Every finding on record at Belleview Valley Nursing Home

Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with physician orders for six residents (Residents #4, #5, #6, #34, #41, and #69) out of 18 sampled residents. The facility also failed to ensure the Hospice Coordinated Plan of Care addressed necessary treatments, supplies, and appliances for two residents (Residents #3 and #27) out of three sampled residents receiving hospice services. These failures had the potential to result in delayed treatment, ineffective symptom management, uncontrolled blood glucose levels, and compromised continuity of care. The facility census was 77.Review of the facility's policy titled, Hospice Plan of Care, showed:- The purpose of this policy is to ensure coordinated, person-centered end-of-life care;- All hospice care and services furnished to residents who elect hospice shall be provided in accordance with an individualized written hospice plan of care;- The hospice plan of care must be individualized and based on the initial assessment, the comprehensive assessment, and updated assessments as the resident's condition changes;- Required content includes: drugs, treatments, medical supplies, and appliances necessary for palliation (relieving pain, symptoms, or suffering caused by a serious illness without curing the underlying disease) and management of the terminal illness and related conditions, identification of needs not related to the terminal illness, and clarification of who is responsible for addressing them. Review of the facility's policy titled, Feeding Tubes, dated 01/06/24, showed:- Did not address a resident's care plan. The facility did not provide a policy for following physician orders. 1. Review of Resident #3's physician order sheet (POS), dated May 2026, showed:- admitted to the facility on [DATE];- admitted to hospice on 02/18/26;- An order for gentamicin (an antibiotic) ointment 0.1% apply to percutaneous endoscopic gastrostomy (PEG - a surgical insertion of a tube through the abdominal wall into the stomach under endoscopic guidance) tube site topically every day shift for infection to the tube site, dated 05/21/26;- An order for doxycycline (an antibiotic) 100 milligrams (mg), give one tablet two times a day for abdominal infection for 10 days, started 05/19/26, with an end date of 05/29/26;- No physician order for the PEG tube and the care of the PEG tube. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/23/26, showed:- Cognitively intact;- Received hospice services. Review of the resident's care plan, last revised 05/11/26, showed- Did not address the PEG tube with interventions of monitoring the PEG tube site, drainage, infection, treatment, or related care needs. Review of the resident's Hospice Coordinated Plan of Care, dated 02/18/26, showed:- Did not address the PEG tube with the responsibility of supplies or care; - The facility failed to develop and maintain a coordinated care plan addressing the resident's PEG tube and related treatment needs and failed to ensure physician orders contained sufficient direction for implementation. During an interview on 05/27/2026 at 8:43 A.M., the Director of Nursing (DON) said Resident #3 had a PEG tube in place but did not use it, ate by mouth, and the PEG tube site was infected and treated with antibiotics. 2. Review of Resident #4's POS, dated May 2026, showed:- admitted on [DATE];- Diagnosis of type 2 diabetes mellitus (DM - a metabolic disease);- An order for Lantus (a long-acting insulin) pen 22 units subcutaneously (under the skin) at bedtime related to type 2 DM, dated 03/27/25;- An order for Humalog (a fast-acting insulin) Kwik Pen inject 6 units subcutaneously before meals related to type 2 DM, give in addition to sliding scale, dated 10/26/25;- An order for Humalog Kwik Pen inject as per sliding scale: if blood sugar 111 - 140 = 0 units, 141 - 180 = 2 units, 181 - 220 = 3 units, 221 - 260 = 4 units, 261 - 300 = 5 units, 301 -350 = 6 units, over 351 = 8 units, if over 350 on two consecutive blood sugar checks, notify the primary care provider (PCP),subcutaneously before meals and at bedtime related to type 2 DM, dated 12/25/24;- An order for Glucagon (a medication used to treat low blood sugar) emergency injection kit 1 milligram (mg) Inject intramuscularly (administered into the muscle) as needed for hypoglycemia (low blood sugar) related to type 2 DM, dated 09/20/24;- An order to notify the physician if blood sugar is greater than 400 or lower than 60 as needed related to type 2 DM, dated 09/20/24. Review of the resident's medication administration record (MAR), dated May 2026, showed:- Lantus not administered one out of 26 opportunities;- Humalog per sliding scale not administered two out of 79 opportunities;- Blood sugar checks not obtained two out of 104 opportunities. Review of the resident's progress notes showed:- No documentation showed the physician was notified of the missed insulin administration and missed blood glucose monitoring;- On 05/27/26 at 5:53 A.M., Humalog per sliding scale, missed;- On 05/27/26 at 5:54 A.M., Lantus 22 units subcutaneously at bedtime, missed;- On 05/27/26 at 8:18 A.M., the nurse was informed upon arriving for shift that the overnight blood sugar was not completed by the night shift nurse. The resident already ate breakfast. The DON was made aware. Instructed to inform the provider upon arrival;- No documentation regarding the resident received Humalog sliding scale, Lantus, and blood sugar check administered or obtained on 05/04/26, 05/26/26, and/or 05/27/26. 3. Review of Resident #5's POS, dated May 2026, showed:- admitted on [DATE];- Diagnosis of Diabetes Mellitus (DM - a metabolic disease);- An order for Lantus Pen-injector inject per sliding scale for blood sugar: 0 - 99 = 0, 100 - 170 = 29 units, over 171 = 58 units, two times a day in the morning and evening, dated 05/06/26;- An order for blood sugar checks before each meal and at bedtime, dated 03/25/26;- An order for Novolog 70/30 (a short acting insulin) FlexPen inject per sliding scale for a blood sugar of: 151 - 200 = 3 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 350 = 8 units, 351 - 999 = 11 units, if over 350 administer 11 units and contact the physician, administer subcutaneously (beneath the skin) before meals and at bedtime, dated 05/17/26. Review of the resident's MAR, dated May 2026, showed:- Lantus not administered one out of 42 opportunities;- Novolog 70/30 not administered two out of 44 opportunities;- Blood sugar checks not obtained one out of 105 opportunities. Review of the resident's progress notes showed:- No documentation showed the physician was notified of the missed insulin administration and missed blood glucose monitoring. 4. Review of Resident #6's POS, dated May 2026, showed:- admitted on [DATE];- Diagnosis of DM;- An order for Lantus Pen-injector inject 40 units at bedtime, dated 02/06/26;- An order for Novolog injection inject 10 units two times a day, in the morning and evening, dated 02/27/26;- An order for Novolog injection inject per sliding scale for a blood sugar of: 150 - 199 = 1 unit, 200 - 249 = 2 units, 250 - 299 = 3units, 300 - 349 = 4 units, over 350 = 5 units before meals, dated 02/27/26;- Insulin pen needle use subcutaneously before meals and bedtime, dated 10/06/25;- Invega Sustenna (an antipsychotic (medication used to treat psychosis of delusions, hallucinations, paranoia, or disordered thoughts) medication) 234 milligram (mg)/1.5 milliliters (ml) intramuscularly (into the muscle) every 28 days, due 05/18/26, last administered 04/20/26, dated 07/15/24. Review of the resident's MAR, dated May 2026, showed:- Lantus not administered one out of 27 opportunities;- Novolog not administered one out of 57 opportunities;- Novolog sliding scale not administered one out of 85 opportunities;- Insulin pen needle not used one out 113 opportunities;- Invega Sustenna not administered one out of one opportunity. Review of the resident's progress notes showed:- On 05/27/26 at 7:56 A.M., the nurse was informed upon arriving for shift that the overnight blood sugar was not completed by the night shift nurse. The resident already ate breakfast. The DON was made aware. Instructed to inform the physician upon arrival; - No documentation showed the physician was notified of the missed insulin administration, missed blood glucose monitoring, and Invega Sustenna injection.Observation on 05/29/26 at 10:30 A.M., of the resident's medications in the B wing medication room showed:- Two Invega Sustenna injections dated 04/24/26 and 05/20/26. 5. Review of Resident #27's POS, dated May 2026, showed:- admitted to the facility on [DATE];- admitted to hospice on 10/28/25;- Diagnosis of chronic obstructive pulmonary disease (COPD - a lung disease);- An order for oxygen at 2 liters per minute (LPM) continuously per nasal cannula (NC - device used to deliver oxygen with two small tubes that fit into the nostrils) due to hypoxia (low oxygen blood level), dated 05/15/22;- An order to attempt to use supplemental oxygen during showering and restroom use. May turn oxygen up to 3 LPM during activity, dated 03/03/26. Review of the resident's quarterly MDS, dated [DATE], showed:- Mild cognitive impairment;- Received hospice;- Received oxygen therapy. Review of the resident's care plan, last revised 05/09/26, showed:- Requires oxygen therapy due to ineffective gas exchange from COPD. Oxygen at 2 LPM via NC every day and night. Monitor for signs and symptoms of respiratory distress and report. Review of the resident's Hospice Coordinated Plan of Care, dated 10/28/25, showed:- Did not address the responsibility for oxygen equipment, supplies, monitoring, or adjustments of the continuous oxygen.Observations on 05/24/26 at 10:45 A.M., and 3:30 P.M., 05/25/26 at 8:15 A.M., and 1:40 P.M., and 05/26/26 at 9:30 A.M., showed:- The resident lay in bed with his/her eyes closed with oxygen at 3 LPM via NC. 6. Review of the Resident #34's POS, dated May 2026, showed:- Diagnoses of gastroesophageal reflux disease (GERD - stomach contents leak backwards into the esophagus);- An order for famotidine (a medication used to treat and prevent GERD, heartburn and stomach ulcers (an open sore in the inner lining of the stomach) 20 milligrams (mg) by mouth two times a day for ulcer, dated 06/18/24. Observation on 05/27/26 at 12:05 P.M., of the resident's medication administration showed:- Certified Medication Technician (CMT) K failed to administer the resident's famotidine dose;- CMT K documented the famotidine dose was unavailable on the resident's MAR;- CMT K did not notify the charge nurse, the DON, and the pharmacy. The physician was not notified;- The facility failed to administer the famotidine as ordered by the physician and failed to notify the physician when the medication was unavailable. Review of the resident's progress notes showed:- No documentation the resident's famotidine dose not administered on 05/27/26;- No documentation the charge nurse, the DON, the pharmacy, or the physician was notified of the resident's famotidine dose not administered on 05/27/26, and not available at the facility. During an interview on 05/27/26 at 12:05 P.M., CMT K said the resident's famotidine dose was a stock medication (over-the-counter medication kept in stock by the facility), but he/she gave the last pill to another resident earlier and there were none left in the facility. CMT K said the medication should be ordered, but it might come today if the pharmacy delivered at 2:30 P.M. 7. Review of Resident #41's POS, dated May 2026, showed:- admitted on [DATE];- Diagnosis of DM;- An order of insulin aspart (a short acting insulin) Pen-injector inject per sliding scale for blood sugar of: 251 - 300 = 2 units, 301 - 350 = 3 units, 351 - 400 = 4 units, if over 400 call physician, dated 02/17/25;- An order for use of an insulin pen needle subcutaneously before meals, dated 10/06/25. Review of the resident's MAR, dated May 2026, showed:- Insulin aspart not administered one out of 85 opportunities;- Insulin pen needle not used one out of 85 opportunities. Review of the resident's progress notes showed:On 05/27/26 at 7:55 A.M., the nurse was informed upon arriving for shift that overnight blood sugar was not completed by the night shift nurse. The resident already ate breakfast. The DON was made aware. Instructed to inform the physician upon arrival;- No documentation regarding the resident received insulin aspart sliding scale and blood sugar check administered or obtained on 05/27/26. 8. Review of Resident #69's POS, dated May 2026, showed:- admitted on [DATE];- Diagnosis of type 2 DM;- An order for Lantus inject 30 units subcutaneously two times a day related to type 2 DM with diabetic nephropathy, dated 12/16/25;- An order for insulin aspart Penfill inject 30 units subcutaneously before meals for DM related to type 2 DM with diabetic nephropathy, dated 12/16/25. Observation on 05/27/26 at 6:38 A.M., of the resident's medication administration showed:- Licensed Practical Nurse (LPN) J failed to administer the resident's insulin aspart medication per physician order;- LPN J looked for the resident's insulin aspart in the A Hall medication room and the medication was not available;- LPN J did not look for the resident's insulin aspart in the B Hall medication room;- LPN J did not notify the Director of Nursing (DON), the pharmacy, or the physician. Review of the resident's diabetic MAR, dated May 2026, showed:Review of the resident's diabetic MAR, dated May 2026, showed:- On 05/27/26 at 6:30 A.M., dose of insulin aspart pen inject 30 units subcutaneously before meals documented as not given and see progress notes;- Insulin aspart not administered four out of 79 opportunities;- Blood sugar checks not obtained five out of 81 opportunities. Review of the resident's progress notes showed:- No documentation regarding the resident's insulin aspart, and blood sugar check not being administered or obtained on 05/04/26, or the 6:30 A.M., dose on 05/27/26;- No documentation the DON, the pharmacy, or the physician was notified of the resident's insulin aspart dose not administered on 05/27/26 at 6:30 A.M., and not available at the facility;- On 05/27/26 at 11:30 A.M., insulin aspart Penfill inject 30 unit subcutaneously before meals for DM related to type 2 DM with diabetic nephropathy, medication on order from the pharmacy;- On 05/27/26 at 11:41 A.M., insulin aspart Penfill inject 30 unit subcutaneously before meals for DM related to type 2 DM with diabetic nephropathy, medication on order from the pharmacy. Provider aware;- On 05/27/26 at 1:53 P.M., resident morning blood sugar reading of 407, 30 units of long acting administered per orders. Order for 30 units of Novolog not available. DON notified and said she would reorder medication. Noon blood sugar reading of 556. Provider notified of resident blood sugar reading and that Novolog was not available however, was ordered. An order for 8 units Novolog was given at this time. Pharmacy contacted by Registered Nurse (RN) L, pharmacy said medication would be delivered at next pass. ADON made aware of situation. ADON contacted pharmacy and informed them needed the medication as soon as possible. Pharmacy said medication was in route. Medication was delivered and a one-time order for 8 units Novolog was administered;- On 05/27/26 at 3:17 P.M., blood sugar reading of high. Provider notified. A one-time order for 10 units sliding scale insulin, continue with order for long acting. During an interview on 05/27/26 at 6:42 A.M., LPN J said he/she must locate the insulin aspart pen for the resident within the facility or reorder it from the pharmacy. Sometimes a resident's medication would be taken down to the A Hall medication room when the medications arrived from the pharmacy. During an interview on 05/29/26 at 3:00 P.M., the Assistant Director of Nursing (ADON) said the night nurse did not administer insulin that night or morning of 05/27/26 because he/she didn't realize there was a DM MAR. The nurse was told if he/she got behind to let administration know and they would help. There was no excuse. The floor nurse was told to contact the physician who said to obtain current blood sugars on everyone and administer morning insulin even if it was late. There should have been documentation showing that on all of the residents. If there were two boxes of Invega for Resident #6, then the 05/18/26 dose was not administered. During an interview on 05/29/26 at 3:38 P.M., LPN D said if the facility was out of a resident's insulin, the nurse should notify the physician and get an order. The physician should know, and a resolution figured out. During an interview on 05/29/26 at 3:45 P.M., the Assistant Director of Nursing (ADON) said if a medication was out of stock and was a stock medication, then staff should contact the physician or the pharmacy if needed. During an interview on 05/29/26 at 4:18 P.M., the DON said the hospice coordinated plan of care should reflect the coordinated care for the resident and be updated as needed. All medications including insulin and Invega should be administered as ordered. She said missing medications and insulin should be documented and the physician notified. Physician orders should be followed. If a resident was out of insulin, staff should notify the physician and the pharmacy. During an interview on 05/29/26 at 4:25 P.M., the Administrator said she expected the hospice coordinated plan of care to reflect what the resident required and what equipment hospice would provide. She expected orders to be administered as ordered and physician orders to be followed. If medications were not available, the physician should be notified. Expectations would be if a medication was unavailable, for staff to check the Cubex (an automated dispensing cabinets used for the secure storage, tracking, and management of controlled substances and emergency first-dose medications), call the pharmacy, and contact the physician. During a phone interview on 06/02/26 at 11:38 A.M., LPN E said he/she did not remember failing to complete blood sugar checks or administration of insulin on the night shift of 05/26/26, or the morning shift of 05/27/26, for the residents who had orders to do so. There was no reason not to administer insulin if the blood sugar check required insulin to be administered and there was an order. He/She did not remember reporting to the oncoming nurse about blood sugar checks not being completed or insulins not administered.

Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for three residents (Residents #4, #21, and #81) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of three sampled residents. The facility's census was 77. Review of the facility's policy titled, Policy and Procedure PTSD, dated 03/26/26, showed: - This policy establishes mandatory requirements for identification, assessment, care planning, service delivery, documentation, and follow-up applicable to residents with a history of trauma and/or PTSD;- The purpose of this policy is to promote resident safety, dignity, psychosocial well-being, and quality of life; reduce the risk of re-traumatization, and maintain compliance with applicable federal requirements, Missouri law, and professional standards of practice. 1. Review of Resident #4's medical record showed:- admitted on [DATE];- Diagnoses of PTSD, major depressive disorder (MDD - long-term loss of pleasure or interest in life), recurrent severe with psychotic symptoms (may involve hallucinations or delusions) schizoaffective disorder (mental health condition that includes features of both schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and a mood disorder) depressive type (only major depressive bouts), and suicidal ideations (suicidal thoughts). Review of the resident's physician order sheet (POS), dated May 2026, showed:- An order for sertraline (an antidepressant medication) 50 milligram (mg) by mouth one time a day for depression, dated 02/14/26;- An order for quetiapine (an antipsychotic medication) 200 mg by mouth at bedtime for general anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday issues) and MDD, dated 02/25/25;- An order for bupropion (an antidepressant medication) extended release (ER) 300 mg by mouth in the morning for MDD, dated 02/25/25;- An order for bupropion ER 150 mg by mouth in the afternoon for MDD after lunch, dated 02/25/25;- An order for quetiapine 400 mg by mouth in the evening related to schizoaffective disorder depressive type, dated 11/05/24;- An order for Effexor (an antidepressant medication) extended release (XR) 150 mg by mouth in the morning related to MDD recurrent severe with psychotic symptoms, give with 75 mg capsule, dated 09/01/24;- An order for Effexor XR 75 mg by mouth in the morning related to MDD recurrent severe with psychotic symptoms, give with 150 mg capsule, dated 09/01/24. Review of resident's Trauma Informed Care Assessment, dated 10/10/25, showed:- Resident experienced this kind of event;- Had nightmares about the event(s) or thought about the event(s) when you did not want to;- Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s);- Felt numb or detached from people, activities, or your surroundings;- Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused. Review of the resident's psychiatric progress notes, dated 12/28/25, showed:- Reported unknown substance abuse history, reported history of methamphetamine abuse, and alcohol abuse. Physical or sexual abuse: patient reported history of physical and sexual abuse;- Patient increased irritability and yelling at staff. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 03/03/26, showed:- Diagnoses of depression, schizophrenia, and PTSD;- No behaviors;- Antipsychotic and antidepressant medication use. Review of the resident's comprehensive care plan, revised 05/08/26, showed:- A diagnosis of PTSD related to trauma;- No goals to maintain the resident's psychosocial and mental health;- No documentation showing the resident had past trauma, physical or verbal abuse, substance or alcohol abuse or any triggers that would cause the resident trauma;- No non-pharmacological interventions for how the facility would address behaviors if they occurred;- Resident uses antidepressant medication related to MDD, and schizoaffective disorder depressed type. No non-pharmacological interventions for diagnoses;- Resident uses psychotropic medications related to behavior management, PTSD, suicidal ideations, schizoaffective depressed disorder, history of polysubstance abuse, and MDD, and did not include non-pharmacological interventions;- Suicidal ideations diagnosis not addressed. During an observation and interview on 05/26/26 at 11:39 A.M., showed:- The resident was fidgety and anxious when talking about his/her past. He/She became quiet, looked around the room, readjusted himself/herself in bed, and avoided eye contact and further conversation;- The resident said he/she did have a history of trauma/PTSD from when he/she was a kid. People being loud freaked him/her out and he/she had nightmares sometimes. He/She stayed to himself/herself. 2. Review of Resident #21's medical record showed: - admission date of 03/12/26;- Diagnoses of PTSD and schizoaffective disorder bipolar type (mood disorder that can cause intense mood swings). Review of the resident's POS, dated May 2026, showed:- An order for prazosin (a blood pressure medication also used to treat PTSD nightmares) 2 mg three capsules by mouth at bedtime for nightmares, dated 03/12/26. Review of the resident's comprehensive care plan, initiated on 05/8/26, showed:- Did not address triggers that would cause resident trauma;- Did not address past trauma or any triggers that would cause the resident to have behaviors;- No goals to maintain the resident's psychosocial and mental health;- No documentation showing the resident had past trauma, physical or verbal abuse, substance or alcohol abuse or any triggers that would cause the resident trauma;- No non-pharmacological interventions for how the facility would address behaviors if they occurred. Observation and interview on 05/29/26 at 2:36 P.M., showed:- The resident sounded regretful, fidgety, and anxious while talking about his/her nightmares, experiences with church leaders, mental healthcare providers, and police. He/She was tearful, looked around the room, and readjusted in his/her chair;- The resident said he/she had a medication used for night terrors, but he/she woke up yelling sometimes, the bad dreams were reoccurring. Some of the facility residents' behaviors were triggering. He/She could use someone to talk to about his/her triggers and the day staff were friendlier. 3. Review of Resident #81's medical record showed: - admission date of 7/06/22;- Diagnoses of PTSD, anxiety, bipolar disorder, and generalized anxiety disorder;- Cognition impairment. Review of the resident's POS, dated May 2026, showed:- An order for Klonopin (a benzodiazepine medication) 0.5 mg two times a day for mood, dated 05/04/26;- An order for Invega Sustenna (an antipsychotic medication) inject 234 mg intramuscular (into the muscle) every day shift every 28 days related to bipolar disorder and PTSD, dated 03/05/25;- An order for risperidone (an antipsychotic medication) 2 mg by mouth twice daily for mood disorder, dated 05/04/26;- An order for benztropine (an anticholinergic medication) 0.5 mg by mouth two times a day for bipolar, dated 07/06/22. Review of the resident's comprehensive care plan, initiated on 07/06/22, showed:- Takes a psychotropic (medication that affects mental function, behavior, and experience) medication related to PTSD;- Did not address triggers that would cause resident trauma;- Did not address past trauma or any triggers that would cause the resident to have behaviors. Observation on 05/26/26 at 1:45 P.M., of the resident showed:- The resident changed moods from being upset to happy during a sentence, very distracted and fidgety, and hard to understand what he/she was referring to because the subject of conversation changed in the middle of each subject discussed. During an interview on 05/29/26 at 2:44 P.M., Licensed Practical Nurse P said when he/she worked with PTSD affected residents, he/she approached the residents and talked about PTSD and coping skills. The nurse practitioner can also be reached, and we look at medication reviews. He/She said he/she also looked at care plans for ways to help the residents. There should be information on PTSD included in the care plan to give him/her a starting point when dealing with a resident that had been triggered. During an interview on 05/29/26 at 4:07 P.M., the Director of Nursing said the care plan should reflect resident's needs, diagnoses, and interventions, including non-pharmacological interventions. If there was a resident with a diagnosis of PTSD, the care plan should include triggers and interventions for the triggers. During an interview on 05/29/26 at 4:18 P.M., the Administrator said care plans should reflect the needs of the residents with interventions, including non-pharmacological interventions.

Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program to prevent the transmission of infectious organisms. The facility failed to follow Enhanced Barrier Precautions (EBP - precautions used during high-contact resident care activities for residents infected or colonized with a multidrug-resistant organism (MDRO - microorganisms resistant to one or more classes of antimicrobial agents) or for residents with chronic wounds and/or indwelling medical devices) for one resident (Resident #2) out of four sampled residents. The facility failed to perform appropriate hand hygiene and glove changes during incontinent care for two residents (Residents #50 and #76) out of five sampled residents. The facility failed to properly clean and disinfect a shared glucometer (a machine used to check blood sugars), perform hand hygiene, and prevent cross-contamination during blood glucose testing and medication pass activities for four residents (Residents #8, #23, #42, and #69) out of 13 sampled residents. The facility also failed to maintain documentation of tuberculosis (TB - an infectious bacterial disease that affects the lungs) screening and testing for three residents (Residents #2, #8, and #23) out of five sampled residents. These deficient practices created the potential for transmission of infectious organisms to residents and staff. The facility census was 77.Review of the facility's policy titled, Incontinence Care, dated 03/30/26, showed:- Place soiled linens and clothing in the appropriate linen containers;- Did not address the infection control aspects of care. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 03/30/26, showed:- This facility's policy is to implement EBP for preventing transmission of MDRO's;- High-contact resident activities include device care or use including urinary catheter (a sterile tube inserted into the bladder to drain urine). Review of the facility's policy titled, Urinary Catheter Care, dated 03/30/26, showed:- Always wash hands before and after handling the catheter, tube, or bag. Review of the facility's policy titled, Glucometer Cleaning and Disinfection, dated 03/21/26, showed:- This policy establishes requirements for safe cleaning and disinfection of blood glucose meters (glucometers) used in the facility to reduce the risk of transmission of bloodborne pathogens and other infectious agents;- Required supplies included facility-approved professional-use blood glucose meter(s), if sharing is necessary. Manufacturer-approved cleaning and disinfection products for the specific meter model;- Perform hand hygiene before gathering supplies and before putting on gloves;- Prepare supplies in a clean area;- If a meter must be shared, only use a device designed for professional multi-patient use;- After each resident use, inspect the meter for visible soil or blood. Clean and then disinfect the meter exactly as directed by the manufacturer, including required wet contact time;- Allow the meter to remain wet for the full contact time specified by the disinfectant or manufacturer instructions, then allow to dry as directed before next use;- Remove gloves and perform hand hygiene after completing the test and device processing;- Do not use a shared meter on another resident until cleaning and disinfection are fully completed;- If a manufacturer does not provide cleaning and disinfecting instructions for shared use, the meter must not be shared between residents;- Medication carts, supply trays, and testing surfaces must be kept clean and organized to reduce cross-contamination;- Unused supplies taken to the bedside during testing should not be used for another resident if contamination is possible. Review of the CareSens N Blood Glucose Monitoring System's Owner Manual, undated, showed:- Use a soft cloth or tissue to wipe the meter exterior;- If necessary, the soft cloth or tissue might be dipped in a small amount of alcohol;- Did not address the glucometer was validated for multi-patient use;- Did not address the disinfecting instructions for shared use. Review of the facility's policy titled, Policy and Procedure Resident Tuberculosis Testing, dated 01/18/26, showed:- To establish a standardized procedure for TB testing using the tuberculosis skin test (TST - type of testing for TB) for residents and staff, ensuring early detection and prevention of TB transmission within the facility;- All incoming residents and newly hired staff will undergo TB screening using an approved method unless a documented history of prior positive TB test or completed treatment for latent TB infection is provided. The TST is used for a resident's baseline test and if there is no documented prior two-step testing, a two-step TST will be completed. Residents with prior positive, an x-ray will be required. An annual TB screening assessment for residents will be required. An annual TB screening assessment for residents will be completed, including review of symptoms, risk factors, and any known exposure, with additional evaluation initiated when clinically indicated or required by local health regulations. 1. Observation on 05/27/26 at 5:20 A.M., of Resident #2's urinary catheter drainage bag care showed:- EBP signage on the door; - Certified Nurse Assistant (CNA) C entered the room, did not put on a gown, did not perform hand hygiene, and put on gloves;- CNA C placed a container on the floor without a barrier, filled the container with urine from the catheter drainage bag, did not clean the spout of the catheter bag before putting back into the hub, and emptied the container full of urine;- CNA C again placed the container on the floor without a barrier, emptied the catheter drainage bag, did not clean the spout of the catheter before putting back into the hub, and emptied the container with urine; - CNA C removed gloves and performed hand hygiene. 2. Observation on 05/27/26 at 5:31 A.M., of Resident #23's blood glucose testing showed:- Licensed Practical Nurse (LPN) E did not perform hand hygiene and put on gloves;- LPN E entered the resident's room, placed the glucometer on the unclean bedside table without a barrier, performed the blood glucose test, did not remove gloves, did not perform hand hygiene, and exited the room;- LPN E placed the glucometer on top of the medication cart without a barrier;- LPN E removed gloves, did not perform hand hygiene, and touched the laptop to enter the blood glucose test results;- LPN E did not clean and disinfect the glucometer. 3. Observation on 05/27/26 at 5:39 A.M., of Resident #8's blood glucose testing showed: - LPN E did not perform hand hygiene and put on gloves;- LPN E entered the resident's room, placed the same uncleaned and unsanitized glucometer on the unclean bedside table without a barrier, performed the blood glucose test, removed gloves, did not perform hand hygiene, and exited the room;- LPN E placed the glucometer on top of the medication cart without a barrier and touched the laptop to enter the blood glucose test results;- LPN E did not clean and disinfect the glucometer, placed the uncleaned and unsanitized glucometer in the medication cart drawer and did not perform hand hygiene;- LPN E entered the supply closet near the B Hall nurse's station, exited the supply closet, sat in a chair behind the B Hall nurse's station, and did not perform hand hygiene. 4. Observation on 05/27/26 at 6:27 A.M., of Resident #42's blood glucose testing showed: - LPN J performed hand hygiene and put on gloves;- LPN J entered the resident's room, placed the same uncleaned and unsanitized glucometer on the resident's bed without a barrier, performed the blood glucose test, did not remove gloves, did not perform hand hygiene, and exited the room;- LPN J placed the glucometer on top of the medication cart without a barrier, removed gloves, and performed hand hygiene;- LPN J did not clean or disinfect the glucometer. 5. Observation on 05/27/26 at 6:38 A.M., of Resident #69 blood glucose testing and insulin administration showed:- EBP signage on the door;- LPN J performed hand hygiene and put on gloves, gown and a mask;- LPN J entered the resident's room; exited the resident's room; returned to the medication cart and removed the resident's empty insulin pen; did not remove gloves, gown, or mask; walked to the B Hall medication room, touched the outside door knob, the refrigerator, multiple packages of insulin pens, and the inside of the door knob; returned to the medication cart; changed gloves; did not perform hand hygiene; and did not change gowns;- LPN J changed gloves, did not perform hand hygiene; opened the medication cart and removed a different insulin pen for the resident; entered the resident's room; performed the blood glucose test with the same uncleaned and unsanitized glucometer; administered the resident's insulin; removed the gown, gloves, and mask; did not perform hand hygiene; and exited the room;- LPN J cleaned the glucometer with an alcohol wipe for four seconds, did not appropriately clean and sanitize the glucometer, placed the glucometer on top of the medication cart without a barrier, and performed hand hygiene. 6. Observation on 05/27/26 at 10:04 P.M., of Resident #76's incontinent care, urinary catheter drainage bag care, and transfer showed:- EBP signage on the door;- CNA A and CNA B put on gowns, performed hand hygiene, put on gloves, and entered the resident's room;- CNA A cleaned the front peri area with the same area of the washcloth, did not perform hand hygiene, and did not change gloves;- CNA A removed the soiled brief with fecal material, cleaned the same area of the resident's buttocks of fecal material four times with the same area of the washcloth, the washcloth soiled with fecal material touched the Hoyer lift (a mechanical lift used to transfer residents from one position to another) sling, did not change gloves, and did not perform hand hygiene;- CNA A put a clean brief under the resident, did not perform hand hygiene, did not change gloves, put barrier cream on the resident's peri area, performed hand hygiene, and changed gloves;- CNA A placed a clean cylinder on the resident's bed and held it against his/her gown, filled the container with urine from the urinary catheter drainage bag, did not clean the spout of the catheter bag before putting back into the hub, placed the urinary catheter drainage bag on the bed between the resident's legs, emptied the container full of urine, did not perform hand hygiene, and did not change gloves;- CNA A and CNA B transferred the resident from the bed to the wheelchair with a Hoyer lift and the Hoyer lift sling soiled with fecal material and left the Hoyer lift sling soiled with fecal material under the resident in the wheelchair; - CNA A and CNA B removed gowns and gloves, performed hand hygiene, and exited the room. 7. Observation on 05/27/26 at 9:30 A.M., of Resident #50's incontinent care showed:- EBP signage on the door;- CNA F and CNA G performed hand hygiene, put on gowns and gloves, and entered the room;- CNA F cleaned the resident's front peri area, did not perform hand hygiene, did not change gloves, retrieved a clean brief out of the package, and placed the clean brief under the urine-soaked brief;- CNA F and CNA G performed hand hygiene, changed gloves, removed the urine-soaked brief, did not perform hand hygiene, did not change gloves, fastened the new brief, dressed the resident, and transferred the resident from the bed to the wheelchair;- CNA F and CNA G removed gloves, performed hand hygiene and exited the room. 8. Review of Resident #2's medical records showed:- admitted on [DATE];- Annual TB TST administered on 11/28/23, with a negative 0.0 millimeter (mm) result and no read date;- No documentation of an annual TB screening assessment. 9. Review of Resident #8's medical records showed:- admitted on [DATE];- First step TB TST administered on 01/01/26, with a negative 0.0 mm result and no read date;- Second step TB TST administered on 01/11/26, with a negative 0.0 mm result and no read date. 10. Review of Resident #23's medical records showed:- Annual TB TST administered on 11/29/23 with no read date or result;- No documentation of an annual TB screening assessment. During an interview on 05/28/26 at 3:31 P.M., LPN J said hand hygiene should be completed between residents, and before and after care. If the glucometer was set on a bedside table or another surface in a resident's room, the area or surface should have a clean barrier placed first. The glucometer should be cleaned and disinfected with alcohol pads for at least 30 seconds, or clean with a disinfectant wipe.During an interview on 05/29/26 at 2:15 P.M., the Director of Nursing (DON)/Infection Preventionist and the Administrator said they would expect hand hygiene and glove changes to be completed according to the policy, and there should be a clean barrier placed if setting the glucometer or supplies down in a resident's room. It was expected that TST be documented with read dates and completed per policy. They were unaware the glucometer was not intended for multi-resident use, was not being cleaned and disinfected, and they would expect manufacturer guidelines to be followed.During an interview on 05/29/26 at 3:45 P.M., the Assistant Director of Nursing (ADON) said hand hygiene and gloves changes should be done before, after, and in between for resident care, including blood glucose monitoring. The glucometer should not be placed anywhere without a barrier and should be cleaned and wrapped in a minute wipe when done. Gowns used for EBP should not be worn outside the resident's room.During a phone interview on 06/02/26 at 11:38 A.M., LPN E said hand hygiene should be done before and after care and tasks. The glucometer should be cleaned before and after use each time. The same glucometer can be used for multiple residents if it was cleaned before and after each person. He/She did not know the facility's policy on checking blood sugars or cleaning the glucometer due to it being the first time he/she had worked in the facility.

Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #76) out of five sampled residents exposed during incontinent care and emptying of a urinary catheter (a sterile tube inserted into the bladder to drain urine) drainage bag. The census was 77. Review of the facility's policy titled, Dignity and Privacy, dated 03/13/26, showed:- This policy establishes standards to protect and promote each resident's privacy, dignity, individuality, and self-determination in the nursing home;- Personal care, bathing, dressing, toileting, transfers, examinations, and treatments will be provided with visual and auditory privacy to the fullest extent practicable;- In shared rooms and common area, staff will balance each resident's privacy and preferences with the rights of roommates and other residents, using curtains or closed doors, whenever possible. 1. Review of Resident #76's medical record showed:- admission date of 02/07/25;- Diagnoses of anxiety disorder (persistent worry and fear about everyday situations), diabetes mellitus (DM - a metabolic disease), and schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/26/26, showed:- Cognition intact;- Dependent on staff for dressing, bed mobility, transfers, and toileting;- Always incontinent of bowel and had an indwelling catheter. Observation of the resident on 05/27/26 at 10:04 A.M., showed:- Certified Nursing Assistant (CNA) A and CNA B entered the room to perform incontinent care and empty the catheter drainage bag;- CNA A and CNA B left the door open, did not pull the privacy curtain, and started to perform incontinent care; - At 10:07 A.M., another resident stood at the open door while staff performed incontinent care for Resident #76;- At 10:09 A.M., while staff continued to provide incontinent care for the resident, a staff member and a resident walked past the open door;- CNA A emptied the resident's urinary catheter drainage bag;- CNA A and CNA B failed to provide privacy during incontinent care and emptying of the catheter drainage bag for the resident. During an interview on 05/29/26 at 1:30 P.M., CNA B said the resident's door should remain closed during incontinent care and emptying of a urine catheter drainage bag for a resident's privacy. During an interview on 05/29/26 at 4:07 P.M., the Director of Nursing (DON) said she would expect staff to always protect a resident's privacy during care by pulling the curtain and/or closing the door. During an interview on 05/29/26 at 4:18 P.M., the Administrator said she would expect a resident's privacy to be protected during all care.

Based on observation, interview, and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for one resident (Resident #3) out of 18 sampled residents. The facility census was 77.Review of the facility's policy titled, Revising Care Plans, undated, showed:- It is the policy of this facility to ensure that all comprehensive care plans are reviewed and revised promptly to reflect changes in the resident's condition, treatment, or goals of care;- Care plan revisions are essential to ensure individualized, person-centered, and safe care and to promote accurate, updated interventions that reflect the resident's needs and preferences;- Care plans must be reviewed and revised quarterly, upon a significant change, new physician's orders that impact resident care, after hospitalizations or acute medical events, and upon resident/family request or concerns;- Nurses and other direct care staff must promptly notify the Interdisciplinary Team (IDT - a group of healthcare professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) new pressure injuries, falls, behaviors, infections, or weight changes;- Revised care plans must identify the reason for revision, include updated goals, interventions, and timetables. 1. Review of Resident #3's medical record showed:- admitted to the facility on [DATE];- admitted to hospice on 02/18/26;- Diagnoses of diabetes mellitus (DM - a metabolic disease) muscle wasting, post-polio syndrome (a progressive neurological disorder that affects some polio survivors), major depressive disorder (long-term loss of pleasure or interest in life), paranoid schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), delusional disorder (a mental disorder marked by false beliefs), and atherosclerotic heart disease of native coronary artery (the buildup of cholesterol, fats and other substances in and on the artery walls). Review of the resident's May 2026 physician order sheet (POS) showed:- An order for gentamicin (an antibiotic) ointment 0.1% apply to percutaneous endoscopic gastrostomy (PEG - a surgical insertion of a tube through the abdominal wall into the stomach under endoscopic guidance) tube site topically every day shift for infection to the tube site, dated 05/21/26;- An order for doxycycline (an antibiotic) 100 mg, give one tablet two times a day for abdominal infection for 10 days, started 05/19/26, with an end date of 05/29/26. Review of the resident's nurse's notes, showed:- On 03/24/26, an order to cleanse and pat dry the PEG tube site and apply a slit gauze dressing every day shift discontinued due to site was no longer draining. Dressing not needed at this time per nursing discretion;- On 05/18/26, during cleaning of the PEG tube site, purulent (containing discharge or causing the production of pus) drainage drained from the site. Upon palpation (a medical examination technique where the sense of feeling is used to assess), a lump was felt in the right lower quadrant (right lower side of the abdomen), and more purulent drainage came from the site. The site was cleansed and hospice notified. Review of the resident's care plan, revised 05/11/26, showed:- Did not address the PEG tube with interventions. Review of the resident's Hospice Coordinated Plan of Care, dated 02/18/26, showed:- Did not address the PEG tube with the responsibility of the supplies or care not specified. Observation on 05/28/26 at 10:00 A.M., showed:- The resident's abdomen exposed with a PEG tube visible. During an interview on 05/29/26 at 4:07 P.M., the Director of Nursing (DON) said she would officially start the position as the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) Coordinator. She said a PEG tube should be reflected on the resident's individualized care plan along with what care and type of use was in place. Resident #3's PEG tube wasn't used at all, and he/she refused to have it removed. During an interview on 05/29/26 at 4:17 P.M., the Administrator said any type of medical appliance should be reflected in the resident's individualized care plan.

Based on observation, interview, and record review, the facility failed to ensure placement of the urinary catheter (a sterile tube inserted into the bladder to drain urine) drainage bag was maintained for two residents (Residents #2 and #76) out of four sampled residents. The facility census was 77.Review of the facility's policy titled, Urinary Catheter Care, dated 03/30/26, showed:- Keep the bag below the level of the resident's bladder at all times;- To empty the bag, place a large plastic container or graduated cylinder (container used to measure liquid) on the floor beneath the bag, remove the drain spout from its sleeve at the bottom of the catheter bag without touching its tip, open the slide valve on the spout, and let the urine flow out of the bag into the container, do not let the drain tube touch anything, close the slide valve and put the drain spout into its sleeve at the bottom of the bag;- Did not address keeping the catheter drainage bag off the floor. 1. Review of Resident #2's medical record showed:- admission date of 11/11/21;- Diagnosis of stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer (injury to the skin and/or underlying tissue usually over a bony prominence because of pressure or friction) of the sacral (triangular bone located above the coccyx) region. Review of the resident's physician order sheet (POS), dated May 2026, showed:- An order for a urinary catheter, 22 French (Fr. - size of catheter) with 5 milliliter (ml) balloon change every month on the 14th, dated 05/14/26; - An order for urinary catheter care every shift, dated 12/16/25. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/24/26, showed:- Utilized a urinary catheter. Review of the resident's care plan, revised 05/08/26, showed:- Did not address the urinary catheter with interventions. Observation of the resident on 05/27/26 at 5:20 A.M., showed:- Certified Nurse Assistant (CNA) C unhooked the catheter drainage bag from the bed frame, laid it on the floor and the bottom of the bag rested on the floor;- CNA C then emptied the urine drainage bag into a container, tapped the spout on the side of the container multiple times, and hung the catheter drainage bag on the bed frame. During an interview on 05/27/26 at 5:30 A.M., CNA C said catheter drainage bags should not touch the floor. 2. Review of Resident #76's medical record showed:- admission date of 04/01/25;- Diagnosis of incomplete emptying of the bladder. Review of the resident's POS, dated May 2026, showed:- An order for a supra pubic (a sterile tube inserted into the bladder through the abdominal wall to drain urine) catheter change every 30 days, dated 05/19/26; - Did not address the supra pubic catheter size and balloon amount;- An order to cleanse the supra pubic catheter site with wound cleanser and apply bacitracin (an antibiotic) daily, dated 05/18/26. Review of the resident's quarterly MDS, dated [DATE], showed:- Utilized a urinary catheter. Review of the resident's care plan, revised 05/09/26, showed:- Resident with a urinary catheter 18 Fr. for neurogenic bladder (the bladder does not empty properly due to a neurological condition);- Position the catheter drainage bag and tubing below the level of the bladder;- Provide urinary catheter care every shift and as needed;- Monitor urinary output every shift and document. Observation of the resident on 05/27/26, showed:- At 10:04 A.M., CNA A picked up the catheter drainage bag and raised it higher than the resident's bladder level to drain the urine into a container. The urine drained back towards the resident's bladder in the tubing. During an interview on 05/29/26 at 2:30 P.M., CNA A said catheter drainage bags should not be on the floor and should not be lifted above the level of the resident's bladder During an interview on 05/29/26 at 3:34 P.M., Licensed Practical Nurse (LPN) D said the catheter drainage bag placement should be below the resident's bladder and it should not be on the floor. During an interview on 05/29/26 at 4:07 P.M., the Director of Nursing (DON) said catheters were expected to remain below the level of the bladder and not on the floor. During an interview on 05/29/26 at 4:18 P.M., the Administrator said she would expect staff to follow proper procedure and ensure catheters didn't touch the floor and stayed below the level of the resident's bladder.

