Every finding on record at Cassville Health Care Center

Based on record review and interview, the facility failed to keep a record of medication sent back to the pharmacy for one Resident (Resident #1). The facility census was 35.The facility did not provide a policy regarding the release of resident's medication after discharge or tracking release of medication back to the pharmacy.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date 05/20/25;-discharge date [DATE];-The resident's primary payor source was Medicaid;-Diagnoses included Type 2 diabetes Mellitus with diabetic kidney complication (occurs when long-term high blood sugar damages the small blood vessels and filtering units in the kidneys.), Schizophrenia (a serious brain disorder that changes how a person thinks, feels, and acts), essential hypertension (high blood pressure), hyperlipidemia (high cholesterol), hypothyroidism (happens when your thyroid gland does not make enough thyroid hormones), polyneuropathy(damage to the peripheral nerves causing numbness, tingling, burning pain, or muscle weakness) anxiety disorder, major depressive disorder(a serious medical mood disorder), gastro- esophageal reflux disease (GERD- a chronic condition where stomach acid frequently flows back into the tube connecting your mouth and stomach). Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 08/12/26, showed the following:-The resident discharged to home/community on 08/09/26;-Resident return to the facility not anticipated. Review of the resident's care plan, last updated on 06/08/26, showed the following:-The resident had Type two diabetes Mellitus, dated 09/29/25;-The resident will have diabetes medication as ordered by physician, dated 09/29/25;-Educate the resident regarding medications and the importance of compliance, have resident verbally state understanding, dated 09/29/25;-The resident used anti-anxiety medications, dated 09/29/25;-Administer anti-anxiety medication as ordered by physician, Monitor for side effects and effectiveness, dated 09/29/25;-The resident is on an anticoagulant therapy for stroke prevention, dated 09/30/26;-Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness, dated 09/30/25;-Resident /family teaching to include taking medication at the same time every day each day. -The resident used psychotropic medications for management for schizophrenia, depression, anxiety, and pain, dated 09/30/25;-Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness, dated 09/29/26; -The resident had constipation, dated 09/30/25;-The resident was on pain medication therapy due to polyneuropathy and chronic pain syndrome, dated 09/30/26;-The resident will be free of any discomfort or adverse side effects from pain medication through the review date, date 09/30/26;-Administer pain medications as ordered by the physician, monitor/ document side effects and effectiveness, dated 09/30/25;-The resident had hypothyroidism due to thyroiditis, dated 09/30/25;-Give thyroid replacement therapy as ordered. Monitor/document/ report any side effects and effectiveness, dated 09/30/25;-Staff is to stress the importance of taking medication every day. Educate resident/family regarding signs/symptoms of sub therapeutic or toxic doses, dated 09/30/25;-The resident had a diagnosis of hyperlipidemia, dated 06/08/26;-The resident will demonstrate compliance with medications, dated 06/08/26. Review of the resident's progress notes showed the following: -On 08/09/26 at 9:53 A.M., Registered Nurse (RN) A said the resident discharged from the facility to his/her family's home. The resident's family member said the resident had been accepted to a different facility he/she will admit there tomorrow. The nurse set up the resident's medications and educated the resident's family member about the medications for that day and next morning. The nurse informed the resident and family member if his/her plans change, the resident would need to get an appointment with his/her primary care physician to have medication prescriptions filled in the event he/she decided to keep him/her at home. At 10:20 A.M., the resident discharged from the facility with the family member in a private vehicle with belongings and medications for this day and tomorrow morning. Review of the resident's physician order sheet (POS), dated August 2026, showed the following: -An order for Amlodipine Besylate (blood pressure medication) oral tablet 10 milligrams (mg), give one tablet by mouth one time a day, start date 07/17/26;-An order for Aripiprazole (atypical anti-psychotic) oral tablet 15 mg, one tablet by mouth one time per day, start date 07/18/26;-An order for Aspirin 81 oral tablet delayed release, give one tablet one time a day for circulation, start date 07/17/26;-An order for Atorvastatin Calcium (treats high cholesterol) oral tablet, give 80 mg at bedtime, start date 07/18/26;-An order for Docusate Sodium Oral Capsule (stool softener), give one 100 mg capsule by mouth two times a day;-An order for Duloxetine HCL (for pain) 60 mg oral capsule by mouth one time a day, start date 07/17/26;-An order for Empagliflozin (treats high blood glucose) oral tablet 10 mg, give one tablet by mouth one time a day, start date 07/18/26;-An order for Famotidine (treats GERD) oral tablet 20 mg, give one tablet by mouth at bedtime, start date 07/21/26;-An order for Gabapentin (treats nerve pain) capsule 300mg, give one capsule by mouth three times per day, start date 07/17/26;-An order for hydralazine (treats hypertension) HCL oral tablet, give three tablets by mouth three times a day, start date 07/17/26;-An order for Insulin Lispro injection solution 100 unit/ml, inject as per sliding scale: If 120-150, give two units; 151-200 equals four units; 201-250 equals six units; 251-300 equals 10 units; 351-600 equals 12 units; subcutaneously at bedtime for diabetes, start date 07/24/26;-An order for Lorazepam (anxiety medication) oral tablet .5 mg, give one tablet by mouth three times a day, start date 07/18/26;-An order for Levothyroxine sodium (for hypothyroidism) oral tablet 25 mcg, give one tablet by mouth one time a day, start date 07/18/26;-An order for Lisinopril oral tablet 20 mg, give one tablet by mouth three times a day, hold if blood pressure is lower than 90/60, start date 07/18/26;-An order for Metoprolol Succinate ER Oral tablet extended release24 hour 100mg, give two tablets by mouth one time a day for heart, start date 07/18/26;-An order for Oxybutynin chloride (for urinary incontinence) oral tablet 5 mg, give one tablet by mouth one time per day, start date 07/17/26;- An order for Pregablin (used to treat nerve pain)75 mg, take one capsule by mouth three times daily, start date 08/07/26;-An order for Prozac (Fluoxetine, antidepressant) oral tablet 20 mg, give four capsules by mouth once daily, start date 07/21/26, last order date 07/21/26;-An order for Rivaroxaban (anticoagulant) oral tablet 20 mg, give one tablet by mouth one time a day, start date 07/18/26;-An order for Ropinirole (for restless leg) HCL 5 mg tablet, give one tablet by mouth at bedtime, start date 07/17/26;-An order for Tresiba Subcutaneous Solution (insulin degludec, to treat blood glucose) 100 unit/ml inject 31 units subcutaneously one time daily, start date 08/01/26;-An order for Trazodone (for insomnia) HCL oral tablet 100 mg, give two tablets by mouth at bedtime, start date 08/06/26.During an interview on 08/19/26, at 3:33 P.M., the Regional Nurse Consultant said the following: -On 08/19/26, he/she looked through the pharmacy records for August 2026 and determined the amount of medication he/she believed staff sent back to the pharmacy and destroyed due to it being partially used;-The facility did not have a log or tracker of medication that staff returned to the pharmacy.Review of the facility records, undated, provided by the facility on 08/19/26 showed the following: -A handwritten list of medications;- Metoprolol Succinate ER Oral tablet extended release 24 hour was filled on 08/02/26 with an 18 day supply left;-Duloxetine HCL was filled on 08/02/26 with an 18 day supply left;-Lisinopril was filled 08/02/26 with an 18 day supply left;-Oxybutynin chloride was filled on 08/02/26 with an 18 day supply left;-Trazadone was filled on 08/07/26 with a 46 day supply left.-The facility did not provide a complete list of resident medications returned to the pharmacy on 08/19/26.Review of the facility medication records, emailed to the regional office by the facility on 08/25/26, showed the following: -Tresiba 10 ml vial filled by the pharmacy on 08/07/26, sent back to pharmacy.-Amlodipine was filled by the pharmacy on 07/10/26 and no medication would have been sent back to the pharmacy;- Prozac (Fluoxetine) 20mg was filled by the pharmacy on 07/17/26 and 20 capsules were estimated to have been sent to the pharmacy;- Gabapentin 300 mg was filled by the pharmacy on 07/17/26 and 15 capsules were estimated to have been sent back to the pharmacy;-Hydralazine 25mg filled by pharmacy for 252 tablets on 07/28/26 with 216 tablets were estimated to have been sent back to the pharmacy;-Insulin Lispro injection solution 100 unit/ml, the pharmacy filled one vial on 07/17/26 and it was sent back to the pharmacy;-Mirtazapine 15 mg pharmacy filled 28 tablets on 7/17/26 with five tablets were estimated to have been sent back to the pharmacy;- Trazodone 100 mg, Pharmacy filled 56 tablets on 08/07/26 with 52 pills left were estimated to have been sent back to the pharmacy.Review of Resident #1's pharmacy records, provided by the pharmacy on 08/19/26, showed the following:-The following unopened medications were sent back to the pharmacy by the facility and credited to the resident;-Metoprolol Succ ER 100 mg;-Duloxetine HCL DR 60 mg two cards;-Lisinopril 20 mg;-Oxybutynin 5 mg;-Atorvastin 80 mg;-Xarelto (Rivroxaban) 20 mg;-Aripiprazole 15 mg two cards;-Jardiance (Empagliflozin) 10 mg two cards;-Levothyroxine 25 MCG;-Lisinopril 40 mg,-Xarelto (Rivaroxaban) 20 mg. Review of the facility records did not show tracking or a log showing what medication with amounts was sent back to the pharmacy by facility staff. During an interview on 08/19/26, at 11:28 A.M., Certified Medication Tech (CMT) B said the following: -The nurse usually directs him/her to get resident's medications ready for discharge;-He/she gets the correct amount based on what the nurse tells him/her;-Resident #1 was initially supposed to go directly to another facility but then his/her family member chose to take her to the family member's home for a night before going to the new facility;-He/she found out the resident had already discharged when he/she went to administer his/her medication 08/10/26 and Resident #1 was not in the building;-Resident #1's medications were all still in the drawer. He/she did not know why the medication was not sent with him/her when he/she discharged from the facility;-He/she was told by the charge nurse, who he/she thought was the ADON, to send all the medications back to the pharmacy and to destroy any narcotics;-There is no log keeping track of what medication is returned to the pharmacy;-He/she thinks the narcotics did not get sent with him/her due to the resident pocketing the medication and selling it in the past;-He/she thinks the resident gets a credit for some of the medication sent back to the pharmacy;-He/she gathered up the medications and put them in the bin to go back to the pharmacy;-He/she destroyed the narcotics with Licensed Practical Nurse (LPN) C. During an interview on 08/19/26 at 11:53 A.M., LPN C said the following:-When a resident discharges from the facility, sometimes medication gets sent with the resident and sometimes it gets destroyed;-He/she checks with the DON to see what needs to be done with the resident's medication;-He/she assisted with destroying Resident #1's narcotics a few days after he/she discharged from the facility because his/her medications were still in the drawer;-Resident #1's medication was not sent home with him/her because he/she tends to pocket his/her pills and he/she was going to a family member's home instead of going straight to the next facility after discharge;-He/she is not sure what happened to the resident's medication that was not narcotics;-He/she assumes his/her medication got sent with the resident with a transfer sheet and list of medications and when to take them. During an interview on 08/19/26, at 12:15 P.M., RN A said the following:-Resident #1 was supposed to discharge to another facility on 8/10/26; but, he/she decided to go home with a family member on 08/09/26 and then the family member would take the resident to the new facility;-He/she sent enough medication for one day;-He/she did not know why he/she was told to only give the resident enough medication for one day. He/she thought the resident usually gets to take any leftover medication that was still prescribed because it was already paid for but he/she did not know what the procedure was normally;-He/she thinks the rest of the resident's medication was sent back to the pharmacy and the narcotics were destroyed;-He/she does not know of any log or tracker for medication that is sent back to the pharmacy;-He/she did not know what the pharmacy does with the medication. During an interview on 08/19/26, at 3:17 P.M., the facility pharmacy technician said the following: -The pharmacy will not take back narcotics;-The pharmacy cannot credit a resident if even one pill has been used or removed. They immediately destroy them if the facility sends them back;-The pharmacy will only credit the resident's insurance for medication that is unopened;-He/she thinks the facility gives the resident any leftover opened medication upon discharge since it will be destroyed if it is sent back to the pharmacy;-He/she thinks the facility keeps track of any medication sent back to the pharmacy;-The pharmacy credited Resident #1 for some of the medication that the facility sent back; There was medication that was opened and destroyed;-The pharmacy did not keep track of what medication they destroyed. During an interview on 08/19/26, at 3:35 P.M., the physician said the following: -The facility staff did not contact him/her about sending home Resident #1's medication except for narcotics;-He/she approved all of Resident #1's regular scheduled medication being sent home with him/her except for narcotics due to the resident having a history of pocketing them;-He/she does not know why the staff would not send resident medication home with them at discharge. During an interview on 08/19/26, at 12:28 P.M., the Assistant Director of Nursing (ADON) said the following: -The residents are not sent home with all of their left-over medications. He/she is not sure why;-The left-over medications are sent back to the pharmacy and narcotics are destroyed;-He/she thinks the resident gets credit for all of the medications that are left;-Resident #1 chose to discharge home with family prior to going to the facility. Resident #1 was sent with enough medications for a day until he/she went to the next facility;-The next facility has to order the resident's medications;-He/she is not sure why the facility does not send the residents with their left over medications since they have already been paid for;-He/she does not know if the facility has a log or tracker for medications returned to the pharmacy. During an interview on 8/19/26, at 1:14 P.M., the Director of Nursing (DON) said the following:-The facility sends the left-over medication, except for narcotics which is destroyed, back to the pharmacy;-The facility does not have a log of what medication is sent back to the pharmacy;-He/she directed staff to send Resident #1's left over medication back to the pharmacy after he/she discharged ;-He/she believes the pharmacy credits the resident for all the medication that is returned;-The facility does not notify the pharmacy of the narcotics they destroyed;-Resident #1's next facility would have to order all of his/her medication;-The medication did belong to the resident; but, he/she believes the pharmacy credits Medicaid. During an interview on 08/19/26, at 2:06 P.M., the Regional Nurse Consultant said the following: -Leftover resident medication should be sent with the resident. If it is narcotic medication, they should get an order from the physician, and it has to be counted and signed off on by the resident or resident's family member with a staff member;-There should be a log sheet filled out for any medication sent back to the pharmacy so they can track what is being sent back. He/she could not find a log at the facility;-He/she could not find a policy regarding sending medications home with discharging residents. During an interview on 08/19/26, at 2:06 P.M., the Administrator said the following: -He/she thinks it is against regulations to send a resident home with the bubble packs from the facility;-Resident #1 was sent with enough medications for one day, since he/she was going to the other skilled facility the next day;-The resident's medication was returned to the pharmacy and the narcotics were destroyed;-He/she does not know if there is a log tracking what medication is sent back to the pharmacy. Complaint 3158267

