Every finding on record at Buffalo Prairie Center for Rehab and Healthcare

Based on observation, interview, and record review, facility staff failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident when staff staff documented one resident (Resident #1) received Cefdinir (antibiotic used to treat various bacterial infections, including pneumonia) for multiple days after the stop date. The facility staff also failed to ensure one resident (Resident #1) received prednisone (a potent steroid used to treat inflammation, severe allergies, autoimmune diseases, asthma, and certain cancers by suppressing the immune system and reducing swelling) as ordered when 10 of 11 possible doses were not documented. The facility had a census of 41.Review of the facility policy titled Medication Errors, revised 05/07/25, showed the following information:-Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescribers order, manufacturer's specifications regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services;-Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety;-The facility shall ensure medications will be administered according to physician's orders, per manufacturer's specifications regarding the preparation and administration of the drug, and in accordance with accepted standards and principles which apply to professionals providing services;-If a medication error occurs, the nurse will assess and examine the residents condition and notify the physician or health care provider as soon as possible, monitor and document the residents condition, including response to medication treatment or nursing interventions, document actions taken in the medical records, and once the resident is stable, the nurse will report the incident to the appropriate supervisor and complete the incident report. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 07/05/24;-Diagnoses included chronic obstructive pulmonary disease (COPD-a progressive, incurable lung disease that causes severe breathing difficulties by obstructing airflow, primarily through bronchitis or emphysema) with acute exacerbation (a sudden, sustained worsening of symptoms-specifically increased breathlessness, cough, and sputum production), nontraumatic intracerebral hemorrhage (a spontaneous bleeding into the brain tissue, not caused by trauma, often resulting from chronic high blood pressure), and malignant neoplasm (cancer) of unspecified kidney. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 01/01/26, showed the following:-The resident had moderate cognitive impairment;-He/she received antibiotic medication;-Shortness of breath with exertion, sitting at rest, and when lying flat;-He/She received oxygen therapy. Review of the resident's care plan showed the following:-Resident had a current diagnosis of COPD;-Administer COPD medication per order. Review of resident's progress notes dated 02/01/26, at 4:09 P.M., showed the following:-Resident found to have an oxygen saturation of 78% (normal oxygen saturation levels for healthy individuals typically range between 95% and 100%, measured via pulse oximetry, indicating the percentage of hemoglobin carrying oxygen) on six liters of oxygen via nasal cannula;-Staff administered albuterol inhalation solution nebulizer (a medical device that converts liquid medication into a fine mist for inhalation) treatment and oxygen saturation increased to 88%;-Resident was currently on prednisone (a potent steroid used to treat inflammation, severe allergies, autoimmune diseases, asthma, and certain cancers by suppressing the immune system and reducing swelling) until 02/02/26;-Resident completed cefdinir (antibiotic used to treat various bacterial infections, including pneumonia) due to pneumonia;-Resident was concerned pneumonia was still present;-Bilateral (both sides) wheezing and rhonchi sounds (low-pitched, rattling, or snoring-like lung sounds caused by airway obstruction from mucus or fluid in the larger airways) in upper lobes with diminished lung sounds in bases bilateral;-Staff notified physician and were waiting further recommendation. Review of resident's progress notes dated 02/01/26, at 6:08 P.M., showed the following:-Provider ordered extension on cefdinir 300 milligrams (mg), IM (injection of medication directly into muscle tissue) ceftriaxone (antibiotic used to treat serious bacterial infections, including pneumonia) 1 gram reconstituted with 1% lidocaine (used to significantly reduce pain during deep IM injections ) once, and solumedrol (a potent intravenous or intramuscular steroid used to rapidly reduce severe inflammation, treat autoimmune flare-ups, severe allergies, asthma, and certain cancers) 125 mg IM injection once and duoneb (a prescription, combination medication used to treat, but not abort, sudden COPD symptoms by opening airways) treatments four times daily for five days;-Staff updated orders;-No acute respiratory distress noted. Resident was alert and oriented and sitting in room watching television. Review of resident's physician's notes, dated 02/06/26, showed the following:-Patient seen on 02/03/26 at the request of nursing staff for pneumonia;-Non-resolving pneumonia, completed Rocephin (ceftriaxone) and solumedrol, continued on Omnicef (cefdinir) 300 mg by mouth (PO) twice a day (BID) for seven days and change prednisone (steroid) to 40 mg PO daily for five days and decrease by 5 mg every 5 days until off. Review of resident's February 2026 Physician Order Sheet showed the following:-An order, dated 02/02/26, for cefdinir capsule 300 mg, one capsule by mouth two times a day for infection for seven days until finished; -An order, dated 02/04/26, for prednisone, oral tablet, give 40 mg by mouth one time a day for wheeze for five days;-An order, dated 02/09/26, for prednisone, oral tablet, give 35 mg by mouth one time a day for wheeze for five days. Review of the resident's February 2026 Medication Administration Record (MAR), showed the following information:-Cefdinir documented as administered twice a day for ten days (02/02/26 to 02/11/26) (three more days than ordered);-Staff did not document administration of prednisone from 02/04/26 to 02/08/26;-Staff did not document administration of prednisone from 02/09/26 to 02/12/26;-Staff prednisone administered documented on 02/13/26. Review of resident's progress notes dated 02/10/26 and 02/11/26, showed cefdinir capsule 300 mg not available. Observation on 02/17/26, at 11:20 A.M., showed the following:-An unopened package of prednisone, 35 mg by mouth for one time a day for wheeze for five days, start date 02/09/26;-A medication card, dated 02/02/26, with three capsules of cefdinir remaining out of 14. During an interview on 02/17/26, at 1:29 P.M., the Medical Director said the following:-If a medication was not administered, staff should contact the physician;-All medications should be administered as prescribed;-Medications administered should be documented. He/she would presume the medication was not administered if there was no documentation;-He/she prescribed cefdinir and prednisone to treat the resident's pneumonia. Both medications were to be administered as prescribed and would have helped his/her pneumonia. During an interview on 02/18/26, at 9:15 A.M., Certified Medication Technician (CMT) C said the following:-Some medications have been unavailable since the facility changed pharmacies. If a medication was unavailable, he/she notified the charge nurse and/or Director of Nursing (DON);-Staff should always document in the MAR, even if a medication is unavailable. The MAR should never be left blank;-Medications should be administered as prescribed;-He/she does not recall the resident having a prescription for prednisone. During an interview on 02/18/26, at 10:00 A.M., CMT D said the following:-If the MAR was blank, the medication was not administered;-Staff should always document in the MAR, even if the resident refused the medication, or if it was unavailable. A progress note should also be entered;-Medications should be administered as prescribed;-He/she believes the resident had packages of prednisone, but does not recall administering the medication;-The resident did not refuse medications;-There have been issues with medication availability due to changing pharmacies;-Staff report unavailable medications to the DON. During an interview on 02/18/26, at 11:06 A.M., CMT E said the following:-If a medication was unavailable, staff should make a note for the charge nurse and/or DON;-When administering medications, staff should always document in the MAR. If the MAR was blank, it would be assumed the medication was not administered;-Medications should be administered as prescribed. During an interview on 02/18/26, at 11:20 A.M., Licensed Practical Nurse (LPN) F said the following:-If a medication was unavailable, staff should notify the charge nurse;-Some unavailable medications can be pulled from the emergency kit;-Medications should be administered as prescribed;-There should not be blanks on the MAR, as there should always be documentation. If staff cannot administer a medication, a reason should be indicated and a progress note made. During an interview on 02/18/26, at 2:10 P.M., LPN G said the following:-Medications should be administered as ordered;-There should not be blanks on the MAR, as it would indicate the medication was not administered. If a medication cannot be administered, it should be documented in the MAR and in the resident's progress note;-If a medication is unavailable, it should be reported to the charge nurse. During interviews on 02/18/26, at 10:45 A.M. and at 3:17 P.M., the DON said the following:-The facility changed pharmacies on 02/10/26;-Staff should document in the MAR when a medication is administered. There should not be any blanks on the MAR;-Medications should be administered as prescribed;-It is important to complete all medications. Both medications, cefdinir and prednisone, would help the resident feel better;-He/she was unaware why the resident had three remaining does of cefdinir or why it was documented as administered past the seven-day prescription;-A medication should not remain on the MAR if it is past the stop date;-The DON was unaware why there was no documentation on the MAR regarding the resident's prednisone or why there were no doses given from the prednisone 35 mg card. During an interview on 02/18/26, at 4:20 A.M., the Administrator said the following:-Medications should be administered as prescribed;-If a medication dose was missed was unavailable, staff should notify the physician;-There should not be blanks on the MAR. Staff should document appropriately, and a progress note should be made if the medication was not given;-The DON should be regularly auditing the MAR. Complaint #2740299

Based on interview and record review, facility staff failed to have a process in place to ensure all resident's wishes regarding cardio-pulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped) were honored when staff stopped performing CPR prior to Emergency Medical Services (EMS) arrival for one resident (Resident #1) who was found unresponsive. The facility census was 41.Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), revised [DATE], showed the following:-The facility will follow current American Heart Association (AHA) guidelines regarding CPR;-If a resident experiences cardiac arrest, facility staff will provide basic life support, including CPR prior to the arrival of EMS and in accordance to with the resident's advance directives, and if the resident does not show obvious signs of clinical death. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of [DATE];-The resident was full code (if a person's heart stopped beating and/or they stopped breathing, staff would perform CPR);-Diagnoses included chronic obstructive pulmonary disease (COPD-a progressive, incurable lung disease that causes severe breathing difficulties by obstructing airflow, primarily through bronchitis or emphysema) with acute exacerbation (a sudden, sustained worsening of symptoms—specifically increased breathlessness, cough, and sputum production), nontraumatic intracerebral hemorrhage (a spontaneous bleeding into the brain tissue, not caused by trauma, often resulting from chronic high blood pressure), and malignant neoplasm (cancer) of unspecified kidney. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated [DATE], showed the following:-The resident had moderate cognitive impairment;-Shortness of breath with exertion, sitting, at rest, and when lying flat;-He/She received oxygen therapy. Review of the resident's care plan showed the following:-The resident's code status was full code (wished to receive CPR). If noticed with respiratory arrest or absent vital signs, get assistance immediately, notify physician and family, and start CPR;-The resident was his/her own responsible party. Review of the resident's February 2026 Physician's Order Sheet (POS) showed an order, dated [DATE], for full code. Review of the resident's progress note dated [DATE], at 7:20 A.M., showed the following:-Upon coming into the resident's room at 5:45 A.M., Licensed Practical Nurse (LPN) A noticed the resident had his/her legs on the side of the bed and a cup in his/her left hand. LPN A asked the resident if he/she was getting up to get something to drink. LPN A went over to tend to the resident's roommate;-LPN A came back over to the resident and he/she was still in the same position. He/she asked the resident if he/she was going to get a drink but got no response;-LPN A tapped the resident's legs and immediately saw fluid coming from the resident's nose and mouth;-He/she asked another staff member the resident's code status and they advised the resident was full code and LPN A advised staff to call 911;-LPN A immediately started chest compressions and fluid continued to come from the resident's mouth and nose. He/she rolled the resident to his/her right side to relieve more fluid and more drained from the resident's mouth;-LPN A rolled the resident back, continued chest compressions without any success of a pulse;-LPN A called the on-call nurse to contact the physician to inform of the situation;-LPN A contacted the Director of Nursing (DON) and left a message. Review a written statement dated [DATE], at 6:59 A.M., showed LPN A noted the following:-LPN A was checking on the resident's roommate and noticed the resident had both his/her legs over the bed and a cup in his/her hand, as if he/she was getting up to take a drink;-After finishing the care of the roommate, LPN A noticed the resident wasn't responding, and asked if he/she was getting up to get a drink;-LPN A tapped the resident's leg and got no response;-LPN A noticed fluid in the resident's mouth and nose;-LPN A had staff check the resident's code status and began chest compressions and yelled out for staff to page a code blue overhead;-While LPN A was administering chest compressions, fluid was coming from the resident's mouth and nose;-LPN A turned the resident to his/her right side and more fluid came from his/her mouth. LPN A also noticed there was vomit on the left side of the resident where his/her head was lying;-Staff stopped CPR at 5:55 A.M. due to no pulse;-Family called the facility at 6:00 A.M.;-Staff notified the physician at 6:03 A.M. and the DON at 6:06 A.M.;-Ambulance arrived at 6:11 A.M. During an interview on [DATE], at 1:50 P.M., LPN A said the following:-LPN A entered the resident's room and the resident looked like he/she was getting up from the lying down. He/she had a cup in his/her hand and had his/her legs over the edge of the bed;-LPN A asked the resident if he/she was getting up and received no response;-LPN A went over to the resident and observed fluid coming out of his/her nose/mouth. He/she checked the resident's pulse and could not find it;-LPN A asked CNA B to obtain the resident's code status and upon learning the resident's code status, LPN A initiated CPR;-LPN A observed the resident to be room temperature, and his/her chest felt soft and mushy when performing chest compressions;-LPN A observed more fluid coming out of the resident's nose/mouth and rolled the resident to his/her right side, and then observed vomit on the resident's sheets;-LPN A discontinued chest compression as he/she felt the resident had aspirated;-LPN A was notified by staff that 911 had been contacted;-LPN A contacted the nurse on-call and left a message for the DON;-LPN A was unsure of the facility policy on continuing chest compressions until EMS arrival;-LPN A made a judgement call to discontinue chest compressions as he/she was not able to resuscitate the resident. Review of the written statement dated [DATE], at 7:27 A.M., showed Certified Nursing Assistant (CNA) B dated [DATE], at 7:27 A.M., noted the following:-CNA B conducted two-hour checks;-At 2:00 A.M., CNA B observed the resident sit up and turn his/her room light off, but was watching television;-Around 4:00 A.M., CNA B went in to assist the resident's roommate out of bed. LPN A came in the room to assist the resident;-CNA B heard LPN A say the resident's name repeatedly. CNA B looked over to the resident's side and LPN A asked if the resident was full code;-CNA B checked the resident's code status and notified LPN A the resident was a full code. CNA B went to get the crash cart;-LPN A did began chest compressions and later stopped;-CNA B asked if LPN A was going to continue compressions or suction and LPN A stated no, as the resident had aspirated too much. During an interview on [DATE], at 2:36 P.M., CNA B said the following:-On [DATE], around 4:00 A.M., CNA B started rounds at the end of the hallway;-At approximately at 5:00 A.M., CNA B went into the resident's room to assist his/her roommate;-The curtain was pulled between the two residents. CNA B did not observe the resident when he/she entered the room;-CNA B turned on the roommate's light and started with cares;-LPN A came in the room to assist the resident;-CNA B heard LPN A calling out the resident's name several times;-CNA B peered around the curtain and observed the resident and it appeared he/she had vomited;-LPN A asked for the resident's code status. CNA B located the code status, and obtained the crash cart;-LPN A began compressions and later stopped;-CNA B inquired if LPN A was going to administer suction and LPN A responded the resident had aspirated too much;-CNA B left the room to call 911, however Certified Medication Technician (CMT) C had already called;-Staff should continue CPR until EMS arrives or a physician declares the resident deceased . During an interview on [DATE], at 9:15 A.M., CMT C said the following:-On [DATE], CMT C came on shift and was waiting at the nurses' station for report;-CMT C heard someone calling the resident's name in a panic;-He/she went to the resident's room and observed LPN A administering CPR;-The resident started spitting up mucus and was rolled to his/her side;-CNA B obtained the crash cart and asked LPN A if he/she was going to suction the resident. LPN A said he/she could not do anything else;-LPN A ceased CPR, because the resident vomited and rolled the resident back on their side. Fluids continued to come out of the resident's mouth;-CMT C called EMS and the police;-LPN A should have continued CPR until EMS arrived because the resident was full code. During an interview on [DATE], at 3:49 P.M., Emergency Medical Technician (EMT) H said the following:-He/She was dispatched to the facility on [DATE] around 6:00 A.M., regarding a report of a resident that had aspirated (when something other than air gets into the airway leading to obstruction);-Staff were not completing CPR on the resident;-The resident appeared ashen with a yellow tint;-The resident condition appeared obvious the resident had already died as he/she had dependent back lividity (bluish-purple discoloration of the skin after death typically observed within twenty minutes to two hours following death);-Facility staff said the resident was sitting with a cup in his/her hand but did not respond. Staff said they assumed he/she had aspirated;-Staff said a nurse started CPR and a large amount of fluid came from the resident's mouth;-CPR should have continued until EMS arrived. During an interview on [DATE], at 12:45 P.M., the County Coroner said the following:-He/she arrived at the facility at 6:20 A.M., after being notified by EMS of the deceased resident;-Upon arrival, he/she was informed staff discontinued CPR prior to EMS arrival;-The resident had lividity (the after death pooling of blood in dependent body parts due to gravity, causing a reddish-purple discoloration of the skin, generally starting within two hours of death) noted at his/her back indicating he/she had already passed;-The Coroner estimated time of death around 5:00 A.M.;-Preliminary results indicate the resident's death was due to natural causes;-Staff should have continued CPR until EMS arrived. During an interview on [DATE], at 10:00 A.M., CMT D said the following;-If a resident was unresponsive, staff should call for a nurse, check for breathing, and verify the resident's code status;-If the resident was full code, the crash cart should be obtained, and staff should initiate CPR;-If the resident has fluid coming out of their mouth/nose, staff should perform suction;-CPR should be continued until EMS arrives and takes over. During an interview on [DATE], at 11:06 A.M., CMT E said the following:-If a resident was unresponsive, staff should check for breathing and pulse, and yell for help;-Staff should check the resident's code status, and start CPR if the resident is a full code;-If liquid is coming out of the resident's nose/mouth, staff should utilize the suction machine located on the crash cart;-Staff should continue CPR until EMS arrives. During an interview on [DATE], at 2:44 P.M., CNA I said the following:-If a resident was found unresponsive, staff are to immediately report to the charge nurse, verify the resident's code status, call 911, and the nurse initiates CPR if the resident is a full code;-CPR should be continued until EMS arrives or a pulse is obtained. During an interview on [DATE], at 3:04 P.M., CNA J said the following: -He/She would immediately report to a nurse of an unresponsive resident, assist with verification of the code status, and call 911;-The nurse is usually the staff that initiates CPR if needed;-CPR should continue until EMS arrives. During an interview on [DATE], at 11:20 A.M., LPN F said the following:-If a resident was unresponsive, staff should notify the nurse, obtain code status and the crash cart;-Chest compressions should be initiated if a resident is full code;-If fluids are observed coming out of a resident's nose or mouth, the resident should be turned to their left side. Staff can also utilize the suction machine on the crash cart;-Staff should continue compressions until EMS arrives and takes over. During an interview on [DATE], at 2:10 P.M., LPN G said the following:-If a resident was found unresponsive, staff should immediately notify the charge nurse, obtain code status and the crash cart, and call 911;-Staff should check for pulse and breathing, and if the resident is full code, initiate CPR;-The suction machine should be utilized if staff observe liquid/vomit coming from the resident's mouth;-CPR should be continued until EMS arrives. During an interview on [DATE], at 3:17 P.M., the DON said the following:-If a resident was found unresponsive, staff should check their breathing, pulse, and airway;-Staff should obtain the resident's code status, obtain the crash cart, and initiate CPR;-If a resident has fluid coming out of their mouth, they should turn the resident to their side. The suction machine on the crash cart can also be utilized;-Staff are to continue to perform CPR until EMS arrival. During an interview on [DATE], at 4:20 P.M., the Administrator said the following:-If staff find a resident unresponsive, they should check the resident's code status, and if full code, initiate CPR;-Staff should also obtain the crash cart, and call 911;-If a resident has fluid coming out of their nose or mouth, they should utilize the suction machine;-Staff should continue to administer CPR until EMS arrival. During an interview on [DATE], at 1:29 P.M., the Medical Director said if a resident was full code, staff should administer CPR until EMS arrival. Complaint #2744009, #2744144, and #2744377

