Armour Oaks Senior Living Community

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident rights were being honored by not treating one resident (Resident #9) out of 12 sampled residents, with dignity while standing up next to the resident and being assisted with eating during scheduled mealtimes. The facility census was 36 residents.A policy regarding feeding assistance was requested and not received.1. Review of the resident's face sheet, undated, showed:-The resident was admitted [DATE].-The resident was diagnosed with aphasia (a condition affecting speech caused by a stroke).Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used in nursing homes to evaluate resident health and functional needs), dated 6/19/25, showed:-The resident had moderate cognitive impairment.-The resident lacked ability to use suitable utensils to bring food and/or liquid to his/her mouth and swallow food and/or liquid once the meal was placed before the resident-The resident needed supervision and touching assistance while eating.Review of the resident's Care Plan (a personalized document outlining a resident's medical, emotional, and daily living needs and the specific strategies used to meet them, ensuring person-centered care), dated 7/12/25, showed:-The resident required assistance with eating.-The resident had a swallowing problem related to aphasia.Observation on 08/19/2025 at 11:31 A.M., showed:-Seven residents were sitting at a round table; one was Resident #9.-Staff were noted to walk around the table and offered feeding assistance to residents.-Residents were fitted with clothing protectors.-Resident #9 was fed by an aide who was standing up next to the resident and between the resident and another resident. -Another aide was standing next to another unidentified resident, also feeding him/her while standing.-Resident ate 25-50% of the lunch meal.During an interview on 08/20/2025 at 9:13 A.M., Certified Nursing Assistant (CNA) A said:-The resident needed feeding assistance.-He/She helped the resident with feeding.-He/She knows how to feed residents, he/she had been a CNA for ten years.-That is the only training he/she received.-He/She sat down to feed the residents.-He/She had seen other aides standing up to feed residents.During an interview on 08/20/2025 at 9:49 A.M., Certified Medication Technician (CMT) A said:-He/She did not usually assist with feeding.-He/She would sit down to feed the residents.-He/She noticed some aides standing over the residents while helping them eat.Observation on 08/21/2025 at 8:45 A.M., showed:-The resident was not at the breakfast table.-Another resident in a Broda chair received feeding assistance from an aide.-The aide stood over the resident while wiping his/her face during the meal.During an interview on 08/21/2025 at 9:13 A.M., Licensed Practical Nurse (LPN) A said:-Aides were expected to sit down and feed the residents.-He/She expected them to have conversations during mealtimes and feeding assistance. During an interview on 08/22/2025 at 1:15 P.M., the Director of Nursing (DON) said:-Aides were expected to know the diet and how to feed residents when they required assistance.-Aides also checked resident preferences to make sure it is what the resident.-Aides were expected to communicate with residents as they were feeding the resident.-All staff were encouraged to sit next to the residents they were assisting and not tower over the top of them.-Clothing protectors should be offered before putting them on the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders when weights were not monitored, documented and reported for one resident (Resident #9) diagnosed with Congestive Heart Failure (CHF- condition where the heart muscle did not pump blood effectively enough to meet the body's needs) out of 12 sampled residents. The facility census was 36 residents.Review of the facility's Medication Administration policy, dated 10/2022, showed to obtain and record vitals (heart rate, pulse, blood pressure and weights) per physician orders.1.Review of the Resident #9's face sheet, undated, showed:-The resident was admitted to the facility on [DATE].-The resident had moderate cognitive impairment.Review of the resident's Physician Order Summary (POS), dated August 2025, showed:-The resident was diagnosed with CHF.-The resident was ordered Torsemide (water pill that helped rid excess fluid) oral table, 40 milligrams (mg), related to edema (swelling that resulted from an abnormal accumulation of fluid in the body's tissues) and CHF.- Weigh daily for 14 days one time a day related to edema and CHF for 14 days.--Notify doctor if there was a weight gain of more than three pounds in 24 hours.--Starting 8/17/25.Review of the resident's Medication Administration Record (MAR), dated August 2025, showed the resident received Torsemide as ordered.Review of the resident's Treatment Administration Record (TAR), dated August 2025, showed:-The resident was not weighed on August 17, 18, 19, 20.-The resident was weighed on August 21 at 136.8 pounds.-The resident was not weighed on August 22.During an interview on 08/20/2025 at 9:13 A.M., Certified Nursing Assistant (CNA) A said:-The aides and sometimes the nurses weighed the residents.-He/She had a list of residents who needed to be weighed and weighed them.-He/She wrote the information on paper and gave it the nurse, or he/she would enter into electronic charting.During an interview on 08/20/2025 at 9:49 A.M., Certified Medication Technician (CMT) A said:-The resident was supposed to be weighed twice a month.-The aides or the nurses did the weights.-The clinical manager printed off a list of residents who needed weighed and he/she wrote the weights down and gave them to the nurse.During an interview on 08/21/2025 at 9:13 A.M., Licensed Practical Nurse (LPN) A said:-The resident was on weight monitoring for nutrition and eating tracking.-The resident was on daily weights.-The aides did the weights for the residents that were assigned to them.-The aides wrote the weights down and gave it to the nurse who documented in the resident's Electronic Health Record (EHR).-He/She expected daily weights to be done for the residents who had orders for it.-If residents had a fluctuating weight it was reported to the physician.-Aides were able to weigh the residents but not able enter into the EHR.During an interview on 08/21/2025 at 11:21 A.M., the Director of Nursing (DON) said:-The resident received daily weights.-The CNAs completed the weights.-The CNAs documented the weights in the vitals tab in the EHR or gave it to the charge nurse or nurse manager.-The nurses input the weights into the EHR quickly. -If they were not documented in the EHR they could be in the nurse manager's office.-He/She would check and provide them if found. -The resident was on daily weights due to CHF. -NOTE: no additional weight documentation was provided.During a follow up interview on 08/22/2025 at 1:15 P.M., the DON said:-He/She expected physician orders to be followed.-If the orders were to obtain daily weights, he/she expected nursing staff to follow those orders.-Normally the CNA assigned to that resident weighed the resident.-Weights were documented in the TAR or the vitals tab in the resident's EHR. -Weights were reported to the charge nurse or nurse manager.-CNAs were able to enter weights into the EHR or they gave a written copy to the nurse to enter.-If there was a change in the weight the charge nurse notified the physician.A message was left with the physician's messenger services 08/26/2025 at 8:40 A.M. Return call has not been received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the correct code status (a form or statement that indicated preferences to receive life sustaining measures such as cardio-pulmonary resuscitation (CPR)) was documented in the Electronic Health Record (EHR) for one resident (Resident #4) out of 12 sampled residents. The facility census was 36 residents.Review of the facility's Residents' Rights Regarding Treatment and Advance Directives (a legal document that stated specific healthcare wishes), undated, showed:-The facility supported each resident's right to formulate an advance directive.-On admission the facility determined if the resident had an Advance Directive, and if not, determined whether the resident would like to formulate one.-Upon admission if the resident had an Advance Directive, copies were made and placed on the chart and communicated with staff.-During the development of the care plan (a detailed document summarizing a person's health conditions, goals, and the specific treatments or services needed to achieve those goals) the facility identified, clarified and reviewed with the resident or legal representative whether they desired to make any changes related to the Advance Directive.-Any decisions were documented in the resident's medical record and communicated to the staff. 1. Review of Resident #4's face sheet, undated, showed:-He/She was admitted into the facility on [DATE].-He/She was cognitively intact. Review of the resident's Physician Order Summary (POS), dated [DATE], showed:-The resident was listed as Do Not Resuscitate (DNR). -There was no DNR form located in the resident's file. Review of the resident's Care Plan, dated [DATE], showed:-The resident was listed as DNR. During an interview on [DATE] at 9:13 A.M., Certified Nursing Assistant (CNA) A said:-The code status was in the resident's chart.-If he/she needed to know the code status he/she looked in the chart. During an interview on [DATE] at 9:49 A.M., Certified Medication Technician (CMT) A said:-Charting in the EHR said what the resident's code status was.-The EHR said at the top of the face page what the code status was. During an interview on [DATE] at 11:17 A.M., the resident was interviewed but did not clearly understand the questions regarding his/her code status. During an interview on [DATE] at 9:13 A.M., Licensed Practical Nurse (LPN) A said:-Advance Directives were in the resident's record.-Paper copies were kept at the nurse's station in a book.-The nurse was asked to provide the book, and it was not at the nurse's station.-The Director of Nursing (DON) must have had it. During an interview on [DATE] at 11:21 A.M., the DON said:-We had a DNR book located at the nurse's station, categorized by last name.-There was a paper copy in the resident's paper chart, and it was scanned into the EHR. -He/She would expect the code status to be in the EHR and the paper chart. -He/She would expect the care plan to say DNR or full code. During an interview on [DATE] at 11:54 A.M., the Minimum Data Set (MDS-a comprehensive assessment tool used in nursing facilities to evaluate resident health and identify needs) Coordinator provided a copy of the resident's progress EHR note and said:-The EHR was showing the resident was a full code (the resident wished to have CPR).-He/She accidentally put the wrong code status in the resident's file.-He/She put another resident's code status in the resident's file. During an interview on [DATE] at 1:15 P.M., the DON said:-He/She expected the resident's code status to be documented as an order in the EHR.-Residents were considered a full code unless there was a DNR signed and dated by the resident or representative and physician and care planned.-He/She would expect the correct code status be assigned to correct resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the door between the kitchenette and the dining room in good repair; failed to prevent the accumulation of debris inside the climate control units of resident rooms [ROOM NUMBERS]; failed to ensure the cover of the cleanout was secured firmly to the floor. This practice potentially affected at least 25 residents who used the dining room and 4 residents who resided in resident rooms [ROOM NUMBERS]. The facility census was 36 residents.1. Observation on 8/18/25 at 10:32 A.M., showed the half door, which separated the dining room from the serving kitchenette dragged on the floor when it was opened and closed.During an interview on 8/18/25 at 10:33 A.M., Maintenance Person A said the door dragged on the floor due to a loose hinge.During an interview on 8/20/25 at 12:44 P.M. the Assistant Plant Operations Director said facility staff lean on that door when it is open and that caused the door to drag.2. Observation on 8/18/25 at 10:51 A.M., showed the presence of debris including a decoration inside the climate control unit in resident room [ROOM NUMBER].3. Observation on 8/18/25 at 10:58 A.M., showed a buildup of debris inside the climate control unit in resident rom 21.During an interview on 8/18/25 at 11:01 A.M., Maintenance Person A said the slats of the grate which covered the inside of the climate control unit, were too wide so more items accumulated within the climate control units in certain rooms and he/she was unaware of items which accumulated into the climate control units.4. Observation on 8/18/25 at 12:43 P.M., showed the cover of the cleanout (a capped pipe that provides access to a sewer or drain line, allowing for inspection, cleaning, and maintenance of the system) outside of laundry in the basement smoke zone, moved, when the cover was stepped on. During an interview on 8/18/25 at 12:43 P.M., Maintenance Person A said he/she did not know the cleanout cover was loose and not tightened.

Based on observation, interview and record review, the facility failed to ensure appropriate measures were taken to provide safe conditions for food storage by not maintaining documentation of walk-in freezer temperatures. The facility census was 36 residents.Review of the facility's Monitoring of Cooler/Freezer Temperature, undated, showed:-The facility maintained temperatures of coolers and freezers at the appropriate temperature to promote food safety.-Logs for recording temperatures for each refrigerator or freezer was posted in a visible location outside the freezer or refrigerator unit.-Temperatures were checked and logged at least twice per day by designated personnel.-Logs were changed out and completed monthly.-All frozen storage was maintained at or below -4 Fahrenheit (F-a unit of measuring temperatures).-If temperatures were above 10 for freezers the supervisor was notified and took corrective action:--The unit was repaired as soon as possible.--If not corrected within two hours all food items were relocated to a different unit.--Internal temperatures readings were taken on all perishables, and potentially hazardous food was discarded if not in an acceptable range.1.Review of the facility's July 2025 Freezer Temperature Log, showed:-Freezer logs were missing temperatures the entire month of July 2025 with a squiggly line drawn down column. -NOTE: these logs were not the logs observed on the outside of the unit during initial kitchen tour.-No walk-in freezer temperature logs were provided for August 2025.Observation on 8/18/25 at 10:58 A.M. showed:-The walk-in freezer had a broken thermometer located outside of the unit.-The thermometer inside of the walk-in freezer read 22 F.-A large container of chocolate ice cream was noted to be melting.-The clip board hanging on the outside of the freezer door, used for documenting daily temperatures was dated July 2025, with multiple dates left blank.During an interview on 8/18/25 at 10:58 A.M., the Dining Services Manager said:-He/She had not been made aware of the freezer not being at the correct temperature.-He/She was going to put in a work order to have it looked at. During an interview on 08/20/2025 at 8:52 A.M., [NAME] A said:-Everybody in the kitchen checked food and equipment temperatures and wrote it on the log.-Reach-in coolers and freezers were temperature checked first thing in the morning.-After they were checked it was documented on the chart hanging on the wall next to the walk-in cooler and freezer.-Freezer should not be above 14 F. During an interview on 08/20/2025 at 9:36 A.M., [NAME] B said:-The temperature in the freezers should be below zero. -He/She noticed it wasn't working and told maintenance about it last month. -Temperature logs were hanging on the outside of the walk-in freezer doors. During an interview on 08/20/2025 at 10:03 A.M., [NAME] C said:-He/She checked freezer temperatures in the beginning and ending of his/her shift.-He/she recorded the temperatures on the log hanging outside of the door.During an interview on 08/20/2025 at 1:58 P.M., the Dietary Services Director said:-Everyone in the kitchen was responsible for checking and documenting equipment temperatures, however it was mainly the cook's responsibility because they are the first one in the kitchen in the morning. -He/She expected the morning and night cooks to do equipment temperature checks and report any issues to him/her.During an interview on 08/20/2025 at 2:33 P.M., the Administrator said:-He expected the Dietary Services Director to make sure temps were being logged for all equipment.-He/She should have been notified if the equipment was not working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP - precautions taken by a facility for the prevention of transmission of multidrug-resistant organisms) for three sampled residents (Resident #24, Resident #7, and Resident #8); failed to ensure accurate documentation of a resident's tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) skin test for five sampled residents (Residents #3, #4, #6, #9, and #18) out of 12 sampled residents and failed to ensure hand hygiene was completed during medication pass. The facility census was 36 residents.
Review of the facility's policy, Enhanced Barrier Precautions, dated 2022 showed:
-The use of gown and gloves for use during high contact resident care activities. High contact activities include: Dressing, bathing, transferring, providing hygiene. changing linens, changing briefs or assisting with toileting, device care: urinary catheters, feeding tubes, any skin opening requiring a dressing.
-All staff would have received training on enhanced barrier precautions upon hire and at least annually and were expected to comply with all designated precautions.
-Clear signage would have been posted on the door or wall outside of the resident's room which indicated the type of precautions, required personal protective equipment (PPE – safety gear used to reduce exposure to substances, germs, and objects), and the high contact resident care activities that require the use of gown and gloves.
-An order for EBP would have been for residents with any of the following: Pressure ulcers (injury to the skin and underlying tissue resulting from prolonged pressure on the skin), diabetic foot ulcers (a breakdown of the skin and deeper tissues of the foot), unhealed surgical wounds, and chronic venous stasis ulcers (a wound on the leg or ankle caused by abnormal or damaged veins), and indwelling medical devices (central lines (a flexible tube inserted into a large vein), urinary catheters (a tube inserted into the bladder for urinary drainage), feeding tubes (a medical device that delivers liquid nutrition directly to the stomach through a flexible tube).
-Implementation of EBP included:
-Make gowns and gloves available immediately outside of the resident's room.
-Ensure access to alcohol-based hand rub in every resident room.
-Position a trash can inside the resident room near the exit for discarding PPE after removal.
-The Infection Preventionist would have incorporated periodic monitoring and assessment of adherence to determine the need for additional training and education.
Review of the facility's policy, Medication Administration, dated 10/2022 showed:
-Staff was to wash hands prior to administering medication per facility protocol.
1. Review of Resident # 24's face sheet showed he/she was admitted on [DATE] with a Stage 2 pressure ulcer (a superficial wound affecting the top two layers of the skin) on his/her buttock.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 6/19/25 showed:
-He/She had a pressure ulcer.
-He/She was moderately cognitively impaired.
Review of the resident's August 2025 Physician's Order Sheet (POS) showed the following orders:
-EBP related to dressings to his/her buttock. Gown and gloves during cares for dressing, dated 8/18/25 at 7:00 P.M.
-Cleanse his/her bilateral buttock with Wound Cleanser, pat dry, apply zinc ointment (medication used to heal skin), and cover with bordered dressing (a non-woven adhesive tape that hold the dressing in place and maintains a moist wound environment) daily and as needed, dated 8/19/25.
-Wash lateral thigh with normal saline, apply Santyl (ointment used for wound debridement), cover with non-adherent dressing then cover with Abdominal pad (ABD highly absorbent used for wound care) every day shift, dated 8/19/25.
Observation and interview on 8/18/25 at 9:26 A.M. showed:
-Staff had went into the resident's room and did not don (apply) PPE.
-Staff had provided care to the resident and had not used PPE.
-There was no sign on the door stating the resident was on EBP.
-There was no isolation cart at the resident's room or along the hallway.
-The resident said he/she had a wound on his/her hip.
-He/she said the staff did not wear PPE when caring for him/her.
2. Review of Resident #7's face sheet showed he/she was admitted with the following diagnoses:
-Protein calorie malnutrition (a nutritional disorder resulting from insufficient intake of protein and calorie).
-Adult failure to thrive (unexplained weight loss, malnutrition, and disability that affects older adults).
-Dysphagia (difficulty swallowing foods or liquids).
Review of the residents quarterly MDS dated [DATE] showed:
-He/She was moderately cognitively impaired.
-He/She had a feeding tube.
Review of the August 2025 POS showed the following orders:
-Enteral feed every six hours: Jevity (a calorie dense therapeutic nutrition) 1.5 240 milliliters (ml) via Percutaneous Endoscopic Gastrostomy tube (PEG tube – a feeding tube that provides direct access to the stomach for nutrition, hydration, and medication), dated 5/8/25.
-EBP related to Peg tube, gown and gloves during cares for peg tube, every shift, dated 8/18/25.
Observation and interview on 8/18/25 at 9:40 A.M. showed:
-Staff went into the resident's room and did not don (apply) PPE.
-Staff provided care to the resident and had not used PPE.
-There was no sign on the door stating the resident was on EBP.
-There was no isolation cart at the resident's room or along the hallway.
-The resident had a feeding tube.
-He/she did not feel up to being interviewed.
3. Review of Resident #8's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Obstructive uropathy (a disorder that occurs when urine flow is obstructed).
-Retention of urine (difficulty urinating and completely emptying the bladder).
-History of urinary tract infections (an illness in any part of the urinary tract).
-Artificial opening of urinary tract (a surgically created pathway for urine to exit the body).
Review of the resident's quarterly MDS dated [DATE] showed:
-He/She was severely cognitively impaired.
-He/She had a catheter (a tube inserted into the bladder to drain urine).
Review of the resident's August 2025 POS showed the following orders:
-18 French (Fr – size of the catheter)10 cubic centimeters (cc – the amount of fluid to fill the balloon it takes to secure the catheter in place) supra pubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen just above the pubic bone to drain urine when a person cannot urinate), change monthly and as needed for occlusion, dated 8/7/25.
-EBP related to supra pubic catheter, gown and gloves during cares every shift, dated 8/18/25.
Observation and interview on 8/18/25 at 1:10 P.M. showed:
-Staff had completed resident cares and had not used PPE.
-There was no sign on the door stating the resident was on EBP.
-There was no isolation cart at the resident's room or in the hallway.
-The resident said staff had emptied his/her foley and had not worn a gown only gloves.
4. During an interview on 8/20/25 at 9:00 A.M. CMT B said:
-They just started using EBP this week.
-There should have been a sign on the door that showed you what to wear when doing cares with the resident.
-The Director of Nursing (DON) came around and provided education on EBP by doing 1:1 education.
-The facility had not been doing EBP before the survey started.
During an interview on 8/20/25 at 9:40 A.M. Certified Nursing Assistant (CNA) A said:
-He/She had worked at the facility for a few months.
-He/She thought that EBP meant washing your hands.
-He/She could not remember if the DON had provided education about EBP during orientation.
-The just started using EBP this week after survey started.
-He/She had not received EBP education from the DON this week.
During an interview on 8/20/25 at 9:50 A.M. Licensed Practical Nurse (LPN) A said:
-They have just started doing EBP since survey started.
-If you had any opening in your body such as a foley catheter, feeding tube, or open wound you should have been on EBP.
-There should have been a sign on the resident's door indicating what PPE to have been worn when performing cares with the resident.
-There should have been an isolation cart outside the resident's room with PPE in it.
-The DON just came around yesterday providing education 1:1 with the staff.
-The DON was responsible for ensuring EBP were in place and providing education to the staff.
5. During an observation of the medication pass on 8/20/25 at 8:20 A.M. with CMT B showed:
-He/She did not cleanse his/her hands before administering medication to the resident in room [ROOM NUMBER] A.
-He/She did not cleanse his/her hands after administering medication to the resident in room [ROOM NUMBER] A.
-He/She did not cleanse his/her hands after administering medication to the resident in room [ROOM NUMBER] B.
-CMT A continued to pass medications to the rest of the residents.
During an interview on 8/20/25 at 9:00 A.M. CMT B said:
-You should wash your hands or use a hand sanitizer before starting the medication pass, before administering medications to each resident, and after you were done passing medications.
-The facility had provided a lot of education about when you were to wash your hands.
-The DON was responsible for ensuring staff washed their hands when they were supposed to have cleansed their hands.
During an interview on 8/20/25 at 9:50 A.M. LPN A said:
-During medication pass staff should cleanse their hands before starting the medication pass, after the medication pass and after passing medications to each resident.
-The DON had provided education almost monthly about washing your hands.
During an interview on 8/22/25 at 1:15 PM the DON said:
-He/She had just initiated EBP after the first day of survey.
-He/She had identified seven residents who should have been on EBP.
-He/She had provided education to the staff on Monday night.
-He/She should have started it previously.
-The CMT or Nurse should have washed/cleansed their hands before and after the medication pass, as well as after each resident.
6. Review of the facility's undated Resident Screening for Tuberculosis policy showed:
-Prior to or at the time of admission all residents will receive TB testing.
-All initial and follow up TB tests shall be administered and interpreted (48-72 hours for skin test) by a trained health care professional on staff.
7. Review of Resident #6's face sheet showed he/she was admitted to the facility on [DATE].
Review of the resident's immunization report showed an annual TB skin test was administered on 9/23/24. The test was documented as 0 mm induration with no read date.
8. Review of Resident #9's face sheet showed he/she was admitted to the facility on [DATE].
Review of the resident's immunization report showed an annual TB skin test was administered on 4/21/25. The test was documented as 0 mm induration with no read date.
9. Review of Resident 3's Face sheet showed he/she was admitted to the facility on [DATE].
Review of the resident's immunization report showed an annual TB skin test was administered on 3/17/25. The test was documented as 0 mm induration with no read date.
10. Review of Resident #18's face sheet showed he/she was admitted to the facility on [DATE].
Review of the resident's immunization report showed an annual TB skin test was administered on 3/24/25. The test was documented as 0 mm induration with no read date.
11. Review of Resident #4's face sheet showed he/she was admitted to the facility on [DATE].
Review of the resident's immunization report showed an admission TB skin test was administered on 7/3/25. The test was documented as 0 mm induration with no read date. The resident did not have a second step TB skin test.
During an interview on 8/22/25 at 1:15 PM, the Director of Nursing (DON) said:
-TB skin test results should be read 48-72 hours after they are administered. The read date should be documented.
-The facility's electronic medical records system did not have a spot to document the TB skin test read dates.
-All new admissions should have a two-step skin test.