Based on record review and interview the facility failed to ensure the resident's needs would be met after discharge when staff did not give one resident (Resident #1) his/her medications upon discharge, creating difficulty for the resident to refill his/her medications. The facility census was 35.The facility did not provide a policy regarding the release of the residents' medication upon discharge.1. Review of Resident #1's face sheet (a document that gave a resident's information at a quick glance) showed the following:-admitted to the facility on [DATE];-Discharge from the facility on 08/09/26;-The resident's primary payor source was Medicaid;-The resident's diagnoses included diabetes with diabetic kidney complication (occurred when long-term high blood sugar damaged the small blood vessels and filtering units in the kidneys.), Schizophrenia (a serious brain disorder that changed how a person thought, felt, and acted), high blood pressure, high cholesterol, hypothyroidism (underactive thyroid), polyneuropathy (damage to the peripheral (located near the surface) nerves causing numbness, tingling, burning pain, or muscle weakness) anxiety disorder, depression, and acid reflux disease. Review of the resident's Discharge Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 08/12/26 showed the following:-The resident discharged to home/community on 08/09/26;-Resident's return to the facility was not anticipated. Review of the resident's care plan last updated 06/08/26, showed the following:-Educate the resident regarding medications and the importance of compliance, have resident verbally state understanding;-Resident /family teaching to include taking medication at the same time every day each day;-Staff to stress the importance of taking medication every day. Educate resident/family regarding signs/symptoms of subtherapeutic (below optimal range) or toxic doses;-The resident would demonstrate compliance with medications. Review of the Resident's August 2026 Physician's Order Sheet showed the following: -Amlodipine Besylate (blood pressure medication) 10 milligrams (mg), one tablet by mouth one time a day;-Aripiprazole (an atypical anti-psychotic) 15 mg, one tablet by mouth one time per day;-Aspirin, 81 mg, one tablet one time a day for circulation;-Atorvastatin Calcium (treats high cholesterol) 80 mg at bedtime;-Docusate Sodium Oral Capsule (stool softener), 100 mg, by mouth two times a day;-Duloxetine HCL (treats long-term pain) 60 mg, by mouth one time a day;-Empagliflozin (for high blood sugar) 10 mg, one tablet by mouth one time a day;-Famotidine (an acid reducer) 20 mg, one tablet by mouth at bedtime;-Gabapentin (for nerve pain) 300 mg, one capsule, three times per day;-Hydralazine (for high blood pressure) three tablets, three times a day;-Insulin Lispro injection solution 100 unit/ml (a fast-acting insulin to lower blood sugar), per sliding scale: If 120-150 give two units, 151-200 equals four units, 201-250 equals six units, 251-300 equals 10 units, 351-600 equals 12 units, subcutaneously at bedtime;-Lorazepam (anti-anxiety medication) 0.5 mg, one tablet by mouth three times a day;-Levothyroxine sodium (for hypothyroidism) 25 micrograms (mcg), one tablet by mouth one time a day;-Lisinopril (for high blood pressure) 20 mg, one tablet by mouth three times a day;-Metoprolol Succinate ER (for high blood pressure) 100 mg, two tablets by mouth one time a day;-Oxybutynin chloride (for urinary incontinence) 5 mg, one tablet by mouth one time per day;-Pregablin (used to treat nerve pain) 75 mg, one capsule by mouth, three times daily;-Prozac (an antidepressant) 20 mg, four capsules by mouth once daily;-Rivaroxaban (a blood thinner) 20 mg, one tablet by mouth one time a day;-Ropinirole (for restless leg) 5 mg, one tablet by mouth at bedtime;-Tresiba Subcutaneous Solution (insulin degludec, to treat blood sugar) 100 unit/ml, inject 31 units subcutaneously (in the fat layer just under the skin) one time daily;-Trazodone (for insomnia) 100 mg, two tablets by mouth at bedtime.Review of the Resident's progress note dated 08/09/26 at 9:53 A.M., showed Registered Nurse (RN) A documented the following: -The resident discharged from the facility to a family member's home;-The resident's family member said a different facility accepted the resident and he/she would admit there tomorrow (08/10/26);-The resident's medications were set up and the resident's family member was educated about medications and items for today (08/09/26) and tomorrow morning (08/10/26);-Informed the resident and family member that if their plans changed, and they decided not to admit to the other facility, the resident would need to make an appointment with his/her primary care physician for prescriptions;-At 10:20 A.M., the resident discharged from the facility with a family member via a private vehicle with belongings and medications for this day (08/09/26) and tomorrow (08/10/26) morning.During an interview on 08/19/21 at 12:15 P.M., Registered Nurse (RN) A said the following:-When a resident discharged from the facility, the staff gave the resident enough doses of medication to take until they could see their primary care physician; -Resident #1 was supposed to discharge to another facility on 8/10/26 but he/she decided to go home with a family member on 08/09/26. The family member would take the resident to the new facility on 08/10/26;-The DON told him/her to only provide the resident with enough medication for one day. The DON also directed him/her to not give the resident any narcotic medication;-He/she told the CMT to prepare enough doses of medication for one day;-He/she educated the resident and family member about the medication and when to take it;-He/she did not know if there was an order directing what to do with the resident's medication upon discharge. He/she did not know if he/she needed an order;-He/she did not know why the DON told him/her only to give the resident enough medication for one day;-He/she was not sure what the normal process was but he/she thought the facility gave all the resident's current medications to the resident upon discharge because the medication was already paid for;-He/she thought they destroyed the resident's narcotic medication and returned the remaining doses of the medication to the pharmacy;-He/she did not know of any log or tracker for medication the facility returned to the facility. During an interview on 08/19/26 at 11:28 A.M., Certified Medication Tech (CMT) B said the following: -The nurse usually told him/her the number of medications to provide to a resident at discharge; -Initially, Resident #1 planned to admit directly to another facility but then his/her family member chose to take the resident to his/her home for a night before admitting to the new facility;-The resident discharged on 08/09/26, but his/her medications were still in the medication cart drawer on 08/10/26;-He/she thought staff did not send the resident's narcotics with him/her due to a history of the resident selling his/her medication, but he/she did not know why staff did not send the other medications with him/her when he/she discharged ;-A charge nurse, who he/she thought was the Assistant Director of Nursing (ADON), told him/her to return the remainder of the resident's medications to the pharmacy and destroy any narcotics;-He/she gathered up the resident's medications and placed them in the bin to send to the pharmacy and destroyed the narcotics with Licensed Practical Nurse (LPN) C;-He/she did not know if he/she needed orders to give a resident his/her medications upon discharge from the facility. During an interview on 08/19/26 at 11:53 A.M., LPN C said the following:-When a resident discharged from the facility, they sometimes sent the medication with the resident and sometimes they destroyed them;-He/she asked the DON what to do with a resident's medication;-He/she destroyed Resident #1's narcotics with another staff member a few days after the resident discharged from the facility as his/her medications were still in the drawer;-Staff did not send Resident #1's narcotic medication home with him/her because he/she tended to hold his/her medications in his/her mouth and not swallow them, plus the resident discharged to a family member's home instead of going directly to the new facility after discharge;-He/she did not know what happened to the resident's non-narcotic medication;-The LPN assumed staff sent the resident's non-narcotic medication with the resident along with a transfer sheet and list of medications and when to take them;-He/she thought the medication belonged to the resident since it was already paid for;-He/she did not know if the physician needed to write an order for staff to send medication with a resident upon discharge. During an interview on 08/19/21 at 12:04 P.M., the Social Services Designee (SSD) said the following: -He/she assisted with discharge planning;-Resident #1 was supposed to directly admit to another skilled facility, however, he/she chose to go home with a family member for a night prior to going to the new facility;-On the day of discharge, nursing staff gathered up the resident's medications then sent the medications with the resident upon discharge as the medication belonged to the resident. During an interview on 08/19/26 at 3:35 P.M., the physician said the following: -The facility staff did not contact him/her or obtain orders to send Resident #1's medications with him/her at discharge except for the narcotic medications;-He/she approved to send all of Resident #1's regularly scheduled medication home with him/her except for the narcotic medication as the resident had a history of pocketing them;-He/she did not know the reason staff would not send a resident's medication with the resident at discharge. During an interview on 08/19/26 at 12:28 P.M., the ADON said the following: -The facility generally provided the residents with enough medication when they discharge to last until they had an appointment with their physician or admit at the new facility;-The DON and administrator told him/her to only send enough medications to last until the resident admitted to the new facility;-He/she believed that was the facility's policy;-They did not send residents home with all of their medications, but he/she did not know the reason;-They destroyed any remaining narcotics and returned the remaining non-narcotic medication to the pharmacy;-Resident #1 chose to discharge home with family prior to admitting to the new facility and they provided him/her with enough medications for one day;-When the resident admitted to the new facility, that facility ordered the resident's medications;-He/she did not know the reason they did not give residents all of their medications since the medications were already paid for. During an interview on 8/19/26 at 1:14 P.M., the DON said the following:-The facility did not have a policy directing staff on what to do with residents' medications at discharge;-It was the facility's procedure to provide the residents with enough medication at discharge until they could get to their follow-up physician appointment. They did not send as needed medication with the resident;-The facility returned the residents' remaining medication, including opened medication, to the pharmacy except for narcotics which they destroyed;-He/she directed staff to send Resident #1's left over medication back to the pharmacy after he/she discharged ;-The resident's new admitting facility would order Resident #1's medication upon admission to their facility;-He/she discussed Resident #1's discharge medications with the physician, and he/she did not want the narcotics sent with the resident as he/she had a history of not taking the medication as prescribed;-The medication did belong to the resident, but he/she believed when they returned the medication to the pharmacy, the pharmacy credited Medicaid.During an interview on 08/19/26 at 3:17 P.M., a pharmacy technician said the following: -The pharmacy only credited unopened, unused medication;-He/she thought the facility gave residents their opened unused medications upon discharge.During an interview on 08/19/26 at 2:06 P.M., the Regional Nurse Consultant said the following: -He/she was educating the DON to give all medications to the residents with Medicaid as a payor source upon discharge;-Left-over resident medication should be sent with the resident. If it was narcotic medication, they should obtain an order from the physician, and it had to be counted and signed off by the resident or resident's family member with a staff member;-He/she could not find policy regarding sending medications home with discharging residents. During an interview on 08/19/26 at 2:06 P.M., the Administrator said the following: -The facility only sends enough medication with a resident until the resident can see their primary physician;-Resident #1 was supposed to discharge to another skilled facility but chose to go home with family a day early then admit to the new facility the next day;-He/she thought it was against regulations to send a resident home with the bubble packs from the facility;-Staff sent Resident #1 home with enough medications for one day, since he/she would admit to the other skilled facility the next day;-He/she could understand why it might be difficult for the resident to get medication if it was not time for a refill yet;-He/she acknowledged that the medication belonged to the resident;-Residents' medications, even if opened, were returned to the pharmacy and the narcotics were destroyed at the facility;-The facility could have obtained a transfer order from the physician and sent the resident's medications to the new facility; -Staff should document communication with the physician in the medical record. Complaint 3158267

1.Please refer to event ID 1D693E-H3, exit date 02/02/26, for details.Complaints #2700845 and #2717249