Based on observation, interview, and record review, the facility failed to care plan and monitor a brain shunt (flexible tube surgically implanted to drain built-up fluid from the brain to another part of the body, helping relieve pressure in the brain), failed to ensure staff were aware of and trained in care of the shunt placement, failed to effectively address increased pain related to the resident's head, neck, and shoulder areas, and failed to notify the physician of increased head pain for one resident (Resident #1). The resident was sent to the hospital where the resident was taken to the operating room for shunt removal/replacement. The resident received a diagnosis of hydrocephalus (an abnormal buildup of cerebrospinal fluid (CSF) deep within the brain. This excess fluid causes the ventricles (cavities) within the brain to widen, putting harmful pressure on the brain's tissues). The facility also failed to address signs of a possible urinary tract infection, including reduced urine output and dark colored urine, in a timely fashion, and failed to complete ordered labs for elevated white counts in a timely fashion for one resident (Resident #1) with a history of kidney infections and sepsis. The resident was sent to the hospital and received diagnoses that included urosepsis (an extreme reaction to a urinary tract infection) and septic shock (a serious medical condition that can occur when an infection in your body causes extremely low blood pressure and organ failure due to sepsis) at the hospital. The resident (Resident #1) was intubated (use of a breathing tube) and sedated at the hospital. The facility census was 40. The administrator was notified on 02/05/26, at 4:49 P.M, of an Immediate Jeopardy (IJ) which began on 01/06/26. The IJ was removed on 02/07/26, as confirmed by surveyor onsite verification. Review of the facility policy titled, Pain Management, dated 05/01/25, showed the following information:-In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility may recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated;-Evaluate the resident for pain and the causes upon admission, during ongoing scheduled assessments, and when a significant change of condition occurs;-Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences;-Facility staff may observe nonverbal indicators of pain which may include recurring restlessness, grimacing, decreased participation of usual physical or social events, loss of appetite, difficulty sleeping, and negative vocalizations such as groaning or crying;-The facility may use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain;-Based upon the evaluation, the facility in collaboration with the attending physician, other healthcare professionals, and the resident may develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission;-Facility staff may reassess resident's pain management at established intervals for effectiveness and or adverse consequences.Review of the facility policy titled, Catheter Care, dated 05/02/25, showed the following information:-Monitor output for changes in amount, color, clarity, or odor;-Monitor for signs of urinary tract infection (UTI);-Record output, and document abnormalities and report to physician immediately. Review of the facility policy titled, Medication Orders, dated 05/09/25, showed the following:-Verbal orders should be received only by licensed nurses and confirmed in writing by the provider. Review of the facility policy titled, Notification of Changes, dated 05/13/25, showed the following:-The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member when there is a change requiring such notification.1. Review of Resident #1's face sheet (brief look at resident information) showed the following information:-admission date 02/08/25;-Diagnoses included spina bifida (a congenital condition in which part of the spinal cord and int's meninges are exposed through a gap in the backbone, often causing paralysis of the lower limbs), paralysis, acute pyelonephritis (a serious kidney infection typically caused by bacteria that ascends from the bladder, with symptoms including fever, flank pain, chills, nausea, and vomiting), resistance to multiple antimicrobial drugs (occurs when germs evolve to defeat the drugs designed to kill them), neuromuscular dysfunction of bladder (disorders affecting the nerves controlling voluntary muscles and the muscled themselves), and history of UTIs and sepsis;-The face sheet did not include diagnoses of a brain shunt or use of urostomy (an opening in the abdomen that redirects urine outside the body). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 01/07/26, showed the following information:-Intact cognition;-Impairment to both lower extremities;-Requires substantial to maximum assistance from staff for toileting, showering, dressing, and mobility;-Requires the use of indwelling catheter and ostomy;-UTI within the last 30 days prior to assessment;-Is not on a scheduled pain regimen, receives an as needed (PRN) pain regimen for occasional pain. Review of the resident's care plan, dated 04/11/25, showed the following information:-Requires assistance from staff for all activities of daily living (ADL- bathing, toileting, dressing) and mobility;-Obtain and monitor lab work as ordered, report results to the Medical Director (MD) and follow up as indicated;-Pain management as needed, evaluate the effectiveness of pain interventions every shift, and as needed;-Urostomy use; position drainage bag for urine and tubing below the level of the bladder, monitor and document intake and output as per facility policy, monitor for signs and symptoms of discomfort related to urostomy or kidney pain, monitor/record/report to MD any signs of kidney infection, sepsis, pain, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, foul smelling urine, fever, chills, altered mental status, and change in eating patterns;-The care plan did not indicate the resident had a brain shunt.Review of the resident's lab results, collected 12/01/25, showed the following:-White blood Cell (WBC- measurement of number of white cells in the blood, measures the body's immune cells used to fight infections, inflammations, and diseases) (normal range 3.8-10.04) count of 14.4.Review of the resident's January 2026 Physician Order Sheet (POS) showed the following:-An order, dated 02/08/25, pain assessment; Check and record every shift;-An order, dated 03/02/25, Tramadol (an opioid pain medication used to treat moderate to severe pain) 50 milligram (mg) tablet; give one tablet by mouth (po) every 4 hours prn for pain;-An order, dated 03/03/25, record urine output two times a day (BID);-An order, dated 09/22/25, Cephalexin (a first generation cephalosporin antibiotic used to treat bacterial infections) 250 mg capsule; Give one capsule by po BID related to acute pyelonephritis;-An order, dated 09/22/25, Acetaminophen (over the counter analgesic and antipyretic (fever reducing) medication used to treat mild to moderate pain) Extra Strength 500 mg; give two tablets (1000mg) po every 6 hours PRN for pain;-An order, dated 12/04/25, lab CBC (complete blood count) order dated for draw on 01/01/26;-The POS did not show an order for monitoring of the resident's brain shunt.Review of the resident's medication administration record (MAR), dated 01/01/26, showed the following;-Day and night shift documented a pain level of 0 out of 10; No PRN pain medication administered.-Day shift recorded a urine output of 1100 milliliters (ml);-Night shift recorded a urine output of 1100 ml.Review of the resident's MAR, dated 01/02/26, showed the following;-Day and night shift documented a pain level of 0 out of 10; No PRN pain medication administered.-Day shift recorded a urine output of 1000 ml;-Night shift recorded a urine output of 2000 ml.Review of the resident's MAR, dated 01/03/26, showed the following;-Day shift documented a pain level of 2 out of 10;-Night shift documented a pain level of 4 out of 10; PRN Acetaminophen given for a pain scale of 6 out of 10 at 2:09 A.M.;-Day shift recorded a urine output of 1800 ml;-Night shift did not document a urine output.Review of the resident's MAR, dated 01/04/26, showed the following:-Day shift documented a pain level of 0 out of 10;-Night shift documented a pain level of 5 out of 10; No PRN pain medication administered;-Day shift recorded a urine output of 600 ml;-Night shift record a urine output of 1250 ml.Review of the resident's progress note, dated 01/04/26 at 1:27 P.M., showed the following:-Call placed to urology provider on-call to clarify cephalexin order from 09/22/25.Review of the resident's progress note, dated 01/04/25, at 1:57 P.M., showed the following:-On call Urologist returned call and said cephalexin should have been discontinued when the urinary stent was removed.Review of the resident's MAR, dated 01/05/26, showed the following;-Day documented a pain level of 5 out of 10; No PRN pain medication administered;-Night shift documented a pain level of 0 out of 10.-Day shift recorded a urine output of 1200 ml;-Night shift record a urine output of 1250 ml.Review of the resident's progress note dated 01/05/26 at 11:06 A.M., showed the providing urologist was contacted and gave approval to discontinue cephalexin.Review of the resident's January 2026 POS showed cephalexin 250 mg tablet was discontinued on 01/05/26.Review of the resident's lab results, dated 01/06/26, showed a WBC count of 16.8.Review of the resident's progress notes, dated 01/06/26, did not show prompt notification to the resident's physician of the increasing WBC count.Review of the resident's MAR, dated 01/06/26, showed the following;-Day and night shift documented a pain level of 0 out of 10;-Day shift and night shift did not document a urine output.Review of the resident's physician progress note with a service date of 01/06/26, showed the following:-The resident was seen for management of chronic medical conditions;-Urostomy with clear yellow urine;-WBC of 14.4.Review of the resident's MAR, dated 01/07/26, showed:-Day and night shift documented a pain level of 0 out of 10;-Day shift did not document a urine output;-Night shift documented a urine output of 1200 ml;-PRN Tramadol was administered at 12:16 A.M., for a pain level of 5 out of 10. Review of the resident's progress note, dated 01/07/26 at 12:16 A.M., showed an administration of Tramadol. The progress note did not indicate any characteristics of the pain.Review of the resident's progress note, dated 01/07/26 at 3:17 A.M., showed the administration of Tramadol was effective with a follow-up pain scale of 0 out of 10.Review of the resident's MAR, dated 01/08/26, showed:-Day and night shift documented a pain level of 0 out of 10;-Day shift and night shift did not document a urine output.Review of the resident's MAR, dated 01/09/26, showed:-Day and night shift documented a pain level of 0 out of 10;-Day shift and night shift did not document a urine output.Review of the resident's MAR, dated 01/10/26, showed:-Day and night shift documented a pain level of 0 out of 10;-Day shift and night shift did not document a urine output.Review of the resident's MAR, dated 01/11/26, showed:-Day and night shift documented a pain level of 0 out of 10;-PRN Acetaminophen was administered at 3:35 P.M, for a pain level of 4 out of 10;-Day shift documented a urine output of 650 ml;-Night shift did not document a urine output.Review of the resident's progress note, dated 01/11/26 at 3:35 P.M., showed an administration of Acetaminophen two tablets. The progress note did not show any characteristics of the pain.Review of the resident's progress note, dated 01/11/26 at 7:19 P.M., showed the administration of Acetaminophen was effective with a follow up pain scale of 0 out of 10.Review of the resident's POS, dated 01/11/26, showed the following:-New order for Ajovy (a prescription medication for preventive treatment of migraines) subcutaneous auto-injector 225 mg/1.5ml; Inject 1.5 ml subcutaneously (under the skin) once a month, on the 13th of every month for migraines. Review of the resident's MAR, dated 01/12/26, showed the following;-Day shift documented a pain level of 4 out of 10; PRN Acetaminophen administered at 7:09 A.M.;-Night shift documented a pain level of 0 out of 10;-Day shift documented a urine output of 1000 ml;-Night shift did not document a urine output.Review of the resident's progress note, dated 01/12/26 at 7:09 A.M., showed an administration of Acetaminophen two tablets. The progress note did not show any characteristics of the pain.Review of the resident's progress note, dated 01/12/26 at 7:10:43 A.M., showed the administration of Acetaminophen was effective with a follow up pain scale of 0 out of 10.Review of the resident's MAR, dated 01/13/26, showed:-Day and night shift documented a pain level of 0 out of 10;-Day shift did not document a urine output;-Night shift documented a urine output of 1600 ml.Review of the resident's MAR, dated 01/14/26, showed:-Day shift documented a pain level of 5 out of 10; PRN Tramadol administered at 12:22 A.M., for a pain level of 5;-Night shift documented a pain level of 0 out of 10;-Day shift and night shift did not document a urine output.Review of the resident's progress note dated 01/14/26 at 12:22 A.M., showed an administration of PRN Tramadol at 12:22 A.M., for generalized body aching, pain level not documented.Review of the resident's progress note, dated 01/14/26 at 9:11 A.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 1 out of 10. Review of the resident's MAR, dated 01/15/26, showed the following;-Day and night shift documented a pain level of 0 out of 10;-PRN Tramadol was administered at 1:50 AM., for a pain level of 5;-Day shift documented a urine output of 900 ml;-Night shift documented a urine output of 825 ml.Review of the resident's progress note, dated 01/15/26 at 1:50 A.M., showed an administration of PRN Tramadol at 1:50 A.M. The progress note did not show any characteristics of the pain.Review of the resident's progress note, dated 01/15/26 at 2:20 A.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10. Review of the resident's MAR, dated 01/16/26, showed:-Day shift documented a pain level of 0 out of 10;-Night shift documented a pain level of 3 out of 10;-Day shift and night shift did not document a urine output.Review of the resident's MAR, dated 01/17/26, showed:-Day and night shift documented a pain level of 0 out of 10;-PRN Acetaminophen was administered at 1:44 AM.;-PRN Tramadol was administered at 3:15 P.M., for a pain level of 5;-Day shift and night shift did not document a urine output.Review of the resident's progress note, dated 01/17/26, at 1:44 A.M., showed an administration of PRN Acetaminophen at 1:44 A.M. The progress note did not show any characteristics of the pain.Review of the resident's progress note, dated 01/17/26 at 5:35 A.M., showed the administration of PRN Acetaminophen was effective with a follow up pain scale of 0 out of 10. Review of the resident's progress note, dated 01/17/26 at 3:15 P.M., showed an administration of PRN Tramadol at 3:15 P.M for back pain. The progress note did not indicate the resident's level of pain.Review of the resident's progress note, dated 01/17/26 at 4:38 P.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 3 out of 10. Review of the resident's MAR, dated 01/18/26, showed the following;-Day and night shift documented a pain level of 0 out of 10;-PRN Tramadol was administered at 11:14 A.M., for a pain level of 6;-Day shift documented a urine output of 1200 ml.-Night shift documented a urine output of 1250 ml.Review of the resident's progress note, dated 01/18/26 at 11:14 A.M., showed the resident requested administration of PRN Tramadol at 11:14 A.M for a pain level of 6 out of 10. The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/18/26 at 1:25 P.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 1 out of 10. Review of the resident's MAR, dated 01/19/26, showed the following;-Day and night shift documented a pain level of 0 out of 10;-PRN Tramadol was administered at 5:52 P.M., for a pain level of 5;-Day shift did not document a urine output;-Night shift documented a urine output of 1200 ml.Review of the resident's progress note, dated 01/19/26, at 5:52 P.M., showed an administration of PRN Tramadol at 5:52 P.M. The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/19/26 at 11:46 P.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10. Review of the resident's MAR, dated 01/20/26, showed the following;-Day and night shift documented a pain level of 0 out of 10;-PRN Tramadol was administered at 2:27 A.M., for a pain level of 7 and 8:09 P.M., for a pain level of 8;-Day shift documented a urine output of 750 ml;-Night shift documented a urine output of 1200 ml.Review of the resident's progress note, dated 01/20/26, at 2:27 A.M., showed an administration of PRN Tramadol at 2:27 A.M . The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/20/26 at 2:31 A.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10. Review of the resident's progress note, dated 01/20/26 at 8:09 P.M., showed an administration of PRN Tramadol at 8:09 P.M., The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/20/26 at 9:00 P.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10. Review of the resident's physician progress notes, for a service date of 01/20/26, showed the following information:-Urostomy with clear yellow urine;-Pain level 2 out of 10;-WBC count of 16.8;-Leukocytosis (a high white blood cell count, most often caused by infections) WBC 16.8, will recheck CBC.Review of the resident's POS, dated January 2026, did not show any new lab orders.Review of the resident's progress notes, dated 01/20/26, did not show any documentation regarding the diagnoses of leukocytosis and/or follow up regarding new lab orders.Review of the resident's MAR, dated 01/21/26, showed the following;-Day and night shift documented a pain level of 0 out of 10;-PRN Tramadol was administered at 12:32 A.M. for a pain level of 9 and 8:29 P.M. for a pain level of 3;-Day shift documented a urine output of 700 ml;-Night shift documented a urine output of 2000 ml.Review of the resident's progress note, dated 01/21/26, at 12:32 A.M., showed an administration of PRN Tramadol at 12:32 A.M. The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/21/26 at 12:50 A.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 1 out of 10. Review of the resident's progress note, dated 01/21/26 at 8:29 P.M., showed an administration of PRN Tramadol at 8:29 P.M., per the resident's request. The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/21/26 at 9:44 P.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10.Review of the resident's MAR, dated 01/22/26, showed the following;-Day shift documented a pain level of 2 out of 10;-Night shift documented a pain level of 0 out of 10;-PRN Tramadol was administered at 1:43 P.M., for a pain level of 5 and 5:22 P.M., for a pain level of 5;-Day shift documented a urine output of 800 ml;-Night shift documented a urine output of 1100 ml.Review of the resident's progress note, dated 01/22/26 at 1:43 P.M., showed an administration of PRN Tramadol at 1:43 P.M., for neck and shoulder aching. The progress note did not show the level of pain.Review of the resident's progress note, dated 01/22/26 at 2:19 P.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 3 out of 10. Review of the resident's progress note, dated 01/22/26 at 5:22 P.M., showed an administration of PRN Tramadol P.M. The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/22/26 at 6:33 P.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 3 out of 10. Review of the resident's MAR, dated 01/23/26, showed the following;-Day shift did not document a pain level;-Night shift documented a pain level of 6 out of 10;-PRN Tramadol was administered at 12:33 A.M. for a pain level of 8 and 5:56 P.M. for a pain level of 9;-Day shift did not document a urine output;-Night shift documented a urine output of 1200 ml.Review of the resident's progress note, dated 01/23/26 at 12:33 A.M., showed an administration of PRN Tramadol at 12:33 A.M . The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/23/26 at 1:34 A.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10. Review of the resident's progress note, dated 01/23/26 at 5:56 P.M., showed an administration of PRN Tramadol at 5:56 P.M. The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/23/26 at 7:25 P.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10.Review of the resident's MAR, dated 01/24/26, showed the following;-Day shift and night shift documented a pain level of 0 out of 10;-PRN Tramadol was administered at 2:25 A.M. for a pain level of 5 and 9:44 A.M. for a pain level of 3;-Day shift documented a urine output of 800;-Night shift did not document a urine output.Review of the resident's progress note, dated 01/24/26 at 2:25 A.M., showed an administration of PRN Tramadol at 2:25 A.M The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/24/26 at 2:26 A.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10. Review of the resident's progress note, dated 01/24/26 at 9:44A.M., showed an administration of PRN Tramadol at 9:44 A.M. The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/24/26 at 10:15 A.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10.Review of the resident's MAR, dated 01/25/26 showed the following;-Day shift documented a pain level of 0 out of 10;-Night shift documented a pain level of 8 out of 10;-PRN Tramadol was administered at 11:03 P.M. for a pain level of 8;-Day shift did not document a urine output;-Night shift documented a urine output of 2000 ml.Review of the resident's progress note, dated 01/25/26 at 11:03 P.M., showed an administration of PRN Tramadol at 11:03 P.M. The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/25/26 at 12:25 A.M., showed the administration of PRN Tramadol was not effective with a follow up pain scale of 5 out of 10. The note did not indicate the physician had been notified of the un-relieved pain.Review of the resident's MAR, dated 01/26/26, showed the following;-Day shift documented a pain level of 5 out of 10;-Night shift documented a pain level of 0 out of 10;-PRN Tramadol was administered at 6:16 P.M. for a pain level of 7 and 9:24 P.M. for a pain level of 8-Day shift documented a urine output of 500 ml;-Night shift documented a urine output of 1200 ml.Review of the resident's progress note, dated 01/26/26 at 6:16 P.M., showed an administration of PRN Tramadol at 6:16 P.M., The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/26/26 at 7:24 P.M., showed the administration of PRN Tramadol was not effective with a follow up pain scale of 5 out of 10. The note did not indicate the physician had been notified of the un-relieved pain.Review of the resident's progress note, dated 01/26/26 at 9:24 P.M., showed an administration of PRN Tramadol at 9:24 P.M., The progress note did not show the characteristics of the pain.Review of the resident's progress note, dated 01/26/26 at 11:25 P.M., showed the administration of PRN Tramadol was effective with a follow up pain scale of 0 out of 10. Review of the resident's physician progress notes, for a service date of 01/27/26, showed the following:-The resident was seen per request of the nursing staff for shoulder pain. The resident denied injury, but reports right shoulder pain for the last several weeks;-Urostomy with clear yellow urine;-Pain level of 7 out of 10;-Will order Zanaflex (muscle relaxant used to treat spasticity, muscle stiffness, spasms, and cramping) 4 mg po three times a day (TID) for 5 days for muscle spasms;-Will order Voltaren (an over-the-counter topical treatment used to relieve arthritis pain) gel BID, and Naproxen (a non-steroidal anti-inflammatory drug used to relieve stiffness, cramps, and muscle aches) 440mg po BID for 5 days then PRN;-Leukocytosis- WBC 16.8, will recheck CBC.Review of the resident's POS, dated 01/26/26, did not show continued orders to recheck CBC.Review of the resident's MAR, dated 01/27/26, showed the following:-Day shift documented a pain level of 0 out of 10;-Night shift documented a pain level of 5 out of 10;-PRN Tramadol was administered at 4:48P.M. for a pain level of 5; PM dose of Naproxen administered for a pain level of 8;-Day shift documented a urine output of 400 ml;-Night shift documented a urine output of 1250 ml.Review of the resident's progress note, dated 01/27/26 at 4:48 P.M., showed an administration of PRN Tramadol at 4:48 P.M., for neck and shoulder. The progress note did not show the level of the pain.Review of the resident's progress note, dated 01/27/26 at 7:24 P.M., showed the administration of PRN Tramadol was not effective with a follow up pain scale of 7 out of 10. The note did not indicate the physician had been notified of the un-relieved pain.Review of the resident's progress note, dated 01/28/26 at 10:21 A.M., showed:-The resident's family member was at the facility and asked to speak to the Director of Nursing (DON), Social Services Director (SSD), and the nurse, regarding health concerns of the resident for the last week;-The family member reported the resident had not been eating regularly;-The family member reporter the resident had tea colored urine, and was concerned the resident was becoming septic;-The DON and charge nurse assessed the resident and discussed going to the hospital with the resident.Review of the resident's progress note, dated 01/28/26 at 1:59 P.M., showed the following:-The resident was sent to the hospital after assessment which showed the resident was confused, hypotensive (low blood pressure), and had dark colored urine;-The family was present at the time of transfer;-Physician and DON aware. Review of the resident's hospital document titled General Surgery Consult, dated 01/28/26, showed the following:-admitted to hospital on [DATE] for altered mental status;-The resident was in the operating room [ROOM NUMBER]/27/26 for External Ventricular Drain (EVD- a neurosurgical procedure to temporarily drain CSF and monitor pressure by inserting a catheter through the skill into the brain's ventricles) replacement by neurosurgery;-The resident is currently intubated and sedated in the intensive care unit;-The resident is being treated for septic shock due to urosepsis. Urostomy in place draining dark cloudy urine;-White blood cell count on 01/28/26 at 4:35 P.M., is 43.7.During an interview on 02/03/26, at 10:13 A.M., Resident #5 said the following;-He/she was Resident #1's roommate;-The resident seemed okay, until about a month ago. At that time, he/she started having a lot of pain. The staff would bring him/her medication, but it didn't relieve the pain;-The resident began getting confused about three days prior to the resident being sent to the hospital;-The resident's head appeared swollen prior to being sent to the hospital.During an interview on 02/03/26, at approximately 11:25 A.M., Certified Nurse Aide (CNA) K, said the following:-He/she has worked with Resident #1, in the past;-Had known the resident to complain about headaches daily;-The resident would say his/her head is blowing up or exploding;-The resident cried a lot from being in so much pain. It was reported to the charge nurse, who would say, okay, and that they would check the resident;-CNA K said he/she was glad when the resident was sent out and hopes he/she is being taken care of.During an interview on 02/03/26, at 1:15 P.M., CNA A said the following:-CNAs are responsible for draining resident's urinary bags and reporting the output for the nurses to document;-If he/she was to notice urine that is anything but pale yellow, he/she would report it to the nurse;-If he/she was to become aware of decreased urine output, he/she would report it to the nurse;-If a resident had continuous complaints of pain, he/she would report it to the nurse;-There is typically one nurse for the whole building, so things slip their mind. He/she likes to follow back up with the resident on any complaints;-The resident was generally alert and oriented;-He/she noticed the resident's urine output had been decreasing. Typically, he/she had to empty the resident's urinary bag several times a shift; that decreased to sometimes just once a day;-The resident complained of headaches a lot. The resident would just have to sit in a dark room;-The medication given to the resident was for migraines and did not relieve the resident's pain; this was ongoing for a little over a month. The resident has a brain shunt and he/she believes that something was possibly malfunctioning as the resident would report the pain directly where the shunt was located;-He/she reported the urine output decrease, the resident's unrelieved pain, and complaints of pain at the brain shunt site to the nurse a few days prior to the resident being hospitalized ;-He/she was off work for a few days, and when he/she returned on 01/28/26, the resident was slurring his/her words, hallucinating (seeing things that were not there), and had only 300 ml of burnt orange colored urine. He/she reported this immediately to the charge nurse and questioned the nurse about obtaining a urinary analysis. The nurse told him/her no, the resident just needed a new drainage bag; -The resident was sent out to the hospital approximately 2 hours later;-The CNA said management did not want to send the resident to the hospital. He/she overheard them saying, the confusion could just be from the new medication the resident started. They wanted to treat him/her in-house;-The CNA observed the resident's face was puffy, and his/her abdomen looked distended (abnormal swelling or enlargement of the abdomen);-He/she obtained vital signs on the resident and reported the resident had extremely low blood pressure;-The CNA reported the findings to Licensed Practical Nurse (LPN) C. During an interview on 02/03/26, at 2:50 P.M., LPN C said the following:-CNAs are responsible for emptying and recording urinary output. They will report to the nurses who are responsible for that documentation;-The CNAs reported the resident's urine was dark in color to him/her. He/she did not instruct the aides to obtain a urinary analysis but instead sent the resident to the hospital a couple hours later;-He/she only noticed the resident was in pain when he/she and other staff members would attempt to roll or reposition the resident. The resident complained of headaches/migraines and was on medication for that. He/she expected information regarding the pain to be documented; -There we