Based on observation, interview and record review the facility failed to ensure appropriate measures were taken to provide safe and sanitary conditions for food storage and preparation by not maintain cleanliness of the kitchen and kitchen equipment; not labeling and dating opened food; not wearing appropriate hair coverings; not cleaning utensils; not documenting food temperatures during preparation; not documenting refrigeration temperatures. The facility census was 36 residents.Review of the facility's Record of Food Temperatures policy, undated, showed:-The facility recorded food temperatures daily to ensure food was at the proper serving temperatures.-Food temps were checked while items were prepared in the dietary department.-Hot foods were to be held at 135 Fahrenheit (F-a unit of measure for temperatures) or greater.-Potentially hazardous cold food temperatures were kept at or below 41 F.-Staff were to measure and record temperatures for each food product at all meals and document on the food temp logs.-No food was served that did not meet the food code standard temperatures.Review of the facility's Monitoring of Cooler/Freezer Temperature, undated, showed:-The facility maintained temperatures of coolers and freezers at the appropriate temperature to promote food safety.-Logs for recording temperatures for each refrigerator or freezer was posted in a visible location outside the freezer or refrigerator unit.-Temperatures were checked and logged at least twice per day by designated personnel.-Logs were changed out and completed monthly.-All refrigerator storage must be maintained at or below 41 F.-All frozen storage must be maintained at or below -4 F.-If temperatures were above 41 for coolers and 10 for freezers, the supervisor was notified and took corrective action:--The unit was repaired as soon as possible.--If not corrected within two hours all food items were relocated to a different unit.--Internal temperatures readings were taken on all perishables and potentially hazardous food was discarded if not in an acceptable range.-Refrigerated food was labeled, dated and monitored for it to be used by the use by date.Review of the facility's Date Marking for Food Safety policy, undated, showed:-The facility adhered to a date marking system to ensure food safety. -Refrigerated food was held at 41 F or less for a maximum of seven days.-Food was clearly marked to indicate the date.-The individual opening the food was responsible for date marking the food.-The Head [NAME] or designee was responsible for checking the refrigerator daily for food items that were expiring and discarded accordingly.-The Dietary Manager or designee spot checked refrigerators weekly for compliance and documented accordingly.Review of the facility's Dietary Employee Personal Hygiene policy, undated, showed:-Hair restraints were worn by all kitchen staff.-Hair restraints included hairnet, hat and beard restraints were to be worn to prevent hair from contacting food.Review of the facility's Routine Cleaning and Disinfection policy, undated, showed:-It was the policy of the facility to ensure routine cleaning and disinfection to provide a safe, sanitary environment.-Cleaning was defined as: removal of visible soil from objects and surfaces using water and detergents or enzymatic (a chemical used for cleaning) products.-Routine cleaning of visibly soiled surfaces was performed as needed.Review of the facility's Food Safety Requirements, undated, showed:-Food was stored, prepared, distributed and served in accordance with professional standards for food service safety.-Equipment used in the handling of food, including dishes, utensils, mixers, grinders and other equipment that came in contact with food was to be clean after use.-Dry food storage must be clean and dry.-Safe refrigerated storage included:--Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals.--Labeling, dating and monitoring refrigerated food.--Keeping foods covered or in tight containers.-All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination.-Clean dishes shall be kept separate from dirty dishes.-Dietary staff must wear hair restraints (including beards) to prevent hair from contacting food.-Hairnets should be worn when cooking, preparing or assembling food.Review of the facility's July 2025 Cooler Temperature Log, showed:-Cooler logs were missing temperatures on July 23rd through July 27th.-NOTE: these logs were not the logs observed on the outside of the units during initial kitchen tour.-No equipment temperature logs were provided for August 2025.Review of the requested food temperature logs for July through August 2025 showed:-July 1st evening meal temperature check was not documented.-July 2, 3, 4 and 5 breakfast, noon and evening meals temperature checks were not documented.-July 7th noon meal temperature checks were not documented.-July 8th evening meal temperature check was not documented.-July 10, 11 and 12 no meals had temperature checks documented.-July 13th evening meal temperature check was not documented.-July 13, 14, 15 breakfast, noon and evening meals temperature checks were not documented.-July 16th evening meal temperature check was not documented.-July 17th and 18th evening meal temperature check was not documented.-July 21st no meals had temperature checks documented.-July 23rd evening meal temperature check was not documented.-July 24th breakfast and evening meals temperature check not documented.-July 25th noon meal temperature checks were not documented.-July 26th breakfast and noon meals temperature check not documented.-July 29th evening meal temperatures check not documented.-August 1st breakfast and noon meals temperature check not documented.-August 3rd noon and evening meals temperature checks were not documented. -August 4th and 5th evening meal temperature check was not documented. -August 5th evening meal temperature check was not documented.-NOTE: No additional August 2025 temperature logs were provided.Observation on 08/18/2025 at 10:58 A.M., showed:-Dry storage had opened and not labeled a bottle of pancake syrup.-There was one dented can of pineapple and one dented can of mandarin oranges on the ready-to-serve storage rack. -There were four Rubbermaid plastic storage containers on the prep table containing dry cereal, two of which were not labeled or dated. -The reach-in cooler had a July 2025 temperature log hanging on the outside of the door.--The temperature log was missing more than 50% of the entries for the month.-There was no temp log for August.-An opened, undated and expired jar of pickles (5/22/25 based on manufacture dating) was in the reach-in cooler.-Floors in the kitchen, storage area and walk-in coolers were noted to have debris and were sticky in some areas. -An undated open bottle of grape jelly was sitting on a shelf in the food prep area, not refrigerated (manufacturer label showed refrigerate after opening).-The stove hoods were covered in grease.-There were drops of grease dripping on to the stove surface. -There was an opened package of sliced cheese in the walk-in cooler with no date.-There were no temperature logs for walk-in cooler.-The thermometer located on the outside of the walk-in cooler was broken. The hanging thermometer was in the back of the cooler and could not be read without moving three large jars of salad dressing.-Jars of salad dressing were in the walk-in cooler and were caked with dried on and gloopy dressing.-Stand up freezer, used for stored bread, had no temp log with a digital thermometer on the top.-Coffee filters were in a box with soaked in dried out brown substance sitting on a cafeteria tray on a portable stainless steel food cart.-A plastic circular container under the wall mounted knife holder was full of utensils. The cook reported they were clean, but upon inspection three knives were found inside the container with dried on food particles stuck to them.During an interview on 08/18/2025 at 10:58 A.M., the Dining Services Director said:-Dented food cans were sent back for credit and should not be on the storage racks.During an observation on 08/182025 at 11:00 A.M., a dishwasher was doing dishes with a beard net tucked below his/her chin.Observation on 08/20/2025 at 8:38 A.M., showed the Dining Services Director was in the food prep and cooking areas with no hair net or beard net.Observation on 08/20/2025 at 8:42 A.M., the August 2025 temp log for the reach-in cooler was blank, hanging on the outside of the door.Observation on 08/20/2025 at 8:44 A.M., an opened container of sour cream in the reach-in cooler was opened with no label showing the date it was opened. Observation on 08/20/2025 at 8:46 A.M., there were no food temp logs present in the cooking and food prep areas. During an interview on 08/20/2025 at 8:52 A.M., [NAME] A said:-He/She temped the foods after they were done cooking.-The food was immediately put on the steam table where it was temped.-Everybody in the kitchen checks food and equipment temperatures and wrote it on the log.-The log was in the kitchen in food prep area.-Reach-in and walk-in coolers and freezers were temperature checked first thing in the morning.-After they were checked it was documented on the chart hanging on the wall next to the units.-The freezer should not be above 14 F and cooler around 30 F.-Hair nets were worn all day until it was time to leave.-A box of new hair nets was located under the serving table when you first walk in the kitchen doors.-When food was opened and not all used it was supposed to be labeled with a date when it was opened. -There should be a label on opened containers, and he/she threw it away if it did not have one. -Dented cans were put aside and were not used in the kitchen. -Jelly should be refrigerated after opening and should have a date label on it.-Cleaning was done everyday and there were schedules we followed.During an interview on 08/20/2025 at 9:36 A.M., [NAME] B said:-He/She checked the food temperatures when it came out of the oven and when the food left the kitchen. -He/She recorded the temperatures in the temp book.-This was done for every meal, every day.-We temp it and the Dining Services Director made sure it was done.-The walk-in and reach-in coolers temperatures should be in the 30s.-The temperature in the freezers should be below zero. -He/She noticed it wasn't working and told maintenance about last month. -If he/she did not see dates on opened food he/she removed it. -There should be dates on all the food, including leftovers. After the third day he/she threw it away.-When he/she opened foods he/she marked it with an open date. -Everyone in the kitchen wore hair nets, even when washing dishes. -Temperature logs were hanging on the outside of the reach-in, walk-in, and freezer doors. -There was a cleaning list.-He/She cleaned messes as he/she saw them. -All kitchen staff were responsible for cleaning the kitchen.-The kitchen and prep equipment were cleaned twice a day, after breakfast and after lunch.-He/she was unsure what the dinner crew did.During an interview on 08/20/2025 at 10:03 A.M., [NAME] C said:-He/She made sure there were no dented cans on the racks.-Dented cans went to a different area in the kitchen and were discarded.-They should never be on the rack to be served.-Kitchen staff put labels on boxes with the date it was opened. -He/She expected there to be dates on any opened containers.-He/She threw out items if they were not dated.-Food that said it should be refrigerated after opening should go in the walk-in or reach-in coolers. -He/She checked the food temps while preparing and put them in the logbook.-He/She checked cooler and freezer temperatures in the beginning and ending of his/her shift and recorded the temperatures on the log hanging outside of the door.-Hair nets were worn when we entered the kitchen.-Should not see anyone in the kitchen cooking area without a hairnet.-Dishwashers need hair nets and beard nets.-There was a clip board with cleaning schedules for the reach-ins and walk-ins.-Once it was cleaned the person who cleaned put their initials on the clipboard.-NOTE: no cleaning schedules of checklists were provided.During an interview on 08/20/2025 at 1:58 P.M., the Dietary Services Director said:-There was a cleaning schedule that staff completed, as well as closing lists for each position.-There is a weekly deep clean list that staff were responsible for doing.-Weekly list was signed-off by the Dietary Services Director. - The Dietary Services Director was responsible for ensuring the cleaning was being done. -He/She had noticed an issue with cleaning not getting done. -There have been some write ups and other disciplinary actions.-He/She provided reminders to staff every day.-He/She provided training and monthly in-services.-He/She expected the kitchen staff to complete the cleaning list.-Staff should have recorded food temperatures and documented them on the log.-Everyone in the kitchen was responsible for checking and documenting equipment temperatures, however it was mainly the cooks responsibility because they are the first one in the kitchen in the morning. -He/She expected the morning and night cooks to do equipment temperature checks.-Staff were expected staff to wear hairnets and beard nets, including the dishwashers.-Opened containers should be labeled and dated with open date and expiration date.-Expect kitchen staff to wipe off bottles and containers before putting them in the coolers.During an interview on 08/20/2025 at 2:33 P.M., the Administrator said:-He/She expected the Dietary Services Director to make sure temps were being logged for all food and equipment.-He/She expected dietary staff to be always wearing hair coverings, including beards and dishwashers.-He/She expected kitchen staff to be cleaning daily. -He/She expected the Dining Services Director to notify him/her of failing equipment. Observation on 08/21/2025 at 1:28 P.M. of the refrigerator in the kitchenette in the dining room on the unit showed:-Opened sliced cheese with no label or date.-Opened gallon of milk with no opened date. -Opened bottle of grape jelly on the counter with no label and no open date.

Based on observation, interview, and record review, the facility failed to ensure the medication refrigerator had a thermometer and the temperature was checked daily, failed to ensure the freezer compartment of the medication refrigerator was not frozen solid, failed to ensure there were no loose pills in the medication cart, failed to ensure medications that were opened had the date they were opened written on them, failed to ensure there were no other items kept in the medication cart in with the resident's prescribed medications and failed to ensure there were not cleaning agents in the medication cart in with the resident's prescribed medications. The facility census was 36 residents.Review of the facility's policy, Storage of Medication Requiring Refrigeration, dated October 2022 showed:-The facility must provide safe and effective storage of all drugs and biologicals in a locked storage area under proper temperature controls.-The facility would ensure that all medications and biologicals would have been stored at proper temperatures and other appropriate environmental controls according to manufacturer's recommendations to preserve their integrity:-Refrigerated refers to temperature maintained between 36 to 46 degrees Fahrenheit (F).-Temperature to have been monitored daily to ensure proper temperature control and documented on the temperature log with the date, time, and signature of the person performing the check clearly written. Review of the facility's policy, Medication Administration, dated 2022 showed to keep the medication cart clean, organized, and stocked with adequate supplies. 1. Observation of the Certified Medication Technicians (CMT) medication cart on 8/20/2025 at 9:00 A.M. with CMT B showed:-There was a facility walkie talkie in with the resident's prescribed medications.-There were a container of bleach wipes in with the resident's prescribed medications.-A resident's prescribed container of Enulose (a medication used to treat constipation) 473 milliliter (ml) bottle was opened without the date it was opened written on it. -There were four white capsules in a medication cup without a name or room number on the medicine cup.-There was one round blue pill loose in the bottom of a drawer.-There was one orange capsule loose in the bottom of a drawer. During an interview on 8/20/25 at 9:20 A.M. CMT B said:-There should not have been any loose pills in the drawers of the medication cart.-There should not have been a container of bleach wipes in with the residents' medications.-Prescribed Medications that were opened should have the date it was opened written on it. -There should not have been a walkie talkie in with the resident's medications.-The staff member who used the cart was responsible for keeping it clean and ensuring the medication had a date written on it if it had been opened. 2. Observation on 8/20/25 at 9:30 A.M. of the Nurses' medication cart, medication room, and medication refrigerator with Licensed Practical Nurse (LPN) A showed:-There was no thermometer in the medication refrigerator. -The Nurse verified there was no thermometer in the medication refrigerator.-There was no temperature recorded on the temperature log for 8/19/25 or 8/20/25. -The freezer department in the medication refrigerator was one solid block of ice.-There were four boxes of Tuberculin (TB a skin test used to detect TB)1 ml vials in the refrigerator.-There was one Glargine Insulin (a long- acting insulin used to treat high blood sugar) pen in the medication refrigerator.-The medication cart showed one loose Ondansetron (a medication used for anti- nausea and vomiting) 4 milligram (mg) pill in a drawer.-A resident's prescribed Guaifenesin (medication used to relieve chest congestion) 473 ml bottle was open without an open date written on it. -There were a container of bleach wipes in with the resident's medications. Review of the Refrigerator Temperature Check for August 2025 showed:-It was recorded on August 5th there was no thermometer in the medication refrigerator. -There was no refrigerator temperature check done on August 18 or 19. During an interview on 8/20/25 at 9:50 A.M. LPN A said:-There should not have been any loose pills in the medication cart.-There should not have been any other objects in with the residents' medication.-There should not have been bleach wipes in with the residents' medications.-The nurse who used the medication cart should have been responsible for keeping it clean.-He/She did not know how staff would have checked the temperature of the medication refrigerator if there was no thermometer in it.-The night nurse was responsible for checking the temperature of the medication refrigerator and documenting it on the sheet.-He/She did not know who was responsible for ensuring the freezer in the medication refrigerator was defrosted. During an interview on 8/22/25 at 1:15 PM with the Director of Nursing (DON) said:-The night Nurse was responsible for checking the temperature of the medication refrigerator.-The temperature should have been checked every day.-The temperature should have been between 38 to 42 degrees F.-The temperature should have been recorded daily. -If something was off the nurse should have adjusted the temperature of the medication refrigerator then rechecked it. -The Nurse Manager or DON should have been informed if the temperature was off and that there was no thermometer.-The freezer compartment should not have been a block of ice, he/she did not know who was responsible for defrosting the freezer.-The Charge Nurse should have ensured the temperature was checked daily, the sink was clean, and there was soap so the staff could wash their hands before preparing medications. -There should not have been any personal items or loose pills in the medication cart.-The staff member who used the cart was responsible for ensuring it was kept clean and there were no loose pills.-The DON was ultimately responsible for the medication carts, medication refrigerator, and the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's oxygen equipment was kept in a sanitary manner when not in used for two sampled residents, (Resident #36 and Resident #37) out of 12 sampled residents. The facility census was 36 residents.Review of the facility's policy, Oxygen Concentrator, dated 2022 showed:-Staff was responsible for the use and care of oxygen concentrators.-Keep delivery devices covered in a plastic bag when not in use.-Change oxygen tubing and mask weekly and as needed if it becomes soiled or contaminated.-Change nebulizer tubing devices every 72 hours. 1. Review of Resident #36's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 6/26/25 showed:-He/She was cognitively intact.-Continuous positive airway pressure (CPAP - a treatment for sleep apnea which uses a mask to deliver constant and steady air pressure to help you breath while asleep) was not checked.-Oxygen (a therapy treatment that provides extra oxygen to help people with breathing difficulties) was not checked. Review of the resident's Physician's Order Sheet (POS) and Treatment Administration Record (TAR) for August 2025 showed to check and change CPAP tubing weekly every Sunday night shift, dated 2/26/23. Observation on 8/18/25 at 9:43 A.M. showed the resident had a CPAP machine and the mask sitting in the resident's drawer not in a bag. During an interview on 8/18/25 at 9:45 A.M. the resident said he/she needs assistance to get in and out of bed, the staff put his/her CPAP in the drawer. Observation on 08/19/25 at 11:50 A.M. showed the resident's CPAP mask sitting on a visible solid pad. Observation on 08/20/25 at 10:00 A.M. showed the resident's CPAP mask sitting on the same dirty pad. Observation on 8/21/25 at 9:45 A.M. showed the resident's CPAP mask was inside his/her pillowcase. 2. Review of Resident #37's Face sheet showed he/she was admitted on [DATE] with a diagnosis of COPD and Chronic Respiratory Failure (a long- term condition where the lungs can't effectively exchange oxygen and carbon dioxide, leading to shortness of breath). Review of the resident's August 2025 POS showed an order for Ipratropium-Albuterol (a combination medication used to treat and prevent wheezing and shortness of breath) Solution 0.5 to 2.5 (3) milligrams (mg)/3 milliliters (ml) one vial orally every six hours for cough related to COPD, dated 8/5/25. Observation on 8/18/2025 at 9:47 A.M. and on 8/20/25 at 10:50 A.M. showed the nebulizer mask was sitting in the drawer of the resident's nightstand not in a bag. 3. During an interview on 8/20/25 at 11:00 A.M. Certified Medication Technician (CMT) B said:-Oxygen equipment when not in use should have been stored in a bag.-They had received education from the Director of Nursing (DON) many times concerning oxygen/oxygen equipment storage.-It was the nurses' responsibility to ensure the oxygen equipment was stored correctly. During an interview on 8/20/25 at 11:10 A.M. Licensed Practical Nurse (LPN) A said:-Oxygen equipment when not in use should have been stored in a bag.-If the CPAP mask was sitting on a soiled pad, it should have been changed out.-They had received education from the DON many times concerning oxygen/oxygen equipment storage.-It was the nurses' responsibility to ensure the oxygen equipment was stored correctly. During an interview on 8/22/25 at 1:15 PM. the DON said when not in use oxygen equipment should have been stored in a bag and dated when it had been changed out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent misappropriation of controlled substances for three sampled residents (Resident #1, #2, #3) when Registered Nurse (RN) A repeatedly signed out duplicate doses of narcotics out of five sampled residents. The facility census was 100 residents.
On 5/7/25 the Administrator was notified of the situation and RN A was suspended immediately pending investigation. Upon completion of the investigation, RN A was terminated for violating facility policy on 5/1/25, 5/4/25 and 5/6/25. Training was completed immediately for 100% of all nurses and Certified Medication Technicians (CMT)s on abuse and neglect, medication administration and controlled substances prior to being allowed to work and/or pass medications. The deficiency was corrected on 5/7/25.
Review of the facility Abuse, Neglect, and Exploitation policy dated 2022 showed:
-It is the policy of the facility to provide protections for the health, welfare and the rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.
-Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.
-The facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.
-New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation.
-Existing staff will receive annual education through planned in-services and as needed.
-Training topics will include:
--Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation.
Review of the facility Controlled Substance Administration and Accountability policy dated 2022 showed:
-It is the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances.
-The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure.
-All controlled substances are accounted for when obtained from a non-automated medication cart or cabinet are recorded on the designated usage form.
-Written documentation must be clearly legible with all applicable information provided.
-The controlled drug record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration.
-The controlled drug record is a permanent medical record document and in conjunction with the medication administration record (MAR) is the source of documenting any patient-specific narcotic dispensed from the pharmacy.
-The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances.
-Inventory verification for areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.
1. Review of the undated facility Internal Investigation showed:
-On 5/7/25 Licensed Practical Nurse (LPN) A reported to Director of Nursing (DON) there was a medication error.
-There was a discrepancy between the amount of hydrocodone (narcotic medication) pills in the bubble pack versus how many were recorded on the narcotic sheet.
-Upon review, it was confirmed that one pill had been removed from the bubble pack, but it was not properly recorded on the controlled substance verification sheet or with the MAR.
-Both staff who were present at the most recent reconciliation were drug tested.
-RN A had already left the facility but was suspended pending investigation and sent for a urine drug screen (UDS).
-RN A reported giving medications outside of time parameters to multiple residents.
-RN A would give medications at the beginning of his/her shift although it did not trigger on the MAR and again about an hour before the end of his/her shift.
-RN A did not chart administration of the narcotics in the resident's MAR.
-The nurses verified during medication count, one nurse would count the pills and the other confirmed the number on the reconciliation sheet.
-That practice was not in compliance with the facility policy as both nurses need to visually count and reconcile because the person counting pills could easily say an inaccurate number to comply with the reconciliation sheet.
-The facility determined RN A either negligently or willfully committed several repeat medication errors and/or inaccurate medication counts, and was terminated from employment and his/her license reported to the board.
-The facility reimbursed medication inventory for all residents and no resident went without prescribed medication.
Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnosis including hypertensive heart disease with heart failure (a condition where the heart is damaged due to prolonged high blood pressure) and chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body).
Review of the residents Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 4/11/25 showed the resident was moderately cognitively impaired.
Review of the resident's Medication Review Report dated 5/28/25 showed Hydrocodone 5 - 325 milligram (mg), give one tablet three times a day for pain.
Review of photocopy of the resident's bubble pack card containing Hydrocodone 5 - 325 mg dispensed 4/19/25 showed:
-Card contained 45 tablets when dispensed on 4/19/25.
-There were 28 pills in pack card when the copy was obtained on 5/7/25.
Review of the resident's Controlled Drug Record dated 4/29/25 through 5/3/25 showed:
-On 5/1/25 RN A signed out an additional Hydrocodone at 8:00 P.M.
-Three prior doses for 5/1/25 were signed out by other nurses.
-No other discrepancies noted on controlled drug record.
Review of the resident's Controlled Drug Record dated 5/3/25 through 5/7/25 showed:
-On 5/4/25 RN A signed out an additional Hydrocodone at 8:00 P.M.
-Three prior doses for 5/4/25 were signed out by other nurses.
-On 5/6/25 RN A signed out an additional Hydrocodone at 8:00 P.M.
-Three prior doses for 5/6/25 were signed out by other nurses.
-On 5/7/25 at 7:00 A.M. RN A signed out a dose for Hydrocodone, count was 31 tablets at that time.
-On 5/7/25 at 1:00 P.M. LPN A signed out a dose of Hydrocodone, count was 30 tablets at that time.
Review of the resident's MAR dated 5/1/25 through 5/31/25 showed:
-5/1/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose.
-5/4/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose.
-5/6/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose.
-No documentation noted for 5/1/25, 5/4/25 and 5/6/25 by RN A.
Review of the resident's progress notes dated 5/8/25 at 9:03 A.M. showed the family and physician were notified of the medication discrepancy.
*NOTE: no progress notes by RN A for additional hydrocodone doses for 5/1/25, 5/4/25 and 5/6/25 related to additional doses of narcotics and/or controlled medications administered and/or other form of accountability for the disposition of the medication.
2. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnosis including age-related cognitive deficit (declines in cognitive abilities like memory, reasoning, and judgment that are more significant than what's typically expected with normal aging) and pain in right hip.
Review of the residents Quarterly MDS dated [DATE] showed the resident was moderately cognitively impaired.
Review of the resident's Medication Review Report dated 5/28/25 showed:
-Hydrocodone 5 - 325 mg, give one tablet by mouth every six hours as needed for pain related to periprosthetic fracture around other internal prosthetic joint.
-Hydrocodone 5 - 325 mg, give one tablet orally two times a day for pain related to periprosthetic fracture around other internal prosthetic joint.
-Pregabalin 50 mg, give one capsule by mouth two times a day for nerve pain.
Review of the resident's Controlled Drug Record for Hydrocodone dated 5/1/25 through 5/7/25 showed:
-On 5/1/25 RN A signed out an additional Hydrocodone at 8:00 P.M.
-On 5/4/25 RN A signed out an additional Hydrocodone at 8:00 P.M.
-Two prior doses for 5/4/25 were signed out by other nurses.
-On 5/6/25 RN A signed out an additional Hydrocodone at 8:00 P.M.
-Two prior doses for 5/6/25 were signed out by other nurses.
Review of the resident's Controlled Drug Record for Pregabalin dated 5/1/25 through 5/7/25 showed:
-On 5/4/25 RN A signed out an additional Pregabalin at 8:00 P.M.
-Two prior doses for 5/4/25 were signed out by other nurses.
Review of the resident's MAR dated 5/1/25 through 5/31/25 showed:
-5/1/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose.
-5/4/25 at 7:00 P.M. Hydrocodone and Pregabalin was administered by the same nurse that signed the controlled drug record for that dose.
-5/6/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose.
- No documentation noted for 5/1/25, 5/4/25 and 5/6/25 by RN A.
Review of the resident's progress notes dated 5/8/25 at 8:51 A.M. showed the family and physician were notified of the medication discrepancy.
*NOTE: no progress notes by RN A for additional hydrocodone doses for 5/1/25, 5/4/25 and 5/6/25 related to additional doses of narcotics and/or controlled medications administered and/or other form of accountability for the disposition of the medication.
3. Review of Resident #3's admission Record showed the resident was admitted on [DATE] with diagnosis including dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) and chronic pain.
Review of the resident's Quarterly MDS dated [DATE] showed the resident was mildly cognitively impaired.
Review of the resident's Medication Review Report dated 5/28/25 showed an order for Clonazepam 1 mg, give one tablet by mouth three times a day for anxiety.
Review of the resident's Controlled Drug Record dated 4/25/25 through 5/5/25 showed:
-On 5/1/25 RN A signed out an additional Clonazepam at 8:00 P.M.
-Three prior doses for 5/1/25 were signed out by other nurses.
Review of the resident's Controlled Drug Record dated 5/5/25 through 5/7/25 showed:
-On 5/6/25 RN A signed out an additional Clonazepam at 8:00 P.M.
-Three prior doses for 5/6/25 were signed out by other nurses.
Review of the resident's MAR dated 5/1/25 through 5/31/25 showed:
-5/1/25 at 7:00 P.M. Clonazepam was administered by the same nurse that signed the controlled drug record for that dose.
-5/6/25 at 7:00 P.M. Clonazepam was administered by the same nurse that signed the controlled drug record for that dose.
-No documentation noted for 5/1/25 and 5/6/25 by RN A.
Review of the resident's progress notes dated 5/8/25 at 9:02 A.M. showed the family and physician were notified of the medication discrepancy.
*NOTE: no progress notes by RN A for additional Clonazepam doses for 5/1/25 and 5/6/25 related to additional doses of narcotics and/or controlled medications administered and/or other form of accountability for the disposition of the medication.
During an interview on 5/28/25 at 11:20 A.M. the DON said:
-He/She was informed of a discrepancy with the count for controlled substances on 5/7/25 at 1:00 P.M. by LPN A.
-Upon investigation he/she noted RN A was signing off controlled medications at about the same time as the previous nurse at 8:00 P.M.
-RN A never confirmed or denied he/she was taking the medications, but did apologize alleging he/she goofed up.
During an interview on 5/28/25 at 11:49 A.M. LPN A said:
-He/She counted controlled medications with RN A one time and there were no concerns noted at that time.
-He/She did not notice any unusual behaviors.
-He/She was the Clinical Coordinator.
-He/She did an audit of medications about once per month to ensure there were no expired medications or any other needs related to medications.
-He/She audits controlled medications looking for pattens of administration, if anything is given outside of timeframes, if a medication not being used or anything suspicious.
-The nurses are expected to review medications on the medication carts.
-The DON assists with controlled substance audits.
During an interview on 5/28/25 at 12:07 P.M. LPN B said:
-He/She counted with RN A two to three times.
-He/She counted with RN A on 5/7/25 and the count was correct.
-He/She was counting the number of pills in the cards from the pharmacy.
-RN A was confirming the numbers on the resident-specific controlled drug record for each medication.
-There were no numbers that did not match on 5/7/25.
-He/She left at approximately 10:30 A.M. on 5/7/25.
-He/She did not have anyone to count with and left the keys with the DON.
-Upon returning he/she counted the controlled substances with LPN A due to the discrepancy.
-When the discrepancy was confirmed about both nurses, it was then reported to the DON.
During an interview on 5/28/25 at 2:44 P.M. LPN A said:
-He/She counted with LPN B when he/she returned from his/her lunch break.
-The count was off and that was when they reported to the DON.
-Resident #1 was the only resident with the count discrepancy.
-Once the DON was notified there were additional discrepancies noted related to times when RN A had signed out medications.
-He/She and LPN B both submitted to urine drug screens and were both negative as far as he/she was aware.
During an interview on 5/28/25 at 3:06 P.M. RN A said:
-He/She started working at the facility mid April.
-He/She was no longer employed at the facility.
-He/She denied knowing why he/she was no longer working at the facility.
-The facility had questions about some medication errors, which was a simple mistake documentation wise.
-There were medications due at 7:00 P.M. that were sometimes given.
-When he/she came in, he/she would start medication pass.
-There were a couple of medications that were given, but he/she administered the medications as well.
-He/She was unable to recall what resident or medication was administered.
-It looked like the second week of May was when the medication error occurred.
-When counting controlled substances, the total amount of cards were counted, each medication was counted in each card.
-There was a sign off sheet in the from of the narcotic book where the nurses signed to confirm count was done at shift change.
-Scheduled controlled substances were to be signed in the controlled substance record and on the MAR on the computer.
-When passing medications he/she would look at the time in the administration record, administer as assess the resident.
-If an as needed (PRN) controlled substance, it should be documented when and why the medication was given in the controlled substance record and the MAR in the computer.
-Most of the medications in question were scheduled.
-He/She was not sure if the PRN medications were included in the progress notes.
-He/She did not chart in the progress notes for any of the residents' (Resident #1, #2, #3, #4 and #5) progress notes.
-He/She did not know how he/she would give controlled medications an hour apart.
-The residents got the medication and it was a screw up on his/her part.
-He/She was not aware of overdosing residents.
-He/She did not confirm utilizing the five rights of medication administration.
-He/she said he/she made some errors.
During an interview on 5/28/25 at 3:50 P.M. the DON said:
-He/She expects the nurse to count controlled substances at the beginning and at the end of each shift.
-While counting the nurses should stand side by side so that both nurses can observed the medications in the card and the controlled substance record.
-The DON, Clinic Coordinator or other delegated nurse are responsible for auditing controlled medications.
-When passing medications, staff passing medications are expected to triple check the orders and sign the controlled substance record and MAR as they go.
-The MAR should match the controlled substance record.
-Staff are expected to follow the five rights of medication administration.
During an interview on 6/3/25 at 11:06 A.M. law enforcement confirmed a report was filed and the investigation remained open at that time.
During an interview on 6/4/25 at 10:17 A.M. the Administrator said:
-He/She was informed of the controlled substance discrepancy on 5/7/25 once it was discovered by the DON.
-The DON handled the investigation and he/she completed the summary of the investigation.
-All new hire background checks are review by him/her.
-He/She did note RN A had some prior incidents however it had been more than 20 years without additional reports or concerns.
-During orientation all staff are educated on abuse and neglect, and all nurses and medication technicians are educated on medication administration, storage and controlled substances.
-He/She expected RN A to follow the policies and procedures for controlled substances and medication administration.
During an interview on 6/4/25 at 11:40 A.M. the physician said:
-He/She was aware of the discrepancy with the controlled substances on 5/7/25.
-Resident's #1, #2, and #3 would not be able to recall if they had gotten too much or not enough pain medication related to their diagnosis of dementia.
-There have been no reports of residents receiving too much medication by the staff or by any residents.
-He/She felt the medication was not administered a second time as there were no reports of any unusual behaviors or complications with any of the residents.
MO00253947

