Every finding on record at Aspire Senior Living Platte City

Based on interview and record review the facility failed to ensure there was a safe and effective medication system in place when ordering and medication administration to ensure no significant medication errors, when one resident, Resident #1, received 28 doses of Torpenz 10mg tablet, a medication used to treat breast cancer, that was not ordered by the physician. This effected one of three sampled residents. The facility census was 66. On 04/16/26, the Administrator was notified of the past noncompliance which began on 03/18/26. On 04/16/26, the facility administrator was notified of the incident, an investigation immediately began and corrective actions were implemented to include education provided to licensed staff on 04/16/26 and 04/17/26. The education included inputting orders in the medical record. Check and verify the order is correct. A new system was put in place in which the Director of Nursing (DON) reviews new medication orders prior to the licensed staff forwarding the orders on to the pharmacy. The noncompliance was corrected on 04/17/26. Review of the facility policy titled, Receiving and Recording Medication Orders, dated 01/30/24 showed when recording orders for routine medications, specify the type, route, dosage, frequency and strength of the medication. Telephone orders may be accepted and must include name and strength of the drug, specific duration, corresponding diagnosis.Review of the facility, undated, policy titled, Resident Rights, showed the resident had the right to be fully informed, in advance, about the care and treatment that may affect the resident's wellbeing. Review of Resident #1's Quarterly Minimum Data Set (a federally mandated assessment tool completed by facility staff) dated 01/29/26 showed:-No cognitive impairment; -Diagnoses of: Heart failure, edema (swelling) and a history of heart attack;-No diagnosis of cancer. Review of the resident's March 2026 physician orders showed:-Torsemide Oral Tablet 20 milligram (MG) (Torsemide) Give 1 tablet by mouth one time a day for fluid retention, ordered 02/24/26; -Torpenz Oral Tablet 10 MG (Everolimus) Give 1 tablet by mouth one time a day for edema, ordered 03/18/26.Review of the resident's nurse progress Notes dated 03/18/26 showed Registered Nurse (RN) A documented New order received from Nurse Practitioner A, to decrease Torsemide to 10mg every day due to dry mouth. No note for the Torpenz medication. Review of the resident's March and April medication administration records (MAR) showed Torpenz 10mg tablet was administered daily from March 19, 2026 to March 31, 2026 and April 1, 2026 to April 15, 2026 for a total of 28 doses. Review of the resident's nurse progress notes dated 03/20/2026 to 04/15/26 showed he/she had multiple complaints of dry mouth, asking if any medications are dangerous, complaints of wanting the heat off and on multiple times due to feeling hot then cold, feeling of not being able to swallow, and difficulty swallowing due to dry mouth. Review of the Pharmacy Medication Error Report completed by Registered Pharmacist (RPh) A dated 04/16/26 showed on 04/15/26 a medication backorder form was requested by a data tech. The RPh reviewed the resident's full diagnosis to find an appropriate alternative. When no diagnosis of cancer was found, the RPh spoke with the facility with instructions to stop the medication and confirm the order for the medication. The nurse called the doctor and confirmed the medication should have been a dose change for Torsemide to 10 MG daily from 20 MG daily and the order had been entered incorrectly by the facility. Review of Inservice Education Record dated 04/16/26 to 04/17/26 showed: education was provided by the Director of Nursing. Topics included: putting orders in the medical record system, reading back and rechecking the order, ensure name, dose, frequency and route are correct.During an interview on 04/29/26 at 12:49 P.M. RN A said:-When he/she typed TOR into the electronic medical medication ordering system, Torpenz and Torsemide were side by side;-He/She thought he/she had picked the correct medication; -He/She did not read the order back before saving it in the electronic record;-New orders go to the pharmacy through the computer; -The resident often had complaints of dry mouth. -He/She had education on carefully entering orders, re-reading the order prior to saving it, and a new procedure for all orders to be sent to the DON for review and approval prior to being sent to the pharmacy; -He/She was involved in the Root Cause Analysis committee to determine what caused the medication error. During an interview on 04/29/26 at 12:52 P.M. the resident's Primary Care Physician (PCP) said:-The facility notified him of the error on 4/15/26 and the resident was sent to the hospital for evaluation and returned to the facility; -The resident was sent back to the hospital a week later, for an acute medical condition, not due to receiving Torpenz;-The pharmacy should have checked the order before filling it; -The resident complains all the time of anything and everything and was waxing and waning (a recurring, cyclical pattern where symptoms, emotions, or behaviors increase (wax) and decrease (wane) in intensity over time) in regards to behaviors;-There was no negative outcome to the resident from receiving the Torpenz.During an interview on 04/29/26 at 10:37 A.M. the Administrator said:-The medication error was caused because of a transcription error; -The medications Torpenz and Torsemide were next to each other in the electronic medical system, the nurse clicked the wrong medication; -The Torpenz was ordered for edema, which was not an approved use, and the pharmacy did not catch the error either; -A Root Cause Analysis was completed and determined it was user error; -Education was done with all nurses for transcription of orders, re-check the order before saving it, orders must be reviewed and approved by the Director of Nursing prior to being sent to the Pharmacy. During an interview on 04/29/26 at 2:00 P.M. the Assistant Director of Nursing said:-He/She recieved education on April 16th or 17th to read and re-read orders,then send the physician's order to the DON or management nurse on call for approval;-Once the order is approved the DON then checks to send the order to the pharmacy to be filled.During an interview on 04/29/26 at 2:15 P.M. RN B said:-He/She had only worked in the facility 3 days; -He/She recieved education to double check an order to ensure it was correct, notify the DON of the order, then the DON would approve the order and send it to Pharmacy; -If there were questions about an order he/she would clarify it with the physician and correct it in the computer before it would be ordered from the pharmacy. Intake 2988991

Based on observation, interview, and record review, the facility failed to ensure residents and/or resident representatives were provided education regarding the benefits and/or risks of immunizations prior to receiving the influenza or pneumococcal vaccines and document the education was provided. This affected five out of sixteen sampled residents (Resident #53, #13, #64, #55, and #33). Facility census was 65. Review of facility policy, Influenza prevention and management, undated, showed: -the facility will provide education prior to the start of each flu season as to the benefits of getting a flu shot. Informed consent or refusal of the vaccine will be expressed in writing using facility -approved forms (residents). Review of facility policy, influenza and pneumococcal immunizations-residents, undated, showed: -Purpose: minimize the risk of residents acquiring, transmitting or experiencing complications from influenza and pneumococcal disease by ensuring that each resident: -Is informed about the benefits and risk of immunizations and had the opportunity to receive the influenza and pneumococcal vaccine(s) unless medically contraindicated, refused, or was already immunized. -Ensure documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization and the administration or refusal of the medical contraindications of the vaccine(s). -Upon admission to the facility, permission must be obtained from the resident or representative to administer pneumococcal vaccine and influenza vaccine annually (in the fall) unless contraindicated. -All new residents will be assessed for pneumococcal vaccine status upon admission; -Residents without proof of previous pneumococcal vaccination should be offered the pneumococcal vaccine(s) unless contraindicated. -Influenza immunizations will be offered annually from October 1st to March 31st (with doctor's order). -Each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization before the immunization is offered. -The resident or the resident's representative had the opportunity to refuse the immunization. -the resident's medical record will include documentation that the resident or the resident's representative was provided education regarding the benefits and potential side effects and the resident either received the immunization, did not receive the immunization due to medical contraindication or refused the immunization. 1. Review of Resident #53's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/1/25, showed: -Resident received influenza vaccine on 10/14/24; -Resident's pneumococcal vaccination was not offered and not up to date. Review of the resident's medical record showed: -Influenza vaccine administered on 10/14/24. No documentation of education provided. -Pneumococcal vaccine showed no record and no documentation of education or refusal. 2. Review of Resident #13's Quarterly MDS, dated [DATE], showed: -Influenza vaccine was offered and declined; -Resident's pneumococcal vaccination was not offered and not up to date. Review of resident's medical record showed: -Influenza vaccine was refused. No documentation of refusal or education provided. -Pneumococcal vaccine showed no record and no documentation of education or refusal. 3. Review of Resident #64's Quarterly MDS, dated [DATE], showed: -Resident did not receive influenza vaccine during influenza season due to resident not being in facility during the year's influenza vaccination season; -Resident's pneumococcal vaccination was not offered and not up to date. Review of resident's medical record showed: -Influenza vaccine was administered on 9/7/18. No documentation of education provided or recent offering or refusal of vaccine. -Pneumococcal vaccine was received on 5/18/16 and 9/21/16. No documentation of education provided. 4. Review of Resident #55's on Annual MDS, dated [DATE], showed: -Influenza vaccine was offered and declined; -Resident's pneumococcal vaccination was not offered and not up to date. Review of resident's medical record on 6/4/25 at 10:24 A.M., showed: -Influenza vaccine was refused. No documentation of refusal or education provided. -Pneumococcal vaccine was administered on 10/4/19 and 12/23/21. No documentation of education provided. 5. Review of Resident #33's Quarterly MDS, dated [DATE], showed: -Influenza vaccine did not receive the influenza vaccine at facility during influenza season; -None of the above was documented for reason influenza vaccine was not received; -Pneumococcal vaccine was up to date. Review of Resident #33's medical record showed: -Influenza vaccine was administered on 7/25/23. No documentation of education provided. -Pneumococcal vaccine was administered on 11/25/16 and 5/14/18. No documentation of education provided. 6. During an interview on 6/4/25 at 2:44 P.M., the Infection Preventionist said: -She had limited knowledge of vaccination process at facility due to being a new employee at facility; -She had seen any paperwork on immunizations provided to residents, but would try to locate that information; -She knew facility offered the influenza vaccine, but did not know about pneumococcal vaccine. During an interview on 6/4/25 at 4:42 P.M., the Infection Preventionist said she did not find any records for resident immunizations except what was in the medical record. During an interview on 6/5/25 at 2:05 P.M., the Director of Nursing (DON) said: -She expected education regarding risk and benefits of immunizations to be offered to residents and available in resident's medical records; -She expected the facility to maintain documentation of education provided to the residents or their representative; -She expected the facility to maintain documentation of refusals and consents of vaccines that were offered to residents or their representatives; -She did not know what vaccines were offered or not offered to residents prior to her start date. During an interview on 6/5/25 at 3:03 P.M., the Administrator said: -He expected immunizations to be offered to residents; -He expected education of risks and benefits of immunizations along with consents and refusals to be maintained in resident's medical records.

