent lights on the SCU. If a staff person noticed missing covers for the fluorescent lights staff should report this to maintenance. During an interview on 10/22/2021, at 1:09 P.M., the Maintenance Director said he was not aware of a missing light cover for a fluorescent light in the SCU television room. He has to replace the entire fixture since he cannot get new covers for them. During an interview on 10/26/2021, at 8:55 A.M., the Housekeeping/Laundry Supervisor said broken light fixtures or fluorescent light fixture covers that are missing should be reported to maintenance to repair or replace. During an interview on 10/26/2021, 10:10 A.M., the Administrator said if there are missing light covers they should be replaced.

Based on interview and record review, the facility failed to document checking the Nurse Aide (NA) Registry prior to the start date of six out of ten sampled staff to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility census was 102. Record review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, dated August 12, 2016, showed the following: -The facility will not knowingly employ any individual who has been found guilty by a court of law of abusing, neglecting, or mistreating resident(s)/guest(s). In addition, the facility will not knowingly employ any individual who has had a finding entered into the state nurse aide registry concerning abuse, neglect, and mistreatment of resident/guest(s) property; -To ensure the facility does not knowingly hire such an individual, it has established the following procedures: the facility will search the appropriate registries and will conduct a background, investigation to determine whether a finding of abuse, neglect, mistreatment, exploitation or misappropriation has been entered against a potential employee. 1., Record review of Nurse Aide (NA) O's personnel records showed the following: -Hire/start date of 10/04/2021; -The facility did not have record of checking the NA registry for a Federal Indicator. 2. Record review of Certified Nurse Aide (CNA) Z's personnel records showed the following: -Hire/start date of 10/04/2021; -The facility did not have record of checking the NA registry for a Federal Indicator until 10/22/2021 (18 days after the CNA's hire/start date). 3. Record review of NA AA's personnel records showed the following: -Hire/start date of 9/03/2021; -The facility did not have record of checking the NA registry for a Federal Indicator until 10/22/2021 (19 days after the NA's hire/start date). 4. Record review of Registered Nurse (RN) BB's personnel records showed the following: -Hire/start date of 9/22/2021; -The facility did not have record of checking the NA registry for a Federal Indicator until 10/22/2021 (30 days after the RN's hire/start date). 5. Record review of Licensed Practical Nurse (LPN) CC's personnel records showed the following: -Hire/start date of 9/07/2021; -The facility did not have record of checking the NA registry for a Federal Indicator. 6. Record review of LPN DD's personnel records showed the following: -Hire/start date of 9/16/2021; -The facility did not have record of checking the NA registry for a Federal Indicator. 7. During an interview on 10/26/2021, at 9:18 A.M., Financial Specialist Assistant EE said the following: -He/she checked the NA registry check at the same time he/she completed the criminal background check (CBC) and the Employee Disqualification List check; -He/she said usually he/she does this when the employee's application is turned in if the facility is planning to possibly hire the employee; -He/she would print all the required background checks including the NA registry check and place them in the employee's personnel file; -The three employee's who were printed on 10/22/2021 had been done, but due to computer issues he/she was unable to print them out. The computer had kicked him/her out of the site to check the NA registry -He/she said today his/her computer got fixed and he/she can print the NA registry checks now; -He/she could not find LPN CC, LPN DD, or NA O in the system so he/she does not have anything to prove he/she checked these employees for the NA registry site prior to hire; -There is no way to prove the NA registry checks had been completed prior to hire/start date. During an interview on 10/26/2021, at 11:00 A.M., the Administrator said the NA registry check should be completed prior to hire. He did not know the Financial Specialist Assistant could not print the NA registry until 10/22/2021. He said he/she did not have the updated browser and the system would not allow him/her to print out the verification pages for the NA registry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #80's face sheet included the following: -admission date of 9/22/2021; -The resident is not responsible for him/herself; family listed as responsible party. Record review of the resident's nursing progress notes showed the following: -On 10/13/2021, at 10:42 A.M., the Director of Nursing (DON) documented resident was discharged to the hospital on [DATE] at approximately 8:30 P.M. with low blood sugar and shortness of breath; -On 10/20/2021, at 12:55 A.M., a charge nurse documented at approximately 6:30 P.M. the resident complained of pain. Staff assessed resident and found edema and Foley catheter (tube placed in bladder to drain urine) leaking with no urine in bag. Staff notified the facility doctor and received new order to send to hospital for evaluation and treatment. Staff notified family of order. Resident out of facility at approximately 7:00 P.M. via ambulance. Record review of the resident's medical record showed staff did not have a copy of any written notice provided to the resident, resident representative, or Ombudsman regarding the hospital transfers on 10/12/21 or 10/20/2021. During an interview on 10/22/2021, at 1:02 P.M., the DON said she was unable to locate the written notification of hospital transfer to the resident's family and ombudsman for hospital transfer on 10/12/21 and 10/20/21. 4. During an interview on 10/26/2021, at 10:18 A.M., Licensed Practical Nurse (LPN) A said if a resident is sent to the hospital, staff fill out a discharge summary, including contact information for responsible party and physician order sheet, and give one copy to transport and one copy to the hospital. He/she does not notify the ombudsman in writing of the hospital transfer. He/she thought the Social Services Director (SSD) or the Assistant Director of Nursing (ADON) did this. Staff does not notify the family in writing. During an interview on 10/26/2021, at 10:27 A.M., the SSD said he/she really doesn't know what to do with hospital transfers. He/she was not aware the facility was to notify the ombudsman for hospital transfers. He/she has had no training on this yet, regarding hospital or family notification in writing. During an interview on 10/26/21, at 10:57 A.M., the DON said he/she is aware the facility is to notify family and the ombudsman in writing of transfers and discharges. During an interview on 10/26/21, at 11:45 A.M. the Administrator said he/she doesn't know requirements for notification regarding hospitalizations. MO00192506 Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge and failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for three residents (Resident #16, Resident #32, and Resident #80). The facility census was 102. Record review of the facility policy titled, Transfer, Discharge, and Therapeutic Leaves (including AMA), dated 11/28/2016, showed procedures for non-emergency transfer or discharges should include: -A licensed nurse should complete discharge summary and should be coordinated by the social service designee; -Notify the resident in writing and the legal representative of transfer or discharge and the reasons for the transfer or discharge; -Record the reason for, and the effective date of transfer, or discharge, and the location to which the resident is being transferred or discharged , in the medical record and on attached state specific forms; -Give a copy of this notice to the resident and his/her legal representative upon transfer or discharge; -A discharge summary and plan of care should be prepared for the resident. Record review of the facility policy titled, Transfer, Discharge, and Therapeutic Leaves (including AMA), dated 11/28/2016, showed procedures for emergency transfer or discharges should include: -Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis; -Complete a Transfer Form and send the original copy with the resident which documents current diagnosis, reasons for transfer/discharge, date, time, physician, current medications, treatments, functional status, any special care needs, and care plan goals, maintain a copy in the medical record; -A copy of the resident bed hold and admission policies/transfer to hospital notice should be provided upon transfer to the resident and representative of the resident. 1. Record review of Resident #16's face sheet showed the following: -admitted to the facility on [DATE]; -discharged to the hospital on [DATE]. Record review of the resident's nurses' progress notes showed the following information: -On 10/11/2021, at 4:33 A.M., staff documented the aide reported the resident was having black liquid stools. Staff notified the physician and received a verbal order to send the resident to the emergency room for evaluation. Record review of the resident's medical record showed staff did not have a copy of any written notice provided to the resident, resident representative, or Ombudsman regarding the hospital transfer on 10/11/2021 2. Record review of Resident #32's face sheet showed the following: -admitted to the facility on [DATE]; -discharged to the hospital on [DATE]. Record review of the resident's nurses' progress notes showed the following information: -On 10/12/2021, at 5:53 P.M., staff documented that the resident was noted to be having difficulty maintaining oxygen saturation levels. Physician was notified and an order to send the resident to the emergency room for evaluation and treatment received. Record review of the resident's medical record showed staff did not have a copy of any written notice provided to the resident, resident representative, or Ombudsman regarding the hospital transfer on 10/12/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #80's face sheet included the following: -admission date of 9/22/21; -The resident is not responsible for him/herself; family listed as responsible party. Record review of the resident's nursing progress notes showed the following information: -On 10/13/21, at 10:42 A.M., the Director of Nursing (DON) documented resident was discharged to the hospital on [DATE] at approximately 8:30 P.M. with low blood sugar and shortness of breath; -On 10/20/21, at 12:55 A.M., a charge nurse documented at approximately 6:30 P.M. the resident complained of pain. Staff assessed resident and found edema and Foley catheter (tube placed in bladder to drain urine) leaking with no urine in bag. Staff notified the facility doctor and received new order to send to hospital for evaluation and treatment. Staff notified family of the order. The resident left the facility at approximately 7:00 P.M. via ambulance. Record review of the resident's medical record showed staff did not document a notice of the bed hold policy was given to the resident, or sent to the resident's responsible party, regarding the transfer on 10/13/21 and 10/20/21. During an interview on 10/22/21, at 1:02 P.M., the DON said she was unable to locate the notification of bed hold policy provided to the resident's family for the hospital transfers on 10/12/21 and 10/20/21. 4. During an interview on 10/26/21, at 10:18 A.M., Licensed Practical Nurse (LPN) A said staff send a bed hold notification form with a resident sent to the hospital. Nursing does not notify the family or guardian in writing of the bed hold policy. During an interview on 10/26/21, at 10:27 A.M., the Social Services Director (SSD) said normally the nurses document the bed hold notification was sent in the progress notes. During an interview on 10/26/21, at 10:57 A.M., the DON said, for a hospital transfer, the nurses notify the family of the bed hold policy verbally when they call them on the phone. The nurse also sends a copy of the bed hold with the resident to the hospital. The nurse should notify the family in writing of the bed hold policy, but she could not find documentation of this being done. During an interview on 10/26/21, at 11:45 A.M., the Administrator said he/she wasn't familiar with the bed hold notification requirements. Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of the bed hold policy when transferring three residents (Resident #16, Resident #32, and Resident #80) to the hospital. The facility census was 102. Record review of the facility's bed hold policy, dated 6/26/19, showed procedures for emergency transfer should include: -A copy of resident/guest bed hold and admission policies/ transfer to hospital notice should be provided upon transfer by assigned nurse to resident and/or representative of resident. 1. Record review of Resident #16's face sheet showed the following: -admission date of 12/7/07; -discharged to the hospital on [DATE]. Record review of the resident's nurses' progress notes showed the following information: -On 10/11/21, at 4:33 A.M., staff documented the aide reported the resident was having black liquid stools. Staff notified physician and received verbal order to send the resident to the emergency room for evaluation. Record review of the resident's medical record showed staff did not document a notice of the bed hold policy was given to the resident or sent to the resident's responsible party regarding the transfer on 10/11/21. 2. Record review of Resident #32's face sheet showed the following: -admitted to the facility on [DATE]; -discharged to the hospital on [DATE]. Record review of the resident's nurses' progress notes showed the following information: -On 10/12/21, at 5:53 P.M., staff documented the resident was noted to be having difficulty maintaining oxygen saturation levels. Staff notified physician and an order to send the resident to the emergency room for evaluation and treatment received. Record review of the resident's medical record showed staff did not document a notice of the bed hold policy was given to the resident or sent to the resident's responsible party regarding the transfer on 10/12/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #36's face sheet showed the following: -admission date of 8/17/21 -Diagnoses include fracture of unspecified part of neck of femur, type 2 diabetes mellitus (a form of diabetes characterized by high blood sugar, insulin resistance, and relative lack of insulin, a hormone normally produced in the pancreas that regulates the body's blood sugar) with skin ulcer, osteomyelitis (bone infection) of verebrae, lumbosacral (lower back) region, and chronic kidney disease stage 5 (near kidney failure). -The resident is responsible for him/herself. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Extensive assistance/two person physical assist for bed mobility, transfers, and toilet use; -Extensive assistance/one person physical assist for locomotion on and off the unit, and dressing. Record review of the resident's care plan, dated 9/30/2021, showed the following information: -The resident has potential for falls related to hip fracture, with intervention of observe the need for additional assistive devices/positioning devices, and assist with ambulation, toileting, and mobility as needed; -The resident required assistance to complete daily activities of care safely related to hip fracture, with interventions to transfer with one staff, and observe for changes in ability to perform care. (Staff did not care plan side rails used.) Record review of the resident's September 2021 (POS) showed no order or documentation for half side rails. Record review of the resident's EMR and paper medical chart showed staff did not document completion of identification and use of possible alternatives prior to use of side rails, receiving a physician's order for the side rails, assessing risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, or ongoing assessments to ensure the side rails were appropriate for use. Observation on 10/19/21, at 10:40 A.M., showed the resident's bed with two half size side rails (one on each side) in the up position. During an interview on 10/19/21, at 10:41 A.M., the resident said he/she needed the half side rails. Staff did not assess him/her for the two half side rails. He/she did not sign a consent form for them. Staff did not discuss risks versus benefits of the side rails with him/her. During an interview on 10/22/21, at 1:50 P.M., the Director of Nursing (DON) said he/she could not find an assessment, gap measurements, a consent form, or monitoring documentation for the resident's side rails. 4. During an interview on 10/22/2021, at 10:34 A.M., the Maintenance Director said he/she installs side rails. Nursing does the gap measurements and the DON documents this. Nursing assesses the resident for the side rails and gets consent. Nursing tells the Maintenance Director where to install them and he/she installs them. During an interview on 10/22/2021, at 12:00 P.M., Licensed Practical Nurse (LPN) K said nursing can do the assessment to determine the resident's need for side rails. If nursing feels the resident needs a siderail then nursing tells therapy, and then therapy takes over. Staff document the resident's need for a side rail and the assessment of the need for a side rail in the computer progress notes, but he/she has never had to do an assessment or any documentation for side rails. He/she does not know about the forms that document a resident's consent for the side rails or gap measurement. During an interview on 10/22/2021, at 12:20 P.M., the DON said there have been no new side rails since he/she started at the facility. On admission the charge nurse does the assessment for the side rail to determine if the resident needs a side rail, the risk versus benefits education, and goes over alternatives that have been tried. The facility has an assessment, particularly for side rails. The nurse has the resident sign for consent for the side rails, and then the Maintenance Director does gap measurements and installs them. During an interview on 10/26/2021, at 9:26 A.M., the Therapy Director said therapy makes recommendations for side rails. Nursing does assessments and gets the order for the side rails as well as the resident's consent. Maintenance Director does the installation and gap measurements. Nursing informs therapy if someone is getting a side rail so therapy is aware. Based on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to get a physician's order for the use of side rails; and/or failed to complete ongoing assessments to ensure the side rails are appropriate for use for three residents (Resident #20, #36, and #40). The facility's census was 102. Record review of the facility's Bedrail Use Policy, dated 1/1/2019, showed the following information: -Bedrails may be used to help a resident/guest position or turn him/herself. Provide instructions to the resident/guest as needed. The interdisciplinary team should determine if the clinical benefits outweigh the risk of device/bedrail; -Possible hazards and clinical benefits of the bedrail use should be explained to the resident/guest and to his/her family/legal representative, during the admission process and upon initial implementation; -Continued use of bedrails requires documentation of the presence of a medical symptom, which would necessitate the use of bedrails, or that the bedrails assist the resident/guest with mobility and transfer abilities and that clinical benefits still outweigh the risks of use; -Complete the Enabler/Assistive Device/Side Rail Review upon admission/readmission, upon initially implementing side rail, with a significant change, and with OBRA (Omnibus Budget Reconciliation Act (OBRA), also known as the Nursing Home Reform Act of 1987) assessments. Side rails should be addressed in the care plan; -This review includes evaluations for entrapment risk which should also be completed when mattress or bed type are changed; -The resident/guest and the resident/guest representative should give informed consent to the use of the device, prior to its use. 1. Record review of Resident #20's face sheet showed the following: -admission date of 3/6/2019; -Diagnoses included hemiplegia (complete loss of strength or paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), seizures (which nerve cell activity in the brain is disturbed, causing abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness), and post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record review of the resident's care plan, dated 3/6/19, showed the following information: -Required side rail enabler to promote independence, self-bed mobility, and transfer assistance; -Observe for change in ability to release enabler on command; -Review need for enabler quarterly as needed; -Therapy consult as needed. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/27/21, showed the following information: -Mild cognitive impairment; -Required limited assistance from one staff for bed mobility and transfers; -Required use of electric wheelchair for mobility. Record review of the resident's October 2021 physician order sheet (POS), showed staff did not document any order pertaining to bed rails. Record review of the resident's electronic medical record (EMR) and paper medical chart showed staff did not document completion of an evaluation, risk assessment, informed consent, gap measurement, or intermittent monitoring of side rails. Observation and interview on 10/19/2021, at 12:20 P.M., showed one quarter size side rail on the left side of the resident's bed in the up position. The resident was in his/her bed and said he/she uses the side rail to reposition. He/she did not remember any assessment or forms required to be signed for the side rail. 2. Record review of Resident #40's face sheet showed the following: -admission date of 11/24/2020; -readmission date of 5/25/2021; -Diagnoses included acute cystitis (inflammation of the lining of the bladder) with hematuria (blood in urine), multiple sclerosis (disease in which the immune system eats away at the protective covering of nerve), and chronic migraine (defined as having at least 15 headache days a month, with at least 8 days of having headaches with migraine features, for more than 3 months). Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Mild cognitive impairment; -Extensive assistance required for bed mobility, transfers, dressing, and toilet use; -Indwelling catheter (a sterile tube used to drain urine). Record review of the resident's care plan, dated 9/14/21, showed the following: -Required side rail use as enabler related to bed mobility assistance; -Observe for proper functioning; -Observe for and report immediately in need of repair; -Observe residents freedom of movement; -Pad side rails as needed; -Bed in lowest position with wheels locked; -Encourage resident movement while in bed; -Observe mattress for appropriate size for bed; -Observe for appropriate lateral and vertical space of rails. Record review of the resident's record showed the following information: -Enabler/assistive device/side rail review, dated 12/16/2020; -Type of side rail recommended was quarter size rails to help with bed mobility; -The plan of care had been updated accordingly. Record review of the resident's October 2021 POS showed an order, dated 5/26/2021, for resident to have enablers for bed mobility. Record review of the resident's EMR and paper medical chart showed staff did not document completion of informed consent, gap measurements, or intermittent monitoring of bed side rail use. During interview and observation on 10/19/21, at 2:03 P.M., showed the resident's bed had bilateral (both sides of the bed) half size side rails on the bed in the upright position. The resident said that he/she does not have the use of his/her legs and this helps him/her reposition. He/she does not remember signing or receiving any information of risks or benefits of side rails.