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that hot water temperatures from faucets throughout the facility, were consistently between 105 ºF (degrees Fahrenheit) and 120 ºF. Resident rooms [ROOM NUMBER]) on the South east side of the facility, had water temperatures between 94 ºF and 99 ºF. Resident rooms 14, 21, 22, and 12 on the north side of the facility had temperatures that were 120.2- 121.4 ºF; and Resident rooms [ROOM NUMBERS] had water temperatures between 76.1 ºF and 92.3 ºF .The facility also failed to ensure that staff who are checking temperatures allowed to flow for at least 2 minutes before measuring the water temperatures. This practice potentially affected all residents. The facility census was 35 residents.
Review of the facility's policy entitled Safe water Temperatures and dated 3/23, showed:
It is the policy of this facility to maintain appropriate water temperatures in resident care areas.
Policy Explanation and Compliance Guidelines:
1. Direct care staff will monitor residents during prolonged exposure to warm or hot water for any signs or symptoms of burns, and will respond appropriately.
2. Staff will be educated on safe water temperatures upon employment and on a regular basis.
3. Thermometers will be available as needed for use by all staff.
4. Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperature (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff.
5. Water temperatures will be set to a temperature of no more than 120° F and no less that 105, or the state's allowable maximum water temperature.
6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed.
7. Documentation of testing will be maintained for 3 years and kept in the maintenance office.
Review of the Section for Long Term Care Policy entitled Maximum/ Minimum Water temperatures revised 10/1/98, showed:
-State Regulations require that all facilities maintain water temperatures between 105 ºF--- 120 ºF at plumbing fixtures accessible to residents.
- DHSS staff shall use the dial or digital thermometers to measure water temperatures.
- In some situations, water temperatures may fluctuate significantly even at the same plumbing fixtures. Measurements at any water fixture should be taken for at least two minutes in order to determine fluctuation patterns or until the temperature has been constant for at least 30 seconds.
1. Review of water temperatures in the following rooms on 4/17/25, after the faucets were allowed to flow for two minutes, showed the following:
The water temperature in Resident room [ROOM NUMBER] was 76.1 ºF.
The water temperature in Resident room [ROOM NUMBER] was 92.3 ºF.
The water temperature in resident room [ROOM NUMBER], was 104.0 ºF.
The water temperature in the shared faucet or rooms [ROOM NUMBERS] was 104.1 ºF.
The water temperature in room [ROOM NUMBER] was 104.5 ºF.
The water temperature in room [ROOM NUMBER] was 94.4 ºF.
The water temperature in room [ROOM NUMBER] was 94.6 ºF.
The water temperature in room [ROOM NUMBER], was 99.5
ºF.
The water temperature in room [ROOM NUMBER], was 120.2 ºF.
The water temperature in room [ROOM NUMBER], was 121.4 ºF.
The water temperature in room [ROOM NUMBER] was 120.5 ºF.
The water temperature in room [ROOM NUMBER], was 120.7 ºF.
Observation on 4/17/24 at 1:12 P.M., showed the temperature gauge of the hot water heater was set at a temperature between 115 ºF and 116 ºF.
During an interview on 4/17/25 at 1:24 P.M., the Maintenance Assistant said the water from the hot water heater delivers water to a holding tank for the facility, then the holding tank delivers hot water to a mixing valve (a component in modern plumbing systems which has the function of blending hot and cold water to achieve a warm outlet temperature) to mix with water that is colder, then delivers the water to the facility.
During an interview on 4/17/25 at 5:50 P.M., the Administrator said the following about the cold water temperatures in resident rooms [ROOM NUMBERS]:
- The water that goes to those rooms has to travel a longer distance.
- Because the water in rooms [ROOM NUMBER] originates from the Assisted Living Facility (ALF) side and the ALF residents are not running water as often as the SNF residents.
During a phone interview on 4/22/25 at 2:07 P.M., the Administrator said:
- He/she was not aware of the water temperatures which varied so much prior to an incident where one resident was reported to had an issue while in the shower.
- Prior to that incident he/she was unaware of any plumbers being called to the facility to look at the issue of inconsistent water temperatures at the facility.
During a phone interview on 4/22/24 at 2:22 P.M., the Maintenance Person said:
- He/she was not sure what occurred on 4/17/25 to cause the inconsistent water temperatures.
- They did not have a correct method of how their water system would regulate hot water temperatures because of the adjustments that were made to the thermostats on the hot water heaters.
- He/she was confused to why there was such a wide variance in hot water temperatures.
- In the past they have not had any inconsistent with water temperatures.
- Facility leadership was evaluating whether to contact a professional plumber to look at their water pipe system.
- In the past, when he/she measured hot water temperatures, he/she let that water flow for one minute, before measuring the hot water temperature, because he/she was unaware of how the hot water should be measured.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 34 residents with a licensed capacity for 38 residents at the time of the survey.
1. Observation on 1/8/24 between 9:41 A.M. and 10:43 A.M. during the Life Safety Code (LSC) kitchen inspection showed a three-sink area, a chemical dish-washing machine, a handwashing sink, and an ice machine.
Observation on 1/11/23 between 12:47 P.M. and 1:48 P.M. during the facility LSC room-by-room inspections with the Assistant Operations Director (AOD) showed the following:
-There was a facility-wide fire sprinkler system.
-There was a boiler room, a beauty shop, and an employee break room in the basement.
-There were at least 20 resident rooms with sinks and bathrooms, a kitchenette, a bathhouse, a janitor's closet with a mop hopper sink, and a public restroom on the first floor.
Review of the facility's water-borne pathogen program entitled Water Management - Infection Control, last reviewed on 9/8/23, showed the following:
-There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188.
-There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
-Under the section Water Management Plan it read under point #2 that the facility implements a water management program that considers the ASHRAE industrial standard and the CDC toolkit.
During an interview on 1/16/24 at 1:45 P.M., the AOD said the following:
-He/She periodically tested water temperatures and flushed pipes.
-There were no tests for chloramine (A secondary disinfectant most commonly formed when ammonia was added to chlorine to treat drinking water to provide longer-lasting disinfection as the water moved through pipes to consumers) levels.
-The paperwork in their water management binder was their complete program.
-He/She was educated on the program with the Operations Director and he/she gradually took over the whole process.
During an interview on 1/16/23 at 2:26 P.M., the Administrator said the following:
-The Operations Director was responsible for the water management program there.
-They had taken a course about it over the last summer and had received instructions from a previous chief executive officer (CEO).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the facility reported an allegation of abuse immediately to the Administration when on 1/1/24 Certified Medication Technician (CMT) B attempted to get Resident #30's vital signs (temperature, pulse and respirations) which resulted in the resident becoming agitated, yelling and remaining upset after the alleged incident out of 12 sampled residents. The facility started their investigation on 1/8/24 seven days after the alleged incident. The facility census was 34 residents.
Review of the facility's Abuse, Neglect and Exploitation policy dated 10/2022 showed:
-It was the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedure that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.
-The facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, establish policies and procedures to investigate any such allegations, include training for new and existing staff on activities that constitute abuse, neglect, and exploitation, and establish coordination with the Quality Assurance and Performance Improvement (QAPI) program.
-The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.
-new and existing staff will receive education through planned in-services and as needed
-Training will include prohibiting and preventing all forms of abuse, neglect, misappropriation and exploitation; identifying what constitutes abuse, neglect, misappropriation, and exploitation; recognizing sighs of abuse, neglect, misappropriation, and exploitation; reporting process for abuse, neglect, misappropriation, and exploitation; and understanding behavioral symptoms of residents that may increase the risk of abuse such as:
--Aggressive reactions of residents.
--Wandering or elopement-type behaviors.
--Resistance to care.
--Outbursts or yelling out.
--Difficulty in adjusting to new routines or staff.
-The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury; not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
1. Review of Resident #30's Move-in Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses:
-Congestive Heart Failure (CHF a chronic condition in which the heart doesn't pump blood as well as it should).
-Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
Review of the resident's Adjustment Issues care plan, dated 10/5/23 showed:
-The resident was having issues related to his/her admission, affecting his/her daily living.
-Staff were to encourage ongoing family involvement.
-Staff were to encourage participation in activities of choice.
--The resident refused to go to activities or have activities brought to his/her room.
-Note: The care plan did not show behaviors or signs or symptoms of distress related to the adjustment issue and did not show what referrals or interventions the resident might need or what staff should do other than encourage family involvement.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 11/20/23 showed the resident:
-Was severely cognitively impaired.
-Had verbal behaviors directed towards others one to three days out of the past seven.
-Behaviors did not disrupt the resident's cares or living environment.
-Did not reject cares.
-Required supervision to moderate assistance with most Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting).
Review of the resident's progress note, dated 1/9/24 at 5:40 P.M. showed:
-It was reported that the resident said he/she was physically and emotionally abused by a worker. The resident described what the staff member looked like and the staff person gave him/her medication. The resident said the staff person had called him/her an asshole many times before and this time said he/she was not as mature as his/her [AGE] year old child. The resident said the staff person wanted to take his/her temperature and he/she said he/she didn't want the staff touching him/her.
-The resident said he/she tried to push the thermometer away and the staff used his/her strength and pushed the resident's hand to the resident's head and took the resident's temperature while the thermometer was still in the resident's hand.
-The resident said he/she didn't feel safe with that staff member in his/her room, but felt safe now.
-The resident said it was physical and verbal abuse and he/she didn't want it happening to anyone else.
-He/She told Licensed Practical Nurse (LPN) B.
-He/She had never saw or heard anyone else being abused, but he/she stayed in his/her room.
-The resident said he/she didn't think the staff person should talk that way or act that way. The staff person was belligerent and rude and he/she didn't want the staff person in his/her room anymore.
Review of the resident's Noncompliance care plan, dated 1/10/24 showed:
-The resident was noncompliant with medical treatments and cares and often refused cares, medications and help with ADL's.
-Staff were to ensure continuity of care and involve the resident in decisions affecting the resident.
-Note: The care plan did not show intervention options staff could try that might be beneficial to the resident.
Review of the resident's Staff to Resident Verbal and Physical Abuse Investigation Incident Summary, for an alleged incident dated 1/1/24 showed:
-LPN B reported on 1/8/24 at 4:46 P.M. to the MDS Coordinator that the resident reported he/she was physically and emotionally abused by a worker. The resident described the alleged perpetrator and said he/she gave his/her medications. The alleged perpetrator was identified as CMT B. The resident said CMT B had called him/her an asshole many times and told the resident he/she wasn't as mature as his/her [AGE] year old child. The resident said CMT B wanted to take his/her temperature and he/she didn't want CMT B touching him/her. He/She tried to push the thermometer away and CMT B used his/her strength and pushed the resident's hand to his/her forehead and took his/her temperature while the thermometer was still in the resident's hand. The resident said he/she felt safe at the time, but not when CMT B was in his/her room. The resident said it was physical and verbal abuse which he/she didn't want to happen to anyone else and he/she didn't want CMT B in his/her room anymore. The resident said he/she told LPN B.
-CMT B was placed on suspension pending investigation findings.
-CMT B said on 1/1/24 the resident verbally abused him/her, calling him/her several curse words and insisting he/she leave him/her alone when he/she attempted to take his/her vitals. He/She attempted to explain he/she had to take his/her vitals in order to give the resident's medicine and as a routine check. When he/she attempted to place the blood pressure cuff the resident said to get away from him/her and the resident pulled his/her own arm away. He/She left the room at the time. He/She denied saying anything negative to the resident at the time. CMT B said he/she would never tell the resident or say he/she was immature because it would demean the resident.
-All residents in the facility were interviewed and all denied staff being rough, rude or abusive, except for incidents which had already been investigated.
-Staff were interviewed to determine if anyone witnessed negative interactions with residents or if the resident was rude or mean to staff.
Review of the resident's Investigation Interview with CMT B dated 1/8/24 showed:
-He/She never said the resident was immature, never called the resident names, and would never be forceful with the resident.
-On 1/1/24 he/she was attempting to take the resident's vitals as part of his/her monthly vital routine. The resident was particularly grumpy and mean.
-When he/she began to wrap the cuff around the resident's arm the resident yelled at him/her, calling him/her a stupid bitch and stating he/she didn't want CMT B to take his/her blood pressure.
-When he/she attempted to remove the cuff the resident yanked his/her arm away and called him/her a bitch and accused him/her of abuse.
-He/She told the resident he/she wouldn't take his/her blood pressure and just needed his/her cuff back. The resident let him/her take the cuff and continued to yell abuse and he/she left.
-He/She didn't report the incident to the Administrator or DON because he/she thought the nurse would.
-He/She decided it was a behavior and would no longer go in the resident's room by himself/herself.
-From the time of the 1/1/24 incident he/she had taken another staff member with him/her when giving the resident's medications to protect himself/herself from the resident being mean to him/her.
Review of the resident's Investigation Interview with LPN B dated 1/8/24 showed:
-On 1/8/24 the resident told him/her he/she didn't want CMT B in his/her room anymore and explained CMT B had verbally and physically abused him/her.
-When CMT B tried to take his/her temperature he resisted by pushing CMT B's hand away, but CMT B held onto his/her hand and forced the thermometer to his/her forehead and said his/her [AGE] year old was more mature than him/her.
-The resident reported the allegation after 3:00 P.M. and CMT B had already left so he/she thought it had just happened on 1/8/24 and reported it to the MDS Coordinator.
Review of the resident's Investigation Interview with the resident dated 1/9/24 showed:
-On 1/9/24 the resident was interviewed and said there were two incidents in which CMT B was abusive to him/her and on one of the occasions CMT B was physically abusive to him/her.
-He/She reported the verbal and physical abuse incident to the nurse who came in his/her room when it happened, but didn't remember the nurse who came in.
-The two verbal incidents were when CMT B called him/her an asshole and when CMT B said his/her [AGE] year old child was more mature than him/her.
-He/She couldn't remember which time the physical abuse had happened. During the physical abuse he/she had a thermometer in his/her hand when CMT B forced his/her hand to his/her forehead to take his/her temperature and acknowledged it was odd that he/she should be holding the thermometer instead of CMT B.
-He/She confirmed repeatedly there had been no other incidents since 1/1/24.
Review of the resident's Investigation Interview with the MDS Coordinator dated 1/9/24 showed:
-He/She hadn't witnessed any abuse himself/herself.
-LPN B reported the allegation to him/her.
-He/She interviewed the resident who gave the same report he/she gave to LPN B.
Review of the resident's Investigation Interview with Registered Nurse (RN) A dated 1/9/24 showed:
-He/She did not witness the alleged incident, but on 1/1/24 he/she heard yelling from the resident's room. When he/she entered the room the resident was yelling abuse.
-He/She asked the resident what happened.
-CMT B said he/she was just trying to take the resident's vital signs and the resident was being mean. CMT B then left.
-The resident told him/her CMT B called him/her an asshole and was trying to force him/her to take his/her blood pressure. The resident didn't mention CMT B forced him/her to take his/her own temperature.
-He/She was dealing with a resident's transfer to the hospital and Emergency Medical Services (EMS) was there so he/she made sure the resident was safe and left the room.
-He/She was caught up in what he/she was doing and failed to report the alleged incident to the DON or Administrator and forgot about it until being interviewed for the investigation.
-He/She was unaware of any other problems since 1/1/24.
Review of the resident's Investigation Interview with Certified Nursing Assistant (CNA) B dated 1/9/24 showed:
-He/She had never heard a staff member being rude to the resident.
-Within the past week CMT B asked him/her to accompany him/her while giving the resident his/her medication.
-He/She had witnessed the resident being rude to CMT B on a few occasions, calling him/her names and telling CMT B to get out of his/her room.
-He/She hadn't witnessed CMT B being rude or mean.
-There were a few residents who would get pretty rude and the resident was one of them. Staff just have to be kind to the resident and smile and not take it personally.
Review of the resident's undated Investigation Interview with CNA C showed:
-He/She had never heard the resident or any other resident complain of a rude staff member or one who had been abusive and had never witnessed that himself/herself.
-He/She had never been in the room with the resident and CMT B.
-The resident could be tough to deal with if he/she was in a bad mood.
-He/She had never heard the resident cuss at staff.
Review of the resident's undated Investigation Interview with the DON showed:
-The resident could be grumpy, but was easy to keep calm and talk to if a person just listened. The resident would go on for a while though.
-He/She had to provide coaching to CMT B before on his/her tone of voice with residents, but had never heard CMT B call residents names or seen him/her be physically forceful with them.
Review of the Investigation Interview section of the resident's investigation showed:
-Ten additional staff, whose names and dates of interviews were not identified, said they had not heard of issues of staff being rude or abusive to residents. They all reported the resident could be difficult to care for if he/she was in a bad mood which was often.
-The MDS Coordinator interviewed all other residents who all denied being a victim of or witnessing abuse.
Review of the Investigation Conclusion showed:
-The facility couldn't substantiate that physical or verbal abuse took place.
-There were not enough facts provided with witnesses on either account of the alleged incident to confirm who was telling the truth and there was no physical evidence of abuse.
-There was no established pattern of behavior or witness statements to confirm either party was telling the truth.
-Staff failed to notify management of the alleged incident when it first was presented, therefore the facility failed to report the abuse allegation in a timely manner. The allegation was reported and investigated immediately once management was made aware.
Review of the Investigation Corrective Actions showed:
-The resident was interviewed and confirmed he/she felt safe in the facility as long as he/she didn't have to interact with the CMT B.
-The resident would receive cares in pairs to confirm he/she was safe from other possible allegations.
-CMT B was immediately suspended pending investigation and had been terminated for other performance related issues unrelated to abuse.
-Staff were educated on abuse and neglect, including reporting allegations immediately to the DON or Administrator.
During an interview on 1/10/24 at 11:58 A.M. LPN B said:
-The resident asked him/her to come into his/her room and said he/she didn't want that other nurse to come. He/She said CMT B was always mean to him/her and said his/her [AGE] year old child was more mature than him/her. CMT B didn't know how to talk to people. CMT B was rude and mean and shouldn't be taking care of residents.
-He/She knew CMT B had a [AGE] year old child so it seemed possible CMT B might have said that.
-He/She spoke to CMT B to ask what happened. CMT B said he/she tried to take the resident's temperature and the resident tried to grab his/her hand. The resident said don't touch me and didn't want him/her in his/her room. CMT B said he/she told the resident he/she had to take his/her vital signs and he/she never offered to get another staff person. CMT B just went ahead and got the resident's vitals.
-The resident had a right to refuse getting his/her vital signs. The staff were all educated on that.
-CMT B told me after the resident grabbed him/her, he/she told the resident he/she wasn't as mature as his/her [AGE] year old child because the resident was being rude to him/her.
-He/She never heard from either CMT B or the resident that CMT B forced the resident's hand to his/her forehead in an attempt to take his/her temperature.
-The resident said he/she didn't want that bitch in his/her room.
-Verbally CMT B comes off as being rough in his/her tone. He/She would tell a resident he/she was busy and didn't have time to do something for them. He/She had spoken to CMT B about his/her tone of voice and to come to him/her if he/she had any problems with any residents.
-He/She had never seen CMT B physically rough with any residents. CMT B's tone of voice was blunt and he/she would sometimes tell a resident he/she was passing medications and was busy instead of seeing if he/she could quickly help. His/Her natural tone of voice was loud and sounded abrasive.
-He/She had talked with CMT B twice about his/her tone of voice and he/she would do better for a while.
-CMT B's focus was on whatever he/she was doing and he/she acted like interruptions were an inconvenience. He/She made residents feel like that. He/She could be nice to residents as well, but was very task focused.
During an interview on 1/10/24 at 1:00 P.M. the resident said:
-CMT B called him/her an asshole and said he/she wasn't as mature as his/her [AGE] year old child.
-There was a physical incident when CMT B wanted to take his/her temperature. He/She told CMT B he/she didn't want him/her taking his/her temperature because he/she had called him/her an asshole one other time. CMT B used force as he/she used counterforce to keep his/her hands and thermometer off his/her forehead. CMT B went ahead and was trying to take his/her temperature anyway, but not with his/her full strength. CMT B kept pushing forward and forced the thermometer onto his/her forehead.
-He/She yelled out he/she was being abused.
-Someone opened the door and he/she told them he/she was being abused, but CMT B said no, he/she wasn't being abused and his/she was just taking his/her temperature.
-The other staff left.
-Days later LPN B came and talked with him/her about it and said he/she had talked with CMT B. He/She hadn't seen CMT B since.
-He/She was afraid CMT B wasn't capable of cleaning up his/her act. He/She didn't want CMT B going around acting like he/she did with him/her.
-He/She hadn't done anything to provoke a comment like being called an asshole. He/She thought that could be classified as either verbal abuse or rudeness. In his/her mind it was verbal abuse. In CMT B's mind he/she didn't do anything wrong. In CMT B's mind the resident should do anything he/she told them to do, but the resident had the final rule on what was done in their care.
-When he/she tried to push CMT B away from taking his/her temperature CMT B said his/her [AGE] year old child was more mature than him/her. When he/she forced the thermometer on his/her forehead he/she would call that abuse. He/She had the right to say no which CMT B completely disagreed with.
During an interview on 1/10/24 at 1:30 P.M. the Administrator said:
-The alleged incident happened 1/1/24.
-He/She interviewed RN A who said he/she de-escalated the situation and was busy with another resident's transfer to the hospital and forgot to report to the DON and Administrator.
During an interview on 1/10/24 at 1:57 P.M. RN A said:
-He/She was busy with trying to get a resident sent out to the hospital emergency room (ER) when he/she heard the resident yelling out hey, hey, hey.
-He/She told the Emergency Medical Technicians (EMT's) he/she needed to check on the resident.
-When he/she got to the resident's room CMT B was in there. When he/she opened the door CMT B had a blood pressure cuff on the resident's wrist and said he/she was trying to get the resident's blood pressure and the resident didn't want that.
-He/She would have told CMT B not to get the resident's blood pressure and that the resident had a right to refuse, but the cuff was already on and at that point the resident had stopped yelling and was allowing CMT B to get his/her blood pressure.
-He/She told the resident he/she would come back and they would talk.
-He/She left to make sure the other resident got sent out and EMS didn't need anything else from him/her.
-He/She returned to the resident's room. The resident said he/she didn't want his/her blood pressure taken and that CMT B was forcing him/her and held his/her hand close to his/her (the resident's) chest. CMT B was forcing him/her to do something he/she didn't want to do which was abusive. When the resident talked with him/her he/she was adamant about getting it reported. He/She told the resident he/she would talk with CMT B.
-He/She talked with CMT B and told him/her the resident alleged he/she called him/her an asshole. CMT B just rolled his/her eyes and gave a smile like the resident's accusations weren't true and never acknowledged he/she said that.
-He She could never recall the resident ever saying any other staff person was abusive.
-The resident could be a little agitated at times. He/She could tell something had set the resident off.
-He/She told the resident CMT B would not come back into his/her room.
-He/She thought the incident in which CMT B said his/her [AGE] year old child was more mature than the resident was a separate one that happened after 1/1/24. The resident didn't mention that on 1/1/24.
-CMT B came across abrasively. It was the way he/she presented himself/herself to the residents. He/She was very short with the residents. For example CMT B rushed when he/she gave residents their medications. He/She wasn't warm with the residents and was focused on getting his/her job done.
-He/She felt it was a dignity issue, like someone who wasn't concerned about the resident's needs, just in getting the job done.
-He/She had never heard CMT B yell at a resident.
-He/She had been educated after the 1/1/24 incident by the Administrator to report to the DON or Administrator with any issues that might be abuse or need addressing. He/She was educated to put any incidents involving a resident in a progress note, complete an incident note and get all staffs' statements.
During an interview on 1/12/24 at 1:09 P.M. CMT B said:
-On 1/1/24 he/she went around the facility getting vital signs on all the residents.
-He/She told the resident he/she had to get his/her vital signs. The resident seemed OK with that until he/she put the blood pressure cuff on his/her wrist and it started tightening. The resident said Ouch, your hurting me. Take it off me.
-He/She was reaching to get the blood pressure cuff and the resident jerked his/her hand away. He/She told the resident he/she had to take the cuff off in order to keep it from tightening on his/her wrist. The resident called him/her a bitch, said he/she was fucking stupid and told him/her to get the fuck out of his/her room.
-He/She pushed a button and it released pressure on the cuff. He/She told the resident he/she had to take the cuff off and wasn't leaving without the cuff.
-He/She denied calling the resident an asshole at that time or any other time and denied he/she told the resident his/her [AGE] year old child was more mature than him/her.
-He/She denied getting or trying to take the resident's temperature.
-CNA C came into the room and asked the resident what he/she needed. The resident told CNA C to get CMT B out of his/her room.
-He/She was in the process of leaving anyway, so he/she just walked out of the resident's room. The nurse never walked into the resident's room (Note: This statement was inconsistent with statements made by CNA C and RN A.)
-LPN B told him/her the resident didn't want him/her in his/her room at all.
-A few months back LPN B told him/her he/she came across as mean and like he/she was mad at the residents. He/She told LPN B he/she tried to stay neutral.
-The DON had talked with him/her about walking away if he/she became frustrated and getting the charge nurse. That was when one of the residents refused to take medication from him/her because of his/her race. He/She might have sighed when the resident said that.
-He/She should have asked the resident if he/she was OK with him/her getting the resident's vital signs prior to just taking them. He/She just assumed it would be OK.
-Since the incident on 1/1/24 the resident would tell him/her, he/she didn't want his/her medications from him/her and to get out of his/her room. He/She would tell a nurse. He/She assumed the resident's being angry with him/her was just temporary.
-He/She might have come across as angry with him/her on 1/1/24 because he/she told the resident he/she had to get his/her blood pressure and hadn't asked the resident if he/she could do so. He/She could have asked another CNA to get the resident's vitals. On 1/1/24 he/she had to ask the nurse to give the resident his/her medications because he/she was so angry with him/her.
-He/She probably could have approached the resident with a smile and greeted him/her before he/she got started. That would have made a difference. He/She was just focused on getting the resident's blood pressure because staff have to get it before giving the resident one of his/her medications.
During an interview on 1/18/24 at 10:51 A.M. the Administrator said:
-He/She expected nurses to talk with staff if there were dignity issues and to report them to the DON immediately who would review the issues with him/her.
-He/She and the DON would decide if Human Resources needed to be involved and have documentation in the employee's record.
-Staff should do a grievance on the resident's behalf so the issue could be addressed.
During an interview on 1/18/24 at 11:37 A.M. the DON said:
-All staff have been educated on dignity upon hire before they ever work on the floor and dignity education was presented throughout the year in monthly meetings.
-He/She had to talk to CMT B a number of months ago about paying attention to his/her tone of voice. When the residents' anxiety levels increased it tended to cause CMT B's anxiety level to increase.
-If there was a possible dignity issue Social Services should complete a resident grievance. If substantiated there would be documentation in the employee's Human Resources file.
-CNA's should report dignity issues to him/her. When in doubt if there was a possible dignity or abuse issue they should report to both him/her and the Administrator.
-Nurses should make sure the resident was OK if they had a complaint against a staff member and they should assign a different CNA to the resident. Nurses should talk to the resident about how they were feeling and let him/her (the DON) and the Administrator know immediately of all dignity and possible abuse issues.
MO00230038