Based on observation, interview, and record review, the facility failed to maintain an effective pest control system when flies were observed in multiple areas of the facility and multiple residents complained about the presence of flies in the facility. The facility census was 43.Review of the facility policy titled, Pest Control Program Policy, dated 05/14/24, showed the following:-It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents;-Effective pest control program is defined as measures to eradicate and contain common household pests (including flies);-The facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis;-The facility will utilize a variety of methods in controlling certain seasonal pests i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations;-The facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures. 1. Observations on 09/19/25, at 3:38 P.M. showed the following:-Resident #2 lay on his/her bed;-The resident had an open area approximately two inches long by one inch wide on his/her left wrist just up from his/her thumb, with slight redness to the surrounding area;-Flies buzzed around the resident. 2. Observations and interview on 09/19/25, at 3:40 P.M., showed the following:-Resident #3 lay on his/her bed fully dressed;-A urine odor surrounded the resident;-Six to seven flies crawled on the resident's body, arms, and face, and buzzed around the resident;-The resident said the flies bothered him/her. 3. Observations and interview on 09/19/25, at 3:52 P.M., showed the following:-Resident #4 lay on his/her bed;-A fly buzzed around the resident;-The resident said, The flies are bad, they buzz my face. 4. Observations and interview on 09/19/25, at 4:53 P.M., showed the following:-Resident # 5 lay on his/her bed;-The resident said he/she would be very grateful if someone could get rid of the flies;-The resident said the flies crawl on his/her face and head;-Several flies buzzed around the resident and crawled on the resident's bedding and arms. 5. Observations and interview on 09/22/25, at 11:09 A.M., showed the following:-Resident #6 sat on the side of his/her bed;-The resident said he/she had a problem with flies, stating the flies were all over the facility and therefore he/she kept his/her door shut all the time;-Due to the flies, he/she put a sign on the outside of the door to his/her room to remind staff to shut the door;-Observation showed two flies in the resident's room buzzing around while the resident ate popcorn out of a bowl;-Observation showed a sign hung on the outside of the resident's room door, that read, NO FLY ZONE, please close the door behind you, thank you! 6. Observations on 09/22/25, at 11:24 A.M, showed the following: -A bug light mounted on the wall on the resident hallway where Residents' #2, #3, #4, and #6 resided;-The bug light was not illuminated. 7. Observations and interview on 09/22/25, at 1;45 P.M., showed the following:-Resident #7 lay on his/her bed. The resident's urinal contained urine and sat atop his/her overbed table next to an open coffee cup containing what appeared to be coffee. A fly buzzed around the resident's urinal. -The resident said the flies were bothering him/her. 8. Observations on 09/22/25, at 4:00 P.M., of the facility dining room showed the following:-Resident #8 sat at a table swatting at flies with a fly swatter;-The exterior door leading from the dining room to the outside courtyard was ajar approximately two to three inches;-Several residents sat out in the courtyard smoking cigarettes. 9. Observations and interview on 09/23/25, at 11:30 A.M., showed the following:-Resident #9 lay on his/her bed;-The resident said the flies were bothering him/her; -Two flies buzzed the resident's face;-The resident said he/she and his/her roommate tried keeping the door shut as much as possible, but the flies still came in his/her room;-Four flies crawled on the roommate's unoccupied bed. 10. Observations on 09/23/25, starting at 1:50 P.M., showed the following:-There was no bug light or pest-control prevention measures observed inside the main entrance of the building;-At the door used for staff smoking and laundry access, an air curtain (device which blows air forcefully down from the top of the doorway) was in use, but the door took approximately six seconds to fully close. One fly was observed inside this door, and two more flies observed close to the door in the exterior;-One of the bug lights by the old dining room, close to the nurses' station, was plugged in, but the bulb was completely dark or burnt out; -Two dead flies were observed on the floor in the middle of the hall (Cardinal Drive), and three dead flies were on the floor at the end of the hall, by the exit;-A 10-inch bug light was plugged in, in the middle of [NAME] Lane (close to room [ROOM NUMBER]). However, the light bulb in this fixture was completely dark or burnt out. Also on this hall, a sign on a resident room said No Fly Zone. Please close the door behind you;-The door to the courtyard, off the main dining room, was stuck open approximately three inches. It appeared to be the bottom of the door which dragged on the ground. Staff nearby said a resident was currently outside taking a break;-A bug light-fixture was plugged in, inside the food serve-out area of the main dining room. However, the bulb was a regular light bulb (white colored), not one specifically made to repel bugs;-On Dogwood Drive hall, staff had plugged in a bug light close to resident room [ROOM NUMBER]. The bulb inside the fixture, however, was dim. There were two dead flies observed on the floor, close to the exit (by rooms [ROOM NUMBERS]);-The bug light on [NAME] Oak Boulevard hall (between resident rooms [ROOM NUMBERS]) was plugged in, but the bulb was completely dark or burnt out. 11. Observations on 09/24/25, at 11:48 A.M., showed residents sat in the main dining room awaiting lunch and the external door leading from the dining room to the enclosed outdoor courtyard was ajar approximately 2 inches. 12. During an interview on 09/22/25, at 11:38 A.M., Certified Nurse Assistant (CNA) H said the following:-The facility had a current issue with flies that had been ongoing all summer;-A pest control company visited the facility, but the fly issue did not improve after their visit;-The residents complained about the flies;-A few of the residents put up signs to keep their doors shut to keep flies out. During an interview on 09/22/25, at 12:10 P.M., CNA I said the following:-The flies remained terrible in the facility;-The facility had an exterminator visit last week;-The residents complained about the flies;-Staff kept fly swatters behind the nurses' desk to try to kill some of the flies and several of the residents also had fly swatters;-Nursing staff told maintenance about the fly problem in the facility and maintenance said he/she had an exterminator coming. The exterminator visited last week, but the facility still had a fly problem. During an interview on 09/24/25, at 11:23 A.M., CNA J said the following:-The facility had a current fly problem. He/she had informed the nurses of the pest problem and had observed the nurses reporting the fly issue to the Maintenance Director and observed nurses reporting the courtyard door issue to the Maintenance Director;-The flies were coming into the facility when the courtyard door was open, and that door frequently got stuck;-Staff left the courtyard door cracked open so the residents could get back inside the building because the outside door release would not work properly;-Staff and residents sometimes propped the door open with a rock to keep the door from closing all the way. During an interview on 09/23/25, at 2:19 P.M., the Maintenance Director said the following:-The facility had not had any complaints about flies;-He/she believed the flies were coming into the facility via an external courtyard door into the resident dining room;-He/she believed residents were propping the courtyard door open;-He/she told the residents in resident council approximately one week ago, not to prop the courtyard door;-Since he/she instructed residents not to prop the courtyard door open, he/she was checking to ensure the door was closed;-The courtyard door would freely swing shut, close, and latch;-The courtyard door was currently broken, and someone had to open from the inside if someone completely closed the door;-He noticed the courtyard door was broken on Monday morning (09/22/25);-A pest control company came to the facility monthly;-He/she discussed the flies with the pest control representative, but the facility did not change their pest control treatment plan;-The flies were drawn to cooler inside temperature when the weather was hot outside. During an interview on 09/24/25, at 12:48 P.M., the Administrator said the following:-He/she called the pest control company about the flies, but was unsure if they had visited the facility or not;-All external doors in the facility should close all the way;-When asked if the facility's flying insect lights should all be operational, the Administrator said not necessarily. e been no recommendations made for pests or unmet needs.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the facility staff failed to keep food contact and non-food contact surfaces clean; when staff failed to ensure the refrigerators maintained proper temperatures for food storage; when staff failed to ensure stored food was properly stored/sealed; and when staff failed to ensure spoiled or contaminated foods were discarded. The facility census was 43.Review of the Food and Drug Administration (FDA) Food Code (2022 edition) showed the following: -Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris;-Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. They may also be passed on by consumers or employees directly, or indirectly from used tableware or food containers;-Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contamination;-Products which are damaged, spoiled, or otherwise unfit for use may become mistaken for safe and wholesome products and/or cause contamination of other foods, equipment, utensils, linens, or single-service or single-use articles. To preclude this, separate and segregated areas must be designated for storing unsalable goods. Review of the facility's policy, titled Dietary - Receiving and Storing Food Supplies, last reviewed 06/30/23, showed the following:-Food items will be stored, thawed, and prepared in accordance with good sanitary practice;-All products shall be dated upon receipt or when they are prepared. Use date shall be marked on all food containers according to the timetable;-All cooked meat shall be used (or discarded) within three days of cooking;-Dairy shall be stored at temperature below 41 degrees Fahrenheit (F);-For dry storage, any opened products shall be placed in seamless plastic or glass containers with tight-fitting lids, or zipper bags;-Label and date all storage containers with the received date (should already be on it), date opened, and date the item expires;-A daily temperature record is to be kept of refrigerated items;-Refrigerator temperatures must be 41 degrees F or below. Review of the facility's policy, titled Dietary - Equipment Operations, Infection Control, and Sanitation Policy, reviewed 02/02/24, showed the following:-The dietary staff shall maintain the sanitation of the dietary department through compliance with written, comprehensive cleaning schedules developed for the facility by the Dietary Manager;-Staff should clean grills after each use;-Counters and shelves should be cleaned and sanitized weekly;-For ovens, staff should immediately clean up spills and burned food deposits, daily wipe down interior and exterior. 1. Observations on 09/23/25, starting at 10:44 A.M., showed the following in the main dining area:-A five-gallon water cooler had a tray/trap under the outlet. There had about an inch of brown-stained water in the tray;-A 17.5-ounce bottle of barbecue sauce, about 3/4 empty, on a dining table. It felt room-temperature to the touch. The bottle's label indicated refrigerate after opening;-A 14-ounce bottle of ketchup on a dining table, which felt room-temperature to the touch. The bottle's label indicated refrigerate after opening. Observations on 09/23/25, starting at 11:00 A.M., in the kitchen showed the following:-An Avanti-brand refrigerator present. The staff last recorded the temperature of the refrigerator on 09/19/25 (four days prior) as 36 degrees F. The thermometer staff placed inside read 49 degrees F. A second thermometer placed inside and left in the refrigerator while closed for 5 minutes confirmed the refrigeration temperature to be 49 degrees F. Inside, staff had placed several pitchers of prepared drinks (tea and Kool-aide). In the bottom drawer there were 12 small cartons of milk-based vanilla shakes;-A Magic Chef-brand mini-refrigerator present. Inside this refrigerator, there was a large bag of bologna, unsealed and labeled 09/13/25. There was also a large, unsealed bag of sliced cheese labeled 09/19/25. A thermometer placed inside and left inside with door closed for 5 minutes confirmed the refrigeration temperature to be 51.9 degrees F;-In a large, chest-style, refrigerator, staff placed one gallon of milk, which appeared to have been open. The best by date on the milk was 09/19/25 (four days prior). Over the best by date, staff had placed a piece of tape dated 9/23/25;-A two-door stainless steel, reach-in refrigerator present. The exterior thermometer for this refrigerator read 50 degrees F. Staff last logged the temperature as 40 degrees F on 09/19/25. A thermometer placed inside and left inside with door closed for 5 minutes confirmed the refrigeration temperature to be 48.7 degrees F. Inside this refrigerator there were many items, including: 1 gallon container of mustard, opened (partially used); 1 gallon of mayonnaise, opened; 1 gallon of Italian dressing, opened; sliced cheese; grated cheese; 1 gallon jar of pickles, opened; eggs; pre-cooked sausage patties; butter; large jar of tomato sauce, opened; three five-pound containers of sour cream; and cooked pork in a steam bin dated 09/13/25 (ten days prior);-The griddle area had significant food debris and grease build-up left on the surface of the grill. Below the griddle, the oven exterior appeared heavily soiled with grease and food debris. The handles of the ovens appeared discolored and were tacky to the touch;-Below a food prep area, staff stored cutting boards and pots and pans on a shelf. On the shelf, around the pots, pans, and cutting boards, there was numerous crumbs, small pieces of food debris, and small pieces of trash. In the dry-storage area, in a locked room across from the kitchen, there was a bulk bin with breadcrumbs which staff had labeled with the date 4/18 (at least five months prior). During an interview and observation on 09/23/25, starting at 2:20 P.M., the Dietary Manager (DM) said the following: -Staff should check and record refrigerator temperatures every shift (twice a day) and record them on the logs taped to each refrigerator. She said ideal temperatures for all refrigerators is 32-40 degrees F. Staff should check temperatures with the thermometer continuously kept inside each refrigerator;-The Avanti-brand reach-in refrigerator sometimes gets warmer due to staff placing pitchers of hot (fresh-brewed) tea inside. If any refrigerator is noted to be above ideal temperatures, the protocol is to move all items to another refrigerator; -Referring to the open gallon of milk in the large chest refrigerator, the DM said she did not know why the best by date was covered with tape of a more recent date;-The DM took the temperature of the sliced bologna - which had been stored in the small Magic Chef refrigerator. Using a thermometer from the dietary department, the DM took the temperature of the bologna as 53.4 degrees F;-The DM took the temperature of the two-door stainless steel refrigerator. She took the temperature of the interior as 46 degrees F, which was above the preferred temperature. She said staff may have to work on moving the food in that refrigerator to a different refrigerator that is working properly;-The DM said she has had some struggle with some dietary staff not cleaning as directed;-The DM said residents like to leave bottles of condiments on the tables in the main dining room. She said most of the bottles were purchased by residents, and the residents have requested the condiments be always kept at the tables. During an interview 09/23/25, starting at 3:51 P.M., the Administrator said temperatures for refrigerators should be posted, and dietary staff should be logging the temperatures every shift. He didn't know if staff were recording temperatures every shift. He didn't know if all refrigerators were keeping appropriate temperatures (41 degrees F or below). He also said the kitchen should be kept clean by dietary staff, and cleaning schedules should be completed every day. Complaint #26515205

Based on observation, interview, and record review, the facility did not provide showers per resident preference for five residents (Resident #4, #5, #7, #9, and #10) who required staff assistance with showering. The facility census was 43.Review of the facility policy titled, Resident Showers Policy, dated 06/26/24, showed the following:-It is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice;-Residents will be provided showers as per request or as per facility schedule protocols based on resident safety.1.Review of Resident #4's face sheet showed:-readmission date of 04/22/24;-Diagnoses included atrial fibrillation (a cardiac dysrhythmia), stage 3 chronic kidney disease, and type 2 diabetes mellitus.Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 01/19/25, showed the following:-Cognitively intact;-Functional limitation in range of motion to all four extremities;-Required wheelchair for mobility device;-Dependent on staff for assistance with toileting and personal hygiene, lower body dressing, and transfers;-Required substantial or maximal assistance of staff with showers, and upper body dressing;-Always incontinent of bowel and bladder;-At risk for development of a pressure ulcer.Review of the resident's care plan, dated 09/16/25, showed the following:-Required assistance with activities of daily living (ADLs) related to poor balance, unsteady gait, and decreased physical mobility;-Required total assistance of two staff via Hoyer lift (a mechanical sling lift used to transfer residents);-Showers dependent upon staff for completion.Review of the resident's point of care shower documentation in the electronic health record (EHR) showed as of 09/20/25:-Staff documented assisting the resident with one shower in the last 30 days;-Staff documented the most recent shower for the resident was on 09/03/25, over two weeks prior to the review.Observation and interview on 09/19/25, at 3:52 P.M., showed the following:-The resident laid on his/her bed;-The resident said staff assisted him/her on and off the bed with a Hoyer lift. He/she was not able to get up out of bed without the assistance of two staff and the lift;-Staff had not assisted the resident with a shower for approximately three weeks;-The facility pulled the shower aide to work the floor as an aide, instead of providing showers to residents;-He/she asked certified nurse assistants (CNAs) to assist him/her with a shower, but they say they did not have time.2. Review of Resident #9's face sheet showed the following:-admission date of 03/04/25;-Diagnoses included of stage 3 chronic kidney disease and type 2 diabetes mellitus.Review of the resident's annual MDS, dated [DATE], showed the following:-Moderately cognitively impaired;-Functional limitation in range of motion to one lower extremity;-Required wheelchair for mobility device;-Dependent on staff for assistance with toileting hygiene,-Required substantial or maximal assistance of staff with showering, personal hygiene, and lower body dressing;-Always incontinent of bowel and bladder;-At risk for development of a pressure ulcer;-Presence of moisture associated skin damage (MASD).Review of the resident's care plan, revised on 09/16/25, showed the following:-Resident required assistance with ADLs related to poor mobility, chronic pain, weakness, and poor endurance;-Required maximum assistance of 2 staff for transfers;-Required maximum assistance with showering.Review of the resident's point of care shower documentation in the EHR showed, as of 09/20/25, showed staff documented assisting the resident with one shower in the last 30 days on 09/20/25.Observation and interview on 09/22/25, at 11:30 A.M., showed the following:-The resident laid on an air mattress on his/her bed;-The resident said staff assisted him/her with a shower a couple of days ago, but prior to that, staff had not assisted him/her with a shower for 21 days;-He/she would like a shower two times per week;-His/her skin itched when he/she did not get a shower;-When he/she asked for a shower, staff informed the resident the facility did not have enough aides working to complete resident showers.During an interview on 09/24/25, at 11:50 A.M., CMT G said the following:-Staff should assist each resident with at least two showers per week, unless their care plan stated the resident requested showers more frequently;-Several of the residents said staff were not assisting them with showers;-The resident said he/she had not had a shower for at least 19 days.3. Review of Resident #10's face sheet showed the following:-admission date of 11/04/21;-Diagnoses included diabetes mellitus, type 2, anxiety, and depression. Review of the resident's annual MDS, dated [DATE], showed:-Cognitively intact;-Functional limitation in range of motion to both lower extremities;-Required walker or wheelchair for mobility device;-Required substantial or maximal assistance of staff with showering, personal and toileting hygiene, and lower body dressing;-Occasionally incontinent of bowel and bladder;-At risk for development of a pressure ulcer.Review of the resident's point of care shower documentation in the EHR, as of 09/20/25, showed staff documented assisting the resident with one shower in the last 30 days on 09/02/25, over two weeks prior to the review.Observation and interview on 09/22/25, at 2:03 P.M., showed the following:-The resident laid on his/her bed; -The resident said staff informed him/her they would assist him/her with a shower on 09/23/25, but staff had not provided him/her with a shower for approximately one month;-Staff had not offered a shower during that time;-During the month of no showers, he/she asked the aides for a shower, but they said the facility did not have a shower aide and they did not have enough staff to assist him/her with a shower;-The resident said his/her skin and scalp itched and he/she could smell him/herself;-The aides told the resident the facility Administrator reportedly said the residents did not need a shower aide, but the CNAs did not have time to complete all the showers.4. Review of Resident #5's face sheet showed:-admission date of 07/15/22;-Diagnoses included Guillain-Barre (an auto-immune disease affecting the peripheral nervous system) and quadriplegia (paralysis of all four extremities and the body from the neck down).Review of the resident's care plan, dated 08/28/24, showed the following:-Personalized care, staff will accommodate/support residents valued activities in care routine as able;-Bathing preference: Shower, resident preferred Monday and Thursday, but requested staff clarify on each scheduled day if he/she wanted to have his/her shower that day;-For transfers: Required total assist of two staff with mechanical lift;-For showers: Required total assist of one to two staff.Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.During an interview on 09/19/25, at 4:53 P.M., the resident said staff assist him/her with showers once per week, or once every two weeks. He/she was frustrated because the facility did not have a consistent shower aide, and he/she did not like different staff assisting him/her with a shower. The resident said he/she did not refuse showers and would like staff to provide him/her with two showers per week.5. Review of Resident #7's face sheet showed:-admission date of 04/12/25;-Diagnoses included bipolar disorder (manic-depression) and diverticulitis (inflammation or infection of pouches in the intestines) with perforation of the small and large intestine.Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact and required supervision or touching assistance of staff with toileting hygiene and showers.During an interview on 09/22/25, at 1:45 P.M., the resident said he/she had gone up to two weeks without a shower, and frequently went a week without a shower, but would like a shower daily. The resident said he/she felt dirty and oily when he/she did not get a shower.6. During an interview on 09/22/25, at 1:24 P.M., Certified Medication Technician (CMT) K said the following:-The facility had not had a designated shower aide for approximately two and a half weeks;-The CNAs were trying to complete some of the resident showers, but staff were unsure which residents needed showers;-The facility did not have a shower list, when staff completed a shower, they documented in the electronic health record;-Some of the residents complained they had not been assisted with a shower in three weeks;-Staff should document any completed showers in the resident's electronic health record.During an interview on 09/22/25, at 11:27 A.M., Registered Nurse (RN) C said the following: -Staff informed the nurse the facility did not have a specific shower aide;-The CNAs were talking about trying to complete some showers earlier that day, but was unsure if they had completed any showers;-He/she thought the facility had a shower book but was unsure of the resident shower schedule.During an interview on 09/22/25, at 11:38 A.M., Certified Nurse Aide (CNA) H said the following:-The facility had a designated shower aide until approximately two weeks prior when management moved the shower aide to work the floor;-The facility no longer had a designated shower aide, and the CNAs did not have time to assist residents with showers on a regular basis;-Residents were waiting over a week for assistance with showers;-Management said they would help the CNAs with shower, but he/she had not seen that happen;-He/she thought the shower aide had a paper shower schedule and staff were supposed to document any showers given in the electronic health record under the care tasks.During an interview on 09/22/25, at 12:10 P.M., CNA I said the following:-The CNAs were not able to complete resident showers on a regular basis;-In the past, the facility had a designated shower aide, and he/she was able to complete resident showers, but the new company that took over the facility said the residents did not need a designated shower aide;-The workload was too heavy to complete all resident showers;-The aides did not know which residents needed showers or when staff last gave the residents a shower;-Staff were trying to guess which residents needed a shower, if they did have time to give a few showers;-The shower aide had a binder, but the facility pulled the shower aide from that position approximately two to three weeks ago;-Some of the residents were complaining about not getting showers;-Staff were supposed to document resident showers in the electronic health record.During an interview on 09/22/25, at 12:27 P.M., CNA J said the following:-Approximately two weeks ago, the facility lost their shower aide;-Management expected the CNAs to complete resident showers, but the CNAs did not have time, because they had to get residents up and down from bed, change incontinent residents, take the residents outside to smoke, and assist the residents with other cares;-Several of the residents were complaining about not getting their showers on a regular basis, some of the residents had gone over a week without a shower.-Staff were unsure who had been showered and who had not;-Staff were supposed to document showers in the electronic health record; -Some of the residents have gone over a week without a shower.During an interview on 09/22/25, at 3:45 P.M., the Social Services Director (SSD) said the following:-Several of the resident have complained about not getting showers or shower assistance;-He/she reported the issue to nursing when residents complained to him/her about not getting a shower.During an interview on 09/23/25, at 11:50 A.M., the Senior Director of Regulatory Affairs (Registered Nurse (RN) E) said the following:-Today was his/her second day at the facility;-One of the other corporate nurses informed RN E he/she completed a resident shower schedule for staff and reported the CNAs were supposed to complete all showers for the residents on their assigned halls;-Residents should have at least two showers per week or per their preference.During an interview on 09/24/25, at 11:35 A.M., Licensed Practical Nurse (LPN) F said the following:-The aides should chart showers in the point of care (POC) section of EHR;-He/she said the aides were responsible for assisting the residents on their assigned halls with showers;-He/she was unsure what type of shower schedule the staff were supposed to use.During an interview on 09/24/25, at 12:20 P.M., the Chief Nursing Officer for the facility's corporation said the following:-Staff should document showers given in POC section of the electronic health record;-Residents should be offered two showers per week, unless requested otherwise.During an interview on 09/24/25, at 12:48 P.M., the Administrator said the following:-The facility's plan for completing showers was decided daily, if the facility had extra aides working on day shift, then he/she expected staff to try to assist residents with showering;-The facility had or should have a shower schedule somewhere;-He/she was unsure where the shower schedule was located or who was responsible for making a shower list;-He/she had not created a resident shower schedule;-Staff should complete residents showers;-He/she would like to see staff assisting residents with showers two times per week.Complaint 2621753

