Every finding on record at Butler Rehab and Healthcare Center

Based on interview and record review, the facility failed to ensure professional standards were met related to the monitoring and documentation of pacemaker (an electrical device that stimulates the heart at a fixed rate) functionality for one sampled closed record resident (Resident #1) and one sampled resident (Resident #2) out of 2 residents sampled for heart monitoring devices. The facility census was 54 residents. Review of the facility's Care and Services policy revised 10/24/22 showed:-Purpose: To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process.-The licensed nurse or designee documents and notifies the resident's physician and responsible party of unusual circumstances.Review of the facility's Physician Orders policy revised 10/24/22 showed:-The Medical Records Department will verify that physician orders are complete, accurate and clarifiedas necessary.-Other orders will include a description complete enough to ensure clarity of the physician's plan ofcare.-Whenever possible, the Licensed Nurse receiving the order will be responsible for documentingand implementing the order.-Documentation pertaining to physician orders will be maintained in the Electronic Health Record (EHR).A copy of the facility's policy related to the maintenance of a pacemaker 'was requested but not provided.1. Review of Resident #1's admission Record showed he/she was admitted to the facility with the following diagnoses:-Dilated Cardiomyopathy (a condition where the heart's main pumping chamber enlarges, thins, and weakens, preventing it from pumping blood efficiently).-Atherosclerotic heart disease (narrowing or blockage of the arteries that supply blood to the heart).-Congestive heart failure (when the heart muscle does not pump blood efficiently).-Paroxysmal atrial fibrillation (intermittent, chaotic heart rhythm).-Presence of cardiac pacemaker.Review of the resident's Order Summary Report dated June 2026 showed the following orders:-Admit to facility with a Pacemaker Medtronic Device and check per cardiologist recommendation. Medtronic device at bedside, rate of 60 beats per minute (BPM).-Resident has a Pacemaker/Defibrillator Medtronic model #24960 serial #84724557 under the care of the local Cardiovascular Clinic Device check per cardiologist recommendation.--NOTE: The order failed to include monitoring parameters, thus there was no recorded documentation.Review of the resident's undated care plan showed he/she had a pacemaker related to atrial fibrillation (an irregular and often very rapid heart rhythm) with the following interventions:-The staff were to monitor/document/report as needed any signs or symptoms of altered cardiac output or pacemaker malfunction.-Pacemaker checks as ordered, document in chart the heart rate, rhythm, and the battery check.2. Review of Resident #2's admission Record showed he/she was admitted to the facility with the following diagnoses:-Presence of cardiac implants and grafts (specialized devices and biological tissues used to repair defects, replace failing heart valves, and redirect blood flow).-Paroxysmal atrial fibrillation.-Syncope (fainting) and collapse.Review of the resident's Order Summary Report dated June 2026 showed:-An order for a Medtronic Loop Recorder (a continuous monitor of the heart's rhythm).--NOTE: The order failed to include monitoring parameters, thus there was no recorded documentation.Review of the resident's undated care plan showed the resident had a Medtronic Loop Recorder with the following interventions:-Pacemaker checks as ordered and request results.Observation on 06/29/26 at 2:40 P.M. showed:-The resident was lying down in bed resting.-The Medtronic Loop Recorder was on the nightstand and powered on as evidenced by the power cord plugged into wall socket and the power light indicator being illuminated.3. During an interview on 06/29/26 at 5:10 P.M., the Care Plan Coordinator, Assistant Director of Nursing (ADON), and the Regional Corporate Nurse said:-The facility was responsible for making sure that residents with pacemakers had complete orders, had a care plan for the pacemaker, and that the cardiologist was contacted to find out when to change the battery.-He/She would expect a resident who had a pacemaker to have physician's orders that included regular monitoring of the resident's heart rate, proper functioning of the device, and proper setting.-The care plan coordinator, ADON, and the nurse on admission who was putting the orders in were responsible for making sure that orders were complete.-Nurses were responsible for making sure the monitoring was documented and carrying the orders out.During an interview on 06/29/26 at 6:38 P.M., the resident's representative said:-He/She was not sure of the date but was called by the cardiologists' device coordinator's office and did not get the call due to being on vacation at the time.-He/She received a certified letter dated 6/17/26 from the device coordination team saying that the Loop Recorder was disconnected and they were not receiving data. The letter was the office's last attempt before services would be suspended within 30 days.-He/She then made a trip to the facility to re-connect the device personally.-The facility never notified him/her there were any issues with the resident's device during this time.During an interview on 07/02/26 at 8:50 A.M., the Cardiologists' Device Coordinator said:-The Medtronic device would try to re-connect on its own for 7 days before notifying them of the disconnection.-The resident's device was first reported as disconnected on 05/12/26.-A call was placed to the resident's representative, whose contact information was what was on file, and a voicemail was left on 5/26/26. The call was not returned.-A letter was sent to the resident's representative's address, which was the contact information that was on file, on 06/02/26.-A certified letter was sent to the resident's representative's address on 06/17/26.

Based on interview and record review, the facility failed to notify the responsible party for one closed record sampled resident's (Resident #1) significant change of condition when on 05/24/26 the resident acquired an unstageable (full thickness and tissue loss has occurred but the true depth of the damage cannot be assessed because the wound bed is obscured by dead tissue), necrotic (death of living tissue or cells) pressure injury/ulcer to his/her coccyx (base of spine, tailbone) out of three residents sampled for pressure injury/ulcer. The facility census was 54 residents. Review of the facility's Care and Services policy revised 10/24/22 showed:-Licensed nurse discusses with the resident, family, legal representative the possible consequences of the refusal and documents that interaction.-The Licensed Nurse notifies the physician of the resident's refusal of treatment.-The licensed nurse or designee documents and notifies the resident's physician and responsible party of:--Change in condition, including progress and/or decline in physical or mental function.--Resident refusal of care or services.--Unusual circumstances. Review of the facility's Change of Condition Notification policy revised 10/24/22 showed:-Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner.-The Facility will promptly inform the resident, consult with the resident's Attending Physician, andnotify the resident's legal representative when the resident endures a significant change in their condition caused by but not limited to an injury accident.-The Licensed Nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition in a timely manner.-Documentation pertaining to a change in the residents' condition will be maintained in the residents' medical record and on the 24-Hour Report. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility with the following diagnoses:-Protein-calorie malnutrition (condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function).-Iron deficiency secondary to blood loss (chronic).-Need for assistance with personal care.-Contracture (a permanent tightening or shortening of muscles, tendons, skin, or other tissues that causes joints to become stiff and restricts normal movement) of muscle to right lower leg.-Contracture of muscle to left lower leg.Review of the resident's medical record showed he/she was not their own responsible party.Review of the resident's General Durable Power of Attorney (DPOA-a legal document that gives one person (such as a spouse, relative, friend, or lawyer) the authority to make medical, legal, or financial decisions for another) dated 03/12/25 showed the resident had a legal DPOA in place and active. Review of the resident's admission assessment dated [DATE] showed the resident:-Required assistance by staff to turn and reposition while in bed.-Was totally dependent on staff for transfers and required a mechanical lift.-Had no skin issues. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) dated 04/17/26 showed the resident was cognitively intact.Review of the resident's shower sheet/skin condition report dated 05/19/26 showed an open area to the resident's coccyx noted by the Certified Nurse's Assistant (CNA) and reviewed by the Licensed Practical Nurse (LPN). Review of the resident's weekly skin observation dated 05/19/26 showed the resident had no skin issues. Review of the resident's progress notes dated 05/24/26 showed the LPN notified the Assistant Director of Nursing (ADON) of an area of concern to the back of the resident's left hip.--NOTE: There was no documentation that the resident's representative was notified. Review of the resident's progress notes dated 05/26/26 showed the ADON noted skin issues were present and to refer to the assessment for more information.--NOTE: There was no documentation that the resident's representative was notified. Review of the facility weekly pressure wound observation dated 05/28/26 showed:-The resident had a wound to his/her sacrum (bone at the base of the spine).-The wound was acquired during the resident's stay.-The wound was acquired on 05/24/26.-This was the first wound observation.-The extent of the necrosis was 75-100%.-The family/Power of Attorney (POA- a person that has the authority to make medical, legal, or financial decisions for another) was notified on 05/29/26. Review of the resident's medical record showed he/she was not receiving hospice (a specialized model of compassionate care for individuals facing a terminal illness with a prognosis of six months or less) services.Review of the third party wound care providers' Initial Wound Evaluation and Management Summary dated 05/26/26 showed:-The resident was being seen for the presence of a wound on his/her sacrum.-The resident was cognitively intact.-The resident had a pressure wound that was necrotic with 80% necrotic tissue and 20% black necrotic tissue.During an interview on 06/29/26 at 5:10 P.M., the ADON and Regional Nurse said:-The resident's wound was first observed and documented on 05/24/26.-The resident was notified. The resident's responsible party/POA was not notified because the resident was his/her own person.--The resident's medical record did not indicate that he/she was their own responsible party.-He/She would expect the nurse to notify the ADON, physician, and the resident's representative. During an interview on 06/29/26 at 6:38 P.M., the resident's POA said:-He/She first became aware of the resident's coccyx wound on 06/13/26 during a phone call with the nurse on duty at the facility when they called informing him/her that the resident had fallen.-He/She had never received notification from the facility regarding the resident's wound. During an interview on 07/01/26 at 12:49 P.M., the Nurse Practitioner (NP) said:-He/She was the primary provider that made rounds at the facility.-He/She would usually address any change of condition in an NP note.-He/She did not recall and could not find any documentation of being notified or addressing a sacrum pressure wound for the resident.-He/She would expect to be notified of any change of condition.

Based on observation an interview, the facility failed to prevent the accumulation of debris on the blade of the table top can opener; failed to remove the accumulation of food particles and debris from under the 6-burner stove; failed to prevent a buildup of dust on the vent fans and the sprinkler head in the walk-in refrigerator; failed to prevent the accumulation of dust and grease on the light fixtures; and failed to prevent the presence of a dust buildup inside the ceiling vents in the kitchen. This practice potentially affected 58 residents who ate food from the kitchen. The facility census was 59 residents. 1.Observation on 2/23/26 from 9:56 A.M. to 12:24 P.M., during the lunch meal preparation, showed:-The presence of food debris on the can opener point.-The presence of food debris under the 6-burner stove.-An accumulation of dust on the sprinkler head and on the vent fans in the walk-in refrigerator.-The presence of dust on light fixtures over the microwave, dust on the ceiling vent over the microwave. -The presence of dust on the light fixtures over the dish storage area next to the reach-in fridge.During an interview on 2/23/26 at 12:58 P.M. the Dietary Manager said:-The dietary staff should clean the debris from under the stove every night. -- It was probably the two weekend nights before the start of survey on 2/23/26, that the area under the 6- burner stove has not been cleaned.-As far as the lights were concerned, the accumulation of dust on the light fixtures had to do with the fact there was not a regular maintenance person in the facility.-He/she expected maintenance to clean the sprinkler head and the fans in the walk-in refrigerator, because cleaning those parts are beyond the duties dietary staff.

Based on observation, interview and record review, the facility failed to ensure hand hygiene and Enhanced Barrier Precautions (EBP - infection control measures of gown and glove use during high contact activities with residents at risk for transmission germs resistant to many antibiotics) for one sampled resident (Resident #47) with a physician's order for EBP and failed to develop a facility policy that instructed nursing staff in the use of gowns with EBP and that included the use of EBP for residents with indwelling devices (medical devices inserted into the body); failed to ensure staff used hand hygiene after insulin (medication used to manage diabetes (Types 1, 2, or gestational) administration after removing gloves and before applying new ones for one supplemental resident (Resident #31); and failed to ensure staff cleaned and disinfected shared medical equipment of a blood pressure cuff prior to its use and after for one supplemental resident (Resident #37) out of 14 sampled residents and five supplemental residents. The facility census was 59 residents. Review of the facility Standard and Enhanced Precautions policy dated July 1, 2023, showed:-No instruction for staff to wear gowns for high contact activities for residents on EBP.-No instruction to use EBP for residents with wounds or indwelling medical devices. Review of the facility Hand Hygiene policy dated October 24, 2023, showed:-The facility considered hand hygiene the primary means to prevent the spread of infections.-Facility staff were trained regularly on the importance of hand hygiene in preventing the transmission of infections. Review of the Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety & Oversight Group (QSO) memo to State Survey Agencies and long-term care (LTC) facilities dated March 20, 2024, showed:-CMS issued new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of EBP to align with nationally accepted standards.-Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multidrug-resistant organisms (MDRO – germs that are resistant to many antibiotics).-Recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their MDRO status. Review of the facility's Hand Hygiene policy dated October 24, 2022, showed:-The facility considers hand hygiene the primary means to prevent the spread of infection.-Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.-Facility staff, visitors, and volunteers must perform hand hygiene procedures in the following circumstances.--Wash hands with soap and water between glove changes.--Alcohol-based hand hygiene products can and should be used to decontaminate hands after removing and disposing of personal protective equipment.-Hand hygiene is always the final step after removing and disposing of personal protective equipment.-The use of gloves does not replace hand hygiene products. 1. Review of Resident #47's Physician's Orders Sheet (POS) dated 2/27/26 showed:-Diagnoses of carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus (MRSA – staph bacteria that is resistant to several common antibiotics).-EPB related to indwelling catheter and Peripherally Inserted Central Catheter (PICC a thin, flexible tube inserted into an upper arm vein used for long-term therapy including antibiotics).-Ertapenem sodium (antibiotic) solution one gram (gm) intravenously (IV into a vein) one time a day for urinary tract infection (UTI). Observation on 2/25/26 at 10:03 A.M. showed:-Licensed Practical Nurse (LPN) B entered the resident's room and placed the resident's Ertapenem Sodium IV medication, IV tubing, IV port cap, IV flushes and alcohol wipe package on the resident's overbed table without first placing a barrier on the resident's overbed table. -He/She washed his/her hands, put on gloves, he/she did not put on a gown. -He/She wiped the resident's IV port with an alcohol wipe, attached the saline flush syringe and flushed the residents PICC line.-He/She attempted to mix the resident's IV medication for administration and being unable to do so left the resident's room with the medication, entered two hallways and asked for assistance with mixing the medication.-He/She continued attempting to mix the resident's IV medication until he/she was successful, returned to the resident's room and placed the resident's IV medication on the resident's overbed table without a barrier and attached IV tubing to the medication.-He/she dropped an alcohol wipe package on the floor, picked up the alcohol wipe package from the floor, opened the package and wiped the resident's PICC line cap with the alcohol wipe.-He/she then attached the IV tubing to the residents PICC line, set the rate of infusion on the IV pump, washed his/her hands and left the resident's room. Observation on 2/25/26 at 10:53 A.M. showed:-LPN B entered the resident's room; a PICC line cap and IV saline flush were on the resident's overbed table without a barrier.-He/she washed his/her hands, put on gloves and did not put on a gown.-He/she disconnected the IV tubing from the resident's PICC line, flushed the PICC line with the saline flush syringe and placed a new cap on the resident's PICC line.-He/she then removed his/her gloves, washed his/her hands and left the resident's room. During an interview on 2/26/26 at 10:58 A.M. LPN B said:-The resident was on EBP.-He/She should have put on a gown when he/she entered the resident's room to administer his/her IV medication and also when he/she entered the resident's room and disconnected the IV tubing and flushed the resident's PICC line.-He/She should have used a barrier for the resident's IV medication and PICC line supplies.-He/She should not have used the alcohol wipe he/she had dropped on the floor and should have discarded the alcohol wipe, removed his/her gloves, washed his/her hands and obtain a new alcohol pad to use. During an interview on 2/27/27 at 3:05 P.M. the Director of Nursing (DON) said:-EBP required at a minimum the use of gloves and gowns when administering IV medications.-Barriers should be used for all medications and supplies placed on a surface in a resident's room.-LPN B should have put on a gown each time he/she entered the resident's room for administration of the resident's IV medication and for disconnecting tubing and flushing the resident's PICC line. -LPN B should have discarded the alcohol wipe he/she had dropped on the floor, removed his/her gloves, performed hand hygiene and he/she could have used the resident's call light or ask for help from the resident's doorway to get a new alcohol wipe.-All management nurses were responsible to monitor that staff followed EBP and used correct infection control procedures. 2. Review of Resident #31's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 1/30/26, showed the resident was:-Cognitively intact.-Able to make his/her needs known.-Received insulin injections seven day per week.-Diagnoses included: Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin) and hypoglycemia (low blood glucose level). Review of the resident's Physicians Order Sheet (POS) dated February 2026 showed an order for Humalog Solution 100 milligram (mg)/milliliter (ml) to inject per sliding scale subcutaneously before meals for diabetes notify provider if less than 70 or 451, ordered on 2/8/26. Observation on 2/24/26 at 12:34 P.M. showed:-LPN C performed hand hygiene with sanitizer and applied gloves.-LPN C placed blood glucose testing supplies on tray and entered the resident's room.-LPN C cleaned fingertip with alcohol and pierced it with lancet.-LPN C wiped blood drop with gauze and squeezed fingertip to get a new drop.-LPN C tested blood drop with glucometer (small, portable device used to measure the concentration of glucose (sugar) in the blood).-LPN C applied pressure to the finger with gauze.-LPN C took tray with supplies back to medication cart and with the same gloves opened the bottom of the drawer and took out a disinfectant wipe.-LPN C removed gloves and did not perform hand hygiene prior to putting on a new pair of gloves.-LPN C cleaned glucometer with a disinfectant wipe.-LPN C failed to perform hand hygiene after contact with resident and removal of gloves before applying new ones. During an interview on 2/24/26 at 12:45 P.M., LPN C said:-He/She had not realized he/she did not perform hand hygiene between gloves changes.-He/She should have washed or sanitized his/her hands between glove changes and before giving the resident his/her insulin.-He/She had been in-serviced on appropriate hand hygiene procedure. During an interview on 2/27/26 at 2:19 P.M., LPN A said:-Nursing staff should always practice good hand hygiene.-Staff should perform hand hygiene between gloves changes-Staff received regular in-services on hand hygiene policy and procedure. During an interview on 2/27/26 at 3:30 P.M the DON said:-Trainings and in-services that included proper hand hygiene were conducted monthly and as needed.-A skills check was done for nursing staff in January 2026.-The Assistant Director of Nursing (ADON) was responsible for making sure that the trainings were done.-He/She would expect staff to perform hand hygiene between glove changes. 3. Review of Resident # 37's admission record showed he/she was admitted with the following diagnoses:-Dementia ((a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Paroxysmal atrial fibrillation (afib) (an irregular, often rapid heart rhythm that starts and stops suddenly on its own or with treatment, lasting less than 7 days).-Hypertension (HTN- high blood pressure).-Heart failure (a chronic, progressive condition where the heart muscle cannot pump enough blood to meet the body's needs, often causing fluid buildup (congestion) in the lungs and legs). Review of the resident's Quarterly MDS dated [DATE] showed:-The resident had moderate cognitive impairment.-The resident was able to make his/her needs known. Review of the resident's POS dated 2/22/26 showed the resident was taking the following medications daily that required a blood pressure measurement prior to administration:-Cardizem LA Oral Tablet Extended Release 24 Hour 300 milligrams (mg) (Diltiazem HCl). Give 300 mg by mouth one time a day for HTN. Hold if systolic blood pressure (sbp) was less than 50.-Metoprolol Tartrate Tablet 50 mg. Give one tablet by mouth two times a day for afib, hold for sbp less than 50. Observation on 2/25/26 at 10:21 A.M. with Certified Medication Technician (CMT) B during medication pass showed:-He/She performed hand hygiene.-He/She entered the resident's room.-He/She did not sanitize the blood pressure cuff prior to using it on resident.-He/She took the resident's blood pressure per physician's order before administering blood pressure medication to the resident.-He/She documented the resident's blood pressure finding.-He/She returned to the resident's room and administered medications.-He/She did not sanitize the blood pressure cuff after using it. During an interview on 2/25/26 at 10:30 A.M. CMT B said:-The blood pressure cuff was used on multiple residents during medication pass.-Blood pressure and pulse should always be checked prior to administering blood pressure medication.-The blood pressure cuff should be cleaned before and after each use.-It was his/her responsibility to make sure shared medical equipment were cleaned before and after each use. During an interview on 2/27/26 at 3:30 P.M., the DON said:-Shared medical equipment should be cleaned before and after use.-Trainings and in-services for the nursing staff including infection control were conducted on a monthly schedule and as needed when an issue comes up.-The ADON was responsible for making sure this was done.