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility 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 of transfer from the facility for two sampled residents (Residents #17, and #32) out of 12 sampled residents. The facility census was 34 residents.
The facility did not have a policy for Ombudsman notification.
1. Review of Resident #17's admission Record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnoses:
-Acute (severe and sudden onset) respiratory failure (a condition where there is not enough oxygen in body tissues) with hypoxia (insufficient oxygen in the blood).
-Pneumonia (an infection that affects one or both lungs).
Review of the resident's hospital record showed he/she admitted to hospital on [DATE] and discharged back to the facility on 8/21/23 for Acute Respiratory failure with Hypoxia.
Review of the facility Ombudsman notification dated August 2023 showed that the facility failed to send the Ombudsman notification of any discharges to hospital.
During an interview on 1/11/24 at 12:47 P.M., the Director of Nursing (DON) said:
-The Business Office Manager (BOM) left the position in March 2023.
-The new BOM had not been sending anything to the Ombudsman.
-A bed hold notification and policy was sent to the resident's family.
-The resident left to the hospital on 8/13/23 and returned on 8/21/23 to his/her original room.
-The current BOM did not know he/she was supposed to be sending discharge notices to the Ombudsman.
-Note: The BOM was out of the building during the interview process.
2. Review of Resident #32's discharge Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by the facility staff) dated 10/31/23 showed a discharge return not anticipated.
Review of the resident's electronic record on 1/11/24 showed no documentation of the Ombudsman being notified of the resident's discharge to the Assisted Living Center on 10/31/23.
During an interview on 1/16/24 at 12:00 P.M., the Administrator said:
-His/Her expectation was for the BOM to notify the state Ombudsman of resident discharge or transfers monthly.
-He/She was responsible of ensuring that the state Ombudsman was notified by the BOM of resident transfer and discharges at least monthly.
--Note: BOM out of building during interview process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to submit a resident's discharge assessment for one supplemental resident (Resident #28) out of four residents who triggered for assessment concerns. The facility census was 34 residents.
There were no policies for this example.
1. Review of Resident #28's discharge assessment dated [DATE] showed it was not submitted to Centers for Medicare & Medicaid Services (CMS) and was marked do not submit to CMS on 9/8/23.
Review of the Resident Assessment Instrument (RAI) Manual dated October 2023 showed the following on page 1 of chapter 5:
-Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS a federally mandated assess tool completed by facility staff for care planning) records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source.
During an interview on 1/11/24 at 7:59 A.M., the MDS Coordinator said he/she did not submit private pay resident's assessments to CMS.
During an interview on 1/16/24 at 1:15 P.M., the Director of Nursing said he/she expected the MDS to be completed and submitted accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for three sampled residents (Residents #19, #31 and #3) out of 12 sampled residents. The facility census was 34 residents.
Review of the facility's MDS 3.0 completion policy dated 2022 showed the facility would conduct an accurate assessment of the resident.
1. Review of Resident #19's care plan dated 3/1/23 showed:
-The resident had a regular diet with mechanical soft texture (a texture-modified diet that restricts foods that are difficult to chew or swallow. Foods are finely chopped, blended, or ground to make them smaller, softer, and easier to chew) and regular, thin liquids.
-The resident admitted to hospice services (end of life care) on 5/19/23.
-An update on 8/5/23 showed the resident had weight loss over the last four months.
-No interventions of receiving tube feeding (a medical device used to provide nutrition to individuals who cannot obtain nutrition by swallowing) or fluids intravenously (IV-a tube placed into a vein).
Review of the resident's significant change MDS dated [DATE] showed the resident weighed 117 pounds.
Review of the resident's quarterly MDS dated [DATE] showed the resident weighed 107 pounds.
Review of the resident's quarterly MDS dated [DATE] showed the following assessment of the resident:
-Weighed 99 pounds.
-Did not have significant weight loss (Significant weight loss is defined as 5% or more in the last month or 10% or more in the last six months. 117 pounds down to 99 pounds is a weight loss of 18.18% in six months, which is significant).
-Was not on hospice.
-Was not on a mechanical soft diet.
-The proportion of total calories the resident received through parenteral (feeding of nutritional products to a person through intravenous (an IV) or tube feeding was 51% or more.
-The average fluid intake per day by IV or tube feeding was 501 cubic centimeter (cc)/day or more.
Observation on 1/8/24 at 10:37 A.M., 10:57 A.M., and 11:14 A.M. showed the resident was not receiving tube feeding or fluids by IV.
Observation on 1/10/24 at 9:34 A.M. and 10:28 A.M. showed the resident was not receiving tube feeding or fluids by IV.
Observation on 1/10/24 at 10:30 A.M. showed the resident had multiple beverages that were thin consistency, was being fed food of soft consistency by hospice staff and was not receiving tube feeding or fluids by IV.
Observation on 1/11/24 at 5:21 A.M. showed the resident was not receiving tube feeding or fluids by IV.
During an interview on 1/11/24 at 7:59 A.M., 1/11/24 10:04 A.M. and 1/16/24 at 9:06 A.M., the MDS Coordinator said:
-The resident went on hospice on 5/19/23.
-He/She made an error on hospice on the MDS.
-He/She should have marked yes for hospice.
-He/She marked the wrong box for diet and artificial route.
-The resident's diet should have been marked as mechanical soft.
-The resident's mechanical soft diet started 5/4/23.
-Weight loss should have been marked as yes.
Review of the resident's Physician's Order Sheet (POS) dated 1/16/24 showed the resident:
-Had a diet order dated 5/4/23 of a regular diet with mechanical soft texture and regular, thin fluid consistency.
-Had an order for hospice dated 6/21/23.
-Did not have an order for tube feeding or fluids by IV.
2. Review of Resident #31's admission MDS dated [DATE] showed:
-The proportion of total calories the resident received through parenteral or tube feeding was 51% or more.
-The average fluid intake per day by IV or tube feeding was 501 cc/day or more.
Review of the resident's care plan dated 1/8/24 showed:
-The resident had a regular diet with regular texture and regular/thin liquids.
-No interventions of receiving tube feeding or fluids by IV.
Observation on 1/8/24 at 10:36 A.M. showed the resident was not receiving tube feeding or fluids by IV.
Observation on 1/10/24 at 8:49 A.M., showed the resident was eating a regular texture breakfast and was not receiving tube feeding or fluids by IV.
Observation on 1/10/24 at 9:17 A.M., at 9:34 A.M., at 10:27 A.M., and at 11:19 A.M. showed the resident was not receiving tube feeding or fluids by IV.
During an interview on 1/11/24 at 7:59 A.M. and 10:04 A.M., the MDS Coordinator said the two items were marked incorrectly on the resident's MDS.
Review of the resident's POS dated 1/11/24 showed the resident:
-Had a diet order dated 12/22/23 of regular texture and regular, thin fluid consistency.
-Did not have an order for tube feeding or fluids by IV.
3. Review of Resident #3's care plan dated 9/15/23 showed:
-The resident had a suprapubic catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis).
-The resident was able to feed himself/herself.
-The resident had a diet order of mechanical soft texture and regular/thin fluid consistency.
Review of the resident's admission MDS dated [DATE] showed the following staff assessment of the resident:
-Had an indwelling catheter (a tube passed through the urethra into the bladder to drain urine).
-Was always incontinent of bladder (The MDS directed users to mark urinary incontinence not rated when an indwelling catheter was in use).
-Mechanically altered diet was left blank.
Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:
-Had an indwelling catheter.
-Was always incontinent of bladder.
-The resident was on a mechanically altered diet.
-The proportion of total calories the resident received through parenteral or tube feeding was 51% or more.
-The average fluid intake per day by IV or tube feeding was 501 cc/day or more.
Observation on 1/8/24 at 11:22 A.M. showed the resident:
-Was not receiving tube feeding or fluids by IV.
-Had a urinary catheter.
Observation on 1/10/24 at 9:45 A.M. and 11:04 A.M. through 11:27 A.M. showed the resident:
-Was not receiving tube feeding or fluids by IV.
-Had a urinary catheter.
Review of the resident's POS dated 1/11/24 showed the resident:
-Had a diet order dated 9/12/23 of regular diet with mechanical soft texture and regular, thin fluid consistency.
-Did not have an order for tube feeding or fluids by IV.
-Had an order for a suprapubic catheter dated 9/12/23.
During an interview on 1/11/24 at 7:59 A.M. and 10:04 A.M., the MDS Coordinator said:
-He/She always marked incontinent of bladder if the resident had an indwelling catheter.
-He/She did not know it should be marked not rated on the MDS if the resident had an indwelling catheter.
-The resident was on a mechanical soft diet.
-He/She marked the wrong box for tube feeding and IV fluids.
4. During an interview on 1/16/23 at 1:15 P.M., the Director of Nursing said he/she expected the MDS's to be accurate.