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for each resident when staff did not address one resident's (Resident #7's) colostomy (a surgical procedure that creates an opening, called a stoma, on the abdomen to allow stool and gas to exit the body when the colon cannot), open wound, or activities of daily living (ADL) needs on his/her care plan. The facility census was 43.Review of the facility policy titled, Baseline Care Plan Policy, dated 05/28/24, showed the following:-The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care;-The care plan will be developed within 48 hours of admission;-Interventions shall be initiated that address the resident's current needs including any health and safety concerns to prevent decline or injury, such as elopement, fall or pressure ulcer risk; any identified needs for supervision, behavioral interventions, and assistance with activities of daily living; and any special needs such as for wound care.1. Review of Resident #7's face sheet showed the following:-admission date of 12/29/24;-Diagnoses included bipolar disorder (manic-depression) and diverticulitis (inflammation or infection of pouches in the intestines) with perforation of the small and large intestine.Review of the resident's care plan, initiated on 01/09/25 and revised on 09/16/25, showed the following problem:-Resident at risk for falls related to weakness, balance deficit, and a history of falls;-Intervention of refer to therapy as needed for evaluation.(Staff did not address any other problems/interventions on the resident's care plan.) Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 06/18/25, showed the following:-Cognitively intact;-Required wheelchair for mobility device;-Required supervision or touching assistance of staff with toileting hygiene and showers;-Resident had a colostomy, was continent of bladder, and always incontinent of bowel;-At risk of development of a pressure ulcer;-Presence of a surgical wound.Review of the resident's care plan showed facility staff did not address the resident's colostomy care, open abdominal wound, or need for staff assistance with activities of daily living including showers. Observations on 09/22/25, at 1:45 P.M., showed the resident lay on his/her bed. The resident said his/her abdominal bandage needed to be changed. A certified medication tech (CMT) pulled up the resident's shirt, exposing a colostomy bag with feces present attached to the resident's left lower abdomen. The CMT pulled back a loose dressing on the resident's mid-upper abdomen revealing an open abdominal wound with thick, yellow drainage present.During an interview on 09/22/25, at 3:45 P.M., the Social Service Director (SSD) said the following:-He/she used to attend resident care plan meetings, but approximately two to three months ago, the facility stopped having care plan meetings and facility staff stopped updating the resident care plans;-The meetings stopped because the former Director of Nursing (DON) refused to come to the meetings, stating he/she did not have time to attend;-When the facility had a care plan meeting and the resident or his/her family attended, they usually asked clinical questions, but the SSD did not know the answers;-He/she informed the previous Administrator of the issue, approximately two months ago. The Administrator said he/she would make sure a nurse attended the care plan meetings, but that did not happen;-As a result, the facility staff stopped having the meetings;-The SSD looked for a care plan for the resident and said the care plan related to falls was the only care plan he/she had for the resident;-Staff should have a comprehensive care plan for the resident addressing each of his/her problems with specific staff interventions.During an interview on 09/23/25, at 11:50 A.M., the Senior Director of Regulatory Affairs, (Registered Nurse (RN) E) said the following:-The facility did not currently have staff completing care plans, but he/she thought a regional corporate person planned to start working on resident care plans;-He/she was unsure if staff had completed recent resident care plans;-Each resident should have a care plan meeting quarterly, and the care plan should address any open areas to the resident's skin and colostomy care.During an interview on 09/24/25, at 11:35 A.M., Licensed Practical Nurse (LPN) F said the following:-If the nurse aides had questions about a resident's care needs, they looked at the resident's care plan;-The facility should ensure each resident's care plan addressed the resident's care needs and should update the care plans as needed;-The facility should ensure the resident's care plan addressed a resident's open wound or a resident with a colostomy.During an interview on 09/24/25, at11:50 A.M., CMT G said the following: -Facility staff had access to the resident care plans;-The facility should ensure the care plans were updated to include resident showering preferences and how much assistance the resident required from staff;-Facility staff should ensure the care plan included information regarding any open wounds and care of a colostomy.During an interview on 09/24/25, at 12:48 P.M., the Administrator said the following:-The facility should have quarterly care plan meetings with residents and or families, if they choose to attend;-The Administrator said he/she was aware the facility did not currently have a clinical person to attend/participate in the care plan meetings;-The Administrator said the new corporation was basically starting from scratch with new staff.

Based on observation, interview, and record review, the facility failed to timely and adequately assess and treat one resident (Resident #1) with a toe and skin injury, when staff did not complete skin assessments weekly, did not timely obtain a mobile X-ray of the resident's foot as ordered by the physician, and when staff administered antibiotics to the resident, despite a listed allergy to the antibiotic. The facility census was 43.Review of the facility policy titled, Clean Wound Dressing Change Policy, dated 05/18/24, showed it is the policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify type of dressing and frequency of changes.Review of the facility policy titled, Skin Assessment, dated 06/26/24, showed the following:-It is policy to perform a full body skin assessment as part of the systematic approach to pressure injury prevention and management. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury;-Documentation of skin assessments include date and time of the assessment; nurse's name and position title; documentation of observations (skin conditions, how the resident tolerated the procedure, etc.); documentation of the type of wound; describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain); documentation if the resident refused the assessment and why; and document other information as indicated or appropriate.1. Review of Resident #1's face sheet showed:-admission date of 01/24/24 and re-admission date of 03/23/25;-Allergic to sulfa antibiotics, blackberries, peanut butter, and iodine;-Diagnoses included chronic kidney disease, stage 4 (severe), blindness in one eye, major depression, and general anxiety disorder;-Recent diagnosis of diabetic foot ulcer and open wound right foot (09/16/25).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 06/04/25, showed the following:-Cognitively intact.-Required wheelchair for mobility device;-Required supervision or touching assistance of staff upper and lower body dressing;-Required partial to moderate assistance of staff with showering;-At risk for development of a pressure ulcer.Review of the resident's care plan, initiated on 04/03/24 at revised/cancelled on 12/02/24, showed the following;-At risk for impaired skin integrity related to weakness and needing assistance for mobility;-Staff to complete weekly skin assessment per schedule.Review of the resident's August 2025 Treatment Administration Record (TAR) showed the following;-Weekly skin assessment every Tuesday;-Nurses initialed completion of the weekly skin assessment on 08/05/25, 08/12/25, 08/19/25, and 08/26/25 as ordered.Review of the resident's September 2025 TAR showed the following:-Weekly skin assessment every Tuesday;-On 09/02/25, a nurse initialed completion of the weekly skin assessment (one time during the month).Review of the resident's progress notes, dated 09/01/25 to 09/14/25, showed staff did not document skin assessment(s) completed for the resident. Review of the resident's progress note dated 09/15/25, at 12:29 P.M., showed a nurse documented the nurse contacted the physician after the resident reported that his/her right foot was, Ran over by a wheelchair last Wednesday. Resident's right foot had swelling noted and was warm to touch. The nurse spoke with the clinic and was told to fax over any requests and the clinic would present the fax to the physician to see if something needed to be addressed. The nurse asked facility staff for a fax cover sheet and was told the fax machine was down and the facility was unable to send or receive faxes. Social services reported he/she could email the physician clinic with medical concerns.Review of the resident's progress note dated 09/15/25, at 4:02 P.M., showed a nurse documented received a verbal physician's order for an X-ray of the resident's right foot. The nurse placed the order in the electronic health record (EHR). The nurse spoke with facility staff, including the regional nurse, about the order and placed the order into the EHR imaging section.Review of the resident's progress note dated 09/16/25, at 12:20 P.M., showed the following order note:-The system has identified a possible drug allergy for the following order: Bactrim DS (an anti-infective) oral tablet 800/160 milligram (mg). Give one table by mouth two times a day for pain related to personal history of diabetic foot ulcer for seven days.Review of the resident's progress notes showed staff did not document addressing the resident's foot/toe ulcer, the order for X-ray, or use of antibiotic Bactrim DS on 09/17/25 or 09/18/25.Review of the resident's September 2025 Medication Administration Record (MAR) showed staff documented administration of Bactrim DS 800/160 mg one tablet on 09/17/25 at 3:00 P.M., on 09/18/25 at 7:00 A.M., and on 09/18/25 at 3:00 P.M.Review of the resident's progress notes, dated 09/19/25, showed nurses documented the following:-At 3:02 A.M., the resident had a sore on his/her right fourth toe. The resident's right fourth toe was very warm, swollen, and red, extending up the resident's foot and into the resident's shin. The resident reported his/her toe was ran over by another resident in a wheelchair. X-ray ordered and X-ray technician to be out on 09/19/25 for the X-ray. Order for Bactrim DS (an antibiotic) with a stop date of 09/24/25. No adverse reaction, the resident remains afebrile (without fever);-At 4:32 A.M., the resident's family member came to the nurse about the resident's foot and said the resident's foot was ran over by another resident in a wheelchair, X-ray was ordered and was supposed to have been completed today. The resident has an allergy to sulfa medications, and the last time the resident was given sulfa medication, he/she ended up in the hospital with kidney issues. The nurse sent a message to the resident's physician. Nurse held medication until physician clarification;-At 9:55 A.M., the facility started the resident on Keflex (an antibiotic) 500 mg by mouth for foot wound. The nurse practitioner rounded on the resident and placed a gauze bandage and a sock on the resident's toe. The nurse encouraged the resident to elevate his/her foot. The resident's vital signs were stable;-At 12:40 P.M., placed an order for Keflex 500 mg three times a day for 10 days for infection to the resident's right fourth toe;-At 6:40 P.M., Mobile X-ray obtained an X-ray of the resident's right foot.Observation and interview of on 09/19/25, at 4:30 P.M., showed the following:-The resident sat in the dining room in a wheelchair awaiting supper;-The resident said he/she had a concern with his/her toe;-The resident said another resident in a wheelchair accidentally ran over the resident's toe and he/she had reported to the nurses every day for the last several days and they said they would get an X-ray of his/her foot, but that had not happened;-The resident said his/her right foot hurt all the way into his/her calf.-The resident lifted his/her pant legs slightly and his/her right lower leg appeared swollen and slightly reddened;-The resident then removed his/her right sock to expose a swollen right foot with an open dark area to the end of his/her right fourth toe at the nail bed and the entire toe appeared purple and swollen.Observation on 09/19/25 at 5:20 P.M., showed the mobile X-ray technician arrived at the facility to obtain the resident's foot X-ray. (Four days after facility staff initially received the X-ray order.)Review of the resident's September 2025 MAR showed an order dated 09/19/25, at 6:00 A.M., for cephalexin (Keflex), staff to give 1 tablet by mouth three times a day at 6:00 A.M., 1:00 P.M., and at 10:00 P.M., for infection in right foot fourth toe for 10 days. The administration documentation showed staff documented the following:-On 09/19/25, at 6:00 A.M. and 1:00 P.M., staff documented a 14 indicating awaiting medication;-On 09/19/25, at 10:00 P.M., staff documented administration of the medication;-On 09/20/25, at 6:00 A.M., staff documented a 14 indicating awaiting medication;-On 09/20/25, at 1:00 P.M., staff documented administration of the medication.Review of the resident's September 2025 TAR showed an order, dated 09/20/25 and discontinued on 09/21/25, for staff to cleanse the resident's right foot fourth toe with wound cleanser, cover with a dry dressing, secure with tape, and change every day. The administration documentation showed staff initialed completion of the treatment on 09/20/25.Review of the resident's progress notes, dated 09/20/25, showed the following:-At 5:30 P.M., (late entry) the resident reported that another resident ran over his/her right foot with a wheelchair on accident. The resident was on antibiotics for the resident's fourth toe. The resident had 2 black spots on his/her toe, with green puss and the resident's skin was sloughing off his/her toe, the top of the resident's foot was swollen, red, and warm to the touch. The resident complained of severe pain of his/her foot. The resident and family member requested the facility send the resident to the hospital for evaluation and treatment;-At 7:08 P.M., the resident returned to the facility via emergency medical services (EMS). The resident's family member said the hospital did not do anything for the resident at the hospital in local hospital. The family member requested the facility send the resident to a larger hospital in the area. The nurse contacted the resident's physician and obtained an order to send the resident to the hospital of the family's preference. The nurse contacted EMS, and they transported the resident to the hospital of the family's preference.Review of the resident's September 2025 MAR showed staff document the following regarding the order for cephalexin :-On 09/20/25, at 10:00 P.M., and on 09/21/25, at 6:00 A.M., staff documented a 6 indicating the resident was hospitalized ;-On 09/21/25, at 1:00 P.M., staff began consistent documentation of administration of the antibiotic.Review of the resident's progress note dated 09/21/25, at 4:43 P.M., showed the resident was at the hospital and returned and received new orders for treatment to right fourth toe.Review of the resident's September 2025 TAR showed an order, dated 09/20/25 and discontinued on 09/21/25, for staff to cleanse the resident's right foot fourth toe with wound cleanser, cover with a dry dressing, secure with tape, and change every day. The administration documentation showed staff documented completion of the treatment on 09/21/25. Review of the resident's emergency room discharge instructions, dated [DATE], showed the following:-Diagnoses of diabetes, foot trauma, and toe fracture;-Follow up with appointments with the podiatrist;-An order for cephalexin 500 milligrams by mouth three times per day;-An order for doxycycline (an antibiotic) 100 mg by mouth twice daily for 10 days.Review of the resident's September 2025 TAR showed an order, dated 09/21/25, for ceftriaxone sodium injection solution, inject 1 gram intramuscularly at bedtime for right fourth toe infection for 3 days. Staff documented administration of the medication on 09/21/25, 09/22/25, and on 9/23/25, as ordered.Review of the resident's September 2025 TAR showed an order, dated 09/22/25, to cleanse the resident's right fourth toe with wound cleanser, pat dry with gauze, apply calcium alginate silver (helps with healing), and cover with gauze, change the dressing every 3 days and as needed if soiled. Staff documented completion of the treatment one time, at 5:00 A.M. on 09/22/25.Review of the resident's progress note dated 09/23/25, at 2:59 A.M., showed the following:-Wound to toe on right foot, warmth, redness, exudate (drainage), black, necrotic (dead) tissue;-Resident has had second dose of Rocephin (an antibiotic) and will complete that order on 09/23/25.Review of the resident's September 2025 TAR showed an order, dated 09/23/25 at 2:00 P.M., to cleanse the resident's right fourth toe with wound cleanser, pat dry with gauze, apply calcium alginate silver, and cover with gauze, change the dressing two times per day and as needed if soiled. Staff documented completion of the treatment on the evening shift on 09/23/25 and on the day shift on 09/24/25.During an interview on 09/19/25 at 4:41 P.M., Licensed Practical Nurse (LPN) L said the following: -The resident reported his/her toe injury to the nurse this morning and asked the nurse earlier in the day, when the mobile X-ray company would arrive to X-ray his/her foot;-The Nurse Practitioner (NP) came in today and the nurse asked the NP to look at the resident's toe/foot;-The NP examined the resident's foot and placed a gauze dressing on the resident's toe and gave an order for a dry dressing to be applied to the resident's toe daily;-The nurse called the mobile X-ray company and notified the company of the resident's X-ray order and prepared the paperwork for the X-ray company.During an interview on 09/19/25, at 5:02 P.M., the resident's family member said the following:-He/she was the resident's responsible party;-The resident reported on 09/14/25 or 09/15/25, one of the other resident's backed over his/her toe in a wheelchair;-The resident spoke to the nurses each day this week about needing an X-ray;-The family member was worried about the condition of the resident's toe.During an interview on 09/22/25, at 4:42 P.M., Certified Medication Technician (CMT) B said the following:-He/she was unsure why the facility delayed in obtaining an X-ray of the resident's foot;-The resident had asked the nurse to do a treatment to his/her toe, but was still waiting on his/her treatment;-The hospital reported the resident's toe was broken.Observation and interview on 09/22/25, at 5:28 P.M., showed the following:-Registered Nurse (RN) C removed the dressing from the resident #1's right fourth toe;-The nurse described the appearance of the resident's toe as macerated (white appearance from prolonged moisture) toe, with the toenail coming loose at the base, and an open necrotic (blackened, dead tissue) area to the underside of the toe, approximately 1.0 centimeter in size with no drainage or odor present;-The nurse said the resident asked earlier in the day for the nurse to change the dressing, but the nurse did not have time until now. During an interview on 09/22/25, at 6:00 P.M., LPN D said the following:-He/she recently came back to work for the facility and worked three to four shifts in the past week; -He/she determined nurses were not completing the resident wound assessments and were not consistently completing the resident skin assessments;-Over the weekend, 09/20/25 to 09/21/25, he/she attempted to identify residents with open wounds and measure the wounds, but was unsure where to document the measurements;-He/she had not documented the wound assessments in the resident's EHR;-He/she was unable to determine if resident 'swounds were better or worse, due to not being able to find recent wound or skin assessments in the medical records;-He/she was unsure who was responsible for wound assessments in the past, but did not think the facility staff were completing the wound assessments;-He/she sent the resident out to the hospital over the weekend due to his/her right fourth toe had a black area on the underside and the toe was draining yellow and green odorous drainage.During an interview on 09/23/25, at 11:50 A.M., the Senior Director of Regulatory Affairs (RN E) said the following:-When the physician ordered an X-ray, facility staff should contact the mobile X-ray company the same day. The resident should have his/her X-ray the day ordered or the next day, if ordered late in the day;-He/she did not think the facility had completed weekly skin or wound assessments consistently.During an interview on 09/24/25, at 11:35 A.M., LPN F said the following:-He/she was the charge nurse for the day;-He/she was unsure who was responsible for resident skin assessments;-The nurses were responsible for completing wound treatments;-If the physician or NP ordered an X-ray, the facility should ensure completion of the X-ray within 24 hours.During an interview on 09/24/25, at 11:50 A.M., Certified Medication Tech (CMT) G said the following:-On 09/18/25, the resident's family member was looking at the resident's toe and asked the CMT to look at the toe;-The CMT said the resident's toe looked like a chewed up hot dog. The toe was swollen, the top of the toe appeared white in color and the underside was open;-The physician started the resident on antibiotics that same day.During an interview on 09/24/25, at 12:48 P.M., the Administrator said the following:-He was unsure who was responsible for completing for weekly skin assessments;-Nurses should obtain physician ordered X-rays within 24 hours.Complaint #2621753