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing when the facility failed to timely assess and monitor, failed to obtain and document treatment orders, and failed to update the care plan regarding a facility acquired pressure ulcer that required surgical intervention for one resident (Resident #1). The facility census was 40. Review of the facility policy titled, Wound Treatment and Management, dated 05/15/25, showed the following information:-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change;-In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse;-Treatment decisions will be based on the etiology of the wound, characteristics of the wound, location of the wound, and goals and preferences of the resident;-Treatments will be documented in the Treatment Administration Record (TAR) for providing wound care;-The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include lack of progression towards healing, changes in the characteristics of the wound, and changes in the resident's goals and preferences, such as end of life care.1. Review of Resident #1's face sheet (brief look at resident information), showed the following information:-admission date of 02/08/25;-Diagnoses included spina bifida (a congenital condition in which part of the spinal cord and int's meninges are exposed through a gap in the backbone, often causing paralysis of the lower limbs), paralysis, acute pyelonephritis (a serious kidney infection typically caused by bacteria that ascends from the bladder, with symptoms including fever, flank pain, chills, nausea, and vomiting), resistance to multiple antimicrobial drugs (occurs when germs evolve to defeat the drugs designed to kill them), neuromuscular dysfunction of bladder (disorders affecting the nerves controlling voluntary muscles and the muscled themselves), and history of urinary tract infections and sepsis.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 01/07/26, showed the following information:-Intact cognition;-Required substantial to maximum assistance from staff for toileting, showering ,dressing, and mobility; -Did not have pressure ulcers;-At risk for pressure ulcers;-Required pressure reducing devices for chair and bed.Review of the resident's care plan, dated 04/11/25, showed the following information:-Required assistance from staff for all activities of daily living (ADL - bathing, toileting, dressing) and mobility;-Assess/record/monitor wound healing as ordered;-Measure wound length, width, and depth when possible;-Assess and document status of wound perimeter, wound bed, and healing process;-Report improvements and declines to the Medical Director (MD);-Follow facility policies and protocols for the prevention and treatment of skin breakdown.Review of the resident's weekly skin assessment, dated 01/03/26, showed the following:-No open areas on the skin;-No pressure reducing devices;-Skin discoloration related to thick, dry, scaling skin on left buttocks.Review of the resident's Braden Scale (assessment tool staff use for predicting pressure ulcers) assessment, dated 01/08/26, showed the resident was at risk for skin breakdown. Review of the resident's progress note, dated 01/09/26, showed the Director of Nursing (DON) documented she was called into the resident's room related to the resident's coccyx (tailbone - a small triangular bone at the very bottom of the spine) area being open. The DON applied Optiform Gentle EX (a 5-layer bordered silicone adhesive foam dressing designed for managing moderate to high drainage in partial and full thickness wounds). The resident tolerated well. The resident was educated on not wearing underwear so his/her coccyx could breathe. The resident verbalized understanding. (Staff did not document a full description of the area including measurement and description and did not document notification of the MD of the new area.)Review of the resident's January 2026 Physician Order Sheet (POS) showed staff did not document orders for pressure reducing devices for chair and bed or new orders for the new area identified on the resident's coccyx. Review of the resident's electronic medical record (EMR) showed staff did not complete a new skin assessment after 01/03/26.Review of the resident's care plan showed staff did not update the care plan to reflect the new area on the coccyx. Review of the resident's progress notes, dated 01/10/26 through 01/16/26, showed staff did not document an assessment or documentation related to the resident's open area on the coccyx.Review of the resident's progress note, dated 01/17/26, showed the following:-Nurse received a report the resident's coccyx and buttocks were open and bleeding. Upon exam bilateral (both) buttocks, coccyx, and sacrum (triangular bone located at the base of the lumbar spine) were open, red, irritated, and weeping (exuding) serous (a thin, watery, clear to pale yellow fluid) drainage;-Staff notified MD and new orders received for wound care of cleanse with wound cleanser, pat dry, and apply border foam dressing change every other day and as needed (PRN);-Staff applied ordered treatment.(Staff did not document an assessment to include wound measurement or detailed description of the wound.) Review of the resident's January POS showed staff did not document the new wound order received on 01/17/26 to the POS. Review of the resident's physician's progress note, dated 01/20/26, showed the following information:-The resident was seen for evaluation of seating and pressure relief needs. The staff reported the resident had ulcerations to the coccyx, sacrum, and bilateral buttocks;-The resident reported prolonged sitting in his/her power chair;-The resident required a wheelchair cushion to provide adequate pressure reduction.Review of the resident's January 2026 POS showed an order, dated 01/20/26, to cleanse bilateral buttocks with wound cleanser, pat dry, apply hydroferra blue (antibacterial foam dressing containing methylene blue and gentian violet used for managing wounds), and cover with protective dressing every day and PRN. (Staff did not document an order for a pressure reducing cushion to chair.)Review showed the resident's wound assessment documentation, dated 01/27/26, showed the following information:-Location of the wound was coccyx;-Left buttock with two open areas measuring 3.5 centimeters (cm) by 1.1 cm and 14 cm by 10 cm with a depth of 0.2 cm;-Right buttock with one open area measuring 5 cm by 1.5 cm;-Dressing changes are daily.(Staff did not document a detailed description of the areas.) Review of the resident's progress note, dated 01/28/26, showed the resident was sent to the hospital for other medical conditions. Review of the resident's electronic medical record (EMR) showed a surgery consult, dated 01/29/26, from the resident's hospitalization on 01/28/26. The consult showed the following:-The skin of the sacral area and around the anus were excoriated (red);-The area around the left side of the anus appears necrotic (dead, non-viable tissue resulting from irreversible cell death caused by lack of blood flow, infection, trauma, or toxins);-Foul-smelling, purulent (pus filled) fluid was seen to be draining from the vaginal area;-Surgical intervention required once resident's other medical concerns stabilize.During an interview on 02/03/26, at 1:51 P.M., Certified Nursing Assistant (CNA) A said the following:-If he/she noticed a resident's wounds were worsening, he/she would report it to the nurse;-Nurses were responsible for providing wound care, performing assessments, and documenting wound care, characteristics, and measurements;-He/she would describe the resident's wound as looking like hamburger meat on both buttocks and bleeding;-There was an odor to the wounds and it sometimes had areas that looked like dried blood.During an interview on 02/03/26, at 2:33 P.M., Registered Nurse (RN) B said the following:-Nurses were responsible for doing wound care;-The facility used to have an Assistant Director of Nursing (ADON) and that was who completed weekly wound assessments to include measurements and documentation;-When he/she finds a new open areas on the resident's, he/she will go ahead and grab measurements and that time, and document the findings;-Anytime a new area of concern is found, it should be assessed, documented, and the MD should be notified for treatment orders;-He/she was aware of the resident's wounds on his/her bilateral buttocks. It appeared to be holes everywhere resembling Swiss cheese. He/she did not note any areas that were necrotic, but the resident did have very fragile skin. During an interview on 02/03/26, at 2:50 P.M., Licensed Practical Nurse (LPN) C said the following:-The resident's buttocks were open;-The floor nurses typically don't do the weekly wound assessments, but he/she happened to on 01/27/26;-He/she documented on paper and should have entered the measurements in a skin assessment form within the resident's EMR;-He/she was not sure of how regularly wounds should be monitored, measured, or documented on.During an interview on 02/04/26, at 12:22 P.M., Certified Medication Technician (CMT) D said the following:-The resident had wounds across his/her bilateral buttocks;-He/she was not sure about wound assessment and documentation, but knew the nurses were to provide treatment. During an interview on 02/04/26, at 3:05 P.M., Housekeeper (HK) L said he/she could smell an odor from the resident's wounds when he/she would be near the resident.During an interview on 02/04/26, at 4:54 P.M., LPN H said the following:-He/she saw the resident's wounds a few days prior to the resident being sent to the hospital. The open areas appeared to be red, and the peri-wound (surrounding skin) was sloughing (shedding) off;-Nurses were responsible for doing wound care;-The facility used to have an ADON and that was who completed weekly wound assessments to include measurements and documentation;-He/she believed staff nurses now collected wound measurements and should be documenting those weekly;-If he/she were to note that a wound was getting worse and/or a new area was opened, he/she would obtain measurements and document that and his/her assessment in the progress notes;-Routinely staff nurses don't measure wounds unless there is a change in the wound.During an interview on 02/05/26, at 12:05 P.M., CNA J said the following:-He/she saw the resident's wounds prior to the resident going to the hospital and described the wounds as appearing as hamburger meat and oozing;-The wounds did have a blackened appearance in several areas;-Nurses were responsible for wound treatment, assessment, and documentation.During an interview on 02/05/26, at 12:46 P.M., the MDS/Medical Records Nurse said the following:-Care plans should be individualized;-Care plans should include wounds and wound treatment and should be updated with any changes.During an interview on 02/06/26, at 10:36 A.M., the DON said the following:-She expected the nurses to assess any new open areas, notify the MD, get treatment orders, perform a skin assessment, and document that skin assessment;-Skin assessments should be completed weekly;-Wound assessments along with measurements should also be completed weekly;-The ADON was previously responsible for wound reports, but that is something she will have to address now;-She did not observe the resident's wounds, but the resident had a history of wounds and had fragile skin;-If the wounds were worsening, she would hope someone would have reported that;-She did not think she was aware of the wounds opening until nursing had brought it to her attention around 01/17/26.During an interview on 02/06/26, at 2:51 P.M., the Administrator said the following:-She expected wounds and skin to be assessed, monitored, measured, and documented on;-She expected care plans to be individualized.Complaint #2731470

Based on observation, interview, and record review, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior when odors, stains, dirty floors, and overflowing trashcans were present in resident use areas. The facility census was 40. Review of the facility policy titled, Cycle Cleaning, The Compliance Store, LLC., dated 06/15/25, showed the following:-It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks;-Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to predetermined schedule and shall be sufficient to keep surfaces clean and dust free;-Specific areas include hallways, dayrooms, dining rooms, showers, utility, bathrooms, and resident's rooms;-The frequency of cleaning and disinfection of the facility environment may vary according to the type of surfaces to be cleaned, the number of individuals in the area, the amount of activity in the area, and the risk to residents;-The environmental services manager is responsible to ensure that cycle cleaning is maintained.Review of the facility policy titled, Routine Cleaning and Disinfection, The Compliance Store, LLC., dated 06/15/25, showed the following:-It is the policy of this facility to ensure the provision of routine cleaning and disinfection to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible;-Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge;-Dry cleaning procedures will be conducted before wet procedures;-Clean from areas that are visibly clean and least likely to be contaminated to areas usually visibly dirty;-Clean from top to bottom (bring dirt from high levels down to floor levels);-Clean from back to front areas;-Clean prior to disinfection as recommended by the manufacturer of the product(s) being used;-Disinfectant solution will be prepared fresh daily and changed frequently in order to ensure effectiveness;-Follow manufacturer recommendations for dilution and frequency of changing of disinfectant solution;-Follow manufacturer recommendations regarding appropriate contact time to ensure adequate disinfection;-Clean and disinfect any equipment that enters the room before use in another location;-Staff will ensure cleaning carts are checked and stocked with necessary supplies at the beginning of each shift.1. Observations on 01/30/26, beginning at approximately 10:35 A.M., of Buffalo Blvd. Hall showed the following:-The floor had a large dried-up, splatter stain with a shiny, white crust-looking edging to it;-At the exit door, there was a large pile of dried leaves accumulated;-room [ROOM NUMBER], had a pillow on the floor, next to and on-top of food crumbs, at the window side of the bed. Several napkins, tissues, a clear cup, and an empty, green, apple-pie box were on the floor, under and to the left side of the bed;-Between rooms [ROOM NUMBERS] was an orange cap that had fallen from a med cart, as well as a single, blue, plastic glove.2. Observations on 01/30/26, beginning at approximately 10:35 A.M., of Memory Lane Hall/Unit showed the following:-There was a strong urine odor upon entering;-The dining room trash can, at the end of the serving counter, was overflowing, with trash and napkins on the floor, surrounding the can;-The TV/Visiting area, located in the dining room, showed Resident #4 reclined in a chair. Next to him/her was a wheeled, side-table cart, that was heaping over with trash including two soda cans, several rolled up tissues, and some wadded up wrappers;-There were food crumbs, tissues, and an elastic hair band just under the left-front of the recliner, on the floor;-room [ROOM NUMBER] had tissue and food crumbs on the floor;-room [ROOM NUMBER], had a large stained, discoloration on the floor, resembling the shape of a rope. Beside bed two, next to the window, there was popcorn, food crumbs, and wadded trash items on the floor;-room [ROOM NUMBER], both bed one and two, had overflowing trashcans. There were stains across the floor that looked like splatter marks. Bed two had a straw, straw wrapper, Q-Tip wrapper, tissues, and bottle cap laying under the bed;-room [ROOM NUMBER] had dried floor splatters on the floor at the foot of the bed, the trashcan was full of trash overflowing, and there were tissue, wrappers, and other discarded items on the floor around the trash can. Observations on 02/03/26, at approximately 10:50 A.M., of Memory Lane Hall/Unit, showed the following:-room [ROOM NUMBER] had a strong smell of urine;-There was wadded up trash on the floor, under the bed;-There were wads of paper that look like they had been wet and splattered, onto the floor. They were dried and hardened onto the floor.3. Observation on 01/30/26, beginning at approximately 10:35 A.M., of Prairie Lane Hall showed outside of room [ROOM NUMBER] a wadded-up piece of paper on the floor. Observation on 02/03/26, at approximately 11:25 A.M., outside of room [ROOM NUMBER] on Prairie Lane Hall showed, what appeared to be, the same wadded-up piece of paper. 4. Review of Resident #6's face sheet showed an admission date of 08/14/25.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/09/25, showed the resident was cognitively intact. Observation and interview on 02/04/26, at approximately 9:55 A.M., showed the following: -There was a strong odor of bowel upon entering the room;-The resident said he/she wanted to share that he/she usually cleaned the room by him/herself since it takes too long when waiting on staff to do it;-The housekeeping staff are good, but there are not enough, so it takes a long time for them to make it to all the rooms;-None of the other staff want to help with cleaning; -He/she pointed to a pile of bedding, laying on the floor, under the sink counter. He/she said they stink because they are soiled and that he/she removed them from his/her bed two days ago;-No one had been in the room for two days to notice the bedding;-He/she said it was embarrassing and if anyone were to come in, he/she would feel shame or be embarrassed.5. Review of Resident #2's face sheet showed an admission date of 01/02/26.Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.During an interview on 01/31/26, at approximately 10:55 A.M., the resident said the following:-Staff will empty trash, but it takes them a long time to come in and do it;-Weekdays are better because housekeeping comes to help clean rooms.6. During an interview on 02/03/26, at approximately 10:45 A.M., Certified Occupational Therapeutic Assistant (COTA) M said the following:-He/she had noticed the facility being somewhat in a disarray, at times;-He/she had recently cleaned up some gum wrappers from under a resident's bed because they had been there so long.During an interview on 02/03/26, at approximately 11:05 A.M., Certified Nurse Aide (CNA) A said the following:-He/she finds the facility to be dirty when he/she arrives to work;-The night shift is the worst about throwing trash around;-He/she always tries to keep the area clean, that they are working from;-He/she will empty trashcans when noticed;-They had a department head of housekeeping up until a few months ago, which was the Maintenance Director, but he/she quit, and they do not have anyone in that position at this time;-Some of the residents are incontinent and if the aides are throwing anything with urine in the trash, it starts to smell;-They have a plumbing issue, as well, that makes the entire building have an odor;-Anytime they do showers, there is a sewer smell that comes up in several rooms throughout the facility.During an interview on 02/03/26, at approximately 11:25 A.M., CNA K said the following:-The facility is filthy when staff come in on Monday mornings;-It is the same after every weekend; -The weekend staff throw the trash down or leave it in residents' rooms, instead of taking it out and throwing it away.During an interview on 02/03/26, at approximately 12:40 P.M., Housekeeper L said the following:-It was normal to come in each day and find the facility a mess;-Typically, that included trash all over the floors;-The shower rooms would have clothes, bedding, and towels, all over, when they arrive in the mornings;-The trashcans in rooms or other areas were often overflowing.During an interview on 02/04/26, at approximately 1:20 P.M., CNA N said the following:-What housekeeping chores get done depend on who is working;-He/she always carried trash bags since someone's room is always dirty;-Housekeepers are supposed to clean every room, every day;-Once a month each room should be deep cleaned.During an interview on 02/04/26, at approximately 10:35 A.M., the Director of Nursing said the following:-There were three or four housekeeping staff;-She did not know if anyone from housekeeping was at the facility on weekends;-He/she believed there is a cleaning schedule that housekeeping was to follow;-Housekeeping should empty trashcans, sweep and wipe surfaces down daily. Aides can also do these tasks;-Generally, the aides change the linens, but anyone can and should sanitize the room.During an interview on 02/06/26, at approximately 4:00 P.M., the Administrator, said the following:-He/she expected all staff to pick up after any mess they make, regardless of the department they work in;-When staff notice an issue with cleanliness or odors, they try to clean right away.Complaint #2731470