Based on interview and record review, the facility failed to develop a comprehensive care plan that included one high risk medication for one sampled resident (Resident #31) out of five residents sampled for medication review. The facility census was 34 residents.
There were no policies for this example.
1. Review of Resident #31's care plan dated 12/28/23 showed no care plan for the use of anticoagulant medication.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed the resident was on an anticoagulant (medication used to slow down the blood clotting process) medication.
Review of the resident's Physician's Order Sheet (POS) and Medication Administration Record (MAR)'s dated January 2024 showed a physician's order dated 12/22/23 for Eliquis (an anticoagulant) 5 milligrams (mg), one tablet by mouth two times a day related to heart disease.
During an interview on 1/16/24 at 9:06 A.M., the MDS Coordinator said he/she did not usually care plan for anticoagulant medications.
During an interview on 1/16/24 at 1:15 P.M., the Director of Nursing (DON) said he/she would expect the use of anticoagulant medication to be in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's Insulin Pen Policy dated 2022 showed:
-Prime the insulin pen.
-Dial two units by turning the dose selector clockwise.
-With needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on tip of the needle. If not, repeat until at least one drop appears.
Review of Resident #23's quarterly MDS dated [DATE] showed:
-He/She was cognitively intact.
-He/She was diagnosed with Insulin Dependent Diabetes.
-He/She received Insulin injections seven out seven days during the assessment look back period.
Observation on 1/10/24 at 11:12 A.M., of Registered Nurse (RN) A showed he/she did not prime the insulin pen prior to administration of insulin.
During an interview on 1/10/24 at 11:22 A.M., RN A said he/she had never been instructed to prime insulin pens prior to administering insulin even from the pharmacy.
During an interview on 1/16/24 at 1:15 P.M., the DON said:
-He/She would expect insulin pens be primed prior to administering.
-He/She would be responsible to audit that insulin was being administered correctly.
-He/She was not aware insulin pen's were not being primed.
Based on observation, interview, and record review, the facility failed to ensure medications were administered safely and were not left at bedside for one sampled resident (Resident #25) and to prime a insulin pen prior to administration for one sampled (Resident #23) out of 12 sampled residents. The facility census was 34 residents.
Review of the facility's Resident Self-Administration of Medication Policy dated November 2017 showed:
-A Resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.
-All Nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary.
1. Review of Resident #25's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/10/23 showed:
-The resident was moderately cognitively impaired.
-He/she was independent or required supervision with his/her activities of daily living (ADL's eating, dressing, bathing, and toileting).
Review of the resident's Care Plan dated 10/23/23 showed:
-There was no assessment or plan for self-administration of medications.
-There was no assessment or plan to have medications at bedside.
Review of the resident's Medication Administration Record (MAR) dated December 2023 showed:
-Calcium Carbonate Tablet (Tums an antacid used to treat heartburn) 500 milligram (mg), give 1 tablet by mouth two times a day for Heartburn.
-Lactulose Encephalopathy Oral Solution (used to treat constipation) 10 grams (gm)/15 milliliter (mL), give 15 mL by mouth two times a day for constipation.
-GlycoLax Powder (Polyethylene Glycol 3350 - Miralax used to treat constipation) give 17 gm by mouth two times a day for constipation.
-No order for medications to be left at bedside.
-No order for Milk of Magnesia (used as an antacid or laxative).
-No order for a throat spray.
Review of the resident's MAR dated January 2024 showed:
-Tums 500 mg, give 1 tablet by mouth two times a day for Heartburn.
-Lactulose 10 gm/15 mL by mouth two times a day for constipation.
-Miralax give 17 gm by mouth two times a day for constipation.
-No order for medications to be left at bedside.
-No order for Milk of Magnesia.
-No order for a throat spray.
Review of the resident's Physician's Order Sheet (POS) dated January 2024 showed:
-Tums 500 mg, give 1 tablet by mouth two times a day for Heartburn.
-Lactulose 10 gm/15 mL by mouth two times a day for constipation.
-Miralax give 17 gm by mouth two times a day for constipation.
-No order for medications to be left at bedside.
-No order for Milk of Magnesia.
-No order for a throat spray.
Observation on 1/8/24 at 10:24 A.M., of the resident's room showed:
-A medicine dosage cup with a large chewable tablet on the overbed table.
-A medicine dosage cup with pink liquid on the overbed table.
-A bottle of throat spray on the nightstand.
During an interview on 1/8/24 at 10:24 A.M., the resident said:
-The pink liquid was Milk of Magnesia.
-The large chewable tablet was Tums.
-Staff would put the medications on the table, and he/she would take them when he/she wanted.
Observation on 1/10/24 at 10:21 A.M., of the resident's room showed:
-A medicine dosage cup with pink liquid was on the overbed table.
-A bottle of throat spray was on the nightstand.
Observation on 1/11/24 at 5:54 A.M., of the resident's room showed:
-A medicine dosage cup with a Tums was on the overbed table.
-A bottle of throat spray was on the nightstand.
Observation on 1/11/24 at 7:07 A.M., of the resident's room showed a bottle of throat spray was on the nightstand.
During an interview on 1/11/24 at 9:59 A.M., Licensed Practical Nurse (LPN) A said:
-The only liquid medication the resident received was Lactulose (used to treat constipation).
-The resident did not have any liquid medication ordered that was pink in color.
Observation on 1/16/24 at 9:15 A.M., of the resident's room showed a bottle of throat spray on the nightstand.
During an interview on 1/16/24 at 9:33 A.M., Certified Medication Technician (CMT) A said:
-He/she followed the instructions on the MAR regarding route, time, and dosage.
-The MAR should match the POS.
-Any Over the Counter (OTC) medications should be on the MAR.
-Staff cannot leave medications at bedside, even if the resident tells them to just leave that medication on the table.
-Staff must watch the resident take all medications.
-There should be an order for an oral throat spray.
-There should be an order for Milk of Magnesia.
-There should be an order for everything.
-If he/she saw a medication in a resident's room that was not on the MAR, he/she would take it out of the room and give it to the nurse.
-He/She had not seen any medications in the resident's room.
-The resident should not have an oral throat spray at bedside.
-No residents were able to self-administer medications.
-There should be no medications at bedside.
-The resident did not have an order for an oral throat spray.
-The resident did not have an order for Milk of Magnesia.
-The only medications that should be given were on the MAR.
-He/She would go to the nurse who would follow up with the doctor if a resident wanted a medication not on the MAR.
-The resident had an order for Tums and Miralax.
-The resident did not like the Miralax.
-The resident had asked for Milk of Magnesia instead of Miralax.
-The Tums was scheduled to be given at 8:00 A.M. and 8:00 P.M., the order did not indicate it was to be left at bedside.
During an interview on 1/16/24 at 10:59 A.M., LPN B said:
-The only pink liquid in the medicine cart was Milk of Magnesia, cherry flavor.
-The resident did not have an order for Milk of Magnesia.
-All PRN medications should be on the MAR.
-There had to be an order to leave medications at bedside.
-No resident's had an order for medications to be left at bedside.
-There should be an order for throat spray.
-There should be an order for Milk of Magnesia.
-There should be an order for anything the resident was taking.
-The MAR should match the POS.
-All OTC medications should be on the MAR.
-CMT's should follow the MAR, and only give medications that were on the MAR.
-When a Certified Nursing Assistant (CNA) or CMT saw any medication at bedside, they should remove it from the resident's room and give it to the charge nurse.
-If he/she saw medications at bedside, he/she would remove it and throw it away.
-He/She said the resident should not have medications at bedside.
-The Tums should not have been left at the resident's bedside.
-The resident did not have orders for Milk for Magnesia or a throat spray.
-Self-administering medications was not appropriate without an order.
-All medications should be on the MAR. These should be the only medications given.
-If a resident asked for a medication, staff should tell the nurse, and the nurse should call the physician.
During an interview on 1/16/24 at 11:39 A.M., the Director of Nursing (DON) said:
-He/she expected the MAR to be followed when passing medications.
-The MAR and POS should match.
-He/She did not recall any resident having an order for medications at bedside.
-The resident had an order for Milk of Magnesia last summer that was discontinued and not reordered.
-The resident should not have any medications at bedside, including Tums, Milk of Magnesia, and a throat spray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to put adequate supervision measures in place to prevent a newly admitted resident, who was assessed to be an elopement risk and showed signs of confusion and exit seeking behaviors, from leaving the facility unannounced for one sampled resident (Resident #335) and to complete an Annual or quarterly Safe Smoking Assessment to assess the resident's ability to safely smoke electronic cigarette with or without supervision for one sampled resident (Resident #20) out of 12 sampled residents. The facility census was 34 residents.
Review of the facility's Elopement and Wandering Resident policy/procedure, dated 2022, showed:
-Residents would be assessed for their risk of elopement and unsafe wandering upon admission and throughout their stay.
-The interdisciplinary team would evaluate the unique factors contributing to the elopement risk in order to develop a person-centered care plan.
-Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or minimize hazards will be added to the resident's care plan and communicated to appropriate staff.
-Adequate supervision will be provided to help prevent accidents or elopements.
-Charge nurses will monitor the interventions, resident response to interventions, and document accordingly.
-The effectiveness of interventions will be evaluated and changes made as needed. Any changes and new interventions will be communicated to relevant staff.
1. Review of Resident #335's Move-in Record showed the resident was admitted to the facility on [DATE] and had the following diagnoses:
-Metabolic encephalopathy (A problem in the brain that can result in personality changes caused by a chemical imbalance of the blood affected by illness or organs not working as well as they should).
-Repeated falls.
-Restlessness and agitation.
Review of the resident's progress notes dated 1/3/24 showed:
-At 3:38 P.M. the resident was assessed to be at risk for elopement. The assessment showed the resident verbally expressed a desire to go home, packed his/her belongings to go home or stayed near an exit door. He/She wandered both aimlessly and in a goal-directed pattern with wandering likely to affect the safety or well-being of others. The resident had not yet accepted his/her admission situation.
-At 3:47 P.M. the resident ambulated with a walker and needed supervision and minimal assistance with Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting). He/She was currently walking the halls with a family member. The resident may be a possible elopement risk.
Review of the resident's Order Summary Report (OSR) showed the resident had an order for staff to check for elopement risk every shift starting on 1/3/24.
Review of texts sent to facility department heads, dated 1/3/24 showed:
-A text was sent at 5:19 P.M. showing:
--A newly admitted resident (Resident #335's name was shown) was exit seeking and may need a locked unit.
--Labs and a urinalysis to be completed.
--Hourly rounds started to see if the resident would calm down, and if not, referrals for other placement would be made.
--When coming to the facility be mindful and inform your staff to watch who was behind them when they are coming and going.
-A text sent at 5:21 P.M. showed the new resident pulled the fire alarm.
Review of the resident's progress notes dated 1/3/24 showed:
-At 5:46 P.M. the resident was found to have pulled the fire alarm. When asked about it the resident said something was wrong with the place and there were fires everywhere. According to a Certified Nurse Assistant (CNA) the resident was looking out the door and then looked over and pulled the fire alarm. The resident stated this was the military and the staff were his/her soldiers.
-At 6:20 P.M. the Social Services Director (SSD) was giving a report on the resident to a local medical hospital.
-At 10:49 P.M. the nurse received a call from the hospital Emergency Department (ED) indicating the resident had been diagnosed with a Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system), would be on antibiotic therapy (ABT) and would be returning to the facility.
-The resident returned to the facility at 11:15 P.M. and was observed to be very unsteady while standing and continued to be confused. The resident preferred to keep on his/her street clothes when assisted to bed. The resident was confused and talked about being in the Reserve Officers Training Corps (ROTC) and Army Reserves.
Review of the resident's progress notes dated 1/4/24 showed:
-At 7:54 A.M. the resident was observed taking his/her brief off and urinating in the trash. He/She was given a urinal, but continued to show signs and symptoms of confusion. He/She was alert to self and his/her name. Staff to reassure and orient as needed.
-At 10:18 A.M. the SSD the resident was referred for a memory care facility.
-At 10:28 A.M. the resident was spotted by a CNA trying to exit the back door and had to be redirected. The resident continued to wander the unit and was seen trying to get onto the elevator. He/She was placed on 15 minute checks.
-At 10:44 A.M. the resident wandered at night and used a walker.
-At 11:53 A.M. at about 11:40 A.M. the resident pulled the fire exit door sounding the alarm. He/She was able to be retrieved before exiting out the door and redirected. Staff explained it was unsafe to leave the facility without a guest or family member. The resident appeared to be confused about the situation and insisted he/she needed to get out. At this time a Certified Medication Technician (CMT) was sitting with the resident one to one for safety and to prevent him/her pulling the fire alarm again.
-At 11:54 A.M. the SSD sent referrals for placement to multiple facilities for the resident.
Review of the resident's Risk for Wandering/Elopement care plan, initiated 1/4/24 showed the following interventions:
-One to one supervision with the resident was initiated on 1/4/24.
-Engage resident in purposeful activity.
-Referral made for memory care unit.
Review of the resident's progress notes, dated 1/5/24 showed:
-At 1:09 P.M. the resident continued on elopement monitoring. He/She was awake sitting at the exit door on the seat of his/her walker. He/She was encouraged to sit in the common area due to his/her stating I'm going out. Snacks and fluids were offered which the resident declined. Staff was present.
-At 3:00 P.M. the resident was seen eating ice cream at a social event.
-At 3:32 P.M. an elopement assessment had been completed. The assessment showed the resident was severely cognitively impaired and had a history of eloping from his/her personal home; attempting to leave the facility without informing staff; expressed the desire to go home, packed his/her belongings to go home or stayed near an exit door; and wandered in a goal-directed pattern as well as aimlessly. His/Her wandering was likely to affect the safety or well-being of others and affect their privacy. He/She was recently admitted and hadn't accepted his/her situation.
-At 4:08 P.M. the nurse was alerted the resident was found in the parking lot. He/She was not hurt and was able to be led back into the facility. His/Her family member was notified of the incident. The resident was placed on one to one with staff at all times.
Review of the resident's Elopement Investigation Incident Summary, dated 1/5/24 for the elopement showed:
-The resident followed staff outside the care center entrance on 1/5/24 around 3:08 P.M. and was later found on campus.
-He/She was last seen in the dining area eating ice cream around 3:00 P.M.
-The resident was fully clothed with shoes but no coat. The temperature was around 33 degrees Fahrenheit (F) with light snow.
-The resident ambulated with a walker and wore glasses and both were in place.
-The resident was found on campus around 3:28 P.M. and returned to the care center around 3:30 P.M. by staff without further incident.
-There were no apparent falls or injuries found on assessment.
Review of the resident's Elopement Investigation Resident Response Summary, dated 1/5/24 for the elopement showed:
-The resident was exploring the property on 1/5/24, he/she thought it was his/her new barracks assignment with the military. The resident thought he/she was active duty and serving on base.
-Staff were educated that if the resident was wandering they should remind him/her the commanding officer ordered that nobody leave the barracks without an escort.
-Immediate actions were to implement one to one supervision and to notify the family member and physician. The resident's discharge had already been arranged.
Review of the resident's Elopement Investigation Summary, dated 1/5/24 for the elopement showed:
-The resident had been referred from a facility in another state where he/she was getting rehabilitation services. There were no memory care or behavior issues noted in the referral paperwork.
-When the resident discharged from the previous facility prior to Christmas, 2023 he/she lived with family members in another state prior to his/her admission on [DATE].
-Upon admission it was noted the resident was disoriented to person and place and exit-seeking and the facility was unable to provide necessary memory care which the resident needed.
-The same day of admission the Director of Nursing (DON) provided written education to all managers that they educate their staff that the resident looked and acted like a visitor and all staff should be diligent not to let anyone out of the facility unless checking with the nurse first.
-Dietary Aide A arrived to work at 3:00 P.M. on 1/5/24, clocked in and reported to the facility dining room to check on his/her tasks. He/She left the dining room and went through the keypad locked door to the solarium at 3:08 P.M. The resident followed Dietary Aide A out the door. Dietary Aide A said he/she did not realize the person who left behind him/her was a resident. The person seemed to be a visitor and looked like he/she knew where he/she was going. He/She had clothes that looked like a light jacket and went out to the management parking lot behind the facility. The person looked like he/she was walking to a sister residence on campus and that was the last he/she saw of the resident.
-At 3:25 P.M. the receptionist called the Administrator and informed him/her that a staff from the school physically located on the same campus as the facility was talking with someone who might be a resident. The Administrator immediately went to the parking lot and found the resident talking to the staff member from the school. The resident was clothed in boots, pants, and two shirts, one a long sleeved shirt and draped with two blankets. The Administrator and Assistant Plant Operations Director (APOD) who just arrived escorted the resident back to the facility.
-The resident was assessed by the nurse. When the Administrator and resident returned to the facility nursing staff had been looking for the resident and called the front desk to notify the Administrator the resident was missing at 3:27 P.M. The physician and family were notified and the resident was placed on one to one monitoring per physician orders until his/her discharge.
Review of the resident's Elopement Investigation Conclusion dated 1/5/24 for the elopement showed:
-The resident left the building on 1/5/24 and was found on the campus grounds.
-There was no harm to the resident.
-It was 20 minutes from the time the resident left the facility until his/her return.
-Review of the Elopement Investigation Corrective Actions for the 1/5/24 elopement showed the Administrator provided immediate education with Dietary Aide A and written education to all staff via e-mail and timeclock notification that when going into and out of the facility never let anyone in or out unless they have a visitor's name tag. If there was someone without a name tag or a vendor's badge redirect them back to the front desk to get a name tag.
-System changes included all visitors, including residents of other campus facilities, were required to check in at the front desk and obtain a name tag before entering the facility. All visitors must ring the doorbell to be let in by staff and were to be let out by staff. Anyone attempting to leave the facility without a visitor's tag cannot be let out until first checking with the charge nurse to confirm whether or not they were a resident.
During an interview on 1/10/24 at 11:28 A.M. the resident said:
-He/She went outside the building once when it was real cold without a coat.
-He/She thought he/she went out to see if they had salvaged any of the military's chapel, but he/she saw no evidence of the chapel.
-He/She didn't remember if anyone asked him/her to go back inside or if anyone helped him/her back inside. He/She was having bad memory problems that day. He/She lost about three hours of that day and didn't have much memory of it.
-The doctors diagnosed him/her with urinary problems. He/She had been very sporadic about peeing the past three weeks and told the doctor in the ER, but didn't tell anyone in the building he/she was having trouble peeing. He/She certainly had more confusion and memory issues at the time because he/she couldn't remember ever losing a part of a day before.
-He/She was frustrated because his/her old unit was being deactivated and that was why he/she thought he/she was in the building (referring to the facility).
-He/She liked being a participating member of the Army and the building was part of the old Army unit.
-Nobody said if he/she went outside that he/she needed to take someone with him/her.
It was definitely cold outside the day he/she went out. He/She was outside only ten minutes. It wasn't deathly cold. It was just cold.
-He/She didn't recall how he/she got outside, but he/she had a vague idea he/she came back to the building (referring to the facility) in a vehicle, but the memory was very vague.
-He had been stationed in the building once before for about 19 years. There was a break in his two points of service. The last time he/she was a supervisor for the bus assembly plant in this building.
During an interview on 1/10/24 at 12:23 P.M. the APOD said:
-He/She was in the Administrator's office around 3:30 P.M. when the front office got a call from a staff person from the school located on campus. The school was not affiliated with the facility corporation. The school called to inform the facility that someone who looked like they could be a resident was outside the building. The receptionist then called the Administrator.
-They weren't sure where on the school grounds the possible resident was so he/she and the Administrator approached the school from different angles.
-The Administrator recognized the resident and asked the resident a couple of questions.
-The resident was in the school parking lot. He/She was talking with someone from the school who was in his/her car and was leaving the parking lot.
-The resident was saying he/she was in the Army and the police, probably meaning the Army police, were talking to him/her.
-He/She thought the resident was wearing tennis shoes and might have had a jacket hanging from his/her shoulders. He/She was not wearing a hat or gloves. It was chilly outside. There was light snow that had stuck to the grass, but hadn't stuck to the sidewalks or campus parking lots.
-It took about a minute or minute and a half to find the resident and four or five minutes to get the resident back into the building.
-Once inside the building the Administrator followed up with the resident and he/she went in another direction.
-There was no distress he/she could see with the resident.
-He/She received a text message a bit later that one of the facility staff opened the door and the resident got out.
During an interview on 1/11/24 at 9:42 A.M. CNA A said:
-The resident pulled the fire alarm one day, maybe the day he/she was admitted , and broke it off the wall. The resident would wander the halls and would be seen looking out the windows and doors. He/She would have to redirect him/her. The resident could read the exit signs. He/She would take the resident somewhere else and encourage him/her to sit and rest.
-After pulling the alarm either the first or second time they put the resident on 15 minute checks, but someone was sitting with the resident one on one after the resident set off the alarm the second time because they had the staff to do it on that shift.
-He/She heard about the resident getting off the unit with a Dietary Aide. He/She heard the Dietary Aide didn't know he/she was a resident and let him/her out the facility door and then the resident got outside.
-The resident was on one to one monitoring after he/she eloped.
During an interview on 1/11/24 at 9:59 A.M. the receptionist said:
-He/She got a call from the school located on campus and they let him/her know someone was outside that looked like they were from the facility.
-He/She got ahold of the Administrator by phone and the Administrator and APOD went out to look for the resident.
-He/She later learned that someone from Dietary went out of the facility and the resident followed the Dietary staff out the door.
-The resident went out the door in the solarium corridor between the facility and the Assisted Living Facility (ALF). The resident never followed the Dietary staff into the ALF or reception area.
-There was no code to get out the solarium door. Anybody could open the door. Nobody could get into or out of the facility without a code.
-The person who called from the school said the resident looked cold. When the resident returned inside he/she was wearing a blanket. He/She didn't know if the school provided the blanket.
-He/She couldn't recall the time of day the school called or when the resident was returned to the building.
During an interview on 1/11/24 at 10:10 A.M. the resident's physician said:
-He/She was made aware of the resident's exit seeking behavior very soon after his/her admission on [DATE]. He/She had an order for monitoring the resident on all shifts. By that he/she meant that staff were to observe where the resident was on a frequent basis.
-The treatment team discussed the resident needed more security measures than the facility could provide and started looking for a secured placement at another facility.
During an interview on 1/16/24 at 9:57 A.M. the SSD said:
-The resident was admitted to the facility on [DATE] around 3:00 P.M.
-He/She heard the fire alarm sound around 5:30 P.M. on 1/3/24. He/She was upstairs in the nursing station as was the DON. He/She saw the resident standing by the fire alarm. CNA A said the resident had been looking out the door prior to sounding the alarm.
-The resident recently moved from another state and lived alone. He/She was in a skilled nursing facility for rehabilitation purposes and then moved back to his/her private home out of state for a couple of weeks.
-The resident's family member said the resident was not restless, exit-seeking or confused when in the skilled facility in the other state. On the day the resident was admitted to the facility he/she first noticed a change in the resident's cognition. On 1/4/24 the same family member said the resident left his/her home after discharge from the skilled facility and drove from his/her state to Colorado to go to a funeral which ended up being in Texas, not Colorado. The resident called him/her from Colorado saying he/she didn't know where he/she was.
-The family member said the level of confusion the resident showed since his/her admission to the facility on 1/3/24 was not normal for the resident. For that reason the facility sent the resident out to the ER for an evaluation and they found he/she had a UTI. There were episodes of the resident urinating in trash cans since his/her admission.
-An elopement care plan was developed on 1/4/24.
-Before the resident's elopement the facility had him/her on 15 minute checks. He/She was on 15 minute checks when he/she was at the ice cream social on 1/5/24. The ice cream social was hosted by an outside group, so there were no staff in the area at the time the resident eloped.
During an interview on 1/18/24 at 9:31 A.M. Licensed Practical Nurse (LPN) A said:
-On 1/4/24 one of the CNA's redirected the resident from exiting the back door and from getting onto the elevator. Staff then gave the resident something to read to try to redirect his/her attention.
-Later that day the resident pulled the fire alarm. Staff redirected the resident to sit elsewhere. Staff were supposed to check on the resident every 15 minutes and mark his/her whereabouts every 15 minute on a 15-minute log. Since there was an extra staff person that day he/she had a staff person sit with the resident for the rest of the day shift, although the resident's supervision status was for staff to do 15 minute checks.
During an interview on 1/18/24 at 10:51 A.M. the Administrator said:
-On 1/3/24 the DON sent a text to all facility managers including the Dietary Manager that there was a new resident who was exit seeking and to alert all staff in their departments. The DON provided education to nursing staff related to the resident's exit seeking behaviors.
-Dietary Aide A claimed he/she never received the information about the resident. The Dietary Manager claimed he/she told all staff including Dietary Aide A. There was no documentation that department staff had been alerted about the resident's exit seeking behaviors.
-He/She didn't know how long the resident was on one to one supervision on 1/4/24. It might have just been for the remainder of the shift. The DON would have advised the precautions if he was on one to one supervision. The resident was not on one to one supervision at the time he/she eloped.
During an interview on 1/18/24 at 11:37 A.M. the DON said:
-When the resident got to the facility on 1/3/24 he/she presented differently than how he/she was portrayed in the referral from the skilled facility.
-On 1/3/24 the resident was hollering out that there were fires everywhere. He/She didn't know if the behaviors were due to the resident's UTI or if the resident had permanent behavioral issues. The hospital ER prescribed antibiotic treatment for the UTI on 1/3/24.
-The evening of 1/3/24 he/she alerted all department heads by text on facility devices there was a resident that looked like a visitor. He/She provided the resident's name, room number and described his/her behaviors of wandering and exit seeking and asked managers to notify their staff to be mindful when coming into and leaving the facility as the resident might want to go out the door.
-The resident was on 15 minute checks until he/she eloped on 1/5/24 at which point he/she was placed on one to one supervision until his/her discharge. On 15 minute checks the resident was still wandering, but was redirectable. Someone might have sat with the resident one to one during the time he/she was on 15 minute checks if they had the staff to do so, but he/she was not sure, and staff did not have direction from him/her to put the resident on one to one supervision until he/she eloped on 1/5/24.
During an interview on 1/19/24 at 10:00 A.M. the Administrator said the school parking lot where the resident ended up on 1/5/24 was approximately the distance of a city block from the door the resident had exited.
During an interview on 1/19/24 at 12:22 P.M. Dietary Aide A said:
-He/She had worked evenings at the facility for about a month and a half and did not know all the residents.
-He/She was not aware there was a new resident. The person he/she let out did not look like a resident. He/She looked like a visitor and didn't look as if he/she needed help. When he/she went to leave the facility the resident said hold on and asked him/her to keep the door open for him/her. Sometimes visitors' tags weren't visible, so he/she didn't think much about it.
-Usually nursing staff are with residents when they walk out. He/She looked like a normal elderly person who didn't need much help.
-He/She didn't know until the Administrator talked with him/her that he/she had let out a resident.
-After exiting the facility he/she walked to the left to go to the ALF and the resident didn't follow so he/she assumed he/she exited the solarium door.
-Later he/she learned the resident had pulled the fire alarm and tried to escape.
-After the incident the Administrator told him/her not to let anyone out the building without a visitor's tag.
-He/She wasn't sure how far the solarium door was from the school parking lot because he/she didn't know which of the buildings on campus was the school.
-Prior to the resident's elopement nobody had told him/her there was a new resident who was exit seeking. Nobody told him/her not to let anyone out the facility without a visitor's tag or to check with nursing first if they don't have a visitor's tag.
During an interview on 1/23/24 at 11:05 A.M. the Dietary Manager said:
-He/She received a group text sent to facility managers that showed there was a new resident who might be an elopement risk.
-The text asked managers to forward the information to our employees.
-Dietary Aide A was forwarded the group text and was told verbally about the new resident prior to the resident's elopement.
-Dietary Aide A said the resident had been dressed like a regular person so he/she didn't realize he/she was a resident.
MO00229841
2. Review of the facility's Resident Smoking policy dated 10/2022 showed resident's who smoke will be assessed quarterly using the Resident Safe Smoking Assessment.
Review of Resident #20's Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses:
-Nicotine dependence.
-Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain).
Review of the resident's electronic record Smoking Safety Evaluation showed the 1/2023 quarterly evaluation was not completed.
Review of the resident's electronic record Smoking Safety Evaluation showed the 4/2023 quarterly evaluation was not completed.
Review of the resident's care plan revised on 6/14/23 showed:
-He/She was nicotine dependent.
-He/She would request nicotine replacement to meet his/her needs.
-Staff would escort him/her out to smoke his/her electronic cigarette by wheelchair with supervision to the designated smoking area outside the facility.
-Staff were to educate him/her on facility electronic cigarette smoking policy due to his/her history of non-compliance.
-He/She had impaired cognitive function and impaired thought processes.
-Staff to cue, reorient and supervise him/her as needed.
Review of the resident's electronic record Smoking Safety Evaluation dated 7/27/23 showed:
-He/She used tobacco.
-He/She did not follow the facility's policy on location and time of smoking.
Review of the resident's electronic record Smoking Safety Evaluation dated 10/27/23 showed:
-He/She used tobacco.
-He/She required supervision.
-He/She had balance problems while sitting.
-He/She had limited range of motion in arms or hands.
Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility staff for care planning) dated 10/27/23 showed:
-He/She had mild cognitive impairment.
-He/She needed supervision and set-up with activities of daily living.
During an interview on 1/16/24 at 10:36 A.M., Registered Nurse (RN) A said he/she did not know how often resident smoking assessments should be completed.
During an interview on 1/16/24 at 1:15 P.M., the DON said:
-He/She expected smoking assessments be completed quarterly.
-It was expected the floor nurse or any nurse completed the smoking assessments.
-It would be his/her responsibility to audit smoking assessments for completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respond to the pharmacist's recommendations for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 34 residents.
Review of the facility's Medication Regimen Review (MRR) policy dated October 2022 showed:
-The pharmacist shall document the findings for each MRR.
-The pharmacist shall communicate any irregularities verbally to the physician, Director of Nursing (DON) and/or staff of any urgent needs.
-The pharmacist shall communicate any irregularities in written communication to the attending physician, the facility's medical director and the DON.
-Facility staff shall act upon all recommendations according to procedures.
1. Review of Resident #31's entry tracking form dated 12/22/23 showed the resident newly admitted to the facility on [DATE].
Review of the resident's pharmacist's note dated 12/26/23 showed:
-The resident was newly admitted to the facility.
-Instructions to ensure target behaviors and side effects were being monitored for medications including Escitalopram (Lexapro used to treat depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life) and anxiety (disorder that involve extreme fear, worry and nervousness)), Bupropion (used to treat depression), and Lorazepam (used to treat anxiety).
-Instructions to ensure anticoagulant (blood thinners used to prevent blood clots) monitoring was in place for Eliquis.
-Instructions to consider adding blood pressure and pulse parameters to high blood pressure medication orders.
Review of the resident's care plan dated 12/28/23 showed:
-The resident had a diagnosis of high blood pressure.
-The resident used an antidepressant and an antianxiety medication with instructions to monitor and document side effects and effectiveness every shift.
-The resident received pain medication with instructions to monitor/document side effects and effectiveness.
-There was no care plan for anticoagulant medication.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed:
-Some of the resident's diagnoses included heart disease, high blood pressure, anxiety and depression.
-The resident received antianxiety, anticoagulant, antidepressant, diuretic (used to reduce fluid buildup) and opioid (used to treat severe pain) medications.
Review of the resident's Medication Administration Record (MAR) dated December 2023 showed:
-A physician's order for Carvedilol (treats high blood pressure and heart failure by slowing down the heart rate) 6.25 milligrams (mg), one tablet two times a day for high blood pressure with rows where the resident's blood pressure was documented.
-There were no parameters for when Carvedilol should have been held.
-There were no orders to document the resident's pulse.
-Carvedilol was held on 12/29/23 at 8:00 A.M. because the resident's blood pressure was 70/51 (the top/first number, called systolic blood pressure, measures the pressure in your arteries when your heart beats. The second/bottom number, called diastolic blood pressure, measures the pressure in your arteries when your heart rests between beats).
Review of the resident's MAR dated January 2024 showed:
-None of the pharmacist's 12/26/23 recommendations were included on the MAR.
-A physician's order for Bupropion 100 mg, one tablet in the morning for depression.
-A physician's order for Escitalopram 20 mg, one tablet one time a day for depression.
-A physician's order for Lisinopril (used to treat high blood pressure and heart failure) 40 mg, one tablet in the morning for high blood pressure.
-A physician's order for Carvedilol 6.25 mg, one tablet two times a day for high blood pressure with rows where the resident's blood pressure was documented.
-There were no parameters for when Carvedilol should have been held.
-Carvedilol was held on 1/9/24 at 8:00 A.M. because the resident's blood pressure was 103/59.
-Carvedilol was held on 1/10/24 at 8:00 P.M. because the resident's blood pressure was 93/56.
-There were no orders to document the resident's pulse.
-A physician's order for Eliquis 5 mg, one tablet two times a day for heart disease.
During an interview on 1/16/24 at 9:06 A.M., the MDS Coordinator said:
-The MRR's were usually put in the physician's folder upon the pharmacist completing them.
-He/She usually put in any orders needed from MRR follow-up.
-He/She was off work for two weeks recently so the orders may have not been completed during the time he/she was gone.
-He/She thought he/she went in and updated all the orders from the pharmacist's MRR's.
-The pharmacist only wrote a note for his/her recommendations for the resident and he/she could not locate any MRR form for the December 2023 recommendations for the resident.
-He/She did not know the pharmacist did a MRR for new admissions.
-Blood pressure parameters were normally set by the physician.
-The nurses should have clarified blood pressure parameters if there were none.
During an interview on 1/16/23 at 10:47 A.M., Licensed Practical Nurse (LPN) B said:
-The MRR's were given to the DON.
-The pharmacist also put notes in the electronic health record and the DON would let them know if they needed to do anything for follow-up.
-There were batch orders that coordinated with the medication orders depending on the type of medication and should be selected when entering the order for the medication.
-If a medication was entered that needed monitoring, they should select each item to monitor such as behaviors, blood pressure, pulse, etc.
-For an anticoagulant, they should monitor for bruising and the environment free of clutter.
-If blood pressure parameters were not included in an order, their standard was to hold the medication if the systolic blood pressure (SBP) was less than 90 (it was held when the resident's SBP was 103/59 and 93/56 when the SBP was above 90) and to notify the physician if SBP was greater than 180.
-Their standard for Carvedilol (betablockers) was to hold if the resident's heart rate was less than 50.
-They should call the physician to clarify the order of any medications which needed parameters.
During an interview on 1/16/24 at 1:15 P.M., the DON said:
-The pharmacist completed MRR's once a month and emailed them to him/her, the MDS Coordinator and the Administrator.
-The pharmacist did little MRR's here and there and those were documented on the 24-hour report.
-He/She and the nurse managers needed to pay closer attention to the 24 hour report for the little MRR's.
-The monitoring was a part of the batch orders that the nurse should select when entering medication orders.
-They do audits on the antidepressant and antianxiety orders.
-They should monitor for any bruising or bleeding for anticoagulants.
-Some blood pressure medication orders came with parameters.
-The resident's attending physician would usually give orders to hold the high blood pressure medication if the resident's SBP was less than 90 and to hold beta blockers for a pulse less than 50 and notify the physician.
-The orders should alert the staff to take the resident's blood pressure and/or pulse and include the blood pressure and pulse parameters of when to hold it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medications were ordered with adequate monitoring for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 34 residents.
There were no policies for this example.
1. Review of Resident #31's entry tracking form dated 12/22/23 showed the resident newly admitted to the facility on [DATE].
Review of the resident's care plan dated 12/28/23 showed:
-The resident had a diagnosis of high blood pressure.
-There was no care plan for anticoagulant (medication used to slow down the blood clotting process) medication.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed:
-Some of the resident's diagnoses included heart disease and high blood pressure.
-The resident received anticoagulant medications.
Review of the resident's Medication Administration Record (MAR) dated December 2023 showed:
-A physician's order for Carvedilol (treats high blood pressure and heart failure by slowing down the heart rate) 6.25 milligrams (mg), one tablet two times a day for high blood pressure with rows where the resident's blood pressure was documented.
-There were no parameters for when Carvedilol should have been held.
-There were no orders to document the resident's pulse.
-Carvedilol was held on 12/29/23 at 8:00 A.M. because the resident's blood pressure was 70/51 (the top/first number, called systolic blood pressure, measured the pressure in your arteries when your heart beats. The second/bottom number, called diastolic blood pressure, measured the pressure in your arteries when your heart rests between beats).
Review of the resident's MAR dated January 2024 showed:
-A physician's order for Lisinopril (used to treat high blood pressure and heart failure) 40 mg, one tablet in the morning for high blood pressure.
-A physician's order for Carvedilol 6.25 mg, one tablet two times a day for high blood pressure with rows where the resident's blood pressure was documented.
-There were no parameters for when Carvedilol should have been held.
-Carvedilol was held on 1/9/24 at 8:00 A.M. because the resident's blood pressure was 103/59.
-Carvedilol was held on 1/10/24 at 8:00 P.M. because the resident's blood pressure was 93/56.
-There were no orders to document the resident's pulse.
-A physician's order for Eliquis (an anticoagulant) 5 mg, one tablet two times a day for heart disease.
-There were no orders for monitoring for an anticoagulant.
During an interview on 1/16/24 at 9:06 A.M., the MDS Coordinator said:
-Blood pressure and pulse parameters were normally set by the physician.
-The nurses should have clarified blood pressure parameters if there were none.
During an interview on 1/16/23 at 10:47 A.M., Licensed Practical Nurse (LPN) B said:
-There were batch orders that coordinate with the medication orders depending on the type of medication and should be selected when entering the order for the medication.
-If a medication was entered that needed monitoring, they should select each item to monitor such as behaviors, blood pressure, pulse, etc.
-For an anticoagulant, they should monitor for bruising and the environment free of clutter.
-If blood pressure parameters were not included in an order, their standard was to hold the medication if the systolic blood pressure (SBP) was less than 90 (it was held when the resident's SBP was 103/59 and 93/56 when the SBP was above 90) and to notify the physician if SBP was greater than 180.
-Their standard for Carvedilol (betablockers) was to hold if the resident's heart rate was less than 50.
-They should call the physician to clarify the order of any medications which need parameters.
During an interview on 1/16/24 at 1:15 P.M., the Director of Nursing said:
-The monitoring was a part of the batch orders that the nurse should select when entering medication orders.
-They should monitor for any bruising or bleeding for anticoagulants.
-Some blood pressure medication orders came with parameters.
-The resident's attending physician would usually give orders to hold the high blood pressure medication if the resident's SBP was less than 90 and to hold beta blockers for a pulse less than 50 and notify the physician.
-The orders should alert the staff to take the resident's blood pressure and/or pulse and include the blood pressure and pulse parameters of when to hold it.

Based on interview and record review, the facility failed to ensure target behaviors and side effects were being monitored for psychotropic medications (any medications that affect brain activities associated with mental processes and behavior) for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 34 residents.
There were no policies for this example.
1. Review of Resident #31's care plan dated 12/28/23 showed the resident used an antidepressant (medications used to treat depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) and an antianxiety (used to treat anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) medication with instructions to monitor and document side effects and effectiveness every shift.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed:
-Some of the resident's diagnoses included anxiety and depression.
-The resident received antianxiety and antidepressant medications.
Review of the resident's Medication Administration Record dated January 2024 showed:
-A physician's order for Escitalopram (used to treat depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life) and anxiety (disorder that involve extreme fear, worry and nervousness)), 20 milligram (mg), one tablet one time a day for depression.
-A physician's order for Bupropion (used to treat (used to treat depression) 100 mg, one tablet in the morning for depression.
-No monitoring of target behaviors and side effects.
During an interview on 1/16/23 at 10:47 A.M., Licensed Practical Nurse B said:
-There were batch orders that coordinated with the medication orders depending on the type of medication and should be selected when entering the order for the medication.
-If a medication was entered that needed monitoring, they should select each item to monitor such as behaviors, blood pressure, pulse, etc.
-They should call the physician to clarify any orders.
During an interview on 1/16/24 at 1:15 P.M., the Director of Nursing said:
-The monitoring was a part of the batch orders that the nurse should select when entering medication orders.
-They did audits on the antidepressant and antianxiety orders.

Based on observation, interview, and record review, the facility failed to keep the walk-in refrigerator, and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary utensils and food preparation equipment; failed to safeguard against mold possibly getting into food and/or beverages; failed to change the deep fryer oil in a timely manner; failed to consistently document hot food temperatures at the steam table to ensure they were suitably cooked to lessen the chance of bacterial contamination; failed to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination); and failed to store foodstuffs within acceptable temperature parameters, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 34 residents with a licensed capacity for 38 residents at the time of the survey.
1. Observation on 1/8/24 between 9:41 A.M. and 10:43 A.M. during the initial kitchen inspection showed the following:
-On a shelf above a four-slice toaster in the Dry Storage (DS) area was an open 20-ounce (oz.) squeeze bottle of grape jelly that was not dated as to when it was opened.
-There was a slick moldy residue on the black partition inside the ice machine.
-Dried residue was encrusted on the manual can opener on a food preparation table by the convection oven.
-The grease in the deep fryer was dark enough to keep the bottom basket resting racks form being seen.
-There were multiple splatters on the inside top and sides of the microwave with large droplets on its turntable plate.
-An aluminum foil lined utensil drawer next to the steam table had an overabundance of food crumbs in its bottom.
-An open 1-gallon (gal.) jug of soy sauce with a label which read refrigerate after opening for quality was on the bottom shelf of the wheeled cart next to the convection oven.
-The wheeled cart next to the convection oven also had a foil lined utility drawer with large bits of food in the bottom.
-The large green cutting boards and small green cutting board were heavily scored to the point of plastic flaking off.
-There was a grape, plastic pieces, and a bread clip on the floor under racks in the walk-in refrigerator.
-There was plastic, paper, and numerous pieces of various foods on the floor of the walk-in freezer.
Observation on 1/10/24 at 9:23 A.M. during the follow-up kitchen inspection showed the following:
-There was a slick moldy residue on the black partition inside the ice machine.
-Dried residue was encrusted on the manual can opener on a food preparation table by the convection oven.
-The grease in the deep fryer was dark enough to keep the bottom basket resting racks form being seen.
-There were multiple splatters on the inside top and sides of the microwave with large droplets on its turntable plate.
-An aluminum foil lined utensil drawer next to the steam table had an overabundance of food crumbs in its bottom.
-An open 1-gallon (gal.) jug of soy sauce with a label which read refrigerate after opening for quality was on the bottom shelf of the wheeled cart next to the convection oven which also had a foil lined utility drawer with large bits of food in the bottom.
-The large green cutting boards and small green cutting board were heavily scored to the point of plastic flaking off.
-There was a grape, plastic pieces, and a bread clip on the floor under racks in the walk-in refrigerator.
-There was plastic, paper, and numerous pieces of various foods on the floor of the walk-in freezer.
-There was no thermometer in the reach-in refrigerator.
Review of the food temperature logs on a clipboard lying on a food preparation table next to the steam table in the kitchenette showed the following:
-The last date for recorded temperatures was in November of 2023.
-Multiple meals were left unrecorded on the last seven days of that month.
During an interview on 1/16/24 at 1:05 P.M. the Dietary Manager (DM) said the following:
-The cooks were responsible for cleaning the walk-ins' floors every day.
-He/She would expect foodstuffs to be stored at their correct temperatures.
-Damaged food preparation items were either found on his/her walk-through inspections or reported to them by their dietary staff and they were discarded.
-Food preparation items were cleaned by rinsing them and then running them through the dishwasher twice.
-He/She would expect food to be free of foreign substances.
-Refrigerators should have a thermometer inside even if there was one built in on the outside.
-The deep fryer's oil was changed every two weeks because they used it a lot, but sometimes they were also waiting on their delivery for new oil.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free from accidental injury when Certified Nursing Assistant (CNA B) left a bruise on the resident inner left forearm during cares out of three sampled residents. The facility census was 37 residents.
Record review of the Facility Employee Handbook revised 1/28/22 showed facility employees were to:
-Not engage in any type of conduct which could be injurious to a resident.
-Ensure that all residents remained safe and injury free.
-Ensure that all residents were treated with kindness, respect and dignity and that resident rights were respected.
-Always provide a safe environment for the residents.
1. Review of Resident #1's Move In Record showed he/she was admitted on [DATE] with the following diagnoses:
-Chronic obstructive pulmonary disease-(COPD - a disease process that decreases the ability of the lungs to perform ventilation).
-Incontinence-(having no or insufficient control over urination or defecation)
Review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 6/2/23 showed he/she:
-Was cognitively intact.
-Had issues with his/her mood including feeling depressed, having little interest in going things, no energy and no appetite seven to 11 days out of 14 days.
-Was incontinent occasionally of urine.
-Required supervision of one staff member for eating.
-Required extensive assistive assistance of one staff member for bed mobility, transfers, locomotion off the unit, dressing, toileting, hygiene and bathing.
Review of the resident's nursing care plan dated 6/9/23 showed:
-He/she had a potential for skin impairment related to age and comorbidities.
-The family and physician was to be notified of any skin changes.
-He/she had a self-care performance deficit related to fatigue and impaired balance.
-The staff were to provide cares in pairs when any care was provided.
-He/she required extensive assistance of two staff for turning in bed.
-He/she required extensive assistance of two staff for toileting and hygiene.
-He/she had a terminal prognosis related COPD and was admitted to hospice services on 5/19/23.
-The facility staff was to observe the resident for pain and give pain medication as ordered.
-He/she had bladder incontinence due to impaired mobility.
-The facility staff was to check on the resident every two hours to ensure he/she was dry and clean and if incontinence care was needed, two staff should provide that care.
Review of the facility incident report for the resident dated 6/25/23 showed:
-The resident had a bruise on his/her inner left forearm.
-The resident stated that Certified Nurse Aide (CNA) B came into his/her room and did not even talk to him/her to tell him/her what CNA B was doing.
--Instead CNA B grabbed his/her left arm and turned him/her towards the wall.
--He/she was scared of rolling back over so he/she would not fall so he/she slept facing the wall.
-The resident was completely oriented.
-No other injuries were observed post incident.
-There were no predisposing environmental, physiological or situational factors.
-The physician, Administrator, Director of Nursing (DON) and family were all notified.
Review of the resident's facility Pain Interview conducted on 6/25/23 at 3:15 P.M., showed:
-The resident had pain or hurting during the past five days.
-The pain that he/she experienced was frequent.
-He/she had no trouble sleeping at night due to the pain.
-The pain he/she had did limit his/her day-to-day activities.
-He/she described the pain as mild and received both non-medication intervention and pain medications.
Review of the resident's Nurse's Note dated 6/26/23 at 10:15 A.M., showed:
-The Director of Nursing (DON) assessed the resident who stated he/she was okay and felt safe.
-He/she had no complaints other than wanting a positioning bar to assist him/her in turning side to side.
-The DON notified Hospice (end of life care) to obtain a positioning bar.
-The DON noted a bruise to the resident's left forearm about the size of a quarter which was light pink/red in color and not painful.
During an interview on 6/26/23 at 12:15 P.M., the DON said:
-CNA B had worked for the facility through an agency about four times prior to being hired to work primarily weekends as a facility employee.
-He/she had not gotten any performance concerns on CNA B while he/she worked for the agency.
-CNA B had only been a facility employee for about two weeks.
-The resident came to the DON the previous Wednesday stating CNA B had been slightly rough with him/her the night before.
-The DON did a training session with CNA B to educate him/her on appropriate positioning technique to use with the resident and how he/she should obtain another staff member to make sure the resident was handled carefully.
-He/she then followed up with CNA B on two other occasions, even coming in the same weekend the incident happened, ensuring he/she knew what was expected and that he/she understood.
-The first shift CNA B worked without the DON being present, was the night shift where the incident occurred.
Record review of CNA B's facility employee record showed:
-He/she had education regarding resident rights and appropriate resident positioning techniques prior to working as a facility employee.
-He/she had additional education provided by the DON on 6/21/23 which was specific to the positioning technique for Resident #1.
During an interview on 6/26/23 at 12:30 P.M., CNA A said:
-The resident told him/her that CNA B had been rough with him/her the night before.
-He/she said CNA B grabbed him/her by the arm really hard and turned him/her on his/her side without even communicating with him/her.
-The resident also said that CNA B had made an inappropriate gesture to him/her when he/she said the CNA was too rough.
-CNA A went and told his/her charge nurse immediately who called the DON to report the incident.
During an interview on 6/26/23 at 1:05 P.M., the facility Physician said:
-He/she had been made aware of the incident right after it was reported to Administration.
-He/she felt that it was very unfortunate that it happened to this resident as the resident was old and very frail.
-He/she felt the incident was especially unfortunate as CNA B had just been fully educated by the DON, on the best technique to use when caring for and repositioning the resident.
-He/she felt the resident was not severely injured as only a small bruise was noted on the resident's inner forearm.
During an interview on 6/26/23 at 1:35 P.M., the resident said:
-CNA B came into his/her room without saying anything to him/her.
-He/she had no idea what CNA B wanted to do.
-CNA B grabbed his/her arm really hard causing him/her pain.
-Instead of asking him/her to roll to his/her side, CNA B just grabbed him/her and pushed him/her onto his/her side without communicating at all.
-He/she said ouch and CNA B just grunted at him/her.
-He/she asked him/her what his/her name was and CNA B refused to tell him/her.
-When he/she attempted to take a hold of his/her name tag, CNA B slapped his/her hand away.
-He/she was afraid he/she was going to fall out of the bed after CNA B left the room, so he/she just slept all night on his/her left side.
-He/she hoped CNA B would not care for him/her again as he/she was afraid CNA B would hurt him/her again.
-He/she did not feel CNA B harmed him/her on purpose, instead he/she felt CNA B just did not want to communicate with him/her.
-If CNA B would have communicated with him/her what was happening, he/she had the ability to help turn himself/herself, preventing him/her from getting hurt.
-He/she felt that maybe CNA B was just not having a good night, possibly due to personal issues.
-CNA B should probably not being taking care of older adults or children.
During an interview on 6/29/23 at 3:00 P.M., the facility Administrator said:
-Staff who become facility staff after having worked for an agency get the same orientation and education as all new employees.
-They get the same competencies as all employees as well, including return demonstrations.
-He/she had gotten no negative reports on CNA B until Resident #1 complained and the DON did one on one education with CNA B the week prior to the incident.
-He/she was especially frustrated with CNA B since he/she had just been re-educated regarding the care for the resident and should have known how to care for the resident.
-He/she would have expected CNA B to have communicated with the resident and not injured him/her.
During an interview on 6/29/23 at 3:15 P.M., the DON said:
-He/she would have expected CNA B to have used the education he/she had just gotten and provided safe care for Resident #1.
-He/she would have expected CNA B to not have harmed Resident #1.
During an interview on 6/30/23 at 1:35 P.M., CNA B said:
-The resident was checked for incontinence and needed to be cleaned up
-The resident refused to be cleaned up but he/she had slid down in the bed and needed to be pulled up in bed.
-He/she told the resident that he/she was going to pull him/her up in the bed and placed his/her arms underneath the resident and pulled him/her up in bed.
-As soon as he/she pulled the resident up in bed, the resident began screaming and cussing at him/her stating that he/she had been too rough with him/her and hurt him/her.
-He/she never heard the resident say ouch.
-He/she denied he/she pulled on the resident in rough manner.
During an interview on 6/30/23 at 5:05 P.M., Registered Nurse (RN) A said:
-He/she was the charge nurse on duty when the resident complained of having been injured by CNA B on the night shift.
-At around shift change on 6/25/23, CNA A approached RN A stating that the resident told him/her that CNA B had been too rough with him/her the night before and hurt his/her left arm.
-He/she went to speak with the resident who said that CNA B came into his/her room sometime in the night, saying nothing.
-CNA B then grabbed the resident's left arm hard enough to hurt him/her, turned him/her over and left the room.
-RN A performed an assessment on the resident and found two small bruises on his/her left forearm, one appeared to be about the size of a quarter and the other a bit smaller.
-RN A then immediately went and called the DON to notify him/her of the allegation.
MO00220523