The facility failed to ensure care and services for one resident (Resident #59) out of a sample of one resident with a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) were provided in accordance with professional standards of practice. The facility allowed Resident #59 to independently perform colostomy care without evidence of a physician order authorizing self-administration of care, without a documented assessment of the resident's competency to safely perform colostomy care, and without ongoing nursing assessment and monitoring of the stoma (opening) and appliance. The facility also failed to develop and implement a comprehensive care plan that addressed the resident's colostomy care needs, including monitoring of the stoma, appliance management, supply needs, resident education, and interventions necessary to maintain the resident's highest practicable well-being. The facility census was 77.Review of the facility's policy titled, Care Plan Completion, dated 03/27/26, showed:- The facility will develop a comprehensive person-centered care plan for each resident within seven days after completion of the comprehensive assessment that includes measurable objectives and timeframes to meet resident's medical, nursing, mental, and psychosocial needs, services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and resident's goals for admission and desired outcomes and the resident's right to refuse treatment. 1. Review of Resident #59's medical record showed:- admission date of 05/24/11;- Diagnosis of colostomy status;- Cognition intact;- No documentation showed the resident assessed for competency to complete his/her own colostomy care. Review of the resident's physician order sheet (POS), dated May 2026, showed:- An order to change the colostomy every three days on the day shift, dated 05/17/22;- An order for colostomy care every day on the day shift, dated 05/17/22;- No order for the resident to provide self-care of the colostomy and monitoring of the stoma. Review of the resident's care plan, revised 05/11/26, showed:- Resident has a colostomy;- Did not address self-care of colostomy and changing of the appliance;- Did not address monitoring the stoma appearance;- Did not address colostomy supplies;- Did not address education regarding the colostomy care. Review of the resident's treatment administration record (TAR), dated May 2026, showed:- Colostomy care every day every day shift, dated 05/17/22;- No documentation of the appliance changed as ordered;- No documentation of monitoring of the stoma;- No documentation of the resident's self-care of the colostomy. Review of the resident's medication administration record (MAR), dated May 2026, showed:- No documentation related to the resident's colostomy. Observation and interview on 05/26/2026 at 7:31 P.M., of the resident showed:- The resident with a colostomy appliance in place;- The resident said he/she changed it himself/herself, cleaned it three times a day and changed the complete appliance on Tuesdays, Thursdays, and Saturdays. The facility provided the supplies. Observation on 05/28/26 at 8:52 A.M., showed:- The resident completed the colostomy appliance change during his/her shower with minimal assistance from Certified Nursing Assistant (CNA) O. During an interview on 05/28/26 at 8:52 A.M., CNA O said the resident used a pen to mark the circle on the colostomy flange (the plastic ring in a two-piece pouching system that connects and adheres to the skin around the around the stoma), and then he/she would cut it on the line to make the hole to go around the stoma, and then he/she handed the resident the second piece of the colostomy pouch when the resident asked for it. The resident did everything else himself/herself, other than cutting the hole. The resident usually did it while in the shower. During an interview on 05/28/26 at 3:22 P.M., the resident said no one had ever watched, assessed, or spoke with him/her for self-care or changing his/her colostomy since his/her admission. During an interview on 05/29/26 at 3:45 P.M., the Assistant Director of Nursing (ADON) said if a resident performed their own ostomy care, a competency assessment should be completed. During an interview on 05/29/26 at 4:07 P.M., the Director of Nursing (DON) said the care plan should reflect needs, diagnoses, and include interventions. Colostomy should be care planned and include monitoring of the stoma, appliance needs, and care of the colostomy. A competency assessment should be completed for ostomy care if the residents do their own care. During an interview on 05/29/26 at 4:18 P.M., the Administrator said the care plan should reflect needs and interventions. The care plan should include monitoring the stoma, and appliance change and care. Competency assessments should be completed for those doing their own care.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and/or disposed of after the expiration date in accordance with currently accepted practices. This had the potential to affect all residents. The facility census was 77.Review of the facility's policy titled, Medication Labeling Policy, dated 03/26/26, showed:- This policy establishes requirements for accurate, complete, legible, and current medication labeling in the nursing home in order to support safe medication use, prevent errors, reduce diversion risk, and maintain compliance with federal requirements, Missouri law, and pharmacy service agreements;- The facility will ensure that medications and biologicals are labeled in a manner consistent with applicable federal and Missouri requirements and in a format that supports safe storage, preparation, dispensing, and administration;- No medication may be administered from a container, package, syringe, cup, blister card, or other storage system that is unlabeled, incompletely labeled, illegible, altered without authorization, or otherwise inconsistent with current orders and applicable law;- This policy applies to all prescription medications, over-the-counter medications, biologicals, controlled substances, emergency medications, refrigerated medications, compounded products, repackaged products, topical products, inhaled products, insulin and injectable supplies, treatment items when labeled as medications, and all medication storage systems maintained by the facility or on the facility's behalf;- All medication labels must be legible, durable, and consistent with current prescribing, dispensing, and administration information;- Medication containers and administration systems must be labeled sufficiently to identify the resident when resident-specific, the medication name, strength when applicable, dosage form, directions or route when needed for safe use, and any other information required by law, pharmacy labeling standards, or facility procedure;- No medication may be transferred to another container or left in an unlabeled cup, syringe, or other device beyond the immediate preparation and administration process allowed by facility procedure and safe practice;- Medications that require dating upon opening, reconstitution, dilution, compounding, or removal from original packaging must be labeled with the applicable open date, preparation date, beyond use date, expiration date, or discard date, as required by manufacturer instructions, pharmacy labeling, or facility procedure;- Multi-dose vials, insulin, ophthalmic products, inhalers, topical preparations, nutritional medication combinations when applicable, and refrigerated products must be dated and discarded in accordance with manufacturer instructions, pharmacist guidance, and facility policy. Review of the Fiasp (a rapid-acting insulin) medication insert, revised 06/2023, showed:- The storage conditions for 10 milliliter (ml) multiple dose vial, at room temperature not in-use (unopened) to be 28 days; In-use (opened) to be 28 days. Review of the NovoLog Mix 70/30 (a dual action insulin medication) injectable suspension medication insert, revised 02/2023, showed:- The storage conditions for Novolog Mix 70/30 Flexpen, 3 ml single-patient-use flexpen, not in-use (unopened) at room temperature to be 14 days; In-use (opened) at room temperature to be 14 days (Do not refrigerate). Review of the Tresiba (a long-acting insulin medication) injection medication insert, revised 07/2022, showed:- The storage conditions for 3 ml single-patient-use Tresiba Flextouch not in-use (unopened) at room temperature to be 56 days (8 weeks); In-use (opened) at room temperature to be 56 days (8 weeks). According to the National Institute of Health, Opened nasal sprays and eye drops should generally be disposed of within 30 to 90 days after opening, even if the printed expiration date has not passed, according to general health guidelines. For specific medical, multidose, or prescription nasal sprays, the Centers of Disease Control and Prevention (CDC) and associated guidelines often recommend discarding them within 28 days of opening or as specified by the manufacturer. 1. Observation of the nurse treatment cart for B and C Halls on 05/27/26 at 7:00 A.M., showed:- Resident #5's Novolog Mix 70/30 Flexpen with an open date of 04/26/26;- Resident #38's Novolog Mix 70/30 Flexpen, with an open date of 04/14/26;- Resident #3's Tresiba Flex Touch Pen with no open date;- Resident #3's Fiasp multiple-dose vial with an open date of 01/17/26;- Resident #41's Novolog Flexpen with an open date of 03/19/26;- Resident #43's hemorrhoidal ointment with applicator with an open date of 08/12/24, and an expiration date of 10/2024;- Resident #43's clindamycin (an antibiotic medication) lotion 1%, with no open date. During an interview on 05/27/26 at 7:23 A.M., Licensed Practical Nurse (LPN) J said all insulin should have an expiration date, and show the date it was opened. Insulin was good for 30 days from the date opened. LPN J said medications should have been removed from the treatment cart when discontinued, completed, or expired. Dispose of insulin if out of date or undated. Insulin was dated when opened by the nurse who pulled the insulin or opened the insulin. He/She believed the night shift nurse was supposed to check the medication and treatment carts and restock the carts, but anyone could. LPN J said he/she checked the dates on the insulin and other medications prior to administration. 2. Observation of the nurse treatment cart for A Hall on 05/27/26 at 7:45 A.M., showed:- Resident #56's streptomycin 130 mg, meropenem180 mg, vancomycin 60 mg (a compounded antibiotic medication) dispensed on 11/10/25, with no open date, an expiration date of 04/12/26, and 55 capsules in the bottle;- 14 unidentified pink plastic vials, unlabeled and undated, lay inside of a tray in a drawer of medication cart, expired 04/2026. During an interview on 05/27/26 at 8:00 A.M., LPN M said he/she believed the vials belonged to Resident #56. Maybe someone just emptied the rest of a package into the tray and did not put the sticker with them. 3. Observation of the B Hall Certified Medication Technician (CMT) cart on 05/29/26 at 1:23 A.M., showed: - One bottle of sodium chloride (an electrolyte replenisher medication) tablet 100 mg tablets, opened and undated;- Resident #72's fluticasone (a corticosteroid medication) 50 mg with an open date of 02/26/26;- Resident #81's fluticasone 50 mg with an open date of 02/26/26;- One unlabeled Artificial Tears eye drops, opened 04/11/26, sat in Resident #81's slot. 4. Observation of the B Hall medication room on 05/29/26 at 9:32 A.M., showed:- One unlabeled vial of olanzapine (an antipsychotic (medication used to manage psychosis, including delusions, hallucinations, paranoia, and disordered thought) medication) 10 mg vial in a bag in the drawer to the left of the sink with an expiration date of 11/25. During an interview on 05/29/26 at 3:33 P.M., CMT K said all medications should be dated with date opened. Usually, whoever was on the mediation cart went through the cart to check for opened and expiration dates. During an interview on 05/29/26 at 3:38 P.M., LPN D and CMT N said medication should be dated and initialed when opened. CMTs went through the CMT medication carts to clean them out and remove expired medications. LPN D said insulin should be dated with the open date, expired treatments and medications should be wasted or thrown away. During an interview on 05/29/26 at 3:45 P.M., the Assistant Director of Nursing (ADON) said medications should be dated when opened and initialed. If medications were expired, they should be wasted. During an interview on 05/29/26 at 4:07 P.M., the Director of Nursing (DON) said medication stock and insulin should have an open date, expired and discontinued medication and treatments shouldn't be in the medication cart or treatment supplies. There should be a discard date for the eye drops and nasal sprays. Medications should be identified with names if in the carts and opened and for a specific resident. During an interview on 05/29/26 at 4:18 P.M., the Administrator said all things, insulin and medications should be dated when opened. Remove expired medications and treatments from the cart and destroy them.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 81.The facility did not provide a dietary cleaning rotation or food storage policy. 1. Observations on 12/03/25 at 10:35 A.M., 12/04/25 at 3:01 P.M., and 12/08/25 at 3:07 P.M., of the kitchen showed:- The commercial dishwasher exterior with flaky white grime build-up and scattered debris on the floor beneath;- The floor below the reach-in freezer, reach-in refrigerator, range, and the food preparation counter with scattered debris, oily film, and brown grime;- The microwave oven interior with food debris build-up along the top and side surfaces;- Three 12-inch (in.) diameter ceiling diffusers (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surface and in between the ventilation louvers;- Two approximate 24 in. x 24 in. ceiling diffusers with dust buildup and a brown substance on the front exterior surface and in between the ventilation louvers;- A window mounted air conditioning unit with black grime and dust buildup above the dishwashing area counter;- The ice machine with a white grime build-up on the exterior surfaces and interior plastic surface, ventilation louvers with a brown substance, plastic drain line with black grime build up, no air gap, and scattered debris and insulation on the floor beneath;- The commercial style can opener with a worn cutting blade with an oily film and a black grime buildup;- The floor and plumbing pipes below the dishwashing area counters and three-compartment sinks with scattered debris, an oily film, and brown grime build-up;- Four connected ceiling lights over the food preparation areas with broken fluorescent light fixture covers and bug debris; - No cleaning log. 2. Observations on 12/03/25 at 10:38 A.M., 12/04/25 at 3:06 P.M., and 12/08/25 at 3:07 P.M., of the dry food storage area showed:- Scattered food debris on the floor, along the walls below the food shelves, and behind the chest-type freezer;- Wooden shelving surfaces with scattered food debris and rodent droppings. 3. Observation on 12/03/25 at 10:36 A.M., of the rear kitchen exit area showed:- The floor below the reach-in freezer with scattered debris; - A chest-type freezer with 1 in. frost build-up along the interior walls;- An upright freezer near the exit with 1 in. frost build-up along the shelves and a discolored, non-intact door gasket. During an interview on 12/03/25 at 10:36 A.M., the Dietary Manager (DM) said rodent droppings were a concern on the shelving and live mice were often seen in the kitchen and dining area. He/she normally completed the deep cleaning in the kitchen and storage areas. Cleaning logs were not currently being utilized. There were rodent glue traps and bait stations being used, maintenance was aware of the concern, and the facility had a pest control company for service. During an interview on 12/04/25 at 3:01 P.M., Dietary Aide (DA) R said he/she had seen mice in the kitchen area and had cleaned up rodent droppings from the shelves and the floor in the past. During an interview on 12/04/25 at 3:05 P.M., Dietary Aide (DA) S said he/she had seen mice in the kitchen area and it was not uncommon. He/she had cleaned up rodent droppings from the shelves and the floor in the past. During an interview on 12/08/25 at 2:39 P.M., the Maintenance Director said he/she had just recently restocked the rodent glue traps in the kitchen and about two weeks ago, traps were placed in the dry storage and in the kitchen cooking area. He/she hadn't checked the dry storage, but was told there were mice. He/she hadn't checked the ceiling vents in a while, and they were probably dirty. The ice machine should be checked to ensure the air vents were clean. Normally the drain for the ice machine was not cleaned, but it should be put on the list for the Maintenance Assistant to complete. The floor below the ice machine should be clean and it looked like insulation had fallen onto the floor. During an interview on 12/08/25 at 3:08 P.M., Dietary Aide (DA) T said he/she cleaned but did not use a cleaning log. He/she had noticed mice in the dry storage room and had not seen them in the kitchen that much. The DM was notified if he/she saw droppings on the shelves or when sweeping. The can opener was wiped clean once a day or as needed. The microwave was cleaned when it was bad but not every time it was used. During an interview on 12/08/25 at 3:20 P.M., the Administrator said the food storage shelves in the dry storage should not have mouse droppings, but they had built back up since last week. There were rodent glue traps down inside and bait traps were outside of the facility. The microwave and appliances should be kept clean. The light fixtures in the kitchen should be intact, clean, and bug free. The ceiling vents and ice machine parts should be kept clean.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. The facility census was 81.The facility did not provide a maintenance policy. 1. Observation of the bathroom door in room [ROOM NUMBER] on 12/03/25 at 10:49 A.M., showed a 6 inch (in.) by 3 in. hole. During an interview on 12/03/25 at 10:49 A.M., the resident in room [ROOM NUMBER] said the hole in the bathroom door had been there since he/she moved into the room about three months ago. He/She spoke with the Maintenance Director about his/her concerns with the room because it was frustrating. 2. Observations on 12/08/25 at 9:30 A.M. and 3:45 P.M., showed:- The A hall dining room area wooden food service counter behind the steam table with an approximate 2 foot (ft.) by 6 in. non-intact section along the floor without a baseboard;- The A hall dining room area metal food and drink service counter near the ice machine with an approximate 6 ft. by 6 in. scraped front section near the floor; - The front office conference room across from the restroom with a 1 in. diameter hole in the wooden baseboard area near the door. 3. Observation on 12/08/25 at 11:35 A.M., of the A Hall men's shower/restroom furthest from the nurse's station showed:- The left sink leaked water under the sink into a bucket while water flowed from the faucet;- The right sink filled with water when the left sink faucet was turned on;- Two soiled towels, two cans of shaving cream, and a foam cup under the shelf on the floor;- The right-side toilet stall with discolored water stood around the toilet on the floor; - A golf ball sized clump of hair on the floor under the shelf next to the wall of the stall behind the door entrance;- The entire shower room floor with a sticky film build-up and scattered debris;- The shower room with an unidentifiable musty odor noticeable before entering the room. 4. Observation on 12/08/25 at 11:50 A.M., of the A Hall men's shower room closest to the nurse's station showed:- The right sink with several pieces of hair in it;- The right sink drained very slowly and the water almost ran over the side of sink when the water was turned on;- The entire shower room floor with a sticky film build-up and scattered debris. During an interview on 12/08/25 at 3:05 P.M., a resident in room [ROOM NUMBER] said both of the men's shower and bathroom area floors were wet, sticky, and dirty. The sinks did not drain and there was a bad smell. 5. Observation on 12/08/25 at 12:05 P.M., of the C Hall shower room and restroom showed:- The shower room stall with a buildup of a black substance around the bottom of the shower walls near the floor in the shower. Review of the facility's Maintenance Request Log showed:- No documentation of maintenance requests regarding the concerned areas. During an interview on 12/08/25 at 12:35 P.M., the Housekeeping Manager said he/she would expect all shower and restroom areas in the facility to be clean. The housekeeping staff had been instructed to clean each shower and restroom area twice daily and as needed during the day. It was very difficult to keep the men's restroom clean with towels and clothes being thrown on the floor. The smell in the A Hall A men's shower and restroom furthest from the nurse's station was due to the leak to the left sink and the backflow to the right sink. During an interview on 12/08/25 at 12:43 P.M., Housekeeper L said he/she cleaned each shower and bathroom that was assigned to him/her twice per shift and as needed. During an interview on 12/08/25 at 12:45 P.M., Housekeeper M and Housekeeper N said they cleaned all shower and bathroom areas at least twice daily per shift. They cleaned more on the A Hall due to water, urine, and clothing found on the floor very often during the day. During an interview on 12/08/25 at 2:35 P.M., the Maintenance Director said both men's shower and restroom areas smelled bad. The sinks needed to be raised above the piping to prevent backflow in both men's shower and bathroom areas. The dining room counters should not have damaged wood and scraped paint. There should not be a mouse hole in the floor of the front office conference room. Staff should fill out a maintenance form for issues they see with the building. During an interview on 12/08/25 at 3:20 P.M., the Dietary Manager said the paint should not be scraped on the front of the drink counter and it should be repaired. The wooden counter near the steam table should be intact. During an interview on 12/08/25 at 3:25 P.M., the Administrator said residents may have scraped the paint on the metal drink counter in the dining area. The dining area food counters should be kept in good repair and there should not be a hole in the wall in the front office conference room.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice when physician orders were not followed for two residents (Residents #1 and #70) out of 18 sampled residents. The facility's census was 81.The facility did not provide a policy on following physician's orders. 1. Review of Resident #1's Physician Order Sheet (POS), dated 12/08/25, showed:- An order for a urinalysis (UA - a group of laboratory tests to examine urine) with a culture and sensitivity (C&S - a laboratory test that identifies germs causing an infection and which antibiotics will be most effective against them) one time only for burning, urgency and frequency for three days. Please complete nurses note when obtained, dated 11/20/25, and completed on 11/24/2025;- An order for Macrobid (an antibiotic) 100 milligrams (mg) by mouth two times a day for urgency, frequency and burning, for 14 days. Notify provider when UA results are obtained, dated 11/20/2025, and completed on 12/04/25. Review of the resident's Progress Notes showed:- On 11/20/25, a new order was obtained for Macrobid 100 mg two times a day x 14 days for signs and symptoms of a urinary tract infection (UTI). An order was obtained for a UA on 11/24/25;- On 11/21/25, the resident started Macrobid for UTI symptoms;- No documentation of U/A and C&S obtained and provider notified with results per the physician orders. Review of the resident's medical record showed:- No laboratory results for the UA with C&S ordered on 11/20/25;- No documentation the physician was notified of the UA with C&S results ordered on 11/20/25. Review of the facility's Infection/Antibiotic Tracking Log, dated November 2025, showed:- On 11/20/25, Resident #1 with a UTI. Signs and symptoms: dysuria (pain, burning, or discomfort during urination), frequency, urgency, incontinence, and decreased pulse oximeter (a medical device that measures the oxygen level in the blood) reading. Antibiotic and dose: Macrobid 100 mg twice a day x 14 days. No antibiotic change. During an interview on 12/04/25 at 8:37 A.M., Resident #1 said he/she was taking antibiotics for a bladder infection. During an interview on 12/04/05 at 3:36 P.M., the Director of Nursing (DON) said the nursing staff drew labs on the resident, but did not perform the UA with C&S as ordered on 11/20/25, prior to starting the antibiotics on 11/20/25. No other UA with C&S was ever performed as ordered after starting the antibiotic. 2. Review of Resident #70's POS, dated 12/08/25, showed:- Diagnoses of schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions) and methicillin resistant staphylococcus aureus infection (MRSA - an infection caused by a type of bacteria that's become resistant to many of the antibiotics);- An order to mix 1 tablespoon (tbsp) of vinegar to 8 ounces (oz) of water, soak gauze in the solution, and apply to the wound for 20 minutes, dry with gauze every day and night shift of the open area, dated 09/20/25;- An order for Benzac AC Wash External Liquid (a topical medication) to apply to the scalp topically one time a day for open areas, dated 09/19/25. Review of the resident's Treatment Administration Record (TAR), dated September 2025, showed: - The Benzac AC Wash External Liquid to apply to the scalp topically one time a day for open areas treatment, dated 09/20/25, with eight out of ten missed opportunities;- The mix 1 tbsp vinegar to 8 oz water, soak gauze in the solution and apply to the wound for 20 minutes, dry with gauze, two times a day for open areas treatment, dated 09/19/25, and discontinued on 09/20/25, with two out of two missed opportunities;- The mix 1 tbsp vinegar to 8 oz water, soak gauze in the solution and apply to the wound for 20 minutes, dry with gauze, every day and night shift for open area treatment, dated 09/20/25, with two out of 21 missed opportunities. Review of the resident's TAR, dated October 2025, showed:- The Benzac AC Wash External Liquid to apply to the scalp topically one time a day for open areas treatment, dated 09/20/25, with 23 out of 31 missed opportunities;- The mix 1 tbsp vinegar to 8 oz water, soak gauze in the solution and apply to the wound for 20 minutes, dry with gauze, every day and night shift for open area treatment, dated 09/20/25, with nine out of 62 missed opportunities. Review of the resident's TAR, dated November 2025, showed:- The Benzac AC Wash External Liquid to apply to the scalp topically one time a day for open areas treatment, dated 09/20/25, with 24 out of 30 missed opportunities. Review of the resident's TAR, dated December 2025 through December 7, 2025, showed:- The Benzac AC Wash External Liquid to apply to the scalp topically one time a day for open areas treatment, dated 09/20/25, with six out of seven missed opportunities. During an interview on 12/03/25 at 11:40 A.M., Resident #70 said the wound on the top of his/her scalp should be healed, but some nurses did the treatment and others didn't. The nurses said the resident needed to ask for the treatment to be done. He/she should not have to ask for the staff to come do the treatment since the physician gave the order and the nurses should follow the order. During an interview on 12/08/25 at 3:52 P.M., the DON said she expects treatments to be completed as ordered and within the time frame it was ordered to be completed. During an interview on 12/08/25 at 4:14 P.M., the Administrator said physician orders should be followed. The DON was expected to ensure physician orders were being followed.

Based on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance and Improvement Program (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee meetings with the required members. The facility census was 81. Review of the facility's policy titled Quality Assurance and Improvement Program (QAPI), dated 05/31/24, showed:- The primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents;- Members of facility management are accountable for QAPI efforts;- The QAPI Committee will include at minimum: the Administrator, Director of Nursing, Medical Director, Activities Director, Social Services Director, Dietary Manager, Housekeeping and Laundry Supervisor, Maintenance Director, additional facility staff, and contracted staff including Pharmacy Consultant, Dietician, and Rehabilitation Director;- The committee shall maintain minutes of all regular and special meetings that include at least the following: the date committee met, start and adjourned time, and the names of the members present and absent;- The policy did not address the requirement of the Infection Preventionist (IP) as a committee member. Review of the facility's QAA/QAPI showed:- No documentation the facility maintained the minimum required quarterly QAA/QAPI meetings with the required members. During an interview on 12/08/25 at 3:08 P.M., the Administrator said the last QAA/QAPI meeting was sometime in October 2025, but she did not have the minutes or the sign in sheet for the meeting. The meetings should be held at least quarterly. She didn't have records of previous QAA/QAPI meetings prior to her becoming the Administrator.