Based on observation, interview, and record review, the facility failed to establish and follow an effective infection control program when staff failed to perform proper hand hygiene and prevent cross-contamination while performing peri-care for one resident (Resident #2) and when providing wound care to one resident (Resident #4). The facility census was 40. Review of the facility policy titled Standard Precautions Infection Control, dated 04/18/25, showed the following:-All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during providing resident care services. Therefore, all staff shall adhere to standard precautions to prevent the spread of infection;-Hand hygiene is a general term for cleaning hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR) and should be performed during the delivery of resident care services. Avoid unnecessary touching of surfaces in close proximity to the resident to prevent contamination of clean hands from environmental services and transmission of pathogens from contaminated hands to surfaces;-Personal protective equipment (PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-contamination. All staff who have contact with the residents and/or their environments must wear personal protective equipment as appropriate during resident care and/or with exposure to blood, body fluids, or potentially infectious materials1.Review of Resident #2's face sheet (brief look at resident information) showed the following information:-admission date of 01/02/26;-Diagnoses included multiple sclerosis (a chronic autoimmune disease of the central nervous system where the immune system attacks the protective myelin sheath covering nerve fibers, disrupting brain to body communication), neuromuscular dysfunction of bladder (occurs when nerve damage disrupts signals between the brain and bladder, causing overactive or under active symptoms), and quadriplegia (paralysis affecting all four limbs and the torso). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 01/02/26, showed the following information:-Cognitively intact;-Dependent on staff assistance for dressing, toileting, and mobility;-Indwelling catheter (a flexible tube inserted into the bladder to drain urine continuously into a bag, held in place by a small, inflated balloon) use.Review of the resident's care plan, dated 01/02/26, showed the following:-Monitor and document intake and output;-Monitor and report to nurse any kinks in catheter tubing;-Monitor and document any pain/discomfort due to the catheter;-Monitor/record/report to Medical Director for signs and symptoms of urinary tract infections.Observation on 02/05/26, at 10:45 A.M., showed the following: -Certified Nursing Assistant (CNA) I and CNA O entered the resident's room to perform catheter care;-Both CNAs performed hand hygiene and applied PPE;-The resident laid in his/her bed, with CNA O on his/her right side and CNA I on his/her left side;-CNA O took off the resident's brief and CNA I provided catheter care;-The resident rolled toward CNA O and CNA I provided care to the resident's backside. The resident had been incontinent of bowel;-CNA I obtained a clean brief and placed it under the resident without performing hand hygiene and changing gloves;-The CNAs rolled the resident back onto his/her back. CNA I adjusted the resident's urinary catheter, and hung the resident's catheter bag on the side of his/her bed without performing hand hygiene or changing gloves;-CNA I obtained a graduate (a disposable or reusable plastic container used in healthcare to accurately measure urine output) and drained the residents catheter bag of urine. CNA I emptied the graduate into the residents toilet, flushed the toilet, touched the resident's sink, and turned on the water to rinse the graduate in the sink;-CNA I removed his/her gloves and performed hand hygiene;-CNA I did not sanitize any of the areas in the room he/she touched with soiled gloves. During an interview on 02/05/26, at 11:14 A.M., CNA I said hand hygiene and glove changes should be performed anytime a staff member was going from a dirty surface to a clean surface to prevent cross-contamination.During an interview on 02/05/26, at 12:05 P.M., CNA J said hand hygiene and glove changes should be performed anytime a staff member goes from a dirty surface to a clean surface to prevent cross-contamination.During an interview on 02/06/26, at 10:30 P.M., the Director of Nursing (DON) said she expected staff to perform hand hygiene and glove changes anytime they move from a dirty surface to a clean surface.During an interview on 02/06/26, at 2:51 P.M., the Administrator said she expected staff to perform hand hygiene and glove changes anytime they go from a dirty surface to a clean surface.2. Review of Resident #4's face sheet showed the following information:-admission date of 05/12/25;-Diagnoses included cellulitis (bacterial skin infection) of left lower limb, non-pressure chronic ulcer (painful sore) of right lower and left lower leg, and pain in right lower and left lower leg.Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Moderate cognitive impairment;-Required substantial to maximum assistance from staff for lower body dressing, and supervision for mobility;-Open lesions on the foot. Review of the resident's care plan, dated 05/21/24, showed the following:-Complete weekly skin assessments;-Notify doctor of any new skin impairments and implement treatment orders.Observation on 02/05/26, at 10:14 A.M., showed the following:-Licensed Practical Nurse (LPN) C entered the resident's room to perform wound care;-An odor was detected from the wound and flies were seen around the resident's left leg. The left leg had gauze wrap that had brownish-yellow drainage coming through the wrap. There was a bed pad under the resident's leg with brownish-yellow drainage;-The LPN placed dressing supplies including gauze roll, bag of gauze, wound cleanser, and tape onto a clean barrier on the resident's bedside table;-The resident laid on his/her back with his/her left leg facing the LPN;-The LPN applied gloves without performing hand hygiene;-The LPN removed the resident's shoe and sock, obtained scissors from his/her pocket, and cut off the soiled dressing. Once the dressing was removed, he/she threw it into the trash can;-The LPN placed the soiled scissors onto the designated clean barrier on the resident's bedside table, beside the clean supplies;-The LPN removed his/her gloves, did not perform hand hygiene, applied clean gloves, and began cleansing the resident's wounds;-The LPN used one gauze pad and discarded it into the trash, obtained an additional gauze pad from the bag of gauze and grabbed the wound cleanser. The LPN did not perform hand hygiene or change his/her gloves before reaching into the bulk gauze bag and/or obtaining clean supplies;-The LPN continued with this process, then placed the wound cleanser bottle back onto the designated clean barrier and obtained the clean gauze roll from the designated clean barrier; -The LPN then said, I'm sorry, I don't remember all the steps, put the gauze roll back onto the designated clean barrier, removed his/her gloves, performed hand hygiene, applied clean gloves, and obtained the previously touched gauze roll;-The LPN began wrapping the resident's wound and put on the resident's sock;-The LPN left the resident's side and went to his/her medication cart, and opened three drawers looking for a biohazard bag;-The LPN returned to the resident's side, put on his/her shoe, and placed the resident's leg back onto the soiled bed pad, then exited the room;-The LPN removed his/her gloves and used hand sanitizer;-The contaminated bulk bag of gauze, scissors, and wound cleanser was placed on top the treatment cart.During an interview on 02/05/26, at 11:14 A.M., CNA I said any item used for multiple residents and/or taken in and out of resident rooms should be sanitized before and after use.During an interview on 02/05/26, at 12:05 P.M., CNA J said any item used for multiple residents and/or taken in and out of resident rooms should be sanitized before and after use.During an interview on 02/06/26, at 10:30 P.M., the DON said the following:-She expected staff to sanitize any item that was used for multiple residents before and after use;-Soiled hands should not be placed into bulk supplies.During an interview on 02/06/26, at 2:51 P.M., the Administrator said the following:-She expected staff to sanitize any item that were used for multiple residents before and after use;-Soiled hands should not be placed into bulk supplies.Complaint #2731470

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and service care to prevent possible urinary tract infections when staff failed to provide catheter (tube placed in the body to drain and collect urine from the bladder) care per standards of practice, failed to obtain an order for catheter care, and failed to complete catheter care per the care plan for one resident (Resident #2). The facility census was 40.Review of the facility policy titled Catheter Care, dated 05/02/25, showed the following information:-Catheter care will be performed every shift and as needed;-Gently grasp penis and draw foreskin back if applicable;-Using a circular motion, cleanse the meatus (opening) with a clean cloth moistened with water and soap;-With a new moistened cloth, starting at the urinary meatus, moving downward, cleanse the shaft of the penis;-With a new moistened cloth, starting at the urinary meatus, moving outward, and wipe the catheter making sure to hold the catheter in place to not pull it;-Dry area with a towel.1. Review of Resident #2's face sheet (brief look at resident information) showed the following information:-admission date of 01/02/26;-Diagnoses included neuromuscular dysfunction of bladder (occurs when nerve damage disrupts signals between the brain and bladder, causing overactive or under active symptoms). Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 01/02/26, showed the following information:-Cognitively intact;-Dependent on staff assistance for toileting;-Indwelling catheter used.Review of the resident's care plan, dated 01/02/26, showed the following:-Monitor and document intake and output;-Monitor and report to nurse any kinks in catheter tubing;-Monitor and document any pain/discomfort due to the catheter;-Monitor/record/report to Medical Director signs and symptoms of urinary tract infections.(The care plan did not address catheter care.) Review of the resident's February 2026 Physician Order Sheet (POS) showed staff did not obtain orders related to catheter care. Observation on 02/05/26, at 10:45 A.M., showed the following:-Certified Nursing Assistant (CNA) I and CNA O entered the resident's room to perform catheter care; -Both CNAs performed hand hygiene and applied personal protective equipment (PPE);-The resident laid in his/her bed, with CNA O on his/her right side and CNA I on his/her left side;-CNA O took off the resident's brief, and CNA I began cleansing the resident's inner thighs with a wet washcloth;-After cleansing the inner thighs, CNA I did not obtain a new washcloth, but folded the washcloth over after swipes. CNA I did not discard soiled gloves, perform hand hygiene, or apply new gloves;-CNA I did not draw back the resident's foreskin and began cleansing the distal (furthest from resident) end of the catheter tubing and working his/her way up to the proximal (closest to the resident) end of the catheter, where it entered the meatus;-The resident rolled toward CNA O and CNA I provided care to the resident's backside, as the resident had been incontinent of bowel;-CNA I did not perform hand hygiene or perform a glove change prior to obtaining a clean brief and placing it under the resident;-The resident was rolled back onto his/her back. CNA I adjusted the resident's urinary catheter, and hung the resident's catheter bag on the side of his/her bed;-CNA I obtained a graduate (a disposable or reusable plastic container used in healthcare to accurately measure urine output) and drained the resident's catheter bag of urine. During an interview on 02/05/26, at 11:14 A.M., CNA I said the general process for catheter care was to perform hand hygiene, apply gloves, obtain the proximal end to the resident's catheter tubing, and clean away from the resident's body, so nothing is contaminated during the process.During an interview on 02/05/26, at 12:05 P.M., CNA J said catheter tubing should be cleansed in a manner away from the body to prevent infections.During an interview on 02/06/26, at 10:30 P.M., the Director of Nursing said she expected catheter tubing to be cleansed away from the body to prevent infections.During an interview on 02/06/26, at 2:51 P.M., the Administrator said she expected catheter tubing to be cleansed away from the body to prevent infections.Complaint #2731470

Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources (facility's operating budget) effectively and efficiently when the facility failed to ensure all bills were paid in a timely manner to prevent credit holds and delays in maintenance of the fire and rescue system. The facility census was 44. Review showed the facility did not provide policy and procedure regarding bill pay.1. During an interview on 01/18/26, at 9:52 A.M., the Maintenance Director said the following:-The fire and safety system, including sprinklers, was serviced by Marmic Fire and Rescue;-The only current concern with the system is an air pressure leak; -Marmic provided inspection and maintenance services quarterly.During an interview on 01/21/26, at 10:02 A.M., Marmic Fire and Safety Representative said the following:-The facility was currently on a credit hold;-The facility's last quarterly review was completed on 08/31/25 of the sprinkler system; -There was a deficientcy in the sprinkler system to include multiple leaks causing the system to trip. This would not be fixed until the facility is no longer had a credit hold;-Additionally, the facility was supposed to have an inspection of the kitchen exhaust system in November of 2025;-The facility was past due for their annual alarm testing, as well as the alarm inspection. -There are several outstanding bills.During an interview on 01/21/26, at 10:15 A.M., Marmic Fire and Safety Supervisor said the following:-The facility was 90 days overdue on $4,838.00. Sometime in the last 60 days the facility paid $2,300.00. At 60 days the facility remained overdue on $2,326.57-The facility currently had a remaining balance of $2,512.08;-There would be no repaired or inspections performed until the facility is no longer on credit hold. During an interview on 01/21/26, at 1:15 P.M., the Business Office Manager said the following:-She was not aware of there being any credit holds;-The Maintenance Director obtained any invoices from the service company and gave them to her. She then sent those invoices to accounts payable;-The credit hold was just brought up to her yesterday;-She was not aware that there are issues within the fire and safety system needing fixed and inspections needing completed. During an interview on 01/22/26, at 11:01 A.M., the Administrator said the following:-She just became aware that there was a bill sent to accounts payable;-Marmic sent all invoices to the Maintenance Director;-On 01/20/26, the Maintenance Director told her that there was a past due bill that was needing to be paid;-She was not aware of any services that have not been provided due to past due bills;-She assumed that all inspections have been completed and that no current maintenance is needed as that has not been relayed to her;-She expected any concerns to be brought to her attention.Complaint #2721480

Based on observation and interview, the facility failed to ensure a safe, functional, sanitary, and comfortable environment was provided for residents and staff when the facility failed to keep the walls in the kitchen free from discoloration, moisture, and fuzzy/powdery substance. The facility census was 44. 1. Observation and interview on 01/18/26, at 1:15 P.M., showed the following:-Upon entering the cleaning side of the kitchen and looking to the right there was black and green spotted discoloration was seen in the corner from the top of the sink area up to the ceiling. The texture appeared powdery;-DA H pulled back the splash guard behind the sink and black and green spotted discoloration was seen. The area also appeared wet;-DA H continued to pull back splash guards/protective paneling going further into the kitchen area near a window. Underneath the paneling was drywall with black and green spotted discoloration. The texture of the discoloration appeared powdery;-DA H pulled back the protective paneling to show dry wall with nearly floor length black and green spotty discoloration. The texture of the discoloration appeared powdery and almost furry in this area;-There was an air unit under the window in between the kitchen sink wall and the furthest corner wall that also appeared to have a black powdery substance on the vents;-DA H said this has been an issue for a long time.During an interview on 01/18/26, at 12:59 P.M., DA G and DA H said the following:-There were concerns of mold in the kitchen. They believed mold could be found behind all splash guards on the dishwasher side of the kitchen;-They spoke with the Administrator regarding this matter before;-They spoke with the Maintenance Director regarding this matter, and he pulled back the splash guard, took a picture, reported to them that he is allergic to it, and left the kitchen.During an interview on 01/20/26, at 1:50 P.M., the Dietary Manager said the following:-She believed the black and green powdery/[NAME] substance to be mildew;-The areas of concern just came to her attention a couple of days ago;-She believed that the Maintenance Director was instructed to get a quote to get the area of concern removed;-She had instructed her staff to clean the areas of concern with vinegar; but believed the panels will need replaced.During an interview on 01/20/26, at 1:54 P.M., the Maintenance Director said the following:-If a mildew or mold concern were brought to him; he would recommend cleaning the area;-He was made aware of the black and green discoloration on 01/18/26;-He has taken the paneling off the wall and the area has been washed. He was currently working on getting all of the old caulk scrapped off. After the walls are thoroughly cleaned, he will replace the paneling;-If the area that is affected is the dry wall, he will call a company to have that addressed;-He was not aware that the areas of concern area on drywall;-He was only aware of the area of concern on the actual paneling, not behind the paneling.During an interview on 01/21/26, at 1:51 P.M., the Director of Nursing (DON) said the following:-She has not personally been in the kitchen, but has heard about some mold concerns;-She believed the Dietary Manager had her staff cleaning the areas of concern with vinegar.During an interview on 01/22/26, at 11:01 A.M., the Administrator said the following:-The Maintenance Director told her on approximately 01/20/26 about a mildew or mold concern in the kitchen;-Since then, housekeeping has been asked to wash the walls; -She asked the Maintenance Director to call some local companies and get some quotes on removal;-Dietary should also have a cleaning schedule.Complaint #2719681

Based on interview and record review, the facility failed to ensure resident representatives and physicians were notified of changes in condition in timely fashion when staff failed to document guardian and physician notification for one resident (Resident #3) who had a documented change in condition. The facility census was 44.Review of the facility's policy titled Notification of Changes, dated [DATE], showed the following information:-The facility must inform the resident, consult the resident's physician, and/or notify the resident's family member or legal representative when there is a change requiring notification;-Circumstances requiring notification include a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status; -For residents that are incapable of making decisions, the representative would make any decisions that have to be made.1. Review of the Resident #3's face sheet (brief look at resident information) showed the following information: -admission date of [DATE];-Diagnoses include heart failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs), diabetes, high blood pressure, and paranoid schizophrenia (a chronic mental disorder marked by intense, irrational distrust, auditory hallucinations and delusions of being persecuted or plotted against).Review of the resident's care plan, initiated on [DATE], showed the following information:-Enjoyed participating in activities;-Had a potential for decline in mood; -Staff to administer medication as prescribed and monitor for signs of depression;-History of care and medication refusals;-History of self harm;-History of heart disease; -History of diabetes. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated [DATE], showed the resident was cognitively intact.Review of the resident's progress note dated [DATE], at 10:47 P.M., showed the following:-The resident was refusing care and all medications;-The resident believed that staff and other residents were trying to kill him/her by poisoning him/her;-Additionally, the resident was self-isolating in his/her room more.(Staff did not document physician and resident representative notifications.) Review of the resident's behavior note dated [DATE], at 2:23 A.M., showed the resident had experienced a loss of appetite and did not eat dinner. (Staff did not document physician and resident representative notifications.)Review of the resident's behavior note dated [DATE], at 9:27 P.M., showed the resident was refusing his/her insulin administration and was swatting at the nurse. (Staff did not document physician and resident representative notifications.)Review of the resident's progress note dated [DATE], at 11:01 P.M., showed the following:-The resident continued to self-isolate and was no longer attending activities, smoking, or eating;-The resident began to only offer one worded answers when staff would attempt to converse with him/her;-The resident continued to refuse medications.(Staff did not document physician and resident representative notifications.)Review of the resident's progress note dated [DATE], at 5:27 A.M., showed the following:-The resident continued to self-isolate and was refusing to attend activities that he/she normally would enjoy. The resident is typically very social;-The resident has been taking all of his/her clothing off and refusing to put clothing on;-The resident continued to refuse medications including insulin and glucose checks, stating no that is poison, you all are trying to kill me.(Staff did not document physician and resident representative notifications.)Review of the resident's physician progress note dated [DATE], at 11:23 A.M., with a service date of [DATE], showed the following:-The resident was seen on [DATE] at the request of nursing staff for hypoglycemia (low blood sugar) and delusions;-Over the past several weeks, staff notes showed two episodes of hypoglycemia;-The staff reported the resident was experiencing increased agitation, paranoia, and confusion, with the resident stating that medications and insulin were poison and that the staff were trying to kill him/her;-He/she had been refusing all medications, insulin, and blood glucose monitoring and was no longer participating in activities he/she previously enjoyed and was isolating his/herself;-New orders included new medication, a decrease in insulin, and lab work.(Staff did not document resident representative notification.)Review of the resident's behavior note dated [DATE], at 8:41 A.M., showed the resident refused mediation and insulin. (Staff did not document physician and resident representative notifications.)Review of the resident's progress note dated [DATE], at 8:25 P.M., showed the resident continued to refuse medications. (Staff did not document physician and resident representative notifications.)Review of the resident's physician progress note dated [DATE], at 2:33 P.M., with a service date of [DATE], showed the following:-The resident was seen on [DATE] for continued delusions;-He/she reported feeling terrible and expressed fixed beliefs that there was no infection, so he/she was refusing the previously ordered labs;-The resident stated that there was a bobcat, snakes, and different animals all over his/her body;-Staff report variable by mouth intake over the last several days;-New orders include labs, chest x-ray, and urinary analysis.(Staff did not document resident representative notification.)Review of the resident's progress note dated [DATE], at 9:40 A.M., showed a phone call was placed to the resident's guardian to communicate that the resident had collapsed and that cardiopulmonary resuscitation was in progress.Review of the resident's progress note dated [DATE], at 9:45 A.M., showed Registered Nurse (RN) B noted the following:-He/she was at the nursing station when an aide came up to him/her and reported that the resident had fallen in the living room;-He/she went back to assess the resident and seen the resident lying on the floor on his/her back with foam and drool coming out of his/her mouth;-CPR was started by staff while the Director of Nursing (DON) called emergency medical services (EMS) and the resident's guardian;-CPR continued until EMS arrived and transported the resident to the emergency Department (ED).During an interview on [DATE], at 12:32 P.M., Certified Nursing Assistant (CNA) F said the following:-When a resident experienced a change in condition, the nurse should assess, document, and make all necessary notifications;-If a resident was frequently refusing medications, meals, and was self isolating. That was something the nurses typically will send the resident out to the hospital for;-The resident was alert and oriented typically but struggled with mental health. He/she was known to cycle and had required hospitalization for psychiatric services about every six months or so.During an interview on [DATE], at 1:31 P.M., CNA E said if a resident experienced a change of condition, he/she would notify the nurse for assessment. The nurse would make his/her assessment and make all necessary notifications as well as document. He/she had heard that the resident was declining.During an interview on [DATE], at 1:51 P.M., CNA I said if a resident experienced a change of condition, he/she would notify the nurse for assessment. The nurse would make his/her assessment, make all necessary notifications, and document.During an interview on [DATE], at 2:06 P.M., Registered Nurse (RN) B said the following:-He/she was aware of the change of condition in the resident. The physician was involved in the care;-He/she tried to get the resident sent to the hospital for altered mental status because the resident was self-isolating, refusing medications, and meals. He/she did communicate that with the physician, but lab work and x-rays were recommended instead. The lab work was refused by the resident;-He/sent an additional message via Mediprocity (a communication application that provides secure communication and workflow tools) to the physician indicating he/she would like to send the resident to the hospital on [DATE] and did not hear back from the physician;-He/she felt that sending the resident out for stabilization would have been the most appropriate action;-He/she did document when the resident would refuse or self-isolate but did not notify the guardian of those changes. Typically those notifications are not made unless there are new orders.During an interview on [DATE], at 2:06 P.M., Licensed Practical Nurse (LPN) C said the following:-If a resident were to experience a change of condition, the physician and guardian should be notified;-Had he/she been the resident's nurse, he/she would of notified the physician and guardian immediately and documented accordingly.During an interview on [DATE], at 2:38 P.M., RN D said the following:-Changes of conditions should be assessed and necessary notifications should be made after a nurse's assessment;-The resident had psychiatric concerns, which he/she documented on in the progress notes;-He/she did not notify the guardian of any changes in the resident and was not sure if anyone else did either.During an interview on [DATE], at 10:55 A.M., the former Assistant Director of Nursing (ADON) said the following:-Residents should be sent to the hospital for altered mental status;-Given the resident's history and symptoms of medication, meal, and socialization refusals he/she should have been sent to the hospital;-She was not sure if the resident's guardian was ever notified of the changes that occurred with the resident;-Ultimately, if there was a change of condition, the resident should be assessed, and the physician and guardian should be notified and everything should be documented.During an interview on [DATE], at 12:26 P.M., LPN A said the following:-He/she had heard the resident was frequently refusing medications and meals;-He/she did not provide care for the resident, but if he/she had and noticed the resident was having a psychotic episode, he/she would notify the physician and ask for a psychiatric evaluation;-The guardian should have been notified and a change of condition assessment should have been documented. During an interview on [DATE], at 1: 51 P.M., the DON said she expected any changes of conditions to be addressed, a change of condition assessment to be completed, and the physician and guardian to be notified.During an interview on [DATE], at 9:45 A.M., the resident's Case Manager said the following:-She and the guardian of the resident had not heard a lot from the facility in regards to the resident;-On [DATE], the facility contacted the guardian's office. She did not hear again about the resident until [DATE] when she was asked for permission on podiatry (foot doctor) services;-The next facility contact made was on [DATE] indicating that the resident had collapsed and CPR was being initiated;-The expectation was for her and the guardian to be contacted with any resident concerns as they have ultimate say on what should be done in response to the resident concerns.During an interview on [DATE], at 11:01 A.M., the Administrator said the following:-Regarding changes of condition, she expected the nurses to assess the situation and document;-Physician and guardians should be notified of any changes of condition.Complaints #2720635