Based on observation, interview, and record review, the facility failed to keep the kitchen, Dry Storage room, and walk-in refrigerator and walk-in freezer floors clean; to retain operable thermometers in all freezers to confirm adequate temperature ranges; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; to follow correct hair hygiene practices; and to separate damaged foodstuffs. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 37 residents with a licensed capacity for 38 residents.
1. Observations during the initial kitchen inspection on 7/13/22 between 8:52 A.M. and 12:15 P.M. showed the following:
-In the basement Dry Storage room there was no thermometer in a freezer to confirm correct temperatures.
-In the basement walk-in refrigerator there was a package of mint leaves, a partial package of cheese slices, and a container of beef stock under the storage racks.
-On the dry storage side of the kitchen on a large can dispenser rack there was a 6 pound (lb.) 10 ounce (oz.) can of creamed corn and a 6 lb. 15 oz. can of three-bean salad dented on their sides, and another can of creamed corn with two dents on the bottom rim.
-There was a small plastic dessert bowl under the food preparation table by the ice machine and a jelly pod under the baker's rack in in the kitchen dry storage area.
-There was an over-abundance of crumbs and two dried liquid splotches on the walk-in freezer floor.
-The dishwashing machine had six of its nozzles clogged with an unknown light beige substance.
-The red, brown, & gray cutting boards were all heavily scored to the point of not being easily cleaned.
-There was a metal ladle hanging on the baker's rack behind the coffee machine with a dried substance in its bowl.
-Two long knives on a magnetic wall rack had dark rust-like spots on blades.
-A scraper in the drying rack next to the 3-sink unit had a melted plastic handle.
-A small brown handled spatula had chips along the edge of its blade.
Observations during the kitchenette inspection on 7/13/22 at 12:33 P.M. showed the following:
-There was a running box fan with excessive amounts of lint built up on its blade guard aimed at the steam table during food service.
-The food server at the kitchenette's steam table did not wear a hairnet.
Observations during the follow-up kitchen inspection 7/14/22 at 11:39 A.M. showed the following:
-In the basement walk-in refrigerator there was a partial package of cheese slices and a container of beef stock under the storage racks.
-On the dry storage side of the kitchen on a large can dispenser rack there was a 6 pound (lb.) 10 ounce (oz.) can of creamed corn and a 6 lb. 15 oz. can of three-bean salad dented on their sides.
-There was a small plastic dessert bowl under the food preparation table by the ice machine and a jelly pod under the baker's rack in in the kitchen dry storage area.
-There was an over-abundance of crumbs and two dried liquid splotches on the walk-in freezer floor.
-There was a metal ladle hanging on the baker's rack behind the coffee machine with a dried substance in its bowl.
-Two long knives on a magnetic wall rack had dark rust-like spots on blades.
-The dishwashing machine had two of its nozzles clogged with an unknown light beige substance.
Observations during the follow-up kitchenette inspection on 7/15/22 at 12:49 P.M. showed the server at the steam table had his/her hair in a bun on the top of their head and only the bun was covered with what appeared to be a hairnet.
During an interview on 7/18/22 at 8:42 A.M., the Dietary Manager said the following:
-The dietary aides and cooks were responsible for cleaning the floors after each shift, which would be twice daily.
-Damaged food stuffs are separated to be picked up by their food vendor for credit.
-Damaged food preparation items are usually reported to him/her by the cook.
-All dietary staff should wear hairnets, but they did not come on last Tuesday's order as expected, so they ran out.
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed:
-Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
-Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the facility's undated TB Testing Policy and Procedure Policy and Procedure showed:
-All new admissions will receive a Mantoux PPD two-step test to rule out TB within one week of admission.
-If the initial result was 0-9 mm, the second test will be given at two weeks after the first test.
-Record of results of the skin test in mm in a prominent place on the resident's medical record.
-Documentation of a chest x-ray ruling out active pulmonary TB within one month prior to admission, along with an evaluation to rule out signs and symptoms of TB may be acceptable by the facility on an interim basis until the Mantoux PPD two step test is completed.
-The two-step test was recommended due to the booster phenomenon (when the TB test itself stimulates the ability to react to tuberculin, causing a false positive reaction to subsequent tests).
-All skin test results of 5 mm or more for an individual immunocompromised or 10 or more for all others, require a chest x-ray within one week, along with an evaluation to rule out current TB disease.
-Record results of the skin test in mm in a prominent place on the resident's medical record.
-An evaluation to determine if the signs and symptoms of TB (unexplained weight loss, fever or persistent cough) were present must be performed.
Record review of Resident #14's record summary showed:
-The resident moved into the facility on 5/17/22.
-Some of the resident's diagnoses included:
--Chronic obstructive pulmonary disease (COPD).
--Hypoxemia
(low oxygen levels in the blood).
--Chronic respiratory failure (when the respiratory system fails in one or both of its gas exchange functions of oxygenation and carbon dioxide elimination) with hypoxia (low oxygen in the body tissues).
Record review of the resident's medical records showed:
-A nurse's note, dated 5/3/22, showed that staff documented the resident refused the first TST.
-No documentation of any TSTs or a chest x-ray to rule out TB.
3. Record review of Resident #26's admission Record showed he/she admitted on [DATE] with the following diagnoses:
-Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body).
-Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
Record review of the resident's Nursing Note, dated 5/3/22, first TB skin test showed:
-The resident was offered the 1st step TB skin test.
-The resident refused.
Record review of the resident's medical records showed no documentation of any further TSTs or a chest x-ray to rule out TB.
4. During an interview on 7/20/22 at 10:34 A.M., the Director of Nursing (DON) said:
-If a resident refused a TST, they should find out when the resident last had a TST.
-He/she could not find any TST for Resident's #14 and #26.
-If a resident refuses a TST 1st step a chest x-ray should be done to rule out TB.
Based on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. The facility also failed to ensure two sampled residents (Resident #14 and #26) were tested/screened for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function). The facility census was 37 residents.
Record review of the facility's undated water-borne pathogen prevention program entitled Facility Legionella Policy and Procedure, printed out and provided by the Administrator, showed a mostly educational, 15-page document that failed to include CMS requirements such as, but not limited to:
-A facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard.
-A completed Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
-A schematic or diagram of the facility's water system.
-Assessments of each individual area's potential risk level.
-Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility.
-Facility-specific interventions or action plans for when control limits are not met.
-Documentation of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned.
Review of CMS' Survey & Certification Memo 17-30 dated June 2, 2017 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires ' Disease (LD), showed nursing home facilities were immediately required to develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water.
1. Record review of the facility's Emergency Preparedness binder entitled Disaster Manual, dated 3/3/22 and obtained from the main nurse office, showed an absence of a water-borne pathogen prevention program.
Observations during the kitchen Life Safety Code (LSC) inspection on 7/13/22 at 9:11 A.M., showed there was an ice machine, a three-sink area, and an area with a low-heat, chemical dish-washing machine.
Observations during the LSC facility basement inspection with the Director of Plant Operations (DPO) on 7/14/22 between 9:59 A.M. and 10:31 A.M., showed the following:
-There was a hot water heater in the Mechanical Room.
-The Laundry Room had a sink and two washing machines.
-The Employee Breakroom had a sink.
-There was a Storage Room with a sink and a shower.
-There were two Restrooms.
During an interview on 7/15/22 at 9:37 A.M., the Administrator said that he/she had a Legionella infections (a serious type of pneumonia called Legionnaires' Disease) and a mild flu-like illness called Pontiac fever program on the computer, but it was not printed out anywhere that people could refer to.
Observations during the LSC facility room-by-room inspection with the DPO on 7/15/22 between 11:34 A.M. and 12:49 P.M., showed the following:
-There were two sinks, an ice machine, and a steam table in a kitchenette by the Main Dining Room.
-A Soiled Utility room had a sink and a hopper.
-There were two resident Shower Rooms.
-Each of the 24 resident rooms had a sink and either a private bathroom or shared bathroom.
During an interview on 7/18/22 at 12:13 P.M., the Administrator said that he/she would appreciate any further references that would help strengthen their existing Legionella program and meet all the requirements.

Based on interview and record review, the facility failed to have a Registered Nurse (RN) on duty eight hours a day, seven days a week. This deficient practice had the potential to negativly affect all residents residing at the facility.The facility's census was 37 residents.
Record review of the facility's undated Registered Nurse Staffing Policy, showed:
-The facility interpreted state and federal guidelines to say the facility must use the services of a RN for at least eight consecutive hours a day, seven days a week.
-The Director of Nursing (DON) or designated staffing coordinator scheduled at least one eight-hour shift each day on the nursing schedule.
-The eight hour shift will be suffice by the RN each day the DON is on site for at least eight consecutive hours.
-When the DON is not on site for eight consecutive hours, the designated staffing coordinator will schedule an RN to be the charge nurse for the day shift (7:00 A.M. to 3:00 P.M.).
-If an RN is not available for the 7:00 A.M. to 3:00 P.M., the DON or designated Staffing Coordinator will schedule an RN as either:
--Charge nurse for the 3:00 P.M. to 11:00 P.M. or the 11:00 P.M. to 7:00 A.M. shifts.
--A nurse supervisor in addition to the scheduled Licensed Practical Nurse (LPN) charge nurse.
-This requirement was met either by an established employee of the facility or by a third party staffing agency.
-If the facility was unable to establish consistent RN staffing according to these regulations, the Administrator will apply for an RN waiver through the Center for Medicaid and Medicare Services (CMS) RN waiver guidelines.
1. Record review of the facility's daily staffing sheet, dated 7/16, 17, and 18/22, showed:
-The DON was on the schedule as the RN on duty.
-The DON was the only RN on the schedule.
-The census was 37 residents.
2. During an interview on 7/13/22 at 1:30 P.M., the DON said:
-He/she had not had a day off since he/she was hired last year.
-He/she was taking time off from 7/15/22 through 7/19/22.
-He/she said the facility had a PRN (as necessary) RN on staff.
-The facility also used agency RN's to cover for him/her.
During an interview on 7/18/22 at 9:30 A.M., Certified Nursing Assistant (CNA) C said:
-He/she did the staffing schedules.
-There was no RN scheduled for 7/15/22 through 7/19/22 while the DON was on vacation.
-He/she was unaware that an RN needed to be scheduled eight hours a day seven days a week.
-He/she believed the regulation to be a Licences Practical Nurse (LPN) would be acceptable.
During an interview on 7/18/22 at 9:45 A.M., LPN A said:
-There was no RN over the weekend.
-There was no RN working today.
-There should have been an RN working eight hours a day.
During an interview on 7/19/22 at 9:00 A.M., the Administrator said:
-There was not an RN in the building on Saturday, 7/16/22; Sunday 7/17/22 or Monday, 7/18/22.
-The DON was the only RN employed at the facility.
-He/she was on vacation 7/16/22 through 7/19/22.
-There should be an RN in the facility eight hours a day.
-There was an agency RN working today.
-The DON was ultimately responsible for approving the staffing.
During an interview on 7/20/22 at 10:35 A.M., the DON said:
-There should be an RN here eight hours a day, seven days a week.
-He/she had been on vacation the last three days.
-The facility recently hired two PRN RN's.