Based on observation and interview, the facility failed to maintain the ceiling vents in the following areas free from a buildup of dust, the dining room, the shared restroom between 308 and 310, 300 Hall Central bath, the shared restroom between 306 and 304, resident room [ROOM NUMBER], resident room [ROOM NUMBER], 100 Hall Central Bath, and the 200 Hall Central Bath; failed to maintain the floor in good repair and in an easily cleanable condition in the shared restroom of resident rooms [ROOM NUMBERS], the 300 Hall Central Bath, the restroom floor in resident room [ROOM NUMBER], and the restroom floor in resident room [ROOM NUMBER]; failed to maintain the floors in the following areas clean and free of debris, resident rooms 313, 307, 304, 302, 305, 303, 300, 111, 105, 106, and 102; failed to maintain the personal fans in resident rooms 300, 303,103, 107, free of a heavy buildup of dust; and failed to maintain the base of the tube feeding pole in resident room [ROOM NUMBER] free from tube feeding debris. This practice potentially affected at least 40 residents who resided in or used those areas. The facility census was 59 residents. 1. Observation on 2/23/26 at 10:39 A.M, and on 2/25/26 at 2:49 P.M, showed a heavy buildup of dust in three ceiling vents over the dining room.2. Observation on 2/25/26 with the Regional Director of Operations showed the following on the 300 Hall:-At 11:12 A.M., in resident room [ROOM NUMBER] there was a heavy buildup of dust in the ceiling vent and a 49-inch (in.) area where the floor peeled away from its base.-At 11:23 A.M., there was a buildup of debris, including hair and dust under and behind the beds in resident room [ROOM NUMBER].-At 11:33 A.M. there was an area of the shower room floor that was 8 inches (in.) long by 10 in. wide where the tiles were peeled away.-At 11:40 A.M., the floor in the restroom of resident room [ROOM NUMBER] had numerous tears in the floor.-At 11:44 A.M., there was a buildup of grime on the floor in resident room [ROOM NUMBER].-At 11:47 A.M, there was a buildup of grime on the floor in resident room [ROOM NUMBER].-At 11:49 A.M., there was a buildup of hair rand dust in on the floor in resident room [ROOM NUMBER], a buildup of dust in the restroom ceiling vent and numerous rips and tears in the restroom floor.-At 11:51 A.M. there was a brown colored substance on the base of the tube feeding pole in resident room [ROOM NUMBER]-At 11:54 A.M, there was a buildup of dust on the fan blades of the fan, a buildup of grime on the floor and a buildup of dust in the restroom vent of resident room [ROOM NUMBER].-At 11:59 A.M., there was a buildup of dust on the fan and a buildup of dust and grime on the floor in resident room [ROOM NUMBER].3. Observation on 2/25/26 with the Regional Director of Operations showed the following on the 100 Hall:-At 12:20 P.M., there was a buildup of grime on the floor of resident room [ROOM NUMBER].-At 12:34 P.M, there was a buildup of dust in the ceiling vent in the 100 Hall Central Bath.-At 12:37 P.M., there was a buildup of dust on the blades of the personal fan in resident room [ROOM NUMBER].-At 12:40 P.M., there was a buildup of dust and debris on the floor in resident room [ROOM NUMBER].-At 12:47 P.M., there was a buildup of grime on the floor in in resident room [ROOM NUMBER].-At 12:55 P.M, there was a buildup of grime on the floor in resident room [ROOM NUMBER].4. Observation on 2/25/26 at 1:49 P.M., with the Regional Director of Operations showed a heavy buildup of dust in the ceiling vent of the 200 Hall Central bath.5. During an interview on 2/25/26 at 2:25 the Housekeeping Supervisor said the following after looking at resident rooms [ROOM NUMBERS]:-He /She was away from his/her duties as a Housekeeping Supervisor from 9/30/25 to 2/3/26 for personal reasons.-No one stepped up to be the Housekeeping Supervisor when he/she was away.-He/She expected the floors to be mopped and swept daily.-The personal fans had not really been cleaned since the former maintenance person left. -The former maintenance person used to clean the ceiling vents, but no one took care of cleaning the ceiling vents at the current time.-He/she expected the housekeepers to clean all floor areas that could be cleaned. During an interview on 2/25/26 at 2:34 P.M., Housekeeper A said:-It was difficult to remove the grime from the floors because scrapers (a tool or device used for scraping, especially for removing dirt, paint, ice, or other unwanted matter from a surface) were not available for the housekeepers at the facility.-He/She did not want to move the beds to clean under the beds if residents were sleeping on their beds.During an interview on 2/26/26 at 11:24 A.M, Housekeeper B said:-The floor in the shared restroom of resident rooms [ROOM NUMBERS], had been like that for several months.-The floor of the restroom in resident room [ROOM NUMBER], was difficult to clean because of the damage to the floor.During an interview on 2/26/26 at 1:36 P.M., Licensed Practical Nurse (LPN) B said:-He/She would have to find out who cleaned the tube feeding pole. -He/She did not clean the tube feeding pole.During an interview on 2/27/26 at 2:03 P.M., the Assistant Director of Nursing (ADON) said it was the responsibility of the housekeepers to clean the tube feeding pole.During an interview on 2/27/26 at 2:07 P.M, Housekeeper A said:-They cleaned the tube feeding pole.-On 2/26/26, the tube feeding pole was missed.

Based on observation, interview and record review, the facility failed to ensure the physician's order prescribed enteral supplemental tube feeding (tubes inserted into the gastrointestinal tract to provide a patient with enteral nutrition) formula and failed to update the resident's care plan to include details on the prescribed tube feeding formula for one sampled resident (Resident #7) who was dependent on enteral nutritional feedings out 14 sampled residents. The facility census of 59 residents. Requested the facility's Tube Feeding policy did not receive at time of exit. Review of the tube feeding formula manufacture information on website dated 2026 showed: -Diabetisource AC 1.2 calories (cal) per milliliter (ml) (a tube feeding formula made with a unique blend of carbohydrates that includes pureed fruits and vegetables for resident that are diabetic for reduce sugar intake). -Fibersource HN 1.2 cal (a nutritionally complete tube feeding formula with fiber, contains protein from milk and soy and was Lactose intolerance and gluten-free).1. Review of Resident#7's admission record showed the resident admitted with the following diagnoses:-Gastrostomy status (is a procedure in which the feeding tube (gastrostomy tube (G-tube) or Percutaneous Endoscopic gastrostomy (PEG) is placed directly into the stomach). Review of the resident's undated Care Plan showed:-The resident required tube feeding related to dysphagia (difficulty swallowing). -NOTE: There was no documentation that showed the type of supplemental formula prescribed by the Physician or by the Registered Dietitian. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 2/10/26 showed he/she:-Was severely cognitively impaired.-Required supplemental tube feeding formula for nutritional intake. Review of the resident's Physician Order Sheet (POS) dated February 2026 showed an order for tube feeding supplemental formula of Fiber Source HN 1.2 via peg tube delivered at 47 ml/ hour (hr) continuous times 22 hours. May have max of two-hour break in 24-hour period for actives and cares, ordered on 2/19/26Review of the resident's Treatment Administration Record (TAR) dated February 2026 showed Fiber Source HN 1.2 calorie via peg tube delivered at 47 ml/hr continuous times 22 hours. May have max of two-hour break in a 24-hour period, every shift, for peg tube feedings. Observation on 2/23/26 at 10:42 A.M., showed:-The resident was in bed with his/her eyes open and non-verbal, he/she would smile.-His/her tube feeding pump was running at 47 ml/hr and the bag of water flush running at 240 ml every 4 hours. -He/she had a premixed formula bag of Diabetisource AC 1.2 cal with a handwritten date of 2/23/26. Review of the resident's Nursing Note dated 2/24/2026 at 2:55 A.M. showed: -The resident continues to be nothing by mouth (NPO) with continuous PEG-tube feedings.-His/Her head of bed was elevated 45 degrees.-Oral care provided. -Resident pleasant during this shift smiling and laughing. -No signs or symptoms of acute distress, pain, or discomfort noted or reported. -Abdomen was soft and non-tender. -Resident resting in bed with call light within reach.-NOTE: The note did not indicate the type of tube feeding formula prescribed and being given.Observation on 2/24/26 at 9:21 A.M., showed:-The resident was in bed.-His/her tube feeding formula was connected to the tube feeding pump and running at 47 ml/hr.-The type of supplement formula was Diabetisource AC and was labeled with date of 2/24/26 at 12:00 A.M. -NOTE: Fibersource HN 1.2 cal was transcribed to the resident's POS on 2/19/26.Observation 2/24/26 at 9:50 AM of the resident's PEG tube medication administration showed.-Diabetisource, AC was running at 47 ml/hr per pump. The formula bag was dated 2/24/26 at 12:00 A.M.-Licensed Practical Nurse (LPN) A placed tube feeding on hold and disconnected the feeding tube.-The Director of Nursing (DON) was present, as LPN A completed administering medication via PEG tube via feeding tube syringe. -The hub of the PEG tube site, looked like a small button connected to a small narrow tubing (tip of tubing snaped into button PEG tube site). -The dry split dressing around the PEG tube site was dated 2/24/26 at 12:00 A.M.-LPN A then reconnected the Diabetisource formula after the medications were administered via PEG tube. During an interview on 2/24/26 at 10:10 A.M., LPN A said: -He/she had checked the resident's physician's order, and it showed the tube feeding formula was to be Fibersource HN and not Diabetisource AC. -He/she said the only difference was Diabetisource AC had less sugar, and Fibersource HN had more fiber content. Observation on 2/24/26 at 10:10 A.M. showed LPN A:-Went to a storage closet to obtain the correct formula of Fibersource HN. -Acknowledged the Fibersource HN bag was similar to the Diabeisource AC bag. Review of the resident's Nursing Note dated 2/24/26 at 10:28 A.M., showed: -The resident received Diabeticsource AC, which was not the tube feeding formula prescribed.-The resident's Nurse Practitioner (NP) the Registered Dietician were notified.-No new orders at that time. Continue with plan of care.During an interview on 2/27/2026 10:20 A.M., the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP) said:-He/she would expect nursing staff to check the physician's orders and TAR before hanging tubing feeding formula. -The nursing staff should ensure to follow the five rights in providing medication and supplemental formulas to include: Right Resident, Right Drug, Right Dose, Right Route, and Right Time.-The MDS Coordinator would be responsible for updating the resident's care plan as needed and during the MDS quarterly review. During an interview on 2/27/26 at 3:04 P.M., the Director of Nursing (DON) said: -He/she would expect nursing staff to check the physician's order to ensure they had obtained the right prescribed tube feeding formula and to have double checked before connecting the tube feeding to the resident's PEG tube. -He/she would expect staff to the monitor the tube feeding bag and pump every shift and when making rounds on the resident to ensure the tube feeding was running and the right formula was being given. -The facility had checked with the RD and confirmed the nutritional value for the Diabetisource AC and the Fibersource HN was the same and there was no outcome from getting the wrong formula. -The resident's care plan was reviewed and was updated during the IDT meetings.