Based on interview, and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting ) received the necessary services to maintain grooming when the facility failed to ensure showers were offered to one resident (Resident #2). The facility census was 44.Review of the facility policy titled Resident Showers, dated 06/10/25, showed the following information:-It is the practice of this facility to assist resident's with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues in accordance with current standards of practice;-Residents will be provided showers in accordance with the resident's preferences, care plan, and safety needs, as well as the facility's scheduled bathing protocol.Review of the resident's face sheet, showed the following information:-admitted to the facility on [DATE];-Diagnoses include diabetes, dementia, high blood pressure, and chronic kidney disease.Review of the resident's admission Minimum Data Sheet (MDS- a federally mandated assessment tool filled out by facility staff), dated 01/09/25, showed the following information:-Moderate cognitive impairment;-Requires partial to moderate assistance from staff for mobility;-Requires substantial to maximum assistance from staff for bathing.Review of the resident's care plan, initiated on 01/09/26, showed the care plan does not address the resident's bathing preferences and/or bathing schedule. Review of the facility policy titled Resident Showers, dated 06/10/25, showed the following information:-It is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues in accordance with current standards of practice;-Residents will be provided showers in accordance with the resident's preferences, care plan, and safety needs, as well as the facility's scheduled bathing protocol.1. Review of Resident #2's face sheet showed the following information:-admission date of 01/05/26;-Diagnoses include diabetes, dementia, high blood pressure, and chronic kidney disease.Review of the resident's progress notes showed the resident discharged from the facility on 01/15/26. Review of the resident's admission Minimum Data Sheet (MDS- a federally mandated assessment tool filled out by facility staff), dated 01/09/26, showed the following information:-Moderate cognitive impairment;-Required partial to moderate assistance from staff for mobility;-Required substantial to maximum assistance from staff for bathing.Review of the resident's care plan, initiated on 01/09/26, showed staff did not care plan related to the resident's bathing preferences and/or bathing schedule.Review of the resident's electronic medical record (EMR) showed staff did not document regarding a shower record.Review showed the facility did not provide any shower sheets for showers completed during the resident's stay.During an interview on 01/20/26, at 2:06 P.M., Licensed Practical Nurse (LPN) C said the following:-He/she did not work during day shift hours, but believed showers were to be completed on the day shift, Monday through Friday;-There should be a schedule posted;-It would not be appropriate for a resident to go without a shower for days;-The shower aides document the showers on a shower sheet. Refusals are also documented on the sheet and then turned into the nurse for review.During an interview on 01/20/26, at 2:38 P.M., Registered Nurse (RN) D said the following:-The facility had a shower aide. The shower aide was expected to have a schedule to follow;-Residents should also be offered showers on an as needed basis;-Showers and shower refusals were documented on shower sheets, and then turned into the nurse for review;-[NAME] had reported to him/her that the resident had not received a shower.During an interview on 01/21/26, at 10:55 A.M., the former Assistant Director of Nursing (ADON) said the following:-The facility had a shower aide;-The expectation was for two showers a week to be offered;-The shower aide made the shower schedule. He/she became aware of new admissions by the nurses accepting the admission;-She was not aware the resident had not received a shower;-Shower sheets were expected to be filled out and indicate if the resident refused. Those shower sheets were then turned into the nurse for review;-She had not seen a progress note on any resident refused and/or missed showers.During an interview on 01/21/26, at 12:11 P.M., Certified Nursing Assistant (CNA) E said the following: -He/she was the shower aide;-He/she did not have a set schedule for showers;-He/she had been pulled to work the floor multiple times possibly causing residents to go without showers;-All aides were able to shower the residents. He/she asked that they leave a note on the shower door indicating whose shower had or had not been completed;-He/she did not shower the resident and was unaware if anyone else did as no one had communicated that to him/her;-The expectation was for each resident to receive two showers a week;-Shower sheets were filled out with each shower and/or refusal and then turned into the nurse for review.During an interview on 01/21/26, at 12:26 P.M., LPN A said the following:-The expectation was for resident to receive showers two times a week;-The facility was short staffed and often pulled the shower aide to the floor, possibly causing residents to go without showers;-He/she had not heard about the resident refusing showers;-He/she had not heard that the resident had not had a shower;-Shower sheets were filled out for showers and/or refusals and then turned into the nurse for review. During an interview on 01/21/26, at 1:31 P.M., RN B said the following:-Showers were expected to be offered two times a week;-The shower aide was usually pulled to the floor, possible causing residents to go without showers;-All showers and shower refusals should be documented on a shower sheet and then turned into the nurse for review.During an interview on 01/21/26, at 1:51 P.M., the Director of Nursing (DON) said the following:-She expected all residents to have two showers a week;-The former ADON was responsible for overseeing showers;-She cannot locate any shower sheets for the resident; -The resident was at the facility for a short period of time, but should have had at least one shower;-All showers and shower refusals should be documented on the shower sheet and then turned into the nurse for review.During an interview on 01/22/26, at 11:01 A.M., the Administrator said the following:-She expected showers to be offered two times a week;-The shower aide should fill out shower sheets for all showers and shower refusals and then turn those into the nurse for review;-Shower schedules should be personalized to the resident's preference. Complaint #2720635

Based on interview and record review, the facility failed to ensure residents were free from accidents when the facility failed to notify the resident's physician and family after a fall and failed to review and update the resident's care plan for one resident (Resident #2) who suffered a fall. The facility census was 44.Based on interview and record review, the facility failed to ensure residents were free from accidents when the facility failed to notify the resident's physician and family after a fall and failed to review and update the resident's care plan for one resident (Resident #2) who suffered a fall. The facility census was 44.Review of the facility policy titled Accidents and Supervision, dated 05/16/25, showed the following information:-Each resident will receive adequate supervision and assistive devices to prevent accidents including identifying hazards, evaluating and analyzing hazards, implementing interventions to reduce hazards, and monitoring for effectiveness and modifying interventions when necessary;-Fall refers to unintentionally coming to a rest on the ground, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen is considered a fall. A fall without injury is still a fall.Review of the facility policy titled Fall Risk Assessment, dated 06/09/25, showed the following:-A risk assessment is to be completed by the nurse or designee upon admission, quarterly, and when a change has occurred;-The risk assessment will identify environmental hazards and individual risks, including the need for supervision, and evaluate and analyze hazards;-An at risk for falls care plan will be completed for each resident to address items identified on the risk assessment and updated accordingly;-An at risk for falls care plan will include interventions, including adequate supervision consistent with a resident's needs, goals, and current standards of practice;-Monitor the effectiveness of the care plan interventions and modify as necessary.Review of the facility policy titled Fall Prevention Program, dated 05/29/25, showed when any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify physician and family, review the resident's care plan and update, document all assessments and actions, and obtain witness statements in care of an injury.1. Review of the Resident #2's face sheet showed the following information:-admission date of 01/05/26;-Diagnoses include diabetes, dementia, high blood pressure, and chronic kidney disease.Review of the resident's fall risk assessment, dated 01/05/26, showed the following information:-Experienced one to two falls in the past three months;-Had intermittent confusion;-Ambulatory with a balance problem and required an assistive device;-At risk for falls.Review of the resident's admission Minimum Data Sheet (MDS- a federally mandated assessment tool filled out by facility staff), dated 01/09/25, showed the following information:-Moderate cognitive impairment;-Required partial to moderate assistance from staff for mobility;-History of falls with no falls since admission.Review of the resident's care plan, dated 01/09/26, showed the following:-At risk for falls;-Ensure the call light is within reach and encourage the resident to use it for prompt assistance.Review of the resident's progress note dated 01/13/26, at 4:08 A.M., showed Licensed Practical Nurse (LPN) C said the following:-The resident was attempting to use the restroom at 3:30 A.M. and fell against the bathroom door. Staff did not see any injuries;-Resident had full range of motion for all extremities;-Vital signs and neurological checks within normal limits;-Small bruise located in the middle of the lower back appeared to be older in nature;-Staff will continue to monitor resident;-Reminded the resident to use the call light for assistance.(Staff did not document physician or family notification. Staff did not document any additional interventions or reason for no additional interventions being implemented.)Review of the resident's care plan, dated 01/09/26, showed staff did not update the care plan with the fall or new interventions.Review of the resident's electronic medical record (EMR) showed LPN C did not complete a new fall risk assessment.During an interview on 01/20/26, at 2:06 P.M., LPN C said the following:-The process for falls was to assess the resident for injury, ensure vital signs, range of motion, and neurological checks are within normal limits;-He/she was alerted to the resident's room, where he/she found the resident sitting on his/her bottom leaning against the bathroom door. The door was noted to be dented in, assuming from the resident's bottom hitting the door. The resident was confused generally, but denied hitting his/her head;-Everything was within normal limits, so the resident was assisted up off the floor-He/she did start neurological checks on the resident;-He/she was unsure of any other documentation needed;-He/she assumed the following shift would make any necessary notifications;-If there had been an injury he/she would have made the notifications his/herself. During an interview on 01/20/26, at 2:38 P.M., Registered Nurse (RN) D said the following:-LPN C told him/her that the resident had fallen overnight on 01/13/26 and was placed on fall follow up;-Proper fall protocol included assessing the resident, beginning neurological checks, initiating fall follow up documentation, completing an incident report, notifying the physician and family, and updating the care plan.During an interview on 01/21/26, at 10:55 A.M., the former Assistant Director of Nursing (ADON) said the following:-After a fall a resident should be left where they are until a nurse assessed them for injury;-Nurses are expected to notify the physician and family, complete an incident report, initiate fall follow up documentation, complete a new fall risk assessment, and update the care plan;-She was not aware the resident had fallen.During an interview on 01/21/26, at 12:11 P.M., Certified Nursing Assistant (CNA) E said the following: -After a fall, the person finding the resident should stay with them while alerting a nurse for assessment;-Once the nurse assesses the resident, the resident is assisted back up;-In report, it was told to him/her that the resident actually fell multiple times in the early hours of 01/13/26;-Nurses should make necessary notifications;-He/she was unaware of what all reports and or documentation needs done on the nurses' end for falls. During an interview on 01/21/26, at 12:26 P.M., LPN A said the following:-After a fall, the residents should be assessed by the nurse;-He/she liked to fill out change of condition forms for falls versus incident reports;-The physician, family and the Director of Nursing (DON) should be notified of falls; -The resident should be educated on interventions, and those interventions should be added in the care plan.During an interview on 01/21/26, at 1:31 P.M., RN B said proper fall protocol included assessing the resident, beginning neurological checks, initiating fall follow up documentation, completing an incident report, notifying the physician and family, and updating the care plan.During an interview on 01/22/26, at 10:44 A.M., the MDS/Medical Records Nurse said care plans should be individualized and include all aspects of the resident's care.During an interview on 01/21/26, at 1:51 P.M., the DON said the following:-Nurses should assess the resident prior to the resident being moved;-Full assessments should be completed regardless of fall type and incident reports should be completed;-LPN C did not complete an incident report. Within the incident report, it prompts the staff member to do a fall risk evaluation, a skin assessment, and update the care plan;-Progress notes should also be completed for fall follow ups for 72 hours;-Physician, family, and she should be notified of all falls. During an interview on 01/22/26, at 11:01 A.M., the Administrator said the following:-She expected falls to be documented, therapy to evaluate the resident, incident reports to be completed, and the care plan to be updated with interventions.Complaint #2720635

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when the facility failed to have a chemotherapy medication (a powerful drug that kill fast-growing cancer cells by disrupting their ability to grow and divide) on hand for administration and failed to follow-up with the pharmacy and physician when the medication was not administered for one resident (Resident #1). The facility census was 44. Review of the facility policy titled Medication Errors. dated 04/07/25, showed the following information:-Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications regarding the preparation and administration of the medication or biological or accepted professional standards and principles which apply to professionals providing services;-Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety;-The facility shall ensure medications will be administered according to physician's orders, per manufacturer's specifications regarding the preparation and administration of the drug, and in accordance with accepted standards and principles which apply to professionals providing services.1. Review of the resident's face sheet showed the following information:-admission date of 07/05/24;-Diagnoses included malignant neoplasm (a cancerous tumor capable of invading surrounding tissue and growing rapidly) of kidney, chronic obstructive pulmonary disease (COPD- a progressive lung disease that causes airflow obstruction and breathing difficulties), and benign intracranial hypertension (a condition of elevated cerebrospinal fluid pressure around the brain).Review of the resident's quarterly Minimum Data Sheet (MDS- a federally mandated assessment tool filled out by facility staff), dated 12/26/25, showed the following information:-Moderate cognitive impairment;-Receives chemotherapy medication;-Requires supervision from staff for mobility. Review of the resident's care plan, revised on 01/22/26, showed the resident had a diagnosis of neoplasm of the kidney. (Staff did not care plan related to the management of the neoplasm.)Review of the resident's January 2026 Medication Administration Record (MAR) showed the following:-An order, dated 07/05/24, Lenvima (a prescription oral multikinase inhibitor medication used to treat certain advanced cancers. The medication works by blocking specific proteins that stimulate tumor growth and inhibiting the formation of new blood vessels that nourish tumors) oral capsule therapy pack 10 milligram (mg), give one capsule by mouth daily for cancer treatment;-On 01/01/26, the staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/01/26, at 9:26 A.M., showed staff needed to order the Lenvima.Review of the resident's January 2026 MAR showed on 01/05/26, the staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/05/26, at 10:20 A.M., showed the Lenvima was not available. (Staff did not document physician or pharmacy notification.)Review of the resident's January 2026 MAR showed on 01/07/26, the staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/07/26, at 8:21 A.M., showed the Lenvima was not available. (Staff did not document physician or pharmacy notification.)Review of the resident's January 2026 MAR, showed on 01/09/26, the staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/09/26, at 8:50 A.M., showed the staff were waiting on the Lenvima. (Staff did not document physician or pharmacy notification. )Review of the resident's January 2026 MAR showed on 01/10/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/09/26, at 8:50 A.M., showed the staff were waiting on Lenvima to be delivered. (Staff did not document physician or pharmacy notification.)Review of the resident's January 2026 MAR showed on 01/11/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/11/26, at 7:57 A.M., showed the staff were waiting on Lenvima to be delivered. (Staff did not document physician or pharmacy notification.)Review of the resident's January 2026 MAR showed on 01/12/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/12/26, at 8:13 A.M., showed the staff were waiting on Lenvima that was on order. (Staff did not document physician or pharmacy notification.)Review of the resident's progress note dated 01/12/26, at 9:41 A.M., showed the medication was on order. Staff were only able to currently fill at specific pharmacy per cancer center. Staff spoke to pharmacy rep who said he/she needed verbal consent from the patient directly. Staff notified the Interdisciplinary Team (IDT).Review of the resident's January 2026 MAR showed on 01/13/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/13/26, at 8:26 A.M., showed the staff were waiting on Lenvima was on order. (Staff did not document physician or pharmacy notification.)Review of the resident's January 2026 MAR, showed on 01/14/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/14/26, at 9:15 A.M., showed staff did not document regarding the Lenvima not being administered. Review of the resident's January 2026 MAR showed on 01/15/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note, dated 01/15/26, showed staff did not document regarding the Lenvima not being administered Review of the resident's January 2026 MAR showed on 01/16/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/16/26, at 8:47 A.M., showed the staff were waiting on Lenvima to be delivered. (Staff did not document physician or pharmacy documentation.)Review of the resident's January 2026 MAR, showed on 01/17/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note dated 01/17/26, at 9:36 A.M., showed staff noted Lenvima order pending. (Staff did not document physician or pharmacy notification.)Review of the resident's January 2026 MAR showed on 01/18/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress not, dated 01/18/26, at 8:50 A.M., showed the Lenvima was not available, pending delivery. (Staff did not document physician or pharmacy notification.)Review of the resident's January 2026 MAR showed on 01/19/26, staff did not administer the medication with no reason provided. Review of the resident's January 2026 MAR showed on 01/20/26, staff did not administer the Lenvima due to other/see progress notes.Review of the resident's progress note, dated 01/20/26, showed staff did not document regarding the Lenvima.During an interview on 01/21/26, at 10:55 A.M., the former Assistant Director of Nursing (ADON) said the following:-Medications were expected to be administered per physician orders;-If a medication was not able to be administered due to not being available, staff should follow up with the pharmacy and physician. The nurses have not been doing that;-She was aware that the resident had been without his/her chemotherapy medication for at least a couple of weeks;-She brought this to the Director of Nursing (DON)'s attention when she noticed that nurses continuously were documenting not available;-The DON told her that the medication needed to come from a different pharmacy than where it had previously been sent to and that another nurse was handling it;-The expectation was to immediately call the pharmacy and physician regarding the medication not being available, as well as document those notifications.During an interview on 01/21/26, at 12:26 P.M., Licensed Practical Nurse (LPN) A said the following:-He/she did not administer medications often, but when he/she did, he/she noticed that a lot of medications were not available to be administered;-Chemotherapy drugs were administered by nurses;-If the medication was not available for administration, the nurse should check the E-Kit (emergency drug kit);-If the medication was not in the E-kit, the pharmacy and physician should be called and notified. The notification should be documented in the progress notes;-He/she would also notify the DON of any medications that were not able to be given.During an interview on 01/21/26, at 1:31 P.M., Registered Nurse (RN) B said the following:-There was an issue with their pharmacy service for a while;-He/she was aware the resident was out of chemotherapy drugs;-He/she did notify the resident's oncologist;-Staff are expected to notify, the physician, pharmacy, and the DON when medications were not available to be administered;-All notifications should be documented in the progress note.During an interview on 01/22/26, at 10:44 A.M., the MDS/Medical Records Nurse said the following:-Anyone can update a resident's care plan;-The care plan should be individualized and include the resident's diagnoses as well as the management of those diagnoses.During an interview on 01/21/26, at 1:51 P.M., the DON said the following: -She expected medication to be administered per physician orders;-If a medication was not available, she expected staff to bring that to her attention;-She expected staff to notify the pharmacy and document the notification;-She was not aware the resident was without his/her chemotherapy medication;-The nurses were responsible for administration of chemotherapy drugs;-She believed the chemotherapy drugs came from an outside pharmacy.During an interview on 01/21/26, at 4:21 P.M., the Medical Director said the following:-He expected physician orders to be followed;-He was not aware of any current medications not being filled;-There have been some issues with the facility's pharmacy service; -[NAME] had notified him of chemotherapy drugs not being available for administration;-He does not manage chemotherapy drugs;-The facility staff should be notifying the resident's oncologist of any medication concerns.During an interview on 01/22/26, at 11:01 A.M., the Administrator said the following:-She expected medications to be administered per physician order;-She was not aware of medications not being available for administration;-If a nurse saw there was a medication that was not available, they were expected to notify the DON, pull from the E-Kit, and notify the pharmacy;-Any interventions should be documented. Complaint 2721550