4. Review of the facility's policy for Indwelling Urinary Catheter Care, revised 1/24/25 showed: - The purpose is to establish safe and effective guidelines for the care and maintenance of residents with indwelling urinary catheter, preventing infections, ensuring comfort, and promoting dignity; - The policy did not address how to empty the drainage bag. Review of the facility's undated policy for Hand Hygiene, showed: - Hand washing will be regarded by the facility as the single most important means of preventing the spread of infection; - Hands should be washed for at least twenty seconds using soap and water under the following conditions: whenever hands are visibly dirty; before having direct contact with a resident; after having direct contact with a resident; before performing invasive procedures;before performing invasive procedures; before preparing or handling medications; before handling clean or soiled dressings; after handling used dressings, contaminated equipment; after contact with blood, body fluids, excretions, secretions, mucous membranes or non-intact skin; after handling items potentially contaminated with blood, body fluids, excretions, or secretions; before putting on gloves; after removing gloves; whenever in doubt; - Hand sanitizers containing at least 60% alcohol may be used when soap and water is not readily available. Review of Resident #13's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, toilet use, dressing, personal hygiene and transfers; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included neurogenic bladder, anxiety, depression, post traumatic stress disorder (PTSD), and quadriplegia (paralysis of all four limbs). Review of the resident's care plan, revised 5/19/25, showed; - The resident had a colostomy related to neurogenic bowel. Ostomy care as needed; - The resident had an indwelling catheter. Catheter care every shift. - The resident had a pressure ulcer related to immobility. Administer treatment as ordered and monitor for effectiveness. Assess, monitor, record wound healing as ordered; - The care plan did not address the use of enhanced barrier precautions. Review of the resident's Physician Order Sheet (POS), dated June, 2025 showed: - Start date: 5/30/25 - Colostomy care every shift; - Start date: 5/30/25 - Supra pubic urinary catheter. Catheter care daily and as needed. - Start date: 5/30/25 - Wound vac functioning properly and dry dressing in place to buttocks every shift for skin integrity. Review of the resident's Treatment Administration Record (TAR), dated June, 2024 showed: - Colostomy care every shift; - Supra pubic urinary catheter. Catheter care daily and as needed. - Wound vac functioning properly and dry dressing in place to buttocks every shift for skin integrity. Observation on 6/4/25 at 12:28 P.M., showed: - There was an isolation cart outside the resident's room with gowns, gloves and masks in the drawers. EBP signage was posted on the resident's door; - The resident sat in his/her electric wheelchair; - CNA B did not wash his/her hands and applied gloves. CNA B did not put on a gown; - CNA B opened the colostomy bag and released the air and fastened it; - CNA B removed gloves and washed his/her hands and applied gloves. CNA B did not put on a gown; - CNA C washed his/her hands and applied gloves then hooked the lift pad up to the mechanical lift. CNA C did not put on a gown; - CNA B removed his/her gloves and did not wash his/her hands; - CNA C and CNA B used the mechanical lift and transferred the resident from his/her electric wheelchair to his/her bed; - CNA B placed the resident's wound vac (a vacuum-assisted closure device used to help wound heal by creating negative pressure around the wound area) and placed the resident's drainage bag in the dignity bag on the side of the bed without the use of gloves; - CNA B did not wash his/her hands and applied gloves; - CNA B and CNA C turned the resident on his/her side; - CNA C used a wipe and dabbed between the resident's legs; - CNA B removed gloves, did not wash his/her hands and stepped out in the hallway; - CNA B entered the room and put on gloves, gown and a surgical mask; - CNA C removed gloves, did not wash his/her hands and stepped out in the hallway; - CNA C entered the room and put on gloves, gown, and a surgical mask; - CNA B placed the graduate (container) directly on the floor, unclamped the drainage spout and emptied 300 mls. of yellow urine into the graduate. CNA B did not clean the drainage spout, clamped it and replaced it in the sleeve; - CNA B removed gown, gloves and mask, did not wash his/her hands and left the room. - CNA B and CNA C entered the resident's room with only gloves on. CNA B and CNA C did not don a gown while emptying air from the resident's colostomy, during the transfer or when he/she started peri care. During an interview on 6/5/25 at 1:26 P.M., CNA B said: - He/She should have washed his/her hands before and after cares and should have sanitized his/her hands between gloved changes; - He/She should have placed the graduate on a clean barrier; - He/She should have cleaned the drainage spout with something, but was not for sure what he/she should have used; - The staff only have to wear the gown, gloves, and masks when they are actually providing wound care or catheter or colostomy care. During an interview on 6/13/2 at 2:19 P.M., CNA C said: - The graduate should have been placed on a clean barrier like a disposable pad; - The drainage spout should have been cleaned with an alcohol wipe; - They only have to wear the PPE for EBP when they are cleaning the colostomy, catheter care, or wound care; - He/She should have washed his/her hands when entering the room, between cares and before leaving the resident's room. Should sanitize or wash hands between glove changes. During an interview on 6/5/25 at 2:28 P.M., the Director of Nursing (DON) said: - Staff should wash their hands when soiled, before and after cares. Staff should wash their hands or sanitize their hands between glove changes and dirty to clean tasks; - Staff only have to wear the gown and gloves when actually doing the wound care, catheter care or colostomy care; - Staff should place the graduate on a clean barrier and the drainage spout should be cleaned with an alcohol wipe. 5. Review of Resident #1's Quarterly MDS, dated [DATE] showed: - Long term and short term memory problems; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, transfers and dressing; - Had a Suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen, to drain urine); - Frequently incontinent of bowel; -Diagnoses included neurogenic bladder, seizure disorder, and quadriplegia. Review of the resident's care plan, revised 6/2/25 showed: - The resident had an activities of daily living (ADL) self-care performance deficit. The resident had a diagnoses of quadriplegia. He/she required total assistance with all ADLs, mobility and ambulating tasks. The resident is NPO (nothing to eat or drink by mouth). Assistance with Enteral feedings ( method of providing nutrition directly into the gastrointestinal (GI) tract when a person cannot consume enough or fluids by mouth); - The resident had a indwelling catheter related to a neurogenic bladder. Observation on 6/4/25 at 6:59 A.M., showed: - Licensed Practical Nurse (LPN) A did not wash his/her hands and applied gloves; - LPN A prepared the resident's tube medications, removed gloves, did not wash his/her hands, applied new gloves and crushed the resident's medications; - LPN A removed gloves, did not wash his/her hands and answered a call light on the hall; - LPN A returned to the medication cart, did not wash his/her hands and applied gloves, gown, and a mask; - LPN A used his/her gloved hands, locked the medication cart, and entered the resident's room with the resident's medication; - LPN A left the resident's room, removed his/her mask, removed his/her gloves, and did not wash his/her hands. He/She placed the gloves and mask on the medication cart and removed his/her gown as he/she went down the hallway towards the nurse's station; - LPN A returned to the medication cart, threw the gown away, placed a new graduate and syringe on the medication cart; - LPN A donned a new gown, did not wash his/her hands, and applied the same gloves and the same mask; - LPN A administered the tube medications, rinsed the graduate and syringe and placed them on the shelf; - LPN A removed his/her gloves, did not wash his/her hands, removed the gown and mask and left the resident's room to get a dressing for the supra pubic catheter; - LPN A returned to the resident's room. He/She did not wash his/her hands, applied gloves, new gown and a new mask. - LPN A cleaned the peg tube and applied a new dressing. He/She removed his/her gloves, did not wash his/her hands, and dated the dressing; - LPN A did not wash his/her hands and applied gloves. He/She cleaned around the supra pubic catheter and applied a new dressing and dated it. He/she removed gloves, did not wash his/her hands, removed the mask and gown and documented in the electronic chart. During an interview on 6/5/25 at 1:10 P.M., LPN A said: - He/She should have sanitized between glove changes; - He/She should have washed his/her hands or sanitized between residents and between dirty and clean tasks. During an interview on 6/5/25 at 2:28 P.M., the DON said: - Staff should wash their hands when soiled, before and after cares; - Staff should wash or sanitize their hands between dirty and clean tasks and between each resident. 6. Review of the facility's policy Glucometer Disinfection, revised November 2017, showed: - The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees; - The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use; - Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use; - Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer; - After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry; - Discard disinfectant wipe in waste receptacle; - Perform hand hygiene. Review of Resident #64's Quarterly MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Independent with eating; - Diagnosis included diabetes mellitus. Review of the resident's POS, dated June 2025, showed: - Start date: 5/30/25 - Insulin Aspart pen--injector per sliding scale . Blood sugar was 104. Sliding scale insulin did not start until 150 - 199; - Did not have a physician's order to obtain blood sugar or how often it should be obtained. Observation on 6/4/25 at 8:08 A.M., showed: - LPN A left Resident #1's room without washing his/her hands and went to Resident #64's room; - LPN A did not wash his/her hands. donned a gown, mask, and gloves due to Resident #64 had a urinary catheter; - LPN A did not clean the glucometer prior to use; - LPN A obtained the resident's blood sugar which showed it was 104; - LPN A removed mask, gown and gloves. He/She did not wash his/her hands; - LPN A did not clean the glucometer. 7. Review of Resident #17's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required the assistance of staff with set up and clean up with eating; - Diagnoses included diabetes mellitus and dementia. Review of the resident's POS, dated June 2025, showed an order with a start date: 4/12/25 - Blood glucose monitoring twice daily related to diabetes mellitus. Observation and interview on 6/4/25 at 8:18 A.M., showed: - LPN A went from Resident #64's room to Resident #17's room; - LPN A did not clean the glucometer prior to use; - LPN A did not wash his/her hands and applied gloves; - LPN A obtained the resident's blood sugar which was 159; - LPN A said the resident did not have an order for insulin, just blood sugar checks; - LPN A removed gloves and did not wash his/her hands and did not clean the glucometer after use. During an interview on 6/5/21 at 1:10 P.M., LPN A said he/she should have cleaned the glucometer prior to use and after the first use. During an interview on 6/5/25 at 2:28 P.M., the DON said staff should clean the glucometer before and after each resident. Based on interview and record review, the facility failed to implement the water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia). The facility also failed to ensure facility staff were educated on Legionnaire's disease and informed on the facility's Water Management Plan. The facility failed to transport linens in a manner to prevent the spread of infection. The facility failed to have enhanced barrier precautions in place for a two residents (Resident #16 and #13). The facility did not use proper infection control practices when hand washing was not completed for four residents (Resident #13, #1 #17 and #64) during care and when staff did not clean the glucometer between two residents (Resident #64 and #17). The facility census was 65. 1. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: - Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - The facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the Center for Disease Control and Prevention (CDC) toolkit. Review of facility policy, Legionella, undated, showed: -Purpose: to inhibit microbial growth in the facility's water systems to reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. -The facility will follow guidance issued by the Centers for Disease Control (CDC) as outlines in IC-03-Form A-Developing a Water Management Program to reduce legionella. -The facility will follow CDC guidelines for treatment and management of Legionnaires' disease. -The facility will use the worksheet on page 2 of IC-03-Form A-developing a water management program to reduce legionella to determine if the facility or parts of the facility are at increased risk of legionella growth. -As indicated by the results of the risk assessment, the Facility will develop a water management program in compliance with the CDC's guidelines. -The facility will consider internal and external factors that may contribute to Legionella growth. -As indicated, the facility will contract with experts to assist with the development of the water management program. -The water management program will be reviewed by the infection control committee no less than annually, or when one of the following events occur: -If an event triggers the facility to review and update the water management program, the facility will i. update the process flow diagram, associated control points, control limits, and corrective actions; ii. Update the written description of the facility's water systems; and iii. Train employees responsible for implementing and monitoring the updated program. -The facility will educate nursing staff about Legionnaires' disease to aid in early identification. -Clinical features of Legionnaires' disease include cough, fever, and radiographic pneumonia. Review of facility policy's on 6/4/25 showed the facility had no water management plan available for review. Review of in-service records from August 2024 to May 2025 showed no training had been provided on Legionella or water management program to facility staff. During an interview on 6/4/25 at 2:44 P.M., the Infection Preventionist said she did not know if a water management system was in place at the facility. During an interview on 6/4/25 at 3:51 P.M., the Maintenance Director said: -He did not do anything for water management; -He did not flush the water lines; -He did not do anything to prevent Legionella; -He had not been educated to do anything related Legionella or water management; -He did not flush water lines in vacant rooms in the facility. During an interview on 6/5/25 at 1:29 P.M., the Maintenance Assistant said: -He received education about Legionella by facility staff on the morning of 6/5/25; -He was not doing any sort of water management in the facility; -He did not flush water lines or toilets in vacant resident rooms; -He did not monitor water systems for legionella or water borne pathogens. During an interview on 6/5/25 at 2:05 P.M., the Director of Nursing (DON) said: -She expected the facility to have a water management program in place; -She did not know the facility did not have a water management in place to protect from legionella. During an interview on 6/5/25 at 3:03 P.M., the Administrator said: -He expected the facility to have a water management program in place to prevent the growth and spread of waterborne pathogens such as Legionella. -There was not a water management program in place prior to 6/4/25. -He expected vacant rooms to have toilets and water systems flushed on a regular and routine basis. 2. Review of facility policy, laundry services, undated, showed: -Ensure that all laundry is handled, stored, processed, and transported in a safe and sanitary method. -Clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during intra and inter-facility loading, transport, and unloading. Record review of staff in-services, dated August 2024 to May 2025, showed on 3/18/25 forty-four staff participated in a training on laundry and handling/transportation of linens. Observation on 6/3/25 at 9:07 A.M., showed Laundry Aide A and Housekeeper A transported laundry uncovered and put it away into resident rooms on B and D-hallway. Observation on 6/5/25 at 1:42 P.M. showed Housekeeper B and Housekeeper C transported laundry uncovered to resident rooms on B -hallway. During an interview on 6/3/25 at 9:14 A.M., Laundry Aide A said: -She just started in laundry three days ago; -She did not cover laundry cart when returning clean laundry to resident room; -She has had training on infection control. During an interview on 6/4/25 at 1:42 P.M., Housekeeper B said he/she did not have a cover for clean laundry transport to resident rooms. During an interview on 6/4/25 at 1:42 P.M., Housekeeper C said: -Clean laundry should be covered; -He/She did not have a cover for the clean laundry cart. During an interview on 6/4/25 at 1:54 P.M., the Housekeeping Supervisor said: -He did not have education on infection control in the laundry; -He did not know that clean laundry should be covered during transport. During an interview on 6/5/25 at 2:05 P.M., the Director of Nursing said she expected staff to follow the infection control standards/policy regarding laundry. During an interview on 6/5/25 at 3:03 P.M., the Administrator said he expected staff to transport laundry according to facility policy to protect clean laundry from contaminants. 3. Review of facility policy, Enhanced Barrier Precautions, undated, showed: -Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated. These precautions refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDROs to staff hands. -High contact resident care activities include: -Dressing; -Bathing/showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use of a device: central line, urinary catheter, feeding tube, tracheostomy, or ventilator; -Wound care: any skin opening requiring a dressing; -Enhanced barrier precautions apply to all residents with any of the following: -Infection or colonization with a novel or targeted MDRO when contact precautions do not apply; -Wounds and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator) regardless of MDRO colonization status; -Infection or colonization with a novel or targeted MDRO (as of July 2019) defined as pan-resistant organisms, carbapenemase-producing Enterobacteriaceae, carbapenemase-producing pseudomonas spp, carbapenemase-producing Acinetobacter baumanii, candida auris; -This facility may consider applying enhanced barrier precautions to residents infected or colonized with other epidemiologically-important MDROs; -Perform hand hygiene with alcohol based hand rub before entering the resident room; -Wear gloves and a gown when providing high-contact resident care activities; -Do not wear the same gown and gloves for the care of more than one resident; -Discard disposable gown and gloves in a waste container located near the exit of the resident room. If a non-disposable gown is used, discard in laundry container near the exit of the resident room; -Perform hand hygiene with alcohol based hand rub before exiting the resident room. Review of Resident #16's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/13/25, showed: -He/She was at risk for pressure ulcers; -Received application of nonsurgical dressings other than to feet and to feet; -He/She was dependent on staff for personal hygiene, toileting, and mobility; -Diagnoses included: stroke, diabetes, hemiplegia, and malnutrition. Review of Resident #16's care plan, dated 5/16/25, showed: -The resident had potential/actual impairment of skin integrity of the heels; -Staff are to monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heel, signs and symptoms of infect, maceration, etc. to the medical doctor; -The resident needed to float his/her heels to protect his/her skin while in bed; -Staffs weekly treatment documentation to include measurement of each skin area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of Resident #16's physician's orders, dated 6/5/25, showed: -An order dated 5/28/25 for Povidone-Iodine to the resident's right heel daily, apply army battle dressing (abd) pad and wrap with kerlix. Change daily until resolved. every day shift for skin integrity; -An order dated 5/28/25 for skin prep to the resident's left heel two times a day for skin integrity. Review of Medication Administration Record, dated June 2025, showed: -Start 5/28/25, Skin prep to left heel two times a day for skin integrity; -Start 5/29/25, Povidone-iodine to right heel daily, apply abd pad and wrap with kerlix. Change daily until resolved. every day shift for skin integrity. Review of the facility matrix, dated 6/2/25, showed the resident identified by staff to have a stage II pressure ulcer that was not present on admission to facility. Observation on 6/2/25 at 10:21 A.M., showed the resident did not have enhanced barrier precautions in place at his/her room and no signage indicating enhanced barrier precautions should be used. Observation on 6/2/25 at 10:33 A.M., showed the Infection Preventionist wheeled out a cart with personal protective equipment in the drawers to include gloves, gowns, and red bags. During an interview on 6/4/25 at 2:44 P.M., the Infection Preventionist said: -She did not have enhanced barrier precautions in place for Resident #16; -There should have been enhanced barrier precautions in place due to resident having a pressure ulcer; -She expected enhanced barrier precaution signage to be in place if resident had a catheter or wound. During an interview on 6/4/25 at 3:55 P.M., CNA B said: -When the resident was on enhanced barrier precautions he/she had to wear gloves and a gown; -He/She should fully gown up for catheter care, ostomy care, or providing any care where something is coming out of someone's body. During an interview on 6/4/25 at 4:29 P.M., the Activity Director said: -Enhanced barrier precautions were posted on resident's door if they were on enhanced barrier precautions; -He should wear mask, gloves, gown, booties, and protective eye wear while providing cares to resident on EBP. During an interview on 6/5/25 at 2:05 P.M., the Director of Nursing said: -Enhanced barrier precautions should be in place for resident's with catheters or wounds; -She expected staff to don gown and gloves when providing direct contact cares with residents on enhanced barrier precautions; -She expected signage in place on resident's doors when they were on enhanced barrier precautions. During an interview on 6/4/25 at 3:03 P.M., the Administrator said: -He expected enhanced barrier precautions to be in place for residents with catheter or open wounds; -He expected staff to know what enhanced barrier precautions were and when to use enhanced barrier precautions; -He expected staff to don personal protective equipment when entering resident rooms on enhanced barrier precautions according to federal regulatory statutes; -He expected staff to apply personal protective equipment before providing close contact cares when working with a resident with a catheter or wound.

Based on observation, interview, and record review, the facility failed to discard expired medications and biologicals stored in the medication cart and the medication room, failed to date an opened vial of insulin for one resident (Resident #16), and failed to ensure refrigerator and freezer temperatures were documented in medication rooms. Additionally, the facility failed to ensure medication packaging (bubble pack) was not punctured which affected two residents (Resident #13 and #50). Staff failed to ensure medication carts were locked when not in use and failed to ensure non-medication/medical items including vape pens, a resident's pocket knife, and loose change were not stored in the medication cart. Lastly, the facility failed to store eye drops appropriately for one resident (Resident #45). The sample size was 16 residents. The facility census was 65. Review of facility's policy for Storage of Medications, dated 1/30/24, showed: - Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are returned to the pharmacy for proper labeling before storing; - Proper temperature in the refrigerator must be maintained in accordance with manufacturer specifications and national guidelines; -Ensure that medications are stored in a safe, secure, and orderly manners; -Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not to be left unattended. Compartments include but are not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes. Review of the facility's policy for Refrigerator Temperature Monitoring, dated 1/25/25, showed: - The purpose is to ensure the safe storage of food, medications, and vaccines by maintaining appropriate refrigerator temperatures, preventing spoilage, and ensuring regulatory compliance; - All refrigerators used to store medications and vaccines, must be maintained within recommended temperature ranges and monitored regularly; - Temperature ranges: medication/vaccine refrigerators: maintain temperature between 36 degrees - 46 degrees Fahrenheit (F); - Facility - operated refrigerators (food and medications) - designated staff shall check and record temperatures twice daily; - Documentation - temperature logs shall include: date and time of reading, actual temperature reading, staff initials, and corrective actions taken if temperatures are out of range; - Logs shall be maintained for 12 months; - If temperatures are outside the recommended range: notify the supervisor or nurse-in-charge. Remove any spoiled or unsafe items. Adjust or repair the unit as needed. Document the issue and corrective action on the temperature log; - Annual training shall include recommended temperature ranges, thermometer use and calibration, corrective action protocols, documentation procedures, and resident personal refrigerator care. 1. Observation and interview on 6/4/25 at 2:46 P.M., of the medication cart for D, E, and F halls showed: - Resident #16 had an open vial of Lantus insulin, filled on 5/10/25, that did not have a date showing when it was opened; - Resident #50 had a bubble pack of Oxycodone HCL 5 mg., one every six hours as needed for severe pain. The bubble pack had two punctures on the back with a pill in each slot; - Resident #13 had a bubble pack of Oxycodone HCL 5 mg., one every eight hours as needed for pain. The bubble pack had one puncture on the back with a pill in the slot; - Resident #13 had three vape pens in the locked drawer of the medication cart; - The locked narcotic drawer also had a pocket knife which belonged to a resident who was no longer in the facility. There was also two quarters, one dime and three pennies loose in the drawer; - Licensed Practical Nurse (LPN) B said he/she did not know who the money belonged to and the insulin vial should have been dated when opened. He/she thought you could have money, vape pens, and the pocket knife in the narcotic drawer with other medications since the drawer was locked. The pills in the bubble pack which had been punctured, should have been destroyed. 2. Observation and interview on 6/4/25 at 4:09 P.M., of the medication room for E and F halls showed: - There were two medication refrigerators that had freezers and they each had a temperature log. Both logs were undated and did not indicate which log was for which refrigerator. One log had three temperatures and no freezer temperatures taken. The second temperature log did not have any refrigerator or freezer temperatures documented; - LPN B thought the logs were from the previous month, but was not for sure since they were not dated. He/she was unable to locate any previous temperature logs; - The MDS/Care Plan Coordinator informed LPN B that everyone was responsible to check the refrigerator and freezer temperatures and document them on the logs. During an interview on 6/4/25 at 6:27 A.M., Certified Medication Technician (CMT) B said he/she checked the medication carts on Thursdays for expired medications. During an interview on 6/5/25 at 12:42 P.M., CMT A said: - If a bubble pack was punctured, the medication should be destroyed; - All the staff take turns checking the refrigerator and freezer temperatures and documenting on the logs; - Should not have money, vape pens or pocket knives in the medication cart. During an interview on 6/5/25 at 1:10 P.M., LPN A said: - Expired medications should be destroyed and not used; - Insulin vials and pens should be dated when opened; - The night shift nurse checks the refrigerator and freezer temperatures and documents on the logs. During an interview on 6/5/25 at 2:28 P.M., the Director of Nursing (DON) said: - Insulin vials and pens should be dated when opened; - If the bubble pack is punctured on the back, the medication should be wasted; - The money, pocket knife and vape pens should not be kept in the medication cart; - The nurses should be checking and documenting the refrigerator and freezer temperatures on the night shift; - Expired medications should be discarded and not used. 3. Review of facility policy, Storage of Medications, dated 1/30/24, showed: -Ensure that medications are stored in a safe, secure, and orderly manners; -Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not to be left unattended. Compartments include but are not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes. Review of facility policy, Resident Rights, dated 2022, showed: the resident has the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/9/25, showed: -Cognition intact; -He/She required set up or clean up assistance with personal hygiene; -He/She was dependent on staff for medication administration; -Diagnoses included: heart disease, anxiety, and depression. Review of the resident's care plan, dated 4/3/25, showed -Resident had an ADL self-care performance deficit; -Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of the resident's physician's orders, dated 6/3/25, showed: -Ordered 11/20/24, opthalmology consult as needed; -No orders for eye drops. Review of medical record, dated 6/3/25, showed he/she had no assessments to self-administer medications. During an observation and interview on 6/2/25 at 9:35 A.M. showed 0.5 mg refresh eye drops were on resident's bedside table. The resident said he/she used the eye drops and normally kept them on his/her bedside table. During an interview on 6/5/25 at 1:33 P.M., CMT A said he/she had no residents that self administered medications or eye drops. During an interview on 6/5/25 at 1:34 P.M., Licensed Practical Nurse (LPN) A said he/she had no residents that self-administered medications or eye drops. During an interview on 6/5/25 at 1:36 P.M., the Staffing Coordinator said: -He did not have any residents that self administered medications or eye drops; -Eye drops should not be left at resident's bedside; -None of the current residents had orders to keep eye drops at bedside. During an interview on 6/5/25 at 2:05 P.M., the Director of Nursing (DON) said: -She was not aware of any residents who self-administered medications; -Eye drops could not be left at bedside unless a resident had physician's orders to keep them. 4. Observation on 6/02/25 2:56 P.M., showed the medication cart left unlocked and unattended on outside of nurses station on the E hall side of the nurses station. Two staff members were at the nurses station inside at computers, but not next to and could not see the medication carts. Multiple residents were seated around the nurses station in their wheelchairs. Observation on 6/02/25 3:02 P.M., showed the medication cart remained parked outside the nurses station next to the E-hall and was unlocked and unattended. Multiple residents were seated around the nurses station and staff were seated at computers inside the circular nurses station with their backs to the medication cart. Observation on 6/4/25 at 7:15 A.M., showed the medication cart parked on the E-hallway side of the nurses station and was unlocked and unattended. There were residents seated around nurses station. Staff were seated at computers inside the circular nurses station with their backs to the medication cart. Observation on 6/4/25 at 7:18 A.M., showed the Staffing Coordinator came up to the unlocked medication cart next to the E-hallway and locked the medication cart. During an interview on 6/5/25 at 1:33 P.M., CMT A said medication carts should not be left unlocked and unattended. During an interview on 6/5/25 at 1:34 P.M., LPN A said medication carts should not be left unattended and unlocked. During an interview on 6/5/25 at 1:36 P.M., the Staffing Coordinator said medication carts should never be left unlocked and unattended by staff. During an interview on 6/5/25 at 2:05 P.M., the DON said he/she expected the medication cart to remain locked when not attended to by staff.