Based on interview and record review, the facility failed to ensure all nurses had appropriate competencies when the facility failed to verify two out of three sampled nurses had a valid license to work in the state of Missouri prior to hire. The facility census was 102. 1. Record review of Licensed Practical Nurse (LPN) CC's personnel records showed the following: -Hire/start date of 9/07/2021; -The facility did not document verifying LPN CC had a valid Missouri nurse's license until 10/22/2021 (45 days after the LPN's hire/start date). 2. Record review of LPN DD's personnel records showed the following -Hire/start date of 9/16/2021; -The facility did not document verifying LPN DD had a valid Missouri nurse's license until 10/22/2021 (36 days after the LPN's hire/start date). 3. During an interview on 10/26/2021, at 9:18 A.M., Financial Specialist Assistant EE said the license verification checks for the two LPNs did not print when he/she checked their license prior to hire. During an interview on 10/26/2021, at 11:00 A.M., the Administrator said nurses' licenses should be verified prior to hire to ensure they have a valid license for the state of Missouri.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review of Resident #47's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required total dependence on staff for all activities of daily living, including personal hygiene, transfers, bed mobility, eating. Observation on 10/21/21, at 3:50 P.M., showed the following: -CNA G and NA F entered the resident room with the Hoyer lift (assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power); -The staff put on gloves without using hand sanitizer or washing his/her hands; -NA F and CNA G provided incontinent care to the resident; unhooked the resident's wet incontinent brief and pulled the brief open. The NA and CNA did not perform hand hygiene; -NA F placed a clean brief and the Hoyer lift pad in place; -The aides rolled the resident to his/her side and pulled the brief and Hoyer pad into place and rolled the resident to his/her back; -Staff taped the new incontinent brief into place; -Without removing gloves and/or completing hand hygiene, the staff moved the Hoyer lift to the bed and attached the Hoyer pad to the lift hooks; -The staff moved the resident to the Broda chair (a specialized type of wheelchair that assists in positioning and helps resolve seating issues such as slumping, sliding, poor lateral support and falls) and unhooked the Hoyer pad from the lift hooks; -The staff picked up a sheet and placed the sheet on the resident's legs; -With the same gloved hands and without washing hands or using hand sanitizer, the staff moved the Broda chair and the Hoyer lift over to the resident's roommate (Resident #71); -Staff did not clean the Hoyer lift before moving it to transfer the roommate. 6. Record review of the Resident #71's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Totally dependent on staff for activities of daily living; -Two person assist to complete activities of daily living such as bathing, grooming, repositioning, transfers; -One person assist for eating; -Indwelling catheter (a sterile tube inserted into the bladder to drain urine). Observation on 10/21/2021, at 4:00 P.M., showed the following: -CNA G and NA F completed cares with the resident's roommate and moved the Hoyer lift over to the resident's bed; -The staff did not change gloves or wash hands after changing the roommate's incontinent brief and moving the resident to the Broda chair by use of the Hoyer lift; -Staff rolled the resident to his/her side to put the Hoyer pad under his/her back; -NA F checked the resident's incontinent brief for soiling with the same gloved hands; -Staff rolled the resident to his/her right side and pulled the Hoyer pad into position; -The staff moved the Hoyer lift into position and hooked the straps to the lift; -The staff moved the resident in to the wheelchair and removed the Hoyer pad from the hooks; -The staff straightened the resident's hair with the same gloved hands, picked up the sheet, covered the resident's legs, and picked up the trash from the room; -Staff pushed the Hoyer lift out of the room, wearing the same gloves; -CNA G and NA F removed gloves in the hallway and pushed the Hoyer lift into another resident's room. Neither staff completed hand hygiene by washing their hands with soap and water or by using hand sanitizer; -Staff did not clean the Hoyer lift before moving to the next resident's room. 7. During an interview on 10/21/2021, at 4:35 P.M., CNA G and NA F they said they try to get hand hygiene done between residents, but sometime get too busy and forget. When they were working with residents in the same room, they try to wash hands between residents, but sometimes are too busy and do not get that done. During an interview on 10/26/2021, at 10:45 A.M., LPN A said staff should wash hands or use hand sanitizer before and after working with a resident, and before and after wearing gloves. During an interview on 10/26/2021, at 1:20 P.M., the DON said staff should complete hand hygiene all the time, before and after resident cares, before and after wearing gloves, when visibly soiled, and any dirty and clean task, such as resident incontinent cares or wound cares. During an interview on 10/27/21, at 8:56 A.M., the Administrator said he expects staff to do hand hygiene before performing incontinent care, and again before touching the resident if the staff member had to stop to get supplies. He expects staff to perform hand hygiene between a contaminated body surface and a clean body surface and at the end of the process. He expects staff to clean equipment between each room. Based on observation, record review, and interview, the facility failed to maintain an infection control program that provided a safe and sanitary environment for all residents during a Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) pandemic when staff failed to wear personal protective equipment (PPE) facemasks appropriately around multiple residents; failed to use appropriate hand hygiene after performing incontinent care for four residents (Resident #21,Resident #47, Resident #71, and Resident #79); and failed to clean equipment used by multiple residents between uses. The facility census was 102. Record review of the Centers for Disease Control and Prevention (CDC) Covid Data Tracker showed the facility's county's transmission rate of substantial from 10/18/2021 through 10/28/2021. 1. Record review of the facility's policy titled Response Phase Protocol for COVID-19, dated 3/13/2020, showed the following: -The facility would use the most current CDC and U.S. Centers for Medicare and Medicaid Services (CMS) guidelines regarding appropriate PPE usage in the facility; -Staff should use the buddy system to ensure PPE is put on and removed safely. Record review of the updated guidance for healthcare workers from the CDC titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the COVID-19 Pandemic, updated on 09/10/21, showed the following: Implement Source Control Measures -Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. -Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission. Record review of the CDC guidance for Healthcare Workers, titled Facemask Do's and Don'ts, dated 06/02/20, showed the following: -Do secure the bands around the ears; -Do secure the straps at the middle of the head and the base of the head; -Don't wear the facemask under the nose or mouth; -Don't wear the facemask around the neck. Observations on 10/19/2021 showed the following: -At 8:12 A.M., Certified Nurse Aide (CNA) H in the dining room passing trays to the residents with his/her mask below his/her nose. There were 18 unmasked residents in the vicinity; -At 8:47 A.M., CNA D braided a resident's hair in the hallway. The aide's face mask only covered his/her mouth and did not cover his/her nose; -At 10:16 A.M., Licensed Practical Nurse (LPN) N entered Resident #71's room to administer oral liquid pain medication. The LPN's face mask only covered his/her mouth. It did not cover his/her nose. The resident was in his/her wheelchair in his/her room and did not have a face mask on; -At 12:39 P.M., Laundry Staff V walked down the 600 hall with his/her mask below his/her nose. He/she walked into room [ROOM NUMBER], dropped off a bag of laundry, and walked back up the hallway with the mask still down. Resident #42 was in the hallway, unmasked, when the laundry staff returned up the hallway; -At 2:18 P.M., CNA P entered a resident room with his/her face mask only covering his/her mouth. The staff assisted the unmasked resident to the bathroom; -At 2:39 P.M., NA O entered a resident room with his/her mask only covering his/her mouth, to speak with the unmasked resident; -At 2:43 P.M., CNA P pushed an ice chest on a cart to resident room doors in the 300 hall with his/her mask just below his/her nose, taking ice into resident rooms; -At 4:31 P.M., NA P entered Resident #32's room with face mask only covering his/her mouth. The resident was on his/her bed unmasked. The staff was assisting the resident to inventory his/her belongings for discharge. Observations on 10/20/21 showed the following: -At 9:34 A.M., Registered Nurse (RN) seated at the nurses' desk with his/her face mask covering his/her mouth. The mask did not cover his/her nose. There were several residents moving around the area; -At 11:11 A.M., RN C at the nurse medication cart with his/her face mask below his/her nose. One unmasked resident in a wheelchair was in the area. Observations on 10/21/2021 showed the following: -At 3:37 P.M., CNA G entered a resident room with his/her face mask covering his/her mouth. The mask did not cover his/her nose; -At 3:41 P.M., CNA G and NA F entered a resident room. CNA G's face mask did not cover his/her nose. Staff assisted a resident to reposition in the wheelchair. Observations on 10/22/2021 showed the following: -Between 10:33 A.M. and 10:51 A.M., eight staff members walked past a group of residents in the common area. Facility staff members failed to remind the residents to wear masks appropriately, covering the mouth and nose, or to socially distance from others. Observations on 10/25/2021 showed the following: -At 10:24 A.M., RN C at the nurse desk with his/her face mask below his/her nose, with several residents moving about the area; -At 4:15 P.M., RN C at the medication cart with his/her face mask below his/her nose. The nurse turned around to sneeze with the face mask below his/her nose. The nurse did not change his/her mask. A resident was within the vicinity asking for pain medications. During an interview on 10/19/2021, at 4:39 P.M., NA O said he/she had not had any education regarding how to appropriately wear the face mask. He/she did try to keep it above his/her nose, but it often slipped down below the nose. During an interview on 10/26/2021, at 10:45 A.M., LPN A said staff should ensure their face mask covers their mouth and nose while at work in the facility. During an interview on 10/26/2021, at 1:20 P.M., the DON said staff should be appropriately wearing face masks above their nose and mouth, and it should fit appropriately. It staff had difficulty keeping the mask on their mouth and nose there were different options such as KN95 and N95 (respirator masks). During an interview on 10/27/21, at 9:08 A.M., the Administrator said staff should wear their masks appropriately over their mouth and nose. He/she was not aware of any staff that were not able to keep their mask over their mouth and nose properly. 2. Record review of the CDC guidance for Healthcare Providers titled Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, showed the following: -Hand hygiene means cleaning hands by using either handwashing, antiseptic hand wash, antiseptic hand rub (alcohol based hand sanitizer), or surgical hand antisepsis (the practice of using antiseptics to eliminate the microorganisms that cause disease); -Hand hygiene should be performed immediately before touching a patient; -Hand hygiene should be performed before moving from work on a soiled body site to a clean body site on the same patient; -Hand hygiene should be performed before applying gloves; -Hand hygiene should be performed after touching a patient or the patient's immediate environment; -Hand hygiene should be performed immediately after glove removal. Record review of the facility policy titled Infection Prevention & Control Manual, dated 9/2017, did not address hand hygiene of facility staff. Record review of the facility policy, titled Perineal Care, dated 10/1/2010, did not address hand hygiene. No cleaning/disinfection of Hoyer/multiple resident use items policy was provided. Record review of Resident #79's current care plan showed the following: -An intervention, dated 9/15/2021, for staff to perform incontinence care after each episode of incontinence. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Incontinent of bladder and bowel. Observation on 10/22/2021 showed the following: -At 9:30 A.M., CNA U and NA S entered the resident's room to perform incontinence care. Both aides performed hand hygiene and applied gloves. The aides performed incontinence care on the resident. Neither staff member performed hand hygiene after completing the care. CNA U touched the resident's pillows and linens. NA S touched the resident's wipe packet. Both staff members positioned the resident up in bed using the draw sheet. CNA U washed his/her hands before exiting the room. NA S did not perform hand hygiene before exiting the room or in the hallway. During an interview on 10/22/21, on 9:50 A.M., CNA U said staff should perform hand hygiene before starting resident care, before going from a dirty area of the body to a clean area of the body, and after finishing the care. 3. Record review of Resident #21's current care plan showed the following: -An intervention, dated 5/26/2021, which showed the resident had incontinent episodes of bladder; -An intervention, dated 5/26/2021, for staff to perform incontinence care after each episode of incontinence. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately cognitively impaired; -Frequently incontinent of urine and always continent of bowel. Observation on 10/26/2021 showed the following: -At 9:41 A.M., CNA H entered the resident's room to perform incontinent care. He/she performed hand hygiene and put on gloves. The aide removed his/her gloves, and started looking for a straw in the nightstand next to the bed. The aide put on new gloves without performing hand hygiene. The aide removed the resident's wet brief and performed incontinent care. The aide removed his/her gloves and did not perform hand hygiene. He/she pulled the resident's gown down, moved the wipe packet to the night stand drawer, took a wet wash cloth and washed the resident's eyes. The aide covered the resident with a blanket, raised the head of the bed with the controller, moved the bedside table within the resident's reach, and then performed hand hygiene. During an interview on 10/26/21 at 9:54 A.M., CNA H said he/she performs hand hygiene before entering a room to perform care and after the care is done. 4. During an interview on 10/26/2021, at 12:15 P.M., RN C said staff should perform hand hygiene and apply gloves before beginning incontinent care. After finishing the care, staff should remove gloves and perform hand hygiene again. During an interview on 10/26/2021, at 12:23 P.M., LPN K said when performing incontinent care, staff should perform hand hygiene and apply gloves before touching soiled items, de-glove, perform hand hygiene, apply new gloves, then apply the clean clothing. When staff is finished applying the clean garments, staff should remove gloves and perform hand hygiene. During an interview on 10/27/2021, at 8:26 A.M., the DON said when staff is doing incontinent care, she expects them to perform hand hygiene prior to resident contact and after completing the task.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public by failing to keep the facility grounds free of trash and debris and by failing to keep light fixtures in the kitchen area clean. The facility census of was 102. 1. Observations around the exterior of the facility on 10/19/21, starting at 10:55 A.M., showed the following: -Outside the kitchen exit there were six milk crates placed in several areas, some turned on their side. In the same are there were numerous cigarette butts on the ground (pavement and in grassy areas) and a bulk-storage container with 24 red and yellow onions without a lid. Some of the onions had large sections that were discolored (green, black. and white); -Outside the kitchen exit, there was an insulated food cart with what appeared to be murky rainwater pooled on top, three grease and water-filled cooking pans sitting on the ground, and numerous pieces of paper and plastic trash items; -Just outside the exit of the dining room (on the 400 hall-side), there were used Styrofoam cups and plates along with discarded food and similar garbage. This trash and garbage could be seen from a person standing inside the dining room, close to the exit door. During an interview on 10/26/21, at 2:27 P.M., Resident #11 said he/she takes a plastic bag when he/she goes to smoke. The resident and several other residents pick up the trash on the ground. During an interview on 10/26/21, at 2:33 P.M., Resident #35 said this morning there was a hamburger fast food McDonald's sack outside the front door in the grass. He/she has also seen a mask on the grounds out the front door. During an interview on 10/19/21, at 3:31 P.M., the Maintenance Director said facility the floor tech and housekeeping was also in charge of keeping things clean and picking up other areas of facility grounds. He does not make any regular trips to pick up any items outside the building. During an interview on 10/26/21, at 2:53 P.M., the Housekeeping/Laundry supervisor on 10/26/21 at 2:53 P.M., said there is sometimes more trash around the back of the building because staff sometimes miss the trash cans. As far as larger items (like the bulk-storage onions, cooking pans, and food cart, etc.), as well as food items, it is the responsibility of the dietary department to clean up. During an interview on 10/26/21, at 3:13 P.M., the Dietary Manager said it was the responsibility of dietary/kitchen staff to help keep clean the area outside the kitchen exit. However, there is no checklist or other means of keeping track of the cleanup. The area is not checked by dietary staff on a routine basis, but staff just keep an eye out for when the grounds need to be picked up. As far as the area outside the dining room exit, the manager said it's not an area dietary staff would use, and so it's not dietary staff responsibility to clean it up. She thought maintenance was in charge of picking up facility grounds. During an interview on 10/19/21, beginning at 5:20 P.M., the Administrator said he was unaware of any problems with trash or other items being left out on facility grounds. He said the facility grounds should be kept neat and clean from trash and other debris. 2. Observation on 10/18/21, beginning at 10:28 A.M., showed the following: -A fluorescent light fixture in the kitchen near the stove had a dead moth and numerous dead bugs that looked like gnats; -A fluorescent light fixture in the kitchen near a shelf where pots and pans are stored had a broken fluorescent light fixture cover; -A fluorescent light fixture near the back entrance to the kitchen had dead bugs in the fluorescent light fixture cover. There were too many dead bugs to count. Observation on 10/21/2021, beginning at 11:21 P.M., showed the following: -The fluorescent light near the stove remained dirty with dead bugs; -The fluorescent light fixture cover in the kitchen near shelf where pots and pans were stored remained broken; -The fluorescent light fixture cover near the back entrance to the kitchen remained dirty with dead bugs. During an interview on 10/21/2021, at 1:16 P.M., Dietary Staff L said if the fluorescent light fixtures in the kitchen need to be cleaned or repaired dietary staff should report this to maintenance so he can clean them. During an interview on 10/21/2021, at 1:42 P.M., the Dietary Manager said if a fluorescent light fixture cover in the kitchen is broken, missing, or dirty staff should report this to maintenance so he can clean, repair, or replace the light fixture covers.

Based on record review, observation and interview, the facility failed to store and prepare food in accordance with professional standards of practice and protect from possible contamination when staff did not follow proper hand hygiene, skillets had non-stick coating peeling from the inside surface, frozen food was allowed to be kept thawed, wire storage shelves where dishes were stored were fuzzy with lint, dented cans were not placed in designated area in the dry pantry, and the ice machine did not have the required air gap to prevent backflow into the ice. The facility census was 102. 1. Record review of the Missouri Food Code for the Food Establishments of the State of Missouri, dated June 3, 2013, showed the following: -Food contact surfaces of equipment may not allow the deleterious (harmful) substances and finished to have a smooth, easily cleanable surface and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Record review showed the facility did not provide a policy relate to cleanliness of food contact surfaces. Observation on 10/18/2021, beginning at 10:28 A.M., of the kitchen showed two large skillets and one small skillet used to prepare resident food had non-stick coating that was scratched and peeling off the inside surface of the skillets. Observation on 10/21/2021, beginning at 10:14 A.M., of the kitchen showed the three skillets with the non-stick coating peeling from the inside surface remained on the shelf with the pots and pans. During an interview on 10/21/2021, at 1:16 P.M., Dietary Staff L said skillets or pots and pans that have non-stick coating peeling or coming off should not be used. He/she said the facility was supposed to replace these. During an interview on 10/21/2021, at 1:29 P.M., Dietary Staff FF said kitchen staff should not use skillets or pots and pans that have the non-stick coating peeling from the interior surface. During an interview on 10/21/2021, at 1:42 P.M., Dietary Manager said skillets or pots and pans that have non-stick coating peeling and coming up should not be used. The facility planned to replace the skillets. 2. Record review of the Missouri Food Code for the Food Establishments of the State of Missouri, dated 6/3/2012, showed the following: -Stored frozen food shall be maintained frozen. Record review showed the facility did not provide a policy related to frozen foods Observation on 10/18/2021, beginning at 10:14 A.M., showed two upright refrigerators in a room between the kitchen and dry pantry area. In the upright refrigerators there was a box of magic cups (with instructions to remain frozen) thawed to the point they were soft and mushy. In the second upright refrigerator in the room between the kitchen and dry pantry was a large bag of shredded hash browns that was completely thawed. The upright refrigerators had a temperature of 36 degrees Fahreinheit (F). During an interview on 10/18/2021, at approximately 10:30 A.M., the Dietary Manager said staff thaw the magic cups and hash browns so the magic cups are easier to dish out and serve to residents and the hash browns for the hash browns casserole are thawed to make it easier to mix. The Dietary Manager said both the magic cups and hash browns should have not been thawed completely. During an interview on 10/20/2021, at 2:02 P.M., Dietary Staff L said staff thaw magic cups slightly so it is easier to dish up and feed to residents. The hash browns are thawed to make it easier to mix up the hash brown casserole. During an interview on 10/20/2021, at 2:09 P.M., Dietary Staff M said he/she thawed magic cups to make it easier for staff to dish up and feed to residents. He/she said hash browns are thawed to make it easier to mix up the hash brown casserole. 3. Record review of the Missouri Food Code for the Food Establishments of the State of Missouri, dated June 3, 2013, showed the following: -Backflow, prevention, air gap-an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. Record review showed the facility did not provide a policy relate to an air gap. Observation 10/18/2021, beginning at 10:14 A.M., showed an ice machine located in the resident dining room beside the door to the kitchen showed a drain behind the ice machine. Inside the drain was a white hose which was connected to the ice machine. There was not a two inch air gap between the drain and the hose from the ice machine. If the drain were to back-up into the hose, the contaminated contents from the drain could fill up and enter the ice machine which would contaminate the ice. Observation on 10/20/2021, at approximately 9:49 A.M., showed the hose for the ice machine was inside the drain remained without a two inch air gap. During an interview on 10/20/2021, at 2:02 P.M., Dietary Staff L said he/she did not know the ice machine had to have a two inch air gap between the hose and the drain. This would be maintenance staff responsibility. During an interview on 10/20/2021, at 2:09 P.M., Dietary Staff M said he/she did not realize the ice machine required a two inch air gap between the hose and the drain. This would be maintenance responsibility. During an interview on 10/21/2021, at 1:42 P.M., the Dietary Manager said he/she did not realize the ice machine required a two inch air gap between the drain and the hose for the ice machine. This would be maintenance responsibility. During an interview on 10/21/2021, at 1:49 P.M., the Maintenance Director said he/she did not realize the ice machine required an two inch air gap between the hose and drain for the ice machine. 