Based on observation, interview, and record review, the facility failed to follow the facility policy to have a nebulizer (a device used to administer medication to people in the form of a mist inhaled into the lungs) mask stored in a bag when not in use for one sampled resident (Resident #14) out of 12 sampled residents. The facility census was 37 residents.
Record review of the facility's undated Oxygen and Nebulizer guidelines showed all nebulizer tubing must be kept in a bag when not in use.
1. Record review of Resident #14's record summary showed:
-The resident moved into the facility on 5/17/22.
-Some of the resident's diagnoses included:
--Chronic obstructive pulmonary disease (COPD).
--Hypoxemia (low oxygen levels in the blood).
--Chronic respiratory failure (when the respiratory system fails in one or both of its gas exchange functions of oxygenation and carbon dioxide elimination) with hypoxia (low oxygen in the body tissues).
Record review of the resident's care plan dated 5/17/22 showed:
-The resident was at risk for respiratory distress related to COPD.
-Instructions to monitor the resident's respiratory status.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/24/22 showed the following staff assessment of the resident:
-Had moderate cognitive impairment.
-His/her diagnoses included lung disease.
-Used oxygen.
Record review of the resident's May, June and July 2022 Medication Administration Record (MAR)s showed the resident had a physician's order for nebulizer treatments twice a day for COPD.
Observation on 7/13/22 at 2:41 P.M. showed the resident's nebulizer mask was on top of his/her dresser and was not in bag, not on a barrier and there was no bag present.
Observation and interview on 7/14/22 at 10:19 A.M. showed:
-The resident's nebulizer mask was on top of his/her dresser and was not in bag, not on a barrier and there was no bag present.
-There were crumbs on the dresser where the nebulizer mask was.
-The resident said he/she uses the nebulizer.
-The resident said it would be nice to have a bag to put the nebulizer mask in but the facility staff have not brought him/her one.
Observation and interview on 7/15/22 at 6:42 A.M. showed:
-The resident said he/she used his/her nebulizer yesterday.
-The resident's nebulizer mask was on top of his/her dresser and was not in bag, not on a barrier and there was no bag present.
During an interview on 7/18/22 at 1:01 P.M., Certified Medication Technician (CMT) A said:
-He/she or a nurse does the resident's breathing treatment.
-The staff should be putting the nebulizer mask in a bag.
-Any staff member can put the bag for the nebulizer in the resident's room.
During an interview on 7/18/22 at 1:36 P.M., Licensed Practical Nurse (LPN) A said:
-The CMTs do the resident's breathing treatments.
-The resident needs a bag for the nebulizer mask.
-Any staff member can put the bag for the nebulizer in the resident's room.
During an interview on 7/20/22 at 10:34 A.M., the Director of Nursing (DON) said:
-The bag for the nebulizer mask should be put in the room by the CMTs or nurses.
-The nebulizer treatments are on the CMT MAR so the CMT is usually the one doing the nebulizer treatment.
-The nebulizer mask should be in a Ziploc bag or a drawstring baggie or at least paper sack and be labeled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Seizures (a sudden uncontrolled electrical disturbance in the brain).
-Anemia (a condition in which the blood doesn't have enough healthy red blood cells).
-Urine retention (a condition in which your bladder doesn't empty completely each time you urinate).
-Edema (swelling caused by excess fluid trapped in your body's tissues).
-Open angle glaucoma (a condition that causes nerve damage to nerve at the back of the eye).
Record review of the resident's care plan dated 11/27/18 showed:
-The resident was able to complete bed mobility, transfers and ambulation independently.
-The resident was at risk for falls due to unsteady gait at times and shuffling gait dated 5/3/18.
-Staff was to complete the fall risk assessment quarterly and PRN (as needed) dated 5/3/18.
-Ensure floors were free from spills or clutter related to a fall dated 6/21/22.
-The resident had a diagnosis of seizure disorder and was prescribed medication management.
-Staff was to assist the resident to a side lying position during seizure to provide safety and prevent falls.
Record review of the resident's Fall Risk assessment dated [DATE] showed:
-Had one or two falls in the past three months.
-Had a balance problem while standing.
-Had a balance problem while walking.
-Had decreased muscular coordination.
-Required the use of an assistive device.
-Took one or two systolic blood pressure medications in the last seven days.
-Had a medication change in the last five days.
-Had seizures.
-Fall risk score was 14 (a score above 10 represents HIGH RISK).
Record review of the resident's Quarterly MDS dated [DATE] showed:
-Minimal difficulty hearing.
-Wore a hearing aid.
-Usually was able to understand others.
-Wore corrective lenses.
-Needed supervision to transfer from bed to chair.
-Brief Interview for Mental Status ((BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident ' s attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.) score was 8 moderately impaired.
Record review of the resident's Fall Investigation Tool dated 6/21/22 at 2:50 A.M. showed:
-The Nurse was notified the resident was observed to be on the floor.
-Upon arrival to the resident's room he/she was observed to be laying flat on his/her back close to his/her recliner.
-The resident stated he/she had slide out of his/her recliner.
-Range of Motion was initiated.
-Mild weakness was observed in his/her upper and lower extremities.
-With the assistance of three people and with the gait belt secured around the resident's waist he/she was assisted off of the floor into his/her bed.
-The resident stated he/she his/her head did not hit the floor.
-The resident denied pain at that time.
-Vital signs were initiated.
-The following were notified of the resident's non-injury fall; the DON and the Administrator via texts.
-The DPOA was called.
-The resident's physician was notified via answering service.
-The resident was in bed with the call light placed within reach.
-The resident was not taken to the hospital.
Record review of the resident's Nurses' Notes on 6/21/22 at 3:35 A.M. showed:
-It was brought to the Nurse's attention the resident was observed to be on the floor.
-Upon arrival to the resident's room he/she was observed laying flat on his/her back next to the recliner.
-The resident stated he/she slide out of his/her recliner.
-ROM was initiated.
-Mild weakness was observed to upper and lower extremities.
-With the assistance of three staff and a gait belt the resident was assisted off of the floor into his/her bed.
-The resident did not complain of pain or discomfort at this hour.
-The resident stated he/she did not hit his/her head.
-The Director of Nursing and Administrator were notified of the non-injury fall via text.
-The DPOA was called.
-The resident's physician was notified via answering service.
-At the time of the fall the resident had slipper (non slip) socks on.
-The call light was placed within the resident's reach.
Record review of the resident's Narrative Note 72 hour charting related to fall (non-injury) dated 6/22/22 at 2:56 A.M. showed:
-The resident was alert and oriented times three (X3) (to person, place, and time).
-The resident was on fall follow up without further incident.
-No complaint of pain or discomfort.
-Encouraged to use the call light for assistance at all times.
-Ambulation via walker with a guarded gait.
-Resident was in bed with the call light placed within reach.
Record review of the resident's Narrative Note 72 hour charting related to fall (non-injury) dated 6/23/22 at 3:39 A.M. showed:
-The resident was alert and oriented X3 (to person, place, and time).
-The resident was on fall follow up without further incident.
-No complaint of pain or discomfort.
-Encouraged to use the call light for assistance at all times.
-Ambulation via walker with a guarded steady gait.
-Resident was in bed with the call light placed within reach.
Record review of the resident's Narrative Note 72 hour charting related to fall (non-injury) dated 6/23/22 at 12:03 P.M. showed:
-Resident continues to be monitored for a follow up for a non-injury fall.
-No injury noted from fall.
-He/she has been up to his/her walker ambulating in the room and out onto the unit without incident.
-Resident denies any pain or discomfort at this time.
-Staff will continue to monitor.
Record review of the resident's Nurses' Notes dated 6/23/22 at 11:14 P.M. showed:
-The resident continues on fall follow up with no visible signs of injury.
-No new complaints of pain or discomfort.
Record review of the resident's Narrative Note 72 hour charting related to fall (non-injury) dated 6/24/22 at 3:22 A.M. showed:
-The resident was alert and oriented X3 (to person, place, and time).
-Follow up completed without further incident.
-No complaint of pain or discomfort.
-Encouraged to use the call light for assistance at all times.
-Ambulation via walker with a steady guarded gait.
-Resident was in bed with the call light placed within reach.
-Head of bed was elevated.
Record review of the resident's Physician's Progress note dated 6/27/22 at 2:30 P.M. showed:
-The physician was there for a follow up visit.
-The resident had no new issues.
-Physical exam the vital signs were left blank.
-The patient (resident) appeared in no apparent distress.
-The resident was oriented X3 without any focal deficits (a problem with nerve, spinal cord, or brain function).
-Musculoskeletal exam revealed equal and symmetric strength throughout.
-No documentation of a fall.
Record review of the resident's complete medical record showed the absence of:
-Updates to the resident's care plan post fall.
-Completed neurological checks for 72 hours as outlined in the facility policy post fall.
During an interview on 7/19/22 at 1:35 P.M., the Administrator said:
-Fall investigations were not being done correctly.
-Staff should have followed the protocol.
-Neuro checks should have been done.
-The Fall investigation was not completed as it should have been, there should have been a root cause and this should have been added to the resident's care plan.
-The Director of Nursing was responsible to ensure this had been done.
-This was all the paperwork he/she could find regarding the fall investigation, there was a lot missing such as neuro checks, the fall investigation, the root cause, and implementing interventions.
During an interview on 7/20/22 at 8:22 A.M., CNA A said examples of fall interventions would include:
-Know the resident's habits and abilities.
-Try to anticipate their needs, such as needing to use the bathroom.
-Check on the residents every two hours and more often if needed.
During an interview on 7/20/22 at 8:26 A.M. Licensed Practical Nurse (LPN) A said:
-If a CNA finds a resident had fallen they tell him/her.
-He/she would assess for movement and injury, ask the resident what happened.
-If injured he/she would send the resident to the hospital.
-He/she would notify the DON, Physician, family, and the Administrator.
-He/she would follow any new orders from the Physician.
-The DON was responsible for completing the investigation.
-Fall interventions would include lowering the resident's bed, floor mats, shoes or appropriate footwear, no throw rugs, call lights within reach, use of gait belts, checking the care plan for other interventions.
During an interview on 7/20/22 at 10:35 A.M. the DON said:
-The MDS person should do a follow up and put interventions in the care plan.
-Unwitnessed falls should have charting immediately and for 72 hours.
-Neuro checks should be completed on all falls.
-The root cause of the fall should be determined and care planned.
-If there is a fall the Nurse should have notified the DON, family, and Physician.
-The facility did not have a formal fall investigation sheet.
-The Nurse should have completed the Fall Investigation Tool.
-The Neuro checks had been documented on paper but can now be documented in the electronic chart.
-The Charge Nurse or DON was responsible to ensure the proper documentation was charted.
3. Record review of Resident #241's face sheet showed he/she was re-admitted on [DATE] with the following diagnoses:
-Malignant neoplasm of prostate (cancer in the gland that produces seminal fluid).
-Repeated falls.
-Polyneuropathy (the simultaneous malfunction of many nerves throughout the body).
-Congestive Heart Failure (a condition in which the heart does not pump blood as well as it should).
-Spinal Stenosis (a narrowing of the spinal canal).
-Chronic pain (long term pain).
-Difficulty in walking.
-Unsteadiness on feet.
-Lack of coordination.
Record review of the resident's baseline Care Plan dated 3/8/22 showed:
-Needed limited assistance with all activities of daily living related to weakness and unsteadiness on feet (dated 7/7/22).
-Had the potential for falls related to slightly unsteady gait, impaired decision making, and memory loss.
-Staff was to ensure the call light was within reach and encouraged the resident to use it.
-Staff was to ensure floors were free from spills or clutter.
-Staff was to ensure lighting was adequate and glarefree.
-Staff was to ensure appropriate footwear when ambulating or up in the wheelchair.
-Staff was to gather information on past falls and attempt to determine the cause of falls.
-Staff was to encourage use of wheelchair during times of pain and weakness.
Record review of the resident's Quarterly MDS dated [DATE] showed:
-Needed supervision for transferring between bed and chair.
-Able to walk in the corridor with supervision only.
-Needed supervision to go to the toilet.
-Brief Interview for Mental Status (BIMS) score was 15 cognitively intact.
Record review of the resident's Nurses' Notes dated 7/5/22 at 9:59 P.M. showed:
-At approximately 8:50 P.M. the Nurse was informed by the Certified Medication Technician (CMT) the resident was on the floor.
-Upon entering the room the resident was observed to be sitting upright on his/her buttocks with both legs outstretched in front of his/her body, both arms were at his/her sides and his/her back was leaned against the wall of the bathroom.
-He/she was fully dressed with both shoes on.
-He/she denied pain.
-When asked what had happened he/she replied that he/she had went to the bathroom. When he/she went back to sit in his/her chair, he/she just slid down on his/her butt.
-The resident was assessed for any injuries.
-He/she denied any pain.
-Grips were equal to (both) hands.
-Was able to move all extremities without difficulty.
-Was able to bend both legs at the knees, and extend same with upper extremities at elbows without difficulty of facial grimacing or voiced complaints.
-No skin tear, bleeding, abrasions, or new bruising was noted.
-He/she was transferred into a wheelchair with a two person assistance as he/she desired.
-Neuro checks were initiated with vital signs stable.
-Pupils were equal and reactive to light.
-He/she denied hitting his/her head.
-No raised or open areas noted to his/her scalp.
-He/she denied dizziness prior to the fall.
-Vital signs with Neuro checks per protocol.
-Physician was notified via answering service.
-DON to be notified.
-Resident observed sitting in his/her wheelchair watching television.
-He/she continues to deny pain or discomfort at this time.
-No documentation the DON or Administrator was notified.
Record review of resident's Nurses' Notes dated 7/6/22 at 2:44 A.M. showed:
-No complaints of pain at this hour.
-He/she had requested pain medication at the start of the shift rating his/her pain at 7 out of 10.
-A PRN (as needed) Oxycodone (narcotic pain medication)10 milligram (mg) tablet was given per the Physician's order.
-He/she was on fall follow up (non injury) without further incident.
-He/she was encouraged to use the call light for assistance at all times.
-He/she was encouraged to ambulate ad lib (as desired) via self propelled wheelchair.
-He/she was in bed with the head of bed elevated and the call light within reach.
Record review of the resident's Nurses' Notes dated 7/6/22 at 2:11 P.M. showed:
-The resident was on follow up fall monitoring for a fall that occurred early this morning.
-He/she has been in bed most of the day.
-He/she is alert and oriented X3 (person, place, and time).
-He/she was able to make his/her needs known.
-No injuries were noted from the fall, but the resident states he/she was sore from the fall.
-PRN pain medication was administered per the resident's request.
-Staff would continue to monitor.
Record review of the resident's Nurses' Notes dated 7/7/22 at 3:07 A.M. showed:
-He/she continues on antibiotic related to cellulitis.
-Pain medication requested for all over body aches.
-PRN Oxycodone was given per request.
-He/she was in bed with the call light placed within reach.
-He/she continues on 72 hour charting and observation relate to a non-injury fall.
-He/she was encouraged to use the call light for assistance at all times.
Record review of the resident's Nurses' Notes dated 7/7/22 at 2:39 P.M. showed:
-Staff was called to the room by the resident stating, he/she was unable to move and that he/she was incontinent.
-He/she stated he/she wanted to go to the Emergency Room.
-The resident's Physician was notified and the resident was sent out to a nearby hospital per Physician's order.
-He/she returned to the facility at this time with paperwork from the hospital stating that he/she had bruised muscles.
-The resident was sent back to the facility with 15 tablets of Flexeril (muscle relaxer) 10 mg tablets to be given three times a day PRN.
-The Physician was notified.
-Orders from the Physician were noted.
Record review of resident's Nurses' Notes dated 7/8/22 at 3:19 A.M. showed:
-He/she requested pain medication related to all over body pain.
-Oxycodone was given per Physician's order.
-Resident in bed with call light placed within reach.
Record review of the resident's Nurses' Notes for antibiotic and fall follow up dated 7/8/22 at 10:28 A.M. showed:
-The resident was out of the facility for a Physician's appointment.
-No assessment was done.
During an interview on 7/13/22 at 10:49 A.M. the resident said:
-He/she has had a couple of falls from weakness in his/her legs.
-He/she believed the falls were related to his/her prostate cancer that metastasized (spread to other sites in the body) the made his/her legs weak.
-His/her legs have been swollen the Physician had placed him/her on water pills then a couple of weeks later put him/her on antibiotics for the swelling in his/her legs.
-Now he/she had to use wheel chair.
During an interview on 7/13/21 at 1:00 P.M. the DON said:
-He/she was not aware the resident had a fall on 7/5/22.
-Staff were to report any falls to him/her.
Record review of the resident's Fall Investigation Tool on 7/15/22 at 9:20 A.M. showed:
-The resident had lost his/her balance and fell into the wall, slid down the wall onto his/her bottom.
-This was a no injury fall.
-His/her condition prior to incident was normal.
-He/she was alert and orient as usual.
-No neurological observation was needed.
-The Physician was notified on 7/15/22 at 10:22 A.M.
-He/she was not sent to the hospital.
-The DON was notified on 7/15/22 at 9:30 A.M.
-The Administrator was notified on 7/15/22 at 9:30 A.M.
-The family was notified on 7/15/22 at 10:30 A.M.
Record review of the resident's Nurses' Notes dated 7/15/22 at 10:18 A.M. showed:
-The resident was found in the sitting position on his/her bathroom floor.
-He/she stated he/she had lost his/her balance, fell up against the wall and slid down the wall into the sitting position.
-He/she stated he/she had not hit his/her head and did not fall hard enough to hurt himself/herself.
-He/she was able to move all four extremities without pain or incident.
-He/she was assisted up to his/her feet by two staff members and was placed in his/her wheelchair.
-He/she was advised to used the call light for assistance and he/she verbalized understanding.
-Physician and next of kin were notified of his/her fall.
-Staff will continue to monitor.
Record review of the resident's Nurses' Notes dated 7/17/22 at 1:04 P.M. showed:
-The resident was on fall follow up.
-He/she had no visible sign of injury.
-He/she had no new complaints of pain.
Record review of the resident's Nurses' Notes fall follow up dated 7/18/22 at 3:09 A.M. showed:
-He/she was encouraged to use the call light at all times.
-He/she was ambulating via wheelchair self propelled.
-He/she was in bed with the call light placed within reach.
-Head of bed was elevated.
-Resident was on fall follow up with no visible sign of injury or new complaints of pain.
Record review of the resident's Nurses' Notes dated 7/18/22 at 3:46 P.M. showed:
-The resident continues to be monitored for follow up related to a fall.
-No complaints of pain or discomfort throughout the day shift.
-No injuries noted from the fall.
-The resident was steady on his feet for transfers and using a wheelchair for locomotion.
-Staff will continue to monitor.
Record review of the resident's complete medical record showed the absence of:
-Updates to the resident's care plan post fall.
-Completed neurological checks for 72 hours as outlined in the facility policy post fall.
During an interview on 7/19/22 at 11:52 A.M., the Administrator said:
-Fall Investigation Incident Reports should start with looking at:
-The resident's environment at the time of the fall.
-The medication the resident was on at the time of the fall.
-The root cause of the fall.
-The neurological check form should be completed if an unwitnessed fall.
-If a resident has another fall during the 72 hour the neuro checks of a fall, the neuro checks should be restarted from beginning of the new fall.
During an interview on 7/19/22 at 1:35 P.M., the Administrator said:
-Fall investigations were not being done correctly.
-A complete investigation Fall Investigation Tool should have been completed which would have included a root cause and what interventions should have been put in place.
-He/she would expect that an unwitnessed fall investigation the nurse would notify the DON, Administrator, Physician, and Family.
-Neuro checks should have been completed.
-A complete investigations should have been completed which would have included a root cause and what interventions should have been put in place.
-Some of the unwitnessed falls did not have neuro checks which included this resident.
-Skin checks were not being done as they should have been.
During an interview on 07/20/22 at 10:35 A.M., the DON said:
-A Fall Investigation Tool should be done on each fall a resident has.
-The neurological check form should start immediately and charted for 72 hours for each fall.
-An Agency nurse may not know how to put the Incident Report into the computer, they write nurses notes for the 72 hours.
-He/She does audits to check to be sure Fall Investigation Tool are done.
-The nurses have been educated to do the neurological check form.
-The MDS Coordinator does the follow up for the Root Cause of a fall.
-A Root Cause looks at Care Plan to see if a fall is recurrent or UTI, age, safety.
-The DON and MDS Coordinator follow up on this for interventions and add to the Care Plan.
Based on interview and record review, the facility failed to follow their fall monitoring policy for three sampled residents (Resident #2, #30 and #241). The facility failed to complete and thoroughly document on the Fall Investigation Tool after each resident's fall; to update care plans after the resident's falls; to ensure appropriate notifications were made after resident's falls, and to document post fall monitoring out of 12 sampled residents. The facility census was 37 residents.
Record review of the facility's Resident Fall Monitoring Policy dated 10/18/2012 showed:
-The facility will identify residents at risk for falls and will plan care and implement interventions to minimize fall occurrences and injury due to falls.
-All residents are assessed for fall risk upon admission, quarterly, and with a significant change.
-A Fall Assessment is completed when a resident is determined to be at risk for falls.
-If a fall occurs, the licensed staff:
--Assesses for injury, immediately investigates the cause using the Fall Investigation Tool.
--Determines the interventions to prevent future occurrences.
--The plan of care is updated to reflect changes in the resident's status, new interventions in place to prevent recurrence of the fall or minimize potential for injury.
-The Physician, family, Director of Nursing (DON) and Administrator are notified and an incident report is completed.
-Post fall documentation on every shift for 72 hours is to include:
--Vital signs (VS-Blood Pressure [BP], Pulse [P], Respirations [R], Temperature [T], Oxygen Saturation [O2]).
--Range of Motion (ROM - the range on which a joint can move).
--Skin checks.
--Change in cognitive status.
--Evidence of pain and or swelling, including assessment and intervention when pain is evident.
-Neuro checks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) are to be done for any unwitnessed fall and documented using the neurological assessment form:
--Every 15 minutes times four.
--Then every 30 minutes times two.
--Then every hour times two.
--Then every shift times 72 hours.
-If the neuro checks show any significant change indicating a potential for a closed head injury condition, notify the Physician immediately and seek immediate medical attention.
-Resident falls will be reviewed during the weekly fall meeting and monitored through the Quality Assurance process.
1. Record review of the Resident # 30's admission Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Heart attack 11/2/18.
-Muscle weakness 11/2/18.
-Unsteadiness on feet 11/2/18.
-Atrial fibrillation (A-Fib-abnormal heart rhythm) 11/2/18.
-Congestive Heart Failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should) 11/2/18.
-Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) 11/2/18.
-Atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls causing obstruction of blood flow) without angina pectoris (severe pain in the chest spreading out to other areas cause by inadequate blood supply to the heart) 11/2/18.
-Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) 11/2/18.
-Urinary Tract Infection (UTI-an infection in any part of the urinary system-kidneys, ureters, bladder and urethra) 7/5/22.
Record review of the resident's Care Plan dated 11/16/18 with next quarterly review for 7/19/22 showed:
-Falls:
--At risk for falls due to poor balance, occasional unsteady gait, impaired decision making and history of falls. 11/16/18.
--Will not sustain any serious injuries related to falls through next review.
--Fall risk assessment quarterly and as needed (PRN). 11/16/18.
--Encourage and assist resident to put on appropriate non-skid foot wear when out of bed. 11/16/18.
--Keep call light within reach at all times when in room. 11/16/18.
--Keep pathways well lit and free of clutter. 11/16/18.
--Keep walker or wheelchair within reach at all times. 11/16/18.
--Resident will walk around with non-skid socks on. 1/15/19.
--Remind her to wear non-skid socks or shoes when out of bed. 1/15/19.
--Educate resident to not put pillows in chair to sit on due to it becoming slippery causing her to slide out of chair. 1/22/19.
--Monitor for orthostatic hypotension (postural hypotension - is a form of low blood pressure that happens when standing after sitting or lying down). Encourage resident to sit on the side of her bed and allow feet to dangle prior to transfer. 4/8/20.
--Increase rounds to every one hour related to non-injury fall on 7/10/22.
Record review of the resident's Fall Risk Assessment Report Date 6/6/2022 showed:
-A total score above 10 represented a high risk.
-The resident's fall risk score was 17.
Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 6/7/22 showed:
-Cognition was severely impaired.
-Had two or more non-injury falls since the last quarterly MDS on 4/12/22.
Record review of the resident's medical record from 7/1/22 through 7/14/22 showed:
-The resident had six falls.
-The resident went to the emergency room (ER) after a fall on 7/4/22.
-Only one Fall Investigation Tool was filled out on 7/6/22, record review of that document showed the absence of:
--What medications the resident was on at the time of the fall.
--The root cause of the fall.
--What interventions were put into place to prevent further falls.
-No Fall Investigation Tool for the other five falls.
-No neurological assessment forms completed for the six falls.
-No updates were done to the resident's care plan other than on 7/10/22.
Record review of the resident's Health Status Notes dated 7/1/22 at 11:37 A.M., showed:
-Resident found to have an extremely swollen right knee.
-The knee is warm to the touch.
-Resident denies pain.
-Physician notified and received new order for a Stat (immediately) 2-view x-ray of the right knee.
Record review of the resident's Health Status Notes dated 7/1/22 at 1:09 P.M., showed:
-Resident's roommate called staff to room to report that this resident had fallen.
-Staff responded to room and the resident was found on the side of his/her bed in the kneeling position.
-The resident's knees were not touching the floor.
-The resident's as holding his/herself up on the side of the bed.
-The call light was placed within reach and resident encouraged to use for help.
-No injuries noted.
-Resident continued to be monitored by staff.
Record review of the resident's Nurses Notes dated 7/3/22 at 12:35 A.M., showed:
-Roommate reported the resident's fall to a Certified Nursing Aide (CNA).
-Nurse and CNA found the resident on floor with no pants on, no non-skid socks on and a t-shirt.
-The resident had a gash in the middle of his/her forehead which was tender to the touch.
-The resident said:
--Feet first trying to go to bathroom and fell.
--Pain level 5/10, Headache, not a lot. per resident.
- Complained of left arm pain with ROM.
-Noted inner Right Upper Extremity (RUE-arm) swollen, bruised, and tender to touch.
-Physician contacted requested STAT XRAY A.M., 2 VIEWS Head and inner RUE.
-Physical Therapy (PT) ordered to evaluate multiple falls due to gait stability.
Record review of the resident's Nurses Notes dated 7/4/22 at 9:23 P.M., showed:
-Resident found on floor next to bed laying down.
-Resident does not appear to be in distress.
-When asked what happened, the resident laughed.
-The resident had multiple falls this weekend.
-Resident sent to ER for evaluation and Treatment.
-Durable Power of Attorney (DPOA) and Physician notified.
Record review of the resident's return to the facility, fall follow up note dated 7/5/22 at 2:50 A.M., showed.
-Resident was diagnosed with a Urinary Tract Infection (UTI).
-Resident was started on antibiotics.
-The nurse went to administer the resident's scheduled medication and found the resident sitting in an upright position by his/her bed.
-When asked what happened the Resident said I don't know.
-The resident was assisted by two people off the floor to his/her bed.
-The Physician, DON, Administrator, and DPOA were notified of this new fall.
-To prevent further falls a wheelchair and commode was placed next to bed and call light within reach.
Record review of the resident's Nurses Notes dated 7/6/22 at 4:02 A.M., showed:
-Resident's call light was on and was answered by the CNA'S.
-Resident was observed to be on the floor by the door to his/her room, sitting in an upright position.
-When asked what happened, the resident said that he/she got up.
-ROM was initiated.
-Weakness is observed to upper & lower extremities.
-Resident was assisted off the floor with the assist of two persons.
-At the time of fall the resident was clothed, had slipper socks and shoes on.
-The resident's wheelchair was about four feet away from him/her.
-The Physician, DON, Administrator, and DPOA were notified of fall.
-VS and Neuro-checks were initiated.
-Resident was placed at the Nurse's station to prevent further falls.
Record review of the resident's Nurses Notes dated 7/10/22 at 10:42 P.M., showed:
-At approximately 7:15 P.M. this nurse was summoned by CNA to resident's room.
-The CNA observed resident sitting on her buttocks near doorway of room.
-This nurse entered room and observed resident lying supine (face up) with a pillow under his/her head, alert awake and verbally appropriate.
-The resident denied pain or discomfort and able to move all extremities (MAE's) without difficulty,
-No facial grimacing noted and resident voiced no complaints.
-The resident's grips to hands were equal, and pupils equal and responsive to light (PERL).
-The resident's scalp intact with no raised open areas, no bleeding, no new abrasions, no new lacerations and no new skin tears.
-The resident said: I just slid down.
-Resident's wheelchair was nearby in unlocked position.
-The resident was fully dressed with non-skid socks onto both feet and one shoe on.
-The CNA reported he/she had just assisted resident to bed.
-With two person [NAME]

Based on observation, interview, and record review, the facility failed to ensure residents' prescription medications that had been opened had the date the medication was opened written on the container; to ensure medication containers were clean, and to ensure residents personal belongings were not mixed in with medications. The facility census was 37 residents.
Record review of the facility's policy, Medication Storage in the Facility, dated 10/4/18 showed:
-Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were to be immediately removed from stock, disposed of according to procedures for medication disposal.
-Medication storage areas were kept clean, well-lit, and free of clutter.
-Medication storage conditions were monitored on a monthly basis and corrective action was taken if problems were identified.
1. Observation on 7/15/22 at 6:20 A.M. of the Nurses' treatment cart with Licensed Practical Nurse (LPN) B showed:
-A resident's prescribed medication, Opium tin (a narcotic pain reliever) 10 milligram (mg) /milliliter (ml) bottle bottle was dirty and sticky where the medication dripped down on the side of the bottle.
-The bottle was opened without an opened date written on it.
-In the locked narcotic box were items belonging to various residents that included:
--A Driver's Licence, Social Security Card, Medical ID necklace, three packages of cigarettes, narcotic medications.
-A resident's prescribed Morphine sulfate (a narcotic pain medication) 30 ml bottle was opened without an opened date written on it.
-A resident's prescribed Diclofenac Sodium (a medication used to treat pain and swelling) 1% topical gel tube was opened without an opened date written on it.
-A resident's prescribed Santyl ointment (a medication that removes dead tissue from wounds so they can heal) tube was opened without an open date on it.
-The tube of Santyl was greasy with ointment on the outside of the tube.
During an interview on 7/15/22 at 6:20 A.M., LPN B said:
-The residents' medication that have been opened should have the date it was open written on it.
-The medications should have been kept clean, not have dripped down the side of the container.
-He/she did not know why there were resident belongings in the locked narcotic box.
-Those belongings should have been locked up in the Social Services office as the residents have been at the facility for a long time.
-Cigarettes should not have been in the same compartment as residents' medications.
-He/she tries to keep the medication cart clean.
-Anyone who uses the medication cart was responsible for keeping it clean and tidy.
During an interview on 7/15/22 at 7:40 A.M. LPN A said:
-Anyone who uses the medication cart was responsible for keeping it clean and tidy.
-Cigarettes should not have been in the same compartment as residents' medications.
-The residents' medication that have been opened should have the date it was open written on it.
-The medications should have been kept clean, not have dripped down the side of the container.
-There should not have been resident belongings in the locked narcotic box.
During an interview on 7/15/22 at 12:45 P.M. the Director of Nursing (DON) said:
-If a medication had been opened it should have the date it was opened written on it.
-The medication containers should have been cleaned.
-Residents' belongings should not have been locked in the medication cart unless they had just admitted over the weekend.
-The two residents' belongings should have been locked in the Social Services office since they had been admitted a while ago.
-Residents' cigarettes should not be in the same drawer with medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or the resident's representative (if applicable) with a written summary of the baseline care plan for three sampled residents (Residents #26, #14 and #22) out of 12 sampled residents. The facility census was 37 residents.
Record review of the facility's undated Base Line Care Plans policy showed:
-Every resident had an interdisciplinary care plan initiated within 24 hours of admission.
-The care plan identified priority problems and needs to be addressed by the interdisciplinary team (IDT).
-The resident and/or the family member was involved in the care planning.
-The facility developed and implemented a base line care plan for each resident that included effective and person-centered care of the resident that met professional standards of quality of care.
-The baseline care plan was developed within 48 hours of the resident's admission.
-The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan was developed within 48 hours of the resident's admission.
-A copy of the baseline care plan was provided to the resident and their representative that included the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility, any updated information based on the details of the comprehensive care plan, as necessary.
1. Record review of Resident #14's face sheet showed:
-The resident moved into the facility on 5/17/22.
-Some of the resident's diagnoses included chronic obstructive pulmonary disease (COPD), hypoxemia (low oxygen levels in the blood), chronic respiratory failure (when the respiratory system fails in one or both of its gas exchange functions of oxygenation and carbon dioxide elimination) with hypoxia (low oxygen in the body tissues), heart failure, anxiety disorder (psychiatric disorder that involve extreme fear, worry and nervousness), chronic pain, high blood pressure, Parkinson's Disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait), osteoarthritis (a degenerative disease of the bones and joints), kidney disease and cellulitis (an infection of deep skin tissue) of his/her right lower limb.
Record review of the resident's care plan started 5/17/22 showed:
-The care plan was updated on 6/17/22 and 6/20/22.
-The care plan addressed the resident's activities, assistance required for care needs, medications, some health conditions and hospice (end of life) care.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/24/22 showed the following staff assessment of the resident:
-Had moderately impaired cognitive skills.
-Some of his/her diagnoses included lung disease, heart failure, high blood pressure, arthritis and Parkinson's Disease.
Record review of the resident's medical records showed no care plan (neither base line or comprehensive) that was provided to the resident.
During an interview on 7/18/22 at 11:53 A.M., the MDS Coordinator said:
-There was no baseline care plan.
-They developed the comprehensive care plan instead of the baseline care plan.
-The resident or the resident's responsible party was not provided with his/her care plan.
2. Record review of Resident #22's face sheet showed:
-The resident was admitted to the facility on [DATE].
-Some of the resident's diagnoses included peripheral vascular disease (PVD-the build-up of fatty material inside the blood vessels), heart disease, high blood pressure, depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life), anxiety and a fracture of right radius (one of the forearm bones).
Record review of the resident's baseline care plan dated 6/20/22 showed:
-A problem of: new admission to nursing facility for the diagnosis of repeated falls.
-An additional problem included a wrist fracture.
-A goal that the resident's basic needs would be met on a daily basis.
-Interventions included:
--Determine the resident's dietary needs and notify the kitchen.
--Evaluate the bowel and bladder status of the resident and place on appropriate toileting schedule.
--Evaluate medications for possible interactions and obtain a diagnosis for each medication.
--Determine bath needs and place on schedule.
--Assess skin condition and treat as needed.
Record review of the resident's care plan started 6/22/22 showed:
-The resident required limited assistance with cares.
-The resident was at risk for falls.
Record review of the resident's admission MDS dated [DATE] showed the following staff assessment of the resident:
-Entered from rehabilitation facility.
-Required limited assistance of one person for bed mobility, walking in room and hygiene.
-Required supervision for walking in the hall, transferring, dressing and toilet use.
-Was independent with eating.
-Had range of motion impairment on one side of his/her upper extremities.
-Used a walker and a wheelchair.
Record review of the resident's medical records showed no care plan (neither base line or comprehensive) that was provided to the resident.
During an interview on 7/18/22 at 11:53 A.M., the MDS Coordinator said the resident and/or his/her responsible party was not provided with a copy of the care plan.
3. Record review of Resident #26's face sheet showed:
-The resident admitted to the facility on [DATE].
-Some of the resident's diagnoses included a stroke with paralysis on one side and with the inability to speak, depression and high blood pressure.
-The resident was receiving hospice (end of life) care.
Record review of the resident's care plan started on 4/25/22 and updated on 5/4/22, 6/1/22, 7/5/22 showed:
-The resident was at risk for falls.
-The resident required extensive to total assistance with cares.
-The resident was receiving hospice care.
Record review of the resident's admission MDS dated [DATE] showed the following assessment of the resident:
-Had no speech.
-Usually understood others.
-Was sometimes understood by others.
-Had long-term and short-term memory impairment.
-Cognitive skills for decision making were moderately impaired.
-Had no falls.
-Was on hospice.
Record review of the resident's medical records showed no care plan (neither base line or comprehensive) that was provided to the resident.
During an interview on 7/18/22 at 11:40 A.M., the MDS Coordinator said the resident or the resident's responsible party was not provided with his/her care plan.
4. During an interview on 7/15/22 at 9:02 A.M., the DON said he/she hasn't heard of the baseline care plan process being in place at the facility.
During an interview on 7/15/22 at 9:02 A.M., the Administrator said:
-The baseline care plan should be done within 24 hours of admission.
-It should be given to resident and/or the resident's responsible party.
-The resident and/or the resident's responsible party should sign a copy of the care plan provided.
During an interview on 7/20/22 at 10:34 A.M., the DON said the MDS Coordinator was responsible for the development of the baseline care plan within one to two days of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report to the State and the local Police within 24 hours, when a resident reported fraudulently charges on his/her credit card. This deficient practice negatively affected one sampled resident (Resident #25) out of 12 sampled residents. The facility census was 37 residents.
Record review of the facility's undated abuse, neglect and exploitation showed:
-Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use, either temporary or permanent, of a resident's belongings, prescriptions or money without the resident's consent.
-Reporting was defined as immediately reporting alleged violations involving misappropriation of resident property to the Administrator and/or Director of Nursing (DON) or other officials in accordance with state law.
-Immediately was defined as as soon as possible:
-Any allegation of abuse, neglect, mistreatment, exploitation or injures of unknown source resulting in serious injury within two hours.
-Other allegations of neglect, mistreatment, exploitation or misappropriation of resident property within 24 hours.
-Results of all investigation should have been reported by the Administrator or DON to the state agency.
1. Record review of Resident #25's face sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Urinary tract infection (UTI - an infection of one or more structures in the urinary system).
-COVID-19 (an infectious disease caused by the SARS-CoV-2 virus).
-Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Chronic obstructive pulmonary disease (COPD - damage to the lungs that cannot be reversed).
-Insomnia (persistent problems falling asleep or staying asleep).
-The resident was his/her own person.
Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by the facility for care planning) dated 5/26/22 showed:
-The resident was able to make self understood.
-The resident was able to understand others.
-The resident's Brief Interview for Mental Status (BIMS) score was 15 showing he/she was cognitively intact.
Record review of the facility investigation dated 6/27/22 showed:
-At 10:00 A.M. the Social Services Designee (SSD) notified the Administrator that Resident #24 had been a victim of debit card fraud.
-Two staff that provided care to the resident were suspended pending the out come of the investigation.
-The absence of documentation to indicate that the local police or state agency were contacted to report the allegation of misappropriation.
-The Administrator had concluded his/her investigation on 7/20/22.
-He/she was not able to conclusively say who had taken the resident's debit card and fraudulently used it.
-He/she had assisted the resident in filling papers with the bank so their fraud department could investigate.
During an interview on 7/13/22 at 9:20 A.M., the resident said:
-Money was missing totaling $300 from purchases made on his/her debt card.
-The debit card had been in his/her purse in his/her room.
-When he/she had received his/her monthly statement from the bank it showed several purchases he/she had not made.
-He/she had not left the faciity on those dates.
-He/she had not had any visitors.
-He/she had not handed his/her debit card to purchase anything for him/her.
-He/she was very angry about someone most likely staff that had come into his/her room took his/her debit card and then went shopping.
-He/she told the DON and the Administrator of the missing money.
-Although the Administrator had been helping him/her file papers with the bank the incident was very aggravating.
-He/she thought the debit card was then returned to his/her purse.
-He/she was having a hard time sleeping as he/she was afraid more of his/her belongings would go missing.
-The Administrator had not been able to figure out what had happened as of this date.
During an interview on 07/19/22 at 2:41 P.M., The Administrator said:
-Resident #24 had items missing that was not reported to the State within the 24 hour time frame.
-He/she had started the online report to the state but was distracted and his/her computer had timed out, which shut down the program.
-The report should have been sent within 24 hours, his/her expectation was to report misappropriation.
-He/she was not done with the investigation as of today.
-He/she had called the local police department to report the fraudulent use of the resident's debit card.
-He/she was told by the local police that it was a small amount of money involved and they would not be coming out to investigate the incident.
-He/she was told to file a report on-line.
-He/she attempted to file a report on-line but did not have the time the incident had occurred so the computer program would not accept the information to complete the report.
During an interview on 7/20/22 at 10:34 A.M. the DON said:
-If a bigger item was misplaced the investigation goes directly to the Administrator such as a missing debit card.
-The Administrator was responsible for the conducting the investigation, contacting the Police, and reporting to the State of a misappropriation of a resident's property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free of misappropriation for one sampled resident (Resident #25) out of 12 sampled residents when the resident's debit card was used for $303.69 in unauthorized purchases. The facility's census was 37 residents.
Record review of the facility's undated abuse, neglect and exploitation showed:
-The facility took appropriate steps to prevent misappropriation of resident property.
-Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use, either temporary or permanent, of a resident's belongings, prescriptions or money without the resident's consent.
-Reporting was defined as immediately reporting alleged violations involving misappropriation of resident property to the Administrator and/or Director of Nursing (DON) or other officials in accordance with state law.
-Immediately was defined as as soon as possible:
-Any allegation of abuse, neglect, mistreatment, exploitation or injures of unknown source resulting in serious injury within two hours.
-Other allegations of neglect, mistreatment, exploitation or misappropriation of resident property within 24 hours.
-Results of all investigation were reported by the Administrator or DON to the state agency.
-Based on investigation findings, the facility will implement corrective actions to prevent recurrence.
-Corrective actions was defined as actions taken by the facility once reasonable efforts were made to determine the cause of the alleged violation.
--Corrective action taken was consistent with the investigation findings and to eliminate any ongoing dangers to the resident or other residents that may be affected.
-This may include in-services or other measures as appropriate.
-Steps taken were documented.
1. Record review of Resident #25's face sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Urinary tract infection (UTI - an infection of one or more structures in the urinary system).
-COVID-19 (an infectious disease caused by the SARS-CoV-2 virus).
-Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Chronic obstructive pulmonary disease (COPD - damage to the lungs that cannot be reversed).
-Insomnia (persistent problems falling asleep or staying asleep).
-The resident was his/her own person.
Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by the facility for care planning) dated 5/26/22 showed:
-The resident was able to make self understood.
-The resident was able to understand others.
-The resident's Brief Interview for Mental Status (BIMS) score was 15 showing he/she was cognitively intact.
Record review of the facility investigation dated 6/27/22 showed:
-At 10:00 A.M. the Social Services Designee (SSD) notified the Administrator that the resident had been a victim of debit card fraud.
-According to the resident's bank statement there were eight charges between May 28-29/22 totally $303.69.
-The resident said that to his/her knowledge the debit card had never left his/her possession.
-The resident did not know who might have used the card.
-The resident had the card since the middle of May 2022.
-The resident had not used the card nor had he/she given the card to anyone else.
-The Administrator had taken the resident to the bank two weeks prior to get recent statements for his/her Medicaid application.
-The resident did not disclose he/she had ordered a new debit card while at the bank that day.
-The SSD was notified by a Certified Nursing Assistant (CNA) B that the resident's debit card was missing.
-The SSD went to the resident's room where the resident was looking at his/her June 21, 2022 bank statement.
-The SSD verified the resident had his/her debit card in his/her purse.
-The SSD notified the Administrator of the fraudulent charges.
-The resident had told the SSD that CNA D had been seen coming out of his/her room (wearing green scrubs) and he/she may have used the stolen debit card.
-There was another CNA who had a very similar name and the resident was asked if he/she thought it was either of them and he/she did not know.
-Both of the CNAs were suspended until the investigation was completed.
-The Administrator took the resident to the bank to file a dispute for the fraudulent actives on the debit card charges.
-The debit card was turned off.
-The charges and overdraft fees were returned to the resident by the bank.
-When the Administrator notified the police the police said to file a report on line as the amount was too small for them to come out onsite.
-The online police report needed a specific time the incident occurred and since the bank was not able to produce the exact time the report was rejected.
-The Administrator also called each of the vendors where charges had been made and they were not able to say what time the charges had been made.
-In conclusion the resident's moneys were returned to him/her.
-The facility was not able to substantiate how the charges got on the resident's card.
-According to the map the Administrator had printed of the businesses the resident's cards were used at showed they were within seven minutes from the facility.
Record review of the resident's bank statement dated 6/28/22 showed the following purchases were made on the residents' debit card:
-The resident had highlighted the fraudulent chargers in yellow on the bank statement.
-On 5/28/22 $50.97 was charged at a local liquor store.
-On 5/28/22 $8.05 was charged at the same local liquor store.
-On 5/28/22 $51.61 was charged at a local grocery store.
-On 5/28/22 $36.20 was charged at a local clothing store.
-On 5/29/22 $60.71 was charged at a local gas station.
-On 5/29/22 $39.78 was charged at a local Mexican restaurant.
-On 5/29/22 $47.98 was charged at a local convenience store.
-On 5/29/22 $8.39 was charged at the same convenience store.
-The total charges were $303.69.
-There was an additional $328.00 fee for returned checks as these charges made the resident's account was overdrawn when his/her regular automatic withdrawals came in.
-The resident declined to allow a photocopy be made of his/her bank statement.
During an interview on 7/13/22 at 9:20 A.M., the resident said:
-He/she had unauthorized charges totaling over $300 from purchases made on his/her debt card.
-The debit card had been in his/her purse in his/her room.
-When he/she had received his/her monthly statement from the bank it showed several purchases he/she had not made.
-He/she had not left the faciity on those dates.
-He/she had not had any visitors.
-He/she had not handed his/her debit card to purchase anything for him/her.
-He/she was very angry about someone most likely staff that had come into his/her room took his/her debit card and then went shopping.
-He/she told the DON and the Administrator of the missing money.
-Although the Administrator had been helping him/her file papers with the bank the incident was very aggravating.
-He/she thought the debit card was stolen then later returned back to his/her purse.
-He/she was having a hard time sleeping as he/she was afraid more of his/her belongings would go missing.
-The Administrator had not been able to figure out what had happened as of this date.
-Most of the overdraft fees have been returned from the bank and was put back into his/her bank account.
-He/she did not have any idea who would have taken the debit card or clothing but he/she felt it must have been a staff member.
During an interview on 7/19/22 at 9:25 A.M., the Administrator said:
-The resident had notified staff he/she had charges on his/her debit card that he/she had not made.
-He/she was responsible investigating money that had gone missing.
-The resident has also had visitors.
-He/she was not sure if the resident had any visitors on the days the debit card was missing.
-He/she was not sure if the resident had left the facility during the times the debit card was used.
-They had started an investigation.
-During a search of the resident's room, the debit card was found in the resident's purse.
-He/she had called the police, they would not come to the facility to make a report he/she was advised to make an online report.
-He/she couldn't determine a certain time/date the charges had been made a person who that thought had stolen the debit card so the online report could not be submitted.
-He/she had also started an online report to the State but the time lapsed on his computer and it was not sent in.
-It should be sent in within 24 hours or two hours if it was considered abuse.
-He/she had not completed the investigation as of today.
During a follow up interview on 7/19/22 at 12:05 P.M., the Administrator said:
-They had not been following their policy regarding missing items.
-The State should have been notified within 24 hours of any suspected theft and they should have had details about the missing items within that time frame.
-He/she had mistakenly not notified the state.
-The police report needed a specific time and he/she was not able to get one from the retailers or the resident's bank so the on line police report would not take his/her report.
During an interview on 7/20/22 at 10:15 A.M., the Administrator said:
-Could not find anything saying the resident had left the building.
-He/she had asked the resident to put his/her debit card in the safe where it could be locked up.
-The resident declined as he/she would not have access to it after office hours.
-During his/her investigation the resident had mentioned two staff members with like names who had worked with him/her.
-The two staff members were suspended.
-The two staff members were suspended until the issue was investigated.
-The two staff members' suspension was lifted and they returned to work.
-One of the two was later terminated for a different reason.
During an interview on 7/20/22 at 10:30 A.M., the Social Service Designee (SSD) said:
-Money missing from the resident's bank account was turned over to the Administrator to investigate.
-The Administrator also handled all of the police reports.
During an interview on 7/20/22 at 10:34 A.M., the DON said:
-Since he/she has been at the facility about 10 months ago some items have gone missing.
-Some of the smaller items had been recovered a cell phone, clothing, and personal items.
-If a bigger item was misplaced the investigation goes directly to the Administrator such as a missing debit card.
-The Administrator was responsible for the investigation, the Police, and reporting to the State.
-He/she was told by the Administrator if a resident wanted a lock box in their room they would have to purchase it themselves.
During a telephone interview on 7/25/22 at 11:55 A.M., the Administrator said:
-The bank had refunded all monies to the resident (overdraft fees and fraudulent charges).
-The resident had agreed to put his/her debit card in the safe and it is currently in the safe.
-There have been no further items or money missing since the staff member was terminated.
-At the time of the bank notification to the resident of the fraudulent charges the facility video was already too old to review.
*Note: Attempts to interview suspended employees was unsuccessful. One number was disconnected; the other had a full voicemail box and unable to leave a message.
**Note: The resident's bank fraud department was contacted, the representative said he/she was unable to verify if the charges from the fraudulent charges and over draft fees had been returned to the resident and could provide no further information.
MO00203665