Based on observation, interview and record review, the facility failed to obtain a physician's order and failed to update the care plan for one sampled resident (Resident #1) to provide own self-care for his/her Colostomy (bowel) and Urostomy (bladder) (surgical openings (stomas) in the abdomen allowing waste to exit the body into a pouching system, used when bowel or bladder function is compromised) out of 14 sampled residents. The facility resident census of 59 residents. Review of the facility Policy and Procedure for Colostomy care revised on 10/24/22 showed: The stoma and surrounding skin will be monitored for irritation with routine care and as part of licensed nurses' weekly assessment. Requested the facility policy for self-administrating of medication and treatments and did not receive at time of exit. 1. Review of Resident #1 admission Face sheet showed he/she was admitted to the facility with diagnoses of:-Paraplegia (is an impairment in motor or sensory function of the lower extremities). -Colostomy status (is an surgical opening (stoma) on your abdomen (belly) that connects your colon (large intestine) to the outside of your body).-Neuromuscular dysfunction of bladder. (is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition).-Artificial opening of urinary tract status. (surgical opening into the urinary tract system, a stoma) Review of the resident's Nursing Self-Medication assessment dated [DATE] showed:-The resident may not self-administer medication (keep medication at bedside or provide own medication). -Nursing staff must be present and administer medications.-There was no nursing assessment to assess the resident's ability and knowledge to provide own self-care of colostomy and urostomy.Review of the resident's Care Plan revised on 12/20/25 showed:-The resident had activity of daily living (ADL) for self-care performance deficit related to Paraplegia.-NOTE: There was no care plan related to the resident's ability to provide own self-care for his/her colostomy or urostomy.Review of the resident's Physician Order Sheet (POS) dated February 2026 showed: -The resident had a urostomy: required a 64-millimeter (mm) wafer, ordered on 1/16/26.-Nursing to provide care and change urostomy every three days (every 72 hours) and as needed, ordered on 12/26/25.-Monitor and document urostomy stoma for signs and symptoms of infection every shift and as needed, ordered on 12/26/25.-Check urostomy site every shift and change bag as needed every shift, ordered on 12/26/25. -Colostomy wafer size of a 38 mm.-Nursing staff to care and change colostomy every three days (every 72 hours) and as needed, ordered on 2/26/25.-Check colostomy site every shift and change bag as needed every shift, ordered on 12/26/25.-NOTE: There was no physician's order for the resident to provide own self-care of ostomy sites and applying ostomy appliance and no nursing assessment to assess the resident ability and knowledge to provide own colostomy and urostomy care. Review of the resident's Treatment Administration Record (TAR) dated February 2026 showed:-Monitor and document colostomy stoma for signs of infection every shift ordered on 12/26/25.-Monitor and document urostomy stoma for signs of infection every shift ordered on 12/26/25.-Check urostomy site every shift and change bag as needed: dated 12/26/25.-Provide urostomy care and change urostomy every 3 days and as needed every 72 hours AND as needed ordered on 12/26/2025.-Provide colostomy care and change colostomy every 3 days and as needed every 72 hours ordered on 12/26/25-There was documentation that nursing staff checked the colostomy and urostomy sites every shift indicated by the nurse's initials in each box by each order. -NOTE: There was no physician's order for self-care assessment for the residents ability to provide own ostomy care and did not physicians order for the resident allowed to assist with or provide own ostomy care. During an interview on 2/24/26 at 2:22 P.M., the resident said:-He/she had a colostomy and urostomy and he/she provided his/her own care. -He/she had shown staff how he/she cared for his/her colostomy and urostomy sites and changing the bags. -He/she had no issues at the urostomy and colostomy sites at that time.Observation on 2/25/26 at 9:15 A.M. showed the resident did not have any lingering odors present.During an interview on 2/25/26 at 9:15 A.M., the resident said:-He/she did not have any concerns with his/her ostomy care.-There was no redness or soreness at either the colostomy or urostomy sites. During an interview on 2/25/26 at 11:19 A.M. Director of Nursing (DON) said: -The resident completed his/her own colostomy and urostomy care. -He/she was unsure if the resident had a physician's order to provide his/her own colostomy and urostomy care. During an interview 2/25/26 at 11:25 A.M., Licensed Practical Nurse (LPN) B said: -The resident had been providing his/her own urostomy and colostomy care.-The resident did not have a physician's order to provide his/her own urostomy and colostomy care.-There should be a physician's order for the resident to provide his/her own urostomy and colostomy care.-Nursing staff should have completed a resident self-care assessment to assess the resident's knowledge and ability to provide his/her own ostomy self-care. Observation on 2/26/26 at 12:18 P.M., of the resident's ostomy site showed:-Certified Nursing Assistant (CNA) D and CNA E were present in the resident's room assisting the resident with personal cares. -The resident had a urostomy on his/her right abdomen and a colostomy on the left side (which had brownish green stool noted). -There was no redness noted at either site and the stomas were pink with no signs of infection. During an interview on 2/26/26 at 12:18 P.M. the resident said: -He/She would change his/her own urostomy and colostomy bag as needed. -Staff were normally in the room assisting him/her when it was time to change or empty the ostomy bags. During an interview on 2/27/26 at 10:20 A.M. the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP) said: -The resident was known to provide most of his/her own colostomy and urostomy care with stand by assistance by care staff. -Nursing had assessed the resident's ability to provide his/her own care but did not document in the resident's medical record and did not obtain a physician's order for the resident to provide his/her own ostomy cares. -He/She would expect to have a physician's order for the resident to provide his/her own urostomy and colostomy care.-He/She would expect nursing staff to have completed and documented a resident self-care assessment at least quarterly in the resident's electronic medical record.-The care plan should reflect the resident's current medical needs and care, to include own self-care for his/her colostomy and urostomy sites. -The Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) Coordinator would ensure the resident's care plan was updated as needed. During an interview 2/27/26 at 3:04 P.M., the DON said: -He/she would expect there to be a physician's order for the resident to provide his/her own colostomy and urostomy care. -Nursing staff should have a physician's order to provide self-care oversight and to assess the resident's ability to provide his/her own colostomy and urostomy care. -Nursing staff should complete the resident self-care assessment at least every quarter.-Would expect nursing staff to complete resident self-care assessment for ability and knowledge to provide his/her own cares. -He/she would expect the resident's care plan to be updated with the resident's ability to provide his/her own colostomy and urostomy cares.-Care plans were reviewed and updated during team meetings. -He/she would expect staff to document the monitoring of the resident colostomy and urostomy care and document findings in the resident's progress notes.-The resident had the right to make choices and to provide his/her own care if he/she had the ability to safely provide all or part of his/her own colostomy and urostomy care.

Based on observation, interview, and record review, the facility failed to ensure that only residents assessed and determined safe by the interdisciplinary team (IDT) may self-administer medication and failed to ensure medications were not left unattended for a resident assessed as unable to self-administer for one sampled resident (Resident #17) out of 14 sampled residents. The facility census was 59 residents. The Medication Self-Administration policy was requested on [DATE] but was not provided before exit time. Review of the facility's policy titled Medication Administration dated [DATE] showed:-Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law.-Medications will not be left at the bedside.-The Licensed Nurse will remain with the resident until the medicine is actually swallowed.-If resident is refusing to take medication, the Licensed Nurse who is passing the medication will initial and draw a circle around his/her initials in the designated area on the Medication Administration Record (MAR). Documentation will be entered on the back of the MAR stating the reason for the refusal.-The Licensed Nurse will re-approach the resident and attempt to give the medications at a later time, but if resident continues to refuse after one hour, the refused medications will be destroyed. Licensed Nurse will notify the Attending Physician and document in the medical record.-If the resident repeatedly refuses medication, the Licensed Nurse will contact the physician to discuss alternative measures for medication administration. The plan of care will be updated as indicated.-If the resident has difficulty swallowing pills, the Licensed Nurse will notify the Attending Physician to discuss the possibility of a different form of the medication.1. Review of Resident #17's face sheet showed he/she was admitted with the following diagnoses:-Cerebral Infarction (a type of ischemic stroke caused by a blockage in brain blood vessels, resulting in tissue necrosis (death) due to lack of oxygen).-Dysphagia (difficulty swallowing).-Congestive Heart Failure (a chronic condition where the heart cannot pump blood efficiently, causing fluid buildup, fatigue, and shortness of breath).-Atrial Fibrillation (reduces cardiac output and significantly increases the risk of stroke, blood clots, and heart failure).-Pulmonary Hypertension (high blood pressure in the lung arteries, causing them to become stiff, narrow, or blocked).-Chronic Kidney Disease (long-term, irreversible loss of kidney function, commonly caused by diabetes and high blood pressure).-Chronic Obstruction Pulmonary Disease (a progressive, incurable, yet treatable lung disease mainly caused by smoking, that restricts airflow, making it difficult to breathe).Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed he/she:-Was cognitively intact.-Was able to understand others and make his/her needs known.Review of the resident's Medication Self-Administration Safety Screen dated [DATE] showed:-The resident was assessed for self-administration of all medications.-The assessment was to be completed at least quarterly.-The resident was determined to require assistance with correctly reading label and/or identifying each medication, correctly stating what each medication was for, correctly stating the time/frequency medications were to be taken, correctly stating the correct dosage and quantity for each administration.-All medications were to remain with staff.-The IDT determined it was not safe for the resident to self-administer any medications.-The results of the resident's assessment were categorized as may NOT self-administer medications.Review of the resident's Physician Order Sheet (POS) dated February 2026 showed:-B-Complex with Vitamin C and Folic Acid oral tablet (supplement) one tablet by mouth one time a day.-Bactrim DS table 800-160 milligram (mg) (Sulfamethoxazole-Trimethoprim) one tablet by mouth one time a day every Tuesday, Thursday and Saturday for prophylaxis (preventative) prostatitis (inflammation of the prostate gland).-Folic Acid oral tablet 400 micrograms (mcg) (supplement) one tablet by mouth one time a day.-Furosemide tablet 40 mg one tablet by mouth one time a day for edema (fluid retention).-Hydrochlorothiazide oral tablet 25 mcg one tablet by mouth one time a day for hypertension (high blood pressure).-Magnesium Oxide tablet 5 mg one tablet by mouth two times a day for hypomagnesemia (low magnesium).-Multiple Vitamins-Minerals tablet one tablet by mouth one time a day for supplement.-Natto kinase oral capsule 100 mg one capsule one time a day for supplement. Medication in bottles called peak blood flow. -Omeprazole oral tablet delayed release 20 mg one tablet by mouth one time a day for heartburn (GERD).-Potassium Chloride ER tablet extended release 20 Milliequivalent (MEQ) one tablet by mouth one time a day for hypokalemia (low potassium).-Vitamin D3 125 mcg (5000 units) one capsule by mouth one time a day for supplement.Review of the resident's MAR dated February 2026 showed:-B-Complex with Vitamin C and Folic Acid oral tablet (supplement) one tablet by mouth one time a day.-Bactrim DS table 800-160 mg (Sulfamethoxazole-Trimethoprim) one tablet by mouth one time a day every Tuesday, Thursday and Saturday for prophylaxis (preventative) prostatitis (inflammation of the prostate gland).-Folic Acid oral tablet 400 mcg (supplement) one tablet by mouth one time a day.-Furosemide tablet 40 mg one tablet by mouth one time a day for edema (fluid retention).-Hydrochlorothiazide oral tablet 25 mcg one tablet by mouth one time a day for hypertension (high blood pressure).-Magnesium Oxide tablet 5 mg one tablet by mouth two times a day for hypomagnesemia (low magnesium).-Multiple Vitamins-Minerals tablet one tablet by mouth one time a day for supplement.-Natto kinase oral capsule 100 mg one capsule one time a day for supplement. Medication in bottles called peak blood flow. -Omeprazole oral tablet delayed release 20 mg one tablet by mouth one time a day for heartburn (GERD).-Potassium Chloride ER tablet extended release 20 MEQ one tablet by mouth one time a day for hypokalemia (low potassium).-Vitamin D3 125 mcg (5000 units) one capsule by mouth one time a day for supplement.-NOTE: There was no physician's order for the self-administration or the ability to keep medications at bedside.Observation on [DATE] at 11:42 A.M. showed the resident had an expired Vitamin D3 bottle with unidentified medication in it that were not Vitamin D3 capsules.Observation on [DATE] at 9:27 A.M., showed the resident:-Had an expired Vitamin D3 bottle with unidentified pills in it on bedside table.-Had an open bag of cough drops on bedside table.During an interview on [DATE] at 9:27 A.M. the resident said: -The pills were for strength and he/she administered them daily.-The cough drops were given to him/her on [DATE].Observation on [DATE] at 9:20 A.M., showed the resident:-Had an expired Vitamin D3 bottle with unidentified pills in it on bedside table.-Had an open bag of cough drops on bedside table.-Had a small plastic cup filled with medications on bedside table.During an interview on [DATE] at 9:20 A.M. the resident said the medications were given to him/her that morning and he/she wasn't ready to take them yet.During an interview on [DATE] at 9:38 A.M., Certified Medication Technician (CMT) A said:-He/She gave the resident all their morning medication between 8:30 A.M. and 8:45 A.M.-He/She watched the resident take all his/her medications and ensured they were swallowed completely.-He/She was not sure if the resident was approved to self-administer any medications and was not aware of any medications kept in the resident's room.-He/She did not know where to find the resident's self-administration assessment information.-He/She always marked each medication cup with resident's name and room number so if was not marked, he/she did not give the medications.-If a resident refused medication at the time of administration, he/she should ask again, advise them of the adverse effects related to not take medication, notify the charge nurse and document it.During an interview on [DATE] at 3:30 P.M. the Director of Nursing (DON) said:-All residents should be assessed quarterly for being able to self-administer or keep medications at beside.-Resident who had been assessed for medication self-administration and determined to be ineligible should not have medications left with them or kept at bedside.-The provider, Assistant Director of Nursing (ADON), and him/her were responsible for determining the resident's eligibility for self-administration.-There should be a physician's order that indicated whether it was safe for the resident to self-administer medications.-Staff should make sure all medications were taken and swallowed before leaving the room.-Residents should be care planned for the self-administration and ability to keep medication at bedside.-Trainings and in-services that included safe medication administration were done monthly and as needed when there was a new issue.-Possible outcomes when allowing a resident who was ineligible for medication self-administration and keeping medication at bedside were medication errors and adverse effects.

Based on interview and record review, the facility failed to submit a Third Party Liability (TPL- a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account) forms were completed and sent to Missouri (MO) Healthnet (a state agency which administers the provision and payment of services for Missouri's Medicaid program) within 30 days of death for one discharged resident (Resident #11) out of three sampled residents selected for TPL submission review. The facility census was 59 residents. 1. Review of Resident #11's medical record showed the resident died on [DATE].Review of the resident's Trust Fund Balance showed the resident had a balance of $8.68 in his/her account.Review of the resident's Trust Fund records on [DATE] (49 days after the resident's death), showed the absence of a TPL that was submitted within 30 days after the resident's death.During an interview on [DATE] at 3:43 P.M., the Business Office Manager (BOM) said he/she did not submit a TPL for the discharged resident because he/she thought the guardian submitted the TPLs.

Based on observation, interview and record review, the facility failed to ensure the facility policy and procedure for checking the Criminal Background Check was followed for two sampled employees (Maintenance Worker A and Certified Nursing Assistant (CNA) C) out of 10 sampled employees. The facility census was 59 residents. Review of the facility Abuse and Neglect policy and procedure dated 10/24/22, showed:-The purpose was to ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.-Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of property. -The facility does not knowingly employ anyone who has had disciplinary action against his/her professional license or a finding entered into the state nure aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting or mistreating other people. The facility screens for potentially abusive staff during the pre-screening process.1. Review of Maintenance Worker A's employee record showed:-He/She was hired on 7/1/23. -His/Her criminal background check showed the facility requested it on 8/19/24 and received it on the same date.2. Review of CNA C's employee record showed:-He/She was hired on 1/6/25. -His/Her criminal background check showed the facility requested it on 9/18/24 and it was received on the same date.During an interview on 2/27/26 at 12:53 P.M., the Human Resources Director said:-Maintenance Worker A was not a re-hire. -His/Her original hire date was 2016 but when the facility was purchased, the corporate office used the date they took over as the new hire date for staff who were current at that time and documented a new hire date. -They did not update the background check information (they were unable to find the original criminal background check for this employee). -Maintenance Worker A was no longer an employee at the facility.-CNA C was rehired on 1/6/25 and it looked like the former Human Resource Director did not re-run the background check and they should have.-He/She completed an audit of all the current staff and noted the staff who were re-hired did not have background checks completed, so he/she completed criminal background checks on staff today. -They were all up to date.