4. Record review showed the facility did not provide a policy relate to storage. Observation 10/18/2021, beginning at 10:14 A.M., of a metal shelf in the room between the kitchen and dry pantry was a metal wire shelving unit. On the shelving unit plasticware such as pitchers and containers to store or prepare food were inverted and the interior surface touched the shelving unit surface. The metal wire shelving unit had a build up of fuzzy lint where the the plasticware was stored. The interior surface of the plasticware had the potential to be contaminated by the fuzzy surface of the metal shelves. During an interview on 10/21/2021, at 1:16 P.M., Dietary Staff L said all staff who worked in the kitchen were responsible for cleaning shelves weekly. He/she did not realize the wire shelf had fuzzy lint on the surface that could contaminate food. During an interview on 10/21/2021, at 1:29 P.M., Dietary Staff FF said all dietary staff were responsible for cleaning the shelves in the kitchen area. The staff have a cleaning schedule they sign off on and the dietary manager reviewed this. During an interview on 10/21/2021, at 1:42 P.M., the Dietary Manager said all staff were responsible for cleaning in the kitchen weekly and shelves should be cleaned at that time. He/she said he/she had been out last week in a training and did not realize the wire shelving unit needed to be cleaned. 5. Record review of the Missouri Food Code for the Food Establishments of the State of Missouri, dated June 3, 2013, showed the following: -Food employees shall keep their hands and exposed portions of their arms clean. The food service employee shall wash his/her hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and after engaging in other activities that can contaminate hands. Record review showed the facility did not provide a policy relate hand hygiene in the kitchen. Observation on 10/21/2021, at 11:21 A.M., showed the following: -Dietary Staff L took temperatures on the steam table; -Dietary Staff L went to throw away the sanitizer pads and empty packets; -He/she touched the trash can lid and did not wash his/her hands; -Dietary Staff L then wiped his/her hands on a towel and then put on pot holders and removed pans of potato wedges from the oven; -He/she then tested the temperature of the potato wedges; -Dietary Staff L did not wash hands prior to putting on the pot holders after touching the trash can lid or prior to testing temperatures of food on the steam table. During an interview on 10/21/2021, at 1:16 P.M., Dietary Staff L said if a staff person touched a trash can lid he/she should wash his/her hands before touching anything else. During an interview on 10/21/2021, at 1:29 P.M., Dietary Staff FF said if a staff person touched a trash can lid the staff person should wash his/her hands before touching anything else. During an interview on 10/21/2021, at 1:42 P.M., the Dietary Manager said if a staff person touched a trash can lid the staff person should wash his/her hands prior to touching anything else. 6. Record review of the Missouri Food Code for the Food Establishments of the State of Missouri, dated June 3, 2013, showed the following: -Food shall be safe and unadulterated. Adultered means a food has been produced, prepared, packaged, or held under unsanitary conditions whereby it may have been contaminated with filth or whereby it may have been rendered diseased, unwholesome, or injurious to health. Record review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: - Food packages should be in good condition and protect the integrity of the contents so the food is not exposed to potential contamination. - Food held for credit, such as damaged products, should be segregated and held in an area separate from other food storage. - Food packages that are damaged, spoiled or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods and should be kept in separate and segregated areas. - Damaged packaging may allow the entry of bacteria or other contaminants into the contained food. Record review showed the facility did not provide a policy relate to dented cans. Observation on 10/18/2021, beginning at 10:28 A.M., showed the dry pantry area where food was stored for resident meals. In the dry pantry were two metal shelves where canned goods were stored. The cans laid on their sides in a row. One row had cans of tropical fruit stored. There were approximately five cans on the row where the tropical fruit was stored. Two of the cans of tropical fruit had dents along the top edges where staff would have to open the cans. Next to the metal shelves in the pantry where the cans of food were served was a designated area for dented cans with a sign that said dented cans. Observation on 10/21/2021, beginning at 11:21 A.M., showed the dry pantry area where food was stored for resident meals on metal shelves. The canned food was stored on it's side. In one row was tropical fruit. Two cans of the tropical fruit had dented edges along the top of the cans where staff would have to open the cans During an interview on 10/21/2021, at 1:42 P.M., the Dietary Manager said dented cans should not be used and removed from the shelf and placed in the designated dented can area. He/she said dented cans should be sent back to the food supplier.

5. Record review of Resident #93's nurses' notes showed the following information: -On 2/6/19, at 6:23 P.M., the resident's blood pressure was 188/100, oxygen saturation 86% with 3 liters of oxygen administered by nasal cannula (a device used to deliver supplemental oxygen). As needed (PRN) medications provided to bring both conditions to normal levels. After the medications, the resident's blood pressure reduced to 172/98 and the resident's oxygen saturation level read at 85% with 3 liters of oxygen administered by nasal cannula. The nurse notified the physician and received an order to send the resident to the emergency room for evaluation and treatment. Staff did not document any verbal or written notification to the resident or resident representative about the transfer. -On 2/12/19, at 4:40 P.M., the resident returned to the facility. Record review of the resident's medical record did not show any letter sent to the resident or resident's responsible party regarding the transfer to the hospital on 2/6/19 or any phone call notification to the family regarding the transfer. During an interview on 3/14/19, at 1:53 P.M., RN D said he/she called the resident's representative at the time of transfer to the hospital. Any resident transferred to the hospital are sent with two face sheets (a document showing the resident's basic information), bed hold guidelines and discharge/medical status summary. 6. During an interview on 03/18/19, at 12:14 P.M., Licensed Practical Nurse (LPN) G said staff obtain a physician order to send a resident out. Staff notify the resident's family or responsible party of where and why the resident is being sent out of the facility. They call for emergency medical services and the hospital or receiving facility to give report. LPN staff call the RN to get clearance to send the resident out. Staff send a bed hold policy form with the resident. No written notification is sent to the family or responsible party, just a phone call. 7. During an interview on 3/14/19, at 8:25 A.M., the social service designee (SSD) A said he/she thought the facility provided written notification to the family and ombudsman following an emergency discharge to the hospital. The administrator took care of this. 8. During an interview on 3/14/19, at 8:34 A.M., the business office manager B said he/she was responsible for sending the ombudsman written notification of the residents who had an emergency discharge to the hospital. He/she did not do written notices to the family and thought the administrator took care of this. The business office manager provided January and February 2019 notifications to the ombudsman. He/she would have to look for reports for the ombudsman notification prior to January 2019. 9. During an interview on 3/14/19, at 8:47 A.M., the administrator said the facility had not been sending written notification to the residents and/or their representatives of resident's emergency transfers to the hospital. He said the facility had just found out about this requirement approximately three weeks ago. The facility had been sending a report each month to the ombudsman of the residents who had been sent to the hospital and the business office manager takes care of this. 10. During an interview on 3/14/19, at 9:33 A.M., the administrator said the business office manager could not find the reports he/she sent to the ombudsman prior to January 2019. Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer for five residents (Resident #21, #49, #58, #81, and #93), and failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for three residents (Resident #21, #58, and #81). A sample of 20 residents was selected for review out of a facility with a census of 98. Record review of the facility's policy titled, Transfer and Discharge, from the Nursing Management Manual, dated 11/28/16, showed the following information: -Transfer means the moving of a resident/guest from the facility to another legally responsible institutional setting; -Discharge means the moving of a resident/guest to a non-institutional setting when the releasing facility ceases to be responsible for the resident/guest's care; -The resident/guest has the right to refuse involuntary transfer out of or discharge from the facility under certain circumstances; -According to federal regulations, the facility must permit each resident/guest to remain in the facility, and not transfer or discharge the resident from the facility unless: 1) The transfer or discharge is necessary for the resident/guest's welfare and the resident/guest needs cannot be met in the facility; 2) The transfer or discharge is appropriate because the resident/guest's health has improved sufficiently so the resident/guest no longer needs the service provided by the facility; 3) The safety of individuals in the facility is endangered; 4) The health of individuals in the facility is endangered; 5) The resident/guest has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility; -Emergency Transfers/Discharges should only occur for medical reasons, or for the immediate safety and welfare of a resident/guest, or other residents/guest; -Emergency transfer procedures should include the following: a) Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on a emergency basis; b) Contact an ambulance service and provide hospital, or facility, of resident/guest's choice, when possible, for transportation and admission arrangements; c) Complete and send with the resident/guest a Transfer Form which documents current diagnosis, reasons for transfer/discharge, date, time, physician, current medications, treatments, functional status, any special care needs, and care plan goals; d) A copy of any advance directive, Durable Power of Attorney, Do Not Resuscitate (DNR) or Withholding or Withdrawing of Life-Sustaining Treatment forms should be sent with the resident/guest; e) The original copies of the transfer form and advance directives accompany the resident/guest; f) Document information regarding the transfer, in the medical record; -Discharge documentation should include the physician's order for discharge and post discharge care. The nurses' notes should reflect the condition of the resident/guest on discharge, the discharge date , time, place discharged to, mode of transportation, person accompanying the resident/guest and any other pertinent data; -The transfer/discharge policy failed to address a written notification must be sent to the resident and/or legal representative and failed to address a written notification must be given to the ombudsman when a resident has an emergency discharge from the facility. 1. Record review of Resident #21's nurses' notes showed the following information: -On 11/15/18, at 7:30 P.M., the resident complained of not feeling well with a temperature of 99.4. The nurse administered 650 mg Acetaminophen. Staff notified the charge nurse at 9:30 P.M., that the resident said the Acetaminophen did not help and he/she had a temperature of 103.1. The resident complained he/she had the shakes and shivers and complained of nausea. The nurse administered 400 mg Ibuprofen. The nurse reassessed the resident's temperature and the resident had a temperature of 103.5. The nurse applied ice packs to the resident's groin and axial (central part of the body) and reassessed the resident's temperature which read 103.1. The staff continued to monitor the resident's temperature and at 10:30 P.M., his/her temperature was 102.7. At 10:45 P.M., the resident's temperature was 103.3, and at 11:00 P.M., his/her temperature was 102.7. The nurse instructed the CNAs to monitor the resident's temperature every 15 minutes and to report the results to the nurse; -On 11/16/18, at 12:42 A.M., the resident had a temperature of 103.4. The nurse received a verbal telephone order from the resident's physician to send the resident to the emergency room for evaluation; -On 11/16/19, at 1:10 A.M., the resident left for the emergency room by ambulance; -On 11/23/19, at 3:15 P.M., the resident returned to the facility after being treated at the hospital for infection of upper great right toe and pneumonia. Record review of the resident's medical record did not show any letter sent to the resident or resident's responsible party or to the ombudsman regarding the transfer on 11/16/19. 