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to control the fly population when multiple flies were present in and around four residents (Resident #1, Resident #2, Resident #3, Resident #4). The facility census was 49.Review of the facility's policy titled Pest Control Program, revised 06/15/25, showed the following:-It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents;-Facility will utilize a variety of methods in controlling certain seasonal pests, flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.1. Review of the facility's pest control service inspection reports showed the following:-On 12/08/25, inspection of the interior at 1:30 P.M. Bug light on main hall showed fly activity; -On 12/18/25, inspection with no detail of noted. 2. Review of Resident #1's face sheet (admission data) showed the resident admitted to the facility on [DATE].Review of the resident's quarterly minimum data sheet (MDS-a federally mandated assessment form completed by facility staff), dated 10/24/25, showed the resident had impaired cognitive skills. Observation on 01/08/26, at 10:00 A.M., showed the following:-The resident was in his/her bed;-Two files buzzed around the resident and one fly crawled around on his/her left hand.Observation on 01/08/26, at 12:26 P.M., showed the following:-The resident was in his/her bed with his/her eyes closed;-Three flies sat on his/her left leg, one fly sat on his/her right shoulder, and two flies crawled on the inside of the resident's right leg;-Two flies buzzed around the resident's bed and landed on the sheet. Observation on 01/08/26, at 12:31 P.M., with the Director of Nursing (DON) showed the resident was in his/her bed with five to six flies on both of the resident's legs and body. 3. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the resident's cognitive skills intact.Observation and interview on 01/08/26 at 10:05 A.M. showed the following:-The resident was in his/her bed. A fly was on his/her forehead and neck. Two flies buzzed around the resident;-He/she said the pest control company comes to the facility;-Approximately six flies buzzed around on the floor beside the resident's bed.Observation on 01/08/26 at 11:25 A.M. with the DON, the resident was in his/her bed. Two flies buzzed around the resident's sheet on top of his/her bed. Five to six flies buzzed around on the floor beside the resident's bed. 4. Review of Resident #3's face sheet showed the resident admitted to the facility on [DATE].Review of the resident's annual MDS, dated [DATE], showed the resident had intact cognitive skills. Observations and interview on 01/08/26, at 10:14 A.M. showed the following:-The resident sat in his/her room in his/her wheelchair;-A fly landed on the resident's head;-He/she said there were always flies in his/her room, they were all over the place;-The resident had a fly swatter on the end of his/her bed;-The resident said the flies bothered him/her;-A fly buzzed around and landed on each of the two pillows on his/her bed;-The resident said he/she kept his/her door closed to keep the flies out. 4. Review of Resident #4's face sheet showed the resident admitted to the facility on [DATE].Observation and interview on 01/08/26, at 10:45 A.M. showed the following:-The resident sat in his/her room in his/her wheelchair;-The resident's family member sat in a chair and swatted at flies on the floor;-The resident said the flies were bad and bothered him/her last night when he/she was in bed;-The resident's family member said he/she killed about eight flies this visit. 5. During an interview on 01/08/26, at 11:53 A.M., Housekeeper A said staff should report to the supervisor of any flies. During an interview on 01/08/26, at 1:58 A.M., Registered Nurse (RN) C said the following:-It had warmed up this past week and flies were everywhere and bad;-The Maintenance Supervisor should notify the pest control company of flies;-He/she had informed the Administrator and Director of Nursing (DON) that the flies were bad and at the nurses' station too;-Flies put residents at risk for infections on skin and get in food also. During an interview on 01/08/26, at 12:31 P.M., the DON said the following:-The pest control company comes to the facility to monitor flies;-Staff should report flies to the maintenance supervisor;-She hadn't heard of complaints of flies recently;-Flies cause infection control issues and a non-homelike environment;-She did not know how the flies got in the building. During an interview on 01/08/26, at 12:36 P.M., the Maintenance Supervisor said the following:-The facility had new bug lights in the hallways;-He called the pest control company to determine the best thing the facility could do for the flies;-Staff should keep resident's rooms clean and the doors shut to the outside of the facility;-The facility always had an issue with flies;-The pest control company said there were certain chemicals to use safely in a nursing home;-Staff should report to him of any flies. During an interview on 01/08/26, at approximately 1:00 P.M., the Administrator said the following:-The facility ordered two lights for the flies;-The pest control company comes to the facility monthly and visited twice in December;-She expected staff to report flies to the Maintenance Supervisor;-She expected the Maintenance Supervisor to notify the pest control company of flies;-She expected the staff to kill the flies as needed. Complaint 2709404

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to facility management and within two hours to the state licensing agency (Department of Health and Senior Services-DHSS) when staff failed to report an allegation of employee to resident abuse until the following day for one resident (Resident #1). The facility census was 46. Review of the facility policy titled, Abuse Prevention, dated 10/21/22, showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitor, or any other individual; -Abuse is any willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by any individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident; -Physical abuse is an employee purposefully beating, striking, wounding, or injuring any consumer. In any manner whatsoever, an employee mistreating or maltreating a consumer in a brutal or inhumane manner. An employee handling a consumer with any more force than is reasonable for a consumer's proper control, treatment, or management; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator or DON must be called at home or must be paged and informed of such incident; -The Administrator or designee shall report any allegations of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of a crime in accordance with Section 1150B of the Social Security Act of the Department of Health as required; -Alleged violations abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; -Report the results of all investigations to the Administrator or designee and other officials in accordance with state law including State Survey Agency within five working day of the incident. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admission date of 06/20/22; -Diagnoses included vascular dementia (brain damage caused by multiple strokes), polyneuropathy (a nervous system disorder that impacts nerve function in multiple areas of the body), dependence on wheelchair, and need for assistance with personal cares. Review of the resident's care plan, revised on 01/24/25, showed the following: -Resident has behavioral symptoms related to diagnosis of dementia; -Staff should approach calmly and unhurried, introduce self and explain all procedures; -Staff should attempt to refocus behaviors to something positive; -Staff should reduce stimulations and keep conversation short/simple; -Staff should speak in a reassuring voice and be supportive of their feelings; -Resident screams out daughter's name and demands from staff, physically abusive to staff, refuses showers, incontinent care, and activities of daily living (ADLs) from staff often. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool administered by staff), dated 05/09/25, showed the following: -The resident had severe cognitive impairment; -The resident required partial/moderate assistance of staff for toileting, transfers, and mobility. Review of Nurse Aide (NA) C's written statement, dated 05/26/25, showed the following: -On Sunday morning (05/25/25) at 3:00 A.M., NA C was doing checks with NA D and went into the resident's room to get him/her changed; -The resident was hitting NA D and NA D hit the resident back; -NA C waited until the following day to report it. During an interview on 06/03/25, at 11:27 A.M., NA C said the following: -Staff should report any abuse allegation immediately to the charge nurse; -On 05/25/25, at approximately 3:00 A.M., she was making rounds on the memory care unit with NA D when they stopped to check on the resident. They told the resident they needed to check to see if he/she was wet. The resident began to yell and curse at them and began hitting NA D. NA D slapped back at the resident. He/she did not report the incident until the following day of 05/26/25. He/she did not want to report NA D while he/she was still on shift with him/her. Review of DHSS records showed facility staff made a self-report regarding an allegation of possible abuse on the afternoon of 05/26/26 (the day following the alleged abuse incident). The self report showed the following: -It was reported to the Administrator 05/26/25, at 12:11 P.M., that two nurse aides were the resident's room doing cares on 05/25/25 at 3:00 A.M. The resident was hitting and scratching NA D. NA D slapped the resident in the face. During an interview on 06/03/25, at 10:16 A.M., Certified Nursing Assistant (CNA) A said the following: -He/she would report any abuse allegation to the charge nurse immediately after ensuring safety of the resident; -The facility has two hours to report any abuse allegation to the state agency; -Slapping a resident would be an allegation of abuse and should be reported immediately. During an interview on 06/03/25, at 10:21 A.M., CNA B said the following: -He/she would ensure safety of a resident first and report immediately to charge nurse following an allegation of abuse; -The facility should report any abuse allegation to the state agency within 24 to 48 hours; -Slapping a resident would be an allegation of abuse and should be reported immediately. During an interview on 06/03/25, at 11:49 A.M., CNA E said the following: -He/she would ensure safety of a resident first and report immediately to charge nurse following an allegation of abuse; -The facility has two hours to report any abuse allegation to the state agency. During an interview on 06/03/25, at 11:55 A.M., Registered Nurse (RN) F said the following: -He/she would ensure safety of the resident and assess the resident following any abuse allegation and then report immediately to the Director of Nursing (DON); -The facility has two hours to report any abuse allegation to the state agency; -Slapping a resident would be an allegation of abuse. During an interview on 06/03/25, at 12:37 P.M., RN G said the following: -Staff report any abuse to him/her immediately, and he/she would ensure resident safety, complete an assessment for injuries, and then report up the chain of command; -The facility has two hours to report any abuse allegation to the state agency; -Slapping a resident would be an allegation of abuse. During an interview on 06/03/25, at 1:08 P.M., the Social Services Director (SSD) said the following: -She would report any abuse allegation immediately to the Administrator; -The facility has two hours to report any abuse allegation to the state agency. During an interview on 06/03/25, at 1:21 P.M., the DON said the following: -Staff should ensure resident safety and then report any abuse allegation immediately to charge nurse, DON, or Administrator; -The facility has two hours to report any abuse allegation to the state agency. During an interview on 06/03/25, at 1:38 P.M., the Administrator said the following: -Staff should ensure the safety of a resident first then report any abuse of allegation immediately to the charge nurse, DON, or Administrator; -The facility has two hours to report any abuse allegation to the state agency. MO00254817

Based on interview and record review, the facility failed to document a timely and thorough investigation, to include interviews with multiple staff and other residents, and immediate steps taken to protect all residents during the investigation for an allegation of possible physical abuse involving one resident (Resident #1). The facility census was 46. Review of the facility policy titled, Abuse Prevention, dated 10/21/22, showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitor, or any other individual; -Abuse is any willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by any individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident; -Physical abuse is an employee purposefully beating, striking, wounding, or injuring any consumer. In any manner whatsoever, an employee mistreating or maltreating a consumer in a brutal or inhumane manner. An employee handling a consumer with any more force than is reasonable for a consumer's proper control, treatment, or management; -The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation; -Any allegation of abuses, or neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident; -Report the results of all investigations to the Administrator or designee and other officials in accordance with state law including State Survey Agency within five working day of the incident. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admission date of 06/20/22; -Diagnoses included vascular dementia (brain damage caused by multiple strokes), polyneuropathy (a nervous system disorder that impacts nerve function in multiple areas of the body), dependence on wheelchair, and need for assistance with personal cares. Review of the resident's care plan, revised 01/24/25, showed the following: -Resident had behavioral symptoms related to diagnosis of dementia; -Staff should approach calmly and unhurried, introduce self and explain all procedures; -Staff should attempt to refocus behaviors to something positive; -Staff should reduce stimulations and keep conversation short/simple; -Staff should speak in a reassuring voice and be supportive of their feelings; -Resident screams out daughter's name and demands from staff, physically abusive to staff, refuses showers, incontinent care, and activities of daily living (ADLs) from staff often. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool administered by staff), dated 05/09/25, showed the following: -Resident had severe cognitive impairment; -Resident required partial/moderate assistance of staff for toileting, transfers, and mobility. Review of Nurse Aide (NA) C's written statement, dated 05/26/25, showed the following: -On Sunday morning (05/25/25), at 3:00 A.M., NA C was doing checks with NA D and went into the resident's room to get him/her changed; -The resident was hitting NA D and NA D hit the resident back; -NA C waited until the following day to report it. During an interview on 06/03/25, at 11:27 A.M., NA C said on 05/25/25, at approximately 3:00 A.M., he/she was making rounds on the memory care unit with NA D when they stopped to check on the resident. They told the resident they needed to check to see if he/she was wet. The resident began to yell and curse at them and began hitting NA D. NA D slapped back at the resident. The resident was screaming and NA D was telling the resident not to hit him/her and hands were flying. He/she did not report the incident until the following day of 05/26/25. He/she did not want to report NA D while he/she was still on shift with him/her. Review of DHSS records showed facility staff made a self-report regarding an allegation of possible abuse on the afternoon of 05/26/26 (the day following the alleged abuse incident). The self report showed the following: -It was reported to the Administrator 05/26/25, at 12:11 P.M., that two nurse aides were the resident's room doing cares on 05/25/25 at 3:00 A.M. The resident was hitting and scratching NA D. NA D slapped the resident in the face. Review of the facility's Investigation Summary, undated, showed the following: -The alleged perpetrator had not worked since the abuse allegation was reported (06/26/25, the day after the abuse allegation occurred) and will not be returning for the safety of all residents; -The resident had not suffered any emotional or mental status change since the incident occurred; -This was a he-said she-said alleged abuse investigation since the resident's cognition was impaired and there were no other witnesses; -The investigation included written statements by Nursing Assistant (NA) C and NA D. (The investigation did not show documented interviews with other staff or residents.) During an interview on 06/03/25, at 10:16 A.M., Certified Nursing Assistant (CNA) A said the following: -He/she would report any abuse allegation to the charge nurse immediately following ensuring safety of the resident; -Slapping a resident would be considered abuse. During an interview on 06/03/25, at 10:21 A.M., CNA B said the following: -He/she would ensure safety of a resident first and report immediately to charge nurse following an allegation of abuse; -Slapping a resident would be considered abuse. During an interview on 06/03/25, at 11:49 A.M., CNA E said he/she would ensure safety of a resident first and report immediately to charge nurse following an allegation of abuse. During an interview on 06/03/25, at 11:55 A.M., Registered Nurse (RN) F said the following: -He/she would ensure safety of the resident and assess the resident following any abuse allegation and then report immediately to the DON; -Slapping a resident would be considered abuse. -He/she does not participate in investigations of abuse allegations; During an interview on 06/03/25, at 12:37 P.M., RN G said the following: -Staff report any abuse to him/her immediately, and he/she would ensure resident safety, complete an assessment for injuries, and then report up the chain of command; -Slapping a resident would be considered abuse. During an interview on 06/03/25, at 1:08 P.M., the Social Services Director (SSD) said the following: -She has not been informed if she has a role in abuse investigations with the new Administrator, but did interview residents on previous abuse allegations; -She did not conduct any interviews for this investigation. During an interview on 06/03/25, at 1:21 P.M., the Director of Nursing (DON) said the following: -Staff should ensure resident safety and then report any abuse allegation immediately to charge nurse, DON, or Administrator; -A full body skin assessment is completed on the resident and 15-minute checks are initiated; -Any staff member accused of abuse is immediately suspended pending an investigation. During an interview on 06/03/25, at 1:38 P.M., the Administrator said the following: -Staff should ensure the safety of a resident first then report any abuse of allegation immediately to the charge nurse, DON, or Administrator; -The nurse should assess the resident and notify the physician and family; -The alleged staff member should be suspended immediately pending an investigation; -An abuse allegation investigation should include obtaining witness statements, conducting assessments of the resident, interviewing residents, and completing in-services. She did not interview any residents or other staff members. MO00254817

Based on observation, interview, and record review, the facility failed to ensure food was served at temperatures that were palatable and appetizing for three residents (Resident #1, Resident #8, and Resident #9) who often ate in their rooms. The facility census was 52. Review of the facility policy titled, Food Temperatures, undated, showed the following: -The temperature of all food items will be taken and properly recorded prior to service of each meal; -All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F); -Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking; -Hot food items may not fall below 135 degrees F after cooking; -All cold food items must be stored and served a temperature of 41 degrees F or below; -Temperatures should be taken periodically to assure hot foods stay about 135 degrees F and cold food stay below 41 degrees F during the holding and plating process and until food leaves the service area; -Food should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures such as hot/cold carts, pellet systems, insulated plate bases and domes. 1. Review of Resident #8's face sheet (brief resident profile) showed the following: -admission date of 09/25/23; -Diagnoses included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), pure hyperglyceridemia (genetic disorder characterized by elevated levels of triglycerides in the blood), and gastro-esophageal reflux disease (GERD-digestive disease in which stomach acid or bile irritates the food pipe lining). Review of the resident's quarterly minimum data set (MDS - a federally mandated assessment tool completed by staff), dated 02/16/25, showed the following: -Resident cognitively intact; -Regular diet; -Supervision with meals. During an interview on 05/05/25, at 9:54 A.M., the resident said the following: -He/she eats meals in his/her room; -The Food is always served cold: -He/she does not ask for food to be reheated or replaced. 2. Review of the Resident #9's face sheet showed the following: -admission date of 08/11/23; -Diagnoses included stroke, slurred speech, GERD, and diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident cognitively intact; -Therapeutic diet; -Supervision with meals. During an interview on 05/06/25, at 2:22 P.M., the resident said the following: -He/she eats meals in his/her room; -Sometimes the food does not taste good because it is not the warmest; -Staff will offer to reheat food, but he/she does not have them reheat it. 3. Review of Resident #1's face sheet showed the following: -admitted on [DATE]; -Diagnosis included hyperlipidemia (high levels of fats in blood, can increase risk of heart attack and stroke) and type 2 diabetes mellitus. Review of the annual MDS, dated [DATE], showed the following: -Resident is cognitively intact; -Regular diet; -Setup assistance with eating. During an interview on 05/06/25, at 3:13 P.M., the resident said the following: -Meals are sometimes meals served cold; -Breakfast is usually served cold; -He/she has complained to staff about the food temperatures, and they offered to replace and/or reheat the meal. 4. Observation on 05/05/25, at 12:52 P.M., showed the following: -A test tray was requested and received from the uninsulated food cart on the Buffalo Boulevard Hall at the end of the meal service; -The meal included baked chicken, broccoli, and baked potato; -Temperatures were taken of the items served; -The baked chicken measured at 124.3 F, the broccoli measured at 125.4 F, and the baked potato measured at 126 degrees F. 5. During an interview on 05/06/25, at 12:41 P.M., Nurse Assistant (NA) D said one resident has complained at times about food being served cold. During an interview on 05/06/25, at 3:04 P.M., Certified Nurse Assistant (CNA E) said the following: -Residents complain food trays on the halls are served cold; -He/she notified the dietary staff about the cold food complaints; -He/she will reheat or replace cold food if requested. During an interview on 05/06/25, at 3:19 P.M., Dietary [NAME] F said the following: -Food should not be served with temperatures below 125 degrees F because that is the danger zone; -The food temperatures from the test tray were too low and not appropriate; -He/she had only received one cold food complaint from a resident. During an interview on 05/07/25, at 10:19 A.M., the Dietary Manager said the following: -He/she had received complaints from residents about food being served on Buffalo Boulevard Hall; -Food should be temping above 120 degrees F when served to the resident; -He/she was not aware of the facility policy regarding food temperatures at service. During an interview on 05/06/25, at 4:21 P.M., the Administrator said staff should never reheat a served meal in the microwave. Staff should always replace a meal with a fresh one. MO00253023, MO00253543