Based on observation, interview and record review, the facility failed to ensure a comprehensive investigation was completed that included details of the circumstances of the fall, notification of the emergency contact/family and completing the risk analysis of what occurred and interventions implemented to prevent the fall from recurring for one sampled resident (Resident #9) who fell, sustaining a minor injury and who was confused and unable to make decisions independently out of 14 sampled residents. The facility census was 59 residents. Review of the facility's Fall Prevention policy and procedure dated 10/24/22, showed:-Following a resident's fall, the licensed nurse will complete an incident report and a Post Fall Assessment & Investigation within 24 hours or as soon as practicable. -The Licensed Nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated.-The Interdisciplinary Team (IDT) Committee will meet within 72 hours of a fall. The IDT Committee will review and document summary of review following a fall, root cause analysis, referrals as necessary and interventions to prevent further falls.-The IDT committee will document findings and recommendations in the resident's medical record. Nursing staff will document the resident response to interventions being utilized in the resident's medical record. The residents care plan will be updated as necessary.1. Review of Resident #9's Face Sheet showed he/she was admitted with the following diagnoses:-Heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs).-Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act).-Anxiety (group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation).-Arthritis in the left ankle and foot.-Auditory and visual hallucinations (the apparent perception of something not present).-Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain).-Muscle weakness. Review of the resident's Fall Risk assessment dated [DATE], showed a fall risk score of 4.0 which was determined to be low risk.Review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/16/26, showed:-The resident had significant cognitive incapacity.-Had no upper or lower extremity range of motion incapacity.-Needed supervision for transfers and mobility and did not use a wheelchair or walker to mobilize.-Did not show the resident had a history of falls or prior falls since the prior assessment.Review of the resident's Care Plan dated January 2026 showed the resident was at risk for falls related to confusion. Interventions showed staff would: -Anticipate and meet the residents needs as needed.-Encourage the resident to participate in activities of resident's choice.-Ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed.-Follow facility fall protocol.Review of the resident's Nursing Notes showed:-On 1/28/26 at 6:01 P.M., resident's peer notified this nurse that the resident had fallen out of his/her chair.-The peer stated (the resident) was asleep and was leaning forward right before he/she fell.-The resident was lying face down on the floor and was able to roll himself/herself over. The nursing assistant assisted this nurse, using a gait belt to lift the resident back into the chair.-His/Her vital signs (blood pressure, temperature, respirations, pulse and oxygen level) and range of motion were within normal limits. The resident had an abrasion to the middle of his/her forehead and the bridge of his/her nose. The Nurse Practitioner and Director of Nursing (DON) were notified.Review of the resident's Fall incident report dated 1/28/26 at 7:00 A.M., showed the resident:-Had an unwitnessed fall out of his/her chair on 1/28/26. -The resident was found lying face down on the floor.-His/her socks were in place without grips.-The resident was sitting in a chair and had fallen asleep and was leaning forward.-The resident was able to roll himself/herself over but was not able to give a description of what occurred.-The resident was alert oriented to person and was ambulatory without assistance.-The nurse assessed the resident and obtained vital signs (undocumented). The Certified Nursing Assistant (CNA unknown) assisted the nurse using a gait belt to get the resident up off the floor.-The resident had an abrasion to the top of his/her scalp (without description).-His/Her Pain assessment showed the resident had no pain.-Had no predisposing environmental factors, physiological factors, or situational factors checked to show what could have contributed to the resident's fall.-There were no injuries observed on the resident after/post incident.-The physician was notified. Documentation showed the resident representative was self and did not show that the resident's family or responsible party was notified.-Predisposing factors did not show the resident was not wearing grips on his/her socks.-The document did not show where the resident was when the fall occurred, when the last time staff had seen the resident and what the resident was doing at that time, a description of the abrasion was not documented (size, color, drainage if applicable) and there was no documentation showing the resident's family or emergency contact was notified (since the resident was unable to make decisions, had confusion and sustained an injury).Review of the resident's Post Fall 72 Hour Documentation showed neurological checks (evaluates brain and nervous system functioning. It's a series of tests that assesses mental status, reflexes, movements and more) were initiated on 1/28/26 and continues through 1/31/26.Review of the resident's Care Plan showed an update dated 1/29/26, that showed the resident had an actual unwitnessed fall with minor injury on 1/28/26. Interventions showed staff would:-Encourage to go to room and go to bed when he/she was asleep in chair in lobby.-Review his/her medication and make changes indicated.-Monitor/document/report as needed for 72 hours to the physician for signs/symptoms of pain/bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation.-Provide neurological checks per facility policy.Observation on 2/25/26 at 2:54 P.M., showed the resident:-Was sitting in a chair in front of the nursing station dressed for the weather without odor. -Was wearing fuzzy socks.-Was sitting quietly.-Was alert but not interacting.-Was watching residents and staff as they passed by. -Was very friendly however he/she was unable to state what occurred on the date he/she fell (unable to recollect).Observation on 2/26/26 at 9:18 A.M., showed the resident:-Was sitting in the dining room finishing breakfast. -Was dressed for the weather without odor and was groomed, wearing fuzzy socks. -Stood up and ambulated out of the dining room without any assistance or assistive device after he/she was finished with breakfast.-Was ambulating without any balance control concerns. No concerns were noted at this time.During an interview 2/27/26 at 1:13 P.M., Licensed Practical Nurse (LPN) B said:-On the day the resident fell, he/she and another staff were sitting at the nursing station, and the resident was sitting in a chair across from the nursing station.-He/She caught the tail end of the resident falling out of the chair onto the floor.-When he/she went over to the resident, he/she assed the resident and he/she had a goose egg a little knot on his/her head.-He/She and another staff assisted the resident up into the chair and he/she started vital signs and neurological checks on the resident.-He/She notified the Physician and the DON.-The resident was his/her own responsible party, so they did not notify anyone from his/her family or emergency contact. -He/She was aware that the resident has a BIMs of 3 but he/she was his/her own responsible party.-He/She did not know if the resident had family. -They were supposed to fill out the incident report, a risk management assessment, which was checkoff sheet to show what was done, and the neurological check sheet. They also wrote the nursing note stating what occurred. -The incident report was the investigation, and it should be comprehensive.-They also had a huddle sheet (review of the fall) that was just implemented about a month ago to discuss the resident's fall and determine the root cause and how to prevent further falls.-He/She did not remember if they completed a huddle for the resident's fall.During an interview on 2/27/26 at 2:15 P.M., the DON said:-They had a fall packet that had a list of items the nurse was supposed to complete when a resident fell that included completing the incident report, writing a nursing summary regarding what occurred, documentation of the resident's vital signs and neurological checks and injuries, documenting all notifications. -The incident report should be comprehensive and include all elements related to the resident's fall.-He/She would expect the nurse to notify family, but in this case, the resident was considered his/her own responsible party so the nurse did not notify any family/emergency contact. -The resident had a BIMS of 3 and he/she did not believe the resident was able to make his/her own decisions.-This resident's daughter was uninvolved in the resident's care and the resident had only had one visitor. He/She did not have any other family (to his/her knowledge) and it would be against the resident's rights for the family to receive information that the resident may or may not want them to have. -They may need to have a conversation about emergency guardianship for the resident.

Based on observation, interview and record review, the facility failed to ensure respiratory face masks and tubing were covered to prevent cross contamination when not in use for two sampled residents (Resident #13, and #6) out of 14 sampled residents. The facility census was 59 residents. Review of the facility Oxygen Administration policy and procedure dated 10/24/22, showed:-All oxygen tubing, humidifiers, masks and cannulas used to deliver oxygen are for single resident use only and will be changed weekly when visibly soiled or as indicated.-Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. 1. Review of Resident #13's Face Sheet showed he was admitted with diagnoses that included:-Chronic Obstructive Pulmonary Disease (COPD a condition involving constriction of the airways and difficulty or discomfort in breathing).-Heart disease.-Respiratory failure.-Chronic cough.-Rhinitis (the inflammation and swelling of the mucous membrane inside the nose). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 8/23/25 showed the resident:-Was alert and oriented with confusion.-Was dependent on staff for bathing, dressing, toileting, transferring and mobility and used a wheelchair.-Used oxygen. Review of the resident's Nursing Notes showed:-On 12/3/25 at 4:00 P.M. the resident continued on antibiotic, Levaquin 500 milligrams (mg) for pneumonia. The resident had no signs/symptoms noted. Resident continued on scheduled breathing treatments. Call light was within reach.-On 12/4/25 Weekly risk meeting with team. This team was currently concerned that this resident was having some respiratory infection. The Nurse Practitioner had the resident on Levaquin (a potent, broad-spectrum fluoroquinolone antibiotic used to treat serious bacterial infections, including pneumonia, sinus infections, and urinary tract infections), and Lasix (a water pill that treats swelling (edema) and fluid retention caused by conditions like heart failure, liver disease, and kidney disease). This resident did appear to be better this week then previously. No further concerns at this time. Review of the resident's Shortness of Breath evaluation dated 1/25/26, showed the resident:-Had a diagnosis of COPD and shortness of breath.-Had shortness of breath or trouble breathing with exertion, when at rest and when lying flat-resident breathed better when sitting up.-Used oxygen. Review of the resident's Physician's Order Sheet (POS) dated February 2026, showed physician's orders for:-Oxygen- 2 liters continuous to maintain oxygen level above 90 percent.-Check bubble humidifier daily and fill as needed everyday shift.-Continuous Positive Airway Pressure (CPAP-a medical device that uses mild, steady air pressure to keep breathing airways open while you sleep) handwash headgear weekly in warm soapy water rinse well and allow to hang dry for COPD.-CPAP wash reusable foam filter in warm soapy water, rinse well and dry with paper towels monthly for COPD.-He/She was not currently on any antibiotics for pneumonia or any respiratory disease. Observation on 2/24/26 at 9:24 A.M., showed the resident:-Was in his/her bed with head of bed up. -Was wearing oxygen via nasal cannula (a lightweight, flexible tube with two small prongs that sits in the nostrils to deliver supplemental oxygen) with oxygen set at 2 liter per minute. -Had his her eyes closed, and he/she was resting comfortably. -There was a CPAP machine on the dresser behind him/her with tubing and a face mask on top of the machine that was uncovered. -The machine was running. -There was also a breathing treatment machine that was sitting beside the CPAP machine with tubing that connected to another face mask that was lying beside the machine, uncovered. -The resident's room was clean without odor and was homelike. Observation on 2/24/26 at 1:21 P.M., showed the resident:-Was sitting up in his/her bed wearing his/her oxygen at 2 liters via nasal cannula. -Was eating lunch. -Had his/her CPAP machine behind him/her on the dresser with the face mask on top of it, uncovered.-The breathing treatment machine was also next to the CPAP machine with the face mask uncovered. Observation on 2/26/26 at 9:07 A.M., showed the resident:-Was in his/her bed sitting up wearing his/her oxygen at 2 liters via nasal cannula. -Had his/her CPAP machine sitting on the dresser behind him/her and the face mask was lying beside it, uncovered. -The resident's breathing treatment machine was sitting next to the CPAP machine and the facemask for that machine was also lying beside it, uncovered. During an interview on 2/26/26 at 9:07 A.M. the resident said:-He/She used the breathing treatment machine during the day to help him/her breathe better.-He/She used the CPAP machine at night.-Nursing staff assisted him/her to use both machines. During an interview 2/27/26 at 2:07 P.M., Certified Nursing Assistant (CNA) B said:-The oxygen face masks, and tubing should be stored in a plastic bag when not in use.-Most of the residents that received oxygen were on continuous oxygen, but he/she usually checked to ensure they are wearing it throughout the day.-The face masks or equipment that was only worn at night should be stored in a bag once they took the equipment off.-Night shift staff usually switched the bags out weekly along with the oxygen tubing and water bottles.-He/She tried to check to ensure the oxygen equipment was stored in the plastic bags during his/her shift. During an interview on 2/27/26 at 12:30 P.M., Nurse Assistant (NA) A said:-The facility staff have given them plastic bags to put all the oxygen equipment in when not in use.-When he/she saw a resident's bag that has been used or did not look to be in good condition, he/she would get a new bag to place their equipment in. -He/She did not know how often the face masks and tubing were replaced but the face masks and tubing should be in a plastic bag, not on the floor or laying on the bed or furniture. During an interview on 2/27/26 at 2:15 P.M., the Director of Nursing (DON) said:-Oxygen equipment (such as face masks, nasal cannulas and tubing) should be stored in a plastic bag off the floor when not in use. -The bags should be labeled with the resident's name and dated. -The night shift staff replaced the bags, tubing, face masks and water bottles every Wednesday night. -Nursing staff should check to ensure the oxygen face masks and tubing were covered when not in use as they made rounds and during the day as they provided cares to residents. 2. Review of Resident #6's admission record showed the resident was admitted with a diagnosis of COPD, nicotine dependence - smoking (addiction to tobacco products). Review of the resident's Quarterly MDS dated [DATE], showed the resident was:-Moderately cognitively impaired and was able to make his/her needs known.-Received oxygen therapy.-Smoked. Review of the resident's care plan dated 2/27/26 showed:-The resident had COPD.-The resident smoked.-The resident received oxygen therapy related to COPD. Review of the resident's POS dated 2/25/26, showed the following prescriber orders:-Oxygen vial nasal cannula as needed.-Check bubble humidifier daily and fill PRN (as needed) everyday shift.-If present, dispose of all O2 tubing, humidifier, & plastic bag weekly on Friday everyday shift. Observation on 2/23/26 at 10:34 A.M., showed:-The resident was sitting in the recliner in his/her room watching television.-The nasal cannula and tubing connected to the oxygen concentrator, were on the floor under clothing items.-The tubing and cannula were not bagged.-The tubing and cannula were dated 2/6/26.-The water container was not dated. Observation on 2/24/26 at 10:32 A.M., showed:-The nasal cannula and tubing connected to the oxygen concentrator, were on the floor under clothing items.-The tubing and cannula were not bagged.-The tubing and cannula were dated 2/6/26.-The water container was not dated. Observation on 2/25/26 at 9:45 A.M., showed:-The nasal cannula and tubing connected to the oxygen concentrator, were on the floor under clothing items.-The tubing and cannula were not bagged.-The tubing and cannula were dated 2/6/26.-The water container was not dated. During an interview on 2/27/26 at 2:10 P.M., CNA F said:-He/She had received trainings and in-services on infection control and oxygen administration.-Oxygen tubing, cannulas, and masks should be changed every week and initialed and dated.-Oxygen water containers should be changed every week and initialed and dated.-Nasal cannulas and tubing should always be kept off the floor.-Nasal cannulas and tubing should always be bagged when not in use.-All nursing staff was responsible for making sure this is done. During an interview on 2/27/26 at 2:19 P.M., LPN A said:-All oxygen equipment should be always kept off the floor.-Oxygen cannula and tubing should be bagged when not in use.-He/She had received training on infection control and proper use of oxygen equipment.-Oxygen tubing, cannulas, and masks should be changed every week and initialed and dated.-Oxygen water containers should be changed every week and initialed and dated.-The night shift nurse was responsible for making sure oxygen cannula, tubing, and water container were changed every week. During an interview on 2/27/26 at 3:30 P.M. the DON said:-Nursing staff had received training and in-services on infection control regarding oxygen masks, tubing, cannulas and accessories.-Nursing staff had received training to ensure all oxygen tubing and accessories were dated and placed in a plastic bag when not in use, not shared and changed weekly.-He/She would expect all oxygen equipment be kept off the floor at all times and bagged when not in use.-He/She would expect oxygen tubing and water containers to be changed weekly and dated.-Nurses were responsible for making sure this was done.-Staff should ensure this was done by making sure there was an order and documenting that it had been done.-Possible outcomes for not keeping oxygen equipment off the floor and changing it weekly could be infection and no availability of oxygen therapy.

Based on observation, interview and record review, the facility failed to ensure a cold dish (cottage cheese fruit plate) was served at a temperature at or close to 41 F (degrees Fahrenheit) to three residents who received room trays and resided on the 100 Hall. The facility census was 59 residents. 1. Review of the undated recipe for cottage cheese fruit plate, showed:-Ingredients which included lettuce leaves, cottage cheese, diced peaches, diced fruit and maraschino cherry halves.-Methods which included: Return ingredients to refrigerator storage if preparation is interrupted.-Place a 4-ounce scoop of cottage cheese on top of lettuce leaf.-Drain canned fruit.-Arrange 4 ounces of fruit around the cottage cheese.-Critical Control Point (CCP- specific step or procedure in a process where control can be applied to prevent, eliminate, or reduce a food safety hazard (biological, physical, or chemical) to an acceptable level, hold for service at 41 F or lower.Observation on 2/23/25 at 11:53 A.M. showed Dietary Aide (DA) A placed the bowls of cottage cheese fruit plate on room tray carts.Observation on 2/23/26 from 11:53 A.M. to 12:19 P.M. showed the cottage cheese fruit plates were on the cart for room trays for that whole time without being replaced into the refrigerator.Observation on 2/23/26 at 12:20 P.M., showed the room trays arrived at the 100 Hall.Observation on 2/23/26 from 12:21 P.M. to 12:30 P.M. showed Certified Nursing Assistant (CNA) F delivered food trays to the 100 and 200 Halls.Observation on 2/23/26 at 12:31 P.M., in the presence of the Director of Nursing (DON) and CNA F, showed the temperature of the cottage cheese fruit plate was 52.1 F at the time of testing.During an interview on 2/23/26 at 12:57 P.M., the Dietary Manager said:-There were times that he/she checked the temperatures of the room trays, but he/she could not check the temperatures on that day (2/23/26) because he/she was the cook and did not have the time to check the temperatures.-The cottage cheese fruit plates probably got warmer because they were on the same cart with the hot foods.