2. Record review of Resident #58's nurse's notes showed the following information: -On 11/2/18, at 7:23 P.M., late entry: at approximately 10:00 A.M., the resident started pacing anxiously back and forth on the unit hallway. The resident started forcefully testing all exit doors. The staff made multiple attempts to redirect the resident with no success. The charge nurse reported the resident's behaviors to the Director of Nursing (DON). At 11:00 A.M., the charge nurse heard a loud noise from the special care dining room and the charge nurse and certified medication technician (CMT) witnessed the resident take a wooden chair from the dining room and slam it into the glass exit door. When the nurse and CMT attempted to approach the resident and ask what he/she was doing, the resident attempted to throw a chair at the CMT and picked up another chair that was within arm's length and throw it at the nurse. The resident repeated the process two more times before no chairs remained in reach. He/she then grabbed hold of the bar of the exit door and laid him/her self down in front of the exit door and began kicking the door. At this time, the Assistant Director of Nursing (ADON) and the administrator entered the special care unit (SCU) and the resident greeted the administrator in a friendly manner and the administrator was able to redirect the resident to his/her room. Approximately 20 minutes later, the resident entered a female resident's room and barred him/her self in the female resident's room. The charge nurse was able to gain a small entryway into the female resident's room. The resident started waving the female resident's walker at the nurse. The charge nurse was able to grab the walker and wedge the door with the walker. The charge nurse instructed a certified nursing assistant (CNA) to get help. The charge nurse gained access to the female resident's room. The female resident remained in bed away from the agitated resident. As the charge nurse gained entry into the room, the resident released the resistance to the door and grabbed a cup and bottle of conditioner off the female resident's bedside table. The resident began swinging a cup and bottle of conditioner at the nurse. The conditioner bottle cap came free and the contents covered the resident, charge nurse, and the floor. The resident began to lose footing in the conditioner that covered the floor and the charge nurse grabbed the resident's shirt preventing the resident from falling. The DON entered at that time and the charge nurse stated the resident must have worn him/her self out and had laid down. Staff carried the resident to his/her room in a bath blanket and placed him/her in bed and the resident appeared to be asleep at this time. The resident remained in bed less than five minutes before beginning to wander again. The charge nurse instructed nursing and housekeeping to give the resident space in attempt to keep the resident from getting more agitated. The resident approached the housekeeping cart and grabbed a long handled duster. The resident smiled at the charge nurse and swung the duster at the charge nurse. The charge nurse evaded the resident's attempt to hit him/her with the duster while instructing staff to retrieve help again. The charge nurse slowly backed away from the resident while guiding him/her to the SCU empty dining room. The charge nurse exited through the locked exit door in the dining room area and pulled the door shut behind him/her. The DON entered the dining area behind the resident. The charge nurse walked around the dining area to a second door leading to the courtyard to attempt to re-enter the facility. The resident noted to follow the charge nurse to the door and remained fixated on the charge nurse. The DON motioned for the charge nurse to enter the facility through a separate hall leading from the courtyard. The charge nurse re-entered through 600 hall and walked around and re-entered the unit through the opposite end. The DON instructed the charge nurse to remain off the unit as the resident was fixated on the charge nurse. Charge nurse notified the DON that multiple attempts to calm the resident down and redirect the resident were unsuccessful. The charge nurse was instructed to notify the physician and obtained orders from the physician to transfer the resident to the emergency room for evaluation and possible transfer to a psychiatric unit. The resident left the facility accompanied by ambulance at 12:00 P.M.; -On 11/12/18, at 9:20 P.M., staff documented the resident returned to the facility at 2:25 P.M. Record review of the resident's medical record did not show any letter sent to the resident or resident's responsible party or to the ombudsman regarding the transfer on 11/02/19. Record review of the resident's nurses' notes showed the following information: -On 1/10/19, at 9:37 A.M., staff found the resident unconscious and non-responsive in his/her bathroom. His/her blood pressure was 62/38, pulse 54 (number of times your heart beats per minute), respirations (refers to a person's breathing and the movement of air into and out of the lungs) 22, temperature 97.5, and oxygen saturation (a blood oxygen level that indicates how well the body distributes oxygen from the lungs to all of it cells. The normal blood oxygen levels in humans is 95-100) was 68% on room air. A nurse called in a report to the hospital. Staff notified the resident's responsible party and the responsible party requested the resident be sent to the hospital. Staff notified the resident's physician of his/her transfer to the emergency room; -On 1/16/19, at 9:56 P.M., the nurse documented the resident returned to the facility by ambulance at 4:00 P.M., after being admitted to the hospital for syncopal (a temporary loss of consciousness caused by a fall in blood pressure) episodes. The resident is alert and oriented to self only. The resident was very pleasant and jovial and joking with staff. The resident is now lying in bed and resting quietly. Record review of the report sent to the ombudsman for January 2019 showed staff notified the ombudsman of the resident's emergency discharge to the hospital. Record review of the resident's medical record did not show any letter sent to the resident or to the resident's responsible party of the transfer on 1/10/19. Record review of the resident's nurses' notes showed the following information: -On 2/08/19, at 12:50 P.M., staff called the charge nurse to the unit due to the resident having purple warm hands. Upon assessment, the resident noted to have cyanosis (a bluish discoloration of the skin from poor circulation or inadequate oxygenation of the blood). Staff checked the resident's oxygen saturation levels and the level was 99% on room air with a pulse rate of 44 and irregular. During a manual check of the resident's pulse, the resident presented with a blank stare and started to bounce up and down and then started to fall. The nurse and a CMT caught the resident and lowered him/her to the floor. The nurse took the resident's vitals and the resident's blood pressure was 92/56, pulse 40, respirations and oxygen saturation level of 85% on room air. Staff assisted the resident to a standing position and walked to his/her room to lay down. The resident appeared very lethargic and abnormal. Staff contacted the physician and the physician gave a verbal order to send the resident to the emergency room for evaluation. Staff notified the responsible party; -On 2/08/19, at 1:31 P.M., the resident left the facility at 1:20 P.M. by ambulance. Staff called a report in to the hospital; -On 2/08/19, at 8:17 P.M., the resident was cooperative when he/she first arrived back to the facility. Staff did not document what time the resident returned from the hospital on 2/08/18. Record review of the report sent to the ombudsman for February 2019 showed staff notified the ombudsman of the resident's emergency transfer for the 2/08/19 transfer. Record review of the resident's medical record did not show any letter sent to the resident or resident's responsible party of the transfer on 2/08/19. During an interview on 3/13/19, at 3:06 P.M., the resident's family said they were notified verbally of the resident being transferred to the hospital. The family said they did not receive written notification that their family member had been sent to the hospital regarding any of the hospitalizations. 3. Record review of Resident #49's nurses' note, dated 3/13/19, at 9:56 A.M., a late entry for 3/9/19, at 2:01 P.M., showed the resident found on the floor beside his/her bed on the right side. The resident complained of increased pain to a previous fracture. The nurse noted the resident's right lower extremity was slightly shorter than the left lower extremity. The nurse notified the physician and received an order to send the resident to the emergency department. The nurse notified the registered nurse (RN) supervisor, the oncall person, and the responsible party. Ambulance called. Record review of a nurse's note, dated 3/9/19, at 7:46 P.M., showed the resident returned via ambulance. The emergency department report xray showed negative for a fracture. Record review of the resident's medical record showed no letter sent to the responsible party regarding the transfer on 3/13/19. 4. Record review of Resident #81's nurses' notes showed the following information: -On 10/7/18, the nurse documented at 11:09 P.M., that at 5:50 P.M., the resident was in his/her room throwing personal belongings on the floor and at staff. The resident became more aggressive and paranoid, yelling and screaming at staff about missing clothes and needing a shower. The resident also said he/she was going to hurt staff. The resident said he/she was going to hurt staff by cutting their throats with broken glass and then kill him/her self by doing the same thing. The resident threw water on the floor and staff and threatened to hit staff with his/her cane. -On 10/7/18, the nurse documented at 11:19 P.M., that at 6:00 P.M., the nurse notified the physician of the resident's behaviors and received new orders to send the resident to the emergency room (ER) to be evaluated. -On 10/7/18, at 11:20 P.M., the nurse notified the resident's responsible party of the resident's behavior and the orders received to send the resident to the ER for evaluation. -On 10/7/18, at 11:25 P.M., the nurse documented that at 6:30 P.M., the ambulance arrived at the facility to transfer the resident. -On 10/25/18, at 8:59 P.M., the nurse documented the resident returned to the facility at approximately 3:00 P.M. Record review of the resident's medical record showed no letter sent to the responsible party or ombudsman regarding the transfer on 10/7/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Record review of Resident #93's hard copy medical record showed a purple OHDNR order signed by the resident's representative and physician dated [DATE]. Record review of the resident's electronic health record (EHR) showed the following: -A physician's order dated [DATE] for DNR; -A nurse's note dated [DATE] showed staff sent the resident to the hospital for respiratory failure. The resident's physician's orders were discontinued at the time of transfer; -On [DATE], the resident returned the facility with a physician's order for DNR status. During an interview on [DATE], at 9:50 A.M., LPN G said a medical status summary document containing the resident's pertinent information and physician's orders are sent to the hospital with the resident at the time of transfer. The resident's summary document sent with the resident at discharge showed the resident's advanced directive as a full code. Staff checked the wrong box for the code status. Review of the resident's care plan showed the resident as a DNR status. The resident currently has an active DNR order on the electronic physician's order sheet. Record review of the resident's medical record did not show documentation of a discussion regarding the resident's end of life wishes. During an interview on [DATE], at 2:13 P.M., the DON said the nurse checked the wrong box when entering data and the resident remained a DNR before, during, and after the hospital transfer. 