Based on observation, record review, and interview, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date, label, and store food items correctly, failed to maintain environmental and cleanliness standards for the kitchen, failed to adhere to proper hygiene standards for hairnets and handwashing, failed to perform temperature checks on food items prior to serving to residents, failed to adhere to proper portion control when serving meals, failed to properly monitor and document sanitizer concentration levels for the dishwashing machine, and failed to follow approved recipe cards for meals prepared. This effected all the residents at the facility. The facility census was 65. Review of facility policy, Employee Hygiene, dated 1/30/24, showed: - Employees must keep hands, arms, fingernails clean; - Employees must wear hairnets to keep hair from contacting exposed food, clean equipment, utensils, and linens. Review of facility Cleaning policy, undated, showed: - The purpose is to ensure a clean and sanitary dietary environment; - All food surfaces will be cleaned at the end of each food preparation session; - The floor of the kitchen must be cleaned daily and after each spill or contamination; - Refrigerator units must be cleaned; - Wall surfaces that become splattered during the food preparation process must be cleaned daily; - Walk-in refrigerators and freezers must be cleaned weekly or more often if needed. Review of facility Dish Washing policy, undated, showed: - The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines; - Facilities must have appropriate and adequate testing equipment, such as test strips and thermometers, to ensure adequate washing and sufficient concentration. Review of facility policy, Food Temperatures, undated, showed: - Ensure food is served at a safe temperature to prevent food-borne illness; - Hot foods should be maintained at a minimum to 135 degrees Fahrenheit (F), cold foods should be maintained at a maximum of 41 degrees F; - Policy didn't contain any guidance, details, or procedures for staff to follow to ensure a proper food temperature monitoring program was in place; Review of facility policy, Storage of Food in Refrigeration, undated, showed: - Ensure food needing refrigeration is properly stored to prevent food-borne illness; - Food being returned to storage after cooking or preparation must be covered; - All containers must be labeled with the contents and date food item was placed in storage; - Previously cooked foods can be held in refrigeration of 41 degrees F or lower for up to 3 days and then must be discarded; - Food items that remain sealed from the supplier may be held until expiration date if unopened. Review of facility recipe cards for 6/4/25 lunch time meal showed: - Garlic Mashed Potatoes and Tomato Soup, were not approved by the Dietician and did not contain serving size, cooking steps for preparation, or allergy precautions; - No recipe cards were provided for the puree or mechanically soft main entrée, Country Fried Steak and gravy; - No recipe cards were provided for the mechanically soft or puree Apple Crisp dessert. Observation on 6/2/25 at 9:00 A.M., showed the following in the kitchen: - No paper towels at the hand washing station; - Dietary Aide (A) did not wear a beard net over his mustache and beard while working in the dishwashing area and kitchen area; In the dry storeroom: - All purpose flour 50 pound bag unsealed and sat on the floor; - Paper trash on the floor; - Flaking paint on the ceiling near the roof access cover. During an interview on 6/2/25 at 9:15 A.M., the Dietary Manager (DM) said If a staff member has a beard they need a beard net in the kitchen. During an interview on 6/2/25 at 9:17 A.M., Dietary Aide (A) said If you have 2 or more of facial hair then you need a beard net, unsure if a beard net is required if you have a moustache. Observation on 6/3/25 at 3:16 P.M., showed Dietary Aide (B) was not wearing a hair net while working with food in the kitchen. Observation on 6/4/25 at 9:52 A.M., of the kitchen showed: - Multiple broken tiles along the wall, across from the kitchen dishwasher; - Five Sanitizer testing strips in a dirty plastic bag (not the original container) stored in the corner near the dishwasher. The surveyor was unable to determine if the testing strips were outdated or suitable for testing purposes; - No dishwasher temperature or sanitizer concentration logs were maintained; - The microwave had stuck on food debris inside of it; - Multiple food debris items left under the steam line between meals not cleaned up; - Heavy dust build up on piping and mechanical connection behind the stove; - Food debris and grease stains observed on table services under serving line; - Hand washing sink inaccessible due to dirty dishes stacked up on it; - Lyonnaise potatoes (traditionally buttery-crisp potatoes with onions), on today's lunch menu, had been substituted with garlic mashed potatoes; - Recipe card was not used for garlic mashed potatoes or for any of the special diets (mechanically soft and puree); - No recipe card on file for the tomato soup that had been prepared by the DM. During an interview on 6/4/25 at 10:20 A.M., the DM said: - She checks the dishwasher sanitizer concentration daily in the morning, but it's not recorded anywhere. If it is not between 100-200 PPM then she will contact the maintenance supervisor; - Food orders placed with the vendor are inconsistently filled by the vendor. This week they did not get the chocolate milk or tomato soup they ordered for the menus the facility had planned; - There was no recipe card approved by the Dietician for garlic mashed potatoes. We substituted this item for Lyonnaise potatoes because it doesn't go with the country fried steak we are serving today which is a substitute due to our vendor not filling our requested order; - The DM makes a homemade recipe of tomato soup for the residents when she needs a substitute item for them. The vendor had not filled the order for tomato soup. Observation on 6/4/25 at 11:12 A.M., in the kitchen, showed: - Bowl of chicken broth was placed in the microwave; - Puree spinach made and taste tested by the DM, but not temperature checked; - Dietary Aide (C) and Dietary Aide (D) filled glass bowls with apple crisp using the same sized scoopers per the recipe, but were inconsistent in the scoop amounts. Some bowls were overflowing with apple crisp while others only filled half the bowl; - The table surface was not wiped down after making apple crisp and the desserts were placed near the steam line and bits of food debris were left behind on the table surface; - DM made the mechanically soft country fried steak with no recipe card used. DM did not add any additives, he/she placed meat in the blender; - DM added an unmeasured amount of gravy into the blended country fried steak and blended. During an interview on 6/4/25 at 11:33 A.M., Dietary Aide (C) said he/she had just started working in the kitchen yesterday and had no training on how to scoop out food for residents. Observation of the kitchen on 6/4/25 at 12:10 P.M., showed: - No temperatures taken of foods from the steam line before staff served the first tray of the meal for lunch; - The chicken broth that was sitting in the microwave for one hour was heated for 30 seconds by the DM, removed from microwave, and the DM did not check the temperature of the broth and then placed it on a tray to be served to a resident; - Dietary Aide (B) entered kitchen from dining room and did not wash hands, went to the back room office, came back into the kitchen area without washing hands and made grape juice and filled a pitcher of water and took those items to the dining room; - Serving ledge between kitchen and dining room was missing 18 of paint and the wall underneath the ledge had missing paint; - CNA (A) touched his/her face then served trays to residents without washing hands twice; - CNA (A) washed his/her hands then wiped his/her hands off on their clothes to dry hands before he/she continued to serve resident plates. Observation on 6/4/25 at 12:28 P.M., in the kitchen showed: - DM did not give a full scoop of mechanical soft entrée for two different residents; - Mashed potato servings were inconsistent from one tray to the next; - Tray covers were wet and not dried completely before putting over plates of food. Observation on 6/4/25 at 12:54 A.M., showed CNA (D) served a resident a food tray, touched items on the resident's bedside table, adjusted the call light, adjusted the bed, and then went on to serve another resident in the room without washing his/her hands. During an interview on 6/4/25 at 2:45 P.M., the DM said: - Everyone in the kitchen should be wearing a hairnet and beards should have a beard net; - She has been at the facility for a little over a month and does the recipes by memory; - Staff should use recipe cards when cooking meals; - There is no current plan that she is aware of for fixing the broken tiles in the kitchen; - The cleaning schedule is daily, weekly, and monthly which covers the entire kitchen and storage areas. There is no cleaning sign off sheet for when cleaning jobs are completed; - Food orders are placed twice a week with high minimum order levels, which are far above usage rates. The menu is changed once a week due to food item outages; - Staff should wipe down surfaces when there is heavy dust build up on them; - Staff should clean as they go throughout the day; - The kitchen staff wipe down the dining room tables after meals and after dinner. - Bulk items such as sugar, rice, and salt that have been transferred to plastic containers should have a date on them of when it was opened from the original packaging; - The handwashing station should not be blocked with dirty dishes sitting on it; - After cooking food in the microwave staff should take a temperature of the cooked food before serving to residents; - Staff normally take the temperature of foods prior to serving them from the steam line, unless the food was placed on the steam line within the last hour; - Portion servings should be consistent from one resident to the next with all servings being similar unless a resident's dietary plan requires extra portions; - When kitchen staff enter the kitchen, even if working in the dining area, staff should wash hands immediately; - There is currently no recipe card on file for the tomato soup or garlic mashed potatoes that I made from scratch today. All copies of approved recipe cards for today's lunch time meal was turned over to the surveyor team including the recipes of meals not approved by the dietician. During an interview on 6/5/25 at 2:30 P.M., the Administrator said: - He would expect the kitchen staff to take temperatures of hot food before starting meal service at the steam line; - He would expect staff to follow approved recipe cards for making meals; - He would expect staff who were not bald to be wearing hair nets and would expect the policy on beard nets to be followed; - He would expect staff to follow facility policy and check the concentration levels for sanitizer in the dishwasher; - He would not expect to see broken tiles in the kitchen; - He would not expect dirty dishes to be stacked in the handwashing sink; - He would expect food orders placed to the food vendor to be filled and delivered to the facility on a consistent basis; - He would not expect food items to be stored on the ground; - He would expect a cleaning program in the kitchen which wipes down horizontal surfaces, removes excess dust and grease and cleans under tables; - He would expect portion control to be consistent from one resident to another except for residents with special dietary orders; - He would expect food prepared in the microwave to be temperature checked before serving to a resident.

Based on interview and record review, the facility failed to act promptly and consider concerns and recommendations of the resident council members when the facility did not communicate back to the resident council with regard to concerns brought forward by the resident council, as reported by twelve of twelve residents who participated in a group interview. The facility additionally did not maintain documentation of resident council concerns or provide follow to the resident council with resolutions or follow up actions. The facility census was 65. Review of facility policy, Resident Grievances, dated April 2006, showed: -The resident has the right to exercise his or her rights as a resident of the facility and as a citizen of the United States. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility exercising his or her rights. -The facility designee shall investigate the complaint to determine validity. The facility designee will maintain files and records of the facility, relating to grievances; -The facility designee will issue a written decision on the grievance no later than 30 days after its filing. Review of facility policy, grievances, dated 2022, showed residents have a right to voice grievances to the facility or any other entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment and the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to file and the facility must make prompt efforts by the facility to resolve grievances the resident may have. 1. Review of the resident council meeting minutes, dated 3/24/25, showed: -Follow up: Call lights being turned off without completing what needed to be done and missing personal items of two residents; -New items: Loud at night around 3:00 A.M., residents beds were not made, bad peri-care, resident clothes were misplaced or given to someone else, failed to restock toilet paper in resident rooms, food served burnt, and diet cards were not followed; -The form did not indicate how the issues were resolved, who was responsible, or if the resolutions were satisfactory with the residents. Review of the resident council meeting minutes, dated 4/28/25, showed: -There was no follow up section; -Recent changes: New administrator and dietary supervisor; -New Items: Music played too loud by morning nurse, CNA took 1-2 hours to answer call lights; wanted more warm food served and less cold sandwiches, residents were missing personal items, and laundry took too long to return personal clothing to the residents. -The form did not indicate how the issues were resolved, who was responsible, or if the resolutions were satisfactory with the residents. Review of the resident council meeting minutes, dated 5/28/25, showed: -Follow up: Residents said noise at night was better; -Recent changes: New housekeeping supervisor started Monday; New Items: Beds were not being made, clothes taken to laundry were not getting cleaned, resident rooms were not cleaned fully, and food served cold, dry, and flavorless. -The form did not indicate how the issues were resolved, who was responsible, or if the resolutions were satisfactory with the residents. 2. During the group meeting on 6/3/25 at 1:47 P.M., all 12 residents said they did not feel like the facility followed up with them regarding the concerns that were voiced by resident council members. During an interview on 6/3/25 at 3:02 P.M., Social Services Director said: -Residents could submit grievance forms directly to her or submit anonymously; -She had grievance forms and envelopes available on the wall for residents to obtain; -Most residents voiced their concerns directly to her; -Grievances were discussed at the morning meeting with the department heads if she felt they were appropriate to be brought up with the group; -The Administrator spoke with her every morning and asked if there was any grievance concerns; -She was not made aware of any grievances discussed at resident council; -She did not handle grievances from resident council; -The activity director hosted and handled resident council meetings; -She did not provide resolutions to resident council regarding grievances voiced during resident council. During an interview on 6/5/25 at 1:14 P.M., the Social Services Director said: -She was not aware of anyone going back to resident council to address concerns presented from residents participating in the resident council meetings or what resolutions were put in place; -The Activity Director did put something in her mailbox one time that showed everything that went on at resident council and he discussed it one time during the morning department head meeting. During an interview on 6/5/25 at 1:22 P.M., the Activity Director said: -He took notes during resident council and so did the resident council president; -He allowed the Social Service Director to know about grievances voiced during resident council and allowed her to handle all the grievances; -He relayed the information; -He documented follow up on the resident council concerns on the minutes; -He discussed resident council concerns at the morning department head meeting; -If the concerns voiced by resident council were not improved he would add it to the appropriate department section on the next resident council minutes. During an interview on 6/5/25 at 1:31 P.M., the Administrator said: -He had already identified resident council grievance response time as an issue; -He had emailed the activity director yesterday a new form to be implemented. During an interview on 6/5/25 at 2:46 P.M., the Director of Nursing said: -She had never received a grievance; -She was not aware of any resident council meeting concerns; -She expected facility staff to go back to resident council and advise the council what interventions or changes had been made to address the resident council concerns. During an interview on 6/5/25 at 3:03 P.M., the Administrator said he expected the facility to follow up with the resident council regarding concerns that were voiced and interventions put in to place to resolve the concerns.

7. Review of facility policy, personal property, undated, showed: -Resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items were replenished. Residents and/or families are requested to assist in documenting and maintaining inventory of Resident's personal property; -The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. Review of facility policy, Safe and Homelike Environment, dated 2021, showed the facility exercises reasonable care for the protection of the resident's property from loss or theft. Review of Resident council minutes, March 2025-May 2025, showed: -On 3/24/25 there was concerns voiced from two residents regarding missing clothing and notes regarding clothes being misplaced with other residents. -On 4/28/25 there was concerns voiced from two residents regarding missing clothing items and discussion on clothes taking a long time to return from laundry. Review of grievances, March 1, 2025-June 3, 2025, showed there were no grievances filed regarding missing personal property. During a group interview on 6/3/25 at 2:00 P.M., eight of twelve residents said they had issues with personal property not coming back from laundry and missing items that had not been found, returned, or replaced for them. 8. Review of Resident #24's Annual MDS, dated [DATE], showed: -Cognition intact; -Required partial to moderate assistance with upper body dressing; -Required substantial to maximal assistance with lower body dressing; -Diagnoses included Parkinson's, depression, and colon cancer. During an interview on 6/3/25 at 2 P.M., the resident said: -He/She was missing gray and black pair of yoga pants and had 1 missing gray [NAME] shirt with 2015 date on it; -He/She had notified administrator of the lost items; -The administrator quit and everyone in laundry also quit at the same time; -He/She had name marked in all his/her clothes. During an interview on 6/3/25 at 9:14 A.M., Laundry Aide A said: -She was not aware of any missing personal items for resident. During an interview on 6/5/25 at 1:14 P.M., Social Services Designee said she was not aware of Resident #24's missing personal property. 9. Review of Resident #30's Quarterly MDS, dated [DATE], showed: -Cognition intact; -Independent with dressing; -Dependent on a walker for mobility; -Diagnoses included Alzheimer's disease, dementia, anxiety, and depression. During a group meeting on 6/3/25 at 2:00 P.M., the resident said: -He/She lost two shirts; -He/She notified laundry staff that the shirts were missing; -His/Her blanket was gone; -He/She tried telling them several times about missing items; -Facility had not located or replaced any of his/her personal items. During an interview on 6/5/25 at 12:57 P.M., the resident said: -He/She was missing one [NAME] shirt that had a picture of a motorcycle on it and a golden girls shirt; -He/She had talked to former laundry staff they had told him/her they had looked for missing items, but never found them; -He/She believed someone may have taken his/her items; -The facility had not replaced his/her missing items. During an interview on 6/3/25 at 9:14 A.M., Laundry Aide A said: -She was not aware of any missing personal items for resident. During an interview on 6/5/25 at 1:14 P.M., Social Services Designee said she was not aware of Resident #30 missing personal property. 10. Review of Resident #36's Quarterly MDS, dated [DATE], showed: -Cognition moderately impaired; -He/She required set up or clean up assistance with dressing; -Dependent on a wheelchair for mobility; -Limited range of motion on one side of upper and lower extremities; -Diagnoses included hemiplegia, aphasia, and stroke. During a group interview on 6/3/25 at 2:00 P.M., the resident said: -He/She was missing six shirts; -He/She had told staff about it every day; -His/Her items had not been replaced or found. During an interview on 6/5/25 at 1:01 P.M., the resident said: -He/She was missing six long sleeve shirts with different colors; -He/She was missing size large shirts with one being gold, one being light blue, and one with a brand of paint across the front of it; -He/She had told everyone in laundry; -No staff came back and followed up on the missing items; -Some staff said they may be in someone else's closet or gone for good; -Facility did not replace the missing items. During an interview on 6/3/25 at 9:14 A.M., Laundry Aide A said: -She was not aware of any missing personal items for resident. During an interview on 6/5/25 at 1:14 P.M., Social Services Designee said she was not aware of Resident #36's missing personal property. 11. Review of Resident #41's Annual MDS, dated [DATE], showed: -Cognition intact; -Very important to choose what clothes to wear; -Very important to take care of his/her personal belongings and things; -Dependent on a wheelchair for mobility; -Required partial to moderate assistance for upper body dressing; -Required substantial to maximal assistance for lower body dressing; -Diagnoses included: anxiety, depression, and asthma. During a group interview on 6/3/25 at 2 P.M., the resident said many of his/her clothes had been shrunk by laundry department due to being washed like normal cotton clothes. During an interview on 6/5/25 at 1:14 P.M., Social Services Designee said she was not aware of Resident #41 items being shrunk in laundry. 12. Review of Resident #59's Quarterly MDS, dated [DATE], showed: -Cognition intact; -Required set up or clean up assistance with upper and lower body dressing; -Dependent on a walker or wheelchair for mobility; -Diagnoses included: diabetes, anxiety, depression, and renal failure. During a group interview on 6/3/25 at 2 P.M., the resident said: -He/She had one pair of compression thigh high socks that were black with a purple stripe; -He/She had lost four pairs of pants and two shirts; -The last shirt had his/her name on it and had been gone for over a month; -The shirt was burgundy, size XL, and had bamboo brand on it; -He/She had spoken to the old head of laundry and housekeeping department; -He/She knew former staff had been looking for items, but never heard back from them; -He/She was missing pair of size 10 jeans that never showed up; -Many of his/her clothes had been ruined and were fading in colors by the laundry department. During an interview on 6/5/25 at 12:53 P.M., the resident said: -He/She had talked to Social Services Designee a couple months after he/she moved the first time and was missing items; -He/She did not come back and tell him/her the results of what he/she found out; -He/She had gone down to laundry department and they had him/her look through the rack of unmarked clothing, but he/she did not locate the missing clothing items; -Facility did not replace the missing items. Items went missing a couple of months ago. During an interview on 6/3/25 at 9:14 A.M., Laundry Aide A said: -She was not aware of any missing personal items for resident. During an interview on 6/5/25 at 1:14 P.M., Social Services Designee said she was not aware of Resident #59 missing personal property. 13. During an interview on 6/3/25 at 9:14 A.M., Laundry Aide A said: -He/She just started working in the laundry department three days ago; -There was just one person working in laundry currently; -When someone looses an item he/she would go through and check all resident rooms and ensure missing item was not in another resident's closet; -When items are not labeled with a name they get placed on another rack in he laundry room; -Clothes were to be labeled when residents were admitted by whoever completed the inventory; -He/She would label clothes back in laundry if a label was needed. During an interview on 6/3/25 at 2:00 P.M., the Social Services Designee said: -She was not involved in the process of locating missing property; -Residents usually went straight to laundry when personal clothing items were missing. During an interview on 6/4/25 at 4:29 P.M., the Activity Director said he was not aware of any issues with resident's laundry or missing personal items. During an interview on 6/5/25 at 1:22 P.M., the Activity Director said: -He took notes during resident council and had noted concerns regarding resident's missing laundry in his notes; -Grievances from resident council he took to the Social Services Designee; -The social services designee handles all the grievances; -He just relayed the information from resident council; -He shared concerns from resident council at the morning meeting with department heads. During an interview on 6/5/25 at 1:42 P.M., Housekeeper B said: -When residents reported missing items he/she would make a report to nursing staff so they could help resident look for missing items; -Missing items go through a process; -There was an unlabeled clothing rack in laundry room that they would search for missing items; -Nursing staff were responsible for labeling personal property. During an interview on 6/5/25 at 1:54 P.M., the Housekeeper Supervisor said: -He expected staff to look for resident's missing items when they were reported missing; -He was aware that the previous supervisor did not have a system for locating residents missing items; -He was aware of resident's missing items; -Someone informed him of a resident that had made a request about six weeks ago prior to his start date regarding missing clothes in laundry; -There was not much he could do to locate the missing items since it was before he started working at facility. During an interview on 6/5/25 at 2:05 P.M., the Director of Nursing said: -She expected that staff notify the social services designee when residents were missing personal property; -She expected a grievance to be filled out; -She expected the facility to either find resident's missing items ore replace the missing items. During an interview on 6/5/25 at 3:03 P.M., the Administrator said: -When resident's personal property was missing he expected a grievance or concern form to be completed; -He expected there to be systems in place to follow and track the follow up of locating the missing the items; -He expected the facility to locate or replace the resident's missing items. Based on observation, record review, and interviews, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain a comfortable temperature in the dining room and ensure furniture, walls, and fixtures were in good repair, directly impacting two residents (Resident #64, #67) rooms. The facility failed to cover an exposed light bulb when a light bulb was left uncovered and exposed near bedroom door and the resident's bed was lowered to ground making the exposed light accessible to resident injury (Resident #33). The facility also failed to have an effective system in place to ensure protection of resident's personal property when it was missing and was not located, returned, or replaced for five residents (Resident #24, #30, #36, #41, and #59), out of the 16 sampled residents. The facility census was 65. Review of facility policy, Resident Rights, revised 4/14/25, included the resident has a right to a safe, clean, comfortable and homelike environment. Review of facility policy, Safe and Homelike Environment, undated, showed: - Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents; - Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment; - The Maintenance Director will perform periodic rounds to ensure functioning lights; - The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit; - Report any furniture in disrepair to Maintenance promptly; 1. Observation on 6/2/25 at 11:43 A.M., showed residents entering the dining room with sweaters and blankets covering them up to their shoulders. Observation on 6/3/25 at 7:43 A.M. showed it was 70.5 degrees by the piano in the dining room, 69.8 degrees in the dining room where the ceiling was lowered, and 69.3 degrees in the center of the dining room by the entry to the kitchen. Residents were observed covered up with blankets and some residents wore winter stocking cap covers on their head. During an interview on 6/3/25 at 7:44 A.M., Resident #15 said it felt cold in the dining room to him/her. Observation on 6/3/25 at 7:52 A.M., showed resident #35 had a blanket on his/her lap and the MDS coordinator asked if he/she wanted another blanket. Resident observed with one blanket on his/her lap. Resident #12 observed with stocking cap on his/her head. Observation on 6/3/25 at 7:54 A.M. showed the MDS Coordinator obtained a second blanket for Resident #35. Observation on 6/3/25 at 8:59 A.M. showed thermostat on B-hallway showed 70 degrees. Observation on 6/3/25 at 9:01 A.M. showed c-hallway temperature was 70.2 degrees. Observation and interview on 6/3/25 at 1:35 P.M. showed Resident #23 had blanket up to his/her neck and covered his/her shoulders while he/she sat in the dining room. During an interview on 6/3/25 at 1:35 P.M., Resident #23 said it was cold in the dining room. During an interview on 6/5/25 at 1:03 P.M., Resident #36 said: -Dining room was colder in the morning; -The dining room had been freezing temperatures the last six months; -The warmer it was outside the colder it would get in the dining room; -Multiple residents had complained about it being cold in the dining room and do not want to go into the dining room due to the temperatures being so cold; -Most residents wear multiple layers when entering the dining room due to the temperatures; -He/She did not eat in the dining room during breakfast because it was too cold. During an interview on 6/5/25 at 1:05 P.M., Resident #36, said: -He/She thought it was cold in dining room; -He/She wore longer sleeved shirts because of the temperature; -He/She noticed other residents complaining about the cold temperatures in the dining room. During an interview on 6/5/25 at 3:03 P.M., the Administrator said: -He was not aware of temperature concerns in the building; -He did note the temperature felt too cold to him on 6/5 and 6/4; -He did not have any follow up on temperature control management due to the maintenance director being terminated from the facility; -He expected temperatures in the building to be maintained for resident's comfort levels and within a certain temperature range. 2. Review of Resident 64's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/24/25, showed: - Resident has moderate cognitive impairment; - Diagnoses: anemia, heart disease, and diabetes. Observation of resident's room on 6/4/25 at 8:50 A.M., showed: - Paint missing on the front of the entrance door to their room and inside the bathroom; - 6 long gouges on the door frame; - Bed side table showed rusted and difficult to raise and lower. During an interview on 6/4/25 at 8:54 A.M., the resident said it's not very appealing to see all of the damage and missing paint in my room. He/she had told numerous staff many times that the table wasn't working properly and it bothered him/her. 3. Review of Resident 67's admission MDS, dated [DATE], showed: - Resident is cognitively intact; - Diagnoses: heart disease, hypertension, diabetes. Observation of resident's room on 6/4/25 at 10:20 A.M., showed no trashcan in the bathroom for placing dirty paper towels after washing hands. During an interview on 6/4/25 at 10:22 A.M., the resident said it doesn't make much sense not to have a trashcan in the bathroom to throw stuff away. 4. Review of Resident #33's Quarterly MDS, dated [DATE], showed: -Cognition severely impaired; -He/She required substantial to maximal assistance for most personal cares and mobility; -Dependent on a wheelchair for mobility; -He/She had one non-injury fall since prior assessment; -Diagnoses included: Alzheimer's disease, arthritis, and depression. Observation on 6/2/25 at 10:54 A.M. showed the resident lay in his/her bed, which was lowered to the ground with a fall mat in place. An exposed light bulb, missing a cover over the glass was at the foot of the bed next to the resident's door. The resident was observed sitting up and leaning their head against the wall near the light bulb and the door. The head of the resident's bed had scrapes and gouges of missing paint at both the side wall and headboard. Observation on 6/3/25 at 9:31 A.M. showed the light bulb had been covered with a hvac register return. Review of maintenance log on 6/3/25 showed no entries regarding exposed light bulb at foot of bed in resident's room. 5. Observation of the A-B Hall shower room on 6/4/25 at 10:45 A.M., showed: - Shower room floor had visible dirt on the floor and also had papers and discarded trash not picked up; - Toilet was not flushed and had feces and a bad smell coming from the fixture; - Cracks in the ceiling with the plaster separating; - Walls tiles broken on a corner near the floor. 6. Observation on 6/4/25 at 12:15 P.M., showed a six foot by one foot area of broken and crumbling concrete by the awing in the front of the building along a curb. Observation on 6/4/25 at 4:16 P.M., showed: - Hall D had large areas of worn scrapped paint on walls and handrails, - Outside Hall D shower room there was a wall patch which was missing a six square inch area of paint; - Entrance wall to Hall D had dirty scrapped and missing paint areas; - Personal care salon had multiple missing paint spots on the door; - Outside of room D110 there was a square patch of paint missing near the hand sanitizer dispenser; - Hall E had scrapped paint along handrails that were attached to the wall; - Room E107 had a rusty sink drain; - Hall C handrails had large scraps missing paint; - Hall C wall patch near electrical door was not painted; - Circular wall patch 5 in diameter was not painted near kitchen entrance; - Resident's room C106 Door had multiple wood gouges throughout door; - Resident room A100 room had large areas of scraped off paint on the resident's drawers and door to the room. During an interview on 6/5/25 at 8:54 A.M., the Maintenance Assistant said: - He/she used a work log to determine what items needed to be repaired or replaced and anyone on the staff can enter items into that log for maintenance department work orders. Currently there are about 7 items still open to be fixed and there was no plan in place right now to fix the holes in the walls and the painting that was needed throughout the facility. Most of the work orders deal with mechanical issues such as broken beds. During an interview on 6/5/25 at 2:45 P.M., the Administrator said: - He would expect hallways, doors and rooms to be free of deep gouges and missing paint; - He would expect holes and broken tiles to be replaced and fixed; - At this time the facility does not have a contract to repair/replace the concrete that was broken at the outside curb.