Based on observation, interview and record review, the facility failed to ensure the pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) chicken tenders were a smooth consistency. This practice potentially affected two residents with pureed diets. The facility census was 59 residents. 1. Review of the undated recipe for pureed baked chicken, for 1 serving, showed:-1 serving of baked chicken.-Chicken base to taste with 1 ounce of water. -Commercial thickener (a substance such as cornstarch or other carbohydrate which is added to foods to increase the viscosity of liquids without altering their, taste).Observation on 2/23/26 at11:24 A.M., showed the Dietary Manager (DM):-Made pureed chicken and added broth, but did not add thickener.-There was not a recipe book open while he/she made the pureed chicken.-After he/she placed the pureed chicken in a pan, he/she did not taste the chicken.Observation on 2/23/26 at 12:02 P.M., showed the state surveyor:-Tasted the pureed chicken. -The pureed chicken did not have a smooth texture and was grainy. -The taste was flavorful.Observation on 2/23/26 at 12:38 P.M., showed the DM tasted the pureed chicken after being asked by the state surveyor.During an interview on 2/23/26 at 12:39 P.M., the DM said the pureed chicken was grainier than it should have been.During an interview on 2/23/26 at 12:43 P.M. after pureeing it the 2nd time, the DM said:-He/She did not taste the pureed chicken the first time.-If he/she had tasted the pureed chicken after making the pureed chicken the first time, he/she would have known that the texture of the pureed chicken was not smooth.

Based on interview and record review, the facility failed to ensure a safe and appropriate discharge when the facility staff sent one resident, (Resident #1) out of seven sampled residents, to the hospital with discharge paperwork indicating to return the resident to a homeless shelter in the city. The facility census was 55 residents. A discharge policy was requested from the facility and not received.1. Review of Resident #1's face sheet, undated, showed:-The resident was admitted to the facility on [DATE].-The resident was his/her own representative.Review of the resident's quarterly Minimum Data Set (MDS-a standardized assessment tool that measured health status in nursing home residents) dated 5/22/25, showed:-The resident was cognitively intact. -The resident had diabetes (a chronic condition where blood sugar levels are too high).-The resident had a Traumatic Brain Injury (TBI- an injury to the brain caused by an external physical force, such as a blow, bump, jolt, or penetration to the head).Review of the resident's care plan (a document created for a person that received healthcare, personal care, or other forms of support), dated 5/25/25, showed the resident wished to stay in long term care.Review of the Physician Order Summary, dated 7/1/25, showed:-The resident was ordered:--Eliquis (medication known as a blood thinner, used to prevent and treat dangerous blood clots) Oral Tablet, 5 milligrams (mg).--Jardiance (oral medication used to treat type 2 diabetes) Oral tablet, 10 mg.Review of the nurse progress notes dated 7/31/2025, showed: -A resident approached the nurse and informed him/her that during bedtime snack pass this resident was making inappropriate comments to him/her. The resident submitted a written statement.-No other documentation in the resident's medical record regarding behaviors.Review of the facility's Electronic Progress Notes, showed:-On 8/1/2025 at 4:29 A.M. a nurse noted the resident's oxygen saturation (how the blood carries oxygen to and from the lungs to other parts of the body) was 71% (normal range was 95-100%).-When the resident answered questions the resident's oxygen saturation was 100%. -The resident began to fall asleep again and it was noted the oxygen saturation immediately began to drop again. -The resident was woken up and nursing attempted to put oxygen on the resident.-The resident refused but then stated, something is not right. -The resident was asked if he/she wanted to go to the hospital to get checked out.-The resident stated he/she would go.-On 8/1/2025 at 4:35 A.M. a nurse noted that Emergency Medical Services (EMS) arrived at the facility and the resident willingly got on the stretcher. -Administrator and Assistant Director of Nursing (ADON) were notified. -On 8/1/2025 at 3:01 P.M. a nurse noted: --The facility provided medications to the resident as he/she was leaving the hospital.--The resident took the medications and threw them all over the parking lot. Review of the residents Notice of Proposed Discharge, dated 8/1/25, showed:-The Discharge Effective Date was 8/1/25 and it was immediate.-The resident was discharged to a shelter which included the name and address of the shelter.-The Reason for Discharge stated: Immediate discharge notice was due to resident being a danger to self and others residing in the facility.-An unreadable signature was on the notice in the staff signature line. -The resident signature line was blank.During an interview on 10/7/25 at 11:51 A.M., the Social Services Director (SSD) said:-The resident did not ask to be discharged .-The resident was discharged on 8/1/25 when he/she went to the hospital.During an interview on 10/7/25 at 1:46 P.M., the Director of Nursing (DON) said:-There was a discharge packet that was filled out by the nursing team.-He/She was unaware if the packet was completed.-He/She was unaware if discharging to a homeless shelter was an appropriate discharge, he/she would have contacted the corporate office.-He/She viewed the staff signature on the discharge form and confirmed it was the Administrator's. -Not sure who the discharge nurse was who brought the paperwork to the hospital.-There is no documentation stating who it was.-He/She expected each resident would have safe discharge plan due to ensure care and services are provided.-He/She expected there to be complete documentation regarding discharges.During an interview on 10/7/25 at 1:56 P.M., the Administrator said:-He/She told the resident he/she would not be allowed to come back to the facility.-The resident wanted to come back to the facility and said he/she was coming back and there was nothing we could do about it.-The resident would not take the notice from the charge nurse.-The resident was an immediate discharge.-The resident was not appropriate with the other residents.-The resident was drinking and sneaking alcohol in the facility.-The resident said sexually inappropriate things to other residents.-He/She felt it was safer for the other residents if the resident was no longer at the facility.-The resident was adamant that he/she wanted to stay at the facility.-The discharge paper said to return him/her to the shelter.-At the time he/she thought it was appropriate to discharge the resident to a homeless shelter, since that is where the resident admitted from.-He/She was under the impression that the resident fit the criteria for an immediate discharge. -The resident did not sign out of the facility Against Medical Advice (AMA).-When he/she was discharged from the hospital it was decided not to let him/her come back to the facility.-One of the nurses delivered the discharge notice he/she initially refused, to the hospital, along with the resident's walker, medication and belongings.-He/She was notified by the veteran's hospital that the resident was there.-He/She would have to check with corporate to see if the resident would be allowed back at the facility. -He/She would expect staff to follow discharge protocol, including completed documentation.

Based on interview and record review, contracted Physical Therapy Assistant (PTA) A did not adhere to resident's rights to be informed of care or refuse care by not explaining each treatment he/she was providing for seen residents prior to providing their treatments for seven residents (Residents #1, #2, #3, #4, #5, #6 and #7) causing those residents to feel uncomfortable with the PTA A's treatments out of eleven sampled residents. The facility census was 77 residents. On 4/29/25, the facility Administration was notified of the past noncompliance which occurred on 4/21/25. Facility staff were educated on resident rights, informed care, abuse and neglect protocols and customer service. The deficiency was corrected on 4/21/25. Review of the facility's Resident Rights-Quality of Life Policy revised on May 1, 2023 showed: -The purpose of the policy was to ensure that all residents are treated with the level of dignity they are entitled to while residing at the facility. -Each resident was to have been cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality. -Facility staff was to always speak respectfully to residents, including addressing the resident by their name and pronoun of choice. -Facility staff was to have explained all procedures to residents before they were performed. -Demeaning practices and standards of care that compromised dignity were prohibited. 1. Review of Resident #1's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Non-traumatic intracerebral brain hemorrhage (also known as a brain bleed or hemorrhagic stroke, is a type of stroke where bleeding occurs within the brain tissue itself). -Generalized weakness. Review of the resident's Physician Order Sheet (POS) dated 10/9/24 showed no order for Physical Therapy (PT). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 4/4/25 showed he/she was cognitively intact. Review of the facility Investigation dated 4/14/25 showed: -The resident reported that he/she saw contract PTA A walking another resident in the dining room and stated to the PTA that he/she would like to walk like that. -Contract PTA A offered to take him/her to the therapy gym to complete a therapy screen. -The resident agreed and went with contract PTA A to the therapy gym where PTA A completed a manual muscle test (a clinical assessment used to evaluate the strength of individual muscles or muscle groups) on his/her lower legs, hip flexion (the movement where the thigh is brought towards the chest at the hip joint), knee extension (the movement of straightening the knee joint) and knee flexion (the movement that bends the knee joint, decreasing the angle between the thigh and lower leg). -He/she also completed a sit to stand transfer. -After this was completed, he/she walked the resident down to his/her room. -The Contract PTA A reported that the resident got upset with him/her because he/she stated that since the resident was recently discharged off therapy services the resident would likely not be able to get back on therapy. -Once the resident returned to his/her room he/she sat on the bed and the contract PTA A continued the assessment by touching his/her legs, stomach, shoulders and back. -At no point during this time did resident feel uncomfortable. -The resident then reported that contract PTA A touched his/her chest area where resident alleged, he/she exposed his/her breast. -The resident stated that he/she told contract PTA A to leave his/her room so contract PTA A left. -This interaction was an unwitnessed event. Resident #1 had discharged from the facility and was unable to be reached for interview after multiple attempts to contact. 2. Review of Resident #2's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Post surgical broken hip. -Generalized post-surgical weakness. Review of the resident's POS dated 4/4/25 showed PT to evaluate and treat as indicated and the resident was to have daily PT. Review of the resident's admission MDS dated [DATE] showed he/she was not cognitively intact. Review of the facility's Investigation dated 4/15/25 showed: -Resident #2 had been interviewed on 4/14/25 and denied any concerns with contract PTA A's treatment. -On 4/23/25 the resident informed the facility staff that a tall slender person with light hair was inappropriate with him/her. -The facility Administrator spoke with the resident as soon as it was reported and the resident stated the contract PTA A stared rubbing his/her arm, going down his/her side and down to his/her leg. -The resident stated the rubbing occurred on top of his/her clothing and there was no touching any private areas. -The resident did not ask him/her to stop but stated it made him/her feel uncomfortable. -The resident did state he/she felt safe at the facility and felt that staff treated him/her with dignity and respect. During an interview on 4/25/25 at 1:15 P.M., Resident #2 said: -Contract PTA A just came into his/her room and asked if he/she was ready. -Resident #2 asked, ready for what?, to which contract PTA A replied, your therapy. -The resident stated that he/she guessed so and contract PTA A began to rub and squeeze his/her legs. -Contract PTA A said nothing regarding why he/she was rubbing the resident's legs. -Contract PTA A then asked if the resident would like a massage. -The resident said he/she guessed so. -Contract PTA A then began massaging his/her shoulders and proceeded to move down to the resident's chest, not touching his/her breast, but getting near his/her right breast with his/her left hand. -He/she said something to the contract PTA like, Hey, what are you doing? and he/she stopped. -He/she did not tell anyone at the facility for over two weeks as he/she thought maybe he/she was making a big deal out of nothing. -But he/she could not get the incident out of his/her mind so he/she told staff about what happened. -The resident stated that he/she hated men, as his/her spouse had raped him/her many years ago. -The incident with contract PTA A made him/her fell crappy. -The resident stated he/she never touched his/her breast or private area but felt the therapist came too close. 3. Review of Resident #3's facility admission Record showed he/she was re-admitted on [DATE] with the following diagnoses: -Metabolic Encephalopathy (a brain dysfunction resulting from impaired cerebral metabolism due to underlying systemic diseases or condition). -Muscle weakness. Review of the resident's Annual MDS dated [DATE] showed he/she was cognitively intact. Review of the resident's POS dated 3/2/25 showed PT was to screen, evaluate and treat as indicated. Review of the facility's Investigation dated 4/15/25 showed: -Resident #3 had reported contract PTA A came into his/her room on 4/12/25 asking if he/she wanted therapy services. -The resident stated he/she did want those services, so contract PTA A started a therapy screen by touching his/her legs. -PTA A then touched his/her abdomen and under his/her breasts. -The resident did not tell him/her to stop or report the incident to anyone. -The facility staff competed an assessment and the resident showed no injuries, and the resident stated no pain. -The resident stated he/she felt safe in the facility and felt that facility staff treated him/her with dignity and respect. During an interview on 4/25/25 at 2:50 P.M., Resident #3 said: -He/she did not realize that he/she was to get therapy services and had not had therapy before. -Contract PTA A came into his/her room and began massaging his/her shoulders. -Contract PTA A also pushed on and massaged his/her legs all the way up his/her thigh. -Contract PTA A said nothing to him/her as to what he/she was doing or why he/she was doing it. -Contract PTA A did not touch his/her breast or private area, but the resident stated even so, he/she felt molested. 4. Review of Resident #4's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Heart Attack. -Left and Right sciatic lumbago (pain in the lower back that also radiates down into the legs and feet). -Muscle Weakness. Review of the resident's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of the resident's POS dated 3/8/25 showed PT was to evaluate and treat. Review of the facility's Investigation dated 4/15/25 showed: -Resident #4 had been treated by contract PTA A on 4/12/25. -The resident reported PTA A came into his/her room and began the resident's scheduled therapy session by touching his/her legs, thighs and mid abdomen. -The resident reported PTA A having treated him/her previously with no concerns. -The resident reported he/she did not tell contract PTA A to stop on 4/12/25 and did not report the incident to anyone. -Resident #4 stated having watched his/her roommate's therapy session as well and contract PTA A had provided therapy to his/her roommate's legs. -Resident #4 was assessed and no issues were found. -The resident reported no pain and stated he/she felt safe as facility staff always treated him/her with dignity and respect. -During an interview on 4/25/25 at 2:25 P.M., Resident #4 said: -He/she watched what happened with his/her roommate, Resident #3 and what happened to him/her was not like that. -Contract PTA A got a little fresh with him/her massaging his/her shoulders and touching his/her chest, but nothing more than that. -The resident stated that he/she did not like what contract PTA A did at all. 5. Review of Resident #5's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses showed: -Post surgical amputation- (the period following a surgical procedure to remove a limb or part of a limb). -Stroke. Review of the resident's quarterly MDS dated [DATE] showed he/she was moderately cognitively intact. Review of the resident's POS dated 4/1/25 showed PT was to evaluate and treat as indicated. Review of the facility's Investigation dated 4/15/25 showed: -Resident #5 was interviewed by facility staff as he/she had been a roommate of a resident on therapy services and treated by contract PTA A. -The resident reported contract PTA A came into the room and asked if he/she wanted his/her necked and shoulders rubbed. -The resident said he/she said yes and that the shoulder rub felt good. -The resident stated contract PTA A, while massaging his/her shoulders contract PTA A's hand began to go own toward his/her shirt. -The resident reported his/her breasts were not touched and he/she did not tell contract PTA A to stop even though it made the resident feel uncomfortable. -Resident #5 did not report the incident to anyone and his/her skin assessment showed no concerns. -The resident reported feeling safe in the facility and that facility staff had treated him/her with dignity and respect. During an interview on 4/25/25 at 3:23 P.M., Resident #5 said: -He/she had not had therapy and did not know contract PTA A prior to the incident. -Contract PTA A did not say anything to the resident, instead he/she just began massaging his/her shoulders. -The therapist then touched the resident's chest, near but not touching his/her breast. -The therapist did not touch him/her under his/her shirt. -The resident was seated in his/her wheelchair while the therapist worked with him/her. -He/she had spoken to his/her roommate, Resident #6 about what happened and his/her roommate said the same thing happened to Resident #6. -He/she felt creepy after the incident, and it made him/her nervous. -He/she did not say anything to any staff after it happened, until they asked him/her questions about contract PTA A. 6. Review of Resident #6's facility admission Record showed he/she was re-admitted [DATE] with the following diagnoses: -Cervical spondylosis- (a degenerative condition that affects the bones and discs in the neck (cervical spine). -Generalized weakness. -Muscle wasting and atrophy- (both refer to the decrease in muscle mass and strength). Review of the resident's POS dated 11/27/24 showed PT was to evaluate and treat as indicated. Review of the resident's annual MDS dated [DATE] showed he/she was cognitively intact. Review of the facility's Investigation dated 4/15/25 showed: -Resident #6 was treated by contact PTA A over the previous weekend and stated he/she came into the residents' room asking if the resident wanted to walk down the hall. -The resident stated he/she sat down on the bed and contract PTA A rubbed his/her shoulders with contract PTA A's hand reaching down to his/her mid abdomen over his/her clothes. -The resident expressed discomfort and contract PTA A left. -The resident had not reported the incident to anyone, and a skin assessment showed no concerns. -The resident reported no pain and stated he/she felt safe and the facility staff had always treated him/her with dignity and respect. During an interview on 4/25/25 at 1:50 P.M., the resident showed: -About two to three weeks ago on a Saturday, contract PTA A came into his/her room and said, I am ready for you. -He/she asked the therapist what was going to happened and the therapist said he/she could give the resident a massage. -Contract PTA A then began to massage the resident's shoulders and while doing so, he/she moved his/her hands down towards the resident's right breast, not touching the breast, but getting close. -The resident knocked the therapist's hand away and said, what are you doing. -Contract PTA A just said he/she was giving a massage and the resident told him/her to stop and leave the room. -Contract PTA A lingered for a short time, watching the resident television near the foot of the bed and then left the room, saying nothing. -Contract PTA A had never treated the resident before that day and ha not treated him/her since. -The incident made him/her mad. 7. Review of Resident #7's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Lumbar spondylosis with myelopathy. -Stroke. Review of the resident's POS dated 1/3/24 showed PT was to evaluate and treat. Review of the resident's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of the facility's Investigation dated 4/15 25 showed: -Resident #7 was spoken with initially on 4/14/25 and denied any issues. ` -On 4/15/25 the resident then reported he/she wanted to inform the facility that a therapist with gray hair came into his/her room. -The resident stated he/she asked contract PTA A to rub his/her arm to which contract PTA A began rubbing his/her arm as requested. -The resident stated that at some point, contract PTA A then touched his/her right breast over his/her shirt. -Resident #7 told him/her to stop to which contract PTA A said he/she would not do that again. -The resident did not report the incident to anyone and also that he/she had provided therapy for the resident on the previous weekend and felt the therapist did a good job. -The resident expressed feeling safe in the facility and that facility staff had always treated him/her with dignity and respect. During an interview on 4/25/25 at 3:38 P.M., Resident #7 said: -Contract PTA A had treated the resident on 4/12/25 and he/she had no issues with the treatment. -Then, the following day, he/she touched his/her breast on the outside of his/her clothing. -The therapist massaged the resident's shoulders and just got too low on his/her chest. -The resident was in his/her wheelchair during the treatment and contract PTA A also massaged the resident's arms. -Contract PTA A said nothing the whole time he/she was with the resident. -The resident did not say anything to any staff after the incident but felt he/she should have. -The incident made the resident feel not good. During an interview on 4/25/25 at 4:39 P.M., contract PTA A said: -He/she had two weeks to reflect on the accusations and felt completely blindsided. -He/she felt as thought he/she did nothing wrong and followed the treatment plans as they were supposed to be done. -He/she spoke to all the residents throughout the treatments, always telling the residents what he/she was doing and why he/she was doing it. -He/she did not use massage as part of the resident's treatment plans. -The only thing he/she could think of what that when he/she was palpating their muscles to check for muscle tone, the resident's could have thought that felt like a massage. -He/she ran his/her hands up and down their arms and legs, pressing throughout to see how their muscles felt. -At no point did he/she feel that he/she touched the residents inappropriately or varied the treatments from the treatment plans. -There were some residents whom he/she treated who were upset that after evaluation, he/she was unable to continue with any more therapy for one reason or another. -He/she felt that for some reason, the residents misinterpreted his/her treatments as something inappropriate when that was not his/her intention. 8. During an interview on 4/29/25 at 10:56 A.M., Social Worker A said: -It was reported to him/her on 4/14/25 by some residents who had all been out smoking together that contract PTA A had allegedly inappropriately touched Resident #1 the day before during a therapy treatment. -He/she immediately went and report the allegation to the facility Administrator. During an interview on 4/29/25 at 1:07 P.M., Contract Therapy Agency Director A said: -It would have been appropriate therapy treatment for contract PTA A to have taken a hold of the residents' arm and while completing range of motion (ROM), placed his/her hand on the resident pectoral muscle located in the chest to evaluation how that muscle reacted to the movement. -It would have been appropriate therapy practice for contract PTA A to have taken a hold of the residents' leg and while performing ROM on the leg, to have placed his/her hand on the inner thigh to evaluate how the leg muscles were performing during ROM. -He/she would have expected that prior to contract PTA A beginning treatment for the residents to have explained to the resident exactly where he/she was going to touch them and why. -He/she would have expected contract PTA A to have explained everything being done for each resident, so the resident was not confused or surprised by what was happening. -He/she would have expected contract PTA A to have ensured the resident was able to hear what the therapist was saying before any explanations were made. -He/she could understand how a resident might believe massage was being completed by the therapist, especially if the therapist did not explain what was being done during treatment. During an interview on 5/2/25 at 3:00 P.M., the Director of Nursing (DON) and facility Administrator said: -He/she would have expected that any staff member whether contract or regular staff to have maintained the resident's dignity and never made them feel uncomfortable. -He/she would have expected contract PTA A to have fully explained each portion of the therapy treatment prior to performing the therapy. -He/she would have expected contract PTA A to have made sure each resident could hear the therapist well. -He/she would have hoped the residents all felt they could always come and report any issues or negative experiences to a facility staff member. MO00252818 MO00253280