8. Record review of #52's face sheet showed the following: -admission date of [DATE]; -Diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), seizures, Type 1 diabetes (chronic condition in which the pancreas produces little or no insulin) and heart disease; -Staff did not document a code status. Record review of the resident's EHR, did not show documentation of the code status. Record review of nurses' and social service's notes, dated [DATE] through [DATE], showed staff did not document any conversation with the resident or resident's representative regarding the resident's code status and end of life wishes. Record review of the resident's social services notes dated [DATE] through [DATE] did not show documentation of a discussion regarding the resident's end of life wishes. Record review of the resident's nurse's notes dated [DATE] through [DATE] did not show documentation of a discussion regarding the resident's end of life wishes. Record review of the resident's care plan dated [DATE] did not show the resident's code status. During an interview on [DATE] at 9:44 A.M., LPN E said the following: -Resident #52's code status should be behind the face sheet of the hard copy chart; -Whenever no purple DNR form behind the face sheet, then the resident was probably a full code; -Resident #52's was probably a full code. 9. During an interview on [DATE], at 10:43 A.M., CNA F and CNA H said if they entered a resident room and found a resident not breathing, they would yell for a nurse. They would find out if the resident was DNR. They would look for this information in the hard copy medical record or care plan. Usually, the medication technician or nurses do that. They would probably look in the medical record first. It is probably in both, the medical record and the careplan book. Neither had ever had to look for the information yet. They have not had a code status situation or a code drill. The nurses have had a code drill. They said they knew this information by listening to nurses talk when a resident came back to the facility, 10. During an interview on [DATE] at 10:57 A.M., LPN E said whenever a resident is admitted to the facility, he/she looks in the computer on the facesheet, POS, echart, and confirm in the hard copy medical record that the resident has a purple sheet signed by the physician. The resident's facesheet should show if a resident is full code or DNR. The POS should show if a resident is full code or DNR. He/she looks to see if the resident has a purple sheet right behind the facesheet. If there is no purple sheet, then the resident is full code and he/she would perform CPR. Sometimes, it might be a white sheet, but would look for a DNR sheet. SSD determines what the code status is and talks to the resident and family about code status. If a resident has a decline in condition, then staff have another discussion about the resident's code status and wishes. 11. During an interview on [DATE], at 12:14 P.M., LPN G said he/she would look in the medical record for code status. He/she could check in the computer under the POS and search the type of order. In the hard copy medical record, he/she would look in the front for a purple sheet. Sometimes, it isn't purple. He/she would be looking for the DNR form to ensure it is signed by the physician and responsible party. He/she has not personally asked any resident about their end of life wishes. He/she does not know of any documentation about discussion of code status or end of life wishes. He/she would also look in the hard copy medical record for the lack of a DNR order. He/she just received an inservice today about how to look up code status in the physician orders. 12. During an interview on [DATE], at 3:00 P.M., the SSD A said during the admission process the facility goes over the Advanced Directive Outside the Hospital form with the resident and/or the resident's representative. If the resident chooses to be a DNR, the resident or responsible party signs the form and then the DNR form is sent to the physician to sign. When the facility gets the signed form from the physician then it should be transferred to a purple OHDNR sheet. He/She shows the DNR form to the nurse. The nurse adds the DNR order to the POS on the computer. Depending on who is available, the DNR information is added to the care plan. He/she said then the purple OHDNR sheet is placed in the resident's paper medical and a copy of this form is placed in a master book kept in the social services office. During business hours his/her office is unlocked if a staff person needs to look in the master book and after normal business hours the nurse has a key to his/her office. When a staff person needs to know code status, they should look in the electronic health record for a physician's order on code status and for the purple sheet, if a resident has a DNR, in the paper medical record. Staff should check both of these before no CPR is done. If someone wants CPR, no DNR form is completed and no physician order is obtained. The DNR form should not be on a white sheet. It should be on a purple sheet. He/she said audits are done regarding code status to ensure all matches. He/she said the DNR sheet, physician's order, and the master DNR book should all match. The Social Service designee said DNR code status should be reviewed during care plan meetings but is not sure it is being documented since he/she no longer does the care plan meetings since he/she is also doing admissions. If a resident chose to be full code, the social service designee said he/she usually documented this in care plan meetings; but, the facility policy does not direct staff to document anywhere if a resident is full code. He/she said during normal business hours or if it is a planned admission, he/she would go over the code status and advanced directives with the resident or resident's responsible party. If it is an emergency admission, then the nurse on duty would do this. 13. During an interview on [DATE], at 1:12 P.M., the administrator and DON said if a resident is full code, staff do not document this. The assumption is if there is no physician order for DNR and there is no Outside the Hospital DNR sheet completed then a resident would be full code. If the resident has chosen to be a DNR, then there should be a physician's order on the POS and a signed DNR Outside the Hospital form in the hard chart. The DNR does not have to be on a purple sheet but the facility tries to do this to catch the staff person's eye. The administrator and DON said all the documentation on code status should match throughout the the hard chart and electronic health record. If there was a conversation regarding a resident's code status, it should be documented in the social service notes. The corporate nurse said the corporate policy is to look for the DNR order in the electronic medical record. The purple sheet, DNR form, should not be placed in the medical record unless there is a signed physician order. If the social service designee is not at the facility during a resident's admission, the admitting nurse should enter the DNR order if there is one. Social services should document admission, quarterly, and annually any discussions they have with a resident regarding code status in the social service notes. 6. Record review of Resident #70's face sheet showed the following information: -admitted into the facility on [DATE]; -Diagnoses included urinary tract infection and Stage II pressure ulcer to the left buttock. -Staff did not document the resident's code status. Record review of the resident's [DATE] POS did not show any order regarding the resident's code status. Record review of the resident's paper medical record showed a form titled, admission Chart Audit, dated [DATE], consisting of a checklist. In the line that states: DNR if Appropriate, staff left the response blank. Record review of the nurses' notes, dated from admission ([DATE]) through the date of [DATE], did not show any conversation documented regarding the resident's code status or end of life wishes. Record review of the social services notes, dated from admission ([DATE]) through the date of [DATE], showed staff did not document any conversation with the resident and/or guardian about the resident's advanced directive and/or code status wishes. Record review of the resident's paper medical record did not have any documentation regarding the resident's code status or end of life wishes. The resident's medical record did not have a purple DNR form. Based on record review and interview, the facility failed to ensure a resident's choice on code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clear and documented and failed to ensure the documentation for code status was consistent throughout the residents' medical records. Staff failed to document a conversation with the resident or resident's representative on advanced directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are followed should a person be unable to communicate them to the physician) and code status. This failure affected eight residents (Resident #39, #46, #22, #49, #81, #70, #93, and #52) out of a facility sample of 20 residents. The facility census was 98. Record review of the facility policy titled, Advance Directives and Refusal of Treatment, dated [DATE], showed the following information: -The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate and advanced directive for the management of his/her care; -Except in an emergency situation, prior to the start of any procedure or treatments, the resident shall receive the information necessary from his/her physician to give an informed consent. Except in an emergency situation, the information provided to the resident to obtain an informed consent shall include, but not necessarily be limited to, the intended procedure or treatments, the reason for the procedure of treatments, the potential risks, and the probable length of disability. Whoever significant alternatives of care or treatment exist, or when the resident requests information concerning alternatives, the resident shall be given such information; -The resident will be given information and the opportunity to formulate Advance Directives-including, but not limited to, a Living Will (a document that lets people state their wishes for end-of-life medical care in case they become unable to communicate their decisions) care and/or attorney in fact appointed pursuant to a Durable Power of Attorney (DPOA-a document that stays in effect if a person becomes incapacitated and unable to handle matters on their own) for Health Care; -The resident shall have a copy of his/her Advance Directive(s), if any, made part of his/her medical record. Forms of Advance Directives include a Living Will and a DPOA for Health Care; -Prior to or upon admission, the Facility's Social Service designee will provide the resident or family with information about the Advance Directives and Do-Not Resuscitate (DNR) orders and Withdraw (WD) and Withhold (WH) orders; -Only when the resident's medical status and the resident's or family wishes indicate, can DNR and WD/WH forms be completed. This can be at any point in the resident's care (admission, readmission, change in status, etc). These forms and related attachments should be placed in the front of the medical record housed in a plastic sheath. Orders should be written in physician orders section of the medical record. The physician must enter the order personally, no orders for DNR or WD/WH will be taken via the telephone. Fax or e-mails are acceptable. Prior to admission, the Social Service designee should obtain from the resident or the resident's family a copy of any existing Living Will, Health Care Declaration or Health Care Directive, DPOA for Health Care, or any previously recorded express written or oral (but has been written down) declarations. This copy of the resident's wishes should be placed in the front of the medical record. The Social Service Designee should enter a progress note in the resident's record regarding the existence of an Advanced Directive; -The resident's Advance Directives and DNR, WD/WH status should be reviewed with all readmissions. The facility should not rely on wishes provided by a hospital or other healthcare organization. The Social Service designee should enter an admission note in the resident's record regarding the update. The resident's Advance Directives and DNR or WD/WH requests should be placed in the resident's medical record upon readmission; -It is suggested that a copy of all documents be placed in the residents' folders that are kept in the Facility's business office; -It is suggested that an extra copy of the Advance Directives be kept in a chart and sent with transfer orders in the event of a resident's discharge to the hospital; -In MIssouri, the original of any Out of the Hospital DNR must accompany the resident when the resident is transferred. A copy should be retained by the facility for its file; -The DNR and WD/WH consent forms should be reviewed thoroughly with the resident or family, and signatures and documentation from family members, physician, and the properly witnessed signature of the resident must be obtained consistent with state law. The Social Service designee shall ensure that residents' and family are aware of their options regarding Advance Directives; -For DNR and WD/WH orders, the facility shall assist the resident or family in setting up a conference with the care givers and physician. This conference should be documented in detail by the facility's Social Service designee. All items listed on the facility's form governing the conference must be covered in the documentation. It should be very clearly documented that the gravity and consequences of these orders are thoroughly explained to all parties and that agreement is unanimous; -Throughout the resident's time at the facility, all discussions leading to a consideration of DNR or WD/WH orders should be documented in the resident's medical record. Held discussions with the resident or family regarding tube feeding, or decline in resident condition, etc.; -DNR orders must be reviewed by the physician at least once every 30 days during a resident's first ninety days of admission, every 60 days thereafter, or as often as appropriate. In addition, DNR Orders and WD/WH Orders should be reviewed by the Interdisciplinary Care Plan team during the quarterly update; -The policy did not address if the resident chose to be a full code (a person will allow all interventions needed to get their heart started. This may include chest compressions and defibrillation to shock the heart out of a life threatening heart rhythm). 