3. Review of Resident #13's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, toilet use, dressing, personal hygiene and transfers; - Had a urinary catheter; - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included anxiety, depression, post traumatic stress disorder (PTSD), and quadriplegia (paralysis of all four limbs). Review of the resident's face sheet showed the resident was a full code. Review of the resident's care plan, revised 5/29/25, showed the care plan did not address the resident's code status. Review of the resident's Physician Order Sheet (POS), June, 2025 showed an order for full code with a date of 5/30/25. 4. Review of Resident #46's purple Out of Hospital Do Not Resuscitate (OHDNR) form showed: - 11/6/23 - the resident signed the form; - 11/6/23 - the physician signed the form. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Upper and lower extremity impaired on one side; - Dependent on the assistance of staff for toilet use and transfers; - Diagnoses included diabetes mellitus, aphasia, stroke, depression and hemiplegia. Review of the resident's POS, dated June 2025, showed an order dated 11/7/24, showing the resident's code status as Do Not Resuscitate (DNR). Review of the resident's face sheet showed the resident was a DNR. Review of the resident's care plan, revised 4/18/25, showed the care plan did not address the resident's code status. 5. Review of Resident #60's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Lower extremity impaired on one side; - Required set up and clean up with toilet use, personal hygiene and dressing; - Independent with transfers; - Diagnoses included diabetes mellitus, depression, other fracture and coronary artery disease (CAD). Review of the resident's face sheet showed the resident's code status as full code. Review of the resident's care plan, revised 4/18/25, showed the care plan did not address the resident's code status. Review of the resident's POS, dated June 2025 showed an order of full code status with a start date of 1/14/25. 6. During an interview on 6/4/25 at 4:10 P.M., the MDS Care Plan Coordinator said the care plans should address the residents' code status. During an interview on 6/4/25 at 4:40 P.M., Licensed Practical Nurse (LPN) A said the resident's care plan should address his/her code status. During an interview on 6/5/25 at 2:05 P.M., the Director of Nursing said: -She expected care plans to include resident's code status; -She expected effective behavioral interventions to be included in resident's care plan; -She expected care plans to be comprehensive and specific to the resident. During an interview on 6/5/25 at 3:03 P.M., Administrator said: -He expected care plans to be personalized with resident specific interventions; -He expected care plans to include code status, behavioral interventions, and skin condition risks. Based on observation, interview, and record review, the facility failed to ensure they developed and implemented a comprehensive person-centered plan of care which included measurable objectives and timeframes to address and meet each resident's specific medical, nursing, mental, and psychosocial needs for five of sixteen sampled residents (Resident #33, #57, #13, #46, and #60). The facility census was 65. Review of facility policy, comprehensive care plan, undated, showed: -Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's nursing medical, physical, mental, and psychosocial needs identified in the comprehensive assessment. -The facility will develop and implement person-centered care plan for each resident that includes: -Measurable objectives and time frames to meet the resident's medical, nursing, and mental/psychosocial needs that are identified in the comprehensive assessment utilizing the RAI process. -Resident's goals, preferences, needs, strengths, and weaknesses. -Services are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Any specialized services or specialized rehabilitative services that the facility will provide as a result of PASARR recommendations, if applicable. -Resident goals for admission and desired outcomes in consultation with the resident/representative. -Resident preference and potential for future discharge. -Discharge plans and -Any services that are not provided due to the resident's exercise of rights, including the right to refuse medical and/or surgical treatment. When the resident has refused treatment, the comprehensive care plan will reflect the facility's efforts to find alternative means to address the care needs of the resident. -The comprehensive care plan will be developed by the Interdisciplinary Team (IDT) using the Minimum Data Set (MDS) to assess the resident's clinical condition as well as cognitive and functional status and the use of services. -The comprehensive care plan will be reviewed and revised, based on changing goals, preferences, and needs of the resident and in response to current interventions, by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 1. Review of Resident #33's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/2/25, showed: -Cognition severely impaired; -Behavioral symptoms were not exhibited; -He/She required substantial to maximal assistance for all personal cares and mobility; -Diagnoses included Alzheimer's Disease, glaucoma, and arthritis. Review of the resident's care plan, dated 2/5/25, showed: -The care plan did not specify resident's behaviors of head banging or interventions; -The resident will remain safe; -Attempt an alternate time to provide care refused per resident's preference; -Encourage participation in self-calming behaviors such as breathing exercises, meditation, or guided imagery; -Ensure the safety of residents and others; -Risk for disturbed sensory perception; -Educate the resident and representative on safety precautions related to decreased sensation; -The resident had behavior problem of yelling out due to dementia with agitation; -Explain all procedures to resident before starting and allow the resident to adjust to changes; -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. remove from situation and take to alternate location. Observation on 6/2/25 at 10:58 A.M., resident was observed hitting head against the wall multiple times and moaning. During an interview on 6/2/25 at 4:42 P.M., Resident's Representative said: -Resident banged his/her head as part of the condition; -He/She wished there was something that could be done about the head banging, but the only real option would likely be a helmet. During an interview on 6/4/25 at 4:10 P.M., the MDS Coordinator said: -She expected interventions for resident's behaviors to be included in his/her care plan; -She did not know what was going on with resident banging her head and yelling out, the facility had tried different medications to help resident with his/her anxiety; -Interventions that help resident to calm down included older country or gospel music playing on his/her radio. During an interview on 6/4/25 at 4:29 P.M., the Activity Director said: -Resident had moments where she would become uncomfortable and bang her head and start making noises; -Music therapy has been found to be most effective intervention for resident; -He/She would expect calming techniques that are effective for resident to be included in resident's care plan. 2. Review of Resident #53's Annual MDS, dated [DATE], showed care areas triggered included pressure ulcer. Review of Resident #53's quarterly MDS, dated [DATE], showed: -Cognition severely impaired; -Dependent for mobility, bathing, personal cares; -He/She had impairment to one side of upper and lower extremity range of motion; -He/She was at risk of pressure ulcers; -He/She had pressure reducing device for chair and bed; -He/She had applications of ointments/medications other than to feet -Diagnosis included: dementia, stroke, aphasia, diabetes, hemiplegia, seizure disorder, Review of physician's orders, dated 6/3/25, showed: -Order date 11/8/24, weekly skin evaluation: complete skin and wound total body assessment one time a day every Friday; -Order date 11/11/24, Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations psychoses, aggression, refusal of care; -Order date 5/7/25, Apply barrier cream to red and open areas to peri area and things two times a day for skin treatment applied by nurse and report changes to DON/ADON. Review of Treatment Administration Record, dated May 2025, showed an order that started on 5/7/25 to apply barrier cream to red and open areas to peri areas and thighs two times a day for skin treatment applied by nurse and report changes to DON/ADON. Review of weekly skin observations, dated 5/1/25-6/1/25, showed: -On 5/7/25, new skin issues, no edema, 1. redness to left inner thigh, 3 cm x 3 cm blanchable with 1.5 cm x 1 cm open area in center of the area. 2. Left posterior lateral thigh, redness 8 cm x 2 cm. Peri care provided and barrier cream applied; -On 5/9/25, existing skin issue , resident had current erythema to buttocks and groins with current wound care orders. Review of progress notes, dated 5/7/25, showed the resident had two new skin areas that were noted in skin assessments. The resident's provider had been notified and treatment for barrier cream started. Review of care plan, dated 5/20/25, showed the care plan did not address risk of pressure ulcers or monitoring of skin. Review of progress notes, dated 6/3/25 at 8:51 A.M., showed the resident had behaviors of yelling out. Review of care plan, dated 5/20/25, showed: -Resident used psychotropic medication Rexulti (antipsychotic) due to behavior management of yelling out at night. -Monitor/record occurrence of for target behaviors symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol; -The resident was on a behavior management program (Specify: alternatives to PRN medication use). -Resident had a mood problem. -Monitor/record mood to determine if problems seem to be related to external causes like medications, treatments, concern over diagnosis -Behavioral health consults as needed; -Resident had impaired cognitive function/dementia and impaired thought processes; -The care plan did not include interventions for the resident's specific behaviors. During an interview on 6/4/25 at 3:55 P.M., CNA B said the resident yells out and antagonizes his/her roommate to get roommate fired up. During an interview on 6/4/25 at 4:10 P.M., the MDS coordinator said: -The resident had behaviors of hollering out; -The resident did yell out at night; -When the resident yelled out at night the resident was usually not tired; -Staff would get the resident up and let the resident hang out with staff; -She expected interventions that were effective for residents to be included in their care plan; -She expected pressure ulcer risk to be care planned. During an interview on 6/4/25 at 4:29 P.M., the Activity Director said: -The resident got agitated easily; -He had learned that when resident was agitated he/she may just want something to drink; -Drinks like a cup of hot coffee usually help resident to calm down; -He expected residents likes and dislikes and calming techniques to be included in resident's care plan. During an interview on 6/5/25 at 2:05 P.M., the Director of Nursing said: -She expected effective behavioral interventions to be included in resident's care plan; -She expected care plans to be comprehensive and specific to the resident. During an interview on 6/5/25 at 3:03 P.M., Administrator said: -He expected care plans to be personalized with resident specific interventions; -He expected care plans to include behavioral interventions, and skin condition risks.

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when the facility did not timely identify, treat, and notify the primary physician of severe weight loss for two of 16 sampled residents (Resident #64 and #67). The facility census was 65. Review of facility policy, Weight Monitoring, undated, showed: - The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: 5% change in 30 days, 7.5% change in 90 days, 10% change in 180 days; - The physician should be informed of a significant change in weight and may order nutritional interventions; - The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss; -Meal consumption information should be recorded and may be referenced by the interdisciplinary care team; - The registered dietitian (RD) or dietary manager should be consulted to assist with interventions, actions are recorded in the nutrition progress notes; - Observations pertinent to the resident's weight status should be recorded in the medical record. 1. Review of Resident #64's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 4/24/25, showed: - The resident had moderate cognitive impairment; - The resident was independent for eating; - No nutritional issues noted; - Diagnoses: Anemia, heart disease, and diabetes; Review of the resident's Care Plan, revised 4/18/25, showed staff to encourage good nutrition and hydration in order to promote healthier skin. Review of the resident's Order Summary Report, dated 6/3/25, showed: - Regular diet and texture, regular and thin consistency; - Offer snack every evening, start date 5/28/25; - Give 120cc of Med Pass supplement (nutritional supplement) every morning and at bedtime, start date 5/30/25; - Give Med Pass 2.0 supplement 120cc twice a day between meals, start date 5/30/25; - Daily weights, notify physician if weight gain of 2 pounds for more, start date 5/31/25. Review of the resident's progress notes showed: - Resident weighed 177.5 pounds on 5/16/25; - Resident weighed 166.0 pounds on 5/20/25 which is a 6.48% significant weight loss in 5 days; - Resident weighed 158.0 pounds on 5/22/25 which is a 10.99% severe weight loss in 7 days; - Resident weighed 157.0 pounds on 6/1/25 which is a 11.27% severe weight loss in 17 days; - No entries showing the physician was notified in the electronic record of the weight loss. During an interview on 6/2/25 at 9:54 A.M., the resident said: - Staff are not consistent in bringing a snack in the evenings, probably only two out of every seven days do they come around at night to offer; - The food here doesn't taste very good and there's a lot of pasta and rice, but nothing interesting on the menu; Meals are cold if they are served in the room. 2. Review of Resident #67's admission MDS, dated [DATE] showed: - The resident was cognitively intact; - The resident required moderate assistance from staff for eating; - The resident uses a wheelchair for mobility; - Diagnoses: heart disease, hypertension (high blood pressure), diabetes, and orthopedic back condition. Review of the resident's Care Plan, dated 4/17/25, showed the resident at risk for potential nutritional problem. Obtain weights as ordered and provide and serve diet as ordered. RD to evaluate and make diet change recommendations as needed. Review of the resident's Order Summary Report, dated 6/3/25, showed: - Regular diet and texture and regular and thin consistency; - Offer snacks every evening at bedtime. Review of the resident's Progress Notes during the survey showed: - On 5/5/25 the resident weighed 207 pounds; - On 6/1/25 the resident weighed 192.5 pounds which was a 7.00% significant weight loss in 28 days; - No physician notification was recorded in the electronic record for the significant weight loss. Observation on 6/2/25 at 11:00 A.M., showed the resident's breakfast plate was still in the resident's room with only 10% of the food eaten. During an interview on 6/2/25 at 2:28 P.M., the resident said: -It was the worst food he/she has ever eaten, he/she did not like the taste at all and there was no variety. The breakfast plate was delivered at 8:30 A.M. and was not removed until the staff brought lunch in the afternoon. The juice doesn't taste good and no one had asked him/her what he/she liked to eat; - The resident felt he/she had lost weight due to how his/her clothes fit, but was not sure how much; - The resident only gets offered a snack in the evening two or three times a week depending on who is working at the facility. 3. During an interview on 6/4/25 at 3:14 P.M., Licensed Practical Nurse (LPN) A said any resident that loses 5% weight in 30 days will have their primary care physician notified and documented in the progress notes. During an interview on 6/5/25 at 1:45 P.M., the Director of Nursing (DON) said: - The dietician and restorative aides and the DON monitor for weight loss. Normally the DON will run a report weekly to check on resident weights. She will analyze the weight numbers for the residents weekly; - When a significant weight loss is found, the physician is notified for orders and supplements and a progress note is entered into the record; - She was not aware of significant weight loss for Residents #64 and #67; - If there is a suspected weighing error in the record for the resident, they should be re-weighed immediately for accuracy; - Staff should offer snacks to residents every evening.