Based on interview and record review, the facility failed to ensure a licensed Administrator was available to the facility, that staff were aware of who the Administrator was, and that the Administrator was aware of and involved in the day-to-day happenings of the facility. This resulted in the facility not having sufficient staffing scheduled and available on-hand to ensure proper care resulting in multiple residents being left wet for extended periods of time; in staff not having access to administer ordered insulin and pain medications; allowing an unlicensed driver to transport residents; and failing to provide protective oversight of residents after a staff member was allowed to return with an investigation of allegations of misappropriation against a staff member ongoing. The facility census was 44. The Administrator was notified on 09/08/25, at 2:18 P.M., of an Immediate Jeopardy (IJ) which began on 09/08/25. The IJ was removed on 09/08/25 as confirmed by surveyor on-site verification. Review showed the facility did not provide a policy related to the Administrator.1. Review of the Former Administrator's license showed the Administrator was not licensed in Missouri. Review of the Board of Nursing Home Administrator's records showed there was no Temporary Emergency Administrator License issued for the facility. During an interview on 09/07/25, at 10:30 A.M., the former Administrator said the following:-He/she was hired on 09/02/25;-He/she did not have a Missouri Administrator license;-He/she was supposed to have someone over him/her, but had never met that person and did not know that person's name.During an interview on 09/09/25, at 2:10 P.M., the Former Administrator said he/she was the Administrator until he/she was terminated on 09/07/25.During an interview on 09/10/25, at 8:26 A.M., the Business Office Manager (BOM) said he/she could not provide a Missouri Administrator License for the former Administrator because the former Administrator only had a license for Arkansas. 2. During an interview on 09/08/25, at 10:49 A.M., the Corporate Operating Officer (COO) said there was an Administrator who was took over after 08/31/25. The Former Administrator was an interim and did not have a Missouri Administrator License yet. The Former Administrator should have had the current Administrator's contact information. During an interview on 09/08/25, at 2:16 P.M. and 2:38 P.M., the Administrator said the following:-He/she was licensed in Missouri;-He/she was the Administrator as of 09/08/25, at 8:00 A.M. and arrived at the facility at 10:00 A.M.;-He/she did not know whose name was listed as the Administrator;-He/she had not heard anything related to the misappropriation allegations.During an interview on 09/08/25, at 2:40 P.M., the Regional Director of Operations (RDO) said he/she could not confirm who the Administrator was for the facility.2. Observation, interview, and record review showed the facility failed to provide routine drugs and biologicals to its residents when the facility failed to ensure nursing staffing had access to and the ability to administer insulin to three residents (Resident #5, # 6, and #7). Observation, interview, and record review showed the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences when the facility failed to ensure pain medication was administered as needed to one resident (Resident #4) who displayed signs of untreated pain. During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-He was not aware residents were not receiving their medication;-He was not familiar with the medication dispensing system, but access should have been provided to nurses prior to starting their shifts. If the nurses did not have access or the ability to perform their jobs, they should have contacted him.3. Interview and record review, showed the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety and allow residents to maintain their highest practicable physical, mental, and psychosocial well-being, when the facility failed to maintain a nursing schedule that provided sufficient staff on-site to assist all residents resulting in nurses working over 24 shifts, lack of staff on-site to meet the needs all residents, and the building left unattended for a short period of time. This resulted in residents being left wet for an extended period of time and in residents feeling concern regarding their well-being. During an interview on 09/09/25, at 10:50 A.M., the Administrator said the following:-The facility was actively recruiting staff for nursing;-The facility had a contract with a staffing agency, but they were not going to use the agency unless they had an emergency with staffing. He/she did not feel the facility had a staffing emergency at the time.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-He/she was getting nursing staffing covered, but the facility did not have enough staff so he/she was bringing staff from other facilities to assist;-Two staff was not enough to care for the residents at night;-He/she had worked on a schedule since he/she arrived on 09/08/25 and all staff were instructed to get with the Regional Nurse Consultant (RNC) about their schedules.4. Based on observation, interview, and record review, the facility failed to prevent any future potential abuse, neglect, exploitation, or mistreatment while an investigation of misappropriation was in progress, when the facility allowed one staff member (RN A) to return to the facility to work as the only nurse on duty causing one resident (Resident #1) to be fearful of retaliation and taking steps to leave the facility due to the fear. During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-If a staff member was accused of misappropriation, they were suspended pending an investigation;-The staff member should not have access to the resident;-Resident #1 was not protected when RN A was allowed back into the facility on [DATE].5. Interview and record review, \showed the facility failed to provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility, when the Transport Driver transported four residents (Resident #1, #9, #11, and #12) in the facility's van to physician appointments when his/her driver's license was suspended. During an interview on 09/08/25, at 6:43 P.M., the BOM said when he/she found out about the transport driver's license being suspended, he/she had no one to tell, because there was no Administrator at that time and the Administrator was the transport driver's supervisor.6, During an interview on 09/08/25, at 10:06 A.M., Housekeeper (HK) U said the facility had an Administrator (Former Administrator), but he/she was let go last night and he/she did not know if the facility had a new Administrator.During an interview on 09/08/25, at 10:42 A.M., the HK Supervisor said the facility did not have an Administrator at this time.During an interview on 09/08/25, at 1:03 P.M., Licensed Practical Nurse (LPN) C said the following:-The facility's old Administrator's last day was 08/29/25;-He/she found out they had a second Administrator other than the Former Administrator when the state surveyor entered on 09/07/25, but had never seen another Administrator.During an interview on 09/08/25, at 7:12 P.M., LPN E said he/she believed the Former Administrator was the Administrator.During an interview on 09/09/25, at 12:10 P.M., LPN D said the Former Administrator had left and now he/she did not know who the new Administrator was.During an interview on 09/10/25, at 11:04 A.M., the Medical Director said the Administrator for the facility should be licensed in Missouri.NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the E level.Complaints #2610146, #2610182, and #2611677