Based on interview and record review, the facility failed to ensure one sampled resident's (Resident #29) care plan was updated to reflect an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed); failed to ensure one sampled resident's (Resident #18) care plan was updated to reflect requiring assistance / supervision with smoking; failed to ensure one sampled resident's (Resident #38) care plan was updated to reflect his/her current pain level, frequency, and interventions; failed to ensure one sampled resident's (Resident #46) care plan reflected all pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) were addressed with current status and interventions/treatments out of 15 sampled residents. The facility census was 56 residents. Review of the facility's policy titled Care Planning dated 10/24/22 showed: -The Facility's Interdisciplinary Team (IDT) would develop a Baseline and/or Comprehensive Care Plan for each resident. -The care plan served as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. -Each resident's comprehensive care plan would describe the following: --Services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. --Any services that would be required but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment. --The resident's goals and desired outcomes. Review of the facility's policy titled Pressure Ulcer Prevention dated October 24, 2022, showed: -The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. -The licensed nurse should complete a Braden Scale Assessment (a standard tool for assessing pressure ulcer risk) upon admission, and quarterly to identify residents at risk for skin breakdown. -The licensed nurse will conduct a skin assessment for a resident upon admission, readmission, weekly, and as needed. -The results of the weekly skin assessment should to be documented in the medical record and may be documented using the Weekly Skin Inspection form. -The licensed nurse should develop a care plan specific to the resident's risk factors such as moisture control, pressure reduction, positioning, mobility, and nutrition in consultation with the following: --Attending physician. --Interdisciplinary Team (IDT)-Skin committee. --Registered Dietician. --Director of Rehabilitation Services. -Nursing staff should monitor interventions for effectiveness and resident tolerance. -The care plan will be revised as indicated. -Certified Nursing Assistants (CNA) should inspect the resident's skin during Activities of Daily living (ADL) care and report unusual findings to the licensed nurse. -CNA's should complete body checks on resident's shower days and report unusual finding to the licensed nurse -The licensed nurse should document effectiveness of pressure ulcer prevention techniques in the resident's medical record on a weekly basis. Review of the facility's Smoking by Residents policy, dated 10/24/22, showed: -Residents who wanted to smoke were assessed for their ability to smoke safely. -A Licensed Practical Nurse (LPN) provided the Safe Smoking Assessment. -A smoking care plan was created for the resident. -If clothing was observed with burn holes the resident must wear a smoking apron (an apron made from flame retardant material which prevented burns in clothing and kept hot ashes from burning the skin). 1. Review of Resident #29's Admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with following diagnoses: -Cerebral Infarction (stroke). -Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following stroke affecting the left non-dominant side. -Muscle wasting and apathy (is characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 1/2/2024 showed: -Risk for pressure ulcer. -One or more unhealed pressure ulcers. -One unstageable pressure ulcer due to coverage of the wound bed by slough. Review of the resident's care plan dated 3/28/24 showed there was no care plan for wounds or risk for wounds and/or skin breakdown. Review of the resident's Physicians Order Summary (POS) dated April 2024 showed: -Weekly skin assessment every evening shift on Friday. -Refer to an outside wound care company for evaluation and treatment. -Wound care treatment every day shift for wound healing: --Cleanse wound on left heel with hypochlorous acid (helps disinfect and provide treatment for wounds), and pat dry. --Cover wound bed with nickel thick Santyl (an enzyme ointment that helps remove dead skin tissue and aids in wound healing by removing damaged tissue from chronic skin ulcers). --Cover Santyl with Calcium Alginate (CaAlg-a type of dressing that can absorb 20 times its weight in exudate [fluid that leaks out of blood vessels into nearby tissues] and soak up loose debris from a wound bed) cut to the size of wound bed. --Cover with bordered gauze (a type of wound dressing) and change daily and PRN if soiled. During an interview on 4/4/24 at 10:45 A.M., the MDS Coordinator said: -The resident should have a care plan for any type of wound if he/she had one. -Corporate made changes to the care plans when something was found. -They tried to make care plans specific. 42955 2. Review of Resident #18's quarterly MDS dated [DATE], showed: -The resident scored a 15 on the Brief Interview for Mental Status (BIMS). --This showed that the resident was cognitively intact. -The resident's diagnoses included: Multiple Sclerosis (MS- a potentially disabling disease of the brain and spinal cord causing communication problems between the brain and the rest of the body), lack of coordination and reduced mobility. -NOTE: Section J of the MDS did not indicate the resident smoked. Review of the resident's Smoking assessment dated [DATE], showed the resident required supervision while smoking. Review of the resident's Smoking Assessment, dated 1/2/24, showed the resident required supervision while smoking. Review of the resident's comprehensive care plan, dated 1/4/24, showed: -The resident was a smoker. -The resident required supervision while smoking. -The resident needed assistance with putting out cigarettes. -The resident needed assistance with ashes. Review of the resident's Smoking Assessment, dated 3/28/24, showed the resident was safe to smoke without supervision. Observation on 4/1/24 at 11:12 A.M., showed the resident was in his/her wheelchair with a cigarette in his/her mouth. Another resident took the cigarette out of his/her mouth. A staff person lit a new cigarette and placed it in the resident's mouth. Another resident then took the cigarette out of the resident's mouth again and threw it away. Observation on 4/3/24 at 11:11 A.M., showed: -The resident was smoking on the smoking patio. -A staff person lit a cigarette for the resident. -The resident was in his/her wheelchair with a cigarette hanging out of his/her mouth with approximately an inch long ash on the end. --No ashes observed on the residents sweatshirt. -A staff person came to up to the resident and removed the cigarette butt from the resident's mouth then assisted him/her in lighting a second cigarette. -The resident smoked most of the cigarette without handling it with his/her fingers, using just his/her lips. -Another inch long ash fell on the resident's shirt. --He/She did not brush it off, no staff or residents assisted. -The resident continued to smoke the second cigarette showing no signs of distress, again not handling it with his/her fingers. -Ashes from second cigarette fell on the shirt again. -Another resident came over to the resident and took the cigarette out of his/her mouth. During an interview on 4/3/24 at 9:00 A.M., Certified Nurse's Assistant (CNA) A said: -The resident was a smoker. -He/She was unaware if the resident needed assistance with smoking. -The resident received assistance with eating because his/her hands and arms did not work well enough to feed himself/herself. -Staff supervised the smokers in the smoking area but they were not CNA's. -The resident had MS and received assistance eating. -He/She was unaware of what staff supervised the smokers. During an interview on 4/3/24 at 9:12 A.M., Registered Nurse (RN) A said: -The resident was a smoker. -The resident was his/her own person and chose to smoke on his/her own and was allowed to smoke on his/her own outside of the facility. -He/She told the resident it was not safe to smoke without supervision. -He/She had seen holes on the resident's shirts, and he/she had educated the resident on the safety aspect. -The resident chose to have other residents help him/her while smoking. -The resident refused to wear a smoking apron. -Designated smoke times were all supervised, but the residents were able sign out and go outside and to smoke on their own. During an interview on 4/4/24 at 8:31 A.M., the Medical Records/CNA said: -The resident required assistance with eating because his/her hands and arms did not work well enough to feed himself/herself. During an interview on 4/4/24 at 8:40 A.M., the resident said: -His/Her left arm was dead and he/she had no ability to move it. -His/Her right arm had some mobility, but he/she was unable to move his/her hand and had no gripping strength. -He/She needed assistance smoking and sometimes resident's helped him/her. During an interview on 4/4/24 at 10:17 A.M., the Activities Director said: -There was a smoking schedule and staff were assigned to supervise. -Nursing was assigned in the evening, during the day it was dietary, activities, and housekeeping. -Staff were in-serviced on the smoking procedure, which included monitoring the residents. -Each department also trained their staff who supervised smoking. -There was no list of residents who required additional supervision. -Everyone watched everyone. -There was no list of residents who required a smoking apron. --He/She thought there were two residents who were to wear a smoking apron, the resident was one of the two. -The resident refused the smoking apron 98% of the time but it was offered. -Smoking aprons were kept at the nurses station. During an interview on 4/4/24 at 10:45 A.M., the MDS Coordinator said: -They tried to make care plans specific. -The resident was independent with smoking. -He/She had not done a MDS on the resident yet. -Corporate was aware of discrepancies between care plans and the MDS. -If there was conflicting information on the care plan then staff looked at the physician orders, or asked the Director of Nursing (DON). 50579 3. Resident #38's Admission MDS dated [DATE] showed he/she: -admitted with an amputation of the left leg above the knee. -Received scheduled and as needed pain medications during the lookback period. -Reported pain almost constantly. -Frequently had pain that effected sleep and day to day activities. Review of the resident's MDS Care Area Assessment (CAA) for pain dated 2/27/23, showed he/she: -Had diseases and conditions that may cause pain including heart conditions, peripheral vascular disease (reduced blood flow in the arms and legs), neurological conditions, musculoskeletal conditions, and gastrointestinal conditions. -Would have pain addressed in the care plan to slow or minimize decline. Review of the resident's POS 4/4/24 showed orders for: -Acetaminophen (a medication for pain) 650 milligrams (mg) by mouth every six hours as needed for pain. -Gabapentin (a medication to treat nerve pain) 100 mg three times daily. -Lidocaine patch (a patch that is applied to the skin for pain) daily to the amputation site. -Hydrocodone (A narcotic pain medication) 5-325 mg three times a day for pain. -Hydrocodone 5-325 mg every six hours as needed for pain. -Voltaren (a gel applied to the skin to relieve pain) apply to the amputation site at bedtime and every 6 hours as needed for pain. Review of the resident's current, undated care plan accessed 4/4/24, showed: -The resident was at risk for pain. -Interventions included administering analgesia per orders and anticipating the resident's need for pain relief. -A lack of documentation related to the resident's current pain status including frequency, type and location of pain, non-pharmacological pain interventions and history of chronic pain. 4. Review of Resident #47's Quarterly MDS 2/28/24 showed he/she: -Had pressure ulcers to the feet. -Was at risk for developing pressure ulcers. -Was being treated with: --A pressure reducing device for chairs. --A pressure reducing device for bed. --A turning/repositioning program --Nutrition/hydration supplementation --Pressure ulcer care including application of dressings and ointments. Review of the resident's Weekly Wound Observation Tool dated 3/25/24, showed he/she had: -A pressure ulcer to the left lateral/medial (outer) 5th toe acquired 2/24/24. -A pressure ulcer to the right heel acquired 2/24/24. -A pressure ulcer to the left heel acquired 1/30/24. -A pressure ulcer to the left great toe acquired 1/30/24. Review of the resident's POS dated 4/4/24 showed orders for: -An air loss mattress for prevention of pressure ulcers. -Nutritional supplementation for prevention/healing of pressure ulcers. -Pressure ulcer skin treatments to both heels, the left great toe, and the left outer foot. Review of the resident's current, undated care plan accessed 4/4/24, showed: -The resident had a potential impairment to skin integrity. -The resident had three unstageable ulcers to the left foot. -A lack of documentation for the pressure ulcer to the right heel. 5. During an interview on 4/5/24 at 12:04 P.M., the DON said: -The IDT was responsible for updating care plans. -Care plans should have been updated quarterly with MDS completion and on an as needed basis. -The MDS Coordinator audited care plans for accuracy. -Regarding Resident #29: --He/She should have had a care plan that indicated the resident had a pressure ulcer and showed the location(s), treatment(s), and been updated to reflect changes as they were made. -Regarding Resident #18: --He/She was his/her own person and checked himself/herself out and left to smoke outside on his/her own. --He/She was supposed to be supervised while on facility grounds. --He/She should not be helped by another resident while smoking. --His/Her care plan should indicate if he/she was educated on safe smoking and if he/she was non-compliant with who assisted him/her. --He/She would expect his/her most recent smoking assessment and the care plan to have the same information. -Regarding Resident #38: --He/She should have had a care plan that addressed his/her pain status, location, frequency, treatment, and response to treatment.