Based on interview and record review, the facility failed to ensure staff provided the Notice of Medicare Non-Coverage (NOMNC) to the resident or resident's representative when changes in coverage are made to items and services covered by Medicare. The facility provided verbal notification over the phone, however no written notice was mailed on the same date and placed in the beneficiary's medical file. Additionally, the facility failed to include the name of the staff person initiating the contact, the time of the phone call, and the telephone number called on the NOMNC form and failed to provide the notice two days preceding the end of covered services for two residents sampled for beneficiary notifications (Resident #172 and Resident #29). The facility census was 65. Review of facility policy, transfer and discharge (including against medical advice), dated 2021, showed: -Anticipated transfers or discharges: Orientation for transfer or discharge must be provided and documented to ensure safe and order transfer or discharge from the facility, in a form and manner that the resident can understand. -Supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and a documented discussions with the resident and/or resident representative. Review of facility policy, resident rights, dated 2022, showed resident had a right to manage his or her financial affairs. This includes the right to know in advance, what charges a facility may impose against a resident's personal funds. 1. Review of Resident #172's discharge minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/8/25, showed: -admitted [DATE]; -discharged [DATE] to short-term general hospital; -Unplanned discharge of part A interrupted stay; -Cognition moderately impaired; Diagnoses included: seizures, muscle weakness, and altered mental status. Review of the resident's NOMNC form, dated 3/7/25, showed: -The resident discharged from skilled Medicare services on 3/7/25; -The NOMNC form showed documentation of a phone call to the resident's durable power of attorney on 3/7/25. -The facility did not deliver notice two days prior to the last day covered; -The facility did not document the name of staff person initiating contact, time of phone call, or telephone number called on the NOMNC form. Review of the resident's medical record on 6/5/25, showed no copy of a NOMNC mailed to resident's representative on the day of the telephone contact. 2. Review of Resident #29's discharge MDS, dated [DATE], showed: -Cognition intact; -admitted on [DATE]; -End of stay Part A discharge; -discharged home on 5/23/25; -Diagnoses included fracture of the right lower leg and diabetes. Review of the resident's NOMNC form showed: -The resident discharged from Medicare services on 5/22/25 -The NOMNC form showed documentation of a phone call to resident's representative on 5/22/25; -The facility did not deliver notice two days prior to the last day covered; -The facility did not document the name of staff person initiating contact, time of phone call, or telephone number called on the NOMNC form. Review of resident's medical record on 6/5/25, showed no copy of a NOMNC mailed to the resident's representative on the day of the telephone contact. 3. During an interview on 6/5/25 at 1:08 P.M., the Business Office Manager said: -He had not issued any beneficiary notices yet but would be taking over the task; -Prior to his hire date the NOMNC were completed by the Social Services Director. During an interview on 6/5/25 at 1:10 P.M., the Social Services Director said: -She did not send a letter by mail when notifying resident's representatives via phone of their last day covered of Part A Services for NOMNC; -She was told she could provide verbal notices over the phone to resident's representatives; -Notices were to be provided two days prior to the end of end of services dates. During an interview on 6/5/25 at 1:10 P.M., the Administrator said: -He expected the NOMNC form to be provided according to regulatory statutes; -The NOMNC form should be given two days prior to the end of covered services; -He did not know notices were not being mailed to resident representatives after verbal consent was obtained.

Based on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge and bed hold which contained all of the required components for three of the 16 sampled residents (Resident #1, #13, and #33). The facility census was 65. Review of the facility's policy for Transfer and Discharge, dated 2021, showed: - It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered; - The facility may initiate transfers or discharges in the following limited circumstances: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; - Emergency transfers/discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified); - Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis; notify resident and /or resident representative; contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements; complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: resident status, including baseline and current mental, behavioral and functional status and recent vital signs; current diagnoses, allergies, and reasons for transfer/discharge; contact information of the practitioner responsible for the care of the resident; resident representative information including contact information; current medications, treatments, most recent relevant lab and /or radiological findings and recent immunizations; - A copy of any Advance Directive, Durable Power of Attorney (DPOA), Do Not Resuscitate (DNR) or withholding or withdrawing of Life-sustaining treatment forms should be sent with the resident; - Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand; - Document assessment findings and other relevant information regarding the transfer in the medical record; - Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer; - Social Services Director or Designee, shall provide notice to transfer to a representative of the State Long-Term Care Ombudsman via monthly list. 1. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/4/25, showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, toilet use, dressing, personal hygiene and transfers; - Had a urinary catheter; - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included anxiety, depression, post traumatic stress disorder (PTSD), and quadriplegia (paralysis of all four limbs). Review of the resident's medical record, under the progress notes tab, dated 4/12/25, showed: - At 10:49 A.M., the resident's lung sounds were congested in bilateral upper and lower lobes. Breathing treatment was administered and continued to have congestion. Oxygen saturation was at 92% on room air. The resident wished to go to the emergency room for evaluation. The resident was self-responsible. Faxed the physician and called 911 to transport to the emergency room at 10:43 A.M.; - At 1:14 P.M., the resident left the facility for the emergency room at 11:15 A.M., The Staffing Coordinator made the Director of Nursing (DON) and the Administrator aware of the resident's transfer to the emergency room. Review of the undated emergency transfer notice form showed it contained the Ombudsman information, but did not contain the information for the appeals unit. 2. Review of Resident #1's Quarterly MDS, dated [DATE], showed: - Long-term and short-term memory problems. Cognition severely impaired; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, personal hygiene, and transfers; - Had a urinary catheter; - Frequently incontinent of bowel; - Diagnoses included aphasia, quadriplegia, and seizure disorder. Review of the Resident's medical record, under the progress notes tab, dated 3/30/25 showed: - At 9:03 P.M., it was reported the resident had blood coming from his/her right knee area. Active bleeding coming from the bony knee area. Gauze was immediately applied over the site. Physician was notified and ordered for resident to be sent to the emergency room for further evaluation. The DON was contacted the responsible party was contacted and left a voice message. Review of the resident's undated emergency transfer notice form showed it did not contain the information for the appeals unit. During an interview on 6/4/25 at 4:40 P.M., Licensed Practical Nurse (LPN) A said: - When he/she sends a resident to the hospital, the paperwork included bed hold, transfer paper, medication list and face sheet; - He/She did not recall seeing the appeal rights or information about residents with mental disorders on the transfer notice form. 3. Review of Resident #33's annual MDS, dated [DATE], showed: -Cognition severely impaired; -admitted from short term hospital stay; -Dependent on wheelchair for mobility; -Required substantial to maximal assistance for all cares and mobility except eating and rolling left and right; -Diagnoses included: Alzheimer's disease, edema, osteoarthritis, and atrial fibrillation. Review of the resident's discharge assessment MDS, dated [DATE], showed unplanned short term hospital discharge with return anticipated. Review of the resident's discharge assessment MDS, dated [DATE], showed unplanned short term hospital discharge with return anticipated. Review of Resident #33's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/2/25, showed: -Cognition severely impaired; -Dependent on a wheelchair for mobility; -He/She was dependent for all cares and mobility except eating; -Diagnoses included Alzheimer's disease, edema, osteoarthritis, and atrial fibrillation. Review of the resident's care plan, dated 5/30/25, showed the resident had an actual fall due to poor communication and comprehension and anxiety. Review of the resident's progress notes in the medical record, on 6/3/25, showed: -On 1/15/25, the resident was transferred to the hospital for increased confusion, poor appetite, complaints of chest and stomach pain. Bed hold notice was provided via verbal consent on 1/15/25 and resident's representative elected to have bed held during his/her absence. -On 2/1/25, the resident had fallen out of bed and landed on left shoulder, left side of face, and his/her left eye was black. The resident was provided bed hold notice and did not want bed held during his/her absence. -On 5/28/25, the resident rolled out of bed and had bruising on left orbital eye socket. Bed hold notice was provided to the resident's representative showed he/she did not elect to have bed held in resident's absence. Record review of the bed hold notices dated 1/15/25, 2/1/25, and 5/28/25, showed they did not contain all required components, including: -A statement of the resident's appeal rights to include the name, address (mailing and email, and telephone number of the entity which receives such requests, and information on how to obtain an appear form and assistance in completing the form and submitting the appeal hearing request -The name, address, and email, and telephone number of the office of the state long-term care ombudsman. 4. During an interview on 6/4/24 at 2:05 P.M., the Director of Nursing (DON) said: -She expected the discharge forms to have all the required regulatory information included on it; -She was not aware of the appeal rights that needed to be included on the transfer and discharge paperwork. During an interview on 6/4/24 at 3:03 P.M., the Administrator said he expected information about notice of appeals and Ombudsman contact information to be included according to regulatory standards on discharge and transfer notices.

Based on interview and record review, the facility failed to provide appropriate treatment and services to maintain the strength and mobility for one resident (Resident #67) of 16 sampled residents. Facility census was 65. Review of the facility policy, Restorative Nursing Documentation, undated, showed: - The facility maintains complete, accurate, and organized documentation of restorative treatments and the response to those treatments; - The need for restorative nursing services will be documented in the medical record and indicated in the resident's care plan; - It will contain the problem, need or strength that is being addressed along with a measurable goal with target date; - It will contain specific interventions/treatments to be provided and the frequency and duration; - Treatment will be documented daily by the restorative aide to include treatment provided and number of minutes performed; - The resident's plan of care will be updated at routine intervals; Review of the facility policy, Activities of Daily Living (ADLs), undated, showed: - The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable; - This includes transfer and ambulation; - The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment; - The facility will maintain individual objectives of the care plan and periodic review and evaluation. 1. Review of Resident #67's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 4/4/25, showed: - The resident was cognitively intact; - No limitation in range of motion in upper extremity or lower extremity; - Used a wheelchair for mobility; -The resident required from staff partial/moderate assistance for eating and oral hygiene; - The resident required from staff substantial assistance for upper body dressing and personal hygiene; - The resident was dependent on staff for toileting hygiene, showering, and lower dressing; - The resident required moderate assistance from staff to roll left and right; - The resident required substantial assistance from staff to go from sitting to lying and lying to sitting on the side of the bed; - The resident was dependent on staff to go from sitting to standing, chair/bed to chair transfers, toilet transfers, and shower transfers; - Diagnosis: heart disease, hypertension, diabetes, and orthopedic back condition; Review of the resident's Care Plan, dated 4/9/25, showed: - The resident had an ADL self-care performance deficit and a diagnosis of somatic dysfunction of the lumbar region (impaired or altered function of the spine); - The resident required moderate assist with all activities of daily living, mobility, and ambulating task. Review of the resident's Order Summary Report, dated 6/3/25, showed: - Skilled Occupational Therapy services discontinued due to exhausted benefits, resident was referred to restorative assistant (RA) therapy program, dated 4/16/25; - May use turn bar for repositioning. Review of the resident's Restorative Functional Maintenance Program, dated 4/16/25, showed: - The resident was ordered to perform 10 repetitions of knee and ankle exercises with RA staff for lower extremities. The goal of the order was to work on bed mobility rolling left to right and right to left including bridging for 5 repetitions; - The resident was ordered to perform 2 sets of 10 repetitions of arm exercises with three pound weights on 6/1/25 for the upper extremities; - The written orders did not specify the how often these exercises were to be scheduled per week. Review of Resident's Medical Record for April-June 2025 showed: - April 2025 no record of Restorative Functional exercises documented; - May 2025 no record of Restorative Functional exercises documented; - June 2025 no record of Restorative Functional exercise documented. During an interview on 6/4/25 at 10:45 A.M., the resident said: - He/she had been at the facility for a few months and he/she was much worse off then when he/she arrived. His/her physical therapy funding had run out, but he/she was told that he/she would have access to RA therapy. No one had come to see his/her about this and staff have not worked with him/her in months. He/she had lost all his/her strength and while he/she used to be able to turn over in bed, he/she can't even reach the grab bar due to his/her loss of mobility and range of motion in his/her arms. His/her turning and mobility have greatly declined. He/she was very depressed and it was hard to carry on without any goals or help to get better. He/she felt like he/she was lying in this bed all day waiting to die; - When asked about his/her Restorative Functional Maintenance Program, the resident did not recall doing any of those exercises since they lost funding for PT in April 2025. During an interview on 6/4/25 at 11:10 A.M., Physical Therapy Aide A said the RA program was for residents who do not have funding for PT. The PT department develops a plan of therapy for them to improve their strength and support their ADLs. We develop the plan but we don't monitor whether the nursing department was keeping up with it or not. During an interview on 6/5/25 at 12:22 P.M., the Director of Nursing (DON) said: - The resident had run out of funding for covered PT services so he/she has been transferred to the in-house Restorative Functional Maintenance Program which was a plan put together by the PT department for residents not covered under funded PT. The program that a resident was assigned to was developed by the PT department and executed by the nursing department. The DON was unable to provide more specifics or orders showing that Resident #67 had participated in the program and was not able to get me access to the person who runs the program in her department; - The DON was not familiar enough with the resident to know why they had not been doing a restorative maintenance program; - Currently a process was not in place to ensure that when an order was written from PT for restorative therapy that the order is carried out by staff; - The purpose of restorative therapy is to keep residents at the top level of their passive and active ADL potential.

Based on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not complete showers for three of the 16 sampled residents, (Resident #13, #46, and #64). The facility census was 65. Review of the facility's policy for Resident Rights, dated 2022, showed: - The resident has the right to a dignified existence, self-determination, and communication with and assess to persons and services inside and outside the facility; - The resident has the right to be informed of, and participate in his/her treatment. 1. Review of Resident #13's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/25 showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, toilet use, dressing, personal hygiene and transfers; - Had a urinary catheter; - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included anxiety, depression, post traumatic stress disorder (PTSD), and quadriplegia (paralysis of all four limbs), urinary tract infection (UTI) in the last 30 days. Review of the resident's care plan, revised 4/9/25 showed: - The resident had an ADL self-care performance deficit. Assist with showers at least two times weekly and as needed. The resident is totally dependent on staff to provide bath/shower as necessary; - Personalized care indicated the resident's bathing preference was a shower and it was very important for the resident to choose the bath type. Review of Resident #13's shower sheets for February, 2025 showed the resident had a shower on the following dates 2/3/25 and 2/8/25. The resident declined a shower on 2/17/25 and requested it on 2/18. No documentation to indicate the resident had a shower on 2/18/25. During the month, the resident missed eight showers. Review of the resident's shower sheets for March, 2025 showed the resident had a shower on the following dates 3/15/25 and 3/29/25. The resident missed six showers. Review of the resident's shower sheets for April, 2025 showed the resident had a shower on the following dates 4/6/25, 4/8/25 and 4/14/25. The resident missed six showers. Review of the resident's shower sheets for May, 2025 showed the resident had a shower on the following dates 5/10/25 and 5/26/25. The resident missed seven showers. Review of the resident's shower sheets for June, 2025 showed the resident had a shower on 6/1/25. The resident missed at least one shower. During an observation and interview on 6/3/25 at 9:51 A.M., the resident said: - He/She has not been getting his/her showers twice weekly; - It made him/her feel dirty and he/she had to cancel an appointment before, because his/her hair was so greasy and he/she felt unclean. - The resident had a heavy odor of body spray on and his/her hair appeared unwashed as it was flat and dull. 2. Review of Resident #46's Annual MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on one side; - Dependent on the assistance of staff for toilet use, showers and transfers; - Diagnoses included diabetes mellitus, stroke, arthritis, aphasia, depression and hemiplegia. Review of the resident's care plan, revised 4/18/25 showed: - The resident had bowel and bladder incontinence. - The care plan did not address how often the resident preferred to shower. Review of Resident #46's shower sheets for February 2025 showed the resident had a shower on the following dates: 2/3/25, 2/10/25, 2/13/25, 2/17/25 and 2/20/25. Review of the resident's shower sheets for March, 2025 showed the resident had a shower on the following dates: 3/13/25, 3/16/25, 3/23/25 and 3/31/25. Review of the resident's shower sheets for April 2025 showed the resident had a shower on the following dates: 4/10/25, 4/14/25, and 4/21/25. Review of the resident's shower sheets for May 2025 showed the resident had a shower on the following dates: 5/19/25, 5/22/25 and 5/26/25. Review of the resident's shower sheets for June 2025 showed the resident had a shower on 6/1/25. During an observation and interview on 6/2/25 at 10:03 A.M., the resident said: - Sometimes it would take two weeks before he/she would get a shower; - It made him/her feel bad when he/she did not get showered. - The residents hair appeared unwashed as it was flat and dull. 3. Review of Resident 64's Quarterly MDS, dated [DATE], showed: - The resident has moderate cognitive impairment; - The resident needs substantial assistance from staff for bathing; - Diagnoses: Anemia, heart disease, and diabetes. Review of the resident's Care Plan, dated 4/18/25, showed the Resident had an ADL self-care performance deficit. Staff to assist the resident with showers at least two times weekly and as needed. Review of the resident's Comprehensive CNA Shower Review, showed: - March 2025 the resident was offered four showers; - April 2025 the resident was offered three showers; - May 2025 the resident was offered four showers; - Over a three month period the resident was offered less than one shower per week. During an interview on 6/3/25 at 2:15 P.M., the resident's family member said he/she was very upset about the lack of showers for the resident and had seen the resident go two weeks without a shower. During an observation and interview on 6/5/25 at 11:00 A.M., the resident said he/she preferred two showers each week, but does not complain when he/she only gets one, because staff push and pull you in your wheelchair to manipulate resident's in the shower and he/she doesn't feel safe and dreads showers. During an interview on 6/5/25 at 10:30 A.M., LPN A said: - The more showers a resident can receive the better it is for the resident. One shower a week is not enough and two showers a week is preferable. The charge nurse on duty is in charge of making sure the showers are administered and residents get their showers. Refusals are documented by the nurse when a resident refuses an offered shower. - With regards to Resident #64 not getting two showers a week it may be due to refusals, but he/she was not sure. -He/she would expect that all refusals are documented in the resident record. 4. During an interview on 6/3/25 at 1:27 P.M., Licensed Practical Nurse (LPN) B said: - He/She has not had any residents complain about not getting their showers recently; - The facility had more staff now and it was a lot better. During an interview on 6/4/25 at 3:08 P.M., Certified Nurse Aide (CNA) A said they usually have a shower aide but if they don't, then the aides on the floor try to get the showers completed. During an interview on 6/5/25 at 12:42 P.M., Certified Medication Technician (CMT) A said: - If there's enough staff working, then the showers get completed; - The facility did not have a designated shower aide; - He/She has had family and residents complain about showers not getting completed; - When a family member or a resident complained about not getting their showers, the staff would try to get them a shower or at least a bed bath. During an interview on 6/5/25 at 1:10 P.M., LPN A said: - He/She has not had any family members or residents complain about not getting their showers; - The facility did not have a designated shower aide; - Sometimes they will call staff in to work just to do showers. During an interview on 6/5/25 at 2:28 P.M., the Director of Nursing (DON) said: - They do not have a shower aide at the moment; - Staff should at least offer a resident a shower at least twice weekly; - Staff should it on the shower sheets and if a resident refused a shower, then the resident should sign it and the charge nurse should check it.