Based on observation, interview, and record review, the facility failed to prevent any future potential abuse, neglect, exploitation, or mistreatment while an investigation of misappropriation was in progress, when the facility allowed one staff member (RN A) to return to the facility to work as the only nurse on duty causing one resident (Resident #1) to be fearful of retaliation and taking steps to leave the facility due to the fear. The facility census was 44. The Administrator was notified on 09/08/25, at 2:18 P.M., of an Immediate Jeopardy (IJ) which began on 09/08/25. The IJ was removed on 09/08/25 as confirmed by surveyor on-site verification. Review of the facility's policy titled Abuse and Neglect Policy, revised 06/12/24, showed the following:-The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification. investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences;-The facility will protect residents from harm during an investigation;-When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: The Licensed Nurse will respond to the needs of the resident and protect him/her from further incident and remove the accused employee from resident care areas;-The Administrator or designee will suspend the accused employee pending completion of the investigation;-The Facility will take steps to prevent mistreatment while the investigation is underway;-Employees of this Facility who have been accused of mistreatment will be immediatelyremoved from contact with any residents and must leave the Facility pending the results of the investigation and review by the Administrator. If the alleged abuse is by the Administrator or Director of Nursing (DON), at the direction of the Executive [NAME] President/Chief Operating Officer or the [NAME] President for Operations, the Administrator or DON may remain at the facility, but are only permitted to be in non-resident areas or his/her office and should have no resident contact pending the outcome of the investigation;-Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home.1. Review of Resident #2's face sheet (brief look at resident information) showed the following information:-re-admission date of [DATE];-Diagnoses included dementia, high blood pressure, Alzheimer's disease, and pain.Review of the resident's Electronic Medical Record (EMR) showed an incident report for Diversion of Medications, dated 09/03/25, at 9:00 A.M. The Regional Nurse Consultant (RNC) documented the following information:-On 09/02/25, the former DON/Registered Nurse (RN) A asked the night shift nurses to come in at approximately 3:30 P.M. Registered Nurse (RN) B and Licensed Practical Nurse (LPN) C entered the building and noted RN A was not in the building. RN B and LPN C did not receive report and were given the medication cart keys by a non-nurse staff member. At this time, staff noted there had been several narcotic medications that were printed from the medication dispensing machine, that were unaccounted for. No medications were accounted for from med passes on 09/02/25. The process was to dispense the medications for the day and then fill the cart. Not only were medications unaccounted for, but there was also medications that were dispensed that were not ordered for residents. Dispense record indicates that two hydrocodone/acetaminophen 5-325 mg tablets were dispense as scheduled daily, but when RN A was on duty, she was dispensing six hydrocodone/acetaminophen 10-325 mg tablets, although there was no reason for the four extra tablets to have been dispensed;-RN A provided controlled substance destruction logs, but the Former Administrator noted that RN A scribbled on the paper prior to handing it to her;-There were still at least 26 hydrocodone/acetaminophen tablets that were unaccounted for at this time in the investigation;-RN A was suspended pending investigation.During an interview on 09/07/25, at 3:46 P.M., the Former Administrator said RN A was placed on suspension pending investigation. 2. Review of Resident #1's face sheet showed the following:-admission date of [DATE];-Diagnoses included chronic obstructive pulmonary disorder (COPD - a group of lung disease that make it hard to breathe), congestive heart failure (CHF - a chronic condition in which the heart does not pump blood as it should), and irregular heartbeat.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 06/26/25, showed the resident was cognitively intact.Review of the facility's Misappropriation of Funds Investigation, dated 09/04/25, showed the following:-At approximately 6:15 P.M., the resident approached the Former Administrator and said the former DON/RN A had asked him/her for money on several occasions;-The resident said that about two months ago, RN A had requested $540.00 dollars from him/her;-The resident said RN A took him/her to the store, and he/she used the ATM to get the RN $200.00, not the full $540.00;-The resident said he/she used a mobile payment app to send the RN money per the RN's request on several other occasions;-The resident also indicated the RN's child was playing with his/her iPad and broke it, shattering the screen;-The resident indicated that RN A told him/her that he/she would pay him/her back, and now the resident indicated he/she felt used and taken advantage of;-Immediate action indicates RN was already on suspension following another incident.Review of the resident's Psychosocial Post-Incident Impact Questionnaire dated 09/04/25, at 11:28 P.M., showed the following:-No coping skills identified. The resident said he/she does not feel he/she was being taken advantage of at the time of in the incident, but felt like it when she later realized he/she was taking advantage of;-The resident [NAME] like he/she should not trust anyone with his/her money now;-The resident felt safe to report due to RN A not being in the building due to a previous suspension.Review of the resident's care plan, revised 09/04/25, showed the resident was at risk for financial exploitation related to cognitive impairment and dependence on others for financial management. Education on abuse, neglect, misappropriation, and exploitation provided to the resident.During an interview on 09/09/25, at 2:09 P.M., the Former Administrator said the following:-On 09/04/25, RN A was suspended for misappropriation of narcotics, later that night Resident #1 and LPN D came into her office and the resident reported to her that RN A had also taken money from him/her;-RN A would drive the resident to the store and have the resident withdraw money for him/her, in addition to several mobile cash app transactions;-After seeing the resident's bank statements and app transactions, she determined RN A needed to be terminated and did so on 09/05/25.During an interview on 09/07/25, at 1:12 P.M., the resident said the following:-He/she loaned the former DON/RN A around $500.00 over a course of four months starting in July 2025;-RN A was aware the resident got a large back check from social security, so the RN started to ask the resident for money to help with bills, kids sports, and food to feed his/her kids. The resident said he/she had a heart and hearing that made him/her feel horrible to the point he/she could not say no;-RN A frequently brought his/her children to work, who also entered the resident's room and broke his/her tablet;-RN A said he/she would pay him/her back;-The first payment to RN A was via cash. RN A took him/her to the store and the resident pulled out $200.00 cash for RN A. He/she believed this happened maybe two times;-The rest of the transactions were through a mobile payment app that allowed users to send and receive money;-Recently RN A was placed on suspension for misappropriation of narcotics (also known as opioids - a class of drugs that interact with opioid receptors in the brain to produce pain relieving properties), which is when he/she felt safe enough to tell another nurse about the money that had been given to him/her;-After telling the nurse, the Former Administrator came and talked with him/her and went through his/her bank statements to determine the amount of money that had been sent to RN A. The determination was $850.00.Observation on 09/08/25, at 4:38 A.M., showed RN A working as the only nurse in the facility.Observation on 09/08/25, at 9:54 A.M., showed RN A sitting on the floor in the office of the Business Office Manager (BOM).During interviews on 09/08/25, at 10:05 A.M. and 3:38 P.M., the resident said the following:-RN A was back working in the building and he/she felt frightened;-He/she had his/her suitcase packed and had plans to leave the facility and find an apartment somewhere;-He/she was feeling mental anguish due to RN A taking money from him/her and then the corporation of the facility allowing RN A back into work;-He/she was afraid RN A would come into his/her room and confront him/her for telling;-RN A had came into his/her room and attempted to talk to him/her regarding taking the resident's money;-He/she did not feel safe at the facility.Observation on 09/08/25, at 10:54 A.M., showed RN A was observed to be the only nurse working in the facility.During an interview on 09/08/25, at 3:25 P.M., Resident #11 said he/she saw RN A attempt to talk to Resident #1 on this date.During an interview on 09/08/25, at 11:52 A.M., RN A said the following:-He/she was terminated for allegations of misappropriation of resident funds and diversion of medication on 09/04/25;-On 09/06/25, at 11:00 P.M., the owner of the facility called him/her and asked him/her if they gave him/her another chance would he/she mess it up and then asked him/her to come to work to relieve a nurse;-He/she arrived at the facility on 09/08/25, at 12:40 A.M.During an interview on 09/08/25, at 1:03 P.M., LPN C said the following:-Corporate staff had RN A relieve him/her on 09/08/25, but the RN was still under investigation for misappropriation of Resident #1's funds;-When RN A arrived, RN B told RN A to leave the building due to being under investigation for misappropriation and the Former Administrator told the RN to leave too;-He/she did not feel it was safe to leave RN A in the building due to misappropriation of the resident's funds;-He/she felt the resident suffered mental anguish because corporate brought the resident's abuser back in the facility.During an interview on 09/08/25, at 10:55 A.M., Certified Nurse Aide (CNA) N said the following:-On 09/08/25, at approximately 12:30 A.M., RN A entered the facility, and the Former Administrator and RN B told RN A he/she could not be in the facility;-The owner was on RN A's phone and directed the former Administrator and RN B to give RN A the keys and get out of the facility;-The residents appeared scared because RN A was there.During an interview on 09/09/25, at 12:10 P.M., LPN D said the following:-RN A was fired on 09/05/25;-When he/she heard that RN A was allowed back in the facility, he/she refused to come back in to work;-He/she felt Resident #1 was fearful of reporting RN A for misappropriation while the RN still worked in the facility.During an interview on 09/08/25, at 11:15 A.M., CNA O said RN A arrived at the facility on 09/08/25, at 12:00 A.M.During an interview on 09/09/25, at 2:10 P.M., the Former Administrator said the following:-He/she terminated RN A on 09/05/25;-He/she was upset when RN A walked in the facility on 09/08/25 and she told the owner that the RN was terminated and was currently under investigation.During an interview on 09/08/15, at 10:40 A.M., the Corporate Operating Officer (COO) said he was aware of some nursing staff issues. He had personally called the former DON/RN A and asked him/her to return to the building. He knew there was an investigation involving RN A, but did not know the outcome. He was not aware Resident #1 was fearful of RN A. He said it was his decision to bring RN A back.During an interview on 09/08/25, at 11:04 A.M., the Regional Director of Operations (RDO) said he/she spoke with the Former Administrator the day before regarding the home. He/she was aware of some staffing challenges. He/she was aware the former DON/RN A had allegations of misappropriation against him/her. RN A had not been cleared, and the investigation was still ongoing. They typically do not bring accused staff back until the investigation is over. During an interview on 09/10/25, at 8:27 A.M., the Social Services Designee (SSD) said the following:-The resident signed himself/herself out and went to another town to find another place to live;-The resident called the SSD on 09/09/25 at 9:31 P.M., and told the SSD that RN A called the resident;-The SSD told the resident to not tell the RN where the resident was;-The resident said he/she was fine, but it scared him/her when the RN called.During an interview on 09/08/25, at 3:05 P.M., Resident #4 said the following:-RN A should not be in the facility;-He/she was worried RN A could steal money from residents and was worried about the safety of the residents.During an interview on 09/08/25, at 10:06 A.M., Housekeeper (HK) U said the following:-If a staff member was accused of misappropriation they were suspended pending the investigation;-If the investigation showed the allegation to be substantiated, the staff member would not be allowed to come back to work;-When he/she arrived at the facility this morning (09/08/25), he/she saw RN A, who was an alleged perpetrator in an investigation in the building working.During an interview on 09/08/25, at 10:48 A.M., CNA P said when he/she arrived at work on 09/08/25, at 5:50 A.M., RN A was working. RN A was under investigation for misappropriation.During an interview on 09/10/25, at 11:58 A.M., Certified Medication Technician (CMT) J said he/she spoke with the resident and the resident was very upset that RN A was in the facility.During an interview on 09/08/25, at 10:55 A.M., CNA Q said the following:-When he/she arrived at work on 09/08/25, at 5:45 A.M., RN A and another CNA were the only staff that worked overnights;-The RN was under investigation for misappropriation of money from Resident #1. During an interview on 09/08/25, at 11:00 A.M., CNA L said when he/she arrived at work on 09/08/25, at 5:45 A.M., RN A was working in the facility.During an interview on 09/08/25, at 11:06 A.M., CNA S said when he/she arrived at work on 09/08/25, at 6:00 A.M., RN A was the nurse.During an interview on 09/09/25, at 2:49 P.M., CNA M said if an employee was accused of misappropriation, they should be suspended pending investigation not allowed to be in the facility.During an interview on 09/10/25, at 11:04 A.M., the Medical Director said he/she would not expect a staff member under investigation to be brought back to the facility unsupervised and the staff member should not have access to the resident.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-If a staff member was accused of misappropriation, they were suspended pending an investigation;-The staff member should not have access to the resident;-Resident #1 was not protected when RN A was allowed back into the facility on [DATE].Complaint #2608924, #2609968, #2609971, #2609989, #2609995, #2610122, #2610146, and #2610229NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level.

Based on interview and record review, the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety and allow residents to maintain their highest practicable physical, mental, and psychosocial well-being, when the facility failed to maintain a nursing schedule to ensure sufficient staff were on-site to assist all residents resulting in nurses working over 24 shifts, lack of staff on-site to meet the needs all residents, and left the building unattended for a short period of time. This resulted in residents being left wet for an extended period of time and residents feeling concern regarding their well-being. The facility census was 44 residents.Review of the facility's policy titled Sufficient Staff Policy, revised 05/18/24, showed the following:-It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment;-The facility will supply services in sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Except when waived, licensed nurses; and other nursing personnel, including but not limited to nurse aides (NA).1. Review showed the facility did not provide any working nursing staffing sheets or nursing staff schedule when requested for review.During interview on 09/07/25, at 10:30 A.M., the Former Administrator said the following:-As of 09/07/25, the facility had three nurses on staff and Registered Nurse (RN) B was the only RN;-RN B had been working for over 36 hours and felt he/she could not leave the facility, but was concerned for the resident's safety due to being tired;-The Former Administrator expressed this concern to corporate staff.During interviews on 09/07/25, at 12:42 P.M., and 09/08/25, at 1:03 P.M., Licensed Practical Nurse (LPN) C said the following:-He/she arrived at the facility on 09/06/25, at 5:15 A.M., and had no relief until he/she was terminated and had worked for over 30 hours;-He/she and RN B were fired on 09/08/25 and left the facility at approximately 1:50 A.M.;-When he/she and RN B left, Certified Nurse Aide (CNA) N, Nurse Aide (NA) T, and another CNA left as well. This left CNA O and RN A in the facility;-The facility census was 44 and should have at least three staff overnights for that census. Corporate was aware of how many staff were left in the building.-The facility had never completed staffing sheets, even when RN A was the Director of Nursing (DON). The only time he/she saw a staffing sheet prior to this was when state was in the building for a complaint;-They do not currently use agency staff;-No staff was actively making the schedule. Staff were just trying to call other staff for help as needed.During interviews on 09/07/25, at 2:42 P.M., and 09/08/25, at 10:55 A.M., CNA N said the following:-There were several days when he/she was the only CNA in the building, and he/she had to stay over due to no CNA coming in to cover for him/her;-He/she was not supposed to work on 09/07/25, but came in to help due to RN B and LPN C being so exhausted. He/she came in at approximately 5:00 P.M.;-The Former Administrator was on the telephone with the Regional Nurse Consultant (RNC) and Regional Director of Operations (RDO) attempting to get coverage for the nurses;-The LPN who was supposed to cover the night shift called in and another LPN had already resigned, but said they would come in if the company gave them a bonus;-The police department came to the facility due to multiple phone calls from residents related to their safety and the police department called the Department of Health and Senior Services (DHSS). The police contacted the owner and told the owner they needed to have a plan for nursing relief;-RN A came to the facility on [DATE], at approximately 12:30 A.M., and the owner told RN B, LPN C, and the Former Administrator they were fired and to give the keys to RN A;-The facility did not have a schedule and would just call staff in if they were shorthanded.During an interview on 09/08/25, at 11:15 A.M., CNA O said the following:-When he/she arrived at the facility on 09/07/25, at 10:00 P.M., LPN C and RN B had been working for 30 hours. CNA N, NA T, and another CNA were also in the facility;-NA T and another CNA said they would stay until 6:00 A.M.;-The CNA did not feel it was safe for LPN C and RN B to continue working, because they were so tired and could possibly pass the wrong medication;-The owner called and said he/she was going to send another nurse;-RN A came to the facility at approximately 12:00 A.M.;-The owner fired LPN C and RN B, because they refused to hand the keys over to RN A because RN A was under investigation for misappropriation of narcotic medication;-LPN C and RN B left the facility around 12:30 A.M. to 1:00 A.M. and CNA N, NA T, and the other CNA walked out at this time. This left him/her and RN A to care for the residents;-Some residents were still wet when day shift arrived, because he/she and the RN could not get them all changed. He/she and the RN tried the best they could, but call lights were hard to keep up with and residents were concerned about their safety and wanted to know what was going on;-RN A went outside to sit and then said he/she needed a drink and sent the CNA to the store leaving only the RN at the facility for approximately 10 minutes;-When the CNA returned, the RN sat in the RN's car and said he/she did not want any allegations against him/her. This meant no staff were in the facility for approximately 10 minutes;-The CNA gave the RN the drink and went in the facility to answer call lights;-The facility did not have a schedule for the nurses or CNAs so he/she did not know what his/her schedule was;-On 09/05/25 and 09/06/25, he/she had to stay over after the end of his/her shift because only one CNA came in to relieve him/her.During an interview on 09/08/25, at 11:52 A.M., RN A said the following:-On 09/07/25, the owner called him/her and asked him/her to work due to the nurse that was working had been at the facility for over 30 hours;-LPN C, RN B, CNA N, NA T, and another CNA left the facility around 1:55 A.M. and the Former Administrator left before that time. This left him/her and CNA O to care for the residents. The census was 44;-Two staff was not appropriate staffing for that many residents;-He/she cared for the residents the best he/she could;-He/she asked CNA O to go to the store and get him/her a drink around 2:00 A.M. and the CNA was gone for approximately 15 minutes;-He/she answered call lights while the CNA was gone;-He/she called the Social Services Designee (SSD) to come into the facility, because he/she did not want to have any more accusations against him/her;-When the CNA returned with his/her drink, he/she met the CNA outside. He/she was sitting outside when the CNA left to get the drink, but was not sitting in his/her car when the CNA returned;-When day shift aides arrived, it was brought to his/her attention that a few residents were left wet;-If the facility would have had sufficient staffing, the residents would have been cared for.During an interview on 09/08/25, at 11:06 A.M., CNA S said the following:-When he/she arrived on 09/08/25, at 6:00 A.M., he/she relieved CNA O. CNA O and RN A were the only staff in the building overnight;-Two staff was not enough to care for the residents;-Several residents were wet and soiled and had to have their bedding changed.During an interview on 09/08/25, at 10:55 A.M., CNA Q said the following:-When he/she arrived at the facility on 09/08/25, at 5:45 A.M., CNA O and RN A were the only staff that worked overnights. The CMT had just arrived as well;-Two staff were not enough to care for the residents overnight;-When he/she started rounds, all the residents were soaked and said they had not been changed since 2:00 A.M.;-CNA N and NA T were supposed to work overnights but walked out when LPN C and RN B were fired.During interviews on 09/08/25, at 11:00 A.M., and 09/10/25, at 8:46 A.M.,CNA L said the following:-When he/she arrived on 09/08/25, at 5:45 A.M., CNA O and RN A were the only staff that worked overnights;-Two staff was not enough to care for the residents;-The CNA believed three to four staff would be sufficient;-He/she did not know if any other staff were scheduled;-The facility did not have enough staff to care for the residents;-He/she was the shower aide and had not been able to give showers for two weeks due to having to work on the floor. During an interview on 09/08/25, at 10:48 A.M., CNA P said the following:-When he/she arrived at work on 09/08/25, at 5:50 A.M., he/she relieved CNA O;-CNA O and RN A were the only staff in the building overnight;-CNA N was supposed to work overnight, but walked out on his/her shift and left one CNA and one nurse in the building;-Two staff was not enough to care for the residents.During an interview on 09/08/25, at 10:05 A.M., Resident #1 said the following:-Last night, LPN C and RN B called the main office to get some staff to relieve them since they had worked 30 hours straight and the main office told them no;-The police department came and corporate fired LPN C and RN B and two aides that were here walked out too. This left no staff to care for the residents and if something happened they had no help;-RN A was at the facility, but was outside walking around the facility.During an interview on 09/08/25, at 3:05 P.M., Resident #4 said the following:-Last night RN B and LPN C attempted to hold it together with no relief;-Last night there was only one CNA in the building with RN A after RN B and LPN C were fired.During an interview on 09/08/25, at 6:11 P.M., Resident #6 said the following:-The facility did not have enough staff;-LPN C and RN B got fired on 09/08/25 at approximately 1:30 A.M. After they left, no staff were in the facility that he/she was aware of. The residents were left alone;-No staff came to change him/her all night and at 9:00 A.M. when staff did change him/her, he/she was wet and soiled, dripping wet and required a bed change. He/she filed a grievance about this;-He/she usually felt safe, but did not feel safe last night because he/she did not believe any staff were in the building to care for the residents and he/she did not get any sleep because of this.During an interview on 09/09/25, at 11:20 A.M., Resident #8 said the following:-He/she was scared the other night because all the staff walked out except for one;-The facility only had one staff in the building for about 5 hours. He/she was told this by CNA O, who was the CNA that night.During an interview on 09/09/25, at 3:59 P.M., Resident #9 said the following:-The other night when LPN C and RN B left and the aides all walked out with them, he/she could not get ahold of any staff;-He/she was concerned because if there was an emergency, there was no staff to take care of it.During an interview on 09/09/25, at 4:10 P.M., Resident #10 said the following:-The other night after RN B and LPN C were fired, there were no staff in the building;-He/she was not changed after the RN and LPN left and was left wet and soiled until day shift came in to change him/her.During an interview on 09/08/25, at 3:25 P.M., Resident #11 said a lot of residents were stressed out about not having a nurse.During interviews on 09/08/25, at 3:49 P.M., and 09/10/25, 12:00 P.M., the Business Office Manager (BOM) said the facility currently only had two nurses (Registered Nurse (RN) A and Licensed Practical Nurse (LPN) E) employed with the facility. He/she could not provide working staffing sheets because they had not been completed for a long time.During an interview on 09/09/25, at 12:10 P.M., LPN D said the following:-The facility did not have a nursing schedule and staff just went by when they were scheduled in the past;-At times, staff worked longer hours due to no staff came in to relieve them;-The facility used to have a working nursing staffing sheet and the night nurse completed it but they recently could not complete this because they had no schedule to go off of. He/she had not seen a daily staffing sheet for approximately a month.During an interview on 09/08/25, at 7:12 A.M., LPN E said the following:-The facility usually had three to four staff in the building at night;-It was not appropriate to only have two staff at night, because that was not enough to care for the residents and the residents would not get the care they deserved;-The facility had a schedule, but it switched off and on for who was responsible for making it. The night nurses had set schedules;-On 09/07/25, LPN C and RN B contacted him/her to come to work, but he/she was unable to due to a sick family member. He/she was scheduled to come in nights on 09/08/25, but already called in.During an interview on 09/10/25, at 11:58 A.M., CMT J said the following:-When he/she first started at the facility six months ago they had a schedule but after the staff member who was doing the schedule quit, they have not had one since;-Recently, he/she had not seen a schedule or a nursing staffing sheet;-The facility had a shortage of nurses and some nurses have worked for thirty plus hours.During an interview on 09/09/25, at 4:33 P.M., the Facility Physician said he/she was not aware that only two staff were left in the building overnight on 09/08/25. Two staff was not enough to care for the residents.During interviews on 09/10/25, at 11:04 A.M., and on 09/11/25, at 3:56 P.M., the Medical Director said the following:-He/she did not know the staffing requirements for 44 residents, but did not believe one nurse and one CNA was sufficient. He/she believed one more staff member added to this would be sufficient, but this depended on the level of care the residents' required;-Having only one staff in the building was not appropriate;-He/she was not aware that no staff was in the building on 09/08/25 for a short amount of time;-He/she expected the facility to have a schedule and a working staffing sheet.During an interview on 09/09/25, at 10:50 A.M., the Administrator said the following:-The facility was actively recruiting staff for nursing;-The facility had a contract with a staffing agency but they were not going to use the agency unless they had an emergency with staffing. He/she did not feel the facility had a staffing emergency at the time.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-He/she was getting nurse staffing covered, but the facility did not have enough staff, so he/she was bringing staff from other facilities to assist;-Two staff was not enough to care for the residents at night;-It was not appropriate for the RN to send the CNA for a drink during the night leaving only one staff in the building and the RN should have stayed in the facility;-He/she had worked on a schedule since he/she arrived on 09/08/25 and all the staff were instructed to get with the Regional Nurse Consultant (RNC) about their schedules.Complaint #2598186, #2609971, #2609968, #2609989, #2609995, #2610146, #2610182, and #2610229