Based on observation, interview, and record review, the facility failed to ensure residents were screened for Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for four sampled residents (Resident #29, #38, #47, and #50) out of 15 sampled residents; and failed to properly screen new employees for TB for two sampled employees, (Employee's G and J) out of ten sampled new employees prior to hire. The facility census was 56 residents. Review of the facility's policy (Tuberculosis - Screening) dated October 24, 2022 showed: -The facility screened residents for TB upon admission, readmission, and as indicated thereafter. -Any resident without documentation receives a baseline (two-step test) upon admission. -When the first TB test is negative, a follow-up TB test is administered one to three weeks after the initial test was read. -The Attending Physician screens new admissions for possible signs and symptoms of TB. -Facility staff were given a screening for TB. -NOTE: the policy did not address any TST procedures or details for employees. Review of 19 Code of State Regulations 20-20.100 TB testing for residents and workers in long-term care facilities, paragraph three, showed: -All new long-term care facility employees who work ten or more hours per week should have the first of two TB skin tests (TST) within one month prior to starting employment in the facility. -The results of TST should be read 48-72 hours from administration. -If the initial TST result is zero to nine millimeters (mm) in duration, the second test should be administered as soon as possible within three weeks after employment begins, unless documentation is provided indicating a two-step TST was completed in the past and at least one subsequent annual test within the past year. 1. Review of Resident #29's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's TB tests showed: -There was no documentation of a TB test being given before 12/17/19. -Step one of the admission two step TB test was administered on 12/17/19. --There was no documentation the test was read. --There was no documentation a second test was given. -Step one of the annual two step TB test was administered on 1/6/20. --There was no documentation the test was read. --There was no documentation a second test was given. -Step one of the annual TB test was administered on 12/21/21. --There was no documentation the test was read. -Step one of the annual TB test was administered on 12/9/22. --There was no documentation the test was read. Review of the resident's Physician's Order Sheet (POS) dated April 2024 showed the following order for a TB test or chest x ray annually. 2. Review of Resident #38's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's TB tests showed: -Step one of the admission two step TB test was administered on 2/14/24 --There was no documentation the test was read. -The second step was administered on 3/26/24 and read on 3/28/24. -The second step was administered more than three weeks after the first TB test was administered. Review of the resident's POS dated April 2024 showed the following order: -TB testing per community protocol. -Initiate TB testing protocol, dated 2/14/24. 3. Review of Resident #47's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's TB tests showed: -Step one of the admission two step TB test was administered on 1/16/24. --There was no documentation the test was read. -The second step was administered on 3/26/24 and read on 3/28/24. -The second step was administered more than three weeks after the first TB test was administered. Review of the resident's POS dated April 2024 showed the following order: -TB testing per community protocol. -Initiate TB testing protocol, dated 1/16/24. 4. Review of Resident #50's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's two step TB tests showed: -Step one of the two step TB test was administered on 3/26/24 and read on 3/28/24. --There were no TB test documented prior to the 3/26/24 test. --There was no documentation that a chest x-ray had been completed at the tie of admission. Review of the resident's POS dated April 2024 showed the following order: -TB testing per community protocol. -Initiate TB testing protocol, dated 6/16/23. 5. During an interview on 4/5/25 at 10:00 A.M. the Infection Preventionalist (IP) said: -He/She had just started in the IP position. -Many of the residents did not have two step TB tests done per protocol. -Newly admitted residents should have had their first TB test done within the first day or so of admission. -72 hours after administration of the first TB test, the test should have been read. -The date and results of the TB test should have been documented on the immunization tag. -A second TB test should have then been administered within three weeks of the first TB test. -The date and results of the second TB test should have been documented on the immunization tag. -The person who was in his/her position previously was not keeping track of the residents' TB tests. -Many of the residents' TB tests were not done timely or documented correctly. During an interview on 4/5/24 at 12:00 P.M. the Director of Nursing (DON) said: -Residents should have their first TB test done as soon as they were admitted . -Residents should have a TB test read within 72 hours of administration. -Residents should have had a second TB test administered one to three weeks after the first test was read. -He/She or the IP were responsible for ensuring the TB tests were given to the residents timely. -The TB test and results should have been documented in the immunization log on the computer. -Many of the TB tests were missed in the past. 42955 6. Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee G was hired on 11/11/23. -Employee J was hired on 11/1/23. Review of Employees G's TB tracking sheet showed: -Employee G had the first step TST administered on 10/30/23 and read on 11/2/23. --Employee G had the second step TST administered on 11/13/23 with no date read dated recorded. Review of Employee J's TB tracking sheet showed: -Employee J had the first step TST administered on 11/4/23 and read on 11/7/23. --Employee J had the second step TST administered on 11/18/23 and read on 11/21/23. 7. During an interview on 4/5/24 9:00 A.M., the Business Office Manger (BOM)/Human Resources (HR) Director said: -The Assistant Director of Nursing (ADON) administered and tracked employee TB. -Employee J started working 11/1/23. -Employee J started working before everything cleared. During an interview on 4/5/24 at 9:41 A.M., the ADON said: -New employees were usually hired directly after the interview. -He/She gave the new employees their first TST directly after the interview. -He/She told them to come back in two to three days to have it read then they could start working. -All new employees received their TST. -New employees started working the day the first TST was read with a negative result. -Employees were not allowed to start working until the first TST was read. -He/She documented on a form and tracked it in a binder. -If he/she was unavailable another nurse read the results. -He/She remembered giving and reading Employee G's TST but could not find the documentation of the reading. -He/She was not working when Employee J hired. -Employee J started before the TST was administered. During an interview on 4/5/24 at 12:04 P.M., the DON said: -TST's were completed before employees started working. -Once a TST was read with a negative result, the employee was able to start working. -The ADON was responsible for tracking employee TST. -He/She expected staff to have the first TST completed and read prior to working.

Based on interview and record review, the facility failed to provide 12 hours of training/in-services to include behavior and dementia training, abuse and neglect prevention, and resident rights, for three Certified Nursing Assistants (CNA B, C, & D). The facility census was 56 residents. A policy was requested and not provided by the time of exit. 1. Review of the list of current employees who were CNA's showed three CNA's were chosen for records to be reviewed for the required 12 hour training/in-services. 2. Review of CNA B's training record dated April 2023 to April 2024 showed he/she was hired on 8/27/21 and worked as needed (PRN) and attended the following in-services: -On 4/28/23 nurses meeting (did not say what the topic was). -On 5/19/23 COVID changes, Transmission Based Precautions (TBP), New owner. -On 7/31/23 abuse prevention and prohibition program, interact-stop and watch early warning tool. -He/She did not receive training/in-services for the following: --Abuse and Neglect. --Behavior and dementia training. --Resident rights. --Care of the cognitively impaired resident. -CNA B did not receive the required 12 hours of training/in-services from April 2023 through April 2024. 3. Review of CNA C's training record dated April 2023 to April 2024 showed he/she was hired on 5/4/20 and attended the following in-services: -On 5/19/23 COVID changes, Transmission Based Precautions (TBP), New owner. -On 6/16/23 accessing kardex (name brand of an informational system used as a quick reference for nursing staff, resident transfer method. -On 6/17/23 care for a specific resident (the in-service sheet did not list what the cares for the resident were). -On 6/18/23 notification processes of grievances, complaints, and events. -On 7/31/23 abuse prevention and prohibition program, interact-stop and watch early warning tool. -September meeting (did not show a date) agenda showed the following areas that were covered: --Skin and Pressure Ulcers, reporting, care and prevention. --Bedbound- turn every two hours, low air loss mattress, bunny boots, rashes, red areas, skin tears. -On 9/5/23 the in-service sheet showed bed hold policy, hydration, skin pressure ulcers, reporting, care and prevention. -In October 2023 (no day listed) transfer of residents. -On 12/26/23 stop and watch (acronym for observing and reporting changes in a resident's condition). -February 2024 meeting agenda had dates of 1/6/24, 1/7/24, and 1/8/24 on it included: --Toileting residents between meals. --Call lights. --Skin issues- let the wound nurse know immediately. -On 2/2/24 monthly nursing meetings (no specific topics listed). -On 3/20/24 abuse and neglect, infection prevention ad control program, hand hygiene -On 4/1/24 enhanced barrier precautions. -CNA C did not receive training/in-services for the following: --Behavior and dementia training. --Resident rights. --Care of the cognitively impaired resident. 4. Review of CNA D's training record dated April 2023 to April 2024 showed he/she was hired on 10/21/19 and attended the following in-services: -On 4/28/23 -nurses meeting (did not say what the topic was). -On 5/19/23 COVID changes, Transmission Based Precautions (TBP), new owner. -On 6/17/23 care for a specific resident (the in-service sheet did not list what the cares for the resident were). -On 6/18/23 notification processes of grievances, complaints, and events. -September meeting (did not show date) agenda showed the following areas that were covered: --Skin and Pressure Ulcers, reporting, care and prevention. --Bedbound- turn every two hours, low air loss mattress, bunny boots, rashes, red areas, skin tears. -On 9/5/23 bed hold policy, hydration, skin pressure ulcers, reporting, care and prevention. -CNA D did not receive training/in-services for the following: --Abuse and Neglect. --Behavior and dementia training. --Resident rights. --Care of the cognitively impaired resident. -CNA D did not receive the required 12 hours of training/in-services from April 2023 through April 2024 when he/she was terminated. 5. During an interview on 4/5/24 at 12:03 P.M., the Director of Nursing (DON) said: -CNA's should receive 12 hours of in-service/training a year. -In-services are held monthly at a minimum. -He/She had a calendar of what topics were covered for each month. -Topics that should be covered at least once a year were: --Abuse and neglect safety. --Dementia and Alzheimer's safety. --Fire safety. --Resident falls. --Any other resident needs that would come up. --In-services were taught by the DON, the Assistant Director of Nursing (ADON) or other department heads depending on the topic presented. --Staff should sign the in-service attendance sheet. --In-services were about an hour each. --Human Resource staff should be monitoring the in-service hours for the CNA's. --PRN staff should attend each month's in-service.

Based on interview and record review, the facility failed to develop a spend down plan for two sampled residents (Resident #13 and #18) out of two residents sampled for the resident fund review process, who maintained a balance of more than $5,726.00 (the legal Missouri Medicaid limit) in their account for more than one month. The total facility census was 56 residents. Review of the facility's policy titled Resident's Funds Handling and Recording revised 10/24/22 showed: -The facility would notify the resident if his/her Resident Trust Fund (RTF) account was within $200.00 of the Social Security Income (SSI-Medicaid) legal limit. 1. Review of Resident #13's RTF statements showed: -On 9/1/23 the resident's balance was $8049.94. -On 10/3/23 the resident's balance was $8806.38. -On 11/3/23 the resident's balance was $8993.86. -On 12/30/23 the resident's balance was $9303.54. -On 1/3/24 the resident's balance was $9656.71. -On 2/2/24 the resident's balance was $11044.75. -On 3/1/24 the resident's balance was $10800.34. 2. Review of Resident #18's RTF statements showed: -On 9/5/23 the resident's balance was $8965.12. -On 10/3/23 the resident's balance was $8634.71. -On 11/2/23 the resident's balance was $8857.69. -On 12/30/23 the resident's balance was $9303.54 -On 1/3/24 the resident's balance was $9656.71. -On 2/7/24 the resident's balance was $10944.75. -On 3/12/24 the resident's balance was $9441.64. 3. During an interview on 4/3/24 at 1:40 P.M. the Business Office Manager (BOM) said: -He/she was responsible for the RTF accounts. -He/she did tell the residents they were over the legal limit. -The legal limit was $5000.00. -He/she did not tell the residents they could lose their Medicaid benefits since they were over the legal limit. -He/she just told the residents to spend their money. -He/she did not assist with a plan to help spend their RTF money to ensure they did not lose Medicaid services.

Based on observation, interview and record review, the facility failed to complete a timely and thorough skin assessment upon a resident's readmission to the facility in order to identify and properly treat any skin issues that may have been present; to accurately assess, measure, and document when pressure ulcers were acquired; ensure the resident's Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) pressure ulcer information was accurate in order to develop a pressure ulcer care plan in a timely manner, and to update the resident's care plan as needed when changes occurred to include new interventions to prevent new and worsening pressure ulcers. The facility failed to clarify and follow physician orders [REDACTED]. and buttocks area from 8/21/17 to 9/11/17 when the wounds worsen from excoriation to a 8 centimeter(cm) by 5 cm pressure area with slough and eschar (dead tissue) for one sampled resident (Resident #5) who developed an unstageable and a new pressure ulcer, out of 12 sampled residents, and the only resident in the facility known to have a pressure ulcer at that time. The facility census was 49 residents. Record review of the facility's Pressure Ulcer Risk policy dated May 2017, showed the following: -Based on the comprehensive assessment of the resident, facility clinical staff will ensure that the resident who enters the facility without a pressure sore will not develop a pressure sore unless the resident's clinical condition demonstrates that the condition was unavoidable. -Characteristics of residents who are at risk for pressure ulcers include: --Braden score of 16 or lower, --Unable to reposition self in bed or chair without assistance, --Unable to pull one's self up in bed without assistance, --Food intake does not meet minimum daily requirements for adequate nutrition, and --Skin exposed to moisture (i.e., incontinent, perspires profusely or has significant wound drainage and -Select appropriate interventions based on the needs and preferences of the resident in the resident's care plan. 1. Record review of Resident #5's face sheet dated 10/16/17, showed the resident was admitted to the facility on [DATE], and most recently readmitted to the facility 8/21/17. The resident's [DIAGNOSES REDACTED].>-Cerebral Infarction (an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain); -Type II Diabetes Mellitus (DM II: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin); -[MEDICAL CONDITION] (a bone disease that occurs when the body loses too much bone); -Overactive Bladder (urinary urgency, usually with urinary frequency and voiding more than two times at night, with or without urgency urinary incontinence); -Muscle Weakness; -Difficulty Walking and -Unsteadiness on he/she feet. Record review of the resident's comprehensive Admission MDS, dated [DATE], showed the resident: -Was cognitively intact; -Had no behaviors; -Needed extensive assistance of one person for bed mobility, transfers, locomotion, hygiene and bathing; -Was occasionally incontinent of bladder; -Was continent of bowel; -Was at risk of developing pressure ulcers and -Had no pressure ulcers or skin issues. Record review of the resident's Significant Change MDS, dated [DATE], showed: -The resident's most recent admission/entry date was 8/21/17, which was a reentry to the facility after an acute hospital stay; -He/she was at risk of developing pressure ulcers; -No Stage I or higher pressure ulcers; -No unhealed pressure ulcers and -No healed pressure ulcers. Record review of the resident's Significant Change MDS, dated [DATE], showed: -The resident's most recent admission/entry date was 8/21/17, which was a reentry to the facility after an acute hospital stay; -He/she was at risk of developing pressure ulcers, had a formal pressure ulcer assessment, and had a Stage I or greater pressure ulcer, a scar over bony prominence, or a non-removable dressing/device; -One or more unhealed pressure ulcers at Stage I or higher; -Two unstageable (slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin): known but not stageable due to coverage of wound bed by slough and/or eschar) pressure ulcers; -Two of the two unstageable pressure ulcers were present upon admission/entry or reentry. (*Note: The previous 8/28/17 MDS showed no pressure ulcers and the last reentry date was 8/21/17, more than three weeks prior to this assessment.; -Two unstageable pressure ulcers with suspected deep tissue injury in evolution; -Two of the two unstageable pressure ulcers with suspected deep tissue injury in evolution were present upon admission/entry or reentry. (*Note: The previous 8/28/17 MDS showed no pressure ulcers and the last reentry date was 8/21/17); -The dimensions of the unhealed Stage III (the wound extends through the dermis (second layer of skin) into the fatty subcutaneous (below the skin) tissue; bone, tendon and muscle are not visible) or Stage IV (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed) pressure ulcers or eschar showed the following: --Pressure ulcer length (longest length from head to toe of pressure ulcer) was 08.0 cm; --Pressure ulcer width (widest width of the same pressure ulcer, side to side perpendicular (90-degree angle) to length was 05.0 cm and -The most severe tissue type for any pressure ulcer that was present was eschar. Record review of the resident's Comprehensive Care Plan showed: -The initiation date was 5/9/16, and the revision date was 10/16/17; -The resident was at risk of alteration in skin integrity related to impaired mobility status. -The goal was that the resident not develop any skin integrity issues through the next review, unless the disease process causes unavoidable deterioration. -Interventions included (initiation date: 5/9/17): --Any skin integrity issues/concerns be conveyed to the Charge Nurse for further evaluation and/or treatment changes/new interventions and the Medical Doctor will be call as needed. --Skin will be checked during routine care on a daily basis and during the weekly/bi-weekly bath or shower schedule and -There was no update or care plan for the resident's existing pressure ulcers. Record review of the resident's Readmission Progress Note, dated 8/21/17, 3:25 P.M., showed the resident: -Was admitted from the hospital with [DIAGNOSES REDACTED]. -Wore oxygen (O2) continuously at 2 liters to maintain O2 saturation at 90% or better; -Needed maximum assistance of one staff for all activities of daily living (ADLs); -Was able to make wants and needs known; -Was on a regular consistent controlled carbohydrate diet and -Had areas of concern to right elbow, coccyx, and back. (Note: There were no further details related to the areas of concern.) Record review of the resident's physician's orders [REDACTED]. -An order dated 8/21/17 for a weekly skin assessment by a licensed nurse on Tuesday evenings between 3:00 P.M. and 11:00 P.M.; -An order dated 8/21/17 for a Braden Scale to be completed weekly for four weeks; -An order dated 8/21/17 for [MEDICATION NAME] (a waterproof dressing that is impermeable to liquids, bacteria, [MEDICAL CONDITION]) to sacral area: Apply foam dressing to sacral area, and change every 7 days between the hours of 7 A.M. and 3:00 P.M. and as needed. Record review on 10/18/17 of the resident's Licensed Nurse Weekly Skin Assessment sheets showed there were no skin assessment sheets for the month of August. Review of the resident's medical record showed a Braden Scale was completed on 8/21/17 with a score of 14, considering the resident at moderate risk of developing a pressure ulcer. There was no Braden Scale for the next three weeks. Record review of the resident's Nurses' Note dated 8/22/17, showed the resident: -Remained on 72 hour readmission checks as well as skilled nursing after a brief stay in the hospital for [MEDICAL CONDITION] pneumonia and Kyphoplasty; -Had poor skin turgor and numerous bruises and abrasions; -Was continent of bowel and bladder with occasional mishap; -Used a wheelchair that was propelled by staff and -Needed maximum assistance with ambulation and ADLs. Record review of the resident's Nurses' Notes dated 8/23/17, showed: -At 8:08 A.M., resident walks with a walker with the assistance of one person; and he/she continued on skilled services for therapy and nursing observation. -At 8:12 A.M., continued on readmit charting with no noted problems or complaints, went to the bathroom with assistance as needed and -At 7:46 P.M., continued on 72-hour readmit assessment, had trace [MEDICAL CONDITION] noted to bilateral lower extremities; and he/she had bandages from the hospital on his/her left elbow, forearm, and coccyx area. He/she was incontinent of urine at times and needed the assistance of one person with transfers and toileting. He/she was wheeled to the dining room for meals. Record review of the resident's General and Nurses' Progress Note for 8/24/17 through 8/27/17 showed no notation of concern or mention of the resident having a coccyx or sacral wound. Record review of the resident's Progress Notes/MDS note dated 8/28/17, 10:04 A.M., showed the resident: -Required extensive assistance with bed mobility, transfers, walking in room, locomotion on and off the unit, dressing, toileting, and personal hygiene. The resident was at risk for complications related to incontinence such as skin integrity issues, dignity issues, pressure ulcers, urinary tract infection and skin breakdown. -Was at risk for pressure ulcers related to impaired mobility, need for extensive assistance, and [DIAGNOSES REDACTED]. -Had a pressure reducing mattress and pressure reducing cushion in his/her wheelchair. Record review of the resident's Nutrition/Weight Progress Note on 8/28/17, 10:30 A.M., showed the resident: -Had significant weight gain, possibly related to [MEDICAL CONDITION]. -Had appropriate current weight, but probable continued fluctuations. -Was at risk for weight loss related to difficulty swallowing and decline in intake. -Had a skin tear to his/her right elbow. -Had a surgical incision to upper mid back vertebrae. -Had shearing on his/her coccyx. Record review of the resident's General and Nurses' Progress Note for 8/29/17 through 9/6/17 showed no notation of concern or mention of the resident's coccyx or sacral area. Record review of the resident's Nurses' General Progress Note dated 9/7/17 at 2:21 P.M., electronically signed by Licensed Practical Nurse (LPN) B showed: -No improvement of excoriated-type area of coccyx area and right buttock, a little more involved than left, blotchy-abraised type reddish-purple areas. Doctor notified and order received for wound care appointment; wound care appointment made for 9/11/17 at 9:00 A.M and -The resident's family member was also notified. Record review of the resident's Licensed Nurse Weekly Skin Assessment, dated 9/7/17, showed: -The resident had an open ulcer on his her coccyx and right buttock; -Zero healing; -Going to wound care on 9/11/17 and -[MEDICAL CONDITION] to he/she bilateral extremities. Record review of the resident's telephone order (TOS) from the attending physician, dated 9/7/17, showed the following order: to make an appointment with Wound Care at the hospital for area on his/her coccyx. Record review of the resident's General/Nurses' Progress Note dated 9/8/17 at 10:55 P.M., showed: -Registered Nurse (RN) E assessed the resident's gluteal wound and -Previously noted wound is open to air superior area that is darkened and has circumscribed [DIAGNOSES REDACTED] (abnormal redness of the skin due to local congestion, as in inflammation) that is nonblanchable (appearance of purpuric (purple or brownish-red) skin rash which does not lose redness when pressed). The inferior excoriation has blanchable (loss of redness, typically indicating temporary obstruction of blood flow) [DIAGNOSES REDACTED]. Record review of the resident's Skilled Nursing Care Progress Note dated 9/11/17 at 8:28 A.M., showed the resident had an appointment at the hospital for wound care related to an area of concern on his/her buttocks. Record review of the resident's Skin/Wound Note on 9/11/17 at 9:05 A.M., showed the resident was transported by facility van for wound care. Record review of the resident's Hospital Patient Evaluation on 9/11/17, with an admission time of 9:11 A.M., and finished status on 9/11/17 at 11:00 A.M., showed the following: -Wound Assessment: -Wound #1 was a decubitus ulcer on sacrococcygeal (the base of the spine by the tailbone), primarily to the right side. --The wound was present upon admission on 9/11/17. The exact date of the wound occurrence was unknown. --The wound was Unstageable. There was a minimal amount of serosanguinous drainage (thin and watery, pink in color (it can also be a darker red) fluid; the pink tinge is the effect of red blood cells in the fluid, which is a sign that there is damage to the capillaries) with a slight odor. The wound was black, pink, purple and yellow. --The wound length was 8 cm, width was 5 cm and the depth was undeterminable due to necrotic/eschar in the wound bed. --There was pain present on touch around the ulcers. --The hospital's initial assessment of wound #1 was 10% granulation, 15% clean, non- granulating, and 75% necrotic. -Wound #2 was on the resident's right hip and had partial thickness. --The wound was present upon admission on 9/11/17. The date of the wound occurrence was unknown. --There was a minimal amount of serosanguinous drainage with no odor. --The wound and wound margins were pink. --The size of the wound was 1.2 X 1.0 X <0.2 cm. --The initial assessment of the wound was 100%clean, non-granulating. --There was pain present on touch. -It was also noted in additional comments that there were four small ulcers, the largest one was measured as above (Wound #2). -The following hospital evaluation notes were under Assessment: --Dressing with silver foam dressings and will need to change every 3-5 days and as needed for drainage. --Patient will need judicious skin care and pressure redistribution and may still not have good progress if not getting nutritional support, etc. --Plan was developed with caregiver and patient. -Discharge recommendations: long term care and call placed to nursing home and discussed with staff. Record review of the resident's TOS dated 9/11/17 at 3:40 P.M., signed by the attending physician, showed the following orders: -ROHO cushion (dry floatation cushion) or equivalent to wheelchair; -May not be out of bed more than 1.5 hours at meals; -Needs Low Air Loss Bed Mattress (LALM) related to wound and -Return to Wound Clinic Thursday or Friday for follow-up. Record review of Nurse's General Progress Note dated 9/11/17 at 5:29 P.M., showed the following orders were called from the hospital wound clinic: -ROHO cushion or equivalent in wheelchair while out of bed; -Cannot be up more than 1.5 hours at meals; -LALM related to wound and -Return to wound care clinic on Thursday or Friday after calling for appointment. Record review on of the resident's POS for September 2017, showed: -An order dated 9/14/17, for a culture of coccyx wound to be sent to the laboratory; -An order dated for 9/15/17, for hospice consultation per family request; -An order dated 9/17/17, for Hiba cleanse (an antiseptic cleanser) to sacrum daily for three days between the hours of 7:00 A.M. and 3:00 P.M.; -An order dated 9/17/17, for [MEDICATION NAME] Topical (an antibiotic used to treat certain skin infections by stopping the growth of certain bacteria), every four hours to sacral area, (BID - twice daily), (*Note: There was no clarification as to whether the treatment was to be done every four hours or twice daily) and -An order dated 9/28/17, to cleanse the resident's wound every eight hours with normal saline, apply [MEDICATION NAME] ointment; use ABD (a sterile, highly absorbent dressing) to cover the wound; every eight hour treatment, on each shift. Record review of the resident's medical record showed there was no Licensed Nurse Weekly Skin Assessment for 9/14/17; and no skin assessment between 9/21/17 and 10/5/17. Record review of the resident's TOS, dated 9/15/17, signed by the attending physician, showed the following order: Admit to Hospice with terminal [DIAGNOSES REDACTED]. Record review of the resident's Treatment Administration Record (TAR) for September 2017, showed: -An order dated 9/28/17, to cleanse the resident's wound every eight hours with normal saline, apply [MEDICATION NAME] ointment; use ABD to cover the wound; change ABD every eight hours to sacrum. There were three shifts noted: 7:00 A.M. - 3:00 P.M. (first shift); 3:00 P.M. - 11:00 P.M. (second shift); and 11:00 P.M. - 7:00 A.M. (third shift); -On 9/28/17, there was no documentation of treatment administration during the second shift; -On 9/29/17, there was no documentation of treatment administration during the second shift or third shift and -On 9/30/17, there was no documentation of treatment administration during the second shift or third shift. Record review of the resident's POS for the month of October 2017, showed: -An undated order for a Braden Scale to be done weekly for four weeks; -An undated order for [MEDICATION NAME] to sacral area: Clean wound with wound cleaner, apply foam dressing, and change every 7 days and as needed; -An order dated 9/22/17 for a weekly skin assessment by a licensed nurse on Thursdays between 7 A.M. and 3:00 P.M. and -An undated handwritten order signed by the physician 10/2/17 for a weekly skin assessment by a licensed nurse on Tuesdays between 7 A.M. and 3:00 P.M. During observation and interview while on initial tour of the facility, on 10/16/17 at 11:00 A.M., the resident was in bed on a LALM, lying on his/her right side. The resident was drowsy, but said he/she was comfortable, not in any pain, and doing okay. The MDS Coordinator said the resident: -Had an unstageable pressure ulcer; -The pressure ulcer was not facility acquired and -The resident returned from the hospital with the pressure ulcer. Observations of the resident showed: -On 10/16/17 at 2:23 P.M., he/she was in a low bed with a LALM, head of bed slightly elevated, and appeared to be asleep; -On 10/17/17 at 5:25 A.M. and 7:35 A.M., he/she was in bed, O2 on, and appeared to be asleep; -On 10/17/17 at 8:15 A.M., he/she was at breakfast in the dining room sitting upright in his/her wheelchair with a cushion in the seat, feeding himself/herself fortified cream of wheat. There was also ground sausage with gravy, toast, coffee, juice, and water at the table. A family member was present at the dining room table and said the resident did not eat much, but enjoyed eating his/her cream of wheat every morning. The resident ate 100% of the cream of wheat, drank approximately 50% of the liquids, but ate less than 25% of the remaining items and -On 10/18/17 at 12:50 P.M., during lunch the resident sat upright in his/her wheelchair with a cushion in the seat, feeding himself/herself in the dining room with a family member present. The meal consisted of ground pork chop with gravy, mashed potatoes, vegetable medley, health shake, tea, and water. He/she ate 80% of the vegetable medley, leaving the green beans (he/she said he/she was tired of eating green beans), about 10% of the mashed potatoes, none of the pork chop with gravy (he/she said he/she felt the meat ground taste different than when in it regular form), a small amount of dessert and drank his/her tea. Observation on 10/18/17 at 2:59 P.M. showed: -Certified Nurse Assistant (CNA) C and CNA D provided peri-care for the resident; -CNA C and CNA D then assisted LPN B with wound care on the resident's coccyx and buttocks; -The coccyx pressure wound was in the upper portion of the inter-gluteal cleft (buttocks crack) and the entire wound bed appeared to be composed of slough; -The right buttock pressure wound was located in the left, upper portion of the right buttock next to the inter-gluteal cleft; -The entire wound bed appeared to be composed of eschar and -No measurements were taken at that time. During an interview on 10/18/17 at 12:55 P.M. LPN B said: -The resident's pressure ulcer started as shearing. It didn't appear to be a definite wound; -When the area started looking like a wound it deteriorated quickly; -LPN's don't measure pressure ulcers or determine the stage; -Sometimes the resident does not want to turn on his/her side and pulls the pillow out that keeps her up on her side; -The resident gets supplements, but doesn't eat well and doesn't drink much; -Sometimes hospice workers come in and change the dressing; -Someone else should have picked up after the notations about the resident's skin issues and -The resident continued not eating a sufficient amount, and did not like the health shakes. During an interview on 10/18/17 at 1:50 P.M., the MDS Coordinator said: -The only wound measurements that he/she had seen were from the hospital; -Sometimes Hospice looked at the wound. (Note: The resident did not start hospice care until 9/15/17.); -He/she did not know if the physician expected the facility staff to do treatments; -The facility staff should have been doing measurements or tracking and -Hospice had orders for the wound treatment, but the physician changed the order. During an interview on 10/18/17 at 4:45 P.M., the MDS Coordinator said: -There were skin assessments sheets, but there were no measurements on the sheets and -The licensed nurses were responsible for skin assessments and should have been documenting information on the wounds on the skin assessment sheets. During an interview on 10/18/17 at 5:30 P.M., CNA G said: -The resident had a wound on his/her right buttock that was covered with a dressing and -He/she did not know when the resident acquired the wound. During an interview on 10/19/17 at 1:33 P.M., the Assistant Director of Nursing (ADON) said: -There should have been a head to toe skin assessment done upon readmission, and every week; -He/she would expect the resident returning from the hospital to also be on 72-hour charting; -The Braden Scale that was completed on 8/4/17 and 8/21/17 showed the resident was at risk for pressure ulcers; -He/she did not find record of a Braden Scale after 8/21/17; -He/she could not give an answer as to why documentation about the resident's wound was not there; -There should have been documentation and wound measurements and -There is no excuse; it should have been done. During an interview on 10/19/17 at 4:00 P.M., the Director of Nursing (DON) said: -The resident should have had a head to toe skin assessment upon reentry; -There should have been a care plan addressing the resident's pressure ulcer and -He/she will have to start doing better chart checks. During a telephone interview on 10/24/17 at 3:20 P.M., the resident's Primary Care Physician said: -He/she would have expected skin assessments to be done often and treatments to be done according to orders; -A compression fracture is what caused the resident to develop a pressure ulcer because he/she could not move freely and -The resident would get into a position and couldn't clinically move because of pain issues.