Based on interview and record review, the facility failed to ensure two out of sixteen sampled residents reviewed for unnecessary medications, (Resident #53, #57) and/or their representative were informed of the risks and benefits of a physician ordered antipsychotic medication. This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 65. Review of facility policy, Use of psychotropic medications, dated 2022, showed residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. Review of facility policy, Resident's Rights, dated 2022, showed the resident has the right to be informed by the physician or other practitioner or professional of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option that he or she prefers. -The right to self-determination. The resident has a right to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. -Information and communication. The resident has the right to receives notices orally (meaning spoken) and in writing in a format and language he or she understanding. -The resident has the right to be informed of, and participate in, his or her treatment, including: -The right to be fully informed in language that he or she can understand his or her total health status, including but not limited to, his or her medical condition -The right to be informed in advance of the care to be furnished and the type of care giver or professional that will furnish the care. 1. Review of Resident #53's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/1/25, showed: -Severely impaired cognition; -Antipsychotics were provided to the resident on a routine basis; -A gradual dose reduction (GDR) was attempted 3/31/25; -GDR was documented by the physician as clinically contraindicated on 3/31/25; -Diagnosis included: dementia, stroke, and seizure disorder. Review of care plan, dated 5/20/25, showed: -Resident used psychotropic medications (Rexulti) for behavioral management and yelling at night. -Resident would be free of psychotropic drug related complications including movement disorders, hypotension, gait disturbance, constipation, diarrhea; -Administer psychotropic medication as ordered by physician. Monitor for side effects and effectiveness; -Consult with pharmacy, medical doctor to consider dosage reduction quarterly; -Discuss with the physician and family regarding ongoing need for use of psychotropic medications. Review behaviors and interventions and alternate therapies attempted and effectiveness; -Monitor/document/report adverse reactions of psychotropic medications; -Monitor and record the occurrence of behavior symptoms and document per facility policy; -The resident was on a behavior management program. Review of physician's orders, dated 6/3/25, showed an order started 5/30/25 for Rexulti (antipsychotic medication) oral tablet 2 milligrams (mg), give 2 mg by mouth one time a day for behaviors related to dementia with agitation. Review of physician's orders medication summary, dated 6/1/24 to 5/31/25, showed: -Started 11/11/24, Rexulti oral tablet 0.5 Mg, give 1 tablet by mouth one time a day for agitation, start discontinued 12/3/24; -Started 12/4/24, Rexulti oral tablet 0.5 mg, give 1 tablet by mouth one time a day for Alzheimer's dementia with agitation, discontinued 1/23/25; -Started 1/24/25, Rexulti oral tablet 1 mg, give 1 mg by mouth one time a day for behaviors until 1/31/25, discontinued 1/31/25; -Started 1/31/25, Rexulti oral tablet 2 mg, give 2 mg by mouth one time a day for behaviors, discontinued 2/28/25; -Started 3/1/25, Rexulti oral tablet 1 mg, give 1 mg by mouth one time a day for behaviors, discontinued 5/17/25; -Started 5/17/25, Rexulti oral tablet 1 mg, give 1 mg by mouth two times a day for behaviors, discontinued 5/22/25; -Started 5/23/25, Rexulti oral tablet 0.5 mg, give 1 mg by mouth one time a day for behaviors to be given with 1 mg to equal 1.5 mg, discontinued 5/29/25; -Started 5/23/25, Rexulti oral tablet 1 mg, give 1 mg by mouth one time a day for behaviors, discontinued 5/29/25; -Started 5/30/25, Rexulti oral tablet 2 mg, give 2 mg by mouth one time a day for behaviors related to dementia in other disease. Review of medical record, dated 6/3/25, showed no consents or education of risks and benefits for psychotropic medication use were found from 6/1/24 through 5/31/25. During a interview on 6/5/25 at 8:58 A.M., the Director of Nursing (DON) said: -She did not have any consents for psychotropic medications use for Resident #53; -The facility should have obtained and provided residents or their representative with education regarding psychotropic risks and benefits prior to use. 2. Review of Resident #57's Quarterly MDS, dated [DATE], showed: -Cognition severely impaired; -Antipsychotic medication was administered on a routine basis; -A GDR was attempted on 2/6/25; -A GDR had not been documented as clinically contraindicated by the physician; -Diagnoses included: anxiety, depression, bipolar, and psychotic disorder. Review of care plan, dated 5/13/25, showed: -Resident used a psychotropic medication (Olanzapine) due to disease process and anxiety disorder; -Administer psychotropic medications as ordered by the physician, monitor for side effects such as: changes in gait, tardive dyskinesia, increase in falls, change in appetite, vision changes, constipation, diarrhea; -Consult with pharmacy and physician to consider dosage reduction when clinically appropriate, and quarterly; -Discuss with the physician, and family the ongoing need for use of Olanzapine medication. Review behaviors/interventions and alternate therapies attempted and the effectiveness; -Educate the resident/family/caregivers about risks and benefits along with the side effects and/or toxic symptoms of this medication like unsteady gait, tardive dyskinesia, extrapyramidal symptoms, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms; -Monitor/record occurrence of for target behaviors ( pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document; -Resident was on a behavior management program ( alternatives to PRN medication use). Review of physician's orders, dated 6/3/25, showed: -Started 4/15/25, Olanzapine oral tablet 10 mg, give 1 tablet by mouth one time a day related to anxiety disorder; -Started 5/29/25, Rexulti (an antipsychotic) oral tablet 2 mg, give 1 tablet by mouth one time a day for depression. Review of medical record, dated 6/3/25, showed: -No consents or education of risks and benefits for psychotropic medication use was found. During an interview on 6/5/25 at 8:58 A.M., the DON said: -She did not have any consents for psychotropic medications use for Resident #57; -The facility should have obtained and provided residents with education regarding psychotropic medication risks and benefits.

Refer to Event ID U31013 for further information. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 03/03/2025. Based on interview and record review, the facility failed to initiate an investigation into an injury of unknown origin when Resident #1 sustained an open fracture (a bone break with a skin opening) to his/her right femur (upper leg bone). The Director of Nursing (DON) assessed the resident and did not initiate an investigation to determine the cause of the injury. This deficient practice affected one of one sampled residents. The facility census was 73.

Refer to Event ID U31013 for additional information. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 03/03/2025. Based on interview and record review, the facility failed to report an injury of unknown origin to the Department of Health and Senior Services (DHSS) when Resident #1 sustained an open fracture (a bone break with an opening to the skin) to his/her right femur (upper leg bone). The Director of Nursing (DON) assessed the resident and did not report the injury of unknown origin to DHSS and did not immediately report to the Administrator. This deficient practice affected one of one sampled residents. The facility census was 73.

Refer to Event ID U31013 for additional information. Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #3 and #2) were treated with dignity and respect when staff members were unnecessarily rough while providing care. This deficient practice affected two of 6 sampled residents. The facility census was 73.

Based on interview and record review the facility failed to protect one resident (Resident #4) of 6 sampled residents, right to be free from verbal and physical abuse when Certified Medication Technician (CMT) A called the resident derogatory names based on his/her body type and abilities and roughly pushed the resident's wheelchair forward. The facility census was 66. Review of the facility policy titled, Abuse Prevention Program, dated 1/20/25 showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Verbal abuse is defined as the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Review of Resident #4 Significant Change Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 1/28/25 showed: -Brief Interview of Mental Status (BIMS) of 12, indicated minimal cognitive loss; -Verbal behaviors (such as yelling, cursing) towards others for one to three of 7 days; -Moderate assistance on staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself); -Use of wheelchair for mobility; -Use of oxygen; - Diagnoses included: Extreme Binge Eating Disorder (is a serious condition involving feeling like one is not able to stop eating, and often involves eating much larger than usual amounts of food.) obesity, and anxiety. Hypertension (high blood pressure), Congestive Heart Failure (CHF: the heart cannot pump blood effectively), Chronic Obstructive Pulmonary Disease (COPD: lung disease that causes air flow obstruction and difficulty breathing). Review of the resident's face sheet showed he/she had a diagnosis of oxygen dependence. Review of the resident's Comprehensive Care Plan 1/28/25 showed: -Need for assistance with ADL's; -Impaired cognitive function. During an interview on 3/13/25 at 10:30 A.M. Resident #4 said: -He/She was fine; -He/She was not afraid of anyone; -No one had been rude, hateful or disrespectful to him/her; -Staff are good to him/her. During an interview on 3/13/25 at 2:00 P.M. HK A said: -He/She was at the D hall housekeeping closet on 3/11/25 around 7:45 A.M. when he/she heard CMT A yell get your ass to the closet three to four times; -HK A walked into the hallway, saw Resident #4 was sitting at the dining room door in his/her wheelchair, then he/she pedaled himself/herself a few feet into the hallway; -CMT A got behind the resident's wheelchair, grabbed the handles, pushed aggressively and said I told you to get your fat ass going as he/she pushed the resident around a corner; -HK A left the hall to notify his/her supervisor. During an interview on 3/13/25 at 3:18 P.M. CMT A said: -On 3/11/25 he/she was passing medications at the dining room; -He/She had told Resident #4 to wheel himself/herself to the oxygen closet; -Resident #4 had pedaled himself/herself a few feet into the hall from the dining room, then would not move; -He/She let his/her frustration get the best of him/her and said get your fat ass rolling to Resident #4; -Resident #4 was almost always out of oxygen in his/her tank in the mornings; -When he/she got the wheelchair he/she gave the resident an energetic push forward; -He/She had Abuse and Neglect education less than a month ago; -He/She knew better, yelling and cursing at the resident was another example of his/her temper getting away from him/her. Review of the facility investigation dated 3/11/25 showed: -8:00 A.M. an allegation of verbal abuse by CMT A to Resident #4 was reported to the Administrator by Housekeeping Aide (HK) A; -8:10 A.M. the resident's physician was notified of the alleged abuse; -8:12 A.M. the resident representative was notified of the alleged abuse; -8:15 A.M. interview with the reporter showed he/she had heard CMT A yell a derogatory term to Resident #4, while pushing the resident's wheelchair roughly; -8:20 A.M. interview with Resident #4 showed he/she was not aware of any derogatory term being used; -8:55 A.M. interview with CMT A showed, he/she was suspended and escorted out of the facility. During an interview on 3/13/25 at 4:10 P.M. the Administrator said: -CMT A's employment had been terminated; -The comments made by CMT A were abuse and unacceptable; -Immediate education was provided for staff; -She would not expect staff to curse or yell at residents. MO250870

Refer to Event ID U31012 Based on interview and record review, the facility failed to complete a thorough investigation when one resident (Resident #1) sustained a femur fracture of unknown origin and failed to maintain documentation that an alleged violation was thoroughly investigated. The facility census was 67.

A revisit was completed and the facility was found to have continued non-compliance. Refer to Event ID U31012 for federal and state deficiencies cited as a result of this complaint investigation. Based on interview and record review, the facility failed to report an injury of unknown origin, when the facility staff became aware on 2/27/25 that one resident (Resident #1) had a right leg femur fracture. The facility census was 67.

Based on interview and record review, the facility failed to follow their policy and ensure two sampled resident's (Resident #1 and #2) code status was correct at the time of admission and carried out in accordance with the guardian's directive to staff. Resident #1's guardian directed Registered Nurse (RN) A upon admission on [DATE] and to RN B on [DATE] to change the resident's code status to Do Not Resuscitate (DNR). On [DATE], the resident stopped spontaneous respirations and pulse and facility staff initiated cardiopulmonary resuscitation (CPR). Emergency Medical Services (EMS) were called to the facility and took over CPR from facility staff. CPR was performed for one hour and 13 minutes. The resident was declared deceased at the facility on [DATE] at 2:16 A.M. Resident #2's guardian notified the Social Services Designee (SSD) on [DATE] of his/her wishes to change the resident's code status from full code to a DNR and staff failed to change the resident's code status. The facility census was 68. The Administrator was notified on [DATE] at 2:24 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on site. Review of the undated facility policy regarding Health Care Directives/Death of a Resident showed: -Purpose: Ensure that the facility is able to, and does provide, emergency basic life support when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with the related physician orders, such as DNR and the resident's advanced directives. - Advanced Directives is defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Some states also recognize documented verbal instruction. - CPR refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. - Code Status refers to the level of medical interventions a person whishes to have started if their heart or breathing stops. - DNR order refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Existence of an advanced directive does not imply that a resident has a DNR order. The medical record should also show evidence of documented discussions leading to a DNR order. Review of the undated facility policy regarding DNR- No Extraordinary Life-Saving Measures: -Purpose: Ensure that resident rights are protected in the presence of a DNR order or Advanced Directive, when the resident wishes for no extraordinary measures to be taken at his/her end of life. -Procedure: - When a resident discusses with a staff member the desire for no extraordinary life-saving measures, the Director of Nursing (DON) will be notified. - The DON will have a more formal discussion with the resident about what no extraordinary life-saving measures means. - This wish will be shared with the resident's family, responsible party, and physician. - A copy of these documents will be maintained in the resident's file, given to the resident family or responsible party and given to the resident's physician. - If the resident has a Health Care Proxy, the EMS/ambulance will be informed as needed and the person with Health Care Proxy will be contacted as needed. That person's phone number will be placed in the resident's chart so they can be contacted during an emergency when the resident is not capable of making healthcare decision. - A copy of the Living Will, Advanced Directives or Health Care Proxy will be sent with the ambulance workers. 1. Review of Resident #1's Admission Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated [DATE], showed: -the resident admitted to the facility on [DATE]; -diagnoses of neurocognitive disorder with Lewy Bodies (a common dementia is caused by a buildup of proteins in the brain. It affects thinking, memory and movement), hallucinations, constipation, arthritis, anemia, chronic pain. -had minimal difficulty hearing, clear speech, sometimes understands others and rarely/never is able to make self understood; -score of ,d+[DATE] on the Brief Interview for Mental Status (BIMS, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care), indicating severely impaired cognition; and -was dependent on staff for all activities of daily living, including dressing, bathing, and personal hygiene. Review of the resident's medical record showed the resident's daughter was granted legal guardianship of the resident on [DATE]. Review of the resident's face sheet, dated [DATE], showed the resident's code status to be Full Code/CPR. Review of the resident's physician orders, dated [DATE], showed an order for the resident's code status as Full Code/CPR. Review of the resident's comprehensive care plan, dated [DATE], showed the resident wished to be a Full Code status. In case of no pulse, no respirations start CPR and call 911. Review quarterly with resident, responsible party and with significant changes to ensure wishes remain the same. Review of the resident's progress notes showed: -[DATE] 3:17 P.M.: RN A wrote: Resident was admitted on [DATE]. Resident is a DNR. Face Sheet and orders faxed to the physician and to pharmacy. -[DATE] 4:46 P.M.: RN B wrote: Guardian was here. Was discussing the resident's care. The guardian noted resident was a DNR, but nothing was in the file stating the resident was a DNR. The Guardian said he/she gave the document to someone in the office here. Will let executive director (ED) know of code status. Let physician know as well. (Review of the medical record showed no documentation that the physician was notified of the desired code status.) -[DATE] 3:31 A.M., Licensed Practical Nurse (LPN) A wrote: Certified Nursing Assistant (CNA) x 2 were in resident room for rounds, providing pericare and repositioning him/her. They stated the resident was not acting at his/her baseline and called for the nurse. Nurse went into room and asked for other nurse to come in the room as well. Resident was staring straight ahead and breathing through his/her mouth. He/She was not looking at staff in the room, this lasted for less than 60 seconds. Resident was responding to staff, yelled a couple times and was making eye contact. Nurses stayed with him/her for approximately five minutes, then he/she started to have another episode of staring straight ahead and mouth breathing. Called 911 at approximately 12:45 A.M. due to concern of seizures. Called guardian at approximately 12:50 A.M., EMS arrived at 12:52 A.M. Paramedics were in the room with resident, he/she became without a pulse, he/she was lowered to the floor and CPR started at 1:00 A.M. Paramedics and firefighters took over CPR and cares at this time. Guardian called back and I let her them know that CPR was currently taking place. He/She stated he/she did not want CPR for the resident, discussed with him/her that without the paperwork that stated he/she was a DNR we had to treat him/her as a full code, but I would tell the paramedic his/her wishes. The paramedic stated that it would be best to see the paperwork, we did not have a DNR to show in the facility. Paramedic stated that a pulse was noted 2 different times during CPR and were more than likely going to be transporting the resident to the hospital. Guardian was made ware of this as well, he/she stated again that he/she did not want the resident to receive anymore CPR. I reported this to the paramedic again, he/she asked to speak to the guardian. Guardian expressed to the paramedic again he/she did not want CPR for the resident. CPR was stopped at 2:13 A.M. They monitored for a heart rate for a couple of minutes and did not have one. The resident's son was here at this time in the facility as well. Physician notified at 2:33 A.M. and gave orders to remove intubation. -[DATE] 2:17 A.M.- Administrator wrote: Spoke with the guardian. He/She was upset that the facility could not take his/her verbalization to stop CPR. He/She then called back and said he/she had spoken with the paramedics and they are going to stop CPR as they do not have a pulse. The residents sons were present in room when request was made. Review of EMS Patient Care Record, dated [DATE], showed: -EMS dispatched to the facility at 12:45 A.M. on [DATE], and arrived at the facility at 12:52 A.M. -An Advanced Life Support assessment (ALS), an assessment conducted by qualified EMS personnel) was performed. The resident was unresponsive to all stimuli. Resident was noted to be breathing but it was abnormal. Resident only made short gasps. Resident pulses were promptly palpated (examined by touch). Resident's pulses were unable to be palpated. -Resident was moved from the nursing home bed to the floor and CPR was started. An intravenous line (IV) was established for medication administration. The resident was intubated (the placement of a flexible plastic tube into the trachea to maintain an open airway) for advanced airway management. Resident was noted to vomit in and around her vocal chords during intubation attempt that was suctioned. Throughout CPR efforts, resident was given epinephrine (a medication used to treat low blood pressure and slow heart rate) eight times. Resident's pulses returned twice. -Resident's family arrived at the facility and adamantly informed ambulance crew that the patient has a DNR and does not wish to be resuscitated. At that time it was decided by the ambulance crew that the patient has undergone significant resuscitation efforts and that further efforts would likely not benefit the resident. Medical control was contacted through the local hospital and the physician gave the order to cease CPR efforts. CPR efforts were ceased where it appeared the resident had agonal breathing (refers to short, labored, gasping breaths that occur because oxygen cannot reach the brain). Palpation of pulses was attempted by multiple providers where no pulse could be found. At that time, the ambulance crew returned their equipment to the ambulance and cleared the scene. -The resident was declared deceased at 2:16 A.M. During an interview on [DATE] at 2:11 P.M., the resident's guardian said: -He/she never received a form to sign to change the resident's code status. -He/she told the nurse at admission. The guardian also told RN B on [DATE] that the resident's code status should be DNR, not Full Code/CPR. He/she also had a discussion with the SSD in [DATE] regarding the resident's desired code status of DNR. He/she is unsure of the exact date of the conversation with SSD. -During the night of [DATE], the facility called the guardian to state that the resident had stopped breathing and CPR had been started. The guardian became very upset and requested multiple times that CPR be stopped. -He/she says the resident would not have wanted to have CPR performed. During an interview on [DATE] at 12:33 P.M., the Business Office Manager (BOM) said: -He/She completed a portion of Resident #1's admission, but did not speak to the family about the desired code status; -It was the SSD responsibility to obtain the resident's code status at the time of admission. During an interview on [DATE] at 11:21 A.M., RN A said: -He/She does not recall doing the admission for Resident #1, as he/she does so many admissions. -During the admission process, he/she will ask the resident or family their wishes for code status. If the resident or family has not made that choice, then the resident will be a full code. -Social Services is responsible for getting the code status choice from the resident and/or family, getting the code status form signed and the chart updated. During an interview on [DATE] at 11:26 A.M., the Social Services Designee (SSD) said: -He/She did not complete Resident #1's admission. The Business Office Manager (BOM) was completing admissions at that time; -He/She was aware the resident was to be a DNR code status. However, when he/she completed his/her chart audit and found there was no signed DNR form on file, the resident was changed to a CPR code status; -He/She contacted the resident's daughter/guardian, who indicated to the SSD that he/she would send the SSD the signed DNR form to the facility. The SSD is unsure of the date the guardian was contacted; -The SSD audits the charts, Code Status book, and door dots once per month. During an interview on [DATE] at 11:37 A.M., RN B said: -RN B confirmed that he/she had a phone conversation with Resident #1's guardian/daughter on [DATE]; -The guardian informed RN B that the resident was to be a DNR code status. RN B asked the guardian to fax the signed form to the facility. The guardian confirmed he/she would do so. RN B was unsure if the form was received by the facility; -RN B believes he/she notified the physician of the guardian's wishes for code status; -The SSD or the Director of Nursing (DON) would be responsible for updating the chart, Code Status book, and dot on name plate; -RN B did not inform the SSD or DON of the guardian's wish for DNR code status for the resident. During an interview on [DATE] at 8:30 A.M., the physician said: -No one from the facility had approached him/her regarding the guardian's desire for Resident #1 to be a DNR code status. He/she never received anything to sign in regards to code status. -His/Her expectation is for the staff of the facility to confirm the resident's/family's desired code status, notify him/her as soon as possible for the order, and then update the chart. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the resident had: -diagnoses of encephalopathy (broad term for any brain disease that alters brain function or structure), lymphocytopenia (a disorder where there are not enough white blood cells in the blood), kidney failure, difficulty walking, weakness, dysphagia (difficulty swallowing), paranoid personality disorder (a personality disorder characterized by exaggerated distrust and suspicion of other people) history of traumatic brain injury, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions); -adequate hearing, clear speech. He/She was usually able to understand others and usually able to make self understood; and -a score of ,d+[DATE] on the BIMS, indicating severely impaired cognition. Review of the resident's medical record on [DATE] showed the resident's son was appointed his/her legal guardian on [DATE]. Review of the resident's physician orders, dated [DATE], showed an order for the resident's code status to be Full Code/CPR. Review of the resident's face sheet, dated [DATE], showed the resident's code status to be Full Code/CPR. Review of the resident's comprehensive care plan, dated [DATE], showed: -the resident and his/her responsible party wish for the resident to have a CPR code status; and -code status will be reviewed quarterly and as needed with the resident and responsible party. Review of the resident's progress notes showed: -[DATE] at 5:56 P.M. SSD wrote: SSD was able to reach resident responsible party. Responsible party states he/she would like to change resident to DNR code status and would be here in the morning to sign and understands the resident will be a full code until the DNR is signed. Observation on [DATE] at 11:55 A.M., showed the dot on the name plate to be green, indicating the resident is a Full Code/CPR code status. Observation on [DATE] at 12:00 P.M., showed the resident to be a Full Code/CPR code status in the Code Status book. During an interview on [DATE] at 1:07 P.M., the SSD said: -Resident #2's guardian has not been to the facility to sign the DNR form. He/She will follow up with the guardian today and email him/her the form; -he/she had not notified the charge nurse or DON regarding the guardian's direction to change the resident's code status to DNR; and -he/she had received education regarding the process of changing a resident's code status. 3. During an interview on [DATE] at 12:27 P.M., the DON said: -it is his/her expectation that the code status be obtained on the day of admission and staff inform him/her of the desired code status; -it is his/her expectation that the charge nurse notify the physician of the desired code status, obtain the order and then update the chart. The SSD will update the Code Status book and the dot on the name plate; and -if a current resident wishes to change the code status, it is his/her expectation that that staff notify the DON of the desired change. He/She will then confirm this with the resident/family. The charge nurse will then notify the physician, obtain the new code status order and then update the chart. The SSD will update the Code Status book and the dot on the name plate. During an interview on [DATE] at 11:40 A.M., the Administrator said: -it is his/her expectation that staff confirm the resident's desired code status on the day of admission. This can be the SSD or charge nurse. The charge nurse will notify the physician of the code status, obtain the order and update the chart. The SSD will update the Code Status book and the dot on the name plate; -if a resident wants to change their code status, the staff who were notified of the desired change will notify the DON. The DON will confirm this with the resident/family and then notify the charge nurse. The charge nurse will notify the physician of the code status, obtain the order and update the chart. The SSD will update the Code Status book and the dot on the name plate; and -it is his/her expectation this be done immediately, the same day the staff are notified of the desired code status. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO236779