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) and follow appropriate infection control practices with hand hygiene and glove changes, when staff performed wound care for one resident (Resident #70) out of two sampled residents, during incontinent and oxygen care for two residents (Residents #5 and #17) out of two sampled residents, catheter care for two residents (Residents #3 and #74) out of two sampled residents, and hand hygiene during medication administration for two residents (Residents #46 and #73) out of seven opportunities. The facility also failed to correctly screen three residents (Residents #34, #70, and #74) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents as required by state regulation 19 CSR 20-20.100. The facility failed to establish and maintain an infection prevention and control program (IPCP) that identified a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and other individuals providing services. The facility census was 81. Review of the facility's policy titled, Urinary Catheter Care, undated, showed: - Nursing assistants always wash your hands before and after handling the catheter, tube, or bag, and wear gloves following standard precautions for infection control; - To empty the catheter bag, place a large plastic container or graduated cylinder (a container with a scale used to measure liquid) on the floor beneath the bag, remove the drain spout from its sleeve at the bottom of the catheter bag without touching its tip, open the slide valve on the spout, and let the urine flow out of the bag into the container; - Do not let the drain tube touch anything. Review of the facility's policy titled, Oxygen, undated, showed: - Did not address contamination of the nasal cannula. Review of the facility's policy titled, Medication Administration, undated, showed: - Did not address performing hand hygiene between each resident during a medication pass or not touching the medications with bare hands. Review of the facility's policy titled, Incontinence Care, undated showed: - Wear gloves when providing peri care or changing briefs or pads; - Did not address hand hygiene during care. Review of the facility's policy, Enhanced Barrier Precautions (EBP) Policy and Procedure, dated August 2024, showed: - This facility's policy is to implement EBP for preventing transmission of multidrug-resistant organisms (MDRO's); - EBP are an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP involve gown and glove use during high-contract resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO (residents with wounds or indwelling medical devices); - High-contact resident activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheter), and wound care; - Infection Preventionist periodically monitors and assesses the adherence to the precautions and determines the need for additional training and education. Review of the facility's policy titled Tuberculosis Testing, Mantoux (refers to the technique for administering the test), Purified Protein Derivative (PPD), undated, showed: - All residents will be tested for TB upon admission, and annually; - The Charge Nurse will maintain a TB Testing Log of all residents on the unit that includes date test administered for present year, date test read, and results. 1. Observation on 12/04/25 at 8:57 A.M. of incontinent care and gait belt transfer of Resident #5 showed: - Certified Nursing Assistant (CNA) I and Licensed Practical Nurse (LPN) U entered room, did not perform hand hygiene, and put on gloves; - CNA I and LPN U placed a gait belt around the resident and assisted him/her to transfer to the bed side commode (BSC); - CNA I and LPN U lowered the resident's pants and brief. CNA I touched the inside area of the urine saturated brief, removed brief and placed in trash can, did not perform hand hygiene, and changed gloves; - LPN U removed gloves, did not perform hand hygiene, exited the room and walked to the nurses' station; - CNA V entered the room, did not perform hand hygiene, put on gloves, removed resident's shoes and pants, put clean brief on resident, and placed pants in a trash bag; - CNA I retrieved clean pants from the resident's closet, put pants and shoes on the resident, removed gloves, touched bathroom doorknob, disposed of gloves in bathroom trash, did not perform hand hygiene, and put on clean gloves; - Both CNAs assisted the resident to stand; - CNA V used a wipe to clean the resident's buttocks, did not clean front peri area or groin, and did not change gloves or perform hand hygiene; - With the same soiled gloves, CNA V assisted CNA I to pull clean brief and pants up into place, and assisted the resident to bed; - CNA V removed gloves, touched bathroom doorknob, tossed soiled gloves into bathroom trash, removed trash bags with trash and soiled items from the room, walked to soiled utility, opened lock, disposed of trash bags in appropriate containers, exited and locked soiled utility, and washed hands in the bathroom at the nurses' station; - CNA I removed gait belt from resident, assisted the resident to lay in bed, touched blanket, removed gloves in bathroom trash, and washed hands. During a phone interview on 12/10/25 at 4:53 P.M., CNA V said hands should be washed before putting on gloves and when gloves are taken off. Hands should be washed when visibly soiled, and gloves should be changed and hands washed when gloves are visibly soiled. Wash or sanitize hands between each resident, when entering a room, and before leaving the room. During incontinent care, use a wipe to clean the bottom, and the front peri area, and groin. During a phone interview on 12/10/25 at 4:57 P.M., LPN U said sanitize hands three times before hand hygiene, when going into a resident's room, perform hand hygiene. Put on gloves when you will come in contact with bodily fluids. Perform hand hygiene and change gloves when visibly soiled and perform hand hygiene upon exiting the room. During a phone interview on 12/10/25 at 5:08 P.M., CNA U said perform hand hygiene as soon as you go into a resident room and put on gloves. Perform hand hygiene and change gloves after transferring a resident, between dirty and clean task, and perform hand hygiene upon exit. When performing incontinent care, clean front to back, the resident's front area and groin should also be cleaned if the resident's brief was wet. 2. Review of Resident #3's medical record showed: - Diagnosis of neurogenic bladder disorder (a condition where nerve damage causes urinary leaking or retention). Review of the resident's Physician Order Sheet (POS), dated December 2025, showed: - An order to change the suprapubic catheter (a flexible tube draining urine from the bladder through a small opening in the lower abdomen) monthly, on the 10th of the month, dated 10/23/25. Observation of the resident's mechanical lift transfer on 12/05/25 at 9:35 A.M. showed: - EBP signage on door; - CNA P put on gloves, did not sanitize hands or put on gown; - CNA P kneeled on the floor, touching the floor with his/her pants, and emptied the urinary catheter into a urinal; - CNA P removed gloves and sanitized hands; - CNA E put on gloves, did not sanitize hands or put on gown; - CNA E removed blanket and placed socks and pants on the resident; - CNA E and P rolled the resident from side to side to place a mechanical lift sling, leaning against the bed, and touching the resident with bare forearms; - CNA P removed gloves, sanitized hands, left room, and obtained mechanical lift from the shower room; - CNA P did not put on gown or gloves or perform hand hygiene; - CNA P transferred the resident via mechanical lift without a gown or gloves; - CNA E transferred the resident via mechanical lift without a gown; - CNA E and P leaned the resident forward in wheelchair and placed a shirt on him/her; - CNA E removed gloves, did not sanitize hands or put on gloves, and brushed the resident's hair, - CNA E applied pressure relieving boot with bare hands; - CNA E left the room with dirty linens; - CNA P washed hands and left the room. During an interview on 12/05/25 at 2:23 P.M., CNA P said nurses use EBP, they have to gown up and stuff like that. During an interview on 12/05/25 at 2:27 P.M., LPN Q said staff should wear a gown and gloves during care and transferring residents that require EBP. During an interview on 12/08/2025 at 3:23 P.M., the Director of Nursing (DON) said she would expect staff to use EBP for residents who require it during high contact activities. 3. Review of Resident #17's medical record showed: - admitted on [DATE]; - Diagnosis of unspecified asthma with acute exacerbation, (a chronic (long-term) condition that affects the airways in the lungs.) Review of the resident's POS, dated December 2025, showed: - An order for continuous oxygen at 2-4 liters per minute (lpm) per nasal cannula (medical tubing with two prongs that fit into the nostrils to deliver supplemental oxygen or increased airflow from an oxygen device). Observations of the resident on 12/05/25 showed: - At 9:47 A.M., staff propelled the resident in wheelchair out of room, nasal cannula lay in the floor near the resident's bed; - At 11:00 A.M., call light on, resident in restroom, and his/her nasal cannula lay in the floor near his/her bed. CNA E entered the room, did not perform hand hygiene, did not put on gloves, assisted resident in restroom, did not perform hand hygiene, touched linens on the resident's bed, picked up the nasal cannula from floor and placed it in the resident's nares. CNA E exited the room, entered soiled utility, did not perform hand hygiene, retrieved a clean trash bag and returned to the resident's room, placed bag in trash can, exited room, did not perform hand hygiene, walked down the hall and entered another resident's room. Observation on 12/08/25 at 11:35 A.M. showed LPN B entered the room, did not perform hand hygiene, picked up the resident's nasal cannula from the floor and draped it across the resident's bedside table within reach of the resident in wheelchair and said it needs to be sanitized. During an interview on 12/05/25 at 2:28 P.M., CNA E said normally he/she uses hand sanitizer before entering a resident's room. He/she said throughout the day, sanitizer is used randomly and once exited from a resident's room. Normally, gloves are used while in a resident's room. When an oxygen cannula is found on the floor and is visibly dirty, it will be replaced before placing it back on the resident. The floor should be clean if everybody is doing their job. The cannula can be placed back on the resident without changing it for a new one if it is not visibly dirty. During an interview on 12/08/25 at 3:52 P.M., the DON said oxygen tubing and the nasal cannula should be stored in a bag on the concentrator. The nasal cannula should not be retrieved from the floor and placed on a resident. It should be thrown away and replaced with a new one. Oxygen tubing should not be sanitized. 4. Observation of Certified Medication Technician (CMT) D performing medication administration on 10/08/25 at 7:55 A.M. showed: - CMT D administered medications in applesauce to Resident #24; - CMT D did not perform hand hygiene; - CMT D placed Resident #46 's medication in a cup and administered the medications to the resident; - CMT D did not perform hand hygiene; - CMT D popped Resident's #73's Lorazepam (an anti-anxiety medication) tablet into his/her bare hand and placed it into a medication cup; - CMT D poured a Sodium Chloride tablet into the lid and used one finger to guide the tablet from the lid into the medication cup, touching the tablet; - CMT D finished putting Resident #73's medications into the medication cup and administered the medications to the resident; - CMT D did not perform hand hygiene afterwards. During an interview on 12/08/25 at 3:20 P.M., CMT D said a person should sanitize hands between residents when passing medications and shouldn't touch pills with their bare hands. 5. Review of Resident #74's medical record showed: - Diagnosis of benign prostatic hyperplasia (BPH – an enlargement of the prostate causing difficulty in urination). Review of the resident's POS, dated December 2025, showed: - An order to change the indwelling catheter once a month on night shift every 30 days, dated 12/01/25, with a due date of 12/24/25. Observation on 12/08/25 at 9:15 A.M. of the resident's catheter care showed: - EBP signage on door; - LPN C put on gown and gloves, and did not sanitize hands; - LPN C picked up the urinal, removed the catheter from privacy bag and hooked to the resident's wheelchair; - LPN C unfastened catheter drainage bag spout (the bottom of the drainage bag where urine is emptied from), cleaned end with alcohol swab, and placed inside urinal, touching the side of the urinal with spout; - LPN C unhooked the catheter drainage bag from wheelchair holding it with one hand, and with the other hand, placed the urinal on the floor, touching the spout to the side of the urinal again; - LPN C emptied the urinary catheter bag and cleansed the spout with alcohol pad; - LPN C replaced spout and placed catheter drainage bag into privacy bag; - LPN C emptied urinal in the resident's restroom and placed on the side of the trash can without sanitizing and removed gloves and gown; - LPN C pushed his/her glasses up with bare hands and washed his/her hands. Observation on 12/08/25 at 9:35 A.M. of the resident's catheter care showed: - EBP signage on door; - CNA A washed hands, put on gloves, and did not put on a gown; - CNA A unfastened the resident's brief and placed wipes on bedside table; - CNA A cleaned the catheter from insertion point down twice with different wipe each time; - CNA A did not perform hand hygiene or change gloves; - With the same gloves, CNA A touched the clean catheter and refastened the brief; - CNA A removed gloves and washed hands. During an interview on 12/08/25 at 3:50 P.M., CNA A and LPN C said EBP should be worn during any care for residents that have catheters or wounds. CNA A said he/she didn't gown when doing catheter care, but should have. Privacy bag should be on catheter when there's a visitor in their room or when they are outside their room. LPN B said there should be a clean barrier placed between the supplies and the surface. Anything brought in should be disinfected. During an interview on 12/08/25 at 3:58 P.M., LPN B said when doing treatments, a barrier should be used between supplies to ensure a clean surface. Then anything taken in the room that's brought out should be washed with the alcohol wipes. 6. Observation on 12/08/25 at 11:39 A.M. of wound care for Resident #70 showed: - No EBP signage on door; - LPN B sanitized hands, put on gloves, did not put on a gown, and rolled treatment cart into the resident's room; - LPN B prepared treatment on top of cart, touched sink faucet to add water to cup of solution, did not change gloves, and did not perform hand hygiene; - With the same gloves, LPN B removed 4-inch x 4-inch (in.) gauze from multi-pack, saturated gauze with treatment solution, squeezed out excess fluid, and placed in second cup; - With the same gloves, LPN B placed gauze wet with treatment solution on resident wounds to soak as ordered, removed gloves, rolled treatment cart out of room into hall, placed multipack of gauze in drawer of cart, sanitized hands, and did not clean treatment cart; - At 12:05 P.M., LPN B returned to room, sanitized hands, put on gloves, did not put on gown, entered room with treatment items including ointment in large resealable plastic bag, a multipack of 4-in. x 4-in. gauze, and placed items on top of the resident's mini-fridge in room, and did not place clean barrier or clean surface; - LPN B removed solution-soaked gauze from resident's wound areas, changed gloves, and did not perform hand hygiene; - LPN B removed 3 gauzes from multipack, dried wound area to top of head with one gauze, used second gauze to dry wound area above right temple, removed glove over soiled gauze, placed in trash can, sanitized hands, and put on clean gloves; - LPN B removed ointment from bag, added to small medicine cup, used cotton tip applicator to apply ointment to wound, dipped applicator back in cup, and applied again to first wound; - LPN B used second applicator, dipped into cup with ointment, applied ointment to second wound area, disposed of items in trash can, removed gloves, sanitized hands, picked up resealable plastic bag with ointment and gauze multipack, exited room and placed items on top of cart, then placed items in appropriate drawers in cart, and did not clean packages prior to placement in cart. Review of the Division of Community and Public Health, Section 2.0 Testing for Latent Tuberculosis Infection, revised May 2020, showed: - Interpretation of Tuberculin Skin Test (TST) reactions should be conducted within 48 to 72 hours after administration by a trained health care professional. If the test is not read within the 48 to 72 hour window, it must be repeated. Patients or family members should not interpret or read TST results. 7. Review of Resident #34's medical record showed: - admitted on [DATE]; - TST step one, dated 10/10/25, with negative 0.0 millimeters (mm) and no read date; - TST step two, dated 10/24/25, with negative 0.0 mm and no read date. 8. Review of Resident #70's medical record showed: - admitted on [DATE]; - TST step one, dated 12/18/24, with negative 0.0 mm and no read date; - TST step two, dated 01/04/25, with negative 0.0 mm and no read date 9. Review of Resident #74's medical record showed: - admitted on [DATE]; - TST step one, dated 02/17/25, with negative 0.0 mm and no read date; -T ST step two, dated 03/03/25, with negative 0.0 mm and no read date. 10. No infection control binder provided for review. During an interview on 12/08/2025 at 3:15 P.M., the DON said they use the Mc Geers Criteria when assessing infections. She does not have an IPCP, she uses the infection control program on the electronic medical record to track infections and antibiotic use. During an interview on 12/08/25 at 12:15 P.M., LPN B said EBP should be used when someone has a wound or indwelling catheter, or something invasive. Staff should put on a gown with gloves when providing care. He/she should have put on a gown too. There should be a EBP sign on the door area, but the residents are decorating their doors for the holiday. Sometimes it is passed in report as reminders of who should have EBP, it has been talked about pretty heavily for a while. He/she probably should not have taken the treatment cart in the room, but it's hard to find an area to set supplies on in some resident's rooms. Items should be cleaned before going back into the cart. During an interview on 12/08/25 at 3:52 P.M., the DON said staff are to wear EBP, gown and gloves, during high contact activities, including wound care. Hand hygiene and glove changes should be completed between dirty and clean task, and before and after care. Medication and treatment carts don't go into resident rooms. Supplies should be left in the room if taken in, a clean barrier should be placed before setting items down and wipe down the item with a cleaning wipe before placing them back into the cart. Residents and employees should receive a two step TST and once administered should be read within 48-72 hours. During an interview on 12/08/25 at 4:14 P.M., the Administrator said she would expect hand hygiene to be performed, and for staff to follow policy for wound care. The Administrator said she would expect TST to be administered and read per standards of practice and facility policy.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) assessment within 14 days of admission to hospice services for one resident (Resident #5) out of two sampled residents. The facility census was 81.The facility did not provide a policy regarding the completion of significant change MDS assessments. 1. Review of Resident #5's medical record showed:- admitted to the facility on [DATE];- admitted to hospice services on 08/22/25. Review of the resident's significant change MDS, dated [DATE], showed: - Received hospice services;- The facility did not complete a significant change MDS within 14 days of the resident's admission to hospice. During an interview on 12/08/25 at 3:52 P.M., the Director of Nursing said a significant change MDS should be completed if a significant change with the resident lasted longer than two weeks, or if the resident was admitted to hospice. The significant change MDS should be completed within 14 days of the resident's change in condition. During an interview on 12/08/25 at 4:14 P.M., the Administrator said a significant change MDS should be completed within 14 days of a change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure urinary indwelling catheter (a tube inserted into the bladder to drain urine) tubing was maintained in the proper position and failed to cover the catheter drainage bag with a dignity bag for one resident (Resident #74) out of three sampled residents. The facility census was 81.Review of the facility's policy titled, Catheter Care, undated, showed:- Keep the bag below the level of the resident's bladder at all times;- Use a catheter bag cover to protect the resident's dignity;- The policy did not address proper positioning of the catheter tubing. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP) Policy and Procedure, dated August 2024, showed:- EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes;- High-contact resident activities include device care or the use of a urinary catheter;- Gowns and gloves will be available outside of the rooms. 1. Review of Resident #74's medical record showed: - admitted on [DATE];- Diagnosis of benign prostatic hyperplasia (BPH - an enlargement of the prostate causing difficulty in urination). Review of the resident's Physician Order Sheet (POS), dated December 2025, showed:- An order to change the indwelling catheter once a month on night shift every 30 days, dated 12/01/25, with a due date of 12/24/25. Observation on 12/03/25 at 10:20 A.M., showed the resident sat in a wheelchair in his/her room, the catheter drainage bag not covered with a dignity bag hung from the wheelchair, and the door open. Observation on 12/03/25 at 11:30 A.M., showed the resident sat in a wheelchair outside smoking with other residents and staff in the smoking area and the catheter drainage bag not covered with a dignity bag hung from the wheelchair. Observation on 12/04/25 at 8:00 A.M., showed the resident sat in a wheelchair in his/her room, the catheter drainage bag not covered with a dignity bag hung from the wheelchair, the door open, and another resident visited with him/her. Observation on 12/04/25 at 8:30 A.M., showed the resident was pushed in the hallway to the smoking area outside by staff and the catheter drainage bag not covered with a dignity bag hung from the wheelchair. Observation on 12/08/25 at 9:35 A.M., of the resident's catheter care showed:- EBP signage on the door;- Certified Nursing Assistant (CNA) A performed hand hygiene, put on gloves, and did not put on a gown;- CNA A performed the resident's catheter care;- CNA A positioned the clean catheter tubing through the top of the brief above the resident's bladder and fastened the brief;- CNA A did not position the catheter tubing below the level of the resident's bladder. During an interview on 12/08/25 at 3:50 P.M., CNA A and Licensed Practical Nurse (LPN) C said a dignity bag should be on a catheter drainage bag when there was a visitor in the resident's room or when the resident was outside their room. Catheters should not be sticking up and out of the brief, but below the bladder so gravity could help drain the bladder. During an interview on 12/08/25 at 3:45 P.M., the Director of Nursing said a catheter drainage bag should be covered in a dignity bag when outside the room or if the resident had visitors. The catheter tubing should never be placed out of the top of the brief, but downwards for the urine to flow down and away from the level of the bladder. During an interview on 12/08/25 at 4:20 P.M., the Administrator said she would expect staff to follow the policies and procedures to ensure proper catheter care including keeping the tubing below the level of the bladder and making sure the drainage bag was covered in a dignity bag.