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to all residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, when the facility failed to ensure staff had access to administer as needed pain medication as requested for one resident (Resident #4) who showed physical and verbal signs of pain. The facility census was 44. Review of the facility policy titled Pain Management, revised on 06/26/24, showed the following information:-In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and prevent or manage pain, the facility staff will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated, evaluate the resident's pain and the causes upon admission, during ongoing assessments, and when a significant change of condition or status occurs, and manage or prevent pain;-Facility staff will observe for nonverbal indicators of pain which may indicate the presence of pain;-Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain;-The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status;-Based upon the evaluation, the facility in collaboration with the physician will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain;-Pharmacologic interventions will follow a systematic approach to include; evaluating the resident's condition and pain regimen, administering medication around the clock versus as needed, reassess and adjust the medication dose;-Opioids will be prescribed and dosed in accordance with current professional standards to optimize their effectiveness and minimize their adverse consequences;-Facility staff will reassess the resident's pain management at established intervals for effectiveness.1. Review of Resident #4's face sheet showed the following information:-admission date of 03/23/25;-Diagnoses included chronic kidney disease, low blood pressure, and heart disease.Review of the resident's care plan, dated 12/02/24, showed staff to administer analgesic (a medication that relieves pain) medications as ordered by the physician.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 06/04/25, showed the following information:-Resident had intact cognition;-Resident took opioid medications;-Resident was not on a scheduled or as needed (PRN) pain regimen.Review of the resident's September 2025 Physician Order Sheet (POS) showed the following:-An order, dated 03/02/25, for dialysis (treatment that filters waste and excess fluid from the blood when kidneys are failing) three times a week on Tuesdays, Thursdays, and Saturdays;-An order, dated 03/02/25, to perform pain scale two times a day;-An order, dated 03/23/25, for acetaminophen (over the counter medication used to relieve pain) 325 mg, give two tablets every four hours as needed for general discomfort;-An order, dated 03/26/25, for tramadol HCL (a controlled substance and synthetic opioid analgesic used to treat pain) 50 milligram (mg) tablet, give one tablet by mouth every four hours as needed for pain.Review of the resident's assessment titled, Pain interview, dated 09/03/25, showed the following:-The resident had pain frequently;-The pain limited sleep and day to day activities;-There was a PRN pain regimen available of tramadol.Review of the resident's Pain Scale Assessment, dated 09/09/25, showed the following information:-The resident rated his/her pain on day shift pain at a level of 8 out of 10;-The resident rated his/her pain on night shift pain at a level of 8 out of 10.Review of the resident's September 2025 MAR showed the following information:-On 09/09/25, staff did not administer the resident's tramadol 50 mg tablet;-On 09/09/25, staff did administer acetaminophen 325mg two tablets at 5:00 A.M.Review of the resident's progress notes, dated 09/09/25, showed staff did not document regarding the resident's pain, steps taken to address the pain, or why tramadol was not administered. Observation and interview on 09/09/25, at 3:52 P.M., showed the resident appeared upset and in pain as he/she grimaced when talking about his/her pain. He/she normally takes a tramadol before he/she goes to dialysis. This morning, he/she was in pain, and he/she asked for his/her medication. The nurse said it was locked away where he/she could not get to it. The nurse gave him/her acetaminophen instead. It worked some, but not as good as the tramadol. The chairs were so uncomfortable at dialysis they make him/her hurt more, but it is more bearable when he/she gets the tramadol. His/her pain this morning was 8 out of 10.Record review of the resident's progress notes, dated 09/09/25, showed staff did not document physician or management notification related to not being able to access the medication. During an interview on 09/09/25, at 7:25 A.M., the Social Services Director (SSD) said the following:-She was aware the nurse on staff, Licensed Practical Nurse (LPN) F, was not given access to the medication dispensing machine so he/she could not pass medications;-The resident was supposed to have tramadol before he/she went to dialysis this morning and the nurse was unable to pull it;-The resident asked the nurse for this and was in reporting a pain level of 8 out of 10;-The nurse gave him/her acetaminophen since he/she did not have access to the tramadol.During an interview on 09/09/25, at 9:58 A.M., LPN F said the following:-He/she was unable to give the residents their medications last night and this morning due to not having access to the electronic medical records (EMR);-The resident did ask for a tramadol around 5:00 A.M. this morning related to pain rated at a 8 out of 10;-He/she typically does not work at the facility and was not provided any access for the EMR system and/or the medication dispensing system. Due to this fact, the resident was not able to have his/her pain medication today before his/her dialysis treatment. He/she did give the resident some acetaminophen, however. During an interview on 09/09/25, at 12:00 P.M., LPN D said the following:-He/she was not aware of any residents not receiving their medications while he/or she was on shift;-If a resident is exhibiting pain, pain should be assessed, and medication should be administered;-If medication is not effective the physician should be called for additional orders;-The resident always gets a tramadol before he/she goes to dialysis. If the nurse on duty yesterday, or this morning, did not have access, he/she would have not been able to administer the resident's medication.During an interview on 09/09/25, at 4:33 P.M., the facility physician said the following:-She would expect nurses to have access to the medication dispensing systems prior to starting their shifts;-If a resident was in pain, pain medication should be administered.Review of the resident's Pain Scale Assessment, dated 09/10/25, showed on the day shift the resident rated his/her pain level at 8 out of 10.Observation and interview on 09/10/25, at 8:42 A.M., showed the resident to be on the verge of tears and appeared to be in distress. The resident said the following:-The staff will not give him/her his/her pain medicine because they do not have access to them;-He/she rated his/her pain at a 8 out of 10 pain in his/her left leg and back;-He/she did not get his/her pain medications last night either;-The nurse said he/she did not have access to the medications.Review of the resident's progress note dated 09/10/25, at 11:18 A.M., showed LPN I documented the following:-Resident complaining of left hip pain 8/10;-Resident was assessed, no grimacing, and able to make wants and needs known. Resident expressed he/she has had a hip replacement in 2004, wheelchair cushion was present;-Resident was educated to offload pressure while sitting in the wheelchair;-Certified Medication Tech (CMT) administered acetaminophen.Review of the resident's progress notes showed staff did not document physician or management notification of the inability to administer pain medication. During an interview on 09/10/25, at 9:49 A.M., LPN I said the following:-If a resident says they are in pain, staff should check to see if there are any orders and if not, call the physician, and try to get them more comfortable;-He/she does not have access to any of the narcotics;-He/she does not believe that LPN H has access either;-If a nurse did not have access, they should call the Director of Nursing (DON), or the Administrator;-He/she did reach out to the Administrator but had not heard back. He/she contacted him around 8:59 A.M.,-Residents should receive their medication per physician's order;-If a nurse does not have access and cannot administer medication, he/she would send the resident out to the hospital for pain control;-He/she would consider pain rated as an 8 out of 10 as severe pain.During an interview on 09/10/25, at 10:11 A.M., LPN H said the following:-He/she had medications pulled for him/her by the CMT that he/she could have given them. He/she did not have access to the medication dispensing machine so if they did not have those pulled for him/her, he/she would not have been able to give PRNs;-He/she should have had access to it before he/she started his/her shift;-He/she did not recall if the resident asked him/her for any pain medication. He/she was aware that the resident usually got a pain medication before dialysis but he/she was unable to administer it due to not having access;-He/she considered pain rated as 8 out of 10 to be severe pain;-He/she could have reached out to the physician or sent the resident to the hospital, but did not feel the resident was in enough pain to warrant that. Review of the resident's September 2025 MAR showed on 09/10/25, staff documented administering acetaminophen 325 mg two tablets at 10:51 A.M.During an interview on 09/10/25, at 11:58 A.M., CMT J said the following:-The resident did complain of pain to the charge nurse this morning. The resident asked the CMT to look at the resident's PRN tramadol;-The CMT had access to give the resident acetaminophen so that is what he/she did;-He/she did not have access to the medication dispensing machine to pull the resident's tramadol;-Pain should be addressed immediately. Observation and interview on 09/10/25, at 12:13 P.M., showed the resident speaking with CMT J. The CMT told the resident he/she would check with the nurse regarding his/her tramadol. The resident reported his/her pain level to be rated at an 8 out of 10. He/she did not get his/her medicine on 09/09/25, as well as hasn't received it today and he/she was tired of asking for it;-LPN I came out of the medication room and administered the tramadol at 12:32 P.M.Review of the resident's September 2025 MAR showed on 09/10/25, staff documented administration of tramadol 50 mg tablet at 12:22 P.M.During an interview on 09/10/25, at 11:04 A.M., the Medical Director said the following:-He expected nurses to have access to the medication dispensing machine prior to starting their shift;-If a resident requested a PRN pain medication, they should receive it per orders. During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-He was not aware residents were not receiving their medication;-He was not familiar with the medication dispensing system, but access should have been provided to the nurses prior to starting their shifts. If the nurses did not have access or the ability to perform their jobs, they should have contacted him.

Based on observation, interview, and record review, the facility failed to provide residents with a complete and fully functional call light system when the facility failed to provide staff with pagers for notification of call lights. This failure resulted in two residents (Resident #7 and #8) waiting for longer periods of time for staff to address incontinent care needs. The facility census was 42. Review of the facility policy titled, Call light Accessibility and Timely Response, revised [DATE], showed the following:-The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response;-All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light;-Staff will report problems with a call light or the call system immediately to the supervisor or the maintenance director and will provide immediate or alternative solutions until the problem can be remedied;-Ensure the call light system alerts staff members directly or goes to a centralized staff work area;-All members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 1. Review of the Department of Health and Senior Services (DHSS) database for exceptions showed the following: -On [DATE], the facility was approved for an exception to part of the state call light requirements to allow for a wireless call system (use of pagers);-The facility was required to ensure the wireless nurse call system was fully operational 24 hours a day, seven days a week;-The facility was required to maintain the system per manufacturer's recommendations;-The facility was required to ensure all direct care staff always carried and utilized the wireless nurse call pages;-The exception expired on [DATE]. 2. Review of Resident #7's face sheet showed diagnoses included chronic obstructive pulmonary disease (COPD, inflammation and obstruction of the airways in the lungs), stroke, diabetes mellitus type II, major depression, and anxiety. Review of the resident's care plan, revised on [DATE], showed the following:-The resident required assistance with activities of daily living (ADLs – dressing, grooming, bathing, eating, and toileting) related to COPD, depression, anxiety, and lack of motivation;-Ensure call light is in reach and answered promptly. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff, dated [DATE], showed the following:-Cognitively intact;-Required partial/moderate assistance of staff with toileting hygiene and showers;-Required supervision/touching assistance with personal hygiene;-Frequently incontinent of bowel. During an interview on [DATE] at 1:00 P.M., the resident said the following:-At night he/she frequently waited 15 to 30 minutes for staff to answer his/her call light and has had to wait up to an hour for staff to answer his/her light;-He/She had to urinate in the bed due to longer wait times.-Laying in urine caused a burning sensation to the resident's skin and was embarrassing to the resident. 3. Review of Resident #8's face sheet showed diagnoses included chronic respiratory failure, major depression, anxiety, and diabetes mellitus type II. Review of the resident's care plan, revised on [DATE], showed the following:-The resident required assistance with ADLs related to impaired balance and gait and assistive devices;-Incontinent of bowel and bladder;-Ensure call light is within reach and answered promptly. Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Functional limitation in range of motion to both legs;-Required substantial/maximal assistance of staff with toileting hygiene and personal hygiene;-Occasionally incontinent of bladder;-Frequently incontinent of bowel. During an interview on [DATE] at 1:02 P.M., the resident said the following:-He/she waited up to one hour for staff to answer his/her call light;-He/she had to lay in feces for an hour;-This made the resident feel undignified and mad to have to lay in feces.4. During an observation on [DATE] at 2:51 P.M., surveyors tested the call bell system by pressing call buttons in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). The lights did not illuminate outside the doorways and the system made no audible sound when the call button was pressed. 5. During an interview on [DATE], at 3:00 P.M., Certified Nurse Assistant (CNA) G said the following:-He/she worked at the facility for approximately a year and a half;-The resident call lights have not illuminated or sounded during that time;-He/she had to walk to the nurses' desk and check the monitor mounted on the wall to see if any resident call lights were on;-He/she did not have a pager to carry. During interviews on [DATE] at 12:00 P.M., CNA H and CNA I said the following:-The CNAs began working in the facility in [DATE] and work the night shift 6:00 P.M. to 6:00 A.M.;-Both aides said they had not had pagers for the call system since starting work at the facility;-The lack of pagers lead to a delay in answering resident call lights;-When assigned to work the back hall, staff must walk to the front of the facility to view the monitor at the nurses' station to see if any resident call lights are turned on. During an interview on [DATE] at 2:15 P.M., CNA M said the following:-The call lights do not light up on the outside of the resident doors or have sound;-Staff have to check a board at the nurses' station to see if there are any call lights on;-He/she used a pager when working on the back hall about six months ago, but does not have one anymore. During an interview on [DATE] at 2:58 P.M., CNA N said the following:-The aides use to have pagers to alert of a resident call light, but he/she thinks they are lost;-The CNAs have not had pagers for two months or more;-Residents have complained to him/her about the time it takes to respond to call lights During an interview on [DATE] at 12:40 P.M., Certified Medication Technician (CMT) C said the following:-When a resident presses a call light, staff must come to the nurses' station and check the monitor to see the call light;-He/she would like a monitor on the back hallway, so staff did not have to run to the front and check the monitor for call lights;-The facility had some old pagers in a tackle box at the nurses' station, but they were all broken or needed batteries. During an interview on [DATE] at 9:58 A.M., Licensed Practical Nurse (LPN) D said the following:-He/she worked at the facility for approximately 2 months part time and for the last 2 weeks full time, 6:00 P.M. to 6:00 A.M.;-Staff check the monitor at the nurses' station to see if resident call lights are turned on;-The call system did not have an audible sound or a visual light, just the monitor;-The staff assigned to the back halls come to the nurses' desk located between the two front halls to check and see if any residents have call lights on for the back hall, because there is no way to see or hear call lights on the back hall and no monitor on the back halls. During an interview on [DATE] at 4:10 P.M., the Administrator said the following:-He/she determined the waiver for the current call light system expired in 2023;-He/she applied for a new waiver, but had not received the waiver at this time;-The waiver was for the currently used system which worked with pagers to notify staff of a call light;-He/she ordered pagers three weeks ago, but they had not arrived;-Staff found two functional pagers on [DATE];-He/she expected staff to answer call lights within 10 to 15 minutes and answer emergency (bathroom) call lights within 3 to 5 minutes. Complaint 2675693