Based on interview and record review, the facility failed to provide pharmacy services that included procedures for accurate administering and documentation of administration of all medications when staff failed to document administration of physician ordered medications for for six residents(Resident #1, #2, #3, #4, #7, and #10). The facility census was 52. Review of the facility policy titled, Administration Procedures for All Medications, revised August 2014, showed the following: -Purpose to administer medications in a safe and effective manner; -After administration of medication, return to the cart, replace the medication container, and document administration in the medication administration record (MAR), and controlled substance sign out record, if indicated; -Monitor for side effects or adverse drug reactions immediately after administration and throughout each shift; -If resident refuses medication document refusal on MAR; -Notify physician of persistent refusals, held medications for pulse, blood pressure low/high blood sugar, or any other reason medication is held, and suspected adverse drug reactions. 1. Review of Resident #1's face sheet (a brief information sheet about the resident) showed the following: -admission date of 08/20/20; -Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), paranoid schizophrenia (type of schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly) characterized by prominent delusions, hallucinations, and a lack of other disorganized symptoms, such as disorganized speech or behavior), restless leg syndrome (condition characterized by a nearly irresistible urge to move the legs, typically in the evenings), hyperlipidemia (high levels of fats in blood, can increase risk of heart attack and stroke), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), and insomnia (sleep disorder with trouble falling and/or staying asleep). Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 04/02/25, showed the following: -Cognitively intact; -Used antipsychotic (drug used to treat psychotic disorders), antianxiety (drug used to treat anxiety disorders), antidepressant drug used to treat depression disorders), and insulin (controls the amount of sugar in the blood) medications. Review of the resident's care plan, reviewed 04/02/25, showed the following: -Resident had diabetes mellitus; -Staff should administer diabetic medication as prescribed and report any adverse effect to the physician; -Resident had chronic pain related to arthritis; -Staff should administer analgesia as per physician orders; -Resident was at risk for pain related to diagnosis of osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), chronic pain, restless leg syndrome, fibromyalgia, impaired mobility and low back pain. Review of the resident's Physician Order Sheet (POS), current as of 05/06/25, showed an order, dated 01/03/25, for insulin aspart (short-acting, manmade version of human insulin, used to treat diabetes) 100 unit/milliliter (ml), inject 20 units subcutaneously (method of administering medication by injecting it into the fatty tissue layer just beneath the skin) with meals related to type 2 diabetes mellitus. Review of the resident's April 2025 and May 2025 Medication Administration Record (MAR) showed the following: -An order, dated 01/03/25, for insulin aspart 100 unit/ml, inject 20 units subcutaneously with meals related to type 2 diabetes mellitus; -Staff did not document whether or not insulin was administered at the 12:30 P.M. on 04/07/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 01/04/25, for fenofibrate (used to treat high cholesterol) 54 milligrams (mg), give 54 mg one time a day related to hyperlipidemia. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 01/04/25, for fenofibrate 54 mg, give 54 mg one time a day related to hyperlipidemia; -Staff did not document whether or not the medication was administered at the 6:00 A.M. to 6:00 P.M. dose on 05/03/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 08/16/24, for ropinirole (used to treat restless leg syndrome) 1 mg three times per day. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order dated 08/16/24, for ropinirole 1 mg three times per day; -Staff did not document administration of the 12:00 P.M., dose on 05/01/25, 05/02/25, and 05/03/25. Review of the resident's POS, current as of 05/06/25, showed the following: -An order, dated 08/16/24, for melatonin (used to help regulate body's sleep wake cycle) 10 mg, give 10 mg at bedtime for insomnia. Review of the resident's April 2025 and May 2025 MAR, showed the following: -An order, dated 08/16/24, for melatonin 10 mg, give 10 mg at bedtime for insomnia; -Staff did not document administration of the medication on 04/15/25. Review of the resident's April and May 2025 nurses' progress notes showed staff did not document related to the medications that were not administered as ordered. During interview on 05/05/25, at 10:30 A.M., the resident said his/her pain medication is often provided several hours late which caused the pain to not be well controlled. The resident said there were times he/she did not receive medication or was told it was not available. 2. Review of Resident #2's face sheet showed the following: -admission date of 09/20/24; -Diagnoses included hypertension (high blood pressure), depression, COPD, muscle spasms, multiple fractures of ribs, and post dental procedure. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Use of antianxiety, opioid (prescription pain medications), antiplatelet (used to prevent blood clots), and hypoglycemic (used to treat low blood sugar levels) medications. Review of the resident's care plan, last reviewed on 04/21/25, showed the following: -Resident was at risk for pain related to history of fractures; -Staff should administer analgesic medications as ordered by the physician; -Resident had a diagnosis of hypertension; -Staff should administer medication per physician order and report any adverse side effects; -Resident was at risk for behavioral symptoms related to diagnosis; -Staff should administer medication per physician order and report any adverse side effects. Review of the resident's POS, current as of 05/06/25, showed an order, dated 11/24/24, for amlodipine besylate (used to help lower blood pressure) tablet 5 mg, given 1 tablet by mouth one time a day for hypertension. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order,dated 11/24/24, amlodipine besylate tablet 5 mg, given 1 tablet by mouth one time a day for hypertension; -Staff did not document administration of the medication for the 9:00 A.M. dose on 04/10/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 03/25/25, for trazodone HCl tablet (can treat depression) 50 mg, give 50 mg by mouth at bedtime for depression. Review of the resident's April 2025 and May 2025 MAR, showed the following: -An order, dated 03/25/25, for trazodone tablet 50 mg, given 50 mg by mouth at bedtime for depression; -Staff did not document administration of the medication on 04/02/25 and 04/15/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 09/24/24, for albuterol sulfate (used to prevent and treat difficulty breathing, shortness of breath, chest tightness caused by lung diseases) HFA inhalation Aerosol Solution (metered-dose container)108 mcg/ACT (amount per dose), 2 puffs inhale orally two times a day for COPD. Review of the resident's April 2025 and May 2025 MAR, showed the following: -An order, dated 09/24/24, for albuterol sulfate HFA inhalation Aerosol Solution 108 mcg/ACT, 2 puffs inhale orally two times a day for COPD; -Staff did not document administration of the morning medication dose on 04/16/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 09/21/24, for budesonide-formoterol (combination medication used for managing asthma and COPD) inhalation aerosol 80-4.5 mcg/act, 2 puffs inhale orally two times a day for COPD. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 09/21/24, for budesonide-formoterol inhalation aerosol 80-4.5 mcg/act, 2 puffs inhale orally two times a day for COPD; -Staff did not document administration of the 9:00 A.M. dose on 04/01/25, 04/02/25, 04/03/25, 04/10/25, and 04/16/25; -Staff did not document administration of the 6:00 P.M. dose on 04/01/25, 04/02/25, and 04/03/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 02/03/25, for methocarbamol (can treat muscle spasms and pain) oral tablet 1000 mg, given 1 tablet by mouth three times a day for muscle spasms. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 02/03/25, for methocarbamol oral tablet 1000 mg, given 1 tablet by mouth three times a day for muscle spasms; -Staff did not document administration of the 1:00 P.M. dose on 04/04/25, 04/08/25, 04/10/25, 04/18/25, 04/20/25, and 04/26/25; -Staff did not document administration of the 8:00 P.M. dose on 04/02/25 and 04/15/25; -Staff did not document administration of the 1:00 P.M. dose on 05/01/25, 05/02/25, 05/03/25 and 05/04/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 02/25/25, for morphine sulfate (strong pain-relieving medication) oral tablet 15 mg, give 1 tablet my mouth three times a day for pain related to multiple fractures of ribs. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 02/25/25, for morphine sulfate oral tablet 15 mg, give 1 tablet my mouth three times a day for pain related to multiple fractures of ribs; -Staff did not document administration of the 12:00 P.M. dose on 04/26/25; -Staff did not document administration of the bedtime dose on 04/02/25, 04/10/25, 04/20/25 and 04/21/25; -Staff did not document administration of the 12:00 P.M. dose on 05/01/25, 05/02/25 and 05/04/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 04/26/25, for amoxicillin (antibiotic to treat infection) oral tablet 500 mg, give 1 tablet by mouth three times a day for post dental procedure for 10 days. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 04/26/25, for amoxicillin oral tablet 500 mg, give 1 tablet by mouth three times a day for post dental procedure for 10 days; -Staff did not document administration of the 2:00 P.M. dose on 5/03/25, 05/04/25, and 05/06/25; -Staff did not document administration of the 9:00 P.M. dose on 05/05/25. Review of the resident's April 2025 and May 2025 nurses' progress notes showed staff did not document related to the medication that were not administered as ordered. During interview on 05/05/25, at 11:00 A.M., the resident said the facility runs out of pain medications at times and he/she missed doses which caused increased pain symptoms and at times the medications were administered late. The resident said that staff was inconsistent with medication administration which made it difficult to get a restful sleep. 3. Review of Resident #3's face sheet showed the following: -admission date of 04/19/24; -Diagnoses included restless leg syndrome, cerebral infarction, depression, gastro-esophageal reflux disease (GERD - digestive disease in which stomach acid or bile irritates the food pipe lining.), COPD, anxiety, and sleep disturbance. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Use of antianxiety, antidepressant, anticoagulant, diuretic (type of drug that causes the kidneys to make more urine), opioid, and hypoglycemic medications. Review of the resident's care plan, last reviewed on 04/22/25, showed the following -Resident had potential for nutritional problems related to pain; -Resident had pain issues related to arthritis, old stroke, muscles spasms, and restless leg syndrome; -Staff should administer medications as ordered, monitor and document effectiveness. Review of the resident's POS, current as of 05/06/25, showed an order, dated 02/27/24, for gabapentin (used to treat nerve pain) oral capsule 300 mg, give 300 mg by mouth three times per day related to restless leg syndrome. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 02/27/24, for gabapentinoral capsule 300 mg, give 300 mg by mouth three times per day related to restless leg syndrome; -Staff did not document administration of the 12:00 P.M. dose on 04/03/25, 04/04/25 and 04/10/25; -Staff did not document administration of the bedtime dose on 04/15/25; -Staff did not document administration of the 12:00 P.M. dose on 05/01/25 and 05/02/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 10/09/24, lorazepam (used to treat anxiety) oral tablet 0.5 mg, give 1 tablet by mouth at bedtime for anxiety. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 10/09/24, lorazepam oral tablet 0.5 mg, give 1 tablet by mouth at bedtime for anxiety; -Staff did not document administration of the medication on 04/15/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 05/31/25, for melatonin oral tablet 5 mg, give 2 tablets by mouth at bedtime for sleep. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 05/31/25, for melatonin oral tablet 5 mg, give 2 tablets by mouth at bedtime for sleep; -Staff did not document administration of the dose on 04/15/25. Review of the physician order sheet, current as of 05/06/25, showed the following: -An order dated 04/24/24, Fluticasone-Umeclidin-Vilant (used to help control the symptoms of COPD and improve lung function) inhalation aerosol power breath activated 100-62.5-25 mcg/alt, 1 puff inhale orally in the morning related to COPD. Review of the resident's April 2025 and May 2025 MAR, showed the following: - An order, dated 04/24/24, Fluticasone-Umeclidin-Vilant inhalation aerosol power breath activated 100-62.5-25 mcg/alt, 1 puff inhale orally in the morning related to COPD; -Staff did not document administration of the morning dose on 04/18/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 02/11/25, for atorvastatin calcium (used to help decrease amount of cholesterol in arteries) oral tablet 20 mg, give 20 mg by mouth at bedtime for history of cerebral infarction. Review of the resident's April 2025 and May 2025 MAR, showed the following: -An order, dated 02/11/25, for atorvastatin calcium oral tablet 20 mg, give 20 mg by mouth at bedtime for history of cerebral infarction (stroke, process results in an area of necrotic (dead or dying) tissue in brain); -Staff did not document administration of the 8:00 P.M. dose on 04/15/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 02/11/25, bupropion HCL ER (drug used to treat depression) oral tablet extended release 24 hour, give 300 mg by mouth at bedtime for major depressive disorder. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 02/11/25, bupropion HCL ER oral tablet extended release 24 hour, give 300 mg by mouth at bedtime for major depressive disorder; -Staff did not document administration of the 8:00 P.M. dose on 04/15/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 02/27/25, for famotidine (used to treat stomach ulcers and GERD) oral tablet 20 mg, give 20 mg by mouth at bedtime related to GERD. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 02/27/25, for famotidine oral tablet 20 mg, give 20 mg by mouth at bedtime related to GERD; -Staff did not document administration of the scheduled dose on 04/15/25. Review of the resident's POS, current as of 05/06/25, showed an order, dated 02/11/25, for ropinirole HCL ER oral tablet extended release 4 mg, give 4 mg by mouth at bedtime for restless legs. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 02/11/25, for ropinirole HCL ER oral tablet extended release 4 mg, give 4 mg by mouth at bedtime for restless legs; -Staff did not document administration of the scheduled dose on 04/15/25. Review of the resident's April and May 2025 nurses' progress notes showed staff did not document related to the medications that were not administered as ordered. During interview on 05/05/25, at 9:30 A.M., the resident said he/she often received his/her bedtime medications with evening dinner time medications, and he/she preferred to receive them at 8:30 P.M. for consistency and help with sleep and pain level. He/she was frequently not receiving his/her noon time gabapentin which helped with his/her pain level. 4. Review of Resident #4's face sheet showed the following: -admission date of 04/21/25; -Diagnoses included acute peptic ulcer (break in the lining of the stomach or the duodenum (the first part of the small intestine), characterized by a sore that is deep enough to form a crater) with both hemorrhage (bled severely) and perforation (hole through wall of stomach or duodenum), hypertension (high blood pressure), congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs). Review of the care plan, reviewed on 04/21/25, showed the following: -Resident was at risk for electrolyte imbalance related to acute peptic ulcer with both hemorrhage and perforation; -Resident at risk for respiratory problems related to CHF; -Staff should administer medication per physician orders and report any adverse side effects. Review of the resident's POS, current as of 05/06/25, showed an order, dated 04/22/25, for pantoprazole sodium (used to treat heartburn or acid reflux) oral tablet delayed release 40 mg, give 1 tablet by mouth two times a day related to acute peptic ulcer with both hemorrhage and perforation. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 04/22/25, for pantoprazole sodium oral tablet delayed release 40 mg, give 1 tablet by mouth two times a day related to acute peptic ulcer with both hemorrhage and perforation; -Staff did not document administration of the 12:00 P.M. dose on 04/28/25, 05/01/25, and 05/02/25. Review of the resident's POS, current as of 05/06/25, showed an order dated 04/22/25, for sucralfate oral suspension (drug used in the treatment of gastric and duodenal ulcers ) 1 gm / 10 ml (milliliters), give 10 ml by mouth four times a day related to acute peptic ulcer with both hemorrhage and perforation. Review of the resident's April 2025 and May 2025 MAR showed the following: -An order, dated 04/22/25, for sucralfate oral suspension 1 gm / 10 ml, give 10 ml by mouth four times a day related to acute peptic ulcer with both hemorrhage and perforation; -Staff did not document administration of the 12:00 P.M. dose on 04/28/25, 05/01/25 and 05/02/25. Review of the resident's April and May 2025 nurses' progress notes showed staff did not document related to the medications that were not administered as ordered. During an interview on 05/05/25, at 8:45 A.M., the resident's representative said that the resident had been receiving the ordered sucralfate after meals instead of before meals. He/she said the resident had missed some doses. 5. Review of Resident #7's face sheet showed the following: -admission date of 10/25/22; -Diagnoses included paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave correctly with paranoia), congestive heart failure (CHF - a chronic condition in which the heart doesn't pump blood as well as it should), major depressive disorder, morbid obesity, type II diabetes mellitus, mild intellectual disabilities, impulse disorder, chronic obstructive pulmonary disorder (COPD - a group of lung diseases that block airflow and make it difficult to breathe), and high blood pressure. Review of the resident's care plan, last revised 06/07/24, showed the following: -Resident had diagnoses of major depressive disorder, schizophrenia, intellectual disability, and impulse disorder with potential for decline in mood; -Resident takes psychoactive medications which put him/her at risk for adverse reactions, continues to have delusions/hallucinations at times; -Administer medications, including psychotropic as ordered; -Psychiatric services as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident cognitively intact; -Resident takes an antipsychotic. Review of the resident's current POS showed the following: -An order, dated 01/13/25, for clozapine (an antipsychotic medication primarily used to treat schizophrenia) oral tablet 50 mg, give 100 mg by mouth at bedtime related to paranoid schizophrenia; -An order, dated 01/14/25, for clozapine oral tablet 50 mg, give 50 mg by mouth one time a day related to paranoid schizophrenia. Review of the resident's April 2025 MAR showed the following: -An order, dated 01/13/25, for clozapine oral tablet 50 mg, give 100 mg by mouth at bedtime related to paranoid schizophrenia; -An order, dated 01/14/25, for clozapine oral tablet 50 mg, give 50 mg by mouth one time a day related to paranoid schizophrenia; -Staff did not document administration of the morning dose on 04/17/25 and 04/24/25; -Staff did not document administration of the bedtime dose on 04/15/25, 04/16/25, 04/17/25, 04/18/25, 04/20/25, 04/24/25, 04/29/25, and 04/30/25. 6. Review of Resident #10's face sheet showed the following: -admission date of 03/10/22; -Diagnoses included vascular dementia (brain damage caused by multiple strokes), chronic kidney disease, paroxysmal atrial fibrillation (episodes of an irregular heartbeat in the upper chambers of the heart come and go), polyneuropathy (nervous system disorders that impact nerve function in multiple areas of the body), sarcopenia (progressive loss of muscle mass, strength and function), anxiety disorder, and hyperlipidemia (condition in which there are high levels of fat particles in the blood). Review of the resident's care plan, last revised 01/24/25, showed the following: -Resident had behavioral symptoms related to diagnosis of dementia and mania, administer medications as prescribed and report any adverse side effects noted to physician; -Resident requires psychoactive medications for diagnosis of mania, administer psychotropic medications as prescribed, and report any side effects notes such as nausea, vomiting, oversedation, and/or increased agitation; -Resident has impaired cognitive function or impaired thought processes related to dementia, administer medication as ordered and monitor for side effects and effectiveness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Resident takes an antipsychotic and antianxiety. Review of the resident's current POS showed an order, dated 01/14/25, for alprazolam (a benzodiazepine used to help calm and relax the nervous system) tablet 0.5 mg, give one tablet by mouth two times a day for anxiety. Review of the resident's April 2025 MAR showed the following: -An order, dated 01/14/25, for alprazolam tablet 0.5 mg, give one tablet by mouth two times a day for anxiety; -Staff did not document administration of the morning dose on 04/08/25; -Staff did not document administration of the evening dose on 04/08/25, 04/16/25, 04/17/25, and 04/21/25. Review of the resident's current POS showed an order, dated 11/06/24, for buspirone (anti-anxiety medication affecting neurotransmitters in the brain, primarily serotonin and dopamine) hydrochloride (HCI) tablet 5 mg, give one by mouth three times a day for anxiety. Review of the resident's April 2025 MAR showed the following: - An order, dated 11/06/24, for buspirone HCI tablet 5 mg, give one by mouth three times a day for anxiety; -Staff did not document administration of the noon dose on 04/03/25, 04/04/25, 04/10/25, 04/12/25, and 04/23/25; -Staff did not document administration of the bedtime dose on 04/16/25, 04/29/25, and 04/30/25. Review of the resident's current POS showed an order, dated 08/07/24, for meclizine (an antihistamine medication used to prevent and treat nausea, vomiting and dizziness) HCI 25 mg, give 25 mg by mouth with meals for dizziness. Review of the resident's April 2025 MAR showed the following: - An order, dated 08/07/24, for meclizine HCI 25 mg, give 25 mg by mouth with meals for dizziness; -Staff did not document administration of the 12:30 P.M. dose on 04/03/25, 04/04/25, 04/10/25, 04/12/25, 04/16/25, 04/20/25, 04/23/25; -Staff did not document administration of the 5:30 P.M. dose on 04/16/25. Review of the resident's current physician order sheet showed the following: -An order dated 09/18/24, for Seroquel oral tablet 25 mg (extended-release antipsychotic medication used to treat schizophrenia and improve moods, thoughts, and behaviors), give one tablet by mouth three times day for agitation/mood stabilization related to vascular dementia. Review of the resident's April 2025 MAR showed the following: -An order, dated 09/18/24, for Seroquel oral tablet 25 mg, give one tablet by mouth three times day for agitation/mood stabilization related to vascular dementia; -Staff did not document administration of the 1:00 P.M. dose on 04/03/25, 04/04/25, 04/10/25, 04/12/25, 04/16/25, 04/17/25, 04/18/25, 04/23/25, 04/26/25, and 04/28/25; -Staff did not document administration of the 6:00 P.M., dose on 04/16/25. Review of the resident's current POS showed an order, dated 04/11/25, for polymyxin B-trimethoprim ophthalmic solution 10000-0.1 Unit/ML-%, instill one drop in both eyes every three hours for eye irritation every three hours while awake. Review of the resident's April 2025 MAR showed the following: -An order, dated 04/11/25, for polymyxin B-trimethoprim ophthalmic solution (a combination antibiotic eye drop that treats bacterial eye infections) 10000-0.1 Unit/ML-%, instill one drop in both eyes every three hours for eye irritation every three hours while awake; -Staff did not document administration of the 12:00 A.M. dose on 04/12/25, 04/14/25, 04/16/25, 04/25/25, 04/26/25, 04/27/25; -Staff did not document administration of the 3:00 A.M. dose on 04/12/25, 04/13/25, 04/14/25, 04/16/25, 04/19/25, 04/21/25, 04/24/25, 04/25/25, 04/26/25, 04/27/25, and 04/28/25; -Staff did not document administration of the 12:00 P.M. dose on 04/12/25 and 04/23/25; -Staff did not document administration of the 6:00 P.M. dose on 04/16/25; -Staff did not document administration of the 9:00 P.M. dose on 04/11/25, 04/12/25, 04/16/25, 04/17/25, 04/19/25, 04/29/25, and 04/30/25. 7. During an interview on 05/06/25, at 8:30 A.M., Certified Medication Tech (CMT) C said staff should document that resident medications as administered or document the reason medication was not provided. There were multiple codes for reasons not provided. Staff should make a progress note if medication was not administered. The MAR should not have empty areas, but staff just get too busy at times and did not chart. Ideally staff should document the work completed. During an interview on 05/06/25, at 1:30 P.M., Licensed Practical Nurse (LPN) B said medications should be administered when due. The staff had one hour before and one hour after administration time to provide the medication. Staff should follow physician orders for medications. The MAR should not have blank spots. Staff should document when given. If the medication was unable to be administered there were codes for the reason not given and should document in a progress note. During an interview on 05/06/25, at 2:15 P.M., LPN A said he/she was not aware of medications not being administered to residents. He/she said staff should document work. If it was not charted it was not done. The MAR should not have blank areas. Staff have one hour before and one hour after the medication time to administer the dose. There were some liberal times that allowed a three-hour time frame of administration. If a medication was not given the staff should document the accurate code and a progress note for the reason not provided. During an interview on 05/06/25, at 4:30 P.M., the Director of Nursing (DON) said the following: -Staff should be aware of medication types and reasons for medication. -Staff should be aware if a medication should be provided before meals or with meals. -Staff should document when the medication was administered. -Staff should document if a medication was not provided and the reason why. -She was not aware of resident not receiving medications on time or missing doses. -If a medication was unavailable the staff were educated to notify the DON or Administrator so they could look in the Automated Dispensing Unit (ADU - computer-controlled systems that store, dispense, and track medications, primarily in hospitals and long-term care facilities) since most medications were available at all times. -Ultimately, the DON was responsible to ensure medications were administered. -The CMTs were responsible for routine scheduled medications, including scheduled narcotics. -The nurses were responsible for as needed narcotic medications and insulin administration. During an interview on 05/06/25, at 4:30 P.M., the Administrator said he was not aware of residents not receiving medications. Staff were educated to notify himself or the DON if a medication was not available. Most medications were available at all times in the ADU. He was not aware of resident MAR's having blank spots. Staff should document medications whether administered or not administered. MO00253426, MO00253672, MO00253689

Based on record review and interview, the facility failed to complete significant change Minimum Data Sets (MDS - a federally mandated assessment instrument completed by facility staff) one resident (Resident #7) who was moved to the locked unit in the facility. The facility census was 52 Review showed the facility did not provide a policy related to MDS assessments. 1. Review of Resident #7's face sheet showed the following: -admission date of 10/25/22; -Diagnoses included paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave correctly with paranoia), congestive heart failure (CHF - a chronic condition in which the heart doesn't pump blood as well as it should), major depressive disorder, morbid obesity, type II diabetes mellitus, mild intellectual disabilities, impulse disorder, chronic obstructive pulmonary disorder (COPD - a group of lung diseases that block airflow and make it difficult to breathe), and high blood pressure. Review of the facility incident report of theft and/or loss report dated 03/03/25, showed the following: -Nursing staff received a complaint from a resident stating he/she won a candy bar at bingo, and Resident #7 was sitting nearby in the dining room and picked the candy bar up from the table and ate it. A replacement candy bar was given to the resident. Review of the facility Incident Report of Theft and/or Loss Report, dated 04/02/25, showed nursing staff received a complaint from a resident stating the resident went into his/her room through adjoining bathroom and drank his/her sodas. Review of the facility Incident Report of Theft and/or Loss Report, dated 04/15/25, showed the following; -The Administrator documented the resident's roommate's child reported the resident had a 12-pack of soda's missing. Staff located the missing cans of soda under the resident's bed. The resident's guardian was notified and permission given to move resident to the unit. Review of the resident's census showed he/she was moved to the memory care unit on 04/15/25. Review of the resident's current Physician Order Sheet showed an order, dated 04/25/25, for resident to be moved to locked unit. Review of the resident's record showed the most recent MDS completed was a quarterly assessment completed on 02/16/25. Staff did not document completion of a significant change MDS following the move of the resident's behaviors and move to the locked unit on 04/15/25. Review of the resident's current care plan on 05/06/25, at 11:28 A.M., showed staff did not care plan the resident's behaviors listed on the Theft and/or Lost Reports, which lead to the resident's move to the locked unit. During an interview on 05/06/25, at 9:35 A.M., the Social Services Director (SSD) said the facility began doing care plan meetings last month and the resident's care plan had not yet been updated for the behaviors leading to moving her to the locked unit. During an interview on 05/06/25, at 10:40 A.M., the MDS Coordinator and the Administrator said the following: -Staff should complete a significant change MDS within 14 days of the change of condition; -Staff should have completed a significant change MDS for the resident's move to the locked unit.