Based on interview and record review, the facility failed to provide packed lunch/snacks for one resident (Resident #72) while at dialysis (a process for removing waste and excess water from the blood) center out of one sampled resident. The facility census was 81.The facility did not provide a policy for dialysis care. 1. Review of #72's medical record showed:- admitted on [DATE];- Diagnoses of chronic kidney disease stage 5 (kidneys have failed or are very close to failing, unable to filter waste and fluid effectively, requiring dialysis) and essential hypertension (high blood pressure);- Cognition intact. Review of the resident's Care Plan, revised 11/16/25, showed:- The resident needs dialysis related to kidney failure;- The resident receives dialysis three times per week on Tuesday, Thursday, and Saturday at the dialysis center. During an interview on 12/05/25 at 9:00 A.M., the resident said transportation took him/her to dialysis every Tuesday, Thursday, and Saturday morning around 6:00 A.M. He/she ate breakfast before leaving the facility and would not eat again until he/she returned from dialysis after lunch time in the afternoon. The facility didn't provide a lunch and/or a snack to take with him/her to dialysis since lunch was missed. During an interview on 12/05/25 at 9:25 A.M., Dietary Staff F said dietary staff made bag lunches with sandwiches, snacks, and a drink for residents that received dialysis or were away from the facility during lunch. Dietary staff took the bagged food to the A Hall refrigerator for nursing staff to provide to the residents prior to dialysis or any other scheduled appointments. During an interview on 12/05/25 at 10:14 A.M., the Director of Nursing (DON) said she would expect dialysis residents to be given a lunch bag with a sandwich and/or snacks while away from the facility during the lunch meal. During an interview on 12/05/25 at 10:27 A.M., Licensed Practical Nurse (LPN) H said he/she typically worked weekend days and had never seen nor provided a bagged lunch for the resident to take with him/her to dialysis. During an interview on 12/05/25 at 10:52 A.M., the Dietary Manger (DM) said he/she would expect residents to receive the bagged lunches prior to leaving the facility for dialysis or any other scheduled appointment. During an interview on 12/05/25 at 10:54 A.M., the DON and Administrator said if there wasn't a lunch bag ready, the nurses were to make the resident something from the kitchen or ask dietary staff for something before the resident left for dialysis. During an interview on 12/10/25 at 2:13 P.M., LPN G said there had been bagged lunch/snacks for the residents in the A Hall refrigerator but had not personally given a bagged lunch/snack to the resident prior to leaving the facility for dialysis. During an interview on 12/10/25 at 2:35 P.M., Dietary Staff R said he/she did make bagged lunches/snacks every morning for any resident that had a scheduled appointment and would be leaving the facility.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and to ensure the resident environment was free from accident hazards for one resident (Resident #1), who had been assessed as needing supervision for smoking, was observed smoking in his/her room on several occasions while receiving supplemental oxygen via a nasal cannula, and failed to investigate the source of the smoking materials (lighters and cigarettes). The resident sustained 2nd degree burns while smoking in his/her room, putting the entire building and its occupants in danger. The facility census was 86. The administration was notified on 10/20/25 at 4:55 P.M. of an Immediate Jeopardy (IJ) which began on 10/13/25. The IJ was removed on 10/21/25, as confirmed by surveyor onsite verification. Record review of the facility's undated smoking policy showed:- Smoking is only permitted in the designated smoking areas under the supervision of a staff member assigned by the charge nurse each shift;- Staff to instruct the resident about the facility policy on smoking including locations, times and safety concerns;- No cigarettes or cigarette lighters are to be kept in the resident rooms;- Staff are to immediately notify the unit charge nurse if it is suspected a resident has violated the facility smoking policy or if the resident clothing or skin show signs of cigarette burns;- The Minimum Data Set (MDS) nurse will update the care plan with any changes in the residents' capabilities or needs. Review of Resident #1's facility admission agreement included a form entitled Rules and Regulations, which showed: - The resident understands smoking is permitted in this facility; it is permitted in designated areas of the facility only. All lighters and matches shall be kept at the nurse's station;- Residents may not keep lighters and matches or cigarettes in their rooms or on the person;- Resident #1 initialed the document as received and understood on 04/18/24. Review of Resident #1's quarterly MDS, a federally mandated assessment instrument required to be completed by the facility staff, dated 08/22/25 showed:- Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic lung disease that causes progressive damage to the airways and air sacs in the lungs), schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia, such as hallucinations and delusions, with symptoms of a mood disorder, like bipolar disorder or depression), borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), intermittent explosive disorder (a mental health condition characterized by recurrent episodes of impulsive, aggressive, and violent behavior that is disproportionate to the triggering situation), and anxiety (excessive fear, worry, and related behavioral disturbances that interfere with daily life);- Cognition intact;- Supervision of staff for activities of daily living;- Ambulates independently;- The resident is his/her own responsible party. Review of Resident #1's care plan, last updated on 06/09/24, showed:- The resident does smoke cigarettes;- The resident required supervision while smoking;- Staff will educate the resident about the facility policy on smoking, locations, times, and safety concerns;- Staff will notify charge nurse immediately if it is suspected the resident has violated the facility smoking policy. Review of the Physician Order Sheet (POS), dated September 2025, showed:- An order, dated 04/22/24, for oxygen (O2) at two liters (L) continuous via nasal cannula ((NC) a thin, flexible tube that wraps around your head, typically hooking around your ears, used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory assistance) while in bed related to COPD at bedtime;- An order dated 08/07/25 for auto continuous positive airway pressure (CPAP) (a device for treating sleep apnea that automatically adjusts air pressure based on the user's breathing needs throughout the night) 8-11 centimeters (cm) water oxygen at 1 liter per minute (LPM), heated in line humidification, and as needed (prn) 20-min ramp to be worn during hours of sleep (prevents the dryness and irritation of the airway that can occur from using the machine. The heated air from the humidifier travels through the tubing to the mask); Review of Resident #1's Progress notes, showed:- On 10/13/25 at approximately 6:45 P.M., Licensed Practical Nurse (LPN) B was notified of fresh smoke smell in hallway adjacent to the Resident #1's room. Upon entering the room, the resident was observed lying in bed, black soot on nares (nostrils), right hand, right side of neck, and the facial hair on the right side of the face was gone. Burned areas were noted on the bed sheets and mattress, with several large burn holes in the blanket. The resident's t-shirt was also noted to have burned holes/black soot. The nasal cannula was in the nares, electrical cords were noted to be melted in places, and a non-invasive ventilation mask that provides two different levels of air pressure to assist breathing (BiPap) mask and tubing were laying on the floor beside the bed. An empty soda can was sitting on the bedside table with smoke coming out. A lighter and one unsmoked cigarette were observed lying beside the soda can. Resident #1 was quiet and alert with shallow breaths. He/she was able to answer yes/no questions. LPN B went to notify the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). DON and ADON assessed the resident and reviewed the scene. The physician was notified, and new orders were received to send Resident #1 to the emergency room for evaluation and treatment. A call was placed to 911. Emergency Medical Transportation arrived and the resident left building at 9:39 PM;- On 10/14/25 at 11:06 A.M., report was received from the burn unit at the hospital Resident #1 was returning to the facility with 2nd degree burns (an injury that damages the top two layers of skin: the epidermis and dermis) to the tip of the nose, the back of the left second finger, and the right side of the collarbone. Some nasal irritation. The burn is to be treated with bacitracin ointment (an antibiotic ointment) applied and left open to air. Resident afebrile (no increased body temperature) and will return on oxygen at 2L per NC. Review of Resident #1's hospital discharge report, dated 10/14/25, showed:- Second degree burns to tip of nose, tip of nose, the back of the left second finger and overlying the right side of the collarbone;- Resident reports lighting a cigarette while he/she was still wearing his/her nasal cannula oxygen. The nasal prongs ignited, burning his/her nose. He/she removed the oxygen tubing from his/her face and got up to turn off the oxygen concentrator (a medical device that takes in the air around you, filters out the nitrogen, and delivers concentrated, purified oxygen to a user). The resident's sheets and mattress caught fire and he/she quickly patted out using his/her hands;- Resident #1 sustained burns to the nose, fingers of the left hand and a patch on the right shoulder. Review of Resident #1's care plan, last updated on 06/09/24, showed no new interventions related to the resident's smoking safety and failure to follow facility rules related to smoking. The care plan did not include information regarding Resident #1 smoking in his/her room, or smoking while wearing O2 and receiving 2nd degree burns. Review of Resident #1's Progress notes, showed:- On 10/16/25 at 4:49 A.M, the resident was noted to be smoking in bed in his/her room four times. Education was provided regarding the facility policy on smoking in house. The resident voiced understanding, but continued to smoke anyway. Cigarettes, lighters, and a soda cup to hold ashes were removed from the room and placed at the nurses' station for review by administration. The resident continues to receive treatment for burns sustained from the prior incident of smoking in bed while receiving oxygen via nasal cannula;- On 10/21/25 at 6:57 A.M., Resident #1 was seen by the wound nurse to assess the burn areas which included the following: -Right upper chest - 8 centimeters (cm) x 14cm x 0.1 cm, wound bed with patches of white charred skin, no odor, no drainage; -Left hand 4th finger measures 2.1 cm x 2 cm x 0.1 cm, wound bed white charred skin, no odor, no drainage; -Right hand index finger 2.5 cm x1.4 cm x 0 cm; -Right hand thumb, 0.8 cm x1 cm x0.1 cm, 75% charred skin with 25% eschar (blackened, dead skin) no odor, no drainage; -Treatment was done per physician orders. The resident tolerated procedure well, no verbal/non- verbal indicator of pain. Review of Resident #1's October 2025 POS showed no treatment orders for the burns. During an interview on 10/20/25 at 2:55 P.M., the Director of Nursing (DON) and the Assistant Administrator (AA) said Resident #1 received burns from lighting a cigarette in his/her room and was sent to the burn center but had since returned. The DON said she did not know how to stop residents from bringing in lighters due to not being able to search resident's or rooms for that type of contraband and she was not willing to lose her nursing license over it. The DON said she was aware Resident #1 had cigarettes and lighters in his/her room and continued to smoke in his/her room unsupervised despite many attempts at re-education. The DON said to her knowledge no additional interventions were put in place for Resident #1, other than trying to keep a closer watch on him/her. An investigation was not done. The DON said she did not know where the resident continued to get lighters and cigarettes from. The DON was not aware of facility policies regarding residents bringing contraband into the facility The AA said, there was not much else the facility could do with Resident #1, other than to keep a closer watch. The AA said the facility does not have the staff or the budget to provide one on one supervision for the resident. The AA said she believes the staff can provide protective oversight to Resident #1 and other residents, just not one on one care or every 15-minute checks. The DON said they are not considering a discharge of Resident #1 at this point. The DON and the AA did not know where the treatment orders for Resident #1's injuries were written, but said they knew they were being treated. Observations and interview on 10/20/25 at 3:15 P.M., showed Resident #1 lying on his/her bed with a nebulizer mask on his/her face connected to an oxygen concentrator (a machine that delivers humidified oxygen). His/her right thumb was noted to have a large yellow scabbed area, along with a quarter size area on the right index finger. His/her left 4th finger above the knuckle and thumb have a quarter size area covered with a scab, yellow in color. Resident #1 said he/she bought cigarettes and lighters while out on transport with staff stopping at stores, and from other residents in the facility. The resident said the sores on his/her hands are burns he/she received when the tubing to the nebulizer mask caught on fire after he/she lit a cigarette. He/she flung the melting tubing causing the melted plastic to land on his/her hands. He/she said it scared him/her bad when it happened. Resident #1 said no one from the facility had ever asked him/her where he got his lighters and cigarettes. He/She said they have told him/her multiple times to not smoke inside, but he/she likes to smoke. During an interview on 10/21/25 at 1:15 P.M., the CEO said she would have expected the DON to investigate the smoking incident on 10/13/25, collect all pertinent information and confiscate all lighters or smoking materials from the resident. Proper notifications were not made to the corporate office as should have been. The Administrator should have determined if this was an isolated event or an on-going issue and follow the facility policies. Complaint #2647850 NOTE: At the time of the 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. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D. 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).

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents residing in the facility. The facility census was 91. Review of the facility's policy titled, Nursing Staff, undated, showed: - The facility must use a RN for at least eight consecutive hours a day, seven days a week. Review of the facility's Facility Assessment Tool, last reviewed 07/09/24, showed: - Did not address RN staffing. Review of the Center for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data Report from the Community Assessment for Public Health Emergency Response (CASPER) REPORT 1705D for the fiscal year quarter 1, 2025 (October 1, 2024 to December 31, 2024) showed: - Triggered four or more days within the quarter with no RN hours; - One day in October 2024 for 10/10/24; - One day in November 2024 for 11/17/24; - Four days in December 2024 for 12/13/24, 12/21/24, 12/25/24 and 12/27/24. The facility did not provide Nursing Schedules for October and November 2024. Review of the Nursing Assignment Sheets, dated 10/01/24 through 11/30/24, showed: - No RN worked for eight consecutive hours on 10/23/24, 10/24/24, 10/25/24, 11/14/24, 11/17/24, 11/21/24, 11/22/24, 11/28/24 and 11/29/24; - Nine opportunities out of 61 opportunities missed. Review of the Nursing Schedules, dated 12/01/24 through 12/31/24, showed: - No RN scheduled for eight consecutive hours on 12/15/24, 12/20/24, 12/21/24, 12/23/24, 12/24/24, and 12/25/24. - Six opportunities out of 31 opportunities missed. Review of the Nursing Schedules, dated 02/02/25 through 04/17/25, showed; - No RN scheduled for eight consecutive hours on 02/14/25, 02/15/25, 02/16/25, 02/20/25, 02/21/25, 02/27/25, 02/28/25, 03/01/25, 03/02/25, 03/07/25, 03/12/25, 03/15/25, 03/21/25, 03/22/25, 03/23/25, 03/26/25, 03/27/25, 03/28/25, 03/29/25, 03/30/25, 04/01/25, 04/04/25, 04/08/25, 04/09/25, 04/10/25, 04/11/25, 04/16/25, and 04/17/25; - 28 opportunities out of 75 opportunities missed. Review of the Nursing Assignment Sheets and time sheets, dated 02/02/25 through 04/17/25 showed: - No RN worked eight consecutive hours on 02/14/25, 02/15/25, 02/16/25, 02/20/25, 02/21/25, 02/27/25, 02/28/25, 03/01/25, 03/02/25, 03/07/25, 03/12/25, 03/15/25, 03/21/25, 03/22/25, 03/23/25, 03/26/25, 03/27/25, 03/28/25, 03/29/25, 03/30/25, 04/01/25, 04/04/25, 04/08/25, 04/09/25, 04/10/25, 04/11/25, 04/16/25, and 04/17/25; - 28 opportunities out of 75 opportunities missed. During an interview on 04/17/25 at 2:30 P.M., the Administrator said the facility did not have a RN scheduled on the listed dates. The facility had three RNs that only worked as needed or a few days a week. The facility had not used agency staff for a long time. The facility had RN openings which were advertised.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility's census was 91. The facility did not provide a policy for a safe, clean, and comfortable homelike environment. 1. Observation on 04/14/25 at 11:01 A.M., of Room A15 showed: - No cover over two fluorescent bulbs in the light fixture above the bed next to the door. 2. Observation on 04/17/25 at 9:51 A.M., of the A Hall shower room showed: - A 2 ft. x 2 ft. vent with a build up of dust and debris next to the right side of the shower stall; - The shower stall with a large floor area with 108 missing tiles and a rigid floor surface; - A large floor area of the shower stall with rusty, brown-colored stains and a build up of dirt and grime; - Several areas of peeled/chipped paint on the right, left, and back walls of the shower stall; - The entrance door frame on the left side with an approximate 3 ft. area of vertical scrapes. 3. Observation on 04/17/25 at 9:59 A.M., of Room B36 showed: - The front cover of the air conditioner/heater unit missing. 4. Observation on 04/17/25 at 10:10 A.M., in front of the nurses' station at the intersection of B and C Halls showed: - Three 4 in. x 1 ft. ceiling tiles with dark circles; - Five 1 ft. x 1 ft. ceiling tiles with large dark circles. 5. Observation on 04/17/25 at 10:25 A.M., of the back area of the main dining room showed: - Six 2 ft. x 4 ft. ceiling tiles with large dark brown circles; - One 2 ft. x 2 ft. ceiling tile with a small dark brown circle. 6. Observation on 04/17/25 at 10:55 A.M., of the B Hall shower room A showed: - Two toilets with a non-intact caulk seal along the base and floor; - The wall section above the right-side toilet had a 6 in. by 3 in. hole above the trim board about 4 ft. above the floor; - A strong urine odor; - A non-intact caulk seal between the backsplash area and a porcelain sink mounted against the wall; - The approximately 20 in. x 24 in. mirror missing the bottom 1 in. of reflective coating; - The wall adjacent to the shower near the trash can with a 2 ft. tile baseboard area in the floor with a black substance. 7. Observation on 04/17/25 at 1:54 P.M., of Room C42 showed: - A non-intact metal bathroom door frame with sharp edges and a brown substance about 1 ft. above the floor; - The sink countertop with a 1 in. front edge strip missing about 8 in.; - The toilet with a non-intact caulk seal along the base and floor, no toilet tank lid, and a 1 in. gap between the water line and wall; - The toilet seat with four 1 in. diameter damaged sections without a smooth painted surface. 8. Observation on 04/17/25 at 2:30 P.M., of the outdoor smoking area showed: - Six strands of wire approximately 75 ft. in length along the exterior wall section left of the entry door hung loosely at least 4 ft. down the exterior wall area and obstructed the view from the resident room windows; - One black wire approximately 25 ft. in length along the exterior wall section right of the entry door hung loosely at least 4 ft. down the exterior wall area. During an interview on 04/15/25 at 9:16 A.M., Resident #65 said the shower rooms had some damage and smelled bad. It was frustrating. During an interview on 04/15/25 at 9:20 A.M., Resident #62 said the shower rooms had odors and there was a hole in the wall. Some issues like that were frustrating at times. During an interview on 04/15/25 at 9:40 A.M., Resident #67 said there were problems with the bathrooms in the facility and it was frustrating because he/she had mentioned it to staff. During an interview on 04/15/25 at 9:45 A.M., Resident #68 said it was frustrating when the floors did not look clean in the shower room. There was damage to the wall behind the toilet and an odor. During an interview on 04/15/25 at 9:53 A.M., Housekeeper G said there were problems in the shower room. Issues with damage in the facility should be reported to maintenance or the supervisor and there were forms. During an interview on 04/17/25 at 10:30 A.M., Certified Medication Technician (CMT) A said when there was a need for repair, there was a clipboard on the maintenance staff door. Staff could fill it out and leave it there on the clipboard. During an interview on 04/17/25 at 10:32 A.M., Licensed Practical Nurse (LPN) C said staff just told maintenance or staff could fill out the form and leave it on the maintenance door. During an interview on 04/17/25 at 11:12 A.M., Housekeeper H said he/she would tell nursing or the charge nurse when he/she saw damage in the facility. He/she wasn't told to log the damage in a binder and hadn't reported any problems yet. During an interview on 04/17/25 at 1:26 P.M., the Maintenance Supervisor said maintenance request forms were part of the repair process. If staff noticed concerns or heard problems from the residents, they should fill the form out and place it in one of four drop boxes. Once the requests were received and a repair was made, he/she completed a portion on the form on how the problem was addressed. Inspections for lighting and any kind of damage should also be completed by the maintenance department. There had been recent changes in the maintenance staffing that might have caused some issues. He/She hadn't been the supervisor for long. A faucet has been ordered for Room C42 but he/she wasn't aware of any other issues in that room or in Shower Room A. During an interview on 04/17/25 at 3:05 P.M., the Administrator said damages in the resident rooms should be reported to the maintenance department. Several rooms had been redone so far but they had more they wanted to work on. If staff noticed problems with the facility environment or if residents complained, the staff should place the information on a maintenance request form. The completed maintenance request forms should be in the maintenance log. She expected the rooms and showers to be kept in good repair.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the statement of appeal rights or the name, address, or telephone number of the office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices for six residents (Residents #18, #35, #46, #47, #54, and #62) out of seven sampled residents. The facility's census was 91. Review of the facility's policy titled, Discharges, undated, showed: - The facility must ensure the discharge is documented in the resident's medical record, including Physician's order for the discharge, basis for the transfer, specific resident needs that can't be met; - Information provided to the receiving provider must include a minimum of contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advanced directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable to ensure a safe and effective transition of care. 1. Review of Resident #18's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]. - No documentation of the written notification to the resident and/or the resident's representative for the resident's transfer to the hospital. 2. Review of Resident #35's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation of the written notifications to the resident and/or the resident's representative for the resident's transfer to the hospital. 3. Review of Resident #46's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation of the written notifications to the resident and/or the resident's representative for the resident's transfer to the hospital. 4. Review of Resident #47's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on 2/28/25; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation of the written notifications to the resident and/or the resident's representative for the resident's transfer to the hospital. 5. Review of Resident #54's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation of the written notifications to the resident and/or the resident's representative for the resident's transfers to the hospital. 6. Review of Resident #62's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation of the written notification to the resident and/or the resident's representative for the resident's transfer to the hospital. During an interview on 04/17/25 at 2:46 P.M., the Regional Administrator said the transfer and discharge notices should address the reason for the discharge along with some other information and the forms weren't detailed enough. During an interview on 04/17/25 at 2:48 P.M., the Social Services Designee (SSD) said transfer and discharge notifications should be given in writing to the resident and/or the resident's representative upon discharge or transfer. The notices should include the appeal rights and information on contacting the Ombudsman which the current forms do not include those details. During an interview on 04/17/25 at 2:51 P.M., the Administrator said she would expect transfer/discharge notifications to be given in writing to the resident and/or the resident's representative upon discharge or transfer. The notices should include the appeal rights and information on contacting the Ombudsman.

Refer to Event ID J4LN13 for SOD Complaint #MO241216 This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 07/18/24. Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #8) was free from physical abuse when Resident #7 punched Resident #8 in the back of the head after an earlier verbal altercation. This resulted in Resident #8's head going forward and smacking his/her face into the medication cart. This caused bruising and swelling to Resident #8's cheek bone. The facility census was 83.

Refer to Event ID J4LN13 for SOD. Complaint #MO241561 and 241643 This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 04/16/24 and 06/11/24. Based on observation, interview and record review, the facility failed to ensure staff followed professional standards of practice when staff did not check on one resident (Resident # 6) out of six sampled residents for over seven hours on the night shift. The resident had fallen around midnight and lay on the floor of his/her bedroom until staff entered the resident's room at 6:55 A.M. The facility also failed to identify, assess, and care plan interventions related to falls. The facility census was 83.