1. Record review of Resident #39's medical record showed the following information: -admission date of [DATE]; -Diagnoses included lung disease, dementia (decline in memory or thinking and social symptoms that interferes with daily functioning) with behavioral disturbances, irregular heart beat, heart disease, seizures, and schizophrenia (a long term mental disorder involving a breakdown in the relationship between thought, emotion, and behavior leading to a faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion and a sense of mental fragmentation). Record review of the resident's face sheet (a document that gives a resident's information at a quick glance) showed staff did not document the resident's code status. Record review of the resident's [DATE] physician order sheet (POS) showed no order for code status. Record review of the resident's paper medical record showed a loose white piece of paper titled Outside the Hospital DNR (OHDNR), signed [DATE]. The resident did not have a purple Outside the Hospital DNR sheet in the paper medical record. Record review of the Social Service's notes, dated from admission ([DATE]) through [DATE] showed no social service notes regarding a conversation with the resident and/or guardian regarding the resident's wishes on Advance Directives and/or code status. Record review of the resident's care plan, dated [DATE], showed staff did not address the resident's wishes regarding end of life wishes, such as having an advanced directive or DNR. During an interview on [DATE], at 11:40 A.M., Certified Medication Technician (CMT) C said if a resident was a DNR there should be a purple sheet in the front section of the paper medical record. The CMT agreed this resident's DNR was on a loose white sheet of paper and said he/she may have missed this if looking for the resident's code status. The CMT said there should also be a physician order on the resident's current POS that showed the resident's code status. The CMT looked on the resident's current POS in the electronic health record and said the resident did not have an order for DNR. During an interview on [DATE], at 3:00 P.M., the Social Service designee (SSD) A agreed the resident's Outside the Hospital DNR was not on a purple piece of paper as the facility typically did. The Social Service designee looked in the resident's physician's orders and said the facility did not have an order for his/her DNR code status. He/she then looked in his/her master book where he/she kept copies of DNR and advanced directives and said he/she did not have a copy of the resident's DNR or advanced directive. The Social Service designee said this resident has been in and out of the facility and had discharged return not anticipated at one time. During an interview on [DATE], at 9:20 A.M., the director of nursing (DON) said over the weekend she had in-serviced staff regarding an easier way to find a resident's code status on the electronic health record. The DON looked and said the resident did not have an order for his/her DNR code status. 2. Record review of Resident #46's medical record showed the following information: -admission date of [DATE]; -Diagnoses included diabetes, end stage kidney disease, heart disease, and lung disease. Record review of the resident's face sheet showed the resident was full code. Record review of the resident's [DATE] POS showed the resident was full code. Record review of the resident's social service notes from admission of [DATE] through [DATE] showed no documentation that facility staff or Social Service designee met with the resident to discuss the resident's choices on Advanced Directives or Code Status. Record review of the resident's care plan, dated [DATE], showed the care plan did not address the resident's choice on code status. 3. Record review of Resident #22's face sheet showed the following information: -admission date of [DATE] with readmission date of [DATE]; -Diagnoses included myocardial infarction, pulmonary edema, acute respiratory failure; -The face sheet did not address code status for the resident. Record review of the resident's care plan, start date of [DATE], last reviewed on [DATE], did not show the resident's end of life wishes. It did not address the resident's code status wishes. Record review of the resident's social services notes from [DATE] through [DATE] did not show any documentation regarding any discussion with the resident and/or representative regarding the resident's code status or end of life wishes. Record review of the resident's [DATE] POS, showed the following information: -Choice of advance directive, yes or no. It did not show a response to the question; -Staff did not document the presence of a do not resuscitate order; -The POS did not address the resident's code status. Record review of the resident's medical record did not show any documentation regarding a discussion regarding the resident's end of life wishes. The hard copy medical record did not have a DNR order or purple sheet in the medical record. During an interview on [DATE], at 10:43 A.M., Certified Nursing Assistant (CNA) H said he/she thought Resident #22 was a DNR. During an interview on [DATE], at 12:14 P.M., Licensed Practical Nurse (LPN) G said regarding Resident #22, he/she did not know for sure about his/her code status. He/she looked in the computer doing a search of the physician orders, by selecting the type of order. He/she believed Resident #22 was full code. The order type did not pull up a DNR order. 4. Record review of Resident #49's face sheet showed the following information: -admission date of [DATE]; -Diagnoses included high blood pressure, constipation, and pain; -The face sheet did not address code status for the resident. Record review of an adult transfer form, admission date of [DATE], showed DNR checked no. The physician signed the form on [DATE]. Record review of the resident's nurses' notes, dated [DATE], showed staff documented resident noted to be full code. It did not clarify how or when staff obtained the code status information. Record review of the resident's comprehensive care plan, start date of [DATE], did not address the resident's end of life wishes. It did not address the resident's code status. Record review of the resident's baseline care plan, dated [DATE], showed the following information: -admission date [DATE]; -Advance directive option yes/no left blank; -Wishes for CPR, blank; -Staff did not document a discussion regarding the resident's end of life wishes; -The care plan did not show the resident's end of life wishes regarding code status. Record review of the [DATE] POS showed the following information: -Choice of advance directive, yes or no. It did not show a response to the question; -Staff did not document a do not resuscitate order; -The POS did not address the resident's code status. Record review of the social services notes, dated [DATE] through [DATE], did not show any discussion of the resident's code status or end of life wishes. Record review of the resident's medical record did not show any documentation regarding a discussion regarding the resident's end of life wishes. The hard copy medical record did not have a DNR order or purple sheet in the medical record. During an interview on [DATE], at 10:43 A.M. CNA H said he/she thought Resident #49 was full code. During an interview on [DATE], at 12:14 P.M., LPN G said Resident #49, upon search of the physician orders, the resident appeared to be full code because no DNR order popped up in the search. 5. Record review of Resident #81's face sheet showed the following information: -admission date [DATE]; -Diagnoses included dementia with behavioral disturbance; -The face sheet did not address code status for the resident. Record review of the resident's baseline care plan summary, dated [DATE], showed the following information: -Resident is here long term and is needing to gain strength with therapy; -He/she has struggled with depression his/her whole life and has a DNR; -The resident also has dementia. Per the resident's family member, (he/she)'s ready to go home. -Yes, the resident had an advance directive; -Wishes for CPR: per family, resident is DNR. Record review of the resident's comprehensive care plan, start date of [DATE], showed it did not address the resident's end of life wishes. It did not address the resident's code status. Record review of the social services note, dated [DATE], showed the resident's family member requested the resident be appointed guardianship with the public administrator. On [DATE], a new guardian appointed for the resident on this date. Staff did not document discussion of the resident's code status or end of life wishes. Record review of the resident's nurses notes, dated [DATE], showed staff transferred the resident to the hospital. Record review of the resident's nurses' notes, dated [DATE], showed the resident readmitted back to the facility. Record review of the resident's baseline care plan summary, dated [DATE], showed the following information: -Resident returned from hospital after fall with a fractured right hip; -Required assist with all care and is not able to walk; -Will continue to remain a long term resident; -Staff did not document a response for the advance directive question; -Staff did not document the resident's wishes for cardiopulmonary resuscitation (CPR). Record review of the social services note, dated [DATE], showed staff reviewed care plan. The resident's responsible party notified via mail, but was not present. Resident invited, but sleeping and did not want to attend. Staff did not document discussion of the resident's code status or end of life wishes. Record review of the [DATE] POS, showed the following information: -Choice of advance directive, yes or no. It did not show a response to the question; -Staff did not document a do not resuscitate order; -The POS did not address the resident's code status. Record review of the social services notes, from [DATE] through current ([DATE]), did not show any documentation of discussion of the resident's code status or end of life wishes. Record review of the resident's medical record did not show any documentation regarding a discussion regarding the resident's end of life wishes. The hard copy medical record did not have a DNR order or purple sheet in the medical record. During an interview on [DATE], at 10:43 A.M., CNF F said Resident #81 is full code, he/she thought. During an interview on [DATE], at 10:43 A.M., CNA H said he/she did not know for sure about Resident #81's code status. During an interview on [DATE], at 12:14 P.M., LPN G looked in the computer for Resident #81's code status information under the POS. LPN G said Resident #81 might be full code because the DNR order does not pop up in the POS. The resident must be full code. During an interview on [DATE], at 3:00 P.M., the social service director/admissions coordinator A said Resident #81, when he/she admitted to the facility, his/her family member was the responsible party. The family member asked for the resident's responsible party to be changed to a public administrator. SSD said she did not know about Resident #81's code status without looking. She reviewed the POS in the computer and did not find a DNR order. She reviewed the SS book and did not find a DNR form. Public administrators will not change code status unless the resident has a critical condition change or a physician order. SSD never obtained a copy of Resident #81's advance directive. SSD cannot just say a resident is DNR without documentation.