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft by failing to document personal belongings upon admission and to follow-up timely as part of the grievance process when clothes were reported missing for three sampled residents (Resident #14, Resident #25, and Resident #33) out of 12 sampled residents. The facility census was 37 residents.
Record review of the facility's undated abuse, neglect and exploitation showed:
-The facility must take appropriate steps to prevent misappropriation of resident property.
-Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use, either temporary or permanent, of a resident's belongings, prescriptions or money without the resident's consent.
-Reporting was defined as immediately reporting alleged violations involving misappropriation of resident property to the Administrator and/or Director of Nursing (DON) or other officials in accordance with state law.
-Immediately was defined as as soon as possible.
-Other allegations of neglect, mistreatment, exploitation or misappropriation of resident property within 24 hours.
-Results of all investigation were reported by the Administrator or DON to the state agency.
-Based on investigation findings, the facility will implement corrective actions to prevent recurrence.
-Corrective actions was defined as actions taken by the facility once reasonable efforts were made to determine the cause of the alleged violation.
-Corrective action taken was consistent with the investigation findings and to eliminate any ongoing dangers to the resident or other residents that may be affected.
-This may include in-services or other measures as appropriate.
-Steps taken were documented.
1. Record review of Resident #14's record summary showed he/she moved into the facility on 5/17/22.
Record review of the resident's medical records showed there was no personal belongings form identifying what belongings the resident brought into the facility.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/24/22 showed the facility staff assessed the resident as having moderately impaired cognitive skills.
During an interview on 7/14/22 at 10:19 A.M., the resident said:
-He/she came with five outfits when he/she moved into the facility and two outfits were lost in the first two days.
-He/she told somebody his/her clothes were missing but he/she doesn't know if they looked for them.
-The facility staff said he/she didn't put his/her name on his/her clothes.
-His/her grandchild took pictures of his/her clothes.
-His/her grandchild talked to the person at the front desk and they said they would look into his/her missing clothes.
Observation on 7/14/22 at 10:55 A.M. showed:
-The resident had one red shirt, one blue shirt, and two pairs of pants (one green, one gray) in his/her closet.
-There were some shorts in his/her top dresser drawer.
-There was one shirt and one sweatshirt in his/her middle dresser drawer.
Observation on 7/15/22 at 9:34 A.M. showed:
-The Social Services Designee approached the resident who was sitting in the living room and asked the resident if his/her top was labeled with the resident's name.
-The Social Services Designee looked at the resident's shirt tag and said yes it was labeled with the resident's name.
-The Social Services Designee suggested to the resident that they get together later that day to go through the resident's clothes and make sure they were all labeled.
During an interview on 7/18/22 at 10:26 A.M., the Social Services Designee said:
-He/she had photos of the resident's clothes.
-He/she took the photos to laundry and looked through all the storage areas and he/she could not locate any of the resident's clothing.
-He/she knows the resident's clothing had the resident's name on them because he/she marked with a marker upon the resident's arrival.
-He/she asked laundry and housekeeping to look in other resident's closets in case they were misplaced.
-On 7/15/22, he/she sent copies of the information regarding the resident's missing clothes to their marketing/sales employee.
During an interview on 7/18/22 at 1:01 P.M., Certified Medication Technician (CMT) A said:
-He/she heard there was a problem with residents' clothes going missing more than a month ago.
-There had been no laundry person and the housekeeper was trying to do both laundry and housekeeping but that was not happening anymore.
During an interview on 7/18/22 at 1:36 P.M., Licensed Practical Nurse (LPN) A said:
-The resident mentioned missing some clothes.
-The resident didn't have any pants a couple of weeks ago but one of the Certified Nursing Assistants (CNA)s found a pair of pants of his/hers and then the resident's family brought more clothes in.
During an interview on 7/19/22 at 8:12 A.M., the Administrator said:
-He/she asked the Social Services Designee for the resident's inventory sheet and the grievance regarding his/her missing clothes and there were none for the resident.
-The resident's missing clothes were not on the grievance log.
-He/she had not figured out what exactly the resident was missing so nothing had been replaced yet.
-Social Services was supposed to fill out a grievance with the resident and/or family and document what was missing; then they would investigate to see if they could find it or if it was missing.
During an interview on 7/20/22 at 10:34 A.M., the DON said:
-The resident told him/her about the missing clothes about a week ago and he/she reported it to the Administrator.
-The family notified Social Services in an email and he/she was copied in the email.
-The family had pictures of the resident's clothes and the facility didn't find any of his/her missing clothes.
During an interview on 7/22/22 at 11:30 A.M., a friend of the resident's said:
-He/she told someone at the front desk about the resident's missing clothes about three weeks ago.
-He/she had tried to address the resident's missing clothes every time he/she visits but nothing has happened.
-He/she had asked any staff member that came into the resident's room while he/she was visiting and they say someone is looking for the resident's clothes.
-He/she had about 20 pictures of each of the resident's clothing items that are missing.
-The resident asks the facility staff about his/her clothes almost every day as he/she is upset about his/her clothes being gone.
2. Record review of Resident # 33's admission Record showed he/she was admitted on [DATE] with the following diagnoses:
-Acute kidney failure (Kidneys fail to remove wastes from the blood).
-Urinary Tract Infections (UTI-an infection in any part of the urinary system-kidneys, ureters, bladder and urethra).
-Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
Record review of resident's Quarterly MDS dated [DATE] showed his/her cognition was intact.
Record review of the original copy of the resident's Personal Possessions Inventory sheet only showed the resident's name and date of admission.
During an interview on 7/13/22 3:26 P.M., the resident and his/her adult child said:
-The resident was missing a combination curling iron/hair dryer and it has not been replaced.
-The resident is also missing several items of clothing.
-The items were reported missing, but didn't remember who they reported the missing items to.
During an interview on 7/18/22 at 10:26 A.M., Social Service Designee said the resident and his/her family have not informed him/her of any missing items since he/she has been the Social Service Designee.
During an interview on 7/19/22 at 11:52 A.M., the Administrator said:
-He/she was unaware of the curling iron/hair dryer or clothes missing.
-He/she is not sure if the Social Service Designee is aware of these items missing.
During an interview on 7/20/22 at 10:35 A.M., the DON said he/she did not know the resident was missing a combination curling iron/hair dryer or clothing
3. Record review of Resident #25's face sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Urinary tract infection.
-COVID-19 (an infectious disease caused by the SARS-CoV-2 virus).
-Depression.
-Chronic obstructive pulmonary disease (COPD - damage to the lungs that can not be reversed).
Record review of the resident's quarterly MDS dated [DATE] showed:
-The resident was able to make self understood.
-The resident was able to understand others.
-The resident's Brief Interview for Mental Status (BIMS) score was 15 showing he/she was cognitively intact.
There was no documentation in the resident's Nurses' Notes for May, June, or July 2022 of any missing money or clothing.
During an interview on 7/13/22 at 9:20 A.M. the resident said:
-He/she had clothes missing; one pair of blue jeans, one pair of blue slacks, one red tie dye shirt, and two other pairs of slacks.
-The clothing was sent to laundry and had not come back to the resident.
-He/she told the DON and the Administrator of the missing clothing.
-He/she was not sure of the date his/her clothing had been missing, but it had been since the first of this year when he/she had moved from the Assisted Living Facility to the current facility.
-No word on the missing clothing.
-He/she did not have any idea who would have taken his/her clothing but he/she felt it must have been a staff member.
During an interview on 7/19/22 at 9:25 A.M., the Administrator said:
-The resident had a history of things missing in the past and reliving that.
-He/she did not know anything about missing clothing but would check the resident's inventory sheet that would show what the resident had brought with him/her when they came to the facility.
During an interview on 7/19/22 at 12:05 P.M., the Administrator said:
-They had not been following their policy regarding missing items.
-There should have been a resolution of missing items within five days.
-He/she should have made sure the resident or family agrees with the resolution.
-A grievance form should have been filled out and signed by the resident once it was completed.
-A copy of the grievance was supposed to go into the grievance binder with a copy to each Department Manager.
-The Department Manager has three days to get back to the Administrator with a result and a copy then goes into the binder.
-He/she has not reviewed the grievance binder and was not aware of any grievances.
-A resident's inventory sheet should go in the resident's paper chart.
-Social Services should keep a copy.
-Nursing staff should have been able to add to the inventory list when new items were brought in for the residents.
During an interview on 7/20/22 at 10:00 A.M., the resident said:
-He/she could not remember if he/she had filed out an inventory sheet with his/her belongings on it when he/she had moved into the facility.
-The staff had also looked through the laundry room, the clothing had not been found.
During an interview on 7/20/22 at 10:15 A.M. the Administrator said:
-The staff had looked in the laundry room for the resident's missing clothes.
-The resident's inventory list was blank.
-They had a problem with ensuring the inventory lists were completed for the residents.
During an interview on 7/20/22 at 10:30 A.M. the Social Service Designee said the items the resident had reported missing happened before he/she started and today was his/her last day of work.
4. During an interview on 7/18/22 at 10:26 A.M., Social Service Designee said:
-There's no process in place on who a resident reports to when missing clothes or other items.
-He/she gets reports from the staff, residents, and family or friends of the residents.
-Staff say that residents are misplacing things.
-He/she came up with a form Resident personal possessions inventory.
-Theft is a big problem.
-He/she reports to Administrator.
-There was no formal grievance process.
-No one had been in the role of Social Service Designee for so long, prior to him/her starting in April.
-The Administrator was the one who would investigate missing items.
-He/she reported any missing items or grievances to the Administrator.
During an interview on 7/19/22 at 8:12 A.M., the Administrator said:
-Today was the Social Service Designee's last day.
-A new Social Services Designee would be starting in two weeks and they would be responsible for grievances and missing items.
-Their grievance policy was not followed regarding missing items.
-Inventory was supposed to be taken upon admission and with new items brought in.
-The Social Services Designee was supposed to take the grievance and document the grievance.
-If the grievance involved missing property, it should have been documented on a grievance form, a copy should have been made of the form and it should have been added to the grievance log.
-They were supposed to tell the residents and the residents' family members that all personal items needed to be documented on the inventory sheet.
-When families brought anything new in, they checked in at the front desk and were supposed to be told to add it to the inventory sheet.
-They failed to capture a list of the resident's belongings.
During a follow up interview on 7/19/22 at 11:52 A.M., the Administrator said:
-In April 2022 he/she had Social Service Designee start re-inventory all facility resident's belongings and update what may not be on a resident's inventory list.
-The inventory list should be in the resident's electronic record and in a paper form in the resident's paper chart so if something is brought in over weekend can be added by the on shift nurse.
During an interview on 7/20/22 at 10:35 A.M., the DON said:
-The Social Service Designee filled out resident's inventory list on admission or when new items are brought in.
-Knows that families bring items in and they don't get added by the staff or don't tell anyone they brought something in.
-He/she is planning on a solution for having family bring items to the front desk to be logged on inventory sheet and labeled.
-The facility will let families know of this new process if implement.
-Completed grievance form was supposed to be given to him/her.
-She/He would then start an investigation such as when was the last time the resident had the item, if it was on the inventory sheet, etc.
-Clothing should be marked with a permanent marker.
-When clothing was missing, they should check laundry and if they couldn't find the clothing, they were to notify the DON and the Administrator.
MO00203263

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide daily oral care to include brushing of teeth to one sampled resident (Resident #20); and to provide fresh water daily to two sampled residents (Resident #20 and #33) out of 12 sampled residents. The facility census was 37 residents.
Record review of the facility's undated policy titled Nutrition/Hydration Status Maintenance showed based on a resident's comprehensive assessment, the facility will ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health.
Record review of the facility's undated policy titled Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) showed:
-It is the policy of the facility to sustain an environment that humanizes and individualizes each resident's quality of life.
-The care and services provided are person-centered, and honor and support each resident's preferences.
-The facility will provide care and services for the following activities of daily living:
--Hygiene- bathing, dressing, grooming, and oral care.
1. Record review of Resident #20's admission Record showed he/she was admitted on [DATE] with the following diagnoses:
-Muscle weakness (when full effort doesn't produce a normal muscle contraction or movement, or a decrease in muscle strength) (generalized).
-Chronic (persisting for a long time or constantly recurring) pain.
-Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
-Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
Record review of the resident's Care Plan dated 5/3/22 showed:
-He/she requires extensive assist with all ADL's.
-He/she will maintain ability to participate with self-care at current level through review date.
-He/she will have all needs anticipated and met by staff daily.
-He/she will receive assistance with daily ADL's as evident by good grooming, neat clean appearance, with no skin breakdown, and free of body odors.
Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 6/8/22 showed the resident's cognition was intact.
Record review of the resident's electronic Oral/Dental Care record from 7/1-18/22 showed:
-The resident received oral care of teeth brushed: seven times out of 18 opportunities.
-The resident oral care of teeth brushed was not done: three times out of 18 opportunities.
-The resident refused oral care of teeth brushed: two times out of 18 opportunities.
-The resident oral care of teeth brushed was not charted: six times out of 18 opportunities.
During an interview on 7/13/22 at 10:14 A.M., the resident said he/she only gets water when he/she asks for it.
Observation on 7/13/22 at 10:14 A.M., showed the resident had a water pitcher (20 ounce (oz.)) on over bed table with approximately 16 oz., in it.
During an interview on 7/14/22 at 9:51 A.M., the resident said:
-He/she doesn't get teeth brushed.
-He/she has his/her own teeth.
-He/she has a tooth brush and paste at the sink.
-Staff do not help him/her anymore.
-He/she got tired of asking for help each day to brush his/her teeth and being told by staff they will be back to help and they don't come back.
-It has been several weeks since had his/her teeth brushed.
-He/she does not have any tooth pain at this time.
-He/she does not get fresh water each day.
-If the water pitcher isn't empty the staff don't refill it.
-Will get fresh water when he/she asks for it.
-At times when asks for fresh water is told by staff they will get it and they don't.
-He/she feels staff should do at least daily without being asked.
-Has not had fresh water since yesterday.
-He/she would like fresh water at least daily or more often.
Observation on 7/14/22 at 9:51 A.M., showed the resident had a water pitcher on his/her over bed table with approximately 8 oz., in it.
During an interview on 7/18/22 at 10:09 A.M., the resident said:
-He/she quit asking to have his/her teeth cleaned due to staff not getting him/her to the sink when up out of bed.
-Staff don't offer to get supplies for him/her to do his/her self.
-Feels the staff should offer to at least give him/her the supplies to do it in bed.
-Over the weekend did not get his/her teeth brushed nor this morning.
-Still not getting fresh water daily.
-Had to ask for it otherwise it is whenever staff decide to do it.
2. Record review of Resident #33's admission Record showed he/she was admitted on [DATE] and re-admitted on [DATE] with the following diagnoses:
-Urinary Tract Infection (UTI-an infection in any part of the urinary system-kidneys, ureters, bladder and urethra).
-Renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease).
-Neurogenic bladder (the nerves that carry messages back-and-forth between the bladder and the spinal cord and brain don't work the way they should and may cause the bladder muscles to lose ability to hold urine).
Record review of the resident's Quarterly MDS dated [DATE] showed the resident's cognition was intact.
Record review of the resident's Care Plan dated 5/20/20 with next review date of 8/23/22 showed:
-Encourage consumption of all fluids provided at meals and snacks.
-Keep ice water in resident's room within reach at all times.
-Encourage resident to take a drink with each encounter by staff.
During an interview on 7/13/22 at 9:29 A.M., the resident said:
-He/she doesn't get fresh water each day.
-The staff put ice in the pitcher and let it melt.
-The water in pitcher is from yesterday.
-He/she gets water with medications and meals.
-Sometimes he/she just gets water every other day if there is water still in pitcher.
-The staff just don't dump the old water out and give him/her new water.
Observation on 7/13/22 at 9:30 A.M., showed the resident's water pitcher had about 200 milliliter (ml) in the pitcher that holds 600 ml's (20 oz) from yesterday.
During an interview on 7/14/22 at 1:30 P.M., the resident said:
-He/she still had not received fresh water today.
-The water in his/her pitcher was leftover from other day.
Observation on 7/14/22 at 1:30 P.M., showed the resident had a water pitcher on over bed table with approximately 2 oz., in it.
During an interview on 7/18/22 at 9:52 A.M., the resident said:
-He/She is still not getting fresh water at least daily.
-He/She would like ice water and only gets it when they do fill up his/her pitcher.
-The water in his/her water pitcher is from yesterday.
Observation on 7/18/22 at 9:52 A.M., showed the resident's 600 ml (20 oz.) water pitcher about half full.
3. During observations while on survey from 7/13/22 through 7/15/22 and 7/18/22 through 7/20/22 showed:
-No staff were observed passing water to residents.
-No hydration cart out in view.
4. During an interview on 7/19/22 at 9:18 A.M., Certified Nursing Assistant (CNA) A said:
-He/she assists residents who need help with teeth brushing every day.
-It is the Aides responsibility to assist with that task.
-Most of (his/her) residents brushed their own teeth.
-He/she passes water and ice every hour.
During an interview on 7/19/22 at 9:22 A.M., CNA B said:
-He/she assists residents who need it with teeth brushing every day.
-Sometimes at night if they ask for it.
-It is done every morning at the beginning of the shift.
During an interview on 7/19/22 at 9:28 A.M., Licensed Practical Nurse (LPN) A, who is also the charge nurse said:
-He/she had been at the facility for less than a month.
-The aides should brush teeth every morning and night, and after meals if the resident wants to.
-The CNA's should be passing fresh water each shift.
During an interview on 7/20/22 at 10:35 A.M., the Director of Nursing (DON) said:
-CNA's should be helping the residents who need help with brushing teeth each morning when getting residents up and should be charting as part of oral cares.
-He/she would like the residents to have fresh water twice a shift.
-Most of the CNA's pass water at the beginning of each shift.