Based on observation, record review and interview, the facility failed to ensure one resident (Resident #2) was free from physical abuse, and 11 other vulnerable residents at an increased likelihood for abuse to occur when facility staff placed residents with a history of physical and verbal altercations and unstable, aggressive behaviors towards other residents, on the secured unit which housed 12 residents with dementia, receiving hospice care, or requiring total care from staff. The aggressive residents were placed on the secured unit for 24 hours to 5 days until the administrator felt they were no longer a risk to residents outside the locked unit. Resident #1 was placed on the secured unit after returning from a hospital evaluation due to physical aggression. Resident #1 got in an altercation with Resident #2, a resident on the secured unit for safety and dementia care. Resident #1 pushed Resident #2 into the toilet. Resident #2 sustained bruising to his/her face. The census was 88. On 07/09/24 at 4:00 P.M., the Administrator was notified of the immediate jeopardy (IJ) which began on 06/23/24. The IJ was removed on 07/09/24, as confirmed by surveyor onsite verification. Record review of the facility undated Abuse policy showed: - The facility will ensure that each resident is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat a resident's medical symptoms; - The facility will ensure the resident is free from physical or chemical restraints imposed for purpose of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility did not provide a policy regarding the criteria for placement on the secured unit. 1. Record review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 05/28/24 showed: - Admission to facility on 09/10/22; - Diagnoses of Schizophrenia (symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation), bipolar (a condition causing uncontrolled mood swings), depression, and Mild Intellectual Disability (significant impairment and adaptive functioning); - Cognition intact; - Requires supervision of one staff with activities of daily living (ADLs); - Receives antipsychotic (medication that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking), depression, and antidepressant medications seven days a week on a routine basis; - Guardian in place. Review of Resident #1's care plan, originally developed on 06/02/22 and updated on 03/01/24, showed: - The resident has the potential to be physically aggressive (outbursts, impatient, agitated at others and a history of verbal and physical altercations) related to anger. History of harm to other and poor impulse control; - The resident has the potential to be verbally aggressive (yelling, screaming) related to ineffective coping skills, mental/emotional illness, poor impulse control, outbursts at others when not getting what asked for right away due to forgetfulness and repetition; - The resident has a communication problem related to language barrier, unspecified intellectual disabilities, and short-term memory loss; - No new interventions since 06/02/22; - No mention of assessing for the appropriateness of placement on the secured unit. - Record review of Resident #1's emergency room record dated 6/23/2024 showed: - The resident was sent to the emergency room for aggression with other residents; - The resident returned to the facility the same date with a diagnosis of medically cleared to return. Record review of the Resident #1's emergency room record dated 7/4/2024 showed: - The resident was sent to the emergency room for aggressive behavior with a resident on the secured unit; - The resident told the hospital he/she had been in a physical altercation with a resident and had exposed him/herself to the facility staff and said suck my dick; - The resident displayed poor ability to handle stressors; - The resident was discharged back to the facility as chronic schizophrenia with aggressive response. During an interview on 07/09/24, at 12:15 P.M., Resident #1 said he/she had been placed on the unit 06/23/24 through 07/04/24 because of previous aggressive behaviors with other residents. He/she said when a resident is aggressive, they are sent out to the emergency room and when they come back are placed on the secured unit. He/she said this is to keep residents on the regular hall safe until the resident can calm down. Resident #1 said he/she does not remember hitting Resident #2 on 07/04/24. The resident said he/she probably did hurt Resident #2, but does not remember. 2. Review of Resident #2's medical record showed: - admitted [DATE]; - Diagnoses included alcohol induced persistant dementia, dementia with severe behavioral disturbances Record review of Resident #2's quarterly MDS, dated [DATE] showed: - Severe cognitive impairment; - Requires supervision of one to two staff with ADLs; - Receives antipsychotic, depression, and antidepressant medications seven days a week on a routine basis; - Guardian in place. Review of Resident #2's care plan, updated 02/04/24, showed the resident cannot communicate, wanders and has the potential to be physically aggressive (hit, kick, push others) related to dementia. Interventions included to anticipate needs and monitor/document/report as needed any sign or symptom of resident posing a threat to him/herself or others. Review of Resident #2's Skin Evaluation note, dated 07/05/24, showed noted bruising to the resident's face from a previous altercation with another resident. Observation on 07/09/24 at 5:15 P.M., showed the resident wandering on the secured unit hallway. The resident was confused and unable to communicate. The resident wandered into other resident's rooms and had to be redirected by staff. Review of the facility's self-report of resident to resident abuse, dated and received in the regional office on 07/04/24 showed: - A written statement by Housekeeping Staff (HS) A, dated 07/04/24 at 10:30 A.M. HS A heard a commotion in the bathroom between rooms [ROOM NUMBERS] on the secured unit. HS A immediately went and found staff, Certified Nurse Aid (CNA) A; - A written statement by CNA A, dated 07/04/24 at 10:30 A.M., showed HS A reported to CNA A of hearing loud banging in the bathroom between rooms [ROOM NUMBERS]. CNA A and HS A immediately went to the room and found Resident #1 had Resident #2 shut in the bathroom saying Stay the fuck out of my room. CNA A attempted to explain to Resident #1 that Resident #2 had dementia and was very confused, but Resident #1 did not seem to care and continued to be very angry about the situation; - The administrator and investigator concluded Resident #1 pushed/shoved Resident #2 into his/her bathroom onto the toilet when Resident #2 went into his room by accident. There were no witnesses for the incident, however, HS A did hear and report this immediately. No injuries noted for Resident #1. Resident #2 noted to have faded bruising to face after the altercation; - Final interventions included: - Separated both residents - Resident #1 sent out for an evaluation - Resident #1 moved to B-Hall (non-secured unit) - Resident #1 placed on 15 min face checks for 24-Hours following re-admission from evaluation - Both residents assessed by nursing for injuries - Residents' doctor and responsible parties made aware of incident. Observation on 07/09/24 at 5:15 P.M., showed the resident wandering on the secured unit hallway. The resident was confused and unable to communicate. The resident wandered into other resident's rooms and had to be redirected by staff. During an interview on 07/03/24 at 5:15 P.M., Licensed Practical Nurse (LPN) A said Resident #2 wanders the hallway on the secured unit. He/she does have to be redirected when he/she enters other resident rooms. During an interview on 08/07/24 at 9:00 A.M., CNA A said on 07/04/24 HS A called out to him/her due to a commotion and noise in the adjoining bathroom between rooms [ROOM NUMBERS]. CNA A went to the room to find Resident #1 holding the bathroom door shut, trapping Resident #2 in while yelling stay the fuck out of my room. CNA A attempted to redirect Resident #1, but the resident remained angry. Resident #1 was able to be removed and the residents were separated. Resident #2 appeared to have red marks on his/her wrist. CNA A said it appeared Resident #1 had grabbed and held Resident #2's wrist and forced Resident #2 into the bathroom and held the door shut. CNA A said Resident #2 wanders all the time. CNA A said it does not seem safe to place the aggressive residents on the secured unit. The staff do 15 minute checks on the secured unit. 3. Review of the resident room roster, provided by the facility, showed a total of 15 residents on the secured unit. The roster showed Residents #1, #3, #4, and #5 on the unit for temporary behavior monitoring. Resident #2 and 11 additional residents lived on the secured unit on a full time basis. Review of the records for those 11 residents showed the following: - All 11 residents had moderate to severe cognitive impairment; - All 11 residents needed the secured unit for increased supervision; - Three of the 11 residents wandered and had to be redirected; - Two of the 11 residents received hospice care for terminal illness. Observations and interviews showed: - On 07/09/24 from 11:30 A.M., through 6:30 P.M., Resident #3 resided on the secured unit. During an interview on 07/09/24 at 11:30 A.M., Resident #3 said he/she will be on the secured unit until Friday of this week due to being in an altercation with other residents on the unsecured hall. Resident #3 said the residents who live on the secured unit all the time are really confused or really sick. Resident #3's medical record showed no documentation or an assessment showing why the resident was placed on the secured/locked unit and no care plan for placement on the secured unit. - On 07/09/24, Resident #4 resided on the secured unit. During an interview on 07/09/24 at 11:20 A.M., Resident #4 said he/she was placed on the secured unit as punishment for hitting another resident. The resident said he/she was not asked or given a choice of moving on the unit or not. Resident #4 said the residents who live full time on the secured unit are very confused and can't do much for themselves. The resident's record showed no documentation or an assessment showing why the resident was placed on the secured/locked unit and no care plan for placement on the secured unit; - On 07/09/24, Resident #5 resided on the secured unit. During an interview on 07/09/24 at 11:45 A.M., Resident #5 said he/she was placed on the secured unit as punishment for hitting another resident. The resident's record showed no documentation or an assessment showing why the resident was placed on the secured/locked unit and no care plan for placement on the secured unit. 4. During an interview on 07/09/24 at 2:15 P.M., LPN A said every resident who is the aggressor in an altercation is placed on the secured unit for a minimum of 24 hours with 15-minute checks by staff on the unit. This is done under the direction of the Administrator, and he/she is the only staff who can decide if the resident is removed from the unit after 24 hours. There is no criteria that he/she is aware of that is used for placement on the secured/locked unit. The normal placement of residents on that unit are hospice residents, residents who need increased supervision due to wandering, confusion and/or medically increased need for assistance with ADLs. The residents who reside on the secured unit full time are the most vulnerable. During an interview on 07/09/24 at 3:00 P.M., the Administrator said residents who are the aggressors in a situation or incident are automatically placed on the secured unit. Residents are not given a choice. The facility does not have the capability to provide one on one care to keep residents separated and or safe from one another after an altercation. The Administrator said he had not thought of the safety of the other vulnerable residents residing on the secured unit due to aggressors are medically cleared before being placed on the unit. There is no criteria for placement and/or when removed from unit, it is at his discretion. The administrator said he/she does not a background in psychiatric care and has not received any special training. During an interview on 07/09/2024 at 3:45 P.M., the Director of Nursing said he/she has concerns related to aggressive residents being placed on the secured unit with other residents who are incapable of protecting themselves, although it is the Administrator's direction to do so after an altercation. The Administrator told him/her, moving the residents to their secured unit is an intervention for bad behavior and not intended to be punishment. During an interview on 7/11/2024 at 5:20 P.M., the facility Psychiartrist said he was not aware that all residents who are aggressive were being placed on the secured unit after going to the emergency room . He believes this is not a good practice, but believes the Administrator is attempting to keep residents on the regular hall safe. He stated placing a resident on one one one is a better practice. When asked, he agreed taking a resident with a psychiatric diagnosis and forcing them to a locked unit and secluding them without a choice could promote aggressive behaviors. He stated he believes he can work with the facility to try to find a safer method to keeping the aggressive residents from harming others. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on 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. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Complaint # MO238516

Based on observation, interview, and record review, the facility staff failed to ensure residents were free from abuse when the maintenance supervisor (MS) grabbed the arm and wrist of one resident (Resident #91) out of 20 sampled residents. The resident had a history of mental health support needs, including behavioral problems. During a behavioral episode, the MS grabbed the resident's arms/wrists and struggled to physically restrain the resident which resulted in bruising to the resident's right upper arm. The facility failed to take appropriate steps to protect the resident from additional abuse and allowed the MS to continue to work around the residents. The facility census was 96. The administrator was notified on 04/09/24 at 9:50 A.M., of an Immediate Jeopardy (IJ) which began on 04/03/24. The IJ was removed on 04/10/24, as confirmed by surveyor onsite verification. Review of the facility's policy titled, Abuse, undated, showed: - Ensure that each resident is free from abuse; - Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; - Staff members will observe for possible indicators of abuse; - Every staff member must immediately report any observed or suspected abuse of a resident; - The Director of Nursing (DON) will ensure all alleged violations are reported immediately, but not later than two hours after the allegation if the events alleged involve abuse or result in serious bodily injury; - The facility will ensure that all alleged violations are thoroughly investigated; - To protect the residents during the abuse investigation, the DON and/or Administrator will reassign or suspend the involved employee at their discretion. Review of Resident #91's medical record showed: - admitted on [DATE]; - Diagnoses of post traumatic stress disorder ((PTSD - a mental health condition triggered by a terrifying event), autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships), oppositional defiant disorder (a disorder marked by defiant and disobedient behavior to authority figures), disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, and attention deficit hyperactive disorder (ADHD - a chronic condition including attention difficulty, hyperactivity and impulsiveness). Review of the resident's care plan, updated 03/22/24, showed: - Behavioral problems (history of manipulation, aggression, aggressive toward others); - Intervene as necessary to protect the rights and safety of others; - Approach/speak in a calm manner and divert attention; - Potential to be physically aggressive; - When resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; - If response is aggressive, staff is to walk calmly away and approach later. Review of the resident's progress notes showed: - Nurse's note, created on 04/04/24 at 10:09 P.M., showed on 04/03/24 at 7:20 A.M., this nurse was at the B hall nurse's station when he/she heard yelling near the dining area. As he/she walked toward the dining area, the resident was blocking the path of the medication cart and yelling at Certified Medication Technician (CMT) E; - No additional documentation related to the resident/staff incident on 04/03/24; - On 04/10/24 at 2:26 P.M., documentation showed a skin evaluation was completed with bruising to the back of the right arm, yellow to green in color, three centimeter (cm) x four cm. Review of the Administrative Investigation Form, completed on 04/04/24 at 10:30 A.M., showed: - Resident #91 as the involved resident in an allegation of abuse; - The Assistant Director of Nursing (ADON) notified the Administrator that a resident said a staff member grabbed him/her by the arm. The Administrator instructed the ADON to watch the camera system, gather statements and have a full body assessment done on the resident; - The ADON reported he/she watched the camera and there was no indication staff grabbed the resident. Nurse's notes stated no skin issues and did not note bruising; - The form indicated the State Agency was not contacted; - The form had no signature of who completed the investigation; - The Administrator signed the form on 04/09/24. Review of the Administrative Investigation Form, completed on 04/09/24, showed: - Follow up from the event 04/04/24, involving Resident #91 and Staff MS; - The Administrator watched the camera system footage and noted MS did grab Resident #91's arms. MS suspended pending investigation; - The MS's employment was terminated effective immediately; - The Administrator signed the form on 04/10/24. Review of the MS employee record showed: - Date of hire 12/07/05; - Last abuse and neglect training 04/28/23; - No training related to behavior management. Review of the facility payroll detail for the period of 04/01/24-04/30/24, showed the MS worked the following dates: - 04/03/24; - 04/04/24; - 04/05/24; - 04/08/24; - 04/09/24. Observation on 04/09/24 at 1:00 P.M., of the facility security camera footage, dated 04/03/24, showed: - At 7:22 A.M., CMT E and Resident #91 walked out of the dining room. CMT E pushed the medication cart down the hall as Resident #91 walked alongside the cart; - At 7:23:04 A.M., Resident #91 hurriedly walked in front of the medication cart and blocked the movement of the cart. CMT E attempted to move the cart a couple of times, then pushed the cart against the wall. CMT E stood next to Resident #91 talking; - At 7:23:13 A.M., Licensed Practical Nurse (LPN) H approached CMT E and Resident #91 and walked away at 7:23:40; - At 7:23:30 A.M., the MS approached and stood to the right of Resident #91; - At 7:23:45 A.M., the MS walked to the left side of Resident #91 as other staff approached. CMT E moved the medication cart away from the wall, and as he/she turned the cart, the MS stepped in between the medication cart and Resident #91; - At 7:23:52 A.M., Resident #91 shoved the MS away from the medication cart and the MS stumbled. The MS immediately turned toward Resident #91 and grabbed his/her right upper arm then right wrist. The MS continued to hold onto the resident's wrist until 7:24:06 A.M.; - At 7:24:19 A.M., the MS walked away. During an interview on 04/09/24 at 9:50 A.M., the resident said: - Last week, the resident was very upset and stood in the way of CMT E moving the medication cart; - The MS grabbed the resident by the arms and left a bruise; - He/she reported the incident to LPN F on the morning of 04/04/24; - On the morning of 04/04/24, the day after the incident, LPN F took a picture of the bruise; - No other staff had interviewed the resident other than LPN F on 04/04/24; - He/she didn't know if LPN F forgot to report it as he/she had not heard anything. Observation on 04/09/24 at 9:50 A.M., showed a large bruise on the back of Resident #91's upper right arm. During an interview on 04/10/24 at 3:59 P.M., CMT E said on 04/03/24, the resident was having behaviors and blocking the medication cart. The MS stepped in to assist in letting him/her move the cart. The resident then shoved the MS, and the MS turned and grabbed the resident's wrist. During an interview on 04/09/24 at 11:02 A.M., the MS said, I help with behaviors. I'm pretty good at de-escalating the situation. I can usually calm them down. The MS said on 04/03/24 at 7:20 A.M., the resident got loud and blocked CMT E from moving the medication cart. While assisting, the resident shoved the MS and the MS got a hold of the resident's wrists. The MS said he/she had never done anything like that before. During an interview on 04/09/24 at 11:30 A.M., Certified Nursing Assistant (CNA) G said on 04/03/24 at 7:20 A.M., he/she was bringing breakfast trays back to the kitchen and the resident was blocking CMT E from moving the medication cart and yelling. The MS was trying to block the resident and the resident shoved the MS. The MS turned and grabbed the resident's wrists. A kitchen worker was yelling at the MS to stop. During an interview on 04/09/24 at 11:39 A.M., the Assistant Dietary Manager (ADM) said on 04/03/24 at 7:20 A.M., the resident was blocking the CMT from moving the medication cart and staff tried to divert him/her. The MS stepped between the resident and the medication cart. The resident shoved the MS, and the MS turned and grabbed the resident's wrist. During an interview on 04/09/24 at 11:10 A.M., LPN H said on 04/03/24 at 7:20 A.M., he/she was at the nurse's station and heard yelling by the dining room. The resident blocked CMT E from moving the medication cart. There were a lot of people jumbled all around and someone yelled out to let him/her go. LPN H said there were too many people around to see anything. The ADON was not there, and they didn't have a DON. A staff member called and reported it to the ADON the next morning. If staff saw something that was out of line or questionable, they should intervene and notify the ADON or DON immediately. During an interview on 04/09/24 at 1:20 P.M., the ADON said the incident was reported to him/her on 04/04/24 at 10:29 A.M., via a text by LPN F. The ADON reported the incident to the Administrator. The ADON completed his/her part of the investigation by getting statements and viewing the video. He/She saw nothing on the video to make him/her feel like it was abuse or a reportable incident. He/She did not interview the resident or staff and did not assess the resident. During an interview on 04/09/24 at 2:32 P.M., the Administrator said her part of the investigation was the follow-up. The ADON had reviewed the video and informed the Administrator it did not show the MS put his/her hands on the resident. It was decided it was not a reportable incident. The Administrator said she honestly believed it did not occur. During an interview on 04/09/24 at 2:57 P.M., the ADON said he/she was the only person that reviewed the video and missed the part where the resident was grabbed by his/her upper arm. The ADON said the text from LPN F did contain a picture of the bruise on the resident's arm. The ADON did not document anything about it in the medical record and did not make an observation. During an interview on 04/16/24 at 02:59 P.M., the Medical Director (MD) said he had not been notified of the altercation, and was not aware an abusive situation had occurred between the resident and staff. The MD said he/she did not think the facility could adequately care for some of the resident's behaviors. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on 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. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Complaint #MO235359

Based on observation, interview and record review, the facility failed to thoroughly investigate an allegation of staff to resident abuse and failed to implement interventions to prevent further abuse from occurring for one resident (Resident #91) out of 20 sampled residents after the Maintenance Supervisor (MS) grabbed the resident's arm and wrist in a restraining manner that resulted in a physical struggle and bruising to the resident's right upper arm. The facility also failed to follow their policy, resulting in the MS continuing to work around the resident. The facility census was 96. The administrator was notified on 04/09/24 at 9:50 A.M. of an Immediate Jeopardy (IJ) which began on 04/03/24. The IJ was removed on 04/10/24, as confirmed by surveyor onsite verification. Review of the facility's abuse policy, undated, showed: - Ensure that each resident is free from abuse; - Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; - Staff members will observe for possible indicators of abuse; - Every staff member must immediately report any observed or suspected abuse of a resident; - The Director of Nursing (DON) will ensure all alleged violations are reported immediately, but not later than two hours after the allegation if the events alleged involve abuse or result in serious bodily injury; - The facility will ensure that all alleged violations are thoroughly investigated; - To protect the residents during the abuse investigation, the DON and/or Administrator will reassign or suspend the involved employee at their discretion. Review of Resident #91's medical record showed: - admitted on [DATE]; - Diagnoses of Post-Traumatic Stress Disorder ((PTSD) a mental health condition triggered by a terrifying event), autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships), oppositional defiant disorder (a disorder marked by defiant and disobedient behavior to authority figures), disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, attention deficit hyperactive disorder (a chronic condition including attention difficulty, hyperactivity and impulsiveness). Review of the resident's care plan, updated 03/22/24, showed: - Resident #91 has behavioral problems (history of manipulation, aggression, aggressive toward others); - Intervene as necessary to protect the rights and safety of others; - Approach/speak in a calm manner; divert attention; - Resident #91 has potential to be physically aggressive; - When resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; - If response is aggressive, staff is to walk calmly away and approach later. Review of the resident's progress notes showed: - Weekly skin assessment completed on 04/03/24 at 2:51 P.M., showed no skin issues; - Nurse's note created on 04/04/24 at 10:09 P.M., (regarding incident on 04/03/24), showed this nurse was at the B hall nurse's station when he/she heard yelling near the dining area. As he/she walked toward the dining area, the resident was blocking the path of the medication cart and yelling at Certified Medication Technician (CMT) E; - Skin evaluation completed on 04/10/24 at 2:26 P.M., with bruising noted to back of right arm, yellow to green in color, three centimeter (cm) x four cm. Review of the Administrative Investigation Form, completed on 04/04/24 at 10:30 A.M., showed: - Resident #91 as the involved resident in an allegation of abuse; - The Assistant Director of Nurses (ADON) notified Administrator that a resident stated a staff member grabbed him/her by the arm. Administrator instructed ADON to watch the camera system, gather statements and have a full body assessment done on the resident; - The ADON reported that he/she watched the camera and that there was no indication staff grabbed the resident. Nurse's notes stated no skin issues, did not note bruising; - The form indicated the State Agency was not contacted; - The form had no signature of who completed the investigation; - The Administrator signed the form on 04/09/24. Review of the Administrative Investigation Form, completed on 04/09/24, showed: - Follow up from event 04/04/24 involving Resident #91 and staff MS; - The Administrator watched the camera system footage and noted MS did grab Resident #91's arms. MS suspended pending investigation; - The MS's employment was terminated effective immediately; - The Administrator signed the form on 04/10/24. Review of the facility payroll detail for the period of 04/01/24-04/30/24 showed the MS worked the following dates: - 04/03/24; - 04/04/24; - 04/05/24; - 04/08/24; - 04/09/24. Observation on 04/09/24 at 1:00 P.M., of the facility security camera footage, dated 04/03/24, showed: - At 7:22 A.M., CMT E and Resident #91 walked out of the dining room. CMT E pushed the medication cart down the hall as Resident #91 walked alongside the cart; - At 7:23:04 A.M., Resident #91 hurriedly walked in front of the medication cart and blocked movement of the cart. CMT E attempted to move the cart a couple of times then pushed the cart against the wall. CMT E stood next to Resident #91 talking; - At 7:23:13 A.M., LPN H approached CMT E and Resident #1 and walked away at 7:23:40; - At 7:23:30 A.M., MS approached and stood to the right of Resident #91; - At 7:23:45 A.M., MS walked to the left side of Resident #91 as other staff approached. CMT E moved the medication cart away from the wall, and as he/she turned the cart the MS stepped in between the medication cart and Resident #91; - At 7:23:52 A.M., Resident #91 shoved the MS away from the medication cart and MS stumbled. The MS immediately turned toward Resident #91 and grabbed his/her right upper arm then right wrist. MS continued to hold onto the resident's wrist until 7:24:06 A.M.; - At 7:24:19 A.M., MS walked away. During an interview on 04/09/24 at 9:50 A.M., the resident said: - Last week, the resident was very upset and stood in the way of the CMT E moving the medication cart; - MS grabbed the resident by the arms and left a bruise; - He/she said it was reported to Licensed Practical Nurse (LPN) F the next morning; - The resident stated a picture was taken of the bruise; - The resident said he/she didn't know if LPN F forgot to report it as he/she had not heard anything. Observation on 04/09/24 at 9:50 A.M., showed a large bruise on the back of Resident #91's upper right arm. During an interview on 04/09/24 at 11:02 A.M., the MS said, I help with behaviors. I'm pretty good at deescalating the situation. I can usually calm them down. The MS said on 04/03/24 around 7:20 A.M., the resident got loud and blocked CMT E from moving the medication cart. While assisting, the resident shoved the MS and the MS got a hold of the resident's wrists. The MS said he/she had never done anything like that before. During an interview on 04/10/24 at 3:59 P.M., CMT E said on 04/03/24 around 7:20 A.M., the resident was having behaviors and blocking the medication cart. The MS stepped in to assist in letting him/her move the cart. The resident then shoved the MS, and the MS turned and grabbed the resident's wrist. The MS usually has a good rapport with the residents and that is the only time he/she had witnessed him/her get a hold of a resident. CMT E told LPN H about the incident afterwards. On 04/04/24 the ADON asked CMT E to write a statement, he/she wrote the statement and sent it by text on 04/04/24 at 01:04 P.M. CMT E said he/she was not interviewed, just asked to write a statement. During an interview on 04/09/24 at 11:10 A.M., LPN H said on 04/03/24 around 7:20 A.M., he/she was at the nurse's station and heard yelling by the dining room. The resident blocked CMT E from moving the medication cart. There were a lot of people jumbled all around and someone yelled out let him/her go. LPN H said there were too many people around to see anything. The ADON was not there, and they don't have a DON. A staff member called and reported it to the ADON the next morning. If staff sees something that is out of line or questionable, they should intervene and notify the ADON or DON. LPN H did not report the incident to the ADON or Administrator or initiate an investigation. During an interview on 04/09/24 at 11:30 A.M., Certified Nursing Assistant (CNA) G, said he/she was bringing breakfast trays back to the kitchen on 04/03/24 around 7:20 A.M., and the resident was blocking CMT E from moving the medication cart and yelling. The MS was trying to block the resident and the resident shoved the MS. The MS turned and grabbed the resident's wrists. A kitchen worker was yelling at the MS to stop. CNA G didn't report the incident to anyone. During an interview on 04/09/24 at 11:39 A.M., the Assistant Dietary Manager (ADM) said on 04/03/24 around 7:20 A.M., the resident was blocking the CMT from moving the medication cart and staff was trying to divert him/her. The MS stepped between the resident and the medication cart. The resident shoved the MS, and the MS turned and grabbed the resident's wrist. The ADM didn't report anything because there were a lot of people and didn't really see anything that needed reported or investigated. During an interview on 04/09/24 at 1:20 P.M., the ADON said the incident was reported to him/her on 04/04/24 at 10:29 A.M., (over 24 hours after the incident occurred) via a text by LPN F. The ADON reported it to the Administrator. The ADON completed his/her part of the investigation by getting statements and viewing the video. The ADON said he/she saw nothing on the video to make him/her feel like it was abuse or a reportable incident. The ADON said he/she did not interview the resident or staff and did not assess the resident. During an interview on 04/09/24 at 2:32 P.M., the Administrator said her part of the investigation was the follow-up and she did not interview the resident. An investigation should be started immediately and followed with a determination of abuse or no abuse. The ADON had reviewed the video and informed the administrator it did not show the MS put his/her hands on the resident. It was decided it was not a reportable incident. The Administrator said she honestly believed it did not occur. However, the staff statements showed the MS grabbed the resident's wrists after he/she pushed the MS. During an interview on 04/09/24 at 2:57 P.M., the ADON said he/she was the only person that reviewed the video and missed the part where the resident was grabbed on the upper arm. The ADON said the text from LPN F did contain a picture of the bruise on the resident's arm. The ADON did not document anything about it in the medical chart and did not make an observation. During an interview on 04/16/24 at 02:59 P.M., the Medical Director (MD) said he was not aware an abusive situation had occurred between the resident and staff. The MD said he did not think the facility could adequately care for some of the resident's behaviors. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on 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. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Complaint #MO235359

Based on interview and record review, the facility failed to provide a crisis plan for one resident (Resident #91) of 20 sampled residents, as directed from the Pre-Admission Screening and Resident Review (PASRR) (a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). Resident #91, who required supervision due to physical aggression, self-harming behaviors, and mental illness, was observed to have escalating behaviors which resulted in the resident: cutting him/herself with sharpened pencil 01/25/24; laying on top of a closed razor so the staff couldn't confiscate it on 02/16/24; cutting him/herself with a dull piece of broken plastic on 02/25/24; cutting him/herself with a razor on 02/29/24; cutting his/her finger by placing it in an open soda can on 03/27/24; attempting to harm him/herself with a broken piece of a cooler lid on 04/04/24; ingesting hair conditioner on 04/05/24; escaping out of the facility door and running towards the road as a truck drove by the facility on 04/07/24, and cutting him/herself with a screw and a razor on 04/11/24. The facility did not put any interventions into place after each behavior and staff were not aware of or trained on any interventions to intercede in these behaviors. The facility census was 96 residents. The administrator was notified on 04/12/24 at 9:00 A.M., of an Immediate Jeopardy (IJ) which began on 04/11/24. The IJ was removed on 04/12/24, as confirmed by surveyor onsite verification. Review of the facility assessment, dated 02/12/23, showed: - Facility assessment not reviewed annually since 2023; - No documentation the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee reviewed the facility assessment; - The number of residents with intellectual and/or developmental disability not accurate; - The behavioral healthcare needs (Including Trauma/PTSD) who have an individualized care plan to be zero and inaccurate; - The competencies required by the facility did not include behavior health (including PTSD and Trauma History), or meeting the needs of individuals with mental illness/intellectual disability or development disability. The facility did not provide a policy on Crisis Intervention. 1. Review of Resident #91's Preadmission Screening and Resident Review (PASRR) (a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 11/27/23, showed: - The PASRR Level II indicated the resident's needs can be met in a nursing facility; - Resident with Post-Traumatic Stress Disorder (PTSD) (a mental health condition triggered by a terrifying event); - PASRR related disability, serious mental illness, intellectual developmental disability; - The PASRR Level II indicated the following supports and services are to be provided by the nursing facility, behavioral support services, structured environment, crisis intervention services; - Behaviors include, impatient, demanding, physically threatening; - Extensive history of, aggression, self-injurious behaviors, suicide attempts, attention seeking behavior, mood liability, anxiety, depression, impulse control issues, limited insight and judgement, poor decision making skills, and inability to keep self safe; - The individual needs a provision of services to address the individuals mental health and behavioral needs, obtain Individual Support Plan (ISP), Individualized Treatment Plan (ITP), Behavioral Support Plan (BSP), from Department of Mental Health (DMH) Community Mental Health Center and/or Developmental Disability Regional Office; - Provision of a structured environment, provide instruction at the individuals level of understanding, environmental supports to prevent elopement, assess and plan for the level of supervision required to prevent harm to self or others, provide individual personal space, provide sensory support, establish consistent routines, provide schedule of daily tasks/activities; - Crisis intervention services, assess and plan for crisis intervention that provides emotional support, education and safety, it should create clear steps that are taken to support the resident during a behavioral crisis, including who to contact for assistance, how to work together, how to determine when a crisis is over. The plan should also identify a physician and emergency medical services that should be contacted, the facility may also wish to utilize Department of Mental Health Behavioral Health Crisis Hotline; - Suicide precautions, assault precautions, and elopement precautions; - The crisis plan is warranted due to the resident has an extensive history of aggression, suicidal ideation, self injurious behaviors and elopements; - Long term care placement recommended for the resident's safety. Review of Resident #91's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships), oppositional defiant disorder (a disorder marked by defiant and disobedient behavior to authority figures), disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, attention deficit hyperactive disorder (a chronic condition including attention difficulty, hyperactivity and impulsiveness). - Medications prescribed and administered for behavior management; - No crisis management plan. Review of Nurse's progress notes, dated 01/25/24 through 04/11/24 showed: - On 01/25/24, the resident cut him/herself with sharpened pencils; - On 02/03/24, the resident found with a dull, broken piece of plastic; - On 02/16/24, the resident noted to be more sad than usual for two days. Resident asked for a razor to shave legs. The nurse was going to go with the resident to supervise but the resident ran to room with the razor. The resident lay on top of a closed razor so the staff couldn't confiscate it; - On 02/25/24, the resident cut him/herself with a dull piece of broken plastic; - On 02/29/24, the resident asked if he/she could shave. A Certified Nurse Aide (CNA) was sent to assist the resident with shaving. The resident went into the shower room with a razor and cut him/herself on the arm with a razor. It was witnessed by a CNA, Certified Medication Technician (CMT) and another resident. The CMT obtained the razor and the resident told the CNA he/she did not want to live anymore. Staff spoke with the resident who said if he/she would be sent to the hospital then he/she would say it was an accident. The resident was offered 1:1, but the resident calmed down. - On 03/12/24, the resident walked down the hall sniffing a marker. Staff requested the marker be handed over to staff so the resident wouldn't [NAME] the marker; - On 03/13/24, resident #91 initiated an altercation with another resident; - On 03/14/24, resident #91 interrupted a conversation between a nurse and the other resident involved in the altercation on 03/13/24. Resident #91 became aggressive toward staff, walked down the hall and became aggressive toward the other resident. Due to being the 4th altercation during day shift the resident was sent out to the hospital. On 03/27/24, the resident put his/her finger in an open soda can and cut his/her finger; - On 03/29/24, during an Epsom salt foot soak the resident independently removed his/her toe nail from the nail bed of his/her left greater toe. The resident stated the toe nail was loose and was bothering him/her; - On 04/01/24, the resident rolled out of bed onto the floor hitting his/her head on the floor; - On 04/03/24, the resident threw dining room chairs against walls in the sitting room; - On 04/04/24, the resident threw hangers at the Assistant Director of Nursing (ADON), hit CNA in chest and ran to room slamming the door shut and hitting the door repeatedly. Prior to this incident the resident grabbed an ice chest cooler lid with a crack and stated he/she wanted to hurt herself/himself. The resident was sent to the hospital due to wanting to harm self. The resident returned from the hospital. The resident reported he/she turned over in bed and hit his/her head against the bedside table; - On 04/05/24 the resident wanted to harm him/herself with a broken piece of a cooler lid; - On 04/05/24 the resident ingested hair conditioner and, after telling staff, moved electric bed into hallway blocking the path to the resident. The resident later told staff he/she had vomited in the toilet but flushed. The resident complained of his/her stomach being upset; - On 04/07/24 the resident left out of the facility door and ran towards the road as a truck drove by the facility. The resident fought Emergency Medical Services (EMS) staff and sheriff about getting into the ambulance. - On 04/09/24 the resident had several behaviors. The resident said he/she is not ok; - On 04/10/24 the resident stated he/she hates feeling like this. Resident asked for an as needed (PRN) medication which was administered. The resident walked into bathroom, given a few minutes for privacy and entered. The resident was tearful saying he/she hates feeling like this. The resident went behind the shower curtain then handed staff a straightened out paperclip. The resident had a superficial scrape to the skin. The resident later ran out of the door into the enclosed courtyard crying that the medication doesn't work; - On 04/11/24 Resident #91 kicked open a locked supply room closet door. The resident pulled a screw from the wall and wedged self between shelving and wall beginning to scratch self with the screw. The resident said staff shouldn't care about him/her or try to help. The resident injured self with a safety razor obtained from the storage room. The resident refused to allow nurse to apply pressure, but agreed to hold gauze him/herself. The resident was sent out to the hospital. Review of the resident's care plan, updated 03/22/24, showed: - Resident #91 has behavior problems (history of manipulation, aggression, aggressive toward other); - Intervene as necessary to protect the rights and safety of others; - Approach/speak in a calm manner; divert attention; - Resident #91 has potential to be physically aggressive; - When resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; - If response is aggressive, staff is to walk calmly away and approach later; - Did not identify the residents triggers; - Did not address, suicidal ideations, elopements, or self harm with interventions; - Did not address a crisis plan. The facility did not put interventions into place after Resident #91's aggressive and self-harming behaviors began to escalate. During an interview on 04/12/24 at 2:20 P.M., CNA E said the facility can't provide the care that Resident #91 requires. They are not trained to care for someone with those types of behaviors. During an interview on 04/12/24 at 2:24 P.M., CNA C said Resident #91 needs more care than the facility can provide. During an interview on 04/12/24 at 2:27 P.M., LPN K said he/she is familiar with Resident #91. Resident #91 doesn't belong at the facility because they can't keep him/her safe and provide the care needed. During an interview on 04/12/24 at 3:10 P.M., the Assistant Director of Nursing (ADON) and Administrator said the facility can't provide the care needed for Resident #91. They had tried sending the resident to the hospital, but the hospital sends him/her right back, saying the behaviors should be handled at the facility. They have done medication changes and are currently seeking other placement. The staff isn't trained to care for a resident like this and they can't keep Resident #91 safe. During an interview on 04/16/24 at 2:59 P.M., the Medical Director (MD) said he/she did not think the facility could adequately care for some residents with these behaviors. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on 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. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). 48532

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the Coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for COVID-19. The facility failed to implement infection control mitigation strategies, including separating 25 residents (Resident #1, #4, #10, #12, #15, #16, #17, #18, #22, #23, #24, #28, #33, #34, #37, #38, #40, #42, #44, #46, #49, #50, #52, #54, and #57) who had tested positive for COVID-19 from 32 residents (Resident #2, #3, #5, #6, #7, #8, #9, #11, #13, #14, #19, #20, #21, #25, #26, #27, #29, #30, #31, #32, #35, #36, #39, #41, #43, #45, #47, #48, #51, #53, #55, and #56) who had tested negative for COVID-19. These failures placed the residents at an increased risk of contracting COVID-19 due to prolonged exposure and Resident #5 and #45 who originally tested negative on 11/6/23 tested positive on 11/9/23 after sharing a room with residents who were positive for COVID-19. The facility census was 93. The Administrator was notified on 11/09/23 at 5:00 P.M.,of an Immediate Jeopardy (IJ) which began on 11/04/23. The IJ was removed on 11/09/23, as confirmed by surveyor onsite verification. Review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/8/23, showed: - The recommendations in the guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency; - The Infection Prevention and Control (IPC) recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing; - Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom; - If cohorting, only patients with the same respiratory pathogen should be housed in the same room; - Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. - Source control is recommended for individuals in healthcare settings who have had close contact (patients and visitors) or a higher-risk exposure with someone with SARS-CoV-2 infection, for 10 days after their exposure. The facility did not provide an infection control policy that referenced COVID-19 outbreaks or infection control mitigation strategies. 1. Review of the facility's Testing Tracker showed staff documented Resident #1 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #2 and #3 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 9:45 A.M., showed Resident #1, #2 and #3, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 2. Review of the facility's Testing Tracker showed staff documented Resident #4 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #5 tested negative for COVID-19 on 11/06/23, positive on 11/09/23, and Resident #6 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 9:46 A.M., showed Resident #4, #5, and #6, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 3. Review of the facility's Testing Tracker showed staff documented Resident #10 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #7, #8 and #9 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 9:47 A.M., showed Resident #7, #8, #9 and #10, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 4. Review of the facility's Testing Tracker showed staff documented Resident #12 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #11 tested negative for COVID-19 on 11/06/23 and 11/09/23, and Resident #13 tested negative on 11/06/23 and was not tested on [DATE]. Observation on 11/09/23 at 9:48 A.M., showed Resident #11, #12, and #13, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 5. Review of the facility's Testing Tracker showed staff documented Resident #15, #16, #17 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate Resident #14 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 9:49 A.M., showed Resident #14, #15, #16, and #17, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 6. Review of the facility's Testing Tracker showed staff documented Resident #18 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #19 and #20 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 9:50 A.M., showed Resident #18, #19 and #20, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 7. Review of the facility's Testing Tracker showed staff documented Resident #22 and #23 tested positive for COVID-19 on 11/09/23. The report showed the residents' roommate Resident #21 tested negative for COVID-19 on 11/09/23. Observation on 11/09/23 at 9:51 A.M., showed Resident #21, #22, and #23, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. Observation on 11/09/23 at 10:10 A.M. and 11:57 A.M., showed Resident #22 walking in the hallway with no mask on, with other unmasked residents. Observation on 11/09/23 at 12:17 P.M. and 2:02 P.M., showed Resident #21, #22, and #23, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing. 8. Review of the facility's Testing Tracker showed staff documented Resident #24 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #25, #26, and #27 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 09:52 A.M., showed Resident #24, #25, #26, and #27, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 9. Review of the facility's Testing Tracker showed staff documented Resident #28 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate Resident #29 tested negative for COVID-19 on 11/06/23 and was not tested on [DATE]. Observation on 11/09/23 at 09:53 A.M., showed Resident #28 and #29, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 10. Review of the facility's Testing Tracker showed staff documented Resident #33 tested positive for COVID-19 on 11/09/23. The report showed the resident's roommates, Resident #30 tested negative for COVID-19 on 11/09/23, Resident #31 refused testing on 11/09/23, and Resident #32 tested negative for COVID-19 on 11/09/23. Observation on 11/09/23 at 9:54 A.M., showed Resident #30, #31, #32, and #33, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. Observation on 11/09/23 at 12:17 P.M., 2:02 P.M., and 5:20 P.M., showed Resident #30, #31, #32 and #33, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing. 11. Review of the facility's Testing Tracker showed staff documented Resident #34 and #37 tested positive for COVID-19 on 11/09/23. The report showed the resident's roommate Resident #35 and #36 tested negative for COVID-19 on 11/09/23. Observation on 11/09/23 at 9:55 A.M., showed Resident #34, #35, #36 and #37, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. Observation on 11/09/23 at 12:18 P.M., 2:03 P.M., and 5:21 P.M., showed Resident #34, #35, #36 and #37 asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing. 12. Review of the facility's Testing Tracker showed staff documented Resident #38 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate Resident #39 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 9:56 A.M., showed Resident #38 and #39, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 13. Review of the facility's Testing Tracker showed staff documented Resident #40 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #41 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 9:457 A.M., showed Resident #40 and #41, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 14. Review of the facility's Testing Tracker showed staff documented Resident #42 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #43 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 9:58 A.M., showed Resident #42 and #43, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 15. Review of the facility's Testing Tracker showed staff documented Resident #44 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #45 tested negative for COVID-19 on 11/06/23 and positive on 11/09/23. Observation on 11/09/23 at 9:59 A.M., showed Resident #44 and #45, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on in their room. 16. Review of the facility's Testing Tracker showed staff documented Resident #46 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #47 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 10:00 A.M., showed Resident #46 and #47, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. 17. Review of the facility's Testing Tracker showed staff documented Resident #49 tested positive for COVID-19 on 11/09/23. Review of the report showed the resident's roommate, Resident #48 tested negative for COVID-19 on 11/09/23. Observation on 11/09/23 at 10:01 A.M. showed Resident #48 and #49, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. Observation on 11/09/23 at 12:23 P.M., 2:05 P.M., and 5:22 P.M., showed Resident #48 and #49, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing. 18. Review of the facility's Testing Tracker showed staff documented Resident #50 tested positive for COVID-19 on 11/09/23. Review of the report showed the resident's roommate, Resident #51 tested negative for COVID-19 on 11/09/23. Observation on 11/09/23 at 10:02 A.M., showed Resident #50 and #51, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. Observation on 11/09/23 at 12:24 P.M., and 2:06 P.M., and 5:23 P.M., showed Resident #50 and #51, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing. 19. Review of the facility's Testing Tracker showed staff documented Resident #52 tested positive for COVID-19 on 11/09/23. Review of the report showed the resident's roommate, Resident #53 tested negative for COVID-19 on 11/09/23. Observation on 11/09/23 at 10:03 A.M. showed Resident #52 and #53, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. Observation on 11/09/23 at 12:25 P.M., and 2:07 P.M., and 5:24 P.M., showed Resident #52 and #53, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing. 20. Review of the facility's Testing Tracker showed staff documented Resident #54 tested positive for COVID-19 on 11/09/23. Review of the report showed the resident's roommate, Resident #55 tested negative for COVID-19 on 11/09/23. Observation on 11/09/23 at 10:04 A.M. showed Resident #54 and #55, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. Observation on 11/09/23 at 12:26 P.M., and 2:08 P.M., and 5:25 P.M., showed Resident #54 and #55, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing. 21. Review of the resident's nurses notes, dated 11/04/23, showed Resident #57 complained of a sore throat and generally not feeling well. COVID-19 test negative on 11/04/23. Review of the facility's Testing Tracker showed staff documented Resident #57 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #56 tested negative for COVID-19 on 11/06/23 and 11/09/23. Observation on 11/09/23 at 10:05 A.M. showed Resident #56 and #57, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on. During an interview on 11/09/23 at 9:37 A.M., the Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility) Coordinator said the Administrator was testing residents for COVID and only had a few left to test. During an interview on 11/09/23 at 9:43 A.M., the Administrator said she just finished COVID testing all of the residents. During an interview on 11/09/23 at 12:17 P.M., Licensed Practical Nurse (LPN) A said residents were told they needed to stay in their room and wear masks in the hallways, but they were non-compliant. He/she said COVID positive residents should wear a mask. He/she said staff should try to get residents to wear a N95 mask, but most don't. He/she said residents can be in the same room as of now, because they are still coming up negative and positive. He/she said staff are trying to keep residents in their rooms, but they are not always compliant. He/she said Saturday, 11/4/23, staff had put the COVID positive resident in his/her room, put up isolation precautions, and the roommate was left in same room. The roommate tested positive the second day. During an interview on 11/09/23 at 3:06 P.M., the Administrator said she would expect COVID-19 positive residents to be isolated separately from COVID-19 negative residents, but the residents got too upset when room changes were made, which caused behaviors. The COVID-19 negative residents were already exposed so they were left in their current rooms. During an interview on 11/09/23 at 3:16 P.M., MDS Coordinator said the COVID-19 positive residents should be secluded from the COVID-19 negative residents, before room changes were made. The facility followed the CDC protocols regarding COVID-19. Residents had to stay in their rooms and wear a N95. The problem was the males on the A hall share two community bathrooms and came in contact with one another. During an interview on 11/09/23 at 6:15 P.M., the Administrator said the process for separating the positive, the negative, and the exposed COVID-19 residents would be started soon. Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. 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. 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). Complaint #MO00227114

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #2) remained free from physical abuse when staff failed to respond appropriately to the resident's behavior. The staff failed to be in control of their own behavior and struck the resident twice with a cane then fell to the floor with the resident. The facility census was 87. The Administrator was notified on 03/11/2021 of an Immediate Jeopardy (IJ) which began on 11/08/2020. The IJ was removed on 03/11/2021, as confirmed by surveyor onsite verification. Record review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident has a Public Administrator as a guardian. Record review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument required to be completed by the facility staff), dated 10/13/2020 showed: - The resident admitted to the facility on [DATE]; - The resident is cognitively intact; - Independent with all activities of daily living (ADLs); - The resident has a behavior of disrobing. Record review of the resident's plan of care, dated 10/13/2020, showed: - A history of public disrobing; - Behaviors not involving others; - The resident requires a calm approach to redirection; - The staff should intervene in a calm manner and redirect the resident to his/her room or to cover himself/herself. Record review of the facility's self report of incident dated, 11/9/2020 showed Resident #2 walked naked in the hall throughout the night. On the morning of 11/8/2020 between 7:00 A.M. and 8:00 A.M., Resident #2 was in the hall wearing only his/her shoes and socks. Licensed Practical Nurse (LPN) E argued with Resident #2 and Resident #2 punched LPN E on the left side of the face. LPN E, who uses a metal cane to walk, swung his/her cane at Resident #2. Resident #2 and LPN E were grappling with each other and Resident #2 was swinging his/her arms and fists. Resident #2 and LPN E ended up falling on the floor. Resident #2 was given an as needed (PRN) injection and the police were called. The police placed Resident #2 in cuffs and detained him/her until the resident could be transported to a psychiatric hospital. During the incident, LPN E threatened to kill Resident #2 and chop his/her head off. Record review of the facility's investigation related to the incident dated, 11/9/2020 showed the facility identified the incident as a resident to staff event related to behavior. Staff noted Resident #2 walked up and down the hall naked, had an altercation with LPN E and was discharged to the hospital because the resident beat up a staff member. The facility's investigation did not address LPN E striking Resident #2 with his/her metal cane or threatening the resident. Record review of the nursing notes dated, 11/08/20 at 6:50 A.M. showed: - The resident was walking in the hallway naked; - LPN E told the resident to go to his/her room and put clothes on that he/she cannot walk around naked; - LPN C asked the resident to return to his/her room, the resident turned and proceeded to his/her room. Record review of the nursing notes dated, 11/08/2020 at 7:00 A.M. showed: - The resident was walking in the hallway naked; - The resident stopped at the nurse's station where LPN E and LPN C told the resident to go put on clothes; - LPN E approached the resident and asked the resident to put clothes on; - The resident lunged at LPN E and hit LPN E in the face; - LPN C assisted LPN E to prevent the resident from hitting LPN E; - LPN E and LPN C assisted the resident to the floor and held the resident there until the police arrived; - They left the resident in the floor until transport arrived; - No documented assessment for injuries to the resident. Observation on 2/9/21 of the security camera footage dated, 11/8/20 showed: -At 6:46 A.M., Resident #2 walked naked down the hallway past the nurses' station. Certified Medication Technician (CMT) D and a male resident stood at the medication cart. The resident calmly walked by the staff and resident without confrontation; -At 6:48 A.M., LPN E walks out from the nurses' station, with the assist of a walking cane, and goes off camera in the same direction as Resident #2; -At 6:49 A.M., Resident #2 and LPN E come back into camera view with LPN E walking behind Resident #2 as Resident #2 heads back towards the other end of the hall. LPN E returns to the nurses' station; -At 6:49 A.M., as Resident #2 starts to head down the hall he/she stops and turns around. He/she says something but makes no movement towards anyone. LPN E comes out from the nurses' station, with the assist of his/her walking cane, and walks abruptly over to Resident #2 in a confrontational manner. LPN E positions himself/herself face to face with Resident #2; -At 6:50 A.M., LPN C comes into camera view and approaches LPN E and Resident #2. LPN E continues to stand in front of Resident #2. LPN E turns to LPN C and both LPNs turn towards Resident #2 and start walking, forcing the resident backwards. Resident #2 hits LPN E in the face. LPN C immediately gets between LPN E and the resident in an attempt to separate the two. LPN E shoves LPN C to the side and continues to go after the resident. LPN C stumbles out of the way, straightens and takes a step back toward LPN E and Resident #2. While LPN C is recovering from the stumble, LPN E drew back his/her cane, almost hitting LPN C, who had to duck out of the way. LPN E brings the cane down in an aggressive manner and strikes the resident twice. After the second strike, Resident #2 lunges at LPN E and they both fall to the floor. During an interview on 2/8/21 at 10:00 A.M., the Administrator (Adm) said the incident was originally reported to him on 11/8/20 as a resident behavioral outburst and the resident was sent for a mental health evaluation. The incident was not reported as abuse. The Adm said he reviewed the security camera footage of the incident and it was apparent LPN E provoked and then hit the resident. The Adm said he had heard LPN E did not like Resident #2 but there had never been anything investigated regarding those claims. The Adm did not know LPN E had anger issues or that other staff were uncomfortable working with LPN E. The Adm said the last inservice presented to all staff regarding recognizing abuse/neglect or employee burn out was 08/2020. After reviewing the camera footage and seeing LPN E hit the resident with his/her cane, the Adm did not call the police and report the abuse. On 11/8/20 LPN E was suspended without pay until the facility could conduct their investigation. During an interview on 2/8/21 at 10:30 A.M., Resident #2 said his/her soul is holy and the skin is the cover and that is why he/she shows it to everyone. The resident said LPN E grabbed his/her right hand and tried to physically take the resident back to get clothing on. The resident admitted to hitting LPN E. The resident did not want to talk about LPN E hitting him/her with a cane and said please do not send me out of the facility. During an telephone interview on 2/9/21 at 12:00 P.M., LPN E said the facility thinks the resident has a right to be naked and he/she disagrees. LPN E said young female Certified Nurse Aides (CNAs) should not have to see a naked man. LPN E said it is dangerous to work at the facility and the staff need to be able to defend themselves from the residents. LPN E said the resident had tried to hit a nurse and he/she was only protecting the nurse. LPN C tried to get between them when the resident slapped LPN E. LPN E said the cane is not a weapon and should not be considered as such. LPN E did not answer questions related to training regarding abuse, neglect or employee stress. During an interview on 2/9/21 at 1:00 P.M., the resident's guardian said the facility called regarding the incident and informed him/her the resident had an outburst and was being sent out. The facility did not tell the guardian about the resident being hit with a cane. The guardian said he/she planned to contact law enforcement. During an interview on 2/9/21 at 1:20 P.M., CMT D said Resident #2 was walking down the hall naked. As the resident neared the nurses' station, LPN E called the police. The resident walked past the nurses' station and LPN E told the resident to put his/her clothes on. The resident ignored him/her. LPN E got up and yelled the resident's name. The resident stopped near the nurses' station and LPN E walked up to him/her, telling the resident to go to his/her room and put on some clothes. The resident said no. CMT D turned away and continued with his/her task. CMT D turned back around and saw LPN E and the resident on the ground with LPN E holding the resident in a headlock. LPN C was on top of the resident trying to hold him/her. The resident was hitting LPN E in the face and they were yelling back and forth. LPN E was digging his/her fingers in the resident's eyes. CMT D told LPN E to stop and tried to pull his/her fingers out of the resident's eyes. When CMT D saw the rage in the LPN's eyes, CMT D called the police again. When LPN E was lifted off the floor, he/she tried to charge the resident again. During the altercation, LPN E was screaming kill him, slit his throat. CMT D said LPN E had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 2/9/21 at 1:30 P.M., LPN C said Resident #2 had been walking up and down the hallway naked. LPN E was at the nurse's station and called the police. LPN E said he/she was done with the resident and going to get the resident. LPN E confronted the resident and used his/her cane to poke at the resident's feet in an effort to push the resident backwards down the hall toward his/her room. LPN E was cursing and yelling at the resident. LPN E was making verbal threats about slitting the resident's throat. LPN C said he/she did not intervene. LPN C said he/she did not contact the Registered Nurse (RN) on duty or notify the Director of Nursing (DON). LPN C said he/she received inservice training on abuse and neglect but did not give a date. During an interview on 2/9/21 at 1:40 P.M., the Maintenance Supervisor (MS) said he/she was called to the facility on the morning of 11/8/2020 to help subdue LPN E. When he/she arrived to the facility, the resident was on the floor with LPN E on top preventing the resident from getting up. The resident was naked and LPN E was attempting to gouge the resident's eyes. LPN E was cursing and yelling at the resident. MS said he/she knew LPN E did not like the resident, however, MS had not reported any incidents or that information to administration. MS said it took a lot of effort to remove LPN E from the resident. MS observed LPN E in a previous angry outburst, go outside and kick empty milk containers. MS did not report the outburst. During an interview on 2/18/21 at 1:20 P.M., RN F said he/she worked the night of 11/07/2020, but on a different hall from LPN E, LPN C and CMT D. At around 7:00 A.M. on 11/08/2020, RN F could hear yelling and went to assist. Upon arriving, Resident #2 was in the floor with LPN E on top. LPN E was cursing and threatening the resident. The resident was not resisting and was laying quietly. RN F said LPN E had verbally expressed to the Adm in the past, but did not know the date, that the resident was upsetting and caused him/her stress. RN F said he/she remained at the desk getting all the papers in order for the ambulance. RN F called the physician for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN F said he/she did not contact the DON or Adm. RN F said he/she did not intervene or remove LPN E from the vicinity. RN F said he/she received training on abuse and neglect but did not provide the date of the last inservice he/she attended regarding abuse and neglect. 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 remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint #MO 887

Based on observation, interview, and record review, the facility failed to report to law enforcement entities a physical assault of one resident (Resident # 2) by an employee of the facility. The facility census was 87. The Administrator was notified on 03/11/2021 of an Immediate Jeopardy (IJ) which began on 11/08/2020. The IJ was removed on 03/11/2021, as confirmed by surveyor onsite verification. Record review of the facility's policy on Abuse, Neglect, Exploitation & Misappropriation of Property Policy dated 12/1/98, showed the facility will annually notify covered individuals, as defined at section 1150B(a)(3) of the Social Security Act, of that individual's obligation to comply with the following reporting requirements - each covered individual shall report to the state agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of or receiving care from the facility. Record review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident has a Public Administrator as a guardian. Record review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument required to be completed by the facility staff), dated 10/13/2020 showed: - The resident admitted to the facility on [DATE]; - The resident is cognitively intact; - Independent with all activities of daily living (ADLs); - The resident has a behavior of disrobing. Record review of the resident's plan of care dated, 10/13/2020, showed: - A history of public disrobing; - Behaviors not involving others; - The resident requires a calm approach to redirection; - The staff should intervene in a calm manner and redirect the resident to his/her room or to cover himself/herself. Record review of the facility's investigation related to the incident dated, 11/9/2020 showed the facility identified the incident as a resident to staff event related to behavior. Staff noted Resident #2 walked up and down the hall naked, had an altercation with Licensed Practical Nurse (LPN) E and was discharged to the hospital because the resident beat up a staff member. The facility's investigation did not address LPN E striking Resident #2 with his/her metal cane or threatening the resident. Observation on 2/9/21 of the security camera footage dated, 11/8/20 showed: -At 6:46 A.M., Resident #2 walked naked down the hallway past the nurses' station. Certified Medication Technician (CMT) D and a male resident stood at the medication cart. The resident calmly walked by the staff and resident without confrontation; -At 6:48 A.M., LPN E walks out from the nurses' station, with the assist of a walking cane, and goes off camera in the same direction as Resident #2; -At 6:49 A.M., Resident #2 and LPN E come back into camera view with LPN E walking behind Resident #2 as Resident #2 heads back towards the other end of the hall. LPN E returns to the nurses' station; -At 6:49 A.M., as Resident #2 starts to head down the hall he/she stops and turns around. He/she says something but makes no movement towards anyone. LPN E comes out from the nurses' station, with the assist of his/her walking cane, and walks abruptly over to Resident #2 in a confrontational manner. LPN E positions himself/herself face to face with Resident #2; -At 6:50 A.M., LPN C comes into camera view and approaches LPN E and Resident #2. LPN E continues to stand in front of Resident #2. LPN E turns to LPN C and both LPNs turn towards Resident #2 and start walking, forcing the resident backwards. Resident #2 hits LPN E in the face. LPN C immediately gets between LPN E and the resident in an attempt to separate the two. LPN E shoves LPN C to the side and continues to go after the resident. LPN C stumbles out of the way, straightens and takes a step back toward LPN E and Resident #2. While LPN C is recovering from the stumble, LPN E drew back his/her cane, almost hitting LPN C, who had to duck out of the way. LPN E brings the cane down in an aggressive manner and strikes the resident twice. After the second strike, Resident #2 lunges at LPN E and they both fall to the floor. During an interview on 2/8/21 at 10:00 A.M., the Administrator (Adm) said the incident was originally reported to him as a resident behavioral outburst and the resident was sent for a mental health evaluation. The incident was not reported as abuse. The Adm said he reviewed the security camera footage of the incident and it was apparent LPN E provoked and then hit the resident. The Adm said he heard LPN E did not like Resident #2 but there had never been anything investigated regarding those claims. The Adm did not know LPN E had anger issues or that other staff were uncomfortable working with LPN E. The Adm said the last inservice presented to all staff regarding recognizing abuse/neglect or employee burn out was 08/2020. The Adm did not call the police and report the abuse. LPN E was immediately suspended without pay until the facility could conduct their investigation. During an interview on 2/9/21 at 1:00 P.M., the resident's guardian said the facility called regarding the incident and informed him/her the resident had an outburst and was being sent out. The facility did not tell the guardian about the resident being hit with a cane. The guardian said he/she planned to contact law enforcement. During an interview on 3/11/21 at 10:30 A.M., the Adm said he had not contacted law enforcement. The Adm said he was not sure the incident should be considered abuse or needed reported to law enforcement. 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 remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint #MO 887

Based on interview and record review, the facility failed to provide care and treatment in accordance with standard care of practice when staff failed to thoroughly assess a resident and provide needed care after continued complaints of stomach pain and swelling. This affected one resident (Resident #1) of ten sampled residents. The facility census was 87. 1. Record review of the facility's policy and procedure titled Change in a Resident's Condition or Status, dated [DATE] and provided by the facility, showed: - The supervisor nurse/charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical/emotional/medical condition; - The policy did not address how staff are to report changes between shifts; - The policy did not address what might constitute a significant change in status. Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument required to be completed by the facility staff), dated [DATE] showed: - Impaired cognitive skills; - One person physical assist with transfer and bed mobility; - Requires assist of two staff for dressing; - Occasional incontinence of bowel and bladder; - The resident experienced depression 3 times within ,d+[DATE] day period; - No behaviors. Record review of the resident's Care Plan dated [DATE] showed: - The resident was receiving an antidepressant for crying and sadness at times; - There were no entries showing stomach issues or pain. Record review of the resident's Nurses Notes showed: - No nurses' notes documented from [DATE]-[DATE]. - On [DATE] at 4:00 A.M., the resident was awake and talking during rounds; - On [DATE] at 5:15 A.M., Licensed Practical Nurse (LPN) B entered the room and found the resident unresponsive, lips cyanotic (gray or blue in coloring) and no pulse; - LPN B immediately started Cardio Pulmonary Resuscitation (CPR - chest compressions and assist with breathing); - On [DATE] at 5:35 A.M., the ambulance arrived and continued to perform CPR; - On [DATE] at 5:45 A.M., the Emergency Medical Technician (EMT) called the physician who noted time of death. Record review of the Certificate of Death dated [DATE] showed the cause of death natural and [CONDITION(S)] (commonly known as a [CONDITION(S)], with pain in the chest, shoulder, arm, back and jaw). During an interview on [DATE] at 1:50 P.M., LPN A said on [DATE] the resident had been crying with stomach pain all day. Prior to end of the day shift, LPN A assisted with placing the resident in bed due to him/her complaining of stomach pain. The resident had a swollen abdomen and his/her clothing was tight and difficult to remove. LPN A said he/she assessed Resident #1 earlier in the shift and listened to the resident's bowel sounds, but did not document it. There were no concerns when he/she completed the assessment, so when LPN A assisted Resident #1 with undressing he/she thought the resident had gained a lot of weight and his/her stomach was swollen. LPN A said the night shift nurse was informed of the stomach pain complaints and the swelling. LPN A said he/she did not call the physician because Resident #1 cried all the time due to depression. During an interview on [DATE] at 11:00 A.M., LPN B said on the night of [DATE], there were no notes or information provided to him/her on Resident #1's medical condition. LPN B said when he/she entered the facility on [DATE], to start the shift, at 7:00 P.M., LPN A was not on the hallway. Resident #1 made no complaints of pain through the night. At 4:30 A.M. on [DATE], he/she was informed by the Certified Nurse Aide (CNA) the resident was having pain. Upon entering the room at 5:15 A.M. the resident was unresponsive. The resident's abdomen was very swollen. During an interview on [DATE] at 11:15 A.M., LPN C said Resident #1 had walked the hallways and cried all day on [DATE]. The resident expressed stomach pain and appeared to be hurting. The resident came to the desk where LPN C was working and appeared to be in pain. This information was given to LPN A who said it was just depression and did not assess the resident at that time. LPN C did not assess the resident because Resident #1 was not on the hallway assigned to LPN C. LPN C said he/she informed LPN A of the symptoms and assumed LPN A would care for him/her. During an interview on [DATE] at 11:25 A.M., the Maintenance Supervisor (MS) said on [DATE] Resident #1 had been in the hallways crying all day complaining of stomach pain. He/she reported this to LPN C. During an interview on [DATE] at 1:30 P.M., the Director of Nurses (DON) said she would have expected the charge nurse to have assessed the resident when there was a change in medical condition, contact the physician and notify her of the change in the resident's condition. It is the policy of the facility to call the physician with any change in medical condition. She would have expected LPN A to have called and informed the physician of the change. During an interview on [DATE] at 8:45 A.M., the resident's physician said he would have expected staff to notify him when the swollen abdomen was observed. The physician said that observation with the continued complaints of stomach pain would be considered a significant change in condition, and staff should have notified his/her office immediately. Complaint #MO 430

Based on observation, interview and record review, the facility failed to ensure that medications were secure and inaccessible to residents. One resident (Resident #10) with a history of self harm, accessed and ingested an unknown amount of acetaminophen that was left in an unlocked cart. The facility census was 87. On 2/24/21 the administrator was notified of the past non-compliance which occurred on 12/21/20. On 12/21/20 facility staff became aware that Resident #1 had ingested medication he/she took from an unsecured cart. The resident received immediate medical attention and the facility initiated an investigation. Facility staff completed inservices and counseled staff involved. Observations made during the onsite visit showed no concerns with medications. The deficiency was corrected on 12/22/20. 1. Record review of the facility policy Medication Storage, dated 5/18/2006 showed: - Compartments containing medications should be locked when not in use. Trays and or carts used to transport such items should not be left unattended. Compartments include, but are not limited to drawers, cabinets, rooms, refrigerators, carts and boxes. Observation and record review on 2/9/21 showed the facility population consisted primarily of residents with mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician Orders Sheets (POS) dated February 2021, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #10's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 5/20/2020 showed: - Cognition intact; - Other behavioral symptoms not directed at others 1-3 days a week; - Ambulatory without assistance. Record review of Resident #10's care plan dated 12/15/2020, showed resident with suicidal ideation and history of incident of self-harm with razor and toenail clippers. When resident threatens, makes suicidal comments, carries out an attempt or gives any indication of self-harm, interventions included: - The charge nurse should identify the seriousness of intent and notify medical and psych doctors for necessary treatment; - Staff to take precautions and closely observe the resident and initiate one on one observation until transfer or as recommended by the doctor; - Staff to observe and document change in mood; - Sharps boxes removed from all carts and kept in nursing station under locked doors; - All staff to monitor for any potential items at both nursing stations that resident could obtain and use to self-harm; - Staff to do one on one with resident until further treatment is ordered and or sent for inpatient psych evaluation; - Nursing to determine why the resident attempted to harm him/herself; - Staff to be mindful that he/she does not take rejection well and to try and intervene if possible if he/she attempts to harm him/herself. Record review of the nurse's notes written on 12/21/2020 at 9:00 A.M. showed: - Resident #10 moved to the isolation unit; - Resident non-compliant with staying on the unit coming out of the doors yelling, wanting to self-harm; - Resident getting razors out of the sharps container; - Resident telling staff he/she would eat a light bulb; - Resident #10 then stated he/she found a bottle of Tylenol and had taken 60 tablets. Then he/she said 70 tablets. - Staff state the bottle of Tylenol would have had 4 to 5 tablets in it, yet unsure of how many tablets the resident swallowed; - The resident continued to the make suicidal statements and refusing to stay on the isolation unit; - Ambulance and guardian aware. Record review of the facility investigation showed on 12/21/2020 the resident was moved to the isolation unit due to testing positive for COVID when he/she immediately began to get agitated and attempt to self-harm. The resident attempted to stick his/her hand in a sharps container and then found a bottle of Tylenol in the isolation cart drawer and swallowed them yelling he/she wouldn't stay back on the isolation unit even if he/she had to swallow a light bulb. The facility notified the physician and guardian, sent the resident to the hospital where his/her acetaminophen level measured at 124 (liver damage level at 200 or above). The resident was transferred from the acute hospital to the psychiatric unit. Staff were interviewed with no staff member admitting to leaving the Tylenol on the isolation cart. Unable to determine how the Tylenol was placed there. Staff members admitted they were aware of the Tylenol being in the drawer yet did not remove it. During an interview on 2/8/2021 at 11:15 A.M., Registered Nurse (RN) G said all medications are to be kept under lock and key at all times. During an interview on 2/8/2021 at 11:30 A.M., Resident #10 said he/she was upset that day and told the staff he/she was feeling sad, but they did not have time for him/her like they usually do because someone else was tearing up the Christmas lights. He/she noticed a staff member get into an isolation cart and noticed the Tylenol bottle there. He/she then went over to the cart after the staff member left and took the bottle of Tylenol with an unknown amount of tablets in it. He/she then reported to them about an hour later what he/she had done because he/she was feeling sick and the staff called the physician and sent him/her to the hospital. During an interview on 2/8/2021 at 11:45 A.M., Certified Medication Technician (CMT) H said all medications over the counter or prescribed are to be kept under lock and key per facility policy. During an interview on 2/8/2021 at 1:20 P.M., Nurse Aide (NA) I said staff are not allowed to carry any medications on their person in the facility. Any medications found that are not under lock and key should be removed and given to the charge nurse. During an interview on 2/8/2021 at 1:35 P.M., Certified Nurse Aide (CNA) J said staff are not allowed to have any personal medications in the facility. If medications are found, staff are to report to the charge nurse and or Director of Nursing (DON). During an interview on 3/11/2021 at 10:30 A.M., the Assistant Director of Nursing (ADON) said three employees including Certified Medication Technician (CMT) D, CMT K and CMT L stated they knew the Tylenol was in the unlocked isolation cart for a few days prior to the incident with Resident #10, but did not remove it. During an interview on 3/11/2021 at 10:40 A.M., CMT D said he/she had seen the Tylenol in the unlocked isolation cart the day prior to the incident with Resident #10. He/she assumed it was placed there for the COVID unit staff to use. During a phone interview on 3/11/2021 at 11:40 A.M., CMT K denied knowledge of the Tylenol being in the unlocked isolation cart prior to the incident with Resident #10. During an interview on 3/11/2021 at 1:10 P.M., CMT L said he/she knew the Tylenol was in the unlocked isolation cart for two to three weeks prior to the incident with Resident #10. He/she assumed it was placed there for the COVID unit staff to use. During an interview on 2/9/2021 at 10:30 A.M. the DON said she would expect all staff to keep any medications prescribed or over the counter locked up and out of the reach of any resident. Complaint #MO 4