Based on record review and interview, the facility failed to complete an admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) in a timely manner for one residents (Resident #6). The facility census was 52. Review showed the facility did not provide a policy related to MDS assessments. 1. Review of Resident #6's face sheet showed the following: -admission date of 04/08/25; -Diagnoses included vascular dementia (brain damage caused by multiple strokes), type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), major depressive disorder, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cerebral atherosclerosis (buildup of plaque in the arteries that supply blood to the brain), and history of mini stroke. Review of the resident's electronic record showed on 04/08/25, at 4:00 P.M., nursing staff documented the resident arriving to the facility. Review of the resident's electronic record showed facility staff did not document completion of an admission MDS for the resident. During an interview on 05/06/25, at 9:35 A.M., the Social Services Director (SSD) said admission MDS should be scheduled to complete two weeks after resident's admission. During an interview on 05/06/25, at 10:40 A.M., the MDS Coordinator and the Administrator said staff should complete admission MDS within first 14 days of admission and staff should have completed an admission MDS for the resident.

Based on observation, record review, and interview, the facility failed to protect the resident's right to be free from involuntary seclusion by staff when one staff member Registered Nurse (RN) A held one resident's (Resident #1) door shut while he/she was in their room and attempting to exit the room, in response to his/her behaviors and combativeness with staff. Multiple staff were present during the time RN A held the door closed and witnessed the resident attempting to exit their room and did not intervene. The facility census was 43. The Administrator was notified on 1/26/23, at 1:39 P.M., of an Immediate Jeopardy which began on 1/19/2023. The Immediate Jeopardy was removed on 01/26/23, as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse-Reportable Events, revised 1/1/2023, showed the following: -It is the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; -Involuntary seclusion: Separation of a resident from others, or from his/her room, or confinement to his/her room (with or without roommates), against the resident's will or the will of the resident's legal representative; -Temporary monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used as a therapeutic intervention as determined by professional staff and consistent with the resident's care plan. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -Readmitted [DATE]; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), impulse disorder (a condition in which a person has trouble controlling emotions or behaviors), problems related to living in a residential institution, dementia with behavioral disturbances, and mild cognitive deficit. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/29/22, showed the following: -Severely cognitively impaired; -Experienced delusions (misconceptions or beliefs that are firmly held, contrary to reality); -No physical or verbal behaviors displayed; -Wandered one to three days of the look back period (the period of time when the assessment was done). Record review of the resident's current care plan showed the following: -On 10/05/2022, staff documented the resident has the potential to be verbally aggressive yelling and fits of frustration due to dementia, ineffective coping skills, mental/emotional illness, and poor impulse control. Interventions included administering medications as ordered, monitor/document for side effects and effectiveness and assess resident's coping skills and support system. -Staff did not care plan temporary monitored separation as an intervention. -The medical record did not include an assessment of seclusion as an intervention- including risks to the resident. Record review of the resident's current active medication orders showed the following: -An order, dated 11/2/22, for Lorazepam (an oral medication for agitation), 2 milligram (mg) tablet, give by mouth every six hours as needed for agitation. Record review of the resident's progress notes, dated 12/27/22 to 1/19/23, showed no behaviors documented. Record review of the resident's progress notes dated 1/20/23, at 4:10 P.M., showed the Assistant Director of Nursing (ADON) documented the following: -On 1/19/23, at approximately 5:30 P.M., the resident was trying to go out an exit door on the unit and take another resident with him/her; -Staff intervened and spoke to the resident calmly about getting ready for supper; -Resident was difficult to divert and various activities were attempted; -The nurse on duty came to the unit and helped assist him/her back to his/her room; -The resident stayed there, calmed, and then ate his/her meal. Record review of the resident's Medication Administration Record, dated 1/19/23, showed Lorazepam was not administered. Record review of the facility's investigation of an allegation of seclusion, dated 1/26/2023, showed the following: -On 1/26/23, the Administrator was advised by a State Inspector of an allegation from 1/19/23 for resident abuse against the ADON and Certified Medication Technician (CMT) D concerning a resident was in his/her room and the door was held preventing him/her from getting out; -On 1/26/23, the Administrator interviewed the ADON, who advised he/she was present at the time of the incident, but it was Registered Nurse (RN) A who had his/her hand on the door knob for a brief time. The resident was trying to hurt staff and push a resident in his/her wheelchair through an exit door. The proper intervention is to take the resident to his/her room to self-calm. The resident took a couple of minutes to self-calm and opened the door and returned to the dining room; -On 1/26/23, the Administrator interviewed Certified Nursing Assistant (CNA) B who said the resident became agitated and was trying to push another resident through the exit doors. When staff tried to intervene, the resident became combative, swinging his/her arms, and trying to bite and scratch. CNA B got the ADON and RN A. When RN A arrived, they assisted the resident to his/her room. He/she sat on the bed and staff left the room. They stood outside the door to listen for any behaviors and RN A held the door knob for a second, but then released it; -On 1/26/23, the Administrator interviewed Maintenance Worker (MW), who said he/she did not see much, but knew the resident was being very combative. MW observed staff take the resident to his/her room. MW saw RN A hold the door shut for a minute; -On 1/26/23, the Administrator interviewed Nursing Assistant (NA) C who said the resident became combative when they tried to intervene when he/she was trying to push another resident through the exit door. Staff took the resident to his/her room and sat him/her on the bed. -The investigation found the incident did occur. RN A followed the care plan and was protecting the resident, other residents, and staff from the resident's combative behavior. Record review of the Regional Human Resources investigation, dated 2/2/23, showed the following: -On 1/19/23, RN A helped a resident into his/her room and when RN A walked out, he/she shut the door and held onto the door not allowing the resident to come out of his/her room (Involuntary Seclusion); -Based on record review (in-service/education, written statements, and care plan of resident), CNA B, the ADON, RN A, and the Administrator, all stated they followed the plan of care for the resident and provided protective oversight of other residents and staff of on the unit; -RN A followed the care plan of temporary separation rather than pharmaceutical approach which was suggested. RN A said that temporary separation would be a last resort when all other interventions failed. This approach has been determined the most appropriate and effective as it wouldn't be causing emotional or physical harm and abuse has been unsubstantiated. Record review of the Regional Human Resources investigation, dated 2/2/23, showed the following: -NA C's written statement, no date, said NA C was getting residents up for dinner and the resident was holding onto another resident's chair and pushing the resident's legs into the exit doors. After multiple attempts of trying to get the resident to let go, NA C was told to get a nurse for a shot. RN A came back and RN A, CMT D, and CNA B grabbed the resident's hands off of the other resident's chair and walked him/her back to his/her room. As they were walking, the resident was trying to bite RN A. When the resident was in his/her room, everyone came out, and RN A held the door shut by the handle. NA C said it was abuse, because staff cannot seclude a resident from others or make them stay in their room. During an interview on 1/26/23, at 11:57 A.M., NA C said the following: -On 1/19/23, around dinnertime, the resident grabbed another resident's wheelchair, and was trying to push the resident through an exit door; -NA C tried to redirect the resident by telling him/her to come to the table for dinner; -The resident continued to be upset and CNA B and CMT D came over to assist; -NA C went to get RN A; -Staff got the resident's hands off of the wheelchair and RN A, CNA B, and CMT D walked him/her to his/her room; -The resident was kicking and biting at staff; -Staff got the resident into his/her room and staff exited; -NA C observed RN A to be holding the door handle down for about a minute, which would prevent the resident from opening the door; -NA C believes the resident was trying to get out as he/she heard the door banging; -NA C said staff cannot hold a resident in their room, as it is a restraint, which is considered abuse; -NA C said he/she told RN E about the incident, and he/she was told to talk to the ADON about the incident; -NA C said he/she spoke to the ADON about his/her concerns, but the ADON said he/she does not recall the conversation; -The resident has behaviors, but normally not as violent, and he/she can usually be redirected with drinks or a snack; -NA C is unsure of the interventions documented in the resident's care plan. Record review of the Regional Human Resources investigation, dated 2/2/23, showed the following: -CNA B's written statement, dated 1/30/23, said on 1/19/23, around 5:00 to 5:30 P.M., the resident became combative. The resident had a hold of another resident, trying to leave with the other resident. The resident was pushing the other resident into a glass door. When trying to pull the resident's hands off of the resident's wheelchair, the resident would try to strike, shaking the resident's wheelchair. The resident let go and became combative. Staff guided the resident to his/her room, where he/she continued to hit, kick, and bite. Staff exited his room and he/she tried to follow. The door was shut and held for a moment to let the resident calm down. During an interview on 1/26/23, at 10:22 A.M., CNA B said the following: -On 1/19/23, at 5:30 P.M., the resident was holding another resident's wheelchair, and trying to exit seek; -The resident would not let go of the wheelchair and kept pushing the other resident into the glass doors at the back of the hallway; -Staff attempted to redirect the resident and the resident finally let go; -CMT D, RN A, the ADON, and NA C walked the resident to his/her room; -While walking to the room, the resident was being combative; -CNA B, CMT D, and the RN walked the resident into his/her room and the ADON stood back; -Staff were able to get the resident in his/her room and sit him/her on his/her bed; -Staff walked out of room and the resident stood up; -CNA B observed RN A shut the door and hold onto the door handle; -CNA B observed the resident trying to get out, as he/she could see the door being pulled back toward the resident; -CNA B walked away, and the ADON and RN A continued to stand by the door; -Staff cannot hold a resident's door shut; -Staff holding a resident's door shut is considered abuse and a restraint; -CNA B is not aware of the interventions in the resident's care plan and said he/she is not on behavior monitoring. During an interview on 1/26/23, at 11:33 A.M., MW said the following: -Last week, (exact date/time unknown) possibly around lunch or dinner time, MW was painting a utility closet back in the unit, by the resident's room; -The resident had a hold of another resident's wheelchair and was trying to push it out a door; -CMT D and CNA B were trying to talk to the resident and to get him/her to sit down; -The resident started swinging and kicking at staff. Staff took the resident to his/her room; -MW has observed the resident to have behaviors, but normally he/she can be redirected by staff and will calm when taken to his/her room; -CMT D, CNA B, the ADON, and RN A all came out of the room; -RN A had a hold of the door handle; -MW observed the resident trying to exit the room while RN A had a hold of the handle, as MW could see the door moving; -MW observed the resident pull on the door a couple of times; -RN A let go and said the resident will calm down; -MW does not believe staff can hold someone in their room as it would be considered a restraint, which is abuse. Record review of the Regional Human Resources investigation, dated 2/2/23, showed the following: -ADON's written statement (no date), said on 1/19/23, CNA B came to the ADON's office as he/she was about to leave for the day and said staff was having a problem with the resident. The ADON went back to the unit and observed the resident standing behind the wheelchair of another resident, wanting to push the resident through the exit door. CMT D was standing next to them, trying to talk to the resident about letting go of the wheelchair. The resident was agitated. CNA B and the ADON stood on each side, and spoke to the resident, slowing moving the other resident's wheelchair away from the door and toward a table. Staff talked to resident for about 15 to 20 minutes and he/she was still agitated. Staff attempted to give the resident supper/drink which did not help. The resident struck at CMT D and the ADON sent staff to check with RN A to see if the resident had a PRN (a medication that is given as needed), the could be administered. RN A came to the unit and attempted to talk with the resident. The resident had his/her hands on the back of the other resident's wheelchair and RN A took one hand and the CMT D took the other hand, and they walked him/her to his room. The ADON followed and staff sat him on his/her bed and tried to talk with him/her. The resident was still agitated, but calmer. RN A closed the door, and held the door knob. The resident did jiggle the door once. It was maybe for 30 to 45 seconds and the resident quieted. The ADON said staff need to contact the physician and family in reference to the situation and to obtain the resident an as needed medication. The ADON did not feel it was abuse as RN A had his/her hand on the knob for a short period of time. RN A was attempting to let the resident calm in a quiet area as per care plan, which had worked in the past. The ADON would have contacted the Administrator if he/she though it was abuse. During an interview on 1/26/23, at 9:59 A.M., ADON said the following: -On 1/19/23, around 5:30 P.M., CNA B told the ADON that the resident was agitated; -CMT D and the MW were present in the hallway of the unit (a secured area in the facility) and CMT D was trying to talk with the resident and trying to get him/her to let go of another resident's wheelchair; -The ADON talked to the resident for about 20 minutes; -RN A came back to the unit. RN A held the resident's hand, with CMT D on the other side and they were able to get the resident to let go of the wheelchair; -RN A and CMT D guided the resident to his/her room. The ADON followed and sat on the resident's bed with him/her; -Staff walked out of the room and the resident had stood up and was ranting; -The ADON was standing next to RN A while he/she held the door knob. The ADON could hear the resident jiggling the door handle, but the ADON did not know if the resident was trying to come out; -RN A said the resident would calm down and held the door hand for approximately 15 seconds; -The ADON said if a resident is trying to get out, staff cannot hold a door handle it could be considered a restraint; -Seclusion, restraints, or restrictions can be considered abuse; -The resident gets agitated off and on and often sun downs (restlessness, agitation, irritability, or confusion that can begin or worsen as daylight begins to fade); -The ADON said the resident normally can be redirected with snacks or walking, but is unsure if those interventions are in the resident's care plan; -The resident does not have routine behavior monitoring; -The resident does not have an as needed medication for agitation. Record review of the resident's medical record showed staff did not document any prior events of taking the resident to an area/room to calm. Record review of the resident's current care plan showed staffed added the following interventions dated 01/20/23: -Diversion: use of foods and temporary separation monitoring is effective for patient for calming. Record review of the Regional Human Resources investigation, dated 2/2/23, showed the following: -RN A's written statement, dated 1/26/23, said CNA B advised RN A that the resident was having some aggression. RN A came to the unit and observed the resident standing behind a resident in a wheelchair. The ADON and CNA B started offering interventions of meals, snacks, and drinks. They walked the resident to his/her room to separate him/her from other resident's and staff. The resident raised his/her hand to swing at RN A and RN A guided him/her away by holding his/her hand. RN A and the ADON walked with the resident to his/her room for temporary separation which had been successful with this resident in the past and following his/her care plan. RN A sat on the bed with the resident, who was the only staff in the room, and the ADON was at the door. The resident was still aggressive by swinging his arms and kicking. RN A continued to offer the resident snacks to calm him/her. The intervention was not working and RN A moved to begin a second intervention of temporary seclusion. RN A and the ADON walked out of the room together as RN A shut the door and both RN A and the ADON stood by the door. RN A's hand was on the door knob and they listened to make sure the resident was safe. During an interview on 1/26/23, at 10:59 A.M., RN A said the following: -Last week, (exact date/time unknown) possibly around lunch break, the resident had a hold of a resident's wheelchair; -The resident was attempting to bite and hit staff and RN A walked the resident to his/her room and shut the door; -RN A stood by the door for approximately five minutes to make sure the resident did not come out and create a problem; -RN A said his/her hand was on the door knob, but he/she did not hold the door shut; -RN A said staff cannot hold someone in their room or prevent a resident from leaving a room, or hold a door shut, as that would be considered abuse; -RN A did not administer any as needed medication for agitation, because normally the resident can be walked to his/her room, and then the resident is pleasant; -RNA A is unsure of the behavior interventions in the resident's care plan; -RN A did not chart the resident behavior in his/her progress notes. During an interview on 1/26/23, at 10:12 A.M., CMT D said the following: -On 1/19/23, around a mealtime, the resident was holding on to another resident's wheelchair; -Staff were able to get the resident to let go of the wheelchair, and the ADON and RN A took the resident to his/her room; -CMT D returned to passing medications; -CMT D observed the ADON and RN A standing by the resident's closed door; -Staff cannot hold a door knob to keep a resident in their room; -CMT D would have notified the Administrator is he/she observed staff hold the resident's door shut, as it is considered abuse; -CMT D said the resident was normally easy to redirect by walking with him/her; -CMT D believes the resident has a PRN medication now, but not when the incident occurred; -CMT D is unsure if the resident is on behavior monitoring, and is unaware of interventions documented in the resident's care plan. During an interview on 1/26/23, at 3:45 P.M., the resident's next of kin (NOK) said the following; -The NOK does not believe holding the resident's door knob to be appropriate; -The NOK said it might upset the resident to be held in his/her room; -The facility has not informed the NOK about his recent behavior or about staff keeping the resident in his/her room. During an interview on 1/27/23, at 11:34 A.M., the facility physician said the following: -The physician was not notified of any behaviors last week; -The facility contacted him/her yesterday, 1/26/23, regarding the resident having behaviors and staff requested an order to send the resident to the hospital; -The physician asked if the resident was administered a PRN for his/her agitation and staff said he/she doesn't have a PRN. The physician said the resident has a PRN for agitation; -Staff did not indicate what behaviors the resident was displaying, but advised the Administrator wanted the resident sent out to the hospital; -The physician expects to be notified of a resident's behaviors if it requires and intervention; -Staff are expected to be aware if a resident has a PRN medication and to administer the medication if necessary; -The physician does not believe holding the door shut to be appropriate, as it is involuntary seclusion. During an interview on 2/1/23, at 4:22 P.M., the Director of Nursing (DON) said it is never ok to shut a resident in their room and hold the door knob. Staff cannot prevent a resident from leaving their room as it is a form of isolation which is abuse. If the DON observed a staff holding a resident in their room, he/she would intervene and report the incident to the Administrator. During an interview on 1/26/23, at 12:51 P.M., the Administrator said the following: -The Administrator was unaware until 1/26/23 of the allegation regarding staff holding the resident's door shut; -The Administrator would expect to be notified if staff held a resident's door shut; -It is not appropriate for staff to hold a resident's door shut, and there is no reason to hold a resident's door shut; -The Administrator interviewed RN A who said they held the door knob for a second and then released it; -The Administrator does not believe staff was trying to seclude the resident; -The Administrator believes staff were trying to protect other residents, not to prevent the resident from coming out of his/her room; -Purposely holding a resident's door shut to keep them from getting out is a restraint and considered seclusion, which is abuse; -The resident normally has behaviors. Staff should address behaviors with the physician; -The Administrator is unsure if the resident has a PRN medication for behaviors; -The Administrator believes the resident's behaviors are documented in his/her care plan, but he/she is unsure of the interventions that have been put in place; -The Administrator believes the interventions are to redirect by taking the resident to his/her room, or offering food. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the 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). MO00213005