Based on observation, interview, and record review, the facility failed to provide protective oversight on the facility's secured unit to prevent two residents from ingesting [MEDICATION(S)] (meth, highly addictive stimulant) which affected two residents (Residents #1 and #2). The facility failed to update the care plans after the residents ingested meth, which affected two residents (Residents #1 and #2). The facility failed to monitor facility windows on a routine basis and failed to ensure that broken/missing windows and screens were immediately replaced on the secured unit. The facility failed to assess the residents for elopement risk and put into place a care plan for elopement which affected two residents (Residents #1 and #2). The facility failed to follow their policy for reporting illegal drugs to local law enforcement. The facility census was 48. The Administrator was notified on 7/6/2021 at 5:00 P.M. of an Immediate Jeopardy (IJ) which began on 6/22/2021. The IJ was removed on 7/8/2021, as confirmed by surveyor onsite verification. 1. Review of the undated facility policy on comprehensive care plans showed: - The purpose of each resident's care plan is to provide measurable goals, developed to meet the resident's physical, mental, and psychosocial well-being. - Assessment of the resident's care plan is ongoing and should be revised as changes in condition occur. - A resident's care plan should be reviewed when changes occur that impact the resident's care. Review of the undated facility elopement/wandering assessment, to be done on admission, quarterly, annually, and as needed per interview with the administrator and the Director of Nursing (DON) on 7/7/21, showed: - Is the resident ambulatory or self-mobile in a wheelchair with a box for yes or no; - If no the assessment is complete; - If yes continue with the following, history of wandering, slow adjustment to admission, voices a desire to leave, paces, confusion, disorientation, cognitively impaired, restless, depression, agitation, takes psychoactive medications; - Each is worth one point; - A score of 0-2 indicates a low risk for elopement/wandering; - A score of 3-4 indicates at risk for wandering; - 5 or more indicates high risk for wandering. Review of the facility self-reporting guide, dated Fall 2018, showed: - Staff must report any reasonable suspicion of a crime against a resident to the Administrator. - Staff are to report any reasonable suspicion of a crime to local law enforcement. Review of the facility's Behavioral Health Services Life Skills Program (LSA), dated 5/1/21, showed: - Purpose of the LSA was to provide mental, emotional, physical, and social living skills for the resident; - Placement in the LSA programs was subject to review and would be frequently reviewed to assess if the LSA was appropriate for the resident; - LSA is designed to equip the resident who has experienced mental health challenges to reach his/her potential; - Safety of the residents and staff is of primary importance; - Residents must be responsible, but did not specify how this was determined; - Residents that are an elopement risk should not be admitted to the LSA; - Prior to admission, the facility must review the resident's Preadmission Screening and Resident Review (PASRR) level II, a federally mandated screening tool, to be completed prior to admission, to show whether a facility can meet a resident's needs; - The facility reserved the right to transfer a resident to a different facility if staff deemed a resident inappropriate for the program; - Residents must exhibit respect for other residents and staff; - Staff may perform a room search if there is a probable cause that a resident has contraband; - Staff will perform regular checks on all residents at least every two hours; - Staff will be oriented at hire to behavioral health care; - Resident #1 and #2 participated in the LSA Program. 2. Review of Resident #1's Level II screening, dated 3/5/21 showed: - Diagnoses included paranoid [CONDITION(S)], anxiety, and mild intellectual disability; - History of setting fires in childhood; - Recent history of elopement from a residential care facility; - History of threatening behaviors towards staff and others; - History of psychotic breaks; - History of pulling fire alarm and threatening to elope. Review of the resident's medical records showed the resident was admitted to the facility's secured unit. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/13/21, showed: - A Brief Interview for Mental Status (BIMS) (a score of 13-15 indicated cognitively intact, 8-12 indicated moderate cognitive impairment, 0-7 indicated severe cognitive impairment) showed the resident had a score of 11; - No behaviors noted; - Independent of cares but required supervision for hygiene; - Diagnosis included depression and psychosis; - Received antipsychotic and antidepressant medications. Review of the resident's medical records showed the facility did not perform an elopement assessment. Review of the resident's nurses' notes, dated 6/22/21 at 8:25 A.M. by Licensed Practical Nurse (LPN) A showed: - Staff reported to LPN A that the resident did not sleep last night; - LPN A noticed the resident up all day on 6/21/21; - The resident said he/she felt fine and had been up all night playing video games; - The resident denied being tired; - Staff observed the resident pacing in the halls. Review of the resident's nurses' notes, dated 6/22/21 at 2:14 P.M., by LPN A showed: - LPN A notified the resident's physician that the resident's pulse was 110 (should be between 60-100 beat per minute) beats per minute, pupils dilated (should react to light), awake over 36 hours, and talking fast; - The physician ordered a urine drug screen (UDS), with instructions to call if positive, and fax if negative; - Staff to notify the resident's psychiatrist of behavior; - Send the resident to the emergency room (ER) if needed. Review of the resident's nurses' notes, dated 6/22/21 at 2:30 P.M., by LPN A showed: - The resident tested positive for meth; - The resident initially denied ingesting meth; - The resident said he/she snuck out several times; - Staff searched the resident's room and did not find anything but a pillow with a ripped seam; - Staff placed the resident on 15 minute checks; - Staff notified the resident's guardian who stated staff could try to find alternate placement. Review of the resident's care plan showed: - Dated 4/4/21, the resident had a history of elopement behaviors and attempted to jump over the fence in the courtyard and injured his/her left leg; - Dated 4/5/21 staff should monitor the resident frequently at least every two hours; - Dated 5/23/21, the resident broke the window out of his/her room window and attempted to escape so staff changed the resident's room and placed the resident on 1:1 supervision; - Did not address the resident testing positive for meth; - Did not update the resident care plan after the resident admitted to eloping several times on 6/22/21. 3. Review of Resident #2's Level II evaluation, dated 1/7/21, showed: - The resident's diagnoses included [CONDITION(S)] with exacerbation, opioid dependence, and marijuana dependence; - Required services included secured behavior unit; - Prior legal history included possession of a controlled substance; - Required behavioral support, structured environment, and medication therapy. Review of the resident's medical records showed the resident was admitted to the secured unit. Review of the resident's medical records showed the facility staff did not perform an elopement assessment for the resident. Review of the resident's quarterly MDS, dated [DATE], showed: - BIMS 14; - No behaviors noted; - Independent of cares but required supervision for hygiene; - Diagnoses included anxiety, depression and [CONDITION(S)] (a serious mental illness that can affect thinking, feeling, and behavior); - Received antipsychotic, antidepressant, and antianxiety medications. Review of the resident's nurses' notes, dated 6/22/21 at 8:53 A.M., by LPN A showed: - Staff reported to LPN A that the resident did not sleep last night; - LPN A noticed the resident up all day on 6/21/21; - The resident told LPN A that he/she felt fine; - The resident told LPN A that he/she stayed up all night playing video games and chilling; - The resident was wearing sunglasses indoors; - The resident said his/her parent got the sunglasses because of light sensitivity contributing to headaches; - The resident was currently watching TV. Review of the resident's nurses notes, dated 6/22/21 at 3:30 P.M., by LPN A showed: - An order to administer a Urine Drug Screen (UDS); - Notify the resident's physician if the UDS was positive; - Fax the results to the resident's physician if the UDS was negative. Review of the resident's nurses' notes dated 6/22/21 at 3:30 P.M., by LPN A showed: - The resident tested positive for meth; - LPN A notified the resident's physician; - The resident's physician did not give any new orders; - LPN A placed the resident on 15 minute checks. Review of the resident's nurses notes, dated 6/22/21 at 3:40 P.M., by Life Skills Coach (LSC) showed: - The resident tested positive for meth; - The resident said another resident gave him/her a cigarette with something in it; - Staff searched the resident's room and found a tobacco chew tin; - Staff notified the resident's guardian. Review of the resident's care plan showed: - Dated 1/18/21 the resident was aggressive towards self and others and staff should monitor the resident's behavior and intervene as needed; - Did not address the resident testing positive for meth. Review of the facility investigation of the residents testing positive for meth, dated 6/22/21 by the Administrator (ADM) showed: - At approximately 2:15 P.M. the ADON and LSC notified her they were performing a urine drug screen (UDS) on Resident #1 due to pacing and hyperactive behaviors; - The ADON called Resident #1's guardian and physician and a UDS was ordered; - Resident #1 tested positive for meth; - Resident #1 told the LSC that he/she snuck out through a window that was taken apart in an empty room about two weeks ago; - Resident #1 said he/she took the window apart but did not admit to leaving the facility; - After staff found the broken window, the window was fixed immediately and all empty rooms were locked; - The resident's physician asked if any other residents had behavioral issues; - LPN A said that Resident #2 was acting strangely also; - Resident #2's physician ordered a UDS and he/she tested positive for meth; - An immediate investigation was begun; - Resident #2 said he/she obtained meth from housekeeper (HK) A and HK B; - HK B had been accused of bringing drugs to a resident, but the facility could not prove this. HK B had not been on the secured unit alone for several months and was only allowed on the secured until with supervision; - HK A was no longer allowed on the unit because of accusations he/she brought drugs to a resident; - The ADM called HK A who said that he/she never sold or gave drugs to resident; - HK A said that he/she only went on the unit to do his/her job; - HK A was suspended immediately pending investigation; - HK B was off on medical leave and had not been on the secured unit without supervision. Review of the LSC investigation, dated 6/23/21 showed: - Resident #1 and Resident #2 tested positive for meth on 6/22/21; - Resident #2 stated that HK A gave him/her the meth; - Resident #1 said he/she eloped from the facility a couple weeks ago and obtained meth from friends; - Resident #1 said he/she had eloped from the facility several times. Review of the statement, dated 6/23/21, by Resident #2 showed: - HK A gave the resident a bag of substance; - The resident put the white substance in a cigarette and smoked it. Review of the facility form labeled Screen Checks All screens are to be checked every day showed: - 5/27/21 staff noted A107 screen plastic piece broken, D102 A screen pushed out, and F107 screen with a hole did not say whether reported and fixed; - 5/28/21 staff noted laundry room with washers broken window, E105 broken window and resident moved, E107 broken window and resident moved; - 6/12/21 B108 top of screen pulled down, C105 lower left corner not secured and did not say whether reported and fixed; - 6/13/21 B108 bottom screen not in and did not say whether reported and fixed; - 6/14/21 B101 no screen, C104 no screen and did not say whether reported and fixed; - 6/15/21 A105 holes in screen, B108 screen frame bent, C105 screws loose on screen and did not say whether reported and fixed; - 6/17/21 B108 top of screen frame pulled down and did not say whether reported and fixed; - 6/18/21 B105 no screen, B109 screen frame bent and did not say whether reported and fixed; - 6/19/21 B105 no screen, B109 screen frame bent and did not say whether reported and fixed; - 6/20/21 A106 frame apart and hanging in the window and did not say whether reported and fixed; - 6/21/21 A 105 hole in screen, B 100 screen pulled up, B104 no screen, B108 screen bent, C104 loose screen, and C105 screen bent back and did not say whether reported and fixed; - 6/23/21 B100 screen off screws, B108 screen frame bent, drill bit inside window between window and screen and hole in screen, and did not say whether reported and fixed; - 6/24/21 A106 part of window frame broken between screen and window and did not say whether reported and fixed; - 6/27/21 A109 window screen out air conditioner pulled out, grate pushed out and door lock on bathroom turned the wrong way, A112 screen out, A106 window panel loose and appears to have been tampered, gate in court yard not secure, B100 grate from outside appears pushed in, room key will not open the door and did not say whether reported and fixed; - 6/28/21 B104 no screen and did not say whether reported and fixed; - 6/29/21 no window issues; - 7/1/21 no window issues; - 7/2/21 A112 no screen, B108 screen frame bent at the lip, library hole in screen and screen not attached with screws and did not say whether reported and fixed; - 7/3/21 B104 no screen and did not say whether reported and fixed. During an interview on 7/6/21 at 10:30 A.M. LPN A said: - He/she was working on 6/22/21; - Normally Resident #1 and Resident #2 slept in, in the mornings; - Both residents were up on the morning of 6/22/21; - Resident #2 was wearing sunglasses indoors which was against the secured unit rules; - Resident #1 was talking rapidly and had dilated pupils; - He/she notified the ADON around 9:00 A.M. Observation of the facility windows on the secured unit on 7/6/21 at 10:45 A.M. showed: - Screens intact on windows and windows only opened about six inches except for the screen on room A 112; - The resident in room A 112 handed the screen to the Assistant Director of Nursing (ADON); - Room A 1-12 opened to the outside of the facility; - The ADON wrote the broken screen on the maintenance log on the secured unit. During an interview on 6/6/21 at 11:55 A.M., Resident #2 said: - He/she took meth after being pressured by HK A; - He/she paid HK A $20 for the meth; - HK A told the resident that HK A would kill the resident if he/she did not take the meth. During an interview on 7/6/21 at 12:00 P.M., the ADON said: - Staff are supposed to check all windows in the secured unit on the day shift; - Due to staffing issues he/she did not monitor the widow/screen checks. During an interview on 7/6/21 at 12:10 P.M., Maintenance Assistant (MA) said: - The maintenance supervisor (MS) was on vacation; - He and the MS checked the repair logs on the secured unit daily; - He had not received a call to repair the screen on room A 112. During an interview on 7/6/21 at 1:00 P.M., the ADM said: - He/she did not contact the police; - Staff wrote any needed repairs, including broken window on the maintenance log; - Maintenance checked the log when walking through the facility; - Staff should call maintenance when any screen or window had issues. During an interview on 7/6/21 at 1:31 P.M., Certified Medication Technician (CMT) A said: - Resident #1 was hanging out with Resident #2; - Both residents were awake when he/she started work at 7:00 A.M; - Both residents were usually in bed when he/she started work; - Resident #1 was talking more than when the resident was manic; - Resident #1's pupils were dilated; - Resident #1 usually napped during the day; - Resident #1 had been awake since at least 6:30 P.M. the day before; - He/she told the ADON that he/she needed to assess the resident; - Staff were supposed to check residents every two hours which was difficult. During an interview on 7/6/21 at 2:30 P.M., the ADON said: - Resident #1 initially said he/she snuck out the facility to get drugs; - Staff found a broken window in one of the empty rooms; - Resident #1 was not succeeding with the Life Skills program. During an interview on 7/6/21 at 2:31 P.M., Resident #1 said: - He/she snuck out the facility through broken window and screen several times; - When he/she was out of the facility, he/she obtained drugs from friends. During an interview on 7/6/21 at 2:53 P.M., Certified Nurse Assistant (CNA) A said: - The facility did not provide any training on working on a behavioral health unit; - Resident #1 broke a window in an empty room several weeks ago; - Staff do not check the windows in empty locked rooms. During an interview on 7/6/21 at 4:05 P.M., the Director of Nursing (DON) said: - Staff should update a resident's care plan after any event; - All nursing staff can update a care plan; - Staff should use a resident's PASRR to formulate a resident's initial care plan; - All residents have the potential to be an elopement risk; - Staff should assess each resident for individual elopement risk. During an interview on 7/7/21 at 4:10 P.M., the Administrator said: - Facility staff were not doing elopement assessments on residents on the secured unit consistently. - Facility staff should perform an elopement assessment on all residents on the secured unit on admission, quarterly, and as needed. - The facility did not have a policy on performing elopement assessments. - Staff had not been trained to perform the elopement assessments. - Staff should not write broken windows on the maintenance log; - Staff should immediately call maintenance for broken windows/screens. During an interview, on 7/7/21 at 9:15 A.M., the Nurse Practitioner (NP) said: - Resident #2 was not an elopement risk; - He/she did not feel Resident #1 eloped to obtain drugs; - He/she felt that facility staff brought in drugs to the residents; - He/she felt that if Resident #1 eloped, the resident would not return to the facility During an interview on 7/7/21 at 10:45 A.M., the DON said: - Staff did not perform elopement assessments on residents on the secured unit in a consistent manner. - Staff should perform an elopement assessment on all residents on the secured unit upon admission, quarterly, and as needed. - The facility did not have a policy for elopement assessments. - Staff had not been trained on how to perform elopement assessments. - The facility should staff the secured unit with two staff at all times; - If the facility is short-staffed, staff from the secured unit should not be pulled to the geriatric side of the facility. During an interview on 7/8/21 at 9:00 A.M., Detective A said: - The facility made a report, regarding the residents testing positive for meth, on 7/7/21 in the evening; - It is very difficult to investigate an incident so long after the incident occurred; - He/she will investigate the issue when he/she has time. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 0

Based on interview and record review the facility failed to promptly report a change in condition for one of three sampled residents (Residents #1 ) when Resident #1 developed chest pain and shortness of breath. The facility census was 51. 1. Review of the facility policy, dated March 2015, on resident change in condition showed: - Purpose of the policy to observe, record, and report any change in condition so that proper treatment can be implemented. - Notify the resident's physician and responsible party. - Monitor the resident frequently until stable. Review of the facility policy, dated March 2015, on emergency care, showed: - The purpose of the policy was to provide emergency care for any condition that would require the use of emergency services. - Staff should call the resident's physician to report any changes. - Staff should provide emergency care as needed. - Staff must obtain vitals signs. - Staff must record the details of the incident and resident's response to emergency care. 2. Review of Resident#1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/21 showed: - Mild cognitive impairment; - Cared for self; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Received antipsychotic (used to treat severe mental illness) and sleeping medications. Review of the resident's care plan, dated 3/12/21, showed: - The resident had a [CONDITION(S)] (TBI) due to narcotic overdose. - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nurses' notes, dated 4/17/21 at 2:30 A.M. by Registered Nurse (RN) A showed: - Called to assess the resident for complaints of chest pain. - The resident's skin was warm and dry. - Placed on oxygen last evening for an oxygen saturation (saO2, for healthy adults the normal saO2 range is 95-100%), of 90%. - On oxygen (O2) and his/her saO2 was 94%. - Call placed to physician two to three times without success. - Will continue to observe. During an interview on 4/18/21 at 7:42 A.M. RN A said: - He/she was working on the geriatric side of the facility on the night shift on 4/16/21, but was the charge nurse for the entire facility. - The Certified Medication Technician (CMT) called him/her to the secured unit in the evening and was told that the resident was having chest pain. - He/she gave the resident two doses of [MEDICATION(S)] (used to treat gastric distress) and placed the resident on 2 liters of O2 due to a saO2 of 90%. - He/she tried to contact the resident's physician, but could not get an answer from the answering service. - The resident's lungs sounded coarse. - If the resident had complained of shortness of breath or was sweaty, he/she would have dialed 911 to send the resident to the emergency department. During an interview on 4/18/21 at 10:30 A.M. the Administrator (ADM) said: - He/she came into the facility on [DATE] and saw the resident sitting at the desk. - The resident told the ADM that he/she did not feel good. - He/she tried to call the resident's physician without success. - He/she called the facility medical director. - The medical director said for staff to try to call the resident's guardian. - If the guardian wanted the resident to be sent out, to send the resident to the emergency department. - The resident did not look any different than usual. - The resident's temp was 100.2 and the resident felt clammy. - Staff should have charted all their observations. Review of the resident's nurses' notes, dated 4/17/21 at 12:36 P.M., by Licensed Practical Nurse (LPN) A showed: - According to change of shift report, the resident complained of shortness of breath and chest pain prior to the 9:15 P.M. smoke break. - At 9:15 P.M., on 4/16/21 the resident's saO2 was 89%. - The night charge nurse attempted to call the on call physician but could not get through. - Nursing judgement was used by the geriatric charge nurse who placed the resident on 2 liters (l) O2. - After change of shift report, no time given, LPN A talked with the resident who said he/she was still short of breath with painful respirations. - The resident insisted on going out to the 7:45 A.M. smoke break. - The resident placed his/her oxygen back on after he/she came back from smoke break. - Lung assessment done with no abnormal sounds. - The resident was breathing shallow with gasping with inhalation. - LPN A attempted to get a hold of the physician on call and could not get through. - LPN A contacted the facility medical director, no time given, and received orders for O2 and said to try to contact the resident's physician but if the physician could not be contacted send the resident to the emergency department. - LPN A, no time given, contacted the resident's physician and received an order to send the resident to the emergency department. - Ambulance called at 11:00 A.M. - At 11:08 A.M. the resident's blood pressure (BP) was 142/104 (normal for an adult should be between 120/80 and 90/80, pulse (p) 116 (should be between 60-100 beats per minute), saO2 95% on 2 liters of O2, respirations (r) 22 breaths per minute (normal 12-16 breaths per minute), and temperature 100 Fahrenheit (F) (normal between 97-99 F). - The resident was transported to the emergency department at 11:35 A.M. During an interview on 4/18/21 at 10:45 A.M. LPN A said: - He/she was the day shift charge nurse on the secured unit. - The resident lived on the secured unit. - The resident's saO2 was 95% after smoke break. - While he/she was doing the unit's 8:00 A.M. med pass, a Certified Nurse Assistant (CNA) told him/her that the resident was complaining of increased shortness breath and sweatiness. - He/she tried to call the resident's physician for one to one and a half hours without success. - He/she spoke with the facility medical director who gave orders to call the resident's guardian for permission to send the resident to the emergency department. - He/she passed the information along to the SS who tried to contact the resident's guardian. Review of the resident's nurses' notes, dated 4/17/21 at 10:06 A.M. by Social Services (SS) showed: - Attempted to contact the resident's guardian due to dropping saO2 last evening. - SS left a message on the guardian's home and cell phone. Review of the resident's medical records from the emergency transport by Emergency Medical Technician- Paramedic (EMT-P) A showed: - Vital signs at 11:18 A.M. BP 139/89, p 119, r 30, saO2 95%; - Vital signs at 11:50 A.M. BP 135/91, p 115, 4 44 saO2 94%; - Resident's chief complaint was abdominal pain. - Lung assessment showed wheezing, rales (abnormal lung sounds typically heard with inhalation), rhonchi (abnormal lung sounds typically heard with exhaling), and diminished breath sounds. -Right upper quadrant abdominal tenderness. -Narrative stated the resident had abdominal pain for two days which was becoming worse and intensified with breathing. During an interview on 4/18/21 at 10:20 A.M. EMT-P A said: - The resident complained of abdominal pain. - The resident had diminished lung sounds. During an interview on 4/18/21 at 12:59 P.M. EMT-P B said: - The resident was complaining of shortness of breath due to abdominal pain. Review of the resident's medical records from the emergency department showed: - Checked in to the emergency department on 4/17/21 at 12:08 P.M. - Chief complaint of increasing right upper quadrant pain for two days, increased pain with inspiration, nausea, vomiting, and shortness of breath. - The resident stated he/she had a fever last night but was unsure how high his/her fever got. - The resident said it hurt to breathe. - The resident was hospitalized for pneumonia July 2020. - The resident was positive for Covid September 2020, but did not have any residual effects. - Vital signs at 3:05 P.M. BP 134/81, p 91, temperature 101, respirations 22. and saO2 94%. - Respiratory distress and abdominal pain present. - White blood cell count ( fights infection) 30.8 (normal 4-11). - Chest X-ray on 4/17/21, no time provided, results showed patchy infiltrates (possible pneumonia), pulmonary nodules (possibly due to infection or cancer), and a pleural effusion (fluid around the lung due to the heart not pumping well or inflammation). - Resident to be admitted to the hospital for pneumonia and a possible urinary tract infection ([CONDITION(S)]). During an interview on 4/18/21 at 7:50 A.M. the resident's hospital nurse said: - The resident was transferred to intensive care unit (ICU) due to increased shortness of breath. - The resident had severe pneumonia. - After the resident was transferred to ICU, his/her physician inserted a chest tube (used to drain fluid from the chest cavity). - The chest tube was draining clear yellow fluid. - The resident was using a respiratory assist device and was on 65% O2 (room air is 21% O2). During an interview on 4/19/21 at 5:00 P.M. the facility Director of Nursing (DON) said: - When staff could not get a hold of a resident's physician, staff should have called the DON. - If staff could not get a hold of the DON, staff should call the facility Medical Director. - Facility staff have had trouble calling the resident's physician. - He/she spoke with the resident's physician's answering service and was told the issue had been resolved. During an interview on 4/20/21 at 4:00 P.M. the resident's physician said: - He/she was not aware of any issues with the answering service. - In case of a change in condition, such as a resident with shortness of breath and decreasing saO2, staff should send the resident to the emergency department and notify him/her later. MO 0

Based on observation, interviews and record reviews, the facility failed to ensure that staff properly intervened when a resident became bradycardic (slow heart rate) and also became bradyapnic (slow respirations). This affected one of two sampled residents (Resident #1). The faciltiy census was 50. 1. Review of the facility policy, dated [DATE] on emergency care, showed: - Staff must call a resident's physician and responsible party if the resident's condition changed. - Staff must call 911 if a resident was not breathing. Review of the undated emergency cart check list showed: - This check is to be done EVERY night by licensed nurse. - Staff to initial and date each box when items were checked. - Gave a list of items in the emergency cart. Review of the facility check list, dated [DATE], showed the cart contained: - A tank of oxygen; - An oxygen mask; - An oxygen cannula, used to administer oxygen; - An ambu bag, used to assist with breathing; - Airways, used to open a resident's throat to facilitate breathing. Review of the facility's policy, dated [DATE], on Cardiopulmonary Resuscitation (CPR, chest compressions to assist with circulation and ventilating to assist with breathing), showed: - Initially staff must establish responsiveness and open the resident's airway. - The facility must have one CPR certified staff member per shift. - If the resident is breathing, staff must apply oxygen. 2. Review of Resident #1's admission Minimum Data Set, a federally mandated assessment instrument completed by facility staff, (MDS), dated [DATE], showed: - Cognitive impairment; - Required extensive staff assistance for transfers and toileting; - Required limited staff assistance for dressing and hygiene; - Required supervision for eating. - Used a wheelchair; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - At risk for malnutrition; - Received insulin injections, antidepressants, and occasionally blood thinners. Review of the resident's face sheet (contains information about the resident), dated [DATE] showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Metabolic [CONDITION(S)], a brain issue caused by a chemical imbalance; - Acute kidney failure; - Diabetes; - Kidney stones; - Muscle weakness; - Heart failure. Review of the face sheet also showed the resident was a full code, which indicated if the resident stopped breathing and/or his heart stopped beating, staff were to perform CPR. Review of the resident's discharge summary, dated [DATE] from a local hospital showed: - Length of hospitalization was 23 days. - The resident's prior medical history included chronic kidney disease, heart failure, and a right above the knee amputation. - The resident presented to the emergency department with confusion and possible hallucinations. - The resident was diagnosed with a urinary tract infection ([CONDITION(S)]) in the facility and started on antibiotics in the facility. Review of the resident's nurses' notes, dated [DATE] at 9:59 P.M. by Registered Nurse (RN A) showed: - Resident alert to name only. - The resident complained of back and leg pain. - RN A gave the resident an as needed (prn) narcotic pain medication with pain relief. - The resident ate just a few bites of supper. - The resident's blood sugar was 62 (normal fasting levels ,d+[DATE]). - RN A gave the resident a snack and fed the resident due to confusion. Review of the resident's nurses' notes, dated [DATE] at 5:51 A.M. by RN A showed: - Certified Nurse Assistant (CNA) A checked on the resident and found the resident unresponsive and got RN A. - RN A found the resident unresponsive to any stimuli. - RN A performed a sternal rub (rubbed the center of the resident's chest), with no response. - The resident took two breaths in a minute. - The resident's pulse was weak and thready. - The resident's pulse was 32, (normal pulse ,d+[DATE] beats per minute), respirations 3 (normal respirations ,d+[DATE]) , and blood sugar 52. - RN A was unable to obtain any other vital signs. - RN A gave [MEDICATION(S)] (medication used to quickly increase a resident's blood sugar). - CNA A was sent to call 911. - Resident continued to take an occasional breath and heart beat slow. During an interview on [DATE] at 2:40 P.M. RN A said: - CNA A called him/her to the resident's room. - He/she found the resident unresponsive. - The resident's pulse was weak and thready at about ,d+[DATE] beats per minute, - The resident was breathing about three to four breaths per minute. - The resident would only breathe with a sternal rub. - He/she did not start oxygen on the resident. - He/she gave the resident a [MEDICATION(S)] injection. - He/she sent CNA A for an oxygen concentrator. Review of the facility emergency cart check list, dated [DATE] showed: - RN B checked the crash cart on [DATE],4,5,8,9,10, 13,14, 22,23,23, 27, and 28. - There were no check marks for RN A. During an interview on [DATE] at 6:00 P.M. CNA A said: - When he/she found the resident unresponsive, he/she called RN A. - RN A asked him/her to find an oxygen concentrator. - The resident had no oxygen on. During an interview on [DATE] 9:15 A.M. the Administrator (ADM) said: - RN A should have placed the resident on oxygen. - The crash cart had a full tank of oxygen. - RN A should have checked the crash cart every night he/she worked. - RN A should have rechecked the resident's blood sugar sometime during the night. During an interview on [DATE] at 4:00 P.M. the resident's physician (Physician A) said when a resident became non-responsive, he/she would have expected staff to apply oxygen and obtain an oxygen saturation (measure the level of oxygen in a resident's blood). During an interview on [DATE] at 11:34 A.M. Paramedic (Pmed) A said: - He/she was part of the crew that arrived at the facility around 6:00 A.M. on [DATE]. - He/she found the resident had a very slow pulse and a very slow respiratory rate. - The resident was not on oxygen and no one opened the resident's airway. - The resident's heart rate was ,d+[DATE] beats per minute. - The resident's respiratory rate was about ,d+[DATE] respirations per minute. - Basic life support required that staff perform assisted breaths when the resident was breathing so slow. - Upon arrival at the facility he/she inserted an airway, administered oxygen, started an IV, administered glucose, and [MEDICATION(S)] (a medication used to raise the resident's heart rate). - He/she then placed the resident in an ambulance and traveled a short distance to the emergency department, during transport to the emergency department the resident spit out the airway, had a pulse and respirations within normal limits. MO 6

Based on interview and record review the facility failed to notify the physician in a timely manor of one of three sampled residents (Resident #1's) change in condition, after the resident had symptoms of [MEDICAL CONDITION] activity, turned blue and became unresponsive for up to 12 hours. Failure to notify the physician in a timely manor caused a delay in treatment and care needed for the resident's acute onset of new symptoms which led to prolonged and worsening symptoms and an inpatient hospitalization . The facility census was 67. 1. Review of the facility's Resident Change in Condition policy showed: - The purpose of the policy is to observe, record and report any condition change to the attending physician, so proper treatment can be implemented. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/22/15, showed the following: - [DIAGNOSES REDACTED]. - Needed assist of two staff members with positioning in the bed; - Needed limited assistance of staff with meals. Review of the nurses' notes showed: - On 5/5/15, at 6:15 P.M., staff removed the resident from the dining room related to being very drowsy and could not hold utensils or a cup; leaned his/her head to the left side; at 6:30 P.M., the resident's body twitched; staff put the resident to bed and the resident continued to twitch; the resident turned cyanotic (blue) and staff could not get a pulse oximetry reading(machine put on the finger tip to see if there is enough oxygen in the blood); staff started oxygen at three liters per nasal cannula (used to increase the oxygen in someone who is not getting enough with normal breathing); at 7:00 P.M., the resident's color improved and his/her blood sugar was 104 (indicating a normal reading); the resident was quiet; at 8:00 P.M., the resident felt warm and continued to be quiet, staff continued the oxygen; at 9:00 P.M., staff notified the resident's family of his/her condition change, temperature 97.7, respirations 24, blood pressure 110/70 and pulse oxygen 98%, indicating normal range; - On 5/6/15, at 5:30 A.M., the resident remained non verbal with shallow respirations and a pulse oximetry of 94%; at 6:45 A.M., the resident had a temperature of 100.9 and staff gave the resident a Tylenol suppository; at 8:00 A.M., the resident's temperature decreased to 99.9 and he/she continued to be unresponsive. The resident's lungs sounded course and wet (indicating fluid in the lungs). The resident coughed but could not clear the secretions. Staff attempted a sternal rub (using the knuckles of the hand and rubbing the sternal area to cause painful stimuli) and the resident did not respond. The resident twitched and jerked in the right and left lower extremities at times and his/her skin was pale and wrinkled. The resident continued to be unresponsive for more than 12 hours. The nurse called the doctor on call at the request of the family and received orders to send the resident to the emergency room for an evaluation and treatment. The family was at the bedside and planned to follow the ambulance to the hospital. The resident continued to be unresponsive to pain and when staff moved the resident in the bed. He/she remained on oxygen at two liters per nasal cannula, blood pressure 106/66, respirations 12 and pulse oxygen 93%; at 2:25 P.M. Staff called the hospital and the resident was admitted with [MEDICAL CONDITION]. Review of the hospital records dated 5/6/15, showed: -Altered mental status for 12 hours per the nursing home staff; increasing small left pleural effusion (fluid build up around the lungs); New trace right pleural effusion; low lung volumes and a left base atelectasis (partial collapse of the lung or lobe of the lung, reduces the amount of oxygen to your body). [MEDICAL CONDITION] activity observed in the emergency department. During an interview on 5/7/15, at 2:06 P.M., the charge nurse, Registered Nurse (RN) A can we show she was the charge nurse to give it more weight that she should have done something said the resident sat in the dining room with his/her head down and food in his/her lap. He/she removed the resident from the dining room and sat the resident in the hall. He/she got busy with something else and another staff member noticed the resident twitching so two other staff members assisted the resident to bed and they could not obtain a pulse oxygen. The staff applied oxygen at three liters per nasal cannula to the resident and the pulse oxygen went up to 98%. The resident continued to twitch a little in his/her hands and feet and continued to be unresponsive and asleep The nurse said he/she did not notify the physician because the resident was a no code blue (indicating the resident did not want to be resuscitated if his/her heart stopped). He/she waited to call the resident's family because he/she wanted to see if the resident's condition would change. A Certified Nurse Aide (CNA) told him/her sometime in the night the resident had blood in his/her mouth. He/she went and cleaned the resident's mouth out with a toothette (sponge tooth brush). The blood appeared to be old and he/she did not think anything of it because the resident had a history of [REDACTED]. During an interview on 5/7/15, at 3:30 P.M., LPN B said during the evening meal on 5/5/15, another staff member pointed out to him/her the resident was twitching. They assisted the resident to bed and the resident would not wake up. The resident and was dead weight during the transfer. He/she the resident started to turn blue and they applied oxygen at three liters per nasal cannula to the resident. After the oxygen was applied the resident's pulse oxygen went up and he/she appeared to be sleeping. The resident had not ever used oxygen in the past. During an interview on 5/7/15, at 2:30 P.M., Licensed Practical Nurse (LPN) A said RN A told him/her the resident had been unresponsive since supper the evening before. He/she attempted to contact the physician for a chest x-ray. The resident's family came to the facility around breakfast time and the director of nursing (DON) said the resident needed to go to the hospital related to running a fever. RN A told him/her in report the resident had blood in his/her mouth and RN A thought the resident bit his/her tongue. If a resident becomes unresponsive, staff should notify the resident's family and physician right away for instructions on care. During an interview on 5/7/15, at 3:00 P.M., the DON said she expected staff to call the physician and family right away with any significant change in condition with a resident to assure the resident received the proper care. MO 2