Based on interview and record review, facility staff failed to fully implement their infection control program when staff failed to ensure the required two step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely as per policy for two staff (Licensed Practical Nurse (LPN) F and LPN G) of two staff sampled. The facility census was 44. Review of the facility's policy titled Tuberculosis Testing, revised 06/29/23, showed the following:-The purpose of the policy was to ensure each resident and employee of the facility is tested for tuberculosis (TB) after entering the facility to prevent the spread of infection;-Upon hire, a new employee will receive a two-step PPD skin test (a test used to determine exposure to TB);-Each employee will also have an annual one-step TB test to ensure that any possible infections can be triggered proactively to prevent further spread;-All TB tests will be kept on file in the according areas (employee files).1. Reviewed showed the facility did not provide personnel files for LPN F and LPN G upon request. Observation on 09/08/25, at 7:46 P.M., showed LPN G was working as the charge nurse.During an observation and interview on 09/09/25, at 9:09 A.M., LPN F said the following:-He/she was not currently employed by the facility. He/she used to work for the facility but left in August or October 2024;-He/she worked the floor last night with a certified nursing assistant (CNA) and a nurse aide (NA);-He/she did not have a TB test prior to working on the floor with the residents.-The LPN was working as the charge nurse.During an interview on 09/09/25, at 8:50 A.M., the Business Office Manager (BOM) said the following:-He/she did not have personnel files for LPN F and LPN G;-LPN F and LPN G were not employees of the corporation and were not employees of a staffing agency;-He/she did not have TB tests for the LPNs.During an interview on 09/09/24, at 12:10 P.M., LPN D said staff should have a negative TB test prior to working the floor and if they did not, this was not safe for the residents. During an interview on 09/09/25, at 4:33 P.M., the facility physician said staff should have a negative TB test prior to working with the residents. During an interview on 09/10/25, at 11:04 A.M., the Medical Director said staff should have a negative TB test prior to working the floor but in the case of emergency staffing needs, he believed if the staff wore a mask that would be sufficient to protect the residents.During interviews on 09/09/25, at 11:02 A.M. and 09/10/25, at 3:36 P.M., the Administrator said the following:-Upon hire, staff should have their first TB skin test read prior to working on the floor;-He did not know who had LPN F and LPN G come to the facility to work and did not know if they were employees of the corporation or a staffing company;-LPN F and LPN G did not have a negative TB test prior to working the floor.Complaint #2611677

Based on observation, interview, and record review, the facility failed to post the current daily nurse staffing information in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility census was 44.Review of the facility's policy titled Nurse Staffing Posting Information Policy, revised 06/26/24, showed the following:-It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time;-The Nurse Staffing Sheet will be posted on a daily basis and will contain facility name; the current date; facility's current census; the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift;-The facility will post the Nurse Staffing Sheet at the beginning of each shift;-The information posted will be presented in a clear and readable format and in a prominent place readily accessible to residents and visitors;-A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current. The information shall reflect staff absences on that shift due to callouts and illness. Staffing shall include all nursing staff who are paid by the facility (including contract staff). Any staff not paid for by the facility, such as hospice staff or individuals hired by families, shall not be included;-Nursing schedules and posting information will be maintained in the Human Resources Department for review for a minimum of 18 months or as required by State law, whichever is greater;-The facility will, upon oral or written request, make the nurse staffing data available to the public for review at a cost not to exceed the community standard.1. Observations on 09/08/25, at 11:03 A.M. and 4:41 P.M., 09/09/25, at 9:03 A.M., and 09/10/25, at 12:27 P.M., showed staff did not have the Nurse Staffing Posting displayed in the entry hall, at the nurses' station, or by the time clock.During an interview on 09/08/25, at 11:06 A.M., Certified Nursing Assistant (CNA) S said he/she did not know where the Nurse Staffing Sheet was posted, but thought it should be posted.During an interview on 09/08/25, at 11:52 A.M., Registered Nurse (RN) A said the following:-The Nurse Staffing Sheet should be posted behind the nurses' station under the white board on the wall visible to anyone that came to the facility;-The Director of Nursing (DON) was responsible for the Nurse Staffing Sheet;-He/she did not know the last time it was posted, and the sheet was not posted today;-He/she was the former DON and was responsible for posting the Nurse Staffing Sheet, but had not posted it for at least four months.During an interview on 09/08/25, at 1:03 P.M., Licensed Practical Nurse (LPN) C said the following:-The Nurse Staffing Sheet should be posted daily;-He/she had not seen the Nurse Staffing Sheet posted and did not know where the DON posted it;-RN A (the former DON) was responsible for posting it.During an interview on 09/08/25, at 7:12 P.M., LPN E said the following:-He/she had not seen the Nurse Staffing Sheet in at least three months; -RN A (the former DON) filled the Nurse Staffing Sheet out and posted it.During an interview on 09/09/25, at 12:10 P.M., LPN D said the following:-He/she had not seen the Nurse Staffing Sheet posted in a long time;-The night nurse was responsible for filling out the Nurse Staffing Sheet.During an interview on 09/10/25, at 12:00 P.M., the Business Office Manager said the facility had not completed the Nurse Staffing Sheet in a long time, so he/she was unable to provide any copies.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the Nurse Staffing Sheet should be posted daily.

Based on interview and record review, the facility failed to implement policies that prevented abuse, neglect, and exploitation of residents when the facility did not complete the required preemployment screenings including Criminal Background Checks (CBC), Employee Disqualification List (EDL - a list of individuals not able to work in long-term care facilities in the state) checks, and Nurse Aide (NA) Registry (checks for a federal indicator of abuse that makes an individual unable to work in long-term care) checks and when the facility failed to ensure the staff had valid nursing licenses for two staff (Licensed Practical Nurse (LPN) F and LPN G) prior to the nurses working with the residents. The facility census was 44.Review of the facility's policy titled Abuse and Neglect Policy, revised 06/12/24, showed the following:-The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents, and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences;-The facility will screen employees for a history of abuse, neglect, or mistreating residents by attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries;-The facility will not employ individuals who have been convicted of abusing, neglecting, or mistreating individuals. Potential employees are screened for a history of abuse, neglect, or mistreating of residents;-The facility is committed to protecting the residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers. and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.Review of the facility's policy titled Background Investigations, revised 12/27/24, showed the following:-Job reference checks, drug screenings, licensure verifications, and criminal conviction record checks are conducted on all personnel making application for employment with this company;-The Human Resource Department will conduct all applicable background investigations on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied;-Persons applying for employment and current employees will be informed of this policy. The company will not conduct a background investigation without an applicant's or employee's advance consent. Applicants or employees who do not consent to a background investigation will, however, not be considered for positions that the company has determined to require the completion of a background investigation;-If the background investigations disclose any material misrepresentation or omissions by the applicant or employee on the application form or reveal information indicating that the individual may not be appropriate for hire, the company will investigate the matter further. Upon completion of such investigation, if the company determines that the applicant's or employee's background makes him/her unsuitable for the position he/she is seeking, the applicant will not be employed, or, if already employed, will be terminated;-The facility will not employ individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property; or have a disciplinary action in effect against his or her professional license in a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property. 1. Review showed the facility did not provide personnel files for LPN F or LPN G.During an observation and interview on 09/09/25, at 9:09 A.M., LPN F said the following:-He/she was not a current employee of the facility. He/she had not worked at the facility since August or October 2024;-The facility staff did not conduct a CBA, Family Care Safety Registry (FCSR - a registry the includes EDL and CBC checks), NA Registry, or EDL check and did not check his/her nursing license prior to him/her starting his/her shift;-He/she did not fill out an application for employment and did not do any orientation or education prior to working his/her shift;-He/she worked last night with a certified nursing assistant (CNA) and a nurse aide (NA);.-The LPN was observed working as the charge nurse.Observation on 09/08/25, at 7:47 PM., showed LPN G working as the charge nurse.During an interview on 09/09/25, at 8:50 A.M., the Business Office Manager (BOM) said the following:-He/she did not have personnel files for LPN F or LPN G;-He/she did not conduct a CBC, EDL, FCSR, or NA Registry on the LPNs prior to the LPNs working the floor.During an interview on 09/09/25, at 12:10 P.M., LPN D said the following:-New staff were required to complete onboarding, orientation, and the appropriate background and licensure checks prior to working a shift;-Nurses should not be allowed to work the floor prior to checking their license because the facility would not know if they had a valid nurses license that was unencumbered, and this would not be safe for the residents.During an interview on 09/10/25, at 11:58 A.M., Certified Medication Technician (CMT) J said the following:-Upon hire, the facility completed background checks, NA registry, and checked the potential employees license;-No one should have access to the residents prior to these being completed and he/she did not believe they could work on the floor before these were completed.During an interview on 09/10/25, at 11:04 A.M., the Medical Director said in the case of emergency staffing, he/she still expected the facility staff to check the status of the nurses' license, check the EDL list, and perform a CBC.During interviews on 09/09/25, at 10:50 A.M., and on 09/10/25, at 3:36 P.M., the Administrator said the following:-When the facility hired staff they conducted a NA registry, EDL, CBC, FCSR checks, and confirmed nurses' licenses;-He/she did not know if LPN F or LPN G completed applications for employment prior to starting their shifts;-The facility did not conduct a CBC, FCSR, NA Registry, or EDL checks and did not check the status of their nursing licenses prior to the LPNs starting their shifts;-He/she did not set the LPNs up to work their shifts and did not know who did this.Complaint #2611677

Based on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation when a facility staff member coerced money from one resident (Resident #1) and when the staff member dispensed and did not administer or destroy narcotic medications of one resident (Resident #2). The facility census was 44. Review of the facility policy, titled Abuse and Neglect revised 06/12/24, showed the following information:-Misappropriation of resident property includes identity theft, theft of money from bank accounts, theft of money from a resident, unauthorized or coerced purchases on a resident's resident card, unauthorized or coerced purchases from resident funds, a resident who provides a gift to staff in order to receive ongoing care, based on staff's persuasion, a resident who provides monetary assistance to staff after staff had made the resident believe the staff was in a financial crisis, misappropriation of resident property, and misappropriation of resident medication;-The licensed nurse will respond to the needs of the resident to protect him/her from further incident, call 911 when there is a medical emergency, remove the accused employee from the resident care areas, notify the Administrator, notify the attending physician, resident's family, and Medical Director, monitor and document the resident's condition including response to nursing interventions, document actions taken in the medical record, complete an incident report, revise the resident's care plan if the resident's medical, nursing, physical, mental or psychological needs or preferences change as a result of the abuse;-The Administrator will complete an administrative investigation to include personal statements from staff and residents involved in a situation that has any type of accusations of abuse either staff or resident abuse, suspend the accused employee pending completion of the investigation, notify the appropriate agencies immediately, report to the state nurse registry of the nursing board any knowledge of any actions which would indicate an employee is unfit for service.1. Review of Resident #1's face sheet (brief look at resident information) showed the following:-admission date of [DATE];-Diagnoses included chronic obstructive pulmonary disorder (COPD - a group of lung disease that make it hard to breathe), congestive heart failure (CHF - a chronic condition in which the heart does not pump blood as it should), and irregular heartbeat.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 06/26/25, showed the resident was cognitively intact.Review of the facility's Misappropriation of Funds Investigation, dated 09/04/25, showed the following:-At approximately 6:15 P.M., the resident approached the Former Administrator and said that the former Director of Nursing (DON)/Registered Nurse (RN) A had asked him/her for money on several occasions;-The resident said that about two months ago, RN A had requested $540.00 dollars from him/her;-The resident said RN A took him/her to the store and he/she used the ATM to get the RN $200.00, not the full $540.00;-The resident said he/she used a mobile payment app to send the RN money per the RN's request on several other occasions;-The resident also indicated the RN's child was playing with his/her iPad and broke it, shattering the screen;-The resident indicated that RN A told him/her that he/she would pay him/her back, and now the resident indicated he/she felt used and taken advantage of;-Immediate action indicates RN was already on suspension following another incident.Review of the resident's Psychosocial Post-Incident Impact Questionnaire dated 09/04/25, at 11:28 P.M., showed the following:-No coping skills identified. The resident said he/she does not feel he/she was being taken advantage of at the time of in the incident, but felt like it when she later realized he/she was taken advantage of;-The resident [NAME] like he/she should not trust anyone with his/her money now;-The resident felt safe to report due to RN A not being in the building due to previous suspension.Review of the resident's care plan, revised 09/04/25, showed the resident was at risk for financial exploitation related to cognitive impairment and dependence on others for financial management. Education on abuse, neglect, misappropriation, and exploitation provided to the resident.During an interview on 09/07/25, at 1:12 P.M., the resident said the following:-He/she loaned the former DON/RN A around $500.00 over a course of four months starting in July 2025;-RN A was aware the resident got a large back check from social security, so the RN started to ask the resident for money to help with bills, kids sports, and food to feed his/her kids. The resident said he/she had a heart and hearing that made him/her feel horrible to the point he/she could not say no;-RN A frequently brought his/her children to work, who also entered the resident's room and broke his/her tablet;-RN A said he/she would pay him/her back;-The first payment to RN A was via cash. RN A took him/her to the store and the resident pulled out $200.00 cash for RN A. He/she believed this happened maybe two times;-The rest of the transