Every finding on record at Avenir at Mark Twain

Based on interview and record review, the facility failed to ensure residents received adequate assistance to prevent accidents when Certified Nurse Aide (CNA) F provided improper transfers to two residents (Residents #3 and #4) resulting in injury. Resident #3 was identified by the facility as requiring a Hoyer lift for transfers. On 05/16/26, CNA F transferred the resident by picking up the resident without a lift, a gait belt, or another employee to assist. The resident's foot got caught, resulting in a fractured right tibia (shin bone) and fibula (calf bone). CNA F was suspended, re-educated on the facility's transfer policies, and returned to work. Resident #4 was identified by the facility as requiring two staff to assist with transfers. On 05/27/26, CNA F performed a transfer by him/herself to assist the resident to the bathroom. CNA F did not use a gait belt. The resident fell, resulting in a fractured fibula. The sample was 5. The census was 83.The Administrator was notified on 06/18/26 at 1:15 P.M. of an Immediate Jeopardy (IJ) which began on 05/16/26. The IJ was removed on 06/19/26, as confirmed by surveyor onsite verification. Review of the facility's Lifting Machine, Use of a Mechanical Device policy, updated 11/2025, showed:-Policy Statement: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device it is not a substitute for manufacturer's training or instructions;-General Guidelines: At least two qualified staff are needed to safely move a resident with a mechanical lift. Review of the facility's Gait Belt Utilization policy, updated 02/04/26, showed:-Policy Statement: The facility is committed to ensuring the safety, dignity, and well-being of our residents and staff. To minimize the risk of falls, injuries, and skin tears during transfers, a gait belt must be utilized for all residents who require physical assistance from staff during ambulation, transfers, or repositioning, unless clinically contraindicated;-Purpose: To protect residents from falls, friction injuries, and bruising during physical assistance;-Scope: Policy applies to all clinical staff, including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), CNAs, and physical/occupational therapy personnel employed or contracted by the facility;-General rules of use:--Prohibited Grips: Staff are expected to use the safest mode of assistance and should avoid lifting a resident by their arms, underarms, pants, or waistbands when practicable;--Mechanical Lifts: A gait belt is not a lifting device. If a resident cannot bear weight on at least one leg, a mechanical lift or sit-to-stand should be used. 1. Review of Resident #3's face sheet, showed diagnoses included protein-calorie malnutrition, adult failure to thrive, and generalized muscle weakness. Review of the resident' physician order sheet (POS), showed an order, dated 12/09/24, dependent transfers at baseline, requires total assistance from staff to transfer resident from bed, chair, toilet. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/20/26, showed:-Cognitively intact;-Dependent on assistance with showers/bathing and chair/bed-to-chair and tub/shower transfers. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident has an activity of daily living (ADL) self-care performance deficit;-Interventions included resident required mechanical aide lift (Hoyer) and two staff for transfers;-Focus: Resident has potential/actual impairment for skin integrity related to immobility;-Interventions included on 05/15/26, resident complained of pain to right ankle and some discoloration noted, resident stated it was hit during a transfer. X-ray order obtained. Review of the resident's progress notes, showed:-On 05/16/26 at 10:30 AM, staff documented the resident complained of increased pain to right foot. Assessed foot at this time and right ankle appeared discolored with bruising and tender to touch;-On 05/16/26 at 10:35 A.M., staff documented a call was placed to the Nurse Practitioner (NP), who was made aware of the complaint of right foot pain and discoloration. X-ray ordered;-On 05/16/26 at 12:30 P.M., staff documented a call was placed to the on-call for physician and spoke with NP. Informed of x-ray results of right foot and ankle. New order to send to emergency room (ER) for evaluation. Review of the resident's ER after visit summary, dated 05/16/26, showed a diagnosis of closed fracture of right tibia and fibula and acute right ankle pain. During an interview on 06/17/26 at 11:21 A.M., the resident said on 05/15/26 at around 8:30 A.M., CNA F came into his/her room to get him/her up without a Hoyer lift. CNA F assisted the resident to the side of the bed. The resident was dizzy. CNA F said he/she had the resident, and the resident would be okay. CNA F lifted the resident underneath his/her arms and transferred the resident to his/her Broda chair (reclining chair). During the transfer, the resident's foot hit the footrest, causing pain. The resident said he/she hit her foot, and it really hurt. CNA F said the resident would be okay. The pain was there all day and after supper, the resident told the nurse on duty what CNA F did and that his/her foot hurt. The next day, the resident reported it to a different nurse on duty and that nurse assessed it and called the physician. The resident received an x-ray and it showed his/her right ankle was broken and he/she was sent to the hospital. During an interview on 06/18/26 at 2:05 P.M., the resident's roommate, Resident #5, said he/she was in the room when the transfer without a lift occurred. Resident #3 told CNA F he/she did not want to get up, but CNA F transferred the resident anyway by placing his/her hands underneath the resident's arms and lifting the resident into his/her wheelchair. Resident #5 heard Resident #3's foot hit the wheelchair and the resident screamed at CNA F saying his/her foot hit the chair. CNA F ignored the resident. During an interview on 06/17/26 at 2:45 P.M., CNA F said he/she and CNA G transferred the resident without a Hoyer lift, because there were no pads. The resident's foot got caught on the chair. Later that day, the resident complained of foot pain. CNA F was suspended the next day. He/She received in-service training on transfers and was allowed to return to work. During an interview on 06/17/26 at 3:05 P.M., CNA G said he/she worked on the day of the resident's fall. He/She asked CNA F to finish getting the resident dressed and CNA G would return after to help with a transfer, because the resident was a Hoyer lift. By the time CNA G returned to the resident's room, the resident was already in his/her Broda chair in the hallway. Review of the facility's investigation, undated, showed:-A written statement from CNA F, dated 05/19/26, in which CNA F documented he/she was rushing to get the resident up. They didn't have any Hoyer pads, so CNA F put the resident in his/her chair and the resident held onto the rail of his/her bed;-A summary, dated 05/19/26, showed CNA F got the resident up into his/her chair on 05/15/26 for day shift with no Hoyer pad. The incident resulted in injury to the resident. CNA F was suspended. He/She admitted he/she got the resident up without using a Hoyer lift and he/she did not wait for a second person to assist with the transfer. CNA F will get corrective action and will complete a mechanical lift and correct transferring techniques inservice with return demonstration with the Therapy Director before allowed to work again;-CNA F was in-serviced by the Therapy Director on 05/20/26 on transfer and safety techniques. 2. Review of Resident #4's admission MDS, dated [DATE], showed:-Cognitively intact;-Dependent on assistance with showers/bathing and tub/shower transfers;-Moderate to maximal assistance with chair/bed-to-chair and toileting-Diagnoses included peripheral vascular disease, right leg amputee, and right leg prosthesis. Review of the resident's care plan, in use at the time of survey, showed:-Focus, revised 05/13/26, of potential for falls related to decreased mobility, fall noted 05/12/26 in bathroom when toileting;-Interventions included monitor for toileting needs and transfer with two when toileting. Review of the resident's progress note, dated 05/27/26 at 4:13 P.M., showed the resident was alert, oriented x4, and able to make needs known. The resident had a witnessed fall in his/her bathroom. CNA F reported to the nurse that the resident was sitting on the floor. Upon assessment, the nurse observed the resident sitting upright on the floor holding his/her left ankle. Resident states, I heard my ankle pop. CNA F reported he/she was assisting the resident to the bathroom when the resident lost his/her balance and was lowered to the floor. The resident complained of left ankle pain/discomfort during the transfer. Nurse observed the resident was unable to bear full weight on left lower extremity. The NP notified and a stat x-ray of the left ankle was ordered. Review of the resident's ER after visit summary, dated 05/28/26, showed the diagnoses included an injury of the left ankle and a closed fracture of the distal end of the left fibula. During an interview on 06/17/26 at 1:12 P.M., the resident said CNA F helped him/her to the bathroom. The resident stood with his/her hands on a bar in the bathroom and he/she felt him/herself going down. CNA F did not have time to help as the resident went down. On the way down, he/she heard his/her ankle pop. During an interview on 06/17/26 at 2:45 P.M., CNA F said he/she assisted the resident to the bathroom without a gait belt and no other staff. CNA F told the resident to hold on to the grab bar when he/she stood up. The resident said he/she was going down and ended up on the floor. Review of the facility's investigation, showed:-A typed statement, dated 05/28/26, in which the Executive Assistant documented she spoke to the resident related to the incident. The resident stated he/she was trying to go to the bathroom. The resident raised him/herself up from the wheelchair and began to lose his/her balance. CNA F reached to try and catch the resident, but could not and lowered him/her to the ground. The resident heard something pop as he/she went down;-An undated written statement from CNA F, showed CNA F documented he/she took the resident to the bathroom and he/she lost his/her balance and the CNA helped the resident to the floor. The resident said his/her foot popped so CNA F got him/her up and to the toilet, then off the toilet to the chair;-An undated summary, showed CNA F assisted a resident in an improper transfer resulting in injury. This employee had a prior incident on 05/15/26 with another resident for improper transfers, also resulting in injury. This employee was given re-education on appropriate transfers from the Therapy Director with return demonstrations before being allowed to work after the first incident. Due to the severity of this incident, this employee has been terminated as of 05/28/26. 3. During an interview on 06/17/26 at 11:00 A.M., CNA I said a resident's transfer status is not documented anywhere. The nurse tells CNAs how to transfer a resident. CNA I had not received additional education about transfers after Resident #3's injury. During an interview on 06/17/26 at 11:12 A.M., Certified Medication Technician (CMT) D said nurses determine how a resident transfers. He/She did not know how to access this information in the resident's record. During an interview on 06/17/26 at 12:30 P.M., the Director of Nurses (DON) said CNA F was given a second chance after the incident involving Resident #3. CNA F transferred Resident #4 without a gait belt. The resident sustained a fractured ankle. CNA F was terminated after this incident. During an interview on 06/18/26 at 9:32 A.M., the Administrator said CNA F failed to utilize the proper transfer of a Hoyer with a two-person assist with Resident #3. After the incident, CNA F had to do competencies training with the Therapy Director before he/she could return to work. The resident failed to use a gait belt when transferring Resident #4. The Administrator expected all nursing staff to perform transfers in accordance with a resident's physician orders, care plan, and therapy recommendations. During an interview on 06/17/26 at 4:18 P.M., the physician for both residents said he was aware both residents had recent fractures. He was not aware the fractures occurred as a result of improper transfers. He expected nursing staff to follow orders, care plans, and therapy orders for how to transfer residents. 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 visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. 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 be taken to address Class I violation(s). 3023257

Based on interview and record review, the facility failed to thoroughly and accurately assess and document a resident's surgical wound upon admission, then weekly per the facility's policy for one resident (Resident #1). The sample was 6. The census was 75.Review of the facility's Skin Integrity-Pressure and Non-Pressure policy, undated, showed:-Purpose: to establish guidelines for assessing, monitoring and documentation the presence of the skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented;-Guidelines: non-pressure skin conditions (surgical wounds) will be assessed for healing process and signs of complications or infection;-A skin condition assessment will be completed at the time of admission/readmission;-Resident identified will have a weekly skin assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/10/25, showed:-Diagnoses included: open wound of left hand; cellulitis (bacterial infection of the skin and the tissues beneath it) of left finger; abscess (swollen area within the skin containing accumulation of pus) of left hand and diabetes;-Had a surgical wound. Required surgical wound care. Review of the resident's medical record, showed:-A care plan in the use at the time of survey, failed to show the wound(s) on left hand;-The progress notes dated 11/3/25, showed no admission note documented;-An admission skin assessment dated [DATE], showed resident admitted with the following skin issues: site: left hand (palm). Description: infected wound. Comments: blank. The assessment failed to show the wound on the left thumb and failed to give a description of the wound;-An order dated 11/4/25 for wound care. Cleanse left hand open area with wound cleanser. Fill wound bed with Hydrofera Blue (advanced, antibacterial foam wound dressings). [NAME] with dry dressing everyday shift. Documented as completed as ordered;-A skin assessment dated [DATE], showed no new changes this week. Site and description: blank. Review of the facility's wound report (a report that tracks wounds for all facility residents and is not part of the resident's medical record) dated 11/7/25 through 11/21/25, showed the following for the resident:-On 11/7/25 and 11/14/25, the resident was not included on the wound report;-On 11/21/25: Left hand palm, surgical wound, size: 0.8 centimeters (cm) length X 2.5 cm width X 0.5 cm depth; no odor or drainage, 100 % granulation (new tissue). Left thumb, surgical wound, size: 0.6 x 2.0 X 0; no drainage or odor; 100% eschar (dead tissue). Review of the resident's wound weekly evaluation-non pressure assessment dated [DATE], showed:-Location of wound: left hand (palm), surgical wound present on admission. Size: 0.2 X 2.0 X 0.4. Wound unchanged;-Location of wound: left hand (palm) left thumb, surgical wound present on admission. Size: 0.6 X 2.0 X 0. Wound unchanged. During an interview on 12/18/25 at 11:35 A.M., Licensed Practical Nurse (LPN) B said if a resident had a new wound, he/she would assess the wound, call the physician and get orders and document it under risk management. During an interview on 12/19/25 at 8:30 A.M., the Wound Nurse said a skin assessment is completed on admission, then weekly by the floor nurse. She was responsible for documenting the wounds weekly. Both pressure and non-pressure wounds are documented weekly under assessments. The note should include the location, size, if there is any drainage and/or odor and what the surrounding tissue looked like. An infected wound would have an odor, drainage and redness around the wound edges. The resident had surgical wounds on his/her hand and thumb. Both were present on admission. The wound on the thumb did not change. The wound on the hand was getting smaller. There was no wound documentation completed in the medical record until 12/1/25. During an interview on 12/19/25 at 10:41 A.M., the Assistant Director of Nursing (ADON) said skin assessments are completed on admission and weekly after that. Wound assessments are documented weekly including non-pressure wounds by the wound nurse and documented under assessments. She would expect skin assessments to be accurately completed on admission, noting all wounds. During an interview on 12/19/25 at 1:30 P.M., the Administrator said non-pressure wounds should be documented weekly. She would expect staff to follow the facility's policies and procedures. 2688707

Based on interview and record review, the facility failed to ensure services meet professional standards of quality by failing to follow physician orders to call the physician when blood sugar levels were out or range and/or obtaining blood sugar checks as ordered. In addition, staff failed to obtain a physician order for when staff should notify the physician of blood glucose (sugar) levels that are out of range for three residents (Residents #6, #1, and #4). The sample was 6. The census was 75.Review of the facility's Nursing Care of the Older Adult with Diabetes's Mellitus (DM, metabolic disease) policy, undated, showed:-Glycemic targets (a personalized blood glucose goal set by a healthcare provider to manage diabetes): use a glucometer (blood sugar meter) for capillary blood sampling to measure current blood glucose levels;-The target range for healthy older adults is considered 90-130 milligrams (mg)per deciliter (dl), (fasting or pre-prandial glucose (blood glucose level just before eating);-Establish provider notification protocols, for example: Call provider immediately if the resident is hypoglycemic (low blood glucose level) less than 70 mg/dl. Review of the facility's mealtimes, showed:-The main dining room, breakfast at 7:30 A.M.; lunch at 12:00 P.M.; and dinner at 5:30 P.M.-The hall trays, breakfast at 7:00 A.M.; lunch at 11:20 A.M.; and dinner at 5:00 P.M. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/23/25, showed the resident cognitively intact. Diagnoses included diabetes. Review of the resident's care plan in use at the survey, showed:-Focus: DM;-Goal: will have minimized risk of complications related to diabetes through the review date;-Interventions: diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of the Medication Administration Record (MAR) dated 12/1/25 through 12/31/25, showed:-A physician order for Humalog (short acting insulin), inject as per sliding scale: if above 300, give 8 units and call physician, subcutaneously (injection under the skin) with meals. Scheduled administration times 7:00 A.M., 12:00 P.M., and 6:00 P.M.:--At 7:00 A.M., six out of 15 opportunities the blood sugar measured above 300;--At 12:00 P.M., five out of 15 opportunities the blood sugar measured above 300;--At 6:00 P.M., three out of 15 opportunities the blood sugar measured above 300. Review of the resident's December 2025 progress notes, showed:-On 12/5/25 at 6:43 A.M., resident voiced that spike in blood sugar was due to eating peanut butter and jelly this morning before the blood sugar check. Resident given 8 units and medical doctor (MD) aware;-No other documentation showed the MD was notified when the blood sugar was above 300. During an interview on 12/19/25 at 10:41 A.M. the Assistant Director of Nursing (ADON) said she did not see any other documentation the physician was notified when the blood sugars were outside the perimeter. 2. Review of Resident #4's quarterly MDS dated [DATE], showed the resident cognitively intact. Diagnoses included diabetes. Review of the resident's care plan in use at the time of survey, showed:-Focus: the resident has potential for hypoglycemia (low blood glucose level);-Goal: the resident will be free from any signs and symptoms of hypoglycemia through the review date;-Interventions included: monitor/document/report to medical doctor as needed signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Review of the resident's MAR dated 11/11/25 through 11/30/25, showed:-A physician order dated 11/11/25, for Humalog solution, inject as per sliding scale: if 181 - 220 = 2 Give 2 units; 221 - 260 = 3 Give 3 units; 261 - 300 = 4 Give 4 units; 301 - 350 = 5; give 5 units, subcutaneously before meals for diabetes, (blood sugar) greater than 350 give 6 units and notify physician;-Documentation showed: blood glucose monitoring was scheduled and completed at 6:30 A.M., 8:00 A.M. and 11:00 A.M.;-No blood glucose monitoring completed before supper. Review of the resident's MAR dated 12/1/25 through 12/18/25, showed:-A physician order for Humalog, inject as per sliding scale: if 181 - 220 = 2 Give 2 units; 221 - 260 = 3 Give 3 units; 261 - 300 = 4 Give 4 units; 301 - 350 = 5; give 5 units, subcutaneously before meals for diabetes, (blood sugar) greater than 350 give 6 units and notify physician;-Documentation showed: blood glucose monitoring was scheduled and completed at 6:30 A.M., 8:00 A.M. and 11:00 A.M.;-No blood glucose monitoring completed before supper. Review of the progress notes dated 11/18/25 through 12/18/25, showed no documentation showing the physician order was changed. During an interview on 12/19/25 at 10:41 A.M. the ADON said she would expect staff to complete the blood sugar checks before each meal as ordered. 3. Review of Resident #1's admission MDS, dated [DATE], showed the resident cognitively intact. Diagnoses included diabetes. Review of the resident's care plan in use at the time of survey, showed:-Focus: the resident has non-insulin dependent diabetes;-Goal: the resident will be free of all signs and symptoms of hypo/hyperglycemia (low or high blood sugar) such as sweating, trembling, thirst, fatigue, weakness, blurred vision through next review;-Interventions included: provide diet as ordered and conduct a comprehensive skin inspection weekly. Review of the resident's physician orders dated 11/4/25, showed a physician order for Humalog solution 100 unit/mL, inject 10 unit subcutaneously before meals for diabetes. The order failed to include perimeters for when staff should notify the MD. Review of the resident's MAR dated 11/3/25 through 11/30/25, showed a physician order for Humalog solution 100 unit/mL, inject 10 unit subcutaneously before meals for diabetes. Documentation showed on 11/25/25 at 12:00 P.M. the resident's blood sugar measured 57 (hypoglycemic) and the insulin was administered. Review of the resident's progress notes dated 11/25/25, showed no documentation the MD was notified of the residents low blood sugar. During an interview on 12/19/25 at 1:30 P.M., the Director of Nursing (DON) said the nurse reported the resident's blood glucose level to her and told her he/she was holding the insulin and placed a call to the on-call through the exchange. The DON did not know if the on-call doctor called back or not. During an interview on 12/18/25 at 11:05 A.M, Licensed Practical Nurse (LPN) A said if a resident did not have a perimeter for his/her blood sugar he/she would notify the MD if the blood sugar was below 70 or above 350 and document it in the progress notes. During an interview on 12/18/25 at 11:35 A.M., LPN B said if a resident did not have perimeters for his/her blood sugar, he/she would notify the MD if the blood sugar was below 60 or above 400. If the MD was notified it would be documented in the progress notes. If a resident's blood sugar was low, he/she would hold the insulin, and give them orange juice or milk and follow up with the MD. During an interview on 12/19/25 at 10:41 A.M., the Assistant Director of Nursing said when the nurse receives an order to check the blood sugar, they should also obtain an order for when the physician wants to be notified. If a resident did not have perimeters for their blood sugar, staff should notify the physician if the blood sugar was below 70 or above 350. If the blood sugar was below 70, staff should not administer the insulin, give them a snack, notify the physician and document it in the progress notes. When the nurse documents the insulin is held on the MAR, it will automatically generate a progress note. 4. During an interview on 12/19/25 at 1:30 P.M. and at 3:37 P.M., the Administrator said she would expect staff to obtain perimeter orders for blood sugars when the order to check the blood sugar was obtained. Physician orders should be followed. 2688707

Based on interview and record review, the facility failed to notify the resident's representative after the resident fell, for one out of three residents sampled for falls. (Resident #1). The census was 75.Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/10/25, showed:-Cognitive intact;-Diagnoses included: diabetes, high blood pressure, end stage renal failure (ESRD, chronic irreversible kidney failure) dependence on renal dialysis (a life-sustaining treatment that filters waste products and excess fluid from the blood when the kidneys are no functioning properly);-Mobility devices: wheelchair and walker;-One fall since admission/entry or reentry;-Partial/moderate assistance (helper does less than half of the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for chair/bed-to-chair transfers. Review of the resident's care plan in the use at the time of survey, showed:-Focus: The resident has had an actual fall with no Injury, minor injury, serious injury;-Interventions: On 11/9/25, resident encouraged to use call light when needing any assistance; Monitor/document /report as needed times 72 hours to physician for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation. Review of the progress notes dated 11/9/25 at 7:20 P.M., showed the nurse was called down to room, the resident was on the floor in the bathroom. States he/she did not lock his/her wheelchair before getting back in it from using the restroom. Vitals stable. Denies hitting his/her head. Able to move extremities within resident's normal limits. Alert and oriented times four (person, place, time and situation). Neurological checks within normal limits. Denies pain. Message left for Medical Doctor (MD);-There was no documentation showing the resident's representative was notified. During an interview on 12/18/25 at 11:05 A.M., Licensed Practical Nurse (LPN) A said if a resident fell, he/she would assess the resident and get the resident up, if the resident was able. The Director of Nursing (DON), MD and the resident representative (RP) are then notified. During an interview on 12/18/25 at 11:35 A.M., LPN B said if a resident fell, he/she would do a head-to-toe assessment and notify the MD and the RP. Falls are documented under risk management, and in the progress notes. During an interview on 12/19/25 at 10:41 A.M., the Assistant Director of Nursing (ADON) said staff should notify management, the physician and the family when a resident falls and document it in the progress notes. During an interview on 12/19/25 at 1:30 P.M., the Administrator said she had no documentation to show the family was notified after the fall. She would expect the nurse to assess any resident who falls and notify the physician and family, and document it. 2688707

Based on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice when staff failed to administer treatments as ordered for non-pressure wounds, to complete comprehensive skin assessments on a routine basis, and to reassess for efficacy of treatments for skin integrity issues for one resident (Resident #54). The sample was 6. The census was 72.Review of the facility's Skin Assessment policy, revised 1/18/24, showed:-Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment;-Policy Explanation and Compliance Guidelines included:--A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury;--Considerations for a bariatric (obese) resident; -Thoroughly inspect each surface of a skin fold; -Consider moisture and weight exerted by opposing skin and/or body folds when determining pressure versus moisture related etiology (cause);--Documentation of skin assessment: -When a new skin concern is identified, documentation will be completed according to the established guidelines. This documentation process is designed to ensure that each newly identified skin concern is thoroughly recorded. Accurate and complete documentation supports effective treatment planning and ongoing care for residents. Review of the facility's Wound Treatment Management policy, undated, showed:-Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-Policy Explanation and Compliance Guidelines included:-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change;-Treatments will be documented on the Treatment Administration Record (TAR) or in the electronic health record (EHR);-The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: -Lack of progression towards healing; -Changes in the characteristics of the wound. Review of Resident #54's comprehensive admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/25/25, showed:-Cognitively intact;-Lower extremity impairment on both sides;-Substantial/maximal assistance required for showering/bathing;-Dependent for lower body dressing, putting on/taking off footwear, and personal hygiene;-Dependent in mobility areas of rolling left and right, sitting to lying, lying to sitting, and transfers;-Diagnoses included paraplegia (paralysis affecting one side), complete traumatic amputation at knee level to left lower leg, morbid obesity, kidney failure, osteomyelitis (bone infection), and generalized muscle weakness;-At risk of developing pressure ulcers/injuries;-Three venous and arterial ulcers (open sores caused by circulatory problems) present;-Skin and ulcer/injury treatments included pressure ulcer/injury care, application of nonsurgical dressings other than to feet, applications of ointments/medications other than to feet, and application of dressings to feet. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Actual impairment to skin integrity related to left stump wound;-Focus: Actual impairment to skin integrity related to excoriation to buttocks, thighs, and calves and open areas to right stump, right hip, and right buttocks;-Interventions/Tasks included: Administer treatments as ordered and monitor for effectiveness. Monitor pressure areas for changes in color, sensation, temperature and report any changes to nurse;-Focus: Activities of daily living (ADL) self-care performance deficit;-Intervention/Tasks included: Resident is totally dependent on staff to provide a bath three times a week and as necessary. Review of the resident's shower sheets for September and October 2025, reviewed 10/7/25, showed:-On 9/8/25, staff documented a bed bath completed. No documentation of any areas noted during a visual assessment of the resident's skin;-On 9/12/25, staff documented on a shower sheet with no indication of whether bed bath or shower provided. Skin tears noted on the buttocks and swelling noted to the lower legs of a drawing of a person;-On 9/19/25, staff documented a bed bath completed. No documentation of any areas noted during a visual assessment of the resident's skin;-On 9/22/25, staff documented assessment of bruising, skin tears, rashes, drying, and scratches, with areas marked on the back, buttocks, and inner thighs of a drawing of a person. No documentation of any areas noted to the legs;-On 9/29/25, staff documented the resident refused a bed bath. No documentation of a visual assessment of the resident's skin or of a shower offered;-No documentation of any other showers or bed baths offered or provided to the resident in September or October 2025. Review of the resident's medical record, showed:-A physician order, dated 8/15/25, for skin assessment every night shift every Friday. Perform head to toe skin assessment and document findings in weekly skin assessment user-defined assessment (UDA) under the assessments tab in the EHR;-On the TAR for the weekly skin assessment, scheduled for 10/3/25, staff documented 9 (other/see nurse's note);-On 10/4/25 at 12:48 A.M., staff documented a progress note that they unable to complete skin assessment due to time constraints;-On 10/6/25 at 2:59 P.M., staff documented a progress note that a wound assessment was completed and to see assessment for additional information;-No skin assessment documented in assessment tab of the EHR since 8/8/25. Review of the resident's electronic physician order summary, showed:-An order, dated 8/2/25, for heel protectors in place at all times, every shift for skin breakdown;-An order, dated 8/2/25, ammonium lactate external lotion 12% (lactic acid ammonium lactate, used to treat dry skin), apply to bilateral lower extremities and intact back skin topically every day and night shift for dry skin. Cleanse bilateral lower extremities and back with soap and water, pat dry, apply to intact skin of bilateral lower extremities and back, avoiding between toes.-An order, dated 8/13/25, for Ace wrap (elastic compression bandage) to bilateral lower extremities related to edema (swelling), every day shift. No instruction or additional physician order to remove the Ace wraps;-An order, dated 9/23/25 for wound care, cleanse right dorsal (top) foot with wound cleanser, pat dry, apply Aquacel Extra (wound dressing) to wound bed, and cover with Aquacel foam dressing every day shift every three days and as needed. Review of the resident's October 2025 TAR, showed:-On 10/5/25, the Wound Nurse documented wound care to the resident's right dorsal foot as administered;-On 10/7/25, Registered Nurse (RN) C documented heel protectors in place at all times as administered. Observation on 10/7/25 at 8:45 A.M., showed the resident in bed with no heel protector on the resident's foot or in any visible area of the room. During an interview, the resident said due to his/her size, he/she can sort of turn him/herself to a certain point, but not much. He/She relies on staff to help reposition him/her, clean him/her up, and dress him/her. He/She sometimes gets bed baths but not showers. He/She had three wounds on his/her buttocks that got better when he/she was recently in the hospital. He/She is unsure of their status now, but his/her buttocks and backside are sore, and he/she feels like something is going on with his/her skin, like maybe the wounds are getting worse. CNAs put a barrier cream on him/her and he/she is not sure if there are other creams used for wound prevention or treatment. He/She is supposed to get a wound dressing on his/her leg daily, but that doesn't always happen. Observation on 10/7/25 at 9:34 A.M., showed the resident in bed. RN C removed the resident's bed covers. The resident had beige compression wraps on his/her right foot and calf, a black sock on his/her right foot, and no heel protector on his/her right foot. The compression wraps appeared very tight around the resident's right foot and calf with the top of the resident's knee and lower thigh area overlapping onto the compression wrap. RN C removed the black sock and compression wraps from the resident's right foot and leg. The compression wrap showed a large area of dried burgundy drainage. The resident's right leg and foot were extremely dry and showed deep crevices of cracked skin and wrinkling. On the resident's dorsal area of his/her right foot, a dressing dated 10/3/25. During an interview, RN C said he/she did not know what was under the dressing. RN C began to remove the dressing and had some difficulty removing the dressing due to the dressing bonded to the resident's skin. The wound to the resident's dorsal foot showed a venous ulcer, approximately 0.5 inches wide. The wound bed appeared pink and healing with no drainage. The resident's left leg had beige compression wraps to his/her left lower leg, which was amputated at the ankle. The compression wraps appeared very tight with the top of the resident's knee and lower thigh area overlapping onto the compression wrap. RN C removed the resident's left leg compression wrap. The resident's left lower leg extremely dry, scaly, and wrinkled. RN C raised the resident's left leg and the resident's left posterior (back) thigh showed extremely dry, scaly skin with an alligator-like skin texture. The resident's posterior left thigh showed several small crevices within the skin that were bleeding. RN C left the compression wraps off and said he/she was getting new ones because the old ones were soiled with drainage. The resident said it had been a couple of days since the compression wraps have been removed and staff do not remove them at night. The resident said it had been a couple of days since his/her right foot dressing was changed. At 9:50 A.M., Certified Nursing Assistant (CNA) B entered the room and assisted the resident turn on his/her right side. Both of the resident's buttocks showed pink scarring from previous wounds. His/Her lower back, directly above the buttocks, showed very thick, scaly, alligator-like skin. CNA B said he/she washes the resident 's back and buttocks every time he/she works and applies lotion to the resident's skin. CNA B removed a bottle of ammonium lactate lotion off the resident's sink and said it was the lotion he/she applies to the resident. CNA B did not know whether or not he/she was supposed to be applying that lotion. The resident said he/she only gets bed baths. CNA B said the facility does not have bariatric (obese) shower chairs to provide the resident a shower. Observation of the shower room on 10/7/25 at approximately 10:00 A.M., showed a bariatric shower chair in the shower room. During an interview on 10/7/25 at 11:49 A.M., the Wound Nurse said the resident has a venous wound that gets dressing changes every three days. She worked on 10/5/25 and did the dressing change that day on the resident's right foot. She was unsure why the resident's dressing observed today was dated 10/3/25. She must have written the wrong date on the dressing. Dressings must be dated with the date the dressing is applied. Nurses are supposed to complete head to toe skin assessments once a week. When a skin assessment is completed, the nurse should mark it as completed on the TAR and complete the skin assessment under the assessment tab of the EHR. If staff cannot complete the skin assessment during the scheduled shift, they should pass it along to the oncoming shift. Staff can set a reminder in the EHR to prompt the next shift to complete the missed assessment. It is not acceptable for a skin assessment not to be completed due to time constraints. It is important for skin assessments to be completed weekly for early identification of skin issues, prevention, and monitoring. Nurses should apply the resident's Ace wraps in the morning and remove them at night. Ace wraps should not be worn 24 hours a day and should be removed at night for blood flow and circulation. There should be a physician order to remove the Ace wraps at night to prompt the charge nurse to complete the removal. The resident gets bed baths. Showers could help with the resident's dry skin. When CNAs complete bed baths or showers with a resident, they should fill out a shower sheet. Any skin issue should be documented on the shower sheet. If staff observe a new skin issue and the Wound Nurse is in the building at that time, staff should come tell her what they saw. If the Wound Nurse is not in the building at the time, staff should report new skin issues to the nurse on duty. Dry, crusted legs and feet should be documented on shower sheets and skin assessments. If the resident has skin crevices that are splitting open and bleeding, their current treatment may not be effective. In that case, the nurse should notify the physician to discuss obtaining new orders. The resident is seen weekly by the Nurse Practitioner (NP) of an outside wound company. The Wound Nurse rounded with the wound company NP this morning and they assessed the resident. During the assessment, the wound company NP observed the resident's foot and buttocks. They did not look at the resident's legs during the assessment. During an interview on 10/7/25 at 2:27 P.M., RN C said he/she marked the resident's heel protector as administered on the TAR this morning because it was going to get done. He/She does not know where the resident's heel protector is. During an interview on 10/7/25 at 2:40 P.M., RN A said nurses are responsible for ensuring physician-ordered compression wraps are applied in the morning and removed at night. Physician orders for compression wraps should instruct staff to remove them at night. Nurses are responsible for completing comprehensive skin assessments on a weekly basis. Skin assessments are documented on the TAR and in the assessment tab of the EHR. CNAs should document all showers and bed baths on shower sheets. Any skin issues identified during bathing should be documented on the shower sheet, and the shower sheet should be reviewed by the nurse. New skin issues should be reported to the nurse and the Wound Nurse. The nurse or Wound Nurse would notify the physician to discuss revising treatments or obtaining new treatments. The shower sheets are reviewed by the nurse. Nurses are responsible for applying medicated creams and heel protectors as ordered. Nurses should not document a treatment as administered on the TAR if they did not actually administer the treatment. During an interview with the Administrator and Regional Director of Operations on 10/7/25 at 4:32 P.M., they said nurses should complete comprehensive skin assessments weekly. If a nurse cannot complete a scheduled skin assessment during their shift, they should pass it along to the nurse in the oncoming nurse in report. If a skin assessment is missed, the resident's physician and family should be notified. Completion of skin assessments should be documented on the TAR. If a new skin issue is identified during the skin assessment, the nurse should complete the comprehensive assessment tool under the assessment tab in the EHR. They expect physician orders to be followed for treatment, including orders for dressing changes and application of creams and heel protectors. When completing wound dressing changes, nurses should ensure they are documenting the correct date on the new dressing. If a nurse cannot complete a treatment, they should document the incomplete treatment on the TAR using the appropriate code to indicate why the treatment was not completed, and notify the Assistant Director of Nurses (ADON) and nurse for the oncoming shift. It is not appropriate to mark any treatment as completed when it was not administered. Nurses are responsible for ensuring compression wraps are applied in the morning and removed at night. Physician orders for compression wraps should include instruction to remove the wraps at night. When such orders are received by the NP from the wound company, the orders should be verified by the Wound Nurse, who would ensure they are accurately added to the physician order summary. The Regional Director of Operations said he expects the wound company NP to perform comprehensive, head to toe skin assessments during their weekly rounds of residents on their caseload. Ideally, the wound company NP would explore new treatment options after approximately two weeks of no improvement to identified skin issues. The resident's skin with bleeding crevices indicates the current treatments may be ineffective. 2623481

Based on observation, interview, and record review, the facility failed to provide food that accommodates resident allergies and preferences, and to provide alternative meal options (Residents #26, #5, #49, #48, #60, #27, #35, and #55). The sample was 18. The census was 75.1. Review of the facility's resident council meeting minutes, showed:-On 6/25/25, 13 residents in attendance. Staff are not properly reading the tickets and sending meals to their rooms that their tickets state they do not want. Alternative menus - some meals they do not have in the kitchen, so they do not reach out to ask if they want another alternative meal; -On 7/16/25, 20 residents in attendance. Residents complained the kitchen staff is rude and fail to read the tickets accurately. They also noted that some meals are not available. One resident expressed frustration of being served daily eggs when he/she is allergic to eggs. During a group interview on 8/18/25 at 11:03 A.M., six out of six residents, whom the facility identified as alert and oriented, said there are ongoing issues with dietary. They have discussed their concerns with staff in resident council meetings and the dietary issues have continued. The facility does not post menus, so residents do not know what meal are going to be served. The facility has an alternate menu, but the kitchen is out of stock of the items on the alternate menu all the time. Three of the six residents in attendance said when dietary slips are provided with meals, staff do not follow the guidance on the dietary slips. 2. Observations on 8/14/25 at 10:14 A.M., 8/15/25 at 8:54 A.M., and 8/18/25 at 8:30 A.M., showed no menus posted in the facility. During an interview on 8/19/25 at 1:56 P.M., the Dietary Manager (DM) said the expectation is that the menus for each day and for the month are to be posted on the wall outside the main dining room. This has not been done. 3. Review of Resident #26's electronic medical record (EMR), showed:-Diagnoses included depression and bipolar disorder (mood disorder that can cause intense mood swings);-Allergies to eggs and poultry flagged at the top of the screen in the EMR;-A comprehensive nutritional assessment, dated 3/6/24, showed allergies to eggs and poultry. Resident has an allergy to chicken;-A physician order, dated 2/15/25, for regular diet. Allergies: Eggs, poultry. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/31/25, showed:-Cognitively intact;-Independent with eating. Review of the resident's care plan, in use at the time of survey, showed a focus of the resident has nutritional problem or potential nutritional problem. No documentation related to the resident's allergies of food preferences. Review of the resident's dietary slips, undated, showed NO EGGS (ALLERGY) and NO POULTRY (ALLERGY) at the top of the slips for breakfast, lunch, and dinner. During an interview on 8/14/25 at 5:36 P.M., the resident said he/she is allergic to poultry and eggs. He/She is served eggs at breakfast all the time. If eggs are on the menu for breakfast, he/she is supposed to get an alternate meat. Observation on 8/18/25 at 9:07 A.M., showed the resident in his/her room eating breakfast. During an interview, the resident said he/she was served eggs for breakfast yesterday. The resident showed a picture he/she took on his/her phone of the eggs. The picture showed a plate of scrambled eggs, and the picture was timestamped 8/17/25 at 9:06 A.M. During an interview on 8/20/25 at 8:24 A.M., Certified Nurse Aide (CNA) B said the resident is allergic to eggs and gets served eggs all the time. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Setup or clean-up assistance required for eating;-Diagnoses included high blood pressure, kidney failure, and diabetes. During an interview on 8/18/25 at 7:40 A.M., the resident said he/she was served a burger for dinner over the weekend that was burned, dry, and covered in nasty sauce. He/She asked for a hotdog as a substitute but was told by dietary staff the item was not available. Observation on 8/18/25 at 12:45 P.M., showed the resident in the hallway outside of the kitchen. He/She requested a hotdog for lunch. Dietary Aide (DA) OO said no, he/she does not get a hotdog today, DA OO will give him/her a burger. During an interview on 8/18/25 at 12:55 P.M., the resident said he/she wanted a hotdog for lunch. He/She has been wanting a hotdog for two weeks, and they never have any. It makes him/her upset. He/She eats a burger every day and he/she doesn't want another burger. 5. Review of the facility's alternate menu, undated, showed:-Please circle: Lunch or dinner;-Date, resident name, room;-Please circle your choice:-Grilled cheese;-Soup;-Hamburger and chips;-Cheeseburger and chips;-Deli sandwich and chips;-Chef salad;-Hot dog and chips;-Tuna salad and chips;-Please have completed and return to Dietary by 10:00 A.M. for lunch and 3:30 P.M. for dinner. Observation of the kitchen on 8/18/25 at 12:27 P.M., showed no hot dogs or tuna in the food storage areas. Cans of cream of chicken soup were located in the pantry. During an interview on 8/18/25 at 12:35 P.M., DA OO and the DM said food listed on the alternate menu is always available. Residents must fill out their request for an alternate and give it to dietary two hours in advance of each meal. The facility is out of hot dogs right now. They are also out of tuna. The only soup they have is cream of chicken, which is more of a base for other dishes rather than a soup someone would order to eat at a meal. 6. Review of Resident #49's medical record, showed:-Diagnoses included respiratory failure, morbid obesity, diabetes, heart failure, kidney failure, dysphagia (difficulty swallowing), disorientation, depression, anxiety, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and schizoaffective disorder (mental illness combining symptoms of a mood disorder and schizophrenia);-A quarterly nutritional assessment, dated 3/1/24 with blank fields for food likes and food dislikes;-No other nutritional assessments completed after 3/1/24. Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Supervision or touching assistance required for eating. Review of the resident's care plan, in use at the time of survey, showed a focus of the resident has a nutritional problem. No documentation related to the resident's food preferences was noted in the care plan. Review of the resident's dietary slips, undated, showed no documentation of likes or dislikes for breakfast, lunch, or dinner. During an interview on 8/14/25 at 11:51 A.M., the resident said the food has gone downhill. He/She doesn't like eggs or cheese and he/she gets served that a lot. He/She hates that because he/she doesn't want to waste food. He/She keeps telling staff he/she does not like eggs. He/She loves breakfast, just not eggs. Observation and interview on 8/15/25 at 8:24 A.M., showed the resident in bed with a breakfast tray on his/her table containing scrambled eggs. The eggs were untouched. The dietary slip on the tray did not show the resident's dislike of eggs. The resident said he/she does not like eggs. He/She told the aide and asked for meat or something. The aide said they would be back and they did not return. At 9:22 A.M., the resident's eggs remained on his/her bedside table, untouched. During an interview, the resident said the aide never came back with meat. He/She just received a food delivery of chips and snacks. He/She guesses that is better than nothing. Observation and interview on 8/18/25 at 9:22 A.M., showed the resident in bed with a breakfast tray on his/her bedside table containing scrambled eggs and no dietary slip on the tray. The eggs were untouched. The resident said he/she does not like eggs. 7. Review of Resident #48's medical record, showed diagnoses included diabetes, hyperlipidemia (high cholesterol), high blood pressure and morbid obesity;-A quarterly nutritional assessment, dated 4/23/24, with blank fields for food likes and dislikes;-No other nutritional assessments completed after 4/23/24. Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Setup or clean-up assistance required for eating. Review of the resident's care plan, in use at the time of survey, showed a focus of the resident has a nutritional problem related to morbid obesity and diabetes. No documentation related to the resident's food preferences was noted in the care plan. Review of the resident's dietary slips, undated, showed no documentation of likes or dislikes for breakfast, lunch, or dinner. Observation and interview on 8/18/25 at 8:46 A.M., showed the resident in bed with a tray of breakfast on his/her bedside table, consisting of a scoop of scrambled eggs and a donut, with no dietary slip on the breakfast tray. The resident said there should be a dietary slip on the tray at every meal. Dietary doesn't post a menu anymore, so he/she never knows what he/she is getting and if he/she should request to get something else. 8. Review of Resident #26's medical record, showed:-A comprehensive nutritional assessment, dated 3/6/24, with no likes or dislikes documented;-No nutritional assessments completed after 3/6/24. Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Independent with eating. Review of the resident's care plan, in use at the time of survey, showed a focus of the resident has nutritional problem or potential nutritional problem. No documentation related to the resident's allergies or food preferences were noted in the care plan. Review of the resident's dietary slips, undated, showed no likes or dislikes documented. During an interview on 8/14/25 at 5:36 P.M., the resident said he/she is allergic to poultry and eggs, so he/she relies on the alternate menu. He/She requests alternates all the time and seldom gets what he/she requested. The kitchen is always out of stuff. 9. Review of Resident #60's comprehensive MDS, dated [DATE], showed:-Moderate cognitive impairment;-Setup or clean-up assistance required for eating;-Diagnoses included diabetes, adult failure to thrive, heart disease, chronic obstructive pulmonary disease (lung disease), and dementia. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's food preferences. Review of the resident's medical record, showed no documentation of nutritional assessments. Observation and interview on 8/18/25 at 8:47 A.M., showed the resident eating breakfast in his/her room, with no dietary slip on the tray. The resident said there are no menus posted in the facility, so residents never know what is going to be served. 10. Review of Resident #27's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Independent with eating;-Diagnoses included diabetes, acute kidney failure, hypertension, dehydration, depression, and anxiety. Review of the resident's care plan, in use at the time of survey, showed a focus of the resident has a potential nutritional problem. No documentation related to the resident's food preferences. Review of the resident's medical record, showed no nutritional assessments documented. During an interview on 8/18/25 at 12:04 P.M., the resident said the facility used to have a menu posted for meals served each day, but they don't do that anymore. The kitchen doesn't actually have the alternates listed. 11. Review Resident #35's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on assistance for eating;-Diagnoses included neurofibromatosis (condition characterized by changes in skin coloring and the grown of tumors along nerves in the skin, brain, and other parts of the body), hypotension (low blood pressure), and anemia. Review of the resident's care plan, in use at the time of survey, showed a focus of the resident has nutritional problem or potential nutritional problem. No documentation related to the resident's allergies of food preferences were noted in the care plan. Review of the resident's medical record, showed no nutritional assessments documented. During an interview on 3/18/25 at 3:28 P.M., the resident said the staff do not follow diet orders. If residents ask for something specific, they are told no. Last week, the resident asked for something, and the DM said they are not going to do that. If the resident requests toast for breakfast, staff tell him/her toast is not on the menu so he/she can't have that. The resident said, It's bread.how hard can it be to serve the residents toast? 12. Review of Resident #55's comprehensive MDS, dated [DATE], showed:-Cognitively intact;-Setup or clean-up assistance required for eating;-Diagnoses included heart failure, high blood pressure, respiratory failure, diabetes, hyperlipidemia, and depression. Review of the resident's dietary meal ticket slip (undated) showed:-The resident is to be served a regular, low sodium, controlled carbohydrate diet for all meals. During an interview on 8/14/25 at 1:58 P.M., the resident said substitutes are not always available from the kitchen. He/She requested two grilled cheese sandwiches from the kitchen after the lunch meal and was served two bologna sandwiches, both of which were marked as expired as of 8/12/25. 13. Observation and interview on 8/20/25 at 8:10 A.M., showed CNA T passed trays of food to resident rooms on the hallway. None of the trays had dietary slips. CNA T said dietary slips are not on the trays sent out to the hallway by dietary. He/She is just passing trays to residents without knowing what should be on their dietary slips. Dietary slips tell staff if the resident has allergies and what the resident likes/dislikes. Residents should receive the right foods. Menus are not posted in the facility. Residents need to know what is on the menu so they can know if they should request an alternate or not. Observation and interview on 8/20/25 at 8:24 A.M., showed CNA B passed trays to resident rooms from carts on the hallway. There were no dietary slips on the trays. CNA B said dietary staff are not sending dietary slips out with room trays. Dietary slips should include diet type and if the resident has allergies and what they like/dislike. Staff won't know what is supposed to be on a resident's tray without the dietary slips, unless they get to know the resident over time and learn it themselves. 14. During an interview on 8/20/25 at 10:24 A.M., [NAME] V said when the previous DM left the facility, he/she took his/her computer, and the dietary slips were on the computer. The kitchen has a copy of all dietary slips that were available when the DM left. When plating food at meals, dietary staff go off the recipes for what they put on the plate. If a resident is allergic to eggs, dietary should give the resident meat instead, and/or cold cereal. Hot dogs and soup are on the alternative menu. The kitchen is out of hot dogs. All they have is cream of chicken soup, not real soup that someone would eat as a meal. The DM places orders for food. 15. During an interview on 8/19/25 at 1:56 P.M., the DM she would expect for all items on the alternate menu to be available for the residents. She would expect all alternate menu requests made by residents to be respected. During an interview on 8/20/25 at 10:08 A.M., the DM said dietary staff should refer to dietary slips when plating food for residents. Dietary slips show if the resident has allergies. Ideally, the slips should include the resident's likes/dislikes. Currently, the slips to not include this information. She does not have access to print the dietary slips at this time. The kitchen is out of hot dogs and tuna. They have cream of chicken soup, but no other soups. The kitchen should be stocked with all items that are available on the alternate menu. At this time, the DM is unable to place food orders. Food orders are currently placed by an outside company that is contracted to provide dietician services. The outside company sticks to a budget and only orders the items listed on each recipe for meals on the planned menu. The outside company is not ordering extra items for alternate meals. 16. During an interview with the Director of Nurses (DON) and Administrator on 8/20/25 at 1:48 P.M., they said they expected menus to be posted daily. Dietary staff should be sending dietary slips out with trays during meals. The DM has access to the dietary slips, and she should print them out at meals. Dietary slips should show the resident's name, room number, diet type, and other information, such as allergies and likes/dislikes. Dietary staff should follow the dietary slips when plating food. Nursing should check the dietary slips and make sure the correct items are there before delivering to the resident. The DM should complete assessments with each resident to determine their likes/dislikes. Dietary should have all items available that are listed on the alternate menu. Traditionally, the DM places food orders but since she is new, food orders are placed by an outside company contracted by the facility for dietician services. Residents have the right to ask for and receive alternative meal options. 16119952588074

Based on interview and record review the facility failed to provide documentation of ongoing educational training provided to active Certified Nursing Aides (CNAs), totaling no less than 12 hours per year, for four of six sampled active CNAs. Insufficient training documentation was provided for four of six sampled CNAs. The sample was 18. The census was 75.1. Review of CNA E's CNA Annual In-Service Training Log, showed:-Inservices completed each month from January 2025 to June 2025, with each inservice totaling one hour;-No record of inservices completed prior to January 2025. 2. Review of CNA Z's CNA Annual In-Service Training Log, showed:-Inservices completed each month from January 2025 to June 2025, with each inservice totaling one hour;-No record of inservices completed prior to January 2025. 3. Review of CNA AA's CNA Annual In-Service Training Log, showed:-No record of inservices completed for the past year, from hire date to hire date, while employed at the facility. 4. Review of CNA BB's CNA Annual In-Service Training Log, showed:-No record of inservices completed for the past year, from hire date to hire date, while employed at the facility. 5. Review of CNA CC's CNA Annual In-Service Training Log, showed:-No record of inservices completed for the past year, from hire date to hire date, while employed at the facility. 6. Review of CNA DD's CNA Annual In-Service Training Log, showed:-No record of inservices completed for the past year, from hire date to hire date, while employed at the facility. 7. During an interview on 8/19/25 at 8:52 A.M., the Director of Nursing (DON) said she was unable to find annual education logs for four of the six sampled CNAs and does not have access to any annual trainings completed by employees prior to January, 2025. The DON said the previous administration walked out of the building with numerous documents and believes CNA trainings may have been among them. Ensuring annual education is completed by CNAs is the responsibility of the DON, and all CNAs at the facility should receive 12 hours of education annually per regulation guidelines.8. During an interview on 8/20/25 at 1:48 P.M the Administrator and DON said they expected all CNAs at the facility to receive 12 hours of ongoing education annually per regulation guidelines. It is believed the previous DON took inservice records and education documentation with them when resigning from the position.

Based on observation, interview and record review, the facility failed to ensure kitchen cooking appliances were in working order, failed to ensure the kitchen and appliances were clean and failed to ensure the dishwasher was in working order. The sample was 18. The census was 75. Review of the facility's kitchen daily cleaning schedule, undated, showed:-The cook is responsible for cleaning the oven, deep fryer, steam table, preparation station table, and microwave;-Dietary Aides are responsible for cleaning stainless steel, walk-in freezer, dish machine area, reach in refrigerator, and walk-in refrigerator. Review of the kitchen maintenance logs, showed no maintenance requests were made from 1/1/25 to 8/20/25 for the broken oven, range oven or walk-in freezer door. 1.Observation on 8/14/25, of the kitchen, showed:-At 10:17 A.M., the walk-in freezer door did not close all the way. Ice was built up on the floor near the door. There was no temperature log for the walk in freezer;-At 10:19 A.M., the dry storage room had food and trash debris on the floor under the racks. Two ceiling tiles above the food storage had a black, mold-like substance;-At 10:23 A.M., the walk-in refrigerator had trash and food debris on the floor. There was no temperature log for the walk in refrigerator;-At 10:26 A.M., the floor surrounding the oven had food debris and a liquid spill/build up;-At 10:27 A.M., the large oven had food debris and build up;-At 10 28 A.M 4 ceiling tiles above the steam cart serving station had dust accumulation and build up;-At 10:29 A.M., the reach-in refrigerator by the oven had a liquid spill and food debris on the bottom. There was no temperature log for the reach-in refrigerator;-At 10:30 A.M., the floor in the dish wash station had food and trash debris. Observation on 8/15/25, of the kitchen, showed:-At 6:38 A.M., the walk-in freezer door was cracked open, unable to shut. The temperature on the door read 15 degrees Fahrenheit (F). There was no temperature log posted for the walk in freezer. Trash and food debris were on the floor; -At 6:40 A.M., the floor in and around the dishwasher had food debris and trash. No temperature logs for the dishwasher were posted;-At 6:42 A.M., the walk-in refrigerator had ice and sludge build up on the floor by the door. The temperature on the door read 43 degrees F;-At 6:44 A.M., the reach -n refrigerator by the oven, had liquid spill and food debris on the bottom. No temperature log was posted for the reach-in refrigerator;-At 6:45 A.M., four ceiling tiles above the steam cart station had dust accumulation and build up. Observation on 8/18/25, of the kitchen, showed:-At 12:58 P.M., the walk-in freezer door was ajar and unable to fully close and latch. The external temperature gauge showed 36 degrees F Slush was on the floor upon entering the walk-in freezer. There was frostbite inside packages of stir-fry vegetables, ham, premade pizzas, hashbrowns, and veggie patties;-At 1:08 P.M., the walk-in freezer door remained ajar and was unable to fully close and latch. The external temperature gauge showed, Fre, and no temperature. A calibrated thermometer sat in the freezer for two minutes showed a temperature of 31.1 degrees F. The thermometer placed inside an open box of packaged ham showed a temperature of 20.9 degrees F, an open box of prepackaged pizza showed a temperature of 20.1 degrees F, and an open box of veggie burgers showed a temperature of 20.2 degrees F. 2. Observation on 8/15/25 at 11:51 A.M., showed the meat in the oven measured at 125 degrees F after being in the over for an hour and a half. The oven dial was set at 375 degrees F.During an interview 8/15/25 at 9:38 A.M., the Dietary Manager said the temperature dial does not work on the oven. She said if you turn the dial to 375 degrees F, the oven will only reach 120 degrees F. She confirmed that the oven was broken by taking the temperature with a hand held thermometer and observing that the food was not being cooked. 3. Observation on 8/15/25 at 10:30 A.M., showed:-Instructions on the outside of the dishwasher showed the machine needed to reach 120 degrees F during the rinse cycle;-The dishwasher only reached 95 degrees F during the rinse cycle. Observation on 8/15/25 at 10:37 A.M., showed the dishwasher reached a temperature of 90 degrees F during the rinse cycle. 4. During an interview on 8/19/25 at 1:03 P.M., Dietary Aide F said kitchen appliances should be in working order. The oven and range oven have not been working for at least two months. Temperatures should be obtained and logged for all food storage. Temperatures had not been recorded for the walk-in refrigerator, freezer, or reach in refrigerator. He/She would expect the dishwasher to get up to the correct temperature when in use. Staff had not been doing the routine temperature tests for the dishwasher. He/She would expect the kitchen to be clean and free from trash and food debris. 5. During an interview on 8/19/25 at 1:56 P.M., the Dietary Manager said kitchen appliances should be in working order. The oven and range oven have not been working correctly since she started working at the facility a week prior. Temperatures should be obtained and logged for all food storage to ensure food does not spoil. Temperatures had not been recorded for the walk-in refrigerator, freezer, or reach in refrigerator in a while. He/She would expect the dishwasher to get up to the correct temperature of 120 degrees F, when in use, in order for dishes to be properly sanitized. Routine temperature tests for the dish washer had not been done. She would expect the kitchen to be clean and free from trash and food debris. She would expect the ceiling tiles to be free from dust accumulation and mold. 6. During an interview on 8/20/25 at 2:12 P.M., the Administrator said he would expect the kitchen to be clean and free from trash and food debris. He would expect all kitchen appliances to be in working order. He would expect the oven and range oven to be in working order. He would expect the dish washer to be working properly and reach 120 degrees F. He would expect dietary staff to obtain routine temperatures of the appliances to ensure food is stored safely. He would expect the Dietary Manager to put in a maintenance request when cooking appliances/ food storage appliances stop working.

Based on observation, interview, and record review, the facility failed to assess residents for safety for side rail use, to obtain informed consent for the use of side rails, and to have a policy that provided guidance for staff assessing residents for use of side rails that were not used as a restraint (Residents #35, #11, #48, #10, #49, and #2). The facility identified 14 residents with side rails. The sample was 18. The census was 75.Review of the facility's Use of Restraints policy, reviewed February 2021, showed: - Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body;-The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint;-The policy failed to provide procedural guidance for staff to follow regarding the use of side/bed rails, grab bars, and enabling devices that are not used to restrict movement. 1. Review of Resident #35's medical record, showed:-Diagnoses included neurofibromatosis (condition characterized by changes in skin coloring and the growth of tumors along nerves in the skin, brain, and other parts of the body);-No physician order for the use of side rails;-No nursing assessment for the use of side rails;-No signed consent for the use of side rails.Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/25, showed:-Cognitively intact;-Upper and lower extremity impairment on both sides;-Dependent for assistance to roll left and right, to move sitting to lying, and to move lying to sitting;-Physical restraints: Bed rails used less than daily.Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has an activities of daily living (ADL) self-care performance deficit;-Tasks included bed mobility - the resident is totally dependent on staff for repositioning and turning;-The care plan failed to identify the resident's use of side rails. Observation on 8/18/25 at 3:28 P.M., showed the resident in bed with full-length side rails raised on both sides of the bed. Observation and interview on 8/19/25 at 8:35 A.M., showed the resident in bed with full-length side rails raised on both sides of the bed. The resident said he/she has minimal movement of his/arms due to tumors on his/her spine. He/She has not had any falls at the facility. He/She cannot turn him/herself. He/She is not sure why he/she has rails on his/her bed because he/she cannot use them. During an interview on 8/20/25 at 9:31 A.M., Registered Nurse (RN) B said he/she did not think the resident had side rails because he/she cannot move his/her arms.2. Review of Resident #11's medical record showed:-Diagnoses included dementia and history of stroke;-No physician order for the use of side rails;-No nursing assessment for the use of side rails;-No signed consent for the use of side rails.Review of the resident's quarterly MDS, dated [DATE], showed:-Short and long-term memory problem;-Partial to moderate assistance required to roll left and right and to move from lying to sitting.Review of the resident's care plan, in use at the time of survey, showed:-Focus: Assist bars - resident has 1/4 rails to increase independence in transferring and/or bed mobility;-Tasks include remove when no longer benefiting resident.Observations on 8/15/25 at 9:29 A.M. and 8/18/25 at 9:14 A.M., showed the resident in bed with U-shaped rails raised on both sides of the bed at the head of the bed. Observation on 8/19/25 at 8:48 A.M., showed the resident in bed with U-shaped rails raised on both sides at the head of the bed. During an interview, the resident said he/she did not know what the rails were or what to do with them. 3. Review of Resident #48's medical record, showed:-Diagnoses included morbid obesity, generalized muscle weakness, lack of coordination, and abnormal posture;-No physician order for the use of side rails;-No nursing assessment for the use of side rails;-No signed consent for the use of side rails.Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Lower extremity impairment on both sides;-Dependent on assistance to roll left and right, to move from sitting to lying, and to move from lying to sitting.Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has an ADL self-care performance deficit and requires maximum assistance;-Tasks included two half-length side rails up to assist with bed mobility. Observation on 8/15/25 at 8:10 A.M., showed the resident in bed with half-length rails raised on both sides of the bed at the head of the bed. Observation and interview on 8/18/25 at 8:46 A.M., showed the resident in bed with half-rails raised on both sides at the head of the bed. The resident said he/she uses the rails for positioning.Observation on 8/19/25 at 9:10 A.M, showed the resident in bed with half-rails raised on both sides at the head of the bed. During an interview on 8/20/25 at 9:31 A.M., RN A said the resident uses side rails for repositioning.4. Review of Resident #10's medical record, showed:-Diagnoses included generalized muscle weakness and anxiety;-No physician order for the use of side rails;-No nursing assessment for the use of side rails;-No signed consent for the use of side rails.Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on assistance to roll left and right, to move sitting to lying, and to move lying to sitting.Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident uses 1/4 rails to increase bed mobility due to diagnosis related to impaired mobility;-Tasks included to remove when no longer benefiting resident. Observation and interview on 8/15/25 at 8:45 A.M., showed the resident in bed with halo-shaped rails raised on both sides of the bed at the head of the bed. The resident said he/she uses the rails when he/she wants to sit up.Observation on 8/19/25 at 9:08 A.M., showed the resident in bed with halo-shaped rails raised on both sides at the head of the bed.During an interview on 8/20/25 at 9:31 A.M., RN A said the resident uses side rails for repositioning.5. Review of Resident #49's medical record, showed:-Diagnoses included morbid obesity and generalized muscle weakness;-No physician order for the use of side rails;-No signed consent for the use of side rails.Review of the resident's Device/Restraint evaluation, dated 11/21/24, showed:-Assessment status: In progress;-Does the resident use or request to use bed rails: Blank;-Device: Side rails;-Medical symptoms necessitating device/restraint: Bed positioning or transferring.Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on assistance to roll left and right, to move sitting to lying, and to move lying to sitting;-Physical restraints: Bed rails used daily.Review of the resident's care plan, in use at the time of survey, showed:-Focus: Assist bars - resident has 1/4 rail to increase independence with bed mobility;-Tasks included: Complete initial assessment and consent per facility protocol. Repeat assessment quarterly or as indicated. Observation and interview on 8/14/25 at 11:51 A.M., showed the resident in bed with quarter-length rails raised on both sides of the bed at the head of the bed. The resident was positioned so his/her upper body was supported by the side rail to his/her left side. The resident said he/she uses the side rails for repositioning.Observations on 8/15/25 at 7:42 A.M. and 8/18/25 at 11:47 A.M., showed the resident in bed with quarter-length rails raised on both sides at the head of the bed. During an interview on 8/20/25 at 9:31 A.M., RN A said the resident uses side rails for repositioning.6. Review of Resident #2's medical record showed:-An admission date of 8/1/13;-Medical diagnoses including hemiplegia and hemiparesis (paralysis, loss of strength, and weakness on one side of the body) of the right side, aphasia (inability to form spoken words), and Parkinson's Disease (a progressive neurodegenerative disorder affecting the brain, primarily causing motor symptoms like tremors, muscle stiffness, and slowness of movement).Observation on 8/14/25 at 11:18 A.M., showed the resident resting in a low bed with 1/2 rails up on both sides of the bed.Observation on 8/15/25 at 8:51 A.M., showed the resident resting in a low bed with 1/2 rails up on both sides of the bed.Observation on 8/18/25 at 2:18 P.M., showed the resident resting in a low bed with 1/2 rails up on both sides of the bed.Review of the resident's assessments showed no assessment conducted or documented indicating the resident was evaluated for safe use of bed rails while residing at the facility.Review of the resident's active physician orders showed no order for bed rails while residing at the facility.Review of the resident's care plan, in use at the time of survey, showed no mention of the resident's use of side rails or the necessity to evaluate the resident for use of the device.During an interview on 8/20/25 at 9:31 A.M., RN A said the resident uses side rails for mobility.7. During interview on 8/20/25 at 8:29 A.M., RN C said any resident with side rails requires a safety assessment to ensure the device is safe for the resident to use. If a resident is deemed safe to use the device, a physician order is obtained by the nursing staff for its use. RN C was unsure how often safety evaluations are repeated, but would assume they are completed at least yearly.8. During an interview on 8/20/25 at 9:31 A.M., RN A said nurses should complete an assessment for the use of side rails upon a resident's admission. Therapy can assess a resident for side rails if the resident is admitted for a short-term stay. A physician order should be obtained for the use of a side rail. Documentation of a resident's consent for the use of side rails is not required.9. During an interview on 8/19/25 at 12:32 P.M., the Director of Rehabilitation said therapy can assess residents for the use of side rails. Once their assessment is documented, they obtain a physician order for the use of side rails, or they give their assessment to the Director of Nurses (DON) for her to obtain the physician order. During an interview on 8/19/25 at 1:55 P.M., the Director of Rehabilitation said she could not locate side rail assessments completed by therapy for Residents #35, #11, #48, #10, or #49. 10. During an interview with the DON and Administrator on 8/20/25 at 1:48 P.M., the DON said she prefers for side rails not to be used. When a resident has side rails, it is usually because their family requested them. If a resident or family member requests side rails, the nurse must obtain a signed consent and document it in the resident's medical record. Nurses should complete an assessment for the resident's ability to use side rails safely. This can also be done by the Director of Rehabilitation. After the initial assessment, neither the DON nor Administrator were sure if the assessment is done again. If a resident is determined to be able to use side rails, a physician order must be obtained.

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice when one resident (Resident #27) did not receive his/her routine anti-anxiety medication as prescribed for over two weeks. The facility also failed to document accurate weights on one resident (Resident #10) and failed to document when two residents (Resident #9 and Resident #68) left the facility for outside appointments and when the residents returned to the facility. The sample was 18. The census was 75. Review of the facility's Medical Provider Orders policy, revised 4/7/23, showed:-Policy: The facility shall use uniform guidelines for the ordering and following of medical provider orders;-Following of Medication and/or Treatment Orders;-Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order;-The policy did not provide guidance for processes on reordering medications or pulling medications from the emergency kit (E-kit) if a prescribed medication was unavailable.Review of the facility's Weight Monitoring Program Guidelines policy, dated 10/11/10, showed:-The Director of Nursing (DON)and the Staff Development Coordinator will be responsible for monitoring the weights of each resident in the facility;-All new admissions will be added to the weekly schedule for the first four weeks after admission; After that time the assigned Nurse Manager will assess the stability of the resident's weight and decide when to continue to monitor the residents weight on a weekly basis or monthly basis. -The Nurse Manager will monitor on a weekly basis if the residents will be added to or removed from the weekly weight list;-The Nurse Manager will review significant weight gains and losses. 1. Review of Resident #27's medical record, showed:-Diagnoses included anxiety;-A physician order, dated 9/12/24, for clonazepam 1 milligram (mg), one tablet by mouth at bedtime for anxiety.Review of the resident's July and August 2025 Medication Administration Record (MAR) and progress notes related to clonazepam, showed:-A nurse's note, dated 7/31/25, showed the medication was ordered;-A nurse's note, dated 8/5/25, showed the medication is out of stock;-A nurse's note, dated 8/8/25, showed waiting on pharmacy to deliver medication;-A nurse's note, dated 8/9/25, showed waiting on medication to be sent by pharmacy, no access to E-kit;-A nurse's note, dated 8/11/25, showed waiting on medication from pharmacy;-A health status note, dated 8/11/25, showed nurse spoke to the resident's primary care physician, Physician EE, regarding resident's clonazepam. Per Physician EE, the facility's psychiatrist, Physician FF, was responsible for filling the script. Pharmacy contacted. Per pharmacy, will send additional request to Physician FF for medication. Resident made aware;-Staff documented 9 to indicate medication not received on 16 occasions from 7/26/25 through 8/13/25.Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/13/25, showed the resident cognitively intact.Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has a potential psychosocial well-being problem related to anxiety;-Focus: The resident has a mood problem;-Tasks included the resident is taking anti-anxiety medications.During an interview on 8/18/25 at 12:04 P.M., the resident said there are issues with getting some medications consistently. He/She was recently out of clonazepam for two weeks. The clonazepam was back in stock within the past week. The facility needed a script from a psychiatrist. Two weeks was too long to be without his/her medication. He/She takes clonazepam for anxiety. He/She had an increase in anxiety during his time without the medication. During an interview on 8/19/25 at 8:51 A.M., Licensed Practical Nurse (LPN) J said the resident was out of clonazepam. The facility was waiting on a signed script from Physician EE. The resident even personally called Physician EE to request refills. Facility nurses have sent scripts and tried contacting Physician EE. When a resident is out of medication, they should notify the physician to get the order filled and pass the information along to the oncoming shift.During an interview on 8/20/25 at 9:31 A.M., Registered Nurse (RN) A said the resident's clonazepam was received on 8/13/25 after being out of stock for two weeks. Physician EE is the resident's physician, but cannot prescribe narcotic medication, so the medication has to be prescribed by Physician FF. The facility has issues getting a hold of Physician FF. When the resident's clonazepam ran out, staff should have pulled it from the E-kit. When a nurse pulls narcotics from the E-kit, it has be removed in the presence of two witnesses. The facility uses some agency nurses and they do not have access to the E-kit, so this is another problem. The resident should not have been without his/her medication for two weeks. People cannot just stop taking medications like that right away. During an interview on 8/19/25 at 11:04 A.M., the DON said there have been ongoing issues getting a response from Physician EE. Clonazepam is a narcotic medication and Physician EE cannot prescribe narcotics, so he/she refers his/her residents to the psychiatrist, Physician FF, for narcotic anxiety medication, or to a pain management clinic for narcotic pain medication. This results in delays in residents getting some of their medications. If a resident is out of their prescribed narcotic medication and Physician EE is their primary physician, nurses should reach out to the facility's medical director, Physician GG, regarding the issue. Nurses could also check the E-kit for the medication.Review of the facility's E-kit Active Inventory list, reviewed 8/19/25, showed a quantity of 23 clonazepam 0.5 mg tablets on hand.During an interview with the DON and Administrator on 8/20/25 at 1:48 P.M., they said they expected residents to receive their medications as prescribed. If a narcotic medication is not on hand, staff should call the pharmacy and place a STAT (immediate) order for the medication, which would require a script from the physician. Since Physician EE cannot prescribe narcotic medication, staff could contact the medical director, Physician GG. Staff should pull the medication, if available, from the E-kit. If a medication is not administered, the physician should be notified. Two weeks was too long for the resident to be without his/her anxiety medication. 2. Review of Resident #10's quarterly, MDS, dated [DATE], showed:-Diagnoses included: Malnutrition (inadequate nutrition), dysphagia (difficulty swallowing), gastrostomy status (a tube surgically inserted into the abdomen that is used for medications, liquid nutrition), and adult failure to thrive. Review of the resident's care plan, in use at the time of the survey, showed the care plan did not note the resident's weekly weights. Review of the resident's physician order sheets, dated, August, 2025, showed:-An order, dated 4/7/25, weekly weights, every Monday, day shift. Review of the resident's weight summary located in the resident's medical records, showed:-On 6/16/25: 112.0 pounds (lbs.);-On 6/30/25: 108.0 lbs;-On 7/7/25: 107.0 lbs;-On 7/7/25: 113. 4 lbs;-On 7/14/25: 116.0 lbs;-On 7/21/25: no weight. Review of the resident's paper documentation of weekly weights showed:-On 6/16/25: 110 lbs;-On 6/30/25: 113.4 lbs;-On 7/7/25: 116.0 lbs;-On 7/14/25: 112.0 lbs;-On 7/21/25: 112.0 lbs. During an interview on 8/18/25 at 1:10 P.M., LPN J said the Restorative Aide (RA) obtains all the weights. The RA will then inform the nurse verbally of the weight and the nurse places the weight in the electronic medical record (EMR). During an interview on 8/19/25 at approximately 10:00 A.M., RA W said he/she was responsible to complete all the weights. Weekly weights were completed every Monday. Once the weights are obtained RA W writes them on the weekly weight sheet, and the sheet is kept in his/her office. RA W said he/she will either verbally communicate the resident's weights to the nurse or write the resident's weights on a separate piece of paper and hand it to the nurse. RA W said he/she was instructed by the former DON that he/she is not allowed to place the residents' weights directly into their EMR. RA W said it would be better if he/she could directly place the weights in the EMR so there would be no delays, confusion or inaccuracy of the weights. During an interview on 8/20/25 at 1:27 P.M., the DON said the Charge Nurse on the floor oversees the residents' weights. The RA was responsible to obtain the weights and place them in the EMR. All weights were expected to be added into the EMR timely and accurately to avoid any inaccuracy about the weights. She was not aware that the RA was not placing the weights directly into the EMR. 3. Review of Resident #9's medical record showed diagnoses that include atrial fibrillation (irregular heartbeat), stroke, slurred speech, pacemaker, heart failure, infection of cardiac devices, and muscle weakness. Review of the resident's request transportation form showed:-On 5/20/25 , eye doctor appointment;-On 5/27/25, cardiology (heart) doctor appointment;-On 5/30/25, infectious disease doctor appointment-On 7/15/25 , foot and ankle surgery doctor appointment;-On 8/14/25, wellness visit appointment;-On 8/19/25, foot and ankle surgery doctor appointment. Review of the resident's progress notes showed:-On 5/20/25, no documentation related to the eye doctor's appointment;-On 5/27/24, no documentation related to the cardiology doctor's appointment;-On 5/30/25 at 9:38 A.M., the nurse received a call that the resident arrived late to the appointment, and the appointment was rescheduled for 8/4/25;-On 7/15/25, no documentation related to the foot and ankle surgery doctor's appointment;-On 8/4/25, no documentation related to the rescheduled infectious disease doctor's appointment;-On 8/14/25, no documentation related to the wellness visit appointment;-On 8/19/25, no documentation related to the foot and ankle surgery doctor's appointment. 4. Review of Resident #68's medical record showed diagnoses that included stroke, high blood pressure, edema (swelling), breast cancer, cardiomegaly (weakened and enlarged heart), atrial fibrillation, and lumbar (lower back) radiculopathy (nerve irritation or compression that causes pain). Review of the resident's request transportation forms showed:-On 5/15/25, primary care doctor appointment;-On 5/20/25, eye doctor appointment;-On 6/13/25, pain management doctor appointment;-On 6/17/25, neurology (brain and nervous system) doctor appointment;-On 7/10/25, pain management doctor appointment. Review of the resident's progress notes showed:-On 5/15/25, no documentation related to the primary care doctor's appointment;-On 5/20/25, no documentation related to the eye doctor's appointment;-On 6/13/25, no documentation related to the pain management doctor's appointment;-On 6/17/25, no documentation related to the neurology doctor's appointment;-On 7/10/25, no documentation related to the pain management doctor's appointment. During an interview on 8/19/25 at approximately at 10:15 A.M., the resident said he/she has many doctor appointments due to his/her many medical conditions. Some of his/her appointments are missed due to transportation delays. 5. During an interview on 8/19/25 at 9:25 A.M., LPN J said when the residents go out to any appointments, there should be a note that the resident left for the appointment and when the resident returned. The return note should contain the condition of the resident, any information the resident said about the appointment and any new orders related to the appointment and when the next appointment is scheduled; all that information should be documented in the progress notes. 6. During an interview on 8/20/25 at 1:27 P.M., the Administrator and DON said a progress note is expected to be added every time the resident leaves for an appointment and when they return. The notes are expected to include when the resident left and where they were going. When the resident returns, a note is expected to include what time the resident returned and if there are any new recommendations, orders or appointments that need to be added to the resident's medical record. If the resident does not go to the appointment a note is expected to be added related to the missed appointment. 1611982

Based on observation, interview and record review, the facility failed to ensure residents received an accurate assessment reflective of the residents' status at the time of assessment by coding side rails as restraints on the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) for four residents who were determined to use side rails without restriction of freedom of movement (Residents #49, #10, #11, and #35). The sample was 18. The census was 75.Review of the facility's Resident Assessment Instrument (RAI) policy, created 4/14/25, showed facility will adhere to Centers for Medicare and Medicaid Services (CMS) regulations which are considered the definitive source in completion of the RAI process. This includes coding the MDS with accuracy, completion of Care Area Assessments (CAAs) and the development of the comprehensive care plan. Facility will use the CMS RAI manual for completion of the RAI process.Review of the CMS Long-Term Care (LTC) Facility RAI 3.0 User's Manual, revised October 2024, showed:-Section P: The intent of this section is to record the frequency that the resident was restrained by any of the listed devices, at any time during the day or night, during the 7-day look=back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definitions in the appropriate categories;-Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.1. Review of Resident #49's medical record, showed diagnoses included morbid obesity and generalized muscle weakness.Review of the resident's Device/Restraint evaluation, dated 11/21/24, showed:-Device: Side rails;-Medical symptoms necessitating device/restraint: Bed positioning or transferring;-Does this device meet the definition of a restraint per the RAI manual: No.Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on assistance to roll left and right, to move sitting to lying, and to move lying to sitting;-Physical restraints: Bed rails used daily.Review of the resident's care plan, in use at the time of survey, showed:-Focus: Assist bars - resident has 1/4 rail to increase independence with bed mobility;-Tasks included: Complete initial assessment and consent per facility protocol. Repeat assessment quarterly or as indicated. Observation and interview on 8/14/25 at 11:51 A.M., showed the resident in bed with quarter-length rails raised on both sides of the bed at the head of the bed. The resident was positioned so his/her upper body was supported by the side rail to his/her left side. The resident said he/she uses the side rails for repositioning.2. Review of Resident #10's medical record, showed diagnoses included generalized muscle weakness and anxiety.Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on assistance to roll left and right, to move sitting to lying, and to move lying to sitting;-Physical restraints: Bed rails used less than daily.Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident uses 1/4 rails to increase bed mobility due to diagnosis related to impaired mobility;-Tasks included to remove when no longer benefiting resident. Observation and interview on 8/15/25 at 8:45 A.M., showed the resident in bed with halo-shaped rails raised on both sides of the bed at the head of the bed. The resident said he/she uses the rails when he/she wants to sit up.3. Review of Resident #11's quarterly MDS, dated [DATE], showed:-Short and long-term memory problem; -Partial to moderate assistance required to roll left and right and to move from lying to sitting;-Diagnoses included dementia and history of stroke;-Physical restraints: Bed rails less than used daily.Review of the resident's care plan, in use at the time of survey, showed:-Focus: Assist bars - resident has 1/4 rails to increase independence in transferring and/or bed mobility;-Tasks included to remove when no longer benefiting resident.Observation and interview on 8/19/25 at 8:48 A.M., showed the resident in bed with U-shaped rails raised on both sides of the bed at the head of the bed. The resident said he/she did not know what the rails were or what to do with them. 4. Review of Resident #35's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Upper and lower extremity impairment on both sides;-Dependent for assistance to roll left and right, to move sitting to lying, and to move lying to sitting;-Diagnoses included neurofibromatosis (condition characterized by changes in skin coloring and the growth of tumors along nerves in the skin, brain, and other parts of the body);-Physical restraints: Bed rails used less than daily;Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has an activities of daily living (ADL) self-care performance deficit;-Tasks included bed mobility - the resident is totally dependent on staff for repositioning and turning;-The care plan failed to identify the resident's use of side rails. Observation and interview on 8/19/25 at 8:35 A.M., showed the resident in bed with full-length side rails raised on both sides of the bed. The resident said he/she has minimal movement of his/arms due to tumors on his/her spine. He/She has not had any falls at the facility. He/She cannot turn him/herself. He/She is not sure why he/she has rails on his/her bed because he/she cannot use them. 5. During an interview on 8/19/25 at 2:48 P.M., the MDS Coordinator said restraints are not used by any resident in the facility. When a resident uses side rails, she marks them as in use in the restraint section of the MDS. She was not aware that if side rails are not used as a restraint, she should not mark them as in use in the restraint section.6. During an interview on 8/20/25 at 7:32 A.M., the Administrator said restraints are not used by any resident in the facility. Side rails used by residents are to assist with repositioning are not a restraint. Side rails used for repositioning should not be marked as restraints on the MDS. He expects the MDS Coordinator to code items in accordance with the guidelines outlined in the RAI Manual.

Based on observation, interview and record review, the facility failed to have a system in place to safeguard resident's personal belongings for two residents (Resident # 68 and Resident #9). The facility also failed to have an admissions policy that did not require residents to waive the facility of liability for loss of personal property. The sample was 18. The census was 75. Review of the facility's current admission packet showed:Personal Property of Resident: The resident is strongly urged to mark all his or her clothing and personal property for easy identification. The resident or authorized representative will be responsible to complete a personal items inventory sheet and update the inventory sheet as needed. The facility shall not be liable for any resident's items that are lost or stolen, with the exception of those items noted for replacement under state guidelines that the facility might reside. 1. Review of Resident #68's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 5/9/25, showed:-An admission date of 5/5/24;-The resident is cognitively intact;-The resident is dependent on staff for personal hygiene, toilet hygiene, upper and lower body dressing, and bed to chair transfer;-The resident uses a wheelchair. Review of the resident's inventory of personal effects sheet, dated, 5/5/24, showed:-Dresses: Several-Ladies sweaters: Several;-Gloves: Several;-One small refrigerator;-Cell phone;-Remarks: The family member will notify the staff after any new items are brought in;-Signed by family representative. 2. Review of Resident #9's, comprehensive MDS, dated , 6/9/25, showed:-An admission date 6/10/24;-The resident is cognitively intact;-The resident is dependent on staff for personal hygiene, toilet hygiene, upper and lower body dressing, and bed to chair transfer;-The resident uses a wheelchair. Review of the resident's inventory of personal effects sheet, dated, 6/10/24, showed:-House slippers: One pair;-Slacks: Several;-Men's hats: Several;-Socks: Several;-Pajamas: Yes;-Shaving kit: Yes;-Small refrigerator; -Remarks: The family member will notify the staff after any new items are brought in;-Signed by family representative. Observation and interview on 8/18/25 at approximately 9:00A.M., showed Resident #68 and Resident #9 share a room. The room had a large curio cabinet with multiple figurines, a land line cordless phone, multiple body lotions, colognes and perfumes, a large digital clock and multiple plastic chest of drawers filled with personal items and snacks. The closets on both sides of the room were filled with multiple clothing items. Resident #68 said about four months ago, he/she had an iPad (computer tablet) and now it is missing. Resident #9 said he/she had a pair of brown shoes that had a non-skid sole so that he/she could wear them to physical therapy. Resident #9 said his/her family member paid $45.00 for the shoes about two weeks ago, and now the shoes are missing. Resident #68 and Resident #9 said staff looked for the shoes, but they could not find them. Resident #68 and Resident #9 said they have not been compensated for their missing items or been offered a lock box to secure items. During an interview on 8/19/25 at 8:55 A.M., the Social Service Director (SSD) said she normally just adds the larger items and more expensive items to the inventory list on admission and the Certified Nursing Assistants (CNAs) are responsible for updating the inventory list when new items arrive to the resident's room. The inventory sheets are kept in her office in a book. CNAs can write new items that the resident receives on a piece of paper or inform the SSD verbally and the SSD will then add the items to the list. The SSD said the process of inventory sheets has not been completed lately. During an interview on 8/19/25 at approximately 9:00 A.M., CNA B said there is an inventory sheet for staff to fill out when a resident is admitted or when any new items come in for a resident. CNA B said he/she does not know where the inventory sheets are kept or who is responsible to keep them updated. During an interview on 8/19/25 at 9:25 A.M., Licensed Practical Nurse (LPN) J said he/she was not sure how the inventory sheets are being completed or who is responsible to fill them out. During interviews on 8/20/25 at 1:47 P.M. and on 8/26/25 at 1:38 P.M., the Administrator said he would expect the inventory list to be completed accurately on admission and when the resident receives new items. He was not aware of Resident #68's missing iPad and Resident #9's missing shoes. The admission Director is responsible for initiating the inventory sheets on admission and the CNAs are responsible to add items as needed to the list. This process is currently not in place, and he is aware the inventory sheets are not being filled out. The Administrator said he was not familiar with the verbiage in the admission packet and was not aware of that the admission packet stated the facility is not responsible for lost or stolen items. The admission packet needs to be updated to clearly reflect the regulations related to the residents' personal belongings.

Based on observation, interview and record review, the facility failed to provide a homelike environment to all residents in the facility by failing to keep resident rooms at a comfortable temperature and cleanliness (Residents #26, #1, #64), ensuring bed sheets are changed when soiled (Resident #47) and failing to keep resident shower rooms free of obstruction. Concerns were noted with the cleanliness of resident rooms for four out of 18 sampled residents in addition to resident shower rooms on the [NAME] hall. The census was 75.1. Review of Resident #26's medical record, showed diagnoses included bipolar disorder (mood disorder that can cause intense mood swings), depression, seizure disorder, generalized muscle weakness, difficulty walking, unsteadiness on feet, and other abnormalities of gait and mobility.Observation on 8/15/25 at 12:27 P.M., showed the resident seated on the side of his/her bed with a small fan on his/her bedside table. The air conditioning (AC) unit beneath the window set to cool, on and blowing warm air, with its external gauge showing 65 degrees Fahrenheit (F). A calibrated thermometer showed the resident's room at 80.2 degrees F. The outside temperature was 92 degrees F. During an interview, the resident said his/her room was hot. His/Her AC has been broken for months, all summer. He/She reported it to maintenance, but they have not fixed the unit. He/she preferred his/her room to be cool, around 65 degrees F, especially when he/she sleeps. During the interview, Housekeeper X entered the room. He/She said it was too hot in the resident's room. Observations on 8/18/25, showed:-At 1:29 P.M., the resident on his/her side in bed. The AC unit underneath the window set to cool, on and blowing warm air, with its external gauge showing 65 degrees F. A calibrated thermometer showed the resident's room at 83.4 degrees F. The outside temperature was 93 degrees F. During an interview, the resident said he/she was [NAME] hot;-At 4:07 P.M., the resident seated in bed. The AC unit underneath the window set to cool, on and blowing warm air, with its external gauge showing 65 degrees F. A calibrated thermometer showed the resident's room at 83.8 degrees F. The outside temperature was 95 degrees F. During an interview, the resident said it was too hot in his/her room.Review of the maintenance communication log at the nurse's station, reviewed on 8/18/25 at 4:14 P.M., showed no documentation over the past two months regarding the resident's AC unit. During an interview on 8/20/25 at 8:10 A.M., Certified Nurse Aide (CNA) T said when staff notice issues with a resident's AC unit, they should document it in the maintenance log at the nurse's station.During an interview on 8/20/25 at 11:07 A.M., the Maintenance Director and Administrator said the facility is trying to get new AC units for resident rooms. They received a couple new units, but they were the wrong type. When staff first notice a maintenance issue in a resident's room, such as a broken AC unit, they should document the issue in the maintenance communication binder at the nurse's station. This binder is checked daily by maintenance staff. Prior to 8/18/25, the Maintenance Director said the resident always told Maintenance Assistant Y about the AC unit. The unit is blowing cool air but does not cool the entire room and probably needs to be replaced. The temperature in a resident's room should not exceed 82 degrees F. 2. Review of Resident #1's annual MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included Ogilvie syndrome (acute dilation of the colon) COPD (chronic obstructive pulmonary disease), and major depressive disorder.Observation and interview on 8/14/25 at 11:07 A.M., showed dirty depends on the floor next to the resident's bed with brown matter on them. [NAME] liquid matter was on the floor next to the depends. [NAME] liquid splatters were in various areas of the floor in the room and bathroom. Multiple flies flew around the resident's room. The resident's mattress had a large brown matter stain with flies on the stain. The resident said staff come in to clean his/her room but he/she would like his/her room cleaned more frequently.Observation on 8/18/25 at 7:07 A.M., showed the resident's room had an odor of feces permeating from the room. Bowel movement (BM )smears were on the floor next to the resident's bed alongside a used incontinence brief. [NAME] matter splatter was on the wall next to the bedroom door above the trash can. [NAME] matter was on the call light, which was on the ground next to the resident's bed. Two flies flew around the resident's bed. During an interview on 8/20/25 at 9:46 A.M., Registered Nurse (RN) C said when cleaning up bodily fluids, nursing staff are to clean the bodily fluids up and then the housekeeping staff come behind and do a deep cleaning of the area. He/She expected resident rooms, medical equipment and furniture to be free from bodily fluids and debris. 3. Review of Resident #64's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included type two diabetes, muscle weakness and major depressive disorder. Observation on 8/14/25 at 11:17 A.M., showed the bathroom toilet to have brown and yellow matter on the seat and sides. The floor surrounding the toilet had brown matter. Trash and debris were surrounding the resident's nightstand. Observation on 8/15/25 at 7:54 A.M., showed the bathroom toilet to have brown and yellow matter on the seat and sides. The floor surrounding the toilet had brown matter. Trash and debris were surrounding the resident's nightstand. Observation on 8/19/25 at 10:49 A.M., showed trash and food debris surrounding the resident's bed and nightstand. Observation and interview on 8/20/25 at 9:25 A.M., showed trash and food debris on the floor surrounding the resident's bed. The resident said he/she does not feel that the housekeeping staff clean his/her room or bathroom enough. He/She has to use the shower room to use the bathroom when his/her bathroom is not clean. During an interview on 8/20/25 at 9:51 A.M., Housekeeping Aide M said both Resident #1 and Resident #64 are nightmare residents to clean after and always make messes in their rooms. He/She said he/she does not like to clean their rooms. 2. Review of Resident #47's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included depression, seizure disorder, and history of stroke;-Partial/moderate assistance with walking 10 feet.Observation on 8/14/25 at 11:08 A.M., showed the resident seated in a chair next to his/her bed. The fitted sheet over the mattress had a yellow stain, approximately five inches long, and small dark brown chunks on top of the sheet. During an interview, the resident said he/she is unsteady on his/her feet and needs staff to assist with changing the sheets on his/her bed. The sheets are supposed to be changed daily.Observation on 8/15/25 at 8:15 A.M., showed the resident seated on the side of his/her bed. The same fitted sheet with a yellow stain on the mattress of his/her bed. During an interview, the resident said staff have not helped him/her change his/her sheets. Observation on 8/19/25 at 12:22 P.M., showed the resident on his/her back in bed with eyes closed. The same fitted sheet with a yellow stain was on his/her mattress of his/her bed. During an interview on 8/20/25 at 8:10 A.M., CNA T said the resident needs help changing his/her sheets and making his/her bed. CNAs are responsible for changing sheets on resident beds. Sheets should be changed on shower days and as needed.During an interview on 8/20/25 at 8:24 A.M., CNA B said CNAs are responsible for changing the sheets on resident beds. Sheets should be changed daily.During an interview on 8/20/25 at 1:48 P.M., the Director of Nurses (DON) and Administrator said CNAs are responsible for changing the sheets on resident beds. Sheets should be changed at least every three to five days, and as needed. Some nursing staff change sheets on shower days. 5. Observation on 8/14/25 at 11:51 A.M., 8/15/25 at 8:58 A.M. and 8/18/25 at 12:31 P.M., of the Hydrotherapy Room near the [NAME] nurse's station, showed the space filled with two Hoyer (full body lifts) lifts, one sit-to-stand lift, two wheelchairs and a bedside commode blocking the path to the walk-in hydrotherapy tub. A loose ceiling tile just above the doorway created an opening into the ceiling and electrical wiring above. 6. Observation on 8/14/25 at 5:32 P.M., 8/15/25 at 1:38 P.M. and 8/18/25 at 8:32 A.M. of the shower room near the [NAME] nurse's station, showed the space contained a Hoyer lift, a sit to stand lift, and a clean linen cart blocking the path into the shower stalls. During interview on 8/20/25 at 8:25 A.M., Housekeeping Aide M said lifts should not be stored in shower rooms or other resident areas as this is not homelike to residents and it makes using these areas harder for staff and residents. Storing lifts in the shower rooms also makes it harder for housekeeping staff to keep those areas clean. 7. During an interview on 8/20/25 at 10:18 A.M., the Environmental Services Director said he expected nursing staff to inform housekeepers if there are any rooms that need more cleanings on top of the regular scheduled cleanings. He expected resident rooms to be free from trash, food and matter debris, and bodily fluids. He expected resident rooms to be free from flies and other pests. Shower rooms located on resident halls should be kept clean and free of obstructions such as carts and lifts. 8. During an interview on 8/20/25 at 1:48 P.M., the Administrator and DON said they expected all resident rooms in the facility to be kept in a clean, homelike manner, including changing sheets and cleaning up food or other biological debris from the room daily and as needed. Resident rooms should be equipped with air conditioning and heating elements that are in working condition to provide a comfortable, homelike environment to the residents. Shower rooms should be kept organized in a manner that allows residents to use the space without being blocked by equipment.

Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified manner affecting 5 of 18 sampled residents (Residents #1, #58, #64, #28 and #5). The census was 75. Review of the facility's resident's rights policy, undated, showed:-Employees shall treat all residents with kindness, respect, and dignity;-Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his or her rights to assure that the resident is always treated with respect, kindness, and dignity;-Respect: Treat others as you want to be treated-every person matters. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 5/31/25, showed:-Cognitively intact;-Diagnoses included Ogilvie syndrome (acute dilation of the colon), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and major depressive disorder. Observation on 8/15/25, in the resident's room, showed:-At 7:33 A.M., Restorative Aide W came into the resident's room and started to clean the room. He/She put on gloves, grabbed a paper towel and then wiped up a pile of bowel movement (BM) located near the resident's bed. He/She turned to the resident and said why did you put this on the ground? You have all these nasty wet clothes. You need to clean this up.;-At 7:39 A.M., he/she walked to the resident's door and grabbed the doorknob with one gloved hand while he/she grabbed the dirty linen cart with his/her other gloved hand. He/She said this resident is always making messes. Observation on 8/15/25 at 8:03 A.M., showed the resident sat in a chair next to the nurse's station. Housekeeping Aide M turned and said, you have to excuse me. This one (gesturing towards resident) and I [NAME] multiple times a day. He/She likes to make messes and throw BM all over. The resident looked up towards where Housekeeping Aide M was standing, visibly upset with a frown. During an interview on 8/15/25 at 8:07 A.M., Restorative Aide W said that is how he/she always talks to the resident. He/She said it hard to work with the resident and the resident should be cleaning up his/her own messes. During an interview on 8/20/25 at 1:48 P.M., the Director of Nurses (DON) and Administrator said staff should speak to residents in a respectful manner. It is not appropriate for staff to express displeasure with residents in front of them. 2. Review of Resident #58's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included anxiety, depression, and mental disorder not otherwise specified. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has a potential psychosocial well-being problem;-Goal: The resident will demonstrate adjustment to nursing home placement by/through review date;-Tasks included allow the resident time to answer questions and to verbalize perceptions and fears. Observation on 8/18/25 at 1:00 P.M., showed the resident propelled into the dining room in his/her wheelchair. The Dietary Manager (DM) passed a lunch tray behind the resident, then bumped into the resident's wheelchair. The Dietary Manager said something in a stern, loud, and rude voice and said, You should have said hi, I'm behind you, and walked away from the resident. At 1:10 P.M., the resident asked dietary staff for silverware. As the DM prepared trays at the food prep line within earshot of the resident, the DM said, We're not doing this today. The resident asked the DM for a plate of food and said he/she did not want a burger and wanted to eat whatever was on the menu. The DM said, It's too late, you already asked for a burger. The resident asked why it was too late and said he/she had the right to change his/her mind. The DM ignored the resident and continued plating food for other residents in the dining room. During an interview on 8/18/25 at 1:23 P.M., Certified Nursing Assistant (CNA) I said the DM speaks rudely to the residents all the time. He/She said he/she goes out of his/her way to not work in the dining room during meals so he/she does not have to hear the DM speak to residents. During an interview on 8/18/25 at 1:32 P.M., the resident said fettuccine was served at lunch. He/She wanted a burger with a side of fettuccine and one of the staff told him/her it was ok to ask for that. The DM said no, he/she could not have what was requested. The way the DM talked to him/her was not very nice. During an interview on 8/19/25 at 8:51 A.M., Licensed Practical Nurse (LPN) J said some of the dietary staff is rude and they get upset with residents asking for things, particularly the DM. Staff should speak to residents nicely and try to accommodate them.During an interview on 8/19/25 at 9:47 A.M., CNA S said the DM talks to people rudely. Residents should get what they request and should be able to ask for things without getting yelled at. During an interview on 8/19/25 at 1:56 P.M., the DM said residents should be treated with dignity and respect. She said she did not intentionally speak rude to the resident. The resident tries to order food too late all the time and it aggravates her. During an interview on 8/20/25 at 1:48 P.M., the DON and Administrator said staff should speak to residents in a respectful manner. It is unacceptable for staff to yell at residents. If these issues are observed by other staff, staff should report their observations to Administration. 3. Review of Resident #64's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included type two diabetes, muscle weakness and major depressive disorder. Observation on 8/19/25 at 8:38 A.M., showed the resident having a conversation with a surveyor. He/She said that he/she was told he/she could only have three bowls of cereal. The DM came up to the table where the resident was having a conversation and said, that didn't come from us in the dietary department. The resident asked the DM to not butt into his/her conversation. The Dietary Manager walked into the kitchen and yelled through the kitchen window, how many bowls do you want, the resident responded with one bowl and a cup of coffee. The DM brought the bowl of cereal to the table and when the resident said thank you, the DM turned without responding and walked back into the kitchen, muttering under her breath. During an interview on 8/19/25 at 1:56 P.M., the DM said residents should be treated with dignity and respect. She said she did not intentionally speak rudely to the resident. She said her tone could have been nicer. During an interview on 8/20/25 at 1:48 P.M., the DON and Administrator said staff should speak to residents in a respectful manner. It is unacceptable for staff to yell at residents. If these issues are observed by other staff, staff should report their observations to Administration. 4. Review of Resident #28's admission MDS, dated [DATE], showed:-Moderately impaired cognition;-Diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis) affecting the dominant right side, type two diabetes and acute kidney failure. Observation on 8/18/25, of the resident in the dining room, showed:-At 8:40 A.M., the resident was seated in the dining room for breakfast. The resident struggled to open a carton of juice with one hand. He/She called out for someone to help him/her;-At 8:46 A.M., CNA I walked past the resident's table. The resident started to ask for help but CNA I walked past him/her;-At 8:49 A.M., the Restorative Aide W walked up to the resident's table. The resident asked him/her for help. Restorative Aide W walked away without assisting the resident;-The resident poked a hole in the seal with a finger in order to open his/her drink. During an interview on 8/18/25 at 9:52 A.M., the resident said no staff ever help him/her in the dining room. They walk away before he/she can even finish asking for help. During an interview with on 8/20/25 at 1:48 P.M., the DON and Administrator said any staff member can assist a resident with opening a food package or retrieving new silverware. They expected staff to assist residents with meals and not ignore the residents or walk away while the residents are talking. 5. Review of Resident #5's medical record, showed:-Diagnoses included hypertension (high blood pressure), end stage renal disease (ESRD, permanent kidney failure requiring transplant or dialysis for survival), history of transient ischemic attack (TIA, a temporary interruption in blood flow to the brain causing stroke-like symptoms) and Type 2 diabetes. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: the resident is at risk for falls as evidenced by a fall the resident suffered on 3/5/25; -Interventions: Ensure personal items were within the resident's reach. Ensure the resident's call light is within reach for the resident to use in order to ask for assistance. During an interview on 8/18/25 at 7:40 A.M., the resident said a few days ago a member of the night shift, CNA P, got into a power struggle with him/her over the call light. The resident said CNA P attempted to pull the call light away from him/her in order to prevent him/her from using it for the rest of the night. The resident said the staff member told him/her this would prevent the resident from pressing it all night and bothering staff on the hall. The resident said he/she felt disrespected by the staff member during that interaction, and these undignified interactions happen with other staff members as well. During an interview on 8/18/25 at 8:39 A.M., the Administrator said the resident came to his office on 8/17/25 to discuss the alleged incident with CNA P. The resident was assessed and found without injury. The resident did not allege abuse occurred and did not state he/she was in pain but felt the treatment given to him/her by CNA P was undignified. CNA P was removed from the future schedule at that time while the facility investigated the incident. The Administrator had not been able to successfully contact CNA P to discuss the alleged incident. 2588074 25793742572384161199516119822591662

Based on interview and record review, the facility failed to maintain documentation and provide evidence of an ongoing Quality Assurance and Performance Improvement (QAPI) program that demonstrated systemic identification, reporting, investigation, analysis, and prevention of adverse events, and development, implementation, and evaluation of corrective actions or performance improvement activities. The census was 75.During an interview on 8/14/25 at 10:21 A.M., the Director of Nurses (DON) and Administrator said they began working at the facility approximately two months ago. Quality Assessment and Assurance (QAA) meetings should take place monthly and should be attended by the facility's department heads and Medical Director. The DON and Administrator were asked to provide documentation of the facility's QAPI plan. During an interview on 8/20/25 at 12:13 P.M., the Minimum Data Set (MDS) Coordinator said she has been a department head at the facility for two years. When the facility has QAA meetings, they are attended by department heads. When she attends the meetings, she brings a form that lists quality measures and areas of improvement or concern. Each department head discusses concerns within their department and the team comes up with a plan to address the concerns. There has been one QAA meeting this year and the last meeting was several months ago. They have not had any Performance Improvement Plans (PIPs) in months. The facility does not have any focus areas as far as QAPI goes right now. During an interview on 8/20/25 at 1:05 P.M., the Rehabilitation Manager said during QAA meetings, department heads write down their caseload, goals, what they need to work on, and a plan of correction. Their last QAA meeting was in April. The department heads meet for risk meetings every day, in which they discuss new business and things like who fell yesterday. There is no discussion of trends in the risk meetings. During an interview on 8/20/25 at 1:09 P.M., the Social Services Director said during QAA meetings, department heads meet to discuss identified problems and solutions. She held a QAA meeting in April 2025 when she was interim Administrator. There has not been a QAA meeting since April 2025. Dietary is the facility's biggest focus right now. She is also focused on trying to do more activities and hiring staff. The facility is not working on facility-wide PIPs at this time. During an interview on 8/18/25 at 10:12 A.M., the Administrator said the facility's last QAA meeting was in April 2025. He started working with the facility in June 2025 and has not had any QAA meetings, yet. QAA meetings are held to review key points he has identified and other trends in the facility. Items reviewed include falls, medication errors, grievances, and dietary issues. Once facility trends are identified, they are reviewed in QAA meetings to ensure all department heads are aware of the issues and they develop plans as a team to address the identified issues.During an interview on 8/20/25 at 10:52 A.M., the Administrator said the facility does not have a QAPI policy. The Director of Operations said the facility should follow the regulations in terms of timeliness, parties in attendance, and topics of discussion. During an interview on 8/20/25 at 4:49 P.M., the Administrator was asked to provide documentation of the facility's QAPI program. During an interview on 8/21/25 at 8:46 A.M., the Administrator was asked to provide documentation of the facility's QAPI program.Review of a QAPI Program, undated, submitted by the Administrator on 9/1/25 at 3:19 P.M., after the survey exit on 8/20/25, showed:-The facility will maintain a comprehensive, facility-wide QAPI Program. The program is designed to ensure continuous monitoring, evaluation, and improvement of resident care, staff performance and facility operations;-This program follows Centers for Medicare and Medicaid Services (CMS) QAPI requirement and will focus on resident-centered care, timeliness and accuracy of documentation, operational efficiency, and staff accountability and training.During an interview on 9/2/25 at 2:53 P.M., the Administrator said the QAPI Program he submitted on 9/1/25 is what he drafted after survey. He will discuss QAPI Program in the facility's upcoming QAPI meeting, scheduled for 9/5/25.

Based on observation, interview, and record review the facility failed to provide respiratory services consistent with professional standards of practice when staff failed to ensure oxygen tubing and nebulizer (a medical device that administers breathing medication in an aerosol form) face masks were changed when contaminated and properly stored for two residents (Resident #1 and Resident #17). The staff failed follow the physician orders and ensure the resident was received the ordered amount of oxygen for three residents (Resident #17, Resident #10 and Resident #55). The sample was 18. The census was 75. Review of the facility's Oxygen and Therapy Policy and Procedure, undated, showed:-Purpose: To ensure residents who require oxygen therapy receive safe, person-centered, and clinically appropriate respiratory care consistent with professional standards of practice;-Policy Statement: Oxygen requires a licensed prescriber order except for emergency use under the facility's standing emergency protocol, with immediate provider notification; -Preparation and Verification: Verify prescriber order, identify allergies, and review care plan; Inspect equipment for integrity and cleanliness; Confirm concentrator (device that separates oxygen from ambient air to provide continuous oxygen) or cylinder function and oxygen availability; Set up humidification if ordered;-Infection Prevention: Replace components per schedule: Nasal cannula (tubing that administers oxygen) and oxygen tubing weekly and immediately if visibly soiled or contaminated., after respiratory infection: Replace masks at least weekly; Use single-use items: Store equipment covered and off the floor. Review of the facility's Medical Provider Orders, revised 4/7/23, showed:-Policy: -This facility shall use uniform guidelines for the ordering and following of medical provider orders;-Documentation of medication and treatment orders: -Each medication and or treatment order should be documented with the date, time, and signature of the person receiving the order; -If using electronic medical records, input the medication and/or treatment according to the electronic health record instructions and facility policy;-Following of medication and or treatment orders: -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contain all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 5/31/25, showed:-Cognitively intact;-Diagnoses included Ogilvie syndrome (acute dilation of the colon) chronic obstructive pulmonary disease (COPD), and major depressive disorder. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: The resident has COPD;-Goal: The resident will display optimal breathing pattern daily through review date;-Interventions: Give oxygen therapy as ordered by the physician. Oxygen at 2 (L) Liters per nasal cannula (NC) as needed via concentrator. Review of the resident's physician orders summary (POS), dated 8/2025, showed:-An order, dated 5/6/25, ipratropium-Albuterol Solution (a medication used to open airway passages) 0.5-2.5 (3) milligrams (mg)/3 milliliters (ml). Inhale three times a day via nebulizer. Observation on 8/18/25 at 11:23 A.M., showed the resident's nebulizer mask on the floor next to the resident's bed, with brown matter on the floor under the mask. The nebulizer mask was dated 9/28/24. The tubing was dated 10/28/24. There was a dusty film on the inside of the mask. Observation on 8/19/25 at 8:33 A.M., showed the resident's nebulizer mask hanging uncovered on a dusty, unused concentrator. The nebulizer mask was dated 9/28/24. The tubing was dated 10/28/24. The mask had a dusty film on the inside. During an interview on 8/19/25 at 7:16 A.M., the resident said staff give him/her the medication for his/her nebulizer treatment, and then he/she sets up and administers the breathing treatment to himself/herself. He/She said he/she does not feel like the nebulizer treatment is working. Observation and interview on 8/19/25 at 11:01 A.M. showed Registered Nurse (RN) H arrived at the resident's room to administer his/her nebulizer treatment. Before administering the treatment, RN H realized the resident's nebulizer mask and tubing needed to be changed. RN H said he/she was not aware that the resident's tubing had not been changed since 2024. He/She said the night shift nurse was responsible for changing oxygen tubing and masks. RN H said he/she did not usually administer the resident's nebulizer treatments due to the resident snatching the medication from him/her. RN H did not stay in the resident's room to ensure the resident administered the treatment properly. During an interview on 8/20/25 at 8:05 A.M., RN C said the resident should be receiving his/her nebulizer treatments three times a day. He/She would expect the nurse to be administering the treatment and not the resident. The resident was not assessed to administer his/her own treatments. RN C would have expected the resident's oxygen tubing to be changed since 2024. During an interview on 8/20/25 at 2:44 P.M., the Director of Nursing (DON) said nurses should be administering the resident's nebulizer treatments. The resident should not be administering his/her own treatments. She would expect the resident's nebulizer mask and tubing to be changed once a week on night shift and cleaned as needed. She would expect the nebulizer mask to be stored properly when not in use. She would expect the resident's nebulizer mask to be off the floor. 2. Review of Resident #17's quarterly MDS, dated , 6/19/25, showed:-Cognitively intact;-Diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis) affecting the non-dominant left side, dementia and acute respiratory failure. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: The resident has asthma;-Goal: The resident will remain free from complications of asthma through the review date;-Interventions: Advise resident to minimize contact with known offending allergens. Give medications as ordered. Monitor/document side effects and effectiveness. Give nebulizer treatments and oxygen therapy as ordered;-Focus: The resident has oxygen therapy, diagnosis of acute respiratory failure;-Goal: The resident will have no symptoms of poor oxygen absorption through the review date;-Interventions: The resident has oxygen via NC at 2L as needed. Review of the resident's POS, dated 8/2025, showed:-An order, revised on 6/16/24, may have oxygen at 2 L as needed;-An order, dated 4/23/25, Albuterol Sulfate Nebulization Solution (a medication used to open airway passages) (2.5 mg/3 ml) 0.083%, inhale orally via nebulizer. Observations on 8/18/25 at 9:51 A.M., 11:24 A.M., and 3:28 P.M., showed the resident in his/her bed asleep. The resident had his/her NC on. The concentrator was turned on and set to 4 L. The resident's nebulizer mask was on the bed uncovered. Observations on 8/19/25 at 7:15 A.M. and 10:31 A.M., showed the resident's uncovered NC on the ground next to the resident's bed. The resident's concentrator was turned on and set to 4 L. During an interview on 8/20/25 at 7:45 A.M., Certified Nursing Assistant (CNA) M said oxygen concentrators should be set to the rate ordered by the physician. Oxygen masks should be stored in a plastic bag when not in use. Nurses were in charge of ensuring resident's concentrators are set to the proper rate. Night shift nurses were responsible for changing oxygen tubing and masks once a week. During an interview on 8/20/25 at 8:05 A.M., RN C said oxygen concentrators are expected to be set at the rate prescribed by the resident's physician. When oxygen is not in use, masks are to be stored in a bag, not on the floor. Oxygen tubing and masks are to be changed once a week by the night shift nurse. During an interview on 8/20/25 at 2:44 P.M., the DON said the resident's oxygen concentrator should be set to 2 L not 4 L. She would expect the resident's NC and nebulizer mask to be stored properly when not in use. 3. Review of Resident #10's, quarterly MDS, dated , 6/27/25, showed:-Cognitively intact;-Diagnoses include malnutrition (inadequate nutrition), dysphagia (difficulty swallowing), adult failure to thrive, and dependence on oxygen;-Requires oxygen therapy. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident receives oxygen therapy;-Interventions: The resident has oxygen per nasal cannula or mask at 1 L. Review of the resident's POS, dated August, 2025, showed:-An order dated, 6/16/23, oxygen 1 L continuously. Review of the resident's Medication Administration Record (MAR), dated, 8/1 through 8/14/25 showed:-An order, undated, oxygen 1 L continuously, monitor every shift related to shortness of breath;-On 8/1, 8/2, 8/3, 8/5, 8/6, 8/7, 8/8 8/9/ 8/10/ 8/11, 8/12, 8/13, and 8/14/25, 7:00 A.M. shift documented as completed;-On 8/1, 8/2, 8/4, 8/6, 8/7, 8/8, 8/9, 8/10, 8/11, 8/12, 8/13, and 8/14/25, 7:00 P.M. shift documented as completed. Observation on 8/14/25 at 11:00 A.M. and 5:51 P.M., 8/15/25 at 8:09 A.M. and 9:15 A.M., 8/18/25 at 9:05 A.M., and 8/19/25 at 8:44 A.M., showed the resident wearing an oxygen nasal cannula. The nasal cannula was connected to his/her oxygen concentrator The oxygen concentrator was turned on and set on 2 L. During an interview on 8/19/25 at 9:25 A.M., Licensed Practical Nurse (LPN) J said the resident is to be on 1 L of oxygen and did not know why the resident's oxygen concentrator was set on 2 L. Checking the resident's oxygen concentrator for the correct setting should be verified every day by the nurse. 4. Review of Resident #55's medical record showed:-An admission date of 8/12/22;-Medical diagnoses included: Diabetes, chronic respiratory failure with hypoxia (a severe, ongoing condition where the lungs cannot supply enough oxygen to the blood), chronic systolic heart failure (a lifelong condition where the heart's left ventricle is too weak or enlarged to pump enough oxygen-rich blood to the body), and dependence on supplemental oxygen. Review of the resident's most recent quarterly MDS, conducted on 6/24/25 showed:-The resident received ongoing oxygen therapy while a resident at the facility. Review of the resident's active physician orders showed:-An active order for oxygen via nasal cannula to be administered at 2L continuously, order placed on 4/13/2022 at 7:08 P.M. Review of the resident's care plan, in use at the time of the survey, showed:-A focus indicating the resident has altered respiratory status and difficulty breathing. Interventions included elevating the head of the bed to 45 degrees, monitoring for symptoms of respiratory distress, and providing oxygen as ordered. Observation and interview on 8/14/25 at 10:55 A.M. showed the resident resting comfortably in bed with oxygen on via nasal cannula. Review of the oxygen concentrator output showed the resident was receiving 3.5 L of oxygen. The resident said he/she did not know the oxygen administration orders, but he/she received oxygen continuously, and this had not been changed since admission to the facility, to his/her knowledge. Observations on 8/15/25 at 1:38 P.M., 8/18/25 at 8:53 A.M., 8/19/25 at 8:30 A.M. and on 8/20/25 at 9:28 A.M., showed the resident resting in bed each day with nasal cannula on and receiving oxygen at 3.5 L per minute. 5. During an interview on 8/20/25 at 8:20 A.M., Certified Medication Technician (CMT) O said the nurses were responsible for ensuring oxygen orders were updated or revised as needed. Active orders should match the output of the resident's oxygen concentrator, and the charge nurse should be notified if the orders are incorrect. 6. During an interview on 8/20/25 at 8:29 A.M., RN C said nursing staff should check a resident's oxygen concentrator on each shift to ensure the resident receives oxygen per the physician's order. If it is noted a resident feels better on a higher dose of oxygen, nursing staff should verify the order with the physician to update it in the medical record. 7. During an interview on 8/20/25 at 1:47 P.M., the DON, said she would expect staff to follow physician orders and document the correct setting of the oxygen. If the resident required more oxygen, staff should notify the physician.

Based on observation, interview and record review, the facility failed to ensure residents were served food at a palatable, safe, and appetizing temperature during meal service. This affected 10 of 18 sampled residents (Residents #5, #7, #17, #26, #27, #48, #54, #60, #64 and #68). The census was 75. Review of the facility's meal temperature policy, revised 1/2019, showed:-Purpose: To ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service;-Policy: Meals temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees Fahrenheit (F) . Cold food shall be chilled to a temperature below 40 degrees F. Foods shall be provided at point of service to support resident/patient satisfaction. Temperatures of hot food shall be supported to promote service temperatures of hot foods to about 120 degrees F and cold foods to below 50 degrees F. 1. Review of Resident #5's medical record, showed:-Cognitively intact;-Diagnoses included hypertension (HTN, high blood pressure), end stage renal disease (ESRD, permanent kidney failure requiring transplant or dialysis for survival), history of transient ischemic attack (TIA, a temporary interruption in blood flow to the brain causing stroke-like symptoms) and tType 2 diabetes. During an interview on 8/18/25 at 7:40 A.M. the resident said meals at the facility are often served cold and taste bland. A hamburger was served for dinner over the weekend that the resident described as burned, dry, and covered in a nasty sauce. 2. Review of Resident #7's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/16/25, showed:-Cognitively intact;-Independent with eating;-Diagnoses included emphysema (lung disease), heart failure, breast cancer, iron deficiency anemia, hyperlipidemia and chronic kidney disease. During an interview on 8/14/25 at 12:18 P.M., the resident said the only issue he/she has with the facility is the food. The food is always cold when it is supposed to be hot. The food doesn't taste good. He/She doesn't bother asking for an alternative food because it won't be good or hot, either. Observation on 8/14/25 at 12:54 P.M., showed the resident eating lunch in his/her room. The food on his/her plate consisted of a pinkish meat, diced mixed vegetables, and mashed potatoes. During an interview, the resident said the food was meh and not very good. 3. Review of Resident #17's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnosis included hemiplegia and hemiparesis (muscle weakness or partial paralysis) affecting the non-dominant left side, dementia and acute respiratory failure. During an interview on 8/14/2025 at 11:19 A.M., the resident said the food is not good. The food is usually cold when delivered. 4. Review of Resident #26's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Independent with eating;-Diagnoses included depression and bipolar disorder (mood disorder that can cause intense mood swings).During an interview on 8/14/25 at 5:36 P.M., the resident said food is often served cold. Residents can ask staff to microwave their food, but he/she doesn't like doing this because he/she feels like he/she is being inconvenient. 5. Review of Resident #27's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Independent with eating;-Diagnoses included diabetes, acute kidney failure, high blood pressure, dehydration, depression, and anxiety. During an interview on 8/18/25 at 12:04 P.M., the resident said the food served by the facility is terrible. The food is served cold when it should be hot. The food tastes bad and can be undercooked. 6. Review of Resident #48's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Setup or clean-up assistance required for eating;-Diagnoses included diabetes, hyperlipidemia, high blood pressure, and morbid obesity. Observation on 8/15/25 at 8:13 A.M., showed Certified Nurse Aide (CNA) HH delivered a breakfast tray to the resident's room. At 8:28 A.M., the resident's breakfast tray contained a scoop of scrambled eggs and a biscuit. During an interview, the resident said his/her food was served cold and it was not enough to eat. At 9:05 A.M., CNA HH removed the resident's breakfast tray. As he/she was leaving the room, the resident said his/her food was nasty. CNA HH laughed and said he/she would remove the tray for the resident. CNA HH did not offer to get the resident an alternate. Observation on 8/18/25 at 8:46 A.M., showed the resident in bed with a tray of breakfast on his/her bedside table, consisting of a scoop of scrambled eggs and a donut. No dietary slip on the breakfast tray. During an interview, the resident said this is ridiculous. He/She is hungry and did not get served enough to eat. He/She is upset, tired and hungry. 7. Review of Resident #54's medical record, showed:-Cognitively intact;-Diagnoses included acute kidney failure, muscle weakness and depression. During an interview on 8/14/2025 at 12:03 P.M., the resident said the food is horrible. He/She said food temperatures are cold when food is delivered. He/She said two months ago, the kitchen served raw meat to the residents. 8. Review of Resident #60's comprehensive MDS, dated [DATE], showed:-Moderate cognitive impairment;-Setup or clean-up assistance required for eating;-Diagnoses included diabetes, adult failure to thrive, heart disease, chronic obstructive pulmonary disease (lung disease) and dementia. Observation on 8/18/25 at 8:47 A.M., showed the resident eating breakfast in his/her room. Breakfast consisted of one donut and one scoop of scrambled eggs. No dietary slip was on the tray. During an interview, the resident said his/her breakfast was not good. The donut was not sweet and it was dry. The food served at the facility does not taste good. It is always served cold when it should be hot. 9. Review of Resident #64's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnosis included type two diabetes, muscle weakness and major depressive disorder. During an interview on 8/14/2025 at 1:48 P.M., the resident said the food is awful. The coffee is not hot when served. Staff do not offer refills. 10. Review of Resident #68's quarterly MDS, dated [DATE], showed:-The resident is cognitively intact;-Diagnoses include stroke, high blood pressure and heart failure. During an interview on 8/14/25 at 5:58 P.M., the resident said he/she does not eat the food in the facility. The food does not look appetizing, and it is often cold. The food is not nutritious and does not provide the 5 food groups. The resident's family brings in meals for him/her every day. 11. Observation on 8/14/25 at 5:37 P.M., of dinner on the [NAME] hallway, showed:-Baked beans measured 103.2 degrees F;-Barbeque (BBQ) burger measured 92.3 degrees F. The meat was chewy. Observation on 8/14/25 at 5:53 P.M., of dinner on the East hallway, showed:-BBQ burger measured 95.6 degrees F. The meat was bland and chewy. 12. During a group interview on 8/18/25 at 11:03 A.M., six out of six residents, whom the facility identified as alert and oriented, said there are ongoing issues with dietary. Food that is supposed to be hot is served cold. Food is served that is not cooked all the way through. They have discussed this in resident council meetings and the dietary issues have continued. During an interview on 8/14/25 at 11:43 A.M., CNA B said the food served at the facility is terrible, not good. The residents don't like the food and won't eat it. The portions are small and residents do not get enough to eat. The food is always served cold when it should be hot. During an interview on 8/19/25 at 1:03 P.M., Dietary Aide F said food should be served at a safe and palatable temperature and should taste good. During an interview on 8/19/25 at 12:44 P.M., the Dietary Manager said food should be delivered to residents at a safe and palatable temperature to prevent illness. She said the food has not been served at the required temperature due to broken kitchen appliances not warming the food. During an interview on 8/20/2025 at 2:12 P.M., the Administrator and Director of Nursing (DON) said they expected food to be served to residents at a safe and palatable temperature. They expected food to be palatable. They expected staff to heat up food if it is not at the appropriate temperature. 161200116119951611992

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable disease and infections. The facility failed to ensure employee two-step tuberculin skin tests were completed in accordance with State guidelines for three out of 10 employees reviewed. The facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with gastrostomy tubes (g-tube, a tube surgically inserted into the abdomen that is used for medications and liquid nutrition) and chronic wounds requiring treatments (Residents #10, #4 and #3). In addition, staff failed to exhibit appropriate hand hygiene practices for infection control when cleaning up fecal material in one resident's room (Resident #1). The sample was 18. The census was 75.Review of the facility's Tuberculosis (TB) Screening - Employees policy, dated 2019, showed:-Residents in long-term care facilities have been identified as a high-risk group for re-activation of latent TB infection, acquisition of TB infection and potential spread of TB within the facility. This facility has a comprehensive TB screening program that is administered by Infection Preventionist (IP) at the direction of the Quality Assurance (QA) committee;-It is the policy of this facility to assess risks for tuberculosis based on regional/community data and screen staff according to State law. For example, all healthcare workers be tested for tuberculosis upon hire and yearly thereafter unless contraindicated or in accordance with State requirements. Initial testing will be a two-step procedure with the first dose given before beginning work and the second booster dose given 7-21 days after the first if the first dose is negative along with an employee risk screening tool;-Tuberculin skin test (TST) results will be documented in the employee's medical record; -a. Skin test results will be documented in millimeters (mm) of induration (raised, hardened area of swelling at injection site) rather than stating result is positive or negative;-b. The tuberculin manufacturer and lot number will be recorded; -TST Administration and Reading:-One-tenth mm of TST is administered intracutaneously (within the skin);-The test is read between 48 and 72 hours after administration by someone trained in Mantoux reading and interpretation. Review of the Department of Health and Senior Services (DHSS) TB Screening for Long Term Care Employees flowchart, updated 3/11/14, showed:-Employee accepts position (the hire date);-If no documentation of prior two-step TST, administer TST first step prior to employment. Can coincide reading the results with the employee start date by administering TST two to three days prior to the employee start date;-Read results of first step TST within 48 to 72 hours of administration. Results must be read and documented in millimeters prior to or on the employee start date;-If negative, administer second step within one to three weeks;-Read results within 48 to 72 hours of administration. Review of the facility's EBP policy, revised 12/12/23, showed:-Policy: It is the policy of this facility to implement EBP for the prevention of transmission of MDROs;-Definitions: EBP refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices);-Policy Explanation and Compliance Guidelines:-All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions -High-contact resident care activities include: -a. Dressing; -b. Bathing;-c. Transferring;-d. Providing hygiene;-e. Changing linens; -f. Changing briefs or assisting with toileting; -g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes; -h. Wound care: any skin opening requiring a dressing;-EBP should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, or any high-contact activity;-EBP should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed. 1. Review of Employee II's personnel file, showed:-Hire date 6/10/24;-No documentation of TB tests completed. Review of Employee MM's personnel file:-Hire date 7/4/24;-No documentation of TB tests completed. Review of Employee NN's personnel file, showed:-Hire date 4/11/25;-No documentation of TB tests completed. During an interview on 8/20/25 at 7:32 A.M., the Administrator said when a new employee is hired, the employee gets their first TB test done before they start working. The second step is done after the first TB test is read. Employee TB tests were overseen by the previous Assistant Director of Nurses (ADON), who has been gone since July. A new ADON started this week and will oversee the TB tests going forward. During an interview on 8/20/25 at 1:48 P.M., the Director of Nurses (DON) and Administrator said all new employees are expected to undergo the two-step TB test process. These should be documented in the employee's personnel file. Employees must undergo the TB testing process because TB is a highly contagious and very serious disease. 2. Review of the sign for EBP, undated, showed:-Everyone must clean their hands, including before entering and when leaving the room;-Providers and staff must also wear gloves and a gown for the following high-contact resident care activities:-Dressing;-Bathing/showering;-Transferring;-Changing linens;-Providing hygiene;-Changing briefs or assisting with toileting;-Device care or use (central line, urinary catheter, feeding tube, tracheostomy);-Wound care: any skin opening requiring a dressing. 3. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/25, showed:-Cognitively intact;-Diagnoses included malnutrition (inadequate nutrition), dysphagia (difficulty swallowing), g-tube status and adult failure to thrive. Review of the resident's care plan, in use at the time of survey showed:-Focus: The resident requires EBP related to g-tube. The use of gown and gloves for use during high-contact resident care activities for residents to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition due to wound or indwelling devices;-Interventions: The resident's room will be posted with clear signage, indication EBP and required EBP use; Appropriate PPE (gowns, gloves, masks, face shields, and foot coverings); EBP will be used for the duration of stay or until the wound heals or the indwelling device is discontinued; Staff have received training on EBP and will comply with all designated precautions. Review of the resident's physician order sheets (POS), dated, August 2025, showed:-An order, dated, 6/9/25, EBP due to gastrostomy tube site, gown and gloves required for high contact resident care activities. Observation on 8/15/25 at 9:15 A.M., showed Registered Nurse (RN) A prepared the resident's medications at the medication cart in the East Wing hallway. The resident's door showed an EBP sign posted. RN A entered the resident's room and applied gloves. The resident raised his/her shirt and exposed a gastrostomy tube located in the resident's abdomen. RN A administered the resident's medications through his/her gastrostomy tube. RN A then prepared a water flush and a bolus (a single dose) tube feeding and administered them to the resident through his/her gastrotomy tube. RN A did not wear an isolation gown while administering medications, water and tube feeding through the resident's gastrostomy tube. 4. Review of Resident #4's medical record, showed:-Diagnoses included sepsis (blood infection) due to pseudomonas (bacteria), pneumonia due to pseudomonas, and gastrostomy (opening into the stomach from the abdominal wall) status;-An order, dated 6/9/25 for EBP related to g-tube site (gown and gloves required or high-contact resident care activities), every day and night shift. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident requires EBP. EBP refers to the use of gown and gloves for use during high-contact care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition due to wounds or indwelling device, gastrostomy tube;-Tasks included: Appropriate personal protective equipment (PPE) shall be available either immediately outside or inside room. High contact activities include, but are not limited to personal care (hygiene, toileting, peri-care). Resident's room will be posted with clear signate indicating EBP precautions, require EBP use. Observation and interview on 8/14/25 at 11:05 A.M., showed a sign posted on the resident's door for EBP. A PPE caddy in the hallway outside of the resident's room contained gloves and gowns. The resident said he/she receives tube feedings. At 11:16 A.M., Certified Nurse Assistant (CNA) S entered the resident's room. At 11:19 A.M., CNA S rolled the resident in bed, from side to side while changing the resident. CNA S wore gloves during the care activity but did not wear a gown. During an interview on 8/19/25 at 9:47 A.M., CNA S said EBP means staff should wear a gown and gloves while providing direct care. He/She acknowledged he/she should have worn a gown when providing incontinence care to the resident on 8/14/25. Sometimes he/she is just moving so quickly to help everyone, he/she forgets. During an interview on 8/20/25 at 8:10 A.M., CNA T said the resident requires EBP because he/she has a g-tube. During an interview on 8/20/25 at 9:31 A.M., RN A said the resident requires EBP because he/she has a g-tube. 5. Review of Resident #3's quarterly MDS, dated , 4/29/25, showed:-The resident is unable to complete a cognitive assessment;-Diagnoses included cancer and Alzheimer's disease. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident requires EBP related to chronic wounds; The use of gown and gloves for use during high-contact resident care activities for residents to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition due to wound or indwelling devices;-Interventions: The resident's room will be posted with clear signage, indicating EBP and required EBP use; Appropriate PPE (gowns, gloves, masks, face shields, and foot coverings); EBP will be used for the duration of stay or until the wound heals or the indwelling device is discontinued; Staff have received training on EBP and will comply with all designated precautions. Review of the resident's POS, dated August 2025, showed:-An order, dated, 6/8/25, EBP due to chronic sacral (tailbone area) wound, gown and gloves required for high contact resident care activities. Observation on 8/18/25 at 1:56 P.M., showed the resident's door showed an EBP sign posted. The resident lay in bed and CNA L provided care and gave the resident a bath with gloved hands. CNA L turned the resident from side to side, changing the resident's bed sheets. The resident had a dressing to his/her sacrum dated 8/18/25. CNA L did not wear an isolation gown while providing care to the resident. 6. During an interview on 8/20/25 at 8:10 A.M., CNA T said EBP means staff should wear gloves and a gown when providing assistance with any contact activity. This includes when providing incontinence care and feeding assistance. EBP are used to protect the residents. 7. During an interview on 8/20/25 at 9:31 A.M., RN A said EBP means to take extra precautions for some residents, like those who have g-tubes and wounds. For residents on EBP, staff must wear a gown and gloves while providing high-contact activities, such as peri-care. Feeding assistance might be included in high-contact activities, but this is a debated area among staff. 8. During an interview on 8/20/25 at 1:48 P.M., the DON and Administrator said residents with a history of MDROs, chronic wounds, and indwelling devices, such as g-tubes, require EBP. When a resident is on EBP, staff should wear gloves, gown, and a mask when providing direct care where they may be exposed to bodily fluid. These activities include incontinence care, dressing changes, skin assessments, administration of g-tube medications, and while providing feeding assistance. 9. Review of Resident #1's annual MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included Ogilvie syndrome (acute dilation of the colon) chronic obstructive pulmonary disease (lung disease, COPD) and major depressive disorder. Observation on 8/15/25, in the resident's room, showed:-At 7:33 A.M., Restorative Aide (RA) W came into the resident's room and started to clean the room. He/She put on gloves, grabbed a paper towel and then wiped up a pile of fecal material located near the resident's bed;-At 7:38 A.M., he/she went to the resident's bathroom and wiped a pile of fecal material on the floor with a paper towel and then threw the paper towel away in the resident's trash can;-At 7:39 A.M., he/she walked to the resident's door and grabbed onto the doorknob with one gloved hand while he/she grabbed the dirty linen cart with his/her other gloved hand;-At 7:40 A.M., the resident asked RA W to hand him/her a remote off the floor. RA W grabbed the remote with his/her gloved hand and then handed it to the resident;-At 7:42 A.M., RA W took off his/her gloves and washed his/her hands and then touched the resident's doorknob to open the door. During an interview on 8/20/25 at 9:51 A.M., RA W said proper hand hygiene should be used when cleaning bodily fluids. Staff should wash their hands before touching clean surfaces. During an interview on 8/20/2025 at 2:58 P.M., the DON said she expected proper hand hygiene to be performed by staff when cleaning bodily fluids in a resident's room. She expected Restorative Aide W to remove his/her dirty gloves, wash his/her hands, and then apply new gloves before touching clean surfaces and objects.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three out of five sampled residents who expired and had money in their accounts (Residents #77, #78, and #79). The census was 75.Review of the facility's Resident Trust Fund policy, revised [DATE], showed:-Purpose: To establish policy and procedures for the Facility Resident Trust Fund;-Policy: It will be the policy of the management company that the Resident Trust Fund is managed and accounted for in accordance with State and Federal regulations. Each facility should follow the State guidelines of the payment programs using the greatest level of specificity if requirements vary in State and Federal programs;-Procedures:-If a resident receives any TPL payments, notification must be sent to the Medicaid caseworker within five business days or per State guidelines;-Facility shall refund the balance of the resident's personal funds when a resident is discharged . The amount shall be refunded by the end of the month following the month of discharge or by State/Federal specific guidelines if such policies are more stringent;-If facility does not receive notification of appropriate claim for deceased /discharged resident's funds, the unclaimed funds will be sent to the Unclaimed Property Section, Secretary of Revenue for the State with detailed information about the resident, next of kin if known, and amount of funds and such disbursement will be handled per the guidelines.-The policy failed to identify the federal requirement for notice and conveyance of funds to be completed within 30 days upon the death of a resident with funds remaining in their account.1. Review of Resident #77's resident fund account, showed:-Expired [DATE];-Ending account balance: $378.26;-No TPL form submitted to Medicaid.2. Review of Resident #78's resident fund account, showed:-discharged to hospital [DATE]. Confirmed as expired [DATE];-Ending account balance: $183.00;-No TPL form submitted to Medicaid.3. Review of Resident #79's resident fund account, showed:-Expired [DATE];-Ending account balance: $12.69;-No TPL form submitted to Medicaid.4. During an interview on [DATE] at 1:26 P.M., the Business Office Manager (BOM) said she started working with the facility in [DATE]. When a resident expired with funds left in their account, the funds should be released if there was somebody to release the funds to. If the resident had a prior account balance, she was unsure of what to do with that. She was unsure how payor source factored in. She was unsure what the notification or release timeframe was. She was not aware that a TPL form should be submitted to Medicaid for residents who expired with funds left in their account. 5. During an interview on [DATE] at 7:32 A.M., the Administrator said he expected the facility to notify Medicaid of funds left in the resident trust account following a resident's expiration. The BOM should submit the TPL as soon as possible, within 30 days of the resident's expiration.

Based on observation, interview and record review, the facility failed to ensure residents' self-determined preferences and requests were implemented. The facility failed to assist two dependent residents to get out of bed after breakfast, in accordance with their preferences (Resident # 48 and Resident #49). In addition, staff failed to provide one resident a shower when requested (Resident #68). The sample was 18. The census was 75. Review of the facility's Resident Rights policy, undated, showed:-Residents are entitled to exercise their rights and privileges to the fullest extent possible: The facility will make every effort to assist each resident in exercising his/her rights to assure the resident is treated with dignity, kindness, and respect; -Self-determination: Personal freedom means allowing residents to make decisions about themselves. Some examples the facility protects are residents' self-determination including when to choose bath time and type of bath, choose waking and sleeping times, and choose activities and healthcare consistent with his/her interests and plan of care. 1. Review of Resident #48's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/5/25, showed:-Cognitively intact;-Lower extremity impairment on both sides;-Dependent on assistance for chair/bed-to-chair transfers;-Diagnoses included morbid obesity, generalized muscle weakness, lack of coordination, and abnormal posture. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has an activities of daily living (ADL) self-care performance deficit and requires maximum assistance;-Tasks included requires Hoyer (mechanical lift) and two staff for transfers. During an interview on 8/24/25 at 12:40 P.M., the resident said he/she required a Hoyer lift for transfers. It took a long time for staff to get him/her up and get him/her back to bed. He/She waited hours for staff to transfer him/her. Observation on 8/18/25 at 11:45 A.M., showed staff got the resident up into his/her wheelchair. During an interview at 12:00 P.M., the resident said he/she waited for hours for staff to get him/her up this morning. This was typical. He/She wanted to get out of bed daily, right after breakfast. 2. Review of Resident #49's medical record, showed:-Diagnoses included morbid obesity, generalized muscle weakness, abnormalities of gait and mobility, lack of coordination, depression, and generalized anxiety disorder;-A physician order, revised 11/5/24, for the resident to be out of bed in a chair two hours a day. Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Lower extremity impairment on both sides;-Dependent on assistance for chair/bed-to-chair transfers. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has an ADL self-care performance deficit;-Tasks included the resident requires two-staff participation and Hoyer lift with transfers;-The care plan did not identify the resident's preference to be out of bed earlier in the day. Observations on 8/15/25 at 9:22 A.M, showed the resident was in bed. During an interview, the resident said he/she required a Hoyer lift for transfers. He/She preferred for staff to get him/her out of bed earlier in the day. He/She liked to get out of bed and to be a part of the facility. At approximately 12:00 P.M., the resident was out of bed and was propelled down the hall by staff. Observations on 8/18/25 at 11:47 A.M showed, the resident in bed. During an interview, the resident said he/she would have liked to have been up and out of bed by now. He/She hoped staff got him/her out of bed for lunch. At 12:26 P.M., staff got the resident out of bed. 3. During an interview on 8/14/25 at 12:06 P.M., Certified Nurse Aide (CNA) B said most of the residents require Hoyer lifts on the hall shared by Resident #48 and #49. There was not enough staff assigned to the hall to provide care and assist with Hoyer transfers for all residents at the same time. The residents had to wait for care and assistance. During an interview on 8/18/25 at 11:51 A.M., CNA U said almost all of the hall shared by Residents #48 and #49 consisted of residents requiring Hoyer transfers. Hoyer transfers required two staff. There was one aide assigned to this hall and it was not enough to get everything done. All the residents should be up and out of bed before lunch. He/She could not get all the residents up before lunch. It was ridiculous. During an interview on 8/19/25 at 9:47 A.M., CNA S said the hall shared by Residents #48 and #49 had numerous residents who required Hoyer transfers. There was one aide assigned to that hall. One aide was not enough to perform all the Hoyer transfers and care needed for these residents. These residents were heavy care and totally dependent on staff for assistance. When one aide was pulled to another hall to provide care that could take an hour. It left all the other residents without an aide. Residents #48 and #49 liked to get up after breakfast. Residents should be able to get out of bed when they wanted. Sometimes, staff could not get residents up until nearly lunchtime or even later. During an interview on 8/20/25 at 8:10 A.M., CNA T said residents had the right to get up whenever they wanted. Residents #48 and #49 required Hoyer transfers and total care. Many of the other residents on their hall required the same thing. All of the residents on that hall liked to get out of bed between 10:00 A.M. and 11:30 A.M. It was impossible to get this done because there was only one employee assigned to the hall and it required two staff to complete Hoyer transfers and the care needed. During an interview on 8/20/25 at 9:31 A.M., Registered Nurse (RN) A said Residents #48 and #49 liked to be out of bed after breakfast but that did not happen every day. They both required total care and Hoyer transfers. Most of the residents on their hall required the same thing. All residents on their assignment liked to get up between 10:30 A.M. and 11:00 A.M. There was not enough staff on the assignment to get that done. 4. During an interview on 8/20/25 at 1:48 P.M with the Director of Nurses (DON) and Administrator, they said the previous Administrator moved all residents requiring Hoyer transfers to the same hall, and promised staffing would be adequate on the hall. Since the DON and Administrator began working with the facility within the past two to three months, they have observed residents unable to get up at their preferred times on that hall. Residents should be assisted out of bed in accordance with their preferences. 5. Review of Resident #68's MDS, dated [DATE], showed:-The resident is cognitively intact;-The resident is dependent on staff for personal hygiene, toilet hygiene, upper and lower body dressing, and bed to chair transfer;-The resident uses a wheelchair. Review of the resident's care plan, in use at the time of survey, showed;-Focus: The resident has ADL self-care performance deficit;-Interventions: The resident is totally dependent on staff to provide a bath three times a week and as needed. Review of the East Wing shower list, showed there were no scheduled showers on Sunday for residents who lived on that hall. During an interview on 8/18/25 at 8:44 A.M., the resident said he/she requested a shower on 8/17/25 because he/she was getting his/her hair braided this morning. His/Her hair needed to be clean and completely dry. His/Her regular shower days were Mondays, Wednesdays, and Fridays on the day shift. The beautician had already been paid and was arriving at the facility on 8/18/25 at 11:00 A.M. The resident said staff told him/her that he/she could not get a shower on a Sunday because there were no showers completed on Sundays. At 10:25 A.M., the resident said his/her shower was completed and the beautician was running late. The resident was hoping his/her hair would be dry by the time the beautician arrived. 6. During an interview on 8/18/25 at 12:09 P.M., CNA I said no resident showers were scheduled on Sundays. If a resident requested a shower on a Sunday, staff should honor the resident's request and provide the resident a shower. During an interview on 8/19/25 at 9:25 A.M., Licensed Practical Nurse (LPN) J said currently there were no showers scheduled for Sundays, but that didn't mean staff couldn't provide a shower if the resident requested it. Staff should honor the residents' requests. 6. During an interview on 8/20/25 at 1:47 P.M., the DON said she would expect the staff to give the resident a shower when requested. She was aware that showers were not scheduled on Sundays but that didn't mean staff could not provide showers on Sundays.

Based on interview and record review, the facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one (Resident #1) of three sampled residents, who was found by staff without a pulse. Staff started CPR on a resident with full code orders but stopped before Emergency Medical Services (EMS) arrived. The Certified Nurse Aides (CNAs) on duty said they did not know how to determine code status. EMS was not notified timely, the resident was discovered without pulse at 5:10 A.M. and EMS was not contacted until 6:14 A.M. The resident expired. Additionally, the facility failed to provide CPR qualified staff for 14, full eight hour shifts between [DATE] through [DATE]. The Staffing Coordinator (SC) did not know he/she was responsible to ensure one CPR certified staff person was available on each shift. Fifty-four residents were listed as full code residents. The census was 71. The Administrator was notified on [DATE] at 12:45 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Medical Emergency Response policy, revised [DATE], showed: -Policy: It is the policy of this facility to respond to medical emergencies for residents, staff and visitors; -Policy Explanation and Compliance Guidelines: -1. The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance; -2. CPR will be initiated unless: -a. There is a DNR order in place. -b. There are obvious signs of clinical death (rigor mortis (stiffening of the joints and muscles of a body a few hours after death), dependent lividity (the pooling of blood in the lower parts of the body after death. This causes the skin to appear discolored, usually in a shade of purple), decapitation (head removed from the body), transection (horizontal cross-section that divides the body into two parts), or decomposition (gradual process that begins at death and continues until the body is reduced to a skeleton)); -c. Initiating CPR could cause injury or peril (being in danger of injury) to the rescuer; -3. A nurse will: -a. Assess the situation and determine the severity of the emergency; -b. Stay with the resident; -c. Designate a staff member to announce emergency code, if necessary, notify the physician and call 911 as needed; -4. A Code will be announced, if necessary; -5. All available staff will respond to the emergency accordingly; -6. A nurse will bring the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed; -7. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services, and: -a. In accordance with the resident's advance directives, or; -b. In absence of advance directives or a Do Not Resuscitate order, and; -c. If the resident does not show obvious signs of clinical death; -8. The Charge Nurse or designee will ensure emergency medications and equipment are inventoried and restocked after the event; -9. The emergency carts and equipment shall be checked daily; -10. The facility will ensure that CPR certified staff are always available; -11. Current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider whose training includes hands-on skills practice and in-person assessment and demonstration of skills. Online certification is not acceptable; -12. This facility will not implement a No CPR policy. Review of the facility's CPR policy, revised [DATE], showed: -Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR); -Policy Explanation and Compliance Guidelines: -1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR; -2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: -a. In accordance with the resident's advance directives, or; -b. In the absence of advance directives or a Do Not Resuscitate order; and; -c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); -3. CPR certified staff will be available at all times; -4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. 1. Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung), emphysema (a chronic lung disease that damages the lungs, making it difficult to breathe), dependence on supplemental oxygen and high blood pressure. Review of the resident's current care plan, showed: -Focus: Advanced directive care; -Goal: Advanced directive will be honored through the end of review period; -Interventions: -Call 911 immediately; -Code status: Full code; -Initiate CPR immediately; -Notify family immediately; -Notify physician immediately; -Review advanced directives quarterly and with any change in condition. Resident to be asked about any desired changes to current advanced directives or whether they wish to execute any. During an interview on [DATE] at 2:11 P.M., the Social Worker (SW) said the resident was alert and oriented. He/She wanted to be a full code (in the event of no pulse, initiation of CPR and summoning 911) and told the SW to bring (him/her) back. They had a clear conversation, and this was maybe in October, 2024. It is the resident's right to choose to have everything done. Review of the resident's physician orders, dated [DATE], showed a full code order. Review of the resident's progress notes, dated [DATE] at 8:50 A.M., showed, Licensed Practical Nurse (LPN A) went into the resident's room to pass early morning medication. After calling out the resident's name without response, LPN A proceeded to apply tactile queue (uses physical touch) as well as higher calling sound but found the resident was not responding. The resident was cold to touch. The nurse contacted another nurse (LPN B) in the building who responded promptly. Both nurses attempted resuscitation per protocol to no avail. LPN A and LPN B concluded with no heartbeat and zero oxygenation further resuscitation could not revive the resident. LPN A called the resident's family and physician to notify them what happened without any signs/symptoms of sudden death. The family member was not available on phone, the physician was called via exchange, message was left that there was emergency news and requested a call back. While waiting for the physician to call back the family called back and gave the name of the funeral home to collect the body. After learning the patient had passed, LPN A called 911 to assess. Administration was notified early after the incidence, and they assisted in making contacts. Review of the 911 phone call placed on [DATE] at 6:14 A.M., showed: -911 Operator: Tell me exactly what happened; -SC: They found a full code resident passed away and 911; -911 Operator: OK, so are you guys doing CPR or?; -SC: Yes, they are doing CPR in there, they was yes; -911 Operator: Ok alright, and I just have to ask he/she is not awake is that correct? -SC: No; -911 Operator: And he/she is not breathing is that correct?; -SC: No, no (he/she) is not; -911 Operator: Ok, do you guys need any further assistance? We are sending the ambulance. Do you need CPR instructions or anything like that?; -SC: No. Review of the EMS report, dated [DATE], showed: -Call type: Cardiac arrest/death; -Disposition: Patient dead at scene no resuscitation attempted; -Dispatch notified: 6:14 A.M.; -Unit dispatched: 6:15 A.M.; -Enroute: 6:17 A.M.; -At scene: 6:21 A.M.; -At patient: 6:22 A.M.; -Depart: 6:34 A.M.; -Narrative: Upon arrival resident was found unresponsive, no CPR in progress, and resident lying supine (lying face up) in bed. Staff stated they had last seen the resident awake and breathing at approximately 2:00 A.M., when giving the resident his/her night medication. Staff came back into the room at approximately 5:10 A.M., to find the resident unresponsive and not breathing. LPN A preceded to state the resident was a full code, they did 10 minutes of manual CPR, no automated external defibrillator used (AED, device designed to analyze the heart rhythm and deliver an electric shock). After the 10 minutes they stopped with compressions stating, there was no signs of life so we stopped. Staff then left the room waiting to call EMS at 6:14 A.M. 4 lead electrocardiogram (EKG, four electrodes to record the heart's electrical activity) was placed showing asystole (heart not beating), extremities and jaw were rigor (stiffening of the joints and muscles of a body after death). Review of the Fire Department's After-Action Report, dated [DATE], showed: -Alarm: 6:15 A.M.; -Arrival: 6:19 A.M.; -Remarks: Responded for report of cardiac arrest, CPR in progress. First to arrive on scene and make patient contact. No CPR was being performed upon arrival at the patient and two workers appeared to be cleaning the patient's body and bedding space. A nurse of the facility was present in the patient's room. The nurse stated that when he/she came into the room this morning at 5:10 A.M. to administer the patient's morning medications the patient was found unresponsive and not breathing. He/She then went to get another nurse and began CPR. Upon arrival in the room, the nurse stated, we have given up, stating the patient had no response to CPR and he/she felt cold. The nurse stated the patient was a full code and that he/she was last seen alive at 2:00 A.M. Performed an initial assessment. Patient was unresponsive, pulseless, not breathing, skin tone very pale, and pupils were fixed and dilated to the extent the patient's iris was almost entirely covered by the size of pupils. Applied a 4-lead EKG showing asystole in lead 2 which was confirmed in lead 3. Another emergency service ambulance arrived on scene and assumed the lead role in patient care. The patient was pronounced deceased on the scene and was not transported. The police department was on the scene and conducting an investigation of the incident. During an interview on [DATE] at 8:27 A.M., LPN A said early in the morning on [DATE], he/she went into the resident's room to give him/her medication. LPN A said when he/she called out the resident's name, the resident didn't respond. LPN A said he/she called the resident's name out loud several times and received no response. LPN A checked on the resident because the resident normally responded when spoken to. LPN A said he/she knew the resident was a full code so he/she started doing CPR for approximately 10 minutes. LPN A did CPR on the resident in bed. When asked if a back board was placed behind the resident, LPN A then said he/she got the crash cart and placed the back board behind the resident while he/she was in bed before starting CPR. LPN A said the resident was on continuous oxygen at two liters and LPN A turned the concentrator up to the highest level, at five liters on the nasal cannula. After doing 10 minutes of CPR, LPN A said he/she verbally called to LPN B who came immediately. LPN A and LPN B both performed CPR on the resident until approximately 5:30 A.M. When LPN A and LPN B found no response to the CPR, they stopped performing CPR. LPN A said he/she called out for CNA C and CNA D and they came into the room. LPN B left and went back to his/her nurse's station because they had given up on resuscitation of the resident. CNA C began chest compressions on the resident and CNA D was giving breaths with the ambu bag. LPN A called the family, the physician, and the Assistant Director of Nurses, who instructed LPN A to contact 911. When EMS came in, everyone had given up and staff were not doing CPR. Staff gave up because the body had no life and was cold and kind of stiff. LPN A said the resident's body was not discolored except some blue discoloration to the lips. LPN A said he/she called 911 to let EMS know what happened and that the resident was a full code. LPN A said he/she removed the back board before EMS arrived. LPN A said when a resident is found unresponsive, start CPR immediately if full code, if the resident starts breathing again then LPN A would call 911. LPN A said the reason for the delay in calling 911 was because in this case, a bit of time passed because there were doubts all along if this was going to be positive effect. During an interview on [DATE] at 9:48 A.M., LPN B said around 5:30 A.M. on [DATE], CNA C ran over to his/her nurse's station and was yelling for him/her and said resident in distress. LPN B said he/she grabbed the crash cart and saw CNA C standing at the door of the resident's room. LPN A and CNA D were doing CPR on the resident. LPN A was doing compressions and CNA D was standing over the resident's head. LPN B pushed CNA D out of the way and hooked the ambu bag up. LPN B put the ambu bag over the resident's mouth and hooked it up to the concentrator. LPN B said he/she did not know how many liters the concentrator was set to. LPN B said CNA C and CNA D took over CPR until 911 showed up. LPN B said another resident needed something so LPN B left the room. LPN B did not know when LPN A called 911. LPN B was not in the room when 911 showed up. LPN B said he/she did not see any color difference in the resident's skin or rigor mortis. The resident was cool to the touch. During an interview on [DATE] at 8:59 A.M., CNA D said the last time he/she saw the resident was at 12:00 A.M. on [DATE]. CNA D said CNA C was assigned to the resident because the CNA who would have been assigned to the resident did not show up for the shift. On the morning of [DATE], LPN A called that he/she needed help because the resident was unresponsive around 5:30 A.M. CNA D called for CNA C and they went into the resident's room. The resident was lying on his/her back on the bed. CNA D said CNA C started doing chest compressions while LPN A started making phone calls. CNA D said he/she did not do chest compressions or do any type of rescue breaths. CNA D said he/she was clearing stuff out of the way. CNA D said nobody ever said to move the resident to the floor, CNA D said LPN B came in the room and made the comment that the resident should have been moved to the floor and said CNA C was not doing the compressions hard enough. CNA C stopped doing compressions when EMS came into the building. CNA D said the resident was between cold and warm and was not freezing cold. CNA D said he/she did not remember if the crash cart was in the resident's room. CNA D said an artificial manual breathing unit (ambu) bag was not used when CNA C did compressions. CNA D said he/she was not CPR certified. CNA D did not know how to access a resident's code status. During an interview on [DATE] at 7:15 A.M., CNA D said he/she saw LPN A and LPN B talking in the hallway around 5:00 A.M. LPN A had two carts in the hallway near the resident's room. One cart was the nurse's medication cart, and the other cart was the Certified Medication Technician's (CMT) medication cart. The nurses do not have CMTs on the night shift, so the nurses have to use both carts when passing medication. LPN A was standing next to the medication cart and LPN B was standing on the back side of the medication cart. CNA D did not see LPN B in the resident's room. Around 5:30 A.M. LPN A was standing outside the resident's doorway and called out for that he/she needed assistance. CNA D called out for CNA C and both went to the resident's room. LPN A started making phone calls and was stepping in and out of the resident's room. CNA C started doing chest compressions on the resident in the bed and CNA D moved the pillows that were propped around the resident and grabbed the bed controller and moved the bed up because it was in a low position. CNA D did not remember if there was a back board behind the resident. During an interview on [DATE] at 5:38 A.M., CNA C said he/she was not assigned to the resident the morning of [DATE]. CNA C said he/she did not see the resident that night, [DATE] or the morning of [DATE] until he/she overheard LPN A say the resident passed away while standing at the nurse's station making phone calls. CNA C said he/she went into the resident's room and CNA D followed. CNA C started doing chest compressions because nobody was doing anything on the resident. CNA C said someone said he/she was not doing chest compressions hard enough. CNA C did chest compressions for 15 to 20 minutes and stopped because LPN A said stop, and asked why he/she was doing CPR. LPN A said the resident was gone so CNA C stopped doing compressions. CNA C said when he/she was doing chest compressions, nobody was giving breaths to the resident. CNA C said it was around 30 minutes after he/she stopped doing compressions before EMS arrived. When EMS arrived, he/she left the room. CNA C said the resident did not have any discoloration to his/her skin that looked like mottling (discoloration on the skin that can appear red, purple, blue, or brown). CNA C did not know if the resident was a full code or a DNR and CNA C did not know how to access a resident's code status. CNA C said he/she was not CPR certified. CNA C said he/she did not see LPN A or LPN B do CPR on the resident. CNA C said there was no backboard under the resident or in the resident's room. CNA C said the crash cart was not in the resident's room. During an interview on [DATE] at 9:19 A.M., the Staffing Coordinator (SC) said he arrived at the facility around 6:15 A.M. on [DATE]. SC said when he arrived, LPN A, LPN B, CNA C and CNA D were in the resident's room. SC said he thought LPN B was doing CPR, but he was not sure. The SC asked LPN A if he/she called 911 and LPN A said he/she was getting ready to call and SC said he needed to call. SC told LPN A he/she needed to call 911 from the nurse's station. SC said the person on the phone could not understand LPN A, so he got on the phone and spoke with 911. During an interview on [DATE] at 9:00 A.M., Emergency Medical Technician (EMT) F said he/she was the first on the scene. EMT F said he/she was dispatched to the facility for CPR in progress. When he/she arrived at the resident's room, three staff members were in the room, LPN A and 2 other staff members. EMT F said CPR was not in progress. The two staff members appeared to be rolling the resident around and cleaning the resident. EMT F told LPN A they were dispatched for a CPR in progress. LPN A told EMT F that he/she found the resident unresponsive at 5:10 A.M. LPN A got another nurse, and they started CPR together. LPN A told EMT F they gave up because the resident had no response to CPR and felt cold. During an interview on [DATE] at 9:09 A.M., EMT E said they were the second on scene. When he/she arrived, no CPR was being performed. LPN A told EMT E he/she found the resident unresponsive at 5:10 A.M. LPN A got another nurse, and they started CPR together. LPN A said CPR was administered for 10 minutes and when the resident showed no signs of life, they stopped CPR. EMT E asked LPN A what they did between 5:10 and 6:00 A.M. LPN A began yelling and said he/she did CPR for 10 minutes and the resident showed no signs of life, so they stopped. EMT E asked why they waited to call 911, but could not get an answer from LPN A. EMT E said if LPN A would have called in a reasonable time, even if the resident had signs that he/she had deceased , EMS could have gone through the CPR protocol and the life saving measures. However, with the amount of time that passed before 911 was called, EMS was unable to do the life saving measures. During an interview on [DATE] at 11:23 A.M., the Assistant Fire Chief (AFC) said he spoke to the Administrator on [DATE]. The AFC was concerned that CPR was not in progress when they arrived. He was also concerned regarding the large time lapse in calling 911 after the resident was found unresponsive. The AFC said once the staff started CPR, it should have been continued until EMS arrived. Once CPR is started, it cannot be stopped until someone more qualified arrives to take over or pronounce the resident. During interview on [DATE] at 12:46 P.M., the Administrator said he received a call from the AFC on Thursday [DATE] around 1:00 P.M. in the afternoon. AFC stated when they arrived, nobody was doing CPR on the resident. The Administrator said once the nurses started CPR, they should not have stopped until EMS arrived and took over. On [DATE] at 10:28 A.M., the Administrator said he expected physician orders to be followed. During an interview on [DATE] at 2:27 P.M., the resident's Primary Care Physician (PCP) said the nurse should start CPR immediately with a full code patient and have someone call 911 immediately. Anyone can call 911. Compressions should continue until EMS arrives. LPNs need to follow the supervision of EMS and not pronounce death, and they should continue CPR until EMS arrives and takes over care. During an interview on [DATE] at 10:22 A.M., the Medical Director (MD) said the purpose of CPR is to resuscitate the patient. The patient code status wishes should be followed. If a patient is found unresponsive, verify code status if full code, 911 should be called immediately and CPR should be initiated immediately. CPR should be continued until EMS arrives and takes over CPR. 2. Review of the facility's staffing sheets from [DATE] through [DATE], showed: -14 out of the 30 days the facility did not have a CPR certified staff member on the night shift (11:00 P.M. - 7:00 A.M.): -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift. During an interview on [DATE] at 9:57 A.M., the SC said he did not know which staff members were CPR certified. He thought all the nurses were CPR certified. During an interview on [DATE] at 10:12 A.M., Human Resources (HR) said she does orientation with new employees and asks for CPR cards at that time. HR said the previous Director of Nursing (DON) used to keep the CPR cards and when they didn't have a DON around [DATE], HR started keeping the CPR cards. HR had not given the SC a list showing what staff were CPR certified. During an interview on [DATE] at 9:19 A.M., the SC said he did not know what staff members where CPR certified. He was not aware he was supposed to have one CPR certified staff member on each shift until [DATE], after talking with state. When the SC spoke to the Administrator, he told the SC there needed to be one on each shift. Currently there is nothing on the staffing sheets to identify what staff members are CPR certified. During an interview on [DATE] at 5:20 A.M., LPN G said he/she does not know who is CPR certified and he/she would not have time to ask in an emergency. The resident would be LPN G's top concern at that time. During an interview on [DATE] at 6:45 A.M., LPN H said the facility did not have LPN H's CPR certification at the facility. During an interview on [DATE] at 3:15 P.M., the Administrator said he expected a CPR certified staff member to be on staff at all times. The Administrator said the SC knows that all nurses are CPR certified. He expected the facility to have the current, up-to-date CPR certifications for staff who are CPR certified. Staff would be considered not CPR certified if the facility did not have the staff members current up-to-date CPR certification. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, 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 E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00247107

Based on observation, interview and record review, the facility failed to ensure the resident environment remained free from hazards and residents received supervision per the facility's smoking protocol and individual resident smoking assessments when five residents were left unattended in the outside courtyard without staff available to let them back in for approximately 30 minutes during freezing weather conditions, with a temperature of 22 degrees Fahrenheit (F) and wind speeds of nine miles per hour (mph) (Residents #69, #58, #65, #63 and #68). One resident (Resident #69) required supervision at all times for safety. The door to the outside courtyard could only be opened from the inside and once closed, residents and staff could not get back inside unless let in by someone inside the building, or by using a slanted walkway through the courtyard to get to a back gate that exited to a driving path where vehicles traveled. In addition, one resident (Resident #65) was observed to enter the code on the keypad used to open the courtyard door without staff assistance, and staff reported knowledge of some residents knowing the code and not reporting it to the Interim Administrator. The Interim Administrator said it is required that all residents be supervised when smoking. The facility identified eight residents who smoke. The census was 69. The Interim Administrator was notified on 1/17/24 at 3:54 P.M. of an immediate jeopardy (IJ) which began on 1/17/24. The IJ was removed on 1/19/24 as confirmed by surveyor onsite verification. Review of the facility's Smoking policy, revised 11/24/23, showed: -Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents; -Policy Explanation and Compliance Guidelines included: -Smoking is prohibited in all areas expect the designated smoking area. A Designated Smoking Area sign will be prominently posted; -Safety measures for the designated smoking area may include, but not limited to, protection from weather; -Residents who smoke shall be further assessed to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all; -Any resident who is deemed safe to smoke, with or without supervision, shall be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan; -All safe smoking measures shall be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who shall be responsible for supervising residents while smoking. Supervision shall be provided as indicated on each resident's care plan. 1. Review of the signs posted on the door leading to the outside courtyard from the facility's dining room, showed: -This door is only allowed to be open by staff. No resident should open this door. Residents are only allowed to go out with staff; -Smoking times, updated 1/8/24: --6:30 A.M., Housekeeping; --8:30 A.M., Dietary; --10:30 A.M., Activities; --1:30 P.M., Activities; --3:30 P.M., Admissions; --6:30 P.M., CNA- East Wing; --8:30 P.M., CNA-West Wing; --10:30 P.M., CNA-East Wing; --Smoking times may differ depending on situation. Residents are not allowed to smoke without staff, smoking without staff could cause facility to become a non-smoking facility. 2. Review of Resident #69's medical record, showed diagnoses included central cord syndrome (spinal cord injury) at unspecified level of cervical spinal cord, spastic hemiplegia (involuntary contractions affecting one side of the body) affecting unspecified side and depression. Review of the resident's smoking assessment, dated 9/14/23, showed: -Does the resident currently smoke: Yes;. -Smoking care plan intervention: Smoking materials are kept secured by staff; -Is the resident cognitively intact: Yes; -Can the resident light a cigarette independently: No; -All residents must be supervised when smoking. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed; -Signed by the resident. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/5/23, showed: -Cognitively intact; -Upper and lower extremity impairment on both sides; -Use of wheelchair. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is a smoker; -Goal: Resident will maintain safety while following smoking protocol; -Interventions: Smoking materials are kept secured by staff; -The care plan did not identify the facility's smoking protocol for supervision while smoking, resident's inability to light a cigarette independently, and the resident's use of an apron while smoking. 3. Review of Resident #58's medical record, showed: -Diagnoses included high blood pressure, acquired absence of right toe, polyneuropathy (decreased ability to move and feel due to nerve damage), sleep apnea, shortness of breath, anxiety and depression. Review of the resident's smoking assessment, dated 10/19/23, showed: -Does the resident currently smoke: Yes; -Smoking care plan intervention: Educate resident about smoking risks and hazards; -Is the resident cognitively intact: Yes; -Can the resident hold a cigarette safely: Yes, is capable but this is a non-smoking facility; -Does the resident only smoke in designated areas at designated times: No; -All residents must be supervised when smoking. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed; -Signed by the resident. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Lower extremity impairment to one side; -Use of wheelchair and walker; -Two or more falls since prior assessment. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is dependent on tobacco and continues to smoke after being made aware this is a smoke free facility; -Goal: Resident will have minimized risk of injury from unsafe smoking practices through review date; -Interventions: Educate resident about smoking risks and hazards; -The care plan did not identify the facility's smoking protocol for supervision while smoking. During an interview on 1/16/24 at 9:42 A.M., the resident said residents smoke in the facility's courtyard during the smoke times posted on the door. Staff have to let the residents outside to smoke, but this is a problem because it's always hard to find staff around to supervise at smoke time. The facility's rule is staff are supposed to supervise and go outside with residents during smoke time, but some of the staff stay inside. 4. Review of Resident #65's medical record, showed diagnoses included dementia, encephalopathy (brain disease), muscle weakness and unsteadiness on feet. Review of the resident's smoking assessment, dated 10/28/23, showed: -Does the resident currently smoke: Yes; -Smoking care plan interventions: Resident is supervised while smoking, smoking per facility protocol; -Is the resident cognitively intact: Yes; -All residents must be supervised when smoking. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed; -Signed by the resident. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Use of walker. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident smoking. 5. Review of Resident #63's medical record, showed diagnoses included colon cancer, brain cancer, weakness, anxiety and depression. Review of the resident's smoking assessment, dated 10/22/23, showed: -Does the resident currently smoke: Yes; -Smoking care plan interventions: Smoking per facility protocol; -Is the resident cognitively intact: Yes; -All residents must be supervised when smoking. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed. -Signed by the resident. Review of the resident's significant change MDS, dated [DATE], showed: -Cognitively intact; -Use of wheelchair. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident smoking. 6. Review of Resident #68's medical record, showed diagnoses included respiratory failure and depression. Review of the resident's smoking assessment, dated 9/13/23, showed: -Does the resident currently smoke: No; -All residents must be supervised when smoking. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Use of walker. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed; -Signed by the resident. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is a smoker; -Goal: Resident will maintain safety while following smoking protocol; -Interventions: Smoking per facility protocol; -The care plan did not identify the facility's smoking protocol for supervision while smoking. 7. Observation on 1/17/24, showed: -At 10:30 A.M., Residents #58, #63, and #69, sat in wheelchairs, and Resident #68 sat on a wheeled rollator, outside in the facility's courtyard, adjacent to the facility's dining room. All four residents wore coats and were smoking cigarettes. No residents wore smoking aprons. No staff were present in the courtyard or dining room. -Review of weather data for that time, showed a temperature of 22 degrees F with wind at nine mph; -At 10:32 A.M., Resident #65 ambulated with a walker through the dining room and approached a keypad on the dining room wall in front of the courtyard door. During an interview, the resident said he/she had to get outside to smoke before time was up. The resident entered a code on the keypad and exited through the door of the dining room, to the outside courtyard; -At 10:41 A.M., Resident #65 knocked on the courtyard door leading to the dining room. No staff were present in the dining room. Seconds later, two unknown employees entered the dining room from the facility's main hall. One employee turned around and exited the dining room through the main hall, while the other employee entered the kitchen, adjacent to the dining room; -At 10:44 A.M., Resident #65 knocked on the courtyard door leading to the dining room. No staff were present in the dining room; -At 10:45 A.M., Housekeeper E walked through the dining room, entered a code on the keypad next to the courtyard door, and exited through the door to the courtyard. The door closed. He/She turned around, knocked on the door to the dining room, and tried the doorknob. The door was locked and no staff were present in the dining room. Housekeeper E walked down a slanted sidewalk through the courtyard and exited through a back gate; -At 10:49 A.M., Resident #63 knocked on the courtyard door leading to the dining room and tried the doorknob. No staff were present in the dining room; -At 10:59 A.M., the residents were back inside the facility from the courtyard. During an interview on 1/17/24 at 10:59 A.M., Resident #58 said he/she and the other four residents who were just outside smoking, had to wait for staff to let them back in. Residents do not have a way to get back inside the facility from the courtyard without staff letting them in. Staff are supposed to be outside with residents during smoke times, but some staff do not want to go outside with the residents. During an interview on 1/17/24 at 11:30 A.M., Resident #63 said staff use the keypad in the dining room to let residents out to the courtyard at smoke time. Unless staff go out with them, residents have to wait outside for staff to let them back in. A cook let him/her and several other residents out to the courtyard this morning, before the 10:30 A.M. smoke time. A different dietary employee let the residents back in. The residents were outside for around 45 minutes. It was cold outside. During an interview on 1/17/24 at 1:00 P.M., Residents #58 and #63 said residents do not have the code for the keypad used to open the door going out to the courtyard. Once outside, there is no way to open the door from the courtyard to get back into the dining room. Staff are supposed to supervise smoke breaks and let residents back in when the smoke break is over, but that does not always happen and residents have been locked outside before today. Resident #63 said he/she once waited 45 minutes to get back inside. Resident #58 said he/she once waited 30 minutes to get back inside. During an interview on 1/17/24 at 1:07 P.M., Resident #65 said it's always the same problem with smoking times. Staff are supposed to go outside with residents during smoking time, but then sometimes they don't. Residents will wait outside for 15 to 20 minutes before staff let them back in. This morning, dietary staff let him/her out to the courtyard at smoking time and then left. He/She was not supervised while smoking and had to wait outside for over 20 minutes before staff let him/her back in. During an interview on 1/17/24 at 1:12 P.M., Resident #65 said residents are not supposed to have the code to use the keypad in the dining room for the courtyard door. Staff are supposed to be with residents during smoking times. If staff are not at the courtyard door when residents are ready to come back inside after smoking, maybe a dietary employee will walk by and open the door. He/She has been left waiting to get back inside for 30 minutes before. During an interview on 1/17/24 at 1:13 P.M., Resident #69 said he/she has limited mobility. He/She can hold a cigarette, but cannot light it. He/She has to be supervised and is supposed to wear an apron while smoking. There is a smoking schedule on the courtyard door for staff and residents to follow. A dietary employee let him/her and other residents outside to the courtyard for the 10:30 A.M. smoke break, but did not stay to supervise. He/She smoked one cigarette and was ready to come back in. He/She had to wait outside for about 30 minutes before staff let him/her back inside. Staff are supposed to stay and supervise smoking, then let the residents back inside. It doesn't make sense because the door locks when it closes and then staff cannot get back inside, either. If there is an emergency while residents are outside smoking and no staff with them, there is nothing the residents can do. Residents have been locked outside in the courtyard before today. On one occasion, a resident who walks went through the courtyard's back gate, around the building, and through the front door to let the other residents back inside. During an interview on 1/17/24 at 11:34 A.M., Cook D said designated smoking times are posted on the door leading from the dining room to the courtyard. Smoking is supposed to be supervised by staff. A specific staff member is assigned to supervise smoke times posted on the schedule. There is a keypad to open the door from the dining room to the courtyard and only staff should know the code; however, some residents are observant and have learned the code to let themselves out. The door to the courtyard cannot be opened from the outside and staff have to use the keypad to open the door and let residents back in. Today at around 10:30 A.M., he/she used the keypad to open the door and let several residents outside to the courtyard to smoke. He/She is unsure which staff member was assigned to supervise the smoke break at that time, but they were not around when the residents wanted to go outside. When he/she let the residents out, he/she told them he/she could not supervise because he/she was the only employee in dietary at the time, and he/she went back to the kitchen. While in the kitchen, staff cannot hear when residents knock on the courtyard door. During an interview on 1/17/24 at 1:47 P.M., Cook D said when he/she does smoke breaks, he/she lets the residents outside and goes back to cooking. Staff don't know when residents are ready to come back in. He/She has been outside with the residents before and has gotten stuck, unable to get back inside from the courtyard. He/She had to leave the residents in the courtyard and walk around the building to get back inside. All of the residents should be supervised while smoking. During an interview on 1/17/24 at 11:49 A.M., Housekeeper E said there is a keypad for staff to use when opening the door from the dining room to the courtyard. Residents are not supposed to know the code to the keypad, but some of them do. At the designated smoking times, staff are supposed to use the keypad in the dining room to let residents outside to the courtyard. Staff are supposed to supervise the residents while they smoke. There is no way to open the door to the dining room from the courtyard because it locks when closed. At 10:45 A.M., he/she went outside to the courtyard to get to the back gate. While he/she was in the courtyard, residents were outside smoking with no staff present. Residents asked him/her to let them back in, but the door to the dining room had already closed and locked behind him/her. He/She reentered the facility through a different entrance. During an interview on 1/17/24 at 11:05 A.M., the Activity Director said if Activities staff are unable to make it for their assigned smoke times, the Task Aides help with supervising residents while they smoke. He/She asked Task Aide H to monitor the 10:30 A.M. smoke time today. At minimum, staff must monitor residents from the door. During an interview on 1/17/24 at 11:12 A.M., Task Aide H said the process for smoke time is to get the residents who need help to the smoking area and meet the rest of the residents in the dining room. Staff enter the code on the keypad for the courtyard door and go out to sit with the residents while they smoke. Residents cannot be alone while smoking in the courtyard. Some residents know the code to the keypad, but shouldn't. He/She is unsure how some of the residents got the code, and he/she did not report this. He/She was told he/she was responsible for monitoring the 10:30 A.M. smoke time today. He/She was on the phone during the smoke time, so he/she did not take the residents outside to smoke and he/she is unsure who did. During an interview on 1/17/24 at 1:01 P.M., Housekeeper G said some residents require supervision while smoking, and he/she sometimes assists with supervising. Resident #69 requires supervision while smoking. He/She has a contracted right hand and requires the use of an apron while outside smoking. Resident #63 coughs and is out of breath before he/she goes out to smoke, then tries to catch his/her breath when he/she comes back inside from smoking. He/She requires supervision while smoking for safety reasons due to being weak. Residents cannot go outside to smoke without staff. There is a schedule posted on the door to the courtyard, which shows which staff are responsible for letting residents outside during each smoking time. At smoke time, staff use the keypad in the dining room to let residents outside to the courtyard. Residents do not have the code for the keypad to the courtyard door. Once the courtyard door closes, it locks and cannot be opened from the outside. If he/she was in the courtyard with residents during smoke time and an emergency occurred, he/she would use his/her cell phone to call someone inside the building, or walk out of the courtyard and go around to the next nearest entrance to find help. During an interview on 1/17/24 at 1:23 P.M., the Admissions Director said the facility has a smoking schedule posted, which shows which staff are responsible for monitoring residents at each smoke time. Resident #69 has a history of seizures and cannot use his/her hands. He/She needs to wear a smoking apron and staff have to light his/her cigarette. He/She needs to be monitored while smoking. Resident #63 requires some oversight because he/she gets winded and by the time he/she is done smoking, he/she is breathing hard. Staff should monitor all smoke breaks so they can let residents back inside. Smoking assessments for all residents show residents should be supervised while smoking because there is no way for residents to get back inside on their own from the courtyard. To monitor smoking, staff should hold the door open to let the residents out to the courtyard, light Resident #63's cigarette at the door, and then supervise while standing inside the dining room. If she was outside in the courtyard with the residents and the door closed, she would text someone to let her back in. There is a back gate in the courtyard, but it is locked. If her phone was dead and there was an emergency, she would kick in the glass on the courtyard door and scream for help. During an interview on 1/17/24 at 1:55 P.M., Certified Nurse Aide (CNA) A said residents are unable to smoke outside, unsupervised. There is a schedule posted that tells which employee is assigned to supervise for smoke times. Supervision while smoking entails going outside to the courtyard with the residents while they smoke. The door from the dining room to the courtyard requires a code to get out and residents do not have the code. Once outside in the courtyard, there is no way to get back inside unless someone is waiting inside at the door to open it. Supervision while smoking would require two people; one to go outside and another to let people back in. During an interview on 1/17/24 at 11:16 A.M., the Interim Administrator said she would not be surprised if residents knew the code for the keypad to get outside. If staff are aware that residents have the code, they should tell her. Staff are responsible for taking residents outside at smoke times. Smoke times are posted throughout the facility to show which staff are assigned at each time. If the assigned staff cannot supervise at their assigned time, they should tell her and she can supervise. Staff are required to watch residents while they are smoking, and residents cannot be unsupervised. She canceled smoke breaks during the last couple of days due to severe cold weather. If residents are left outside and unable to get back in, they are at risk of harm. During an interview on 1/17/24 at 1:00 P.M., the Interim Administrator said smoke times are supervised by one staff. The residents do not require staff to physically stay outside with them. This morning when she supervised the early smoke break, she stood by the door to monitor the residents. The residents used to smoke by themselves, but there is always a risk of injury and that is why the policy changed. All but one of the residents who smoke are independent. Resident #69 cannot be outside by him/herself. Staff have to light his/her cigarette and he/she has to wear an apron while smoking. If something happened while the residents were smoking and she needed to respond by going outside to the courtyard and the door closed, she would have to use her cell phone to call someone to have them come open the door. The residents who smoke can move around, but staff do not want to encourage them to go through the back gate of the courtyard for safety reasons because the walkway is slanted and they might fall. During an interview on 1/19/24 at 8:58 A.M., the Wound Nurse said smoking assessments are done by Social Services (SS). She expected smoking assessments to be completed accurately. The outcome of a smoking assessment should be reflected on the resident's care plan. Care plans are updated by the MDS Nurse. During an interview on 1/19/24 at 9:07 A.M., Licensed Practical Nurse (LPN) B said SS completes smoking assessments. LPN expected smoking assessments to be completed accurately and to be reflected on a resident's care plan. Care plans are updated by the MDS Nurse. During an interview on 1/22/24 at 12:37 P.M., the MDS Nurse said she has worked with the facility for eight months and is new to the position. She is responsible for completing all MDS's and care plans for each resident at the facility. Care plans should be completed upon admission and updated quarterly and with changes. She generates care plans based on resident hospital records, interviews with CNAs and nurses, and resident assessments completed by other departments, including nursing and SS. SS completes smoking assessments. The MDS Nurse expected the assessments to be completed accurately because she uses the responses to identify interventions for the care plans. She expected care plans to accurately reflect a resident's individual needs and preferences related to smoking, including whether or not supervision is required while smoking, or if the resident requires any devices or precautions for smoking safely. During an interview on 1/19/24 at 9:50 A.M., the Director of Nurses (DON) said smoking assessments are completed by SS and the DON assists. Smoking assessments are completed upon admission and readmission, quarterly, and as needed. She expected smoking assessments to be accurate. There is verbiage at the bottom of all current smoking assessments stating all residents must be supervised while smoking. When the DON started working at the facility last year, the facility was non-smoking. In October or November 2023, the facility initiated a smoking protocol due to non-compliance by residents, who were smoking outside the front of the facility. The new smoking protocol moved resident smoking to the courtyard at specific times, supervised by staff. Care plans should reflect a resident's smoking status, and whether or not they should be supervised while smoking. During an interview on 1/19/24 at 10:28 A.M., the Interim Administrator said she has been working as SS with the facility for around seven months. When she first started working with the facility, two residents smoked, but they could not smoke on the facility's premises. Over time, residents started lining up to go outside to smoke and then there were eight residents who smoked. Around October 2023, the previous Administrator implemented a new smoking policy, which was reviewed and signed by residents who smoked. The new policy was for smoking to take place in the courtyard, supervised at specific times by staff. As SS, she is responsible for completing smoking assessments upon admission, quarterly, and with changes. The smoking assessments should be completed accurately and the findings should be reflected on the resident's care plan, which is updated by the MDS Nurse. If a resident should be supervised while smoking, it should be indicated on their care plan. Resident #69 is the only resident who requires supervision while smoking at this time. During an interview on 1/31/24 at 11:47 A.M., the facility's Medical Director said previously, the facility was non-smoking. The facility implemented a new smoking policy in September or October 2023. He was not involved in developing the policy, but did approve the facility's smoking policy. Staff is responsible for assessing residents for their safety while smoking. He expects staff to visually supervise residents while they are outside smoking for safety. This applies to any resident with a physical disability, a diagnosis such as dementia, or any resident who requires some assistance, which includes most residents. The residents who were outside for 30 minutes, unable to get back inside, should have been able to get back inside the facility when they were finished smoking or as desired. He expects the facility to have a system in place for residents to be let out to the smoking area and to be let back inside. He expects there to be a standard protocol for staff to follow in the event of getting locked outside in the courtyard while residents are smoking. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions 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 the exit, the deficiency was lowered to the E level. This statement does not denote 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). MO00229167

Based on interview and record review, the facility failed to ensure agency staff performed Cardiopulmonary Resuscitation (CPR, life sustaining measure in the event the heart stops beating) for a resident (Resident #1) with a full code (in the event a resident is found without signs of life (respirations, pulse) CPR will be initiated) order. The resident was found unresponsive by the certified nursing assistant (CNA) who notified the agency nurse. The agency nurse thought since the resident had been admitted to hospice, his/her code status changed to do not resuscitate (DNR, no attempts at resuscitation will be made), but failed to check the resident's chart to verify the order. The resident had been admitted to receive hospice services, but his/her code status remained a full code. Staff did not call a code, start CPR or call 911. The resident expired. There were 39 residents with full code orders. The census was 58. On [DATE] at 3:00 P.M., the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred [DATE]. On [DATE], the administrator became aware of the violation. The facility inserviced staff on the care of dependent residents and the CPR policy and procedures. The facility audited resident records to ensure congruent code status, audited CPR status for nursing staff and completed staff education on reading and identifying the code status of a resident and where the code status was located. The IJ was removed and corrected on [DATE]. Review of the facility's Policy and Procedure: Cardio-Pulmonary Resuscitation policy, dated as reviewed ,d+[DATE], showed the following: -Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest; -Cardiac arrest is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness); -Sudden cardiac arrest (SCA) is a leading cause of death in adults; -Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse; -Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness; -If a resident is found unresponsive and not breathing normally, a licensed staff member will verify code status using the medical record; -If the resident is full code, per the medical record, a staff member that is certified in CPR will initiate CPR. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted [DATE]; -Makes self understood/understands others; -Cognitively intact; -Total assistance of one person required for bed mobility, transfers, locomotion on/off the unit, dressing, toilet use, personal hygiene and bathing; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Received hospice care. Review of the resident's Code Status Form, showed the resident chose full resuscitation/full code - provide all medically appropriate care. The form was signed by the resident on [DATE] and the physician on [DATE]. Review of the resident's physician's progress note, dated [DATE], showed the resident was complaining of right-sided chest pain and pelvic and hip pain. The resident's dementia had been progressing. The resident had failure to thrive and had multiple medical problems and was on hospice. Goal was to keep him/her comfortable. Review of the resident's [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's vital sign log for [DATE] at 12:26 A.M., showed: -Blood Pressure: ,d+[DATE]; -Temperature: 97.2 Fahrenheit; -Pulse: 78 beats per minute; -Respirations: 18 breaths/minute; -Oxygen Saturation: 96.0 %. Review of the resident's vital sign log for [DATE] at 5:52 A.M., showed: -Pain Level: 4. Further review of the resident's nurse's notes, showed the following: -[DATE] at 8:01 A.M., showed at 7:45 A.M., this writer (Nurse A) was called into the resident's room by the CNA (CNA B) caring for him/her, and he/she stated I think (he/she) is gone. Upon entering the room, the resident's pupils were fixed and dilated. No visible signs of life noted. Unable to obtain any vital signs (VS, pulse, blood pressure, respiration). Bowel sounds absent, no heart rate noted. At 7:50 A.M., a call was placed to hospice and Nurse A spoke with the on call nurse, who stated themselves or another nurse would be in to handle the paperwork and contact the family, physician, and medical examiner (ME). Postmortem care provided while awaiting on hospice nurse arrival. During an interview on [DATE] at 9:45 A.M., CNA B said he/she had worked for the facility for three years. He/she arrived at work and was making his/her first rounds and noticed the resident was lying down in bed with his/her eyes open. He/she said good morning to the resident and the resident did not respond. He/she then noted the resident's head was hanging off the pillow and his/her covers were hanging off him/her. He/she told the resident let's pull your covers up, it is kind of chilly and at that time noted the resident was not breathing. He/she touched the resident's hand and he/she was still warm. He/she ran and told Nurse A the resident was not responding. Nurse A grabbed the blood pressure cuff and went and checked the resident. He/she was not breathing. He/she asked the nurse if he/she was a full code or DNR and if they needed to do CPR. Nurse A said the resident was a hospice resident and hospice residents didn't get CPR. He/she did not question that and just went with what Nurse A said. He/she was CPR certified and knew where the code status book was located on the crash cart. He/she now knows that if the nurse does not check the code status book, that he/she needs to go get the crash cart and check it himself/herself. If the resident was a full code and the nurse does not start CPR, he/she will start it immediately. There was a code status book on the crash cart. It had been there since he/she had started there. All new nurses and CNAs (facility staff or agency) take a tour of the facility and get shown where the code book and crash cart are and get information on facility policies before they start. During an interview on [DATE] at 9:13 A.M., Nurse A said he/she was supposed to be off, but the day nurse was running late. The CNA told him/her that he/she thought the resident had passed away. He/she went and assessed the resident at approximately 7:45 A.M. and he/she had expired. The resident was still warm, but the heat in the room was 80 degrees. He/she did not know if that made a difference or not. The resident had no pulse or respirations. He/she then went and called hospice and notified them the resident had expired. He/she did not check to see if the resident was a full code or DNR. He/she saw a purple sheet at the front of the hospice book, but did not read it, he/she just assumed it was the resident's DNR. The day shift nurse got there about 8:10 A.M. and said he/she would contact management. It was the end of his/her shift and he/she left the building. At around 10:00 A.M., the facility contacted him/her and said the resident was a full code. He/she previously worked at the facility, but this was his/her first time on that hall. He/she did not receive any orientation at any time. He/she did not know there was a code status book on the crash cart. He/she did not know where the crash cart was. The CNA did not ask him/her about the resident's code status or if they should start CPR. He/she last saw the resident at approximately 6:00 A.M., when he/she administered the resident's medication. The resident was alert and took the medications whole with a sip of water. Review of the facility's Resident Abuse Final Investigation Report Form showed the following: -Date Incident Occurred: [DATE]; -Time Incident Occurred: 7:45 A.M.; -Date Incident Reported: [DATE]; -Date Incident Reported: 11:23 A.M.; -Summary of Interview with Person(s) Reporting Incident: On [DATE] at approximately 7:45 A.M., Resident was found unresponsive by CNA B. He/she notified Nurse A, and Nurse A did assessment and determined the resident had expired. Agency nurse, Nurse A, did not check code status, even after prompt from CNA. Nurse A stated the resident was on hospice, and proceeded to call hospice about the resident expiring; -Summary of Interview with Staff Members Having Contact with the Resident during the Period of the Location: Writer interviewed staff member, CNA B. CNA B stated he/she checked on the resident at approximately 7:00 A.M. and he/she was lying in bed. At 7:45 A.M., he/she returned to the room and saw the resident did not have a pulse. At this time, CNA B stated he/she notified the nurse on duty, Nurse A, who proceeded to tell CNA B that the resident was hospice, so he/she would notify them. At this time, CNA B stated that the nurse should check the code status book on the crash cart to confirm code status, in which the nurse replied, No (he/she) is hospice. The Assistant Director of Nurses (ADON), interviewed Nurse A, regarding not performing CPR on the resident. Nurse A stated that he/she was notified by the day shift CNA, CNA B, that the resident had passed. At that time, he/she completed an assessment and determined that he/she was unable to obtain vital signs. He/she then grabbed the hospice binder and placed a call to the hospice provider about the resident passing. When asked why he/she did not perform CPR, Nurse A stated he/she found a pink form which he/she assumed was a DNR form. The Director of Nursing (DON) asked Nurse A why he/she did not check the code status binder or the resident face sheet to which he/she had no comment. The ADON also asked Nurse A why he/she did not have a second nurse sign off on the death, and Nurse A also had no comment; -Summary of Investigators Findings: A thorough investigation was conducted with many interviews done. It was determined that agency nurse, Nurse A, had previously worked in the facility and had completed both new hire and agency orientation in the facility which included where code status was located. It was also determined that a staff member, CNA B, reminded Nurse A where to find the code status, and Nurse A did not check the code status book, or the face sheet of the resident; -Facility Action Taken: The facility immediately put into place a post-noncompliance related to code status. This included training for all nursing staff, training with management staff, identifying code status and auditing, notification of the medical director, ensuring all agency staff are oriented to the facility before the start of their shift, future training upon hire with new employees, auditing to ensure processes are in place, and ensuring a staff member with CPR training was on each shift. Auditing will continue to ensure compliance; -Notification of Investigation: State Licensing Agency on [DATE] at 11:23 A.M. and medical director on [DATE] at 12:30 P.M. Review of the facility's blank Agency Personnel/Contract Checklist, showed: -The following information is reviewed with agency personnel on his/her first visit to the facility and prior to contact with the residents. After reviewing all information on the checklist, it is signed by the agency person and the facility representative to verify that the orientation had been completed. The completed checklist was returned to the facility's Staff Development Coordinator or facility designee. Checklists are specific to just nurses and do not need to be covered with non-licensed staff; -All agency personnel/contract; --Emergency procedures; --Resident rights, confidentiality; --Abuse prohibition, Grievance procedure; --Emergency response protocol, location of crash carts, emergency suction, etc; --Identification of CODE Status and to initiate CPR if resident was found without vitals and was a FULL CODE until emergency medical services (EMS - ambulance) arrives. During an interview on [DATE] at 11:07 A.M., the administrator said the resident passed away the morning of [DATE]. The resident was a hospice patient, but still a full code. Nurse A found the resident without respirations or a pulse, but did not call a code, initiate CPR or call 911, because he/she thought the resident had a DNR order since he/she was a hospice patient. It was later noted the resident was a full code and an investigation was started. All agency staff and new staff receive orientation before their first shift. The orientation included where to find a resident's code status and that there was a code status book on the crash cart, where the crash cart was, and when to start CPR. During an interview on [DATE] at 2:07 P.M., the DON said he/she or the ADON were responsible for agency staff orientation packet/checklist. All agency staff receive orientation and a tour prior to their first shift. That orientation does include when to do CPR, where to find a resident's code status, and where to find the crash cart. A resident's code status can be found in the code status book on the crash cart. The tour includes showing them where to find the crash cart and the code status book. The code status book was updated weekly and as needed. She expected staff to check the code status book with each incident because you don't know when there has been a change. She expected staff to perform CPR on all full code residents. She expected CNAs to start compressions, get help, and call the DON and/or ADON. All staff have been recently CPR certified. When the facility became aware that the resident was a full code and Nurse A did not perform CPR, the facility contacted the physician, family, staffing agency, and Nurse A. An investigation was started and was still in progress. Nurse A will not be coming back to the facility. MO 505

Based on interview and record review, the facility staff failed to call emergency personnel and failed to provide basic life support, including cardiopulmonary resuscitation (CPR), an emergency procedure that is performed when a person's heartbeat or breathing has stopped, for one of six sampled residents (Resident #500). The census was 81. The administrator was notified on [DATE] at 1:45 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance that occurred on [DATE]. On [DATE], the administrator became aware of the violation of the facility CPR policy. The staff member was suspended pending investigation. The facility inserviced the staff on the CPR policy and procedures. The IJ was removed and corrected on [DATE]. Review of the facility's undated CPR policy, showed the following: -Responsibility: Licensed nurse and any person in the facility with CPR experience; -Purpose: To ventilate and establish circulation on a resident with absence of respirations and pulse; -Procedure: -Determine unresponsiveness by tapping or gently shaking resident and shouting, Are you okay?; -Call out for help; -Delegate a specific individual to check resident's CPR status; have individual to call paramedics, attending physician and administrative personnel when appropriate. Note: Do not start CPR if resident is breathing and has a pulse. -Breathing: Determine breathlessness. Maintaining the open airway, place ear over resident's mouth and nose (three to five seconds). Look for chest rise and fall. Listen for exhalation. Feel for exhaled air; -Circulation: Determine pulselessness. Palpate the carotid pulse (may be felt on either side of the front of the neck just below the angle of the jaw) to avoid compressing the artery (or near side of victim five to ten seconds); -Delegate a specific individual to check on status of paramedics and instructions from attending physician and report back as soon as possible; -Once CPR is started, do not discontinue until the paramedics arrive or a physician pronounces the resident dead and gives orders to discontinue CPR; -Documentation: -Condition change that was observed; -Vital signs or absence of vital signs; -Exact time CPR was started; -Exact time paramedics were notified and arrived; -Exact time attending physician was called and time reached; -physician's orders [REDACTED]. -Notification of the resident's family or responsible party. Review of the facility's undated Code Status policy, showed the following: -Responsibility: Social Services, licensed nurse; -Purpose: To honor the final wishes of the resident if resident is unable to voice the life prolonging procedures they may want or is unresponsive; -Procedure: -Upon admission, the social service designee will obtain the advance directive, living will or power of attorney documents for health or financial purposes; -If able to do so, the resident can give his/her verbal directive with the witness of two people; -If the resident or responsible party is unable to produce such documents, the resident will be considered a full code until such time that a directive can be made; -Purple Form: If the resident is a DNR (do not resuscitate) a Purple Form (Out of hospital Do Not Resuscitate) will be placed in the front of the resident chart and in the Code Status book kept on the crash cart of each wing; -Documentation: -The resident code status will be noted on the face sheet and in the physician's orders [REDACTED].> -A copy of the directive will be obtained and placed in the Advance Direction section of the resident's chart; -Copies of the physician certifications will be obtained by nursing and placed in the Advance Direction section of the resident chart; -A copy of the directive will be placed in the Code Status book located on each wing on the crash cart. Review of Resident #500's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted [DATE]; -Brief Interview for Mental Status (BIMS, a brief screen for cognitive impairment) score: 2 of 15 (indicating severe cognitive impairment); -Extensive assistance of one to two persons with care. Total dependence on two persons with transfers; -[DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the resident's nurse's notes, documented by Nurse A, dated [DATE] at 6:45 P.M., showed the resident was found by the certified nurse assistant (CNA) at 1:20 P.M. The resident was last seen alive at 12:45 P.M. after a bed change. Vitals were taken, sternum rub was performed. The resident was pronounced dead by two nurses at 1:40 P.M. Resident's physician was notified first, then the coroner's office. The resident's responsible party was notified, and he/she notified the funeral home and made arrangements to have the body picked up. During an interview on [DATE] at 9:15 A.M., Nurse A said he/she did not check the resident's code status. He/she was swamped that day. The resident was fine at 12:45 P.M. and had no complaints. When the CNA entered the room later, he/she called out and Nurse A went to the resident's room. Nurse A checked the resident's vitals, and there were none. Nurse A said he/she really did not even think about checking the resident's code status. The resident's skin was somewhat cool to the touch. In hindsight, he/she should have checked the resident's code status. Nurse A asked the nurse from the other hall to confirm the death, and then called the resident's physician exchange. The resident's family was also contacted, who came to the facility later in the day. During an interview on [DATE] at 8:47 A.M., Nurse B said he/she was the nurse on East hall on [DATE]. Nurse A came over and asked him/her to confirm the death of a resident. Nurse B went in the resident's room, got out his /her stethoscope, and tried to get an apical pulse (a measure of cardiac function that is completed by placing a stethoscope at the apex of the heart and counting for one minute. It represents the opening and closing of the valves in the heart) and did not hear any sound. Nurse B could not locate a pulse anywhere. He/she also did a sternum rub and put his/her face over the resident's nose and mouth to see if the resident's chest rose and fell . The resident's pupils were fixed. Nurse B then confirmed the resident was dead. Nurse B did not know the resident's code status and did not ask. He/she assumed Nurse A knew the code status. Nurse A approached Nurse B as if it were a normal death and did not appear to be anxious or excited. While assessing the resident, he/she noted the resident was warm to the touch. If a resident is full code and warm to the touch, then nursing staff should immediately start CPR, have someone call 911 and get the crash cart. During an interview on [DATE] at 10:47 A.M., Nurse C said he/she was the on-call supervisor on [DATE] and was made aware that day of the resident's death by the administrator. On [DATE], when Nurse C returned to the facility, he/she reviewed the floor report sheets. No staff contacted him/her to report any deaths on [DATE]. Nurse C checked the resident's chart and saw the resident was a full code. The nurse's notes showed a CNA notified Nurse A that the resident was unresponsive. Nurse A did a sternum rub, confirmed the resident's death and then called the doctor and family. Nurse A should have initiated CPR when he/she found the resident unresponsive and have a CNA get the chart and continue CPR until the code status was known. The code status can be found in the electronic medical record, on the face sheet and on the crash cart. Review of Nurse A's employee counseling form, dated [DATE], showed the following: -Nurse A failed to initiate CPR for the resident; -Nurse A should have followed the resident's preferred code status; -Nurse A's employment will be terminated if another similar infraction occurs. During an interview on [DATE] at 9:16 A.M., the administrator said she expected staff to check the code status and start CPR if necessary. Someone should also call 911 and the doctor. CPR should continue until the paramedics arrive. To her knowledge, Nurse A did not check the resident's code status. Code status was kept in the hard chart, the electronic medical record and on the crash cart. Nurse A had one on one experience with dealing with an unresponsive resident, because he/she worked with the wing supervisor on an unresponsive resident during orientation. He/she should have known what to do. MO 699

Based on interview and record review, the facility failed to identify a resident's change in condition, immediately contact the physician, and failed to call 911 for immediate transportation to the hospital for one of three sampled residents. A resident (Resident #1) developed acute arterial blood clots to the left external iliac artery (a large artery which supplies [MEDICATION NAME] blood to the lower trunk and to the back of the legs), left femoral artery (supplies [MEDICATION NAME] blood to the legs and is a continuation of the iliac artery), and left popliteal artery (originates behind the knee, supplies [MEDICATION NAME] blood to the lower legs, and is a continuation of the femoral artery). The census was 92. 1. Review of Resident #1's undated face sheet, showed [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 7/19/17, showed the following: -The resident was unable to speak, but could answer yes/no questions appropriately, most of the time; -The resident had high blood pressure; -The resident needed extensive to total assistance with his/her activities of daily living; -The resident's [DIAGNOSES REDACTED]. Review of the resident's weekly skin assessment sheet, dated 10/8/17 (no time), showed dark discoloration to the front of the resident's lower legs and feet, drawn on the body diagram. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/11/17, showed the following: -[DIAGNOSES REDACTED]. -Severe cognitive impairment; -Required extensive staff assistance of staff for bed mobility, dressing, eating, and personal hygiene; -Required total staff assistance for transfers, toileting, bathing, and locomotion via a wheelchair; -No impairment of upper or lower extremity range of motion; -No pressure ulcers, no venous ulcers, and no arterial ulcers. Review of the resident's weekly skin assessment sheet, dated 10/15/17 (no time), showed the same discoloration that was documented on 10/8/17, along with additional problem areas: -The front part of the left foot was circled, with a line leading from the circled area to the word dark, and written below that word was bruises to toes, dark, and peeling; -The body diagram, of the back side, showed a line drawn from the left leg only, to the word BLE (bilateral lower extremity) and the left heel was circled, with a line drawn to the words left heel black. Review of a nurse's note, dated 10/16/17 at 5:55 A.M., showed Nurse A performed the resident's skin assessment last night (no time given) and the resident's left foot, toes, and the top of toes one through four, were dark in color with peeling skin. The back of the left heel, and the bottom front part of the sole, were dark in color and cool to the touch. The nurse was unable to feel a pedal pulse (palpable foot pulse that reflects arterial blood supply to the foot). The wound treatment nurse will be informed, this morning, of the resident's condition. There were no vital signs documented. During an interview on 1/25/18 at 4:00 P.M., Nurse A said the night nurses do all the residents skin assessments, which are started around 3:00 A.M. and are completed by 4:30 to 5:00 A.M. There were eight to ten skin assessments to do that night and the resident's skin assessment was one of the last ones completed. The resident's skin assessments were due on 10/15/17, which is why the skin assessment sheets were dated 10/15/17. He/she wrote last night in the nurse's note because they all work 12 hour shifts which start at 7:00 P.M., on one date, and end at 7:00 A.M., on the next date, so he/she was accustomed to saying last night. The resident's aide, Certified Nurse Aide (CNA) D, came to him/her, a little after 4:00 A.M. on 10/16/17, and said the resident's foot did not look right. Nurse A had just done the resident's skin assessment, about 15 minutes earlier, but went back to look at the resident's foot again and there was no change. The left foot was without a pedal pulse, there were skin scales, it was dark in color, and cool to the touch. He/she thought they were pressure ulcers and thought someone should have found them before then. The physician was not called because he/she finished the skin assessments at 5:00 A.M., the resident was the last skin assessment completed, and the Wound Treatment Nurse was due in at 5:45 A.M The day shift nurse, Nurse B, called the physician that morning. The Wound Nurse Supervisor C was notified of the resident's left foot, after he/she came in to work, and looked at the resident's foot. Nurse B came in after the Wound Nurse Supervisor, was told about the resident's foot, and he/she went to evaluate it. During an interview on 1/31/18 at 2:45 P.M., CNA D said he/she was the resident's aide from 11:00 P.M. on 10/15/17 until 6:30 A.M. on 10/16/17. He/she repositioned the resident and removed his/her yellow non-skid socks, around midnight, and did not notice any problems with his/her feet. While making last rounds, somewhere between 4:00 A.M. to 4:30 A.M., CNA D noticed the resident's left foot and toes were real dark. There was a difference in the color of his/her foot. He/she notified Nurse A, who said he/she just completed the resident's skin assessment. Nurse A went to the resident's room to look at the resident's left foot, with CNA D, and said his/her foot was cold, something was not right, and something needed to be done about it. The Wound Nurse Supervisor C came in around 4:45 A.M., and all three of them (Nurse A, CNA D, and the Wound Nurse Supervisor C) went to look at the resident's left foot. The foot looked basically the same. CNA D left at 6:30 A.M. and did not see Nurse B, the day shift nurse, come in. Review of Nurse A's second nurse's note, dated 10/16/17 at 6:21 A.M., showed the wound treatment nurse was made aware of the resident's left foot. During an interview on 1/24/18 at 10:25 A.M., Wound Treatment Nurse E said he/she helped someone get the resident up, two days prior to 10/16/17, and the resident's left foot was not dark in color. On the morning of 10/16/17, someone said the resident's left foot did not look right and the Wound Nurse Supervisor C went to look at it. The day shift nurse, Nurse B, did not get in till close to 7:00 A.M. that morning. Nurse B was the one who later told Wound Treatment Nurse E to get the resident's vital signs. That was when he/she saw the resident's left foot. The foot was dark in color, was turning black, and it started at the toes. There was no pulse in the foot. During an interview on 1/24/18 at 4:05 P.M., Wound Nurse Supervisor C said there were no wounds found on the resident's feet, during his/her stay at the facility. During a second interview on 2/5/18 at 12:35 P.M., Wound Treatment Nurse E said he/she did not see the resident's left foot until Nurse B asked him/her to get the resident's vital signs, some time after 7:00 A.M., on 10/16/17. The resident's toes, on the left foot, looked like they were turning black and necrotic (premature cell death caused by blood and oxygen deprivation). He/she thought there was something going on with the resident's circulation. Review of Nurse B's nurse's note, dated 10/16/17 at 7:43 A.M., showed the night shift nurse, Nurse A, reported the resident's left foot was darkened. Nurse B inspected the resident's left foot and found it was cool to the touch, there was no pedal pulse, and there were darkened areas to the upper foot, ball of the foot, and the left heel. The toes were completely darkened, from top to bottom, and there were reddened areas on top of each toe. The resident was alert and agreeable to going to the hospital, if so ordered. The resident's pulse was 68 (normal range, 60 to 100 beats per minute), blood pressure was 118/56 (normal range, 90 to 140/60-90), respirations were 18 (normal range, 12 to 20 breaths per minute), body temperature was 98.5 degrees Fahrenheit (normal range,97 to 99 degrees F), and blood oxygen saturation was 95% (normal range, 95-100%). He/she called the physician's exchange at 7:18 A.M., and the physician called back at 7:28 A.M. with an order to send the resident to the emergency room . He/she then called a private ambulance service company at 7:33 A.M. to arrange for the resident's transportation to the emergency room . Review of Nurse B's nurse's note, dated 10/16/17 at 8:30 A.M., showed the private ambulance service arrived to transfer the resident to the hospital. The resident was alert, non-verbal, and pleasant, on the way out of the facility. During an interview on 2/1/18 at 12:26 P.M., Nurse B said the resident had a discolored area on the top of his/her left foot, from an injury, which occurred in July, (YEAR). The foot was x-rayed on 7/12/17 and there was no fracture. Aside from that, he/she did not know of any other problems to his/her feet. On the morning of 10/16/17, Nurse A told him/her the resident's left foot was discolored and did not look good. He/she could not recall any other information told to him/her by Nurse A. He/she went to look at it right away and found the foot was cool to the touch, there was no pedal pulse, and the top of the foot, and the ball of the foot, were dark in color. The toes were darker than the other areas and there were tiny, pinpoint, red areas on top of each toe. He/she figured there was a vascular problem that was happening quickly. The resident's physician was notified and the resident was sent to the hospital. He/she did not call 911 because 911 was for life and death emergencies, like respiratory distress and cardiac issues. Review of the hospital emergency department record, dated 10/16/17, showed the resident presented to the emergency room (ER), via the ambulance service, at 8:59 A.M., with complaints of a cool to the touch, darkened left foot, which was discovered during the night. The resident had a [DIAGNOSES REDACTED]. The ER found no palpable pulse on either foot, but the left foot was cold and turning black with desquamation (peeling skin) over the top of the toes and the underneath side of the great toe was black. Additionally, there was no popliteal pulse (behind the knee), or femoral pulse (inner left thigh), on the left. A computerized tomography angiogram (an imaging test that looks at the arteries that supply blood to the leg) of the resident's left leg was done. Critical care was necessary to treat imminent deterioration of the threatened limb due to presumed embolic occlusion of the left external iliac artery, left common femoral artery, with extension to the left superficial and deep femoral arteries. There was minimal collateral blood flow (blood flow going around the clot) left hemipelvis and occlusion of the left popliteal artery. During an interview on 1/30/18 at 3:20 P.M., the resident's physician said she spoke to Nurse B at 7:24 A.M. on 10/16/17. Nurse B said the resident's left foot had no pulse and the toes were turning black. If the resident's foot truly looked like Nurse B's description, earlier at 4:00 A.M., the resident should have been immediately sent to the hospital, and 911 should have been called, because time was of the essence. The resident's leg would not have been without oxygen for many more hours. When she first read the resident's hospital report, ultimately her first thought was the nursing home was at fault, for letting the resident's leg get gangrenous, because they had not found the circulatory problem sooner and because they did not send the resident out quickly enough, after it was discovered. The gangrene most likely came from the clot in the resident's leg. It would have taken more than a few hours for gangrene to develop. The resident's left leg was probably without oxygen for at least 24 hours or more. During an interview on 2/1/18 at 12:26 P.M., the Director of Nurses (DON) said she did not know if Nurse A should have known the difference between the presentation of an emergency, arterial, circulatory occlusion versus pressure ulcers. She guessed Nurse A did not know the difference if he/she said the areas on the foot were pressure ulcers, but she hoped he/she would know the difference. Review of the facility's Condition Change, Observing, Recording, and Reporting policy, no date, showed that after a resident's change in condition, the charge nurse was to call the attending physician. If unable to reach the physician, in an emergency, send the resident to the emergency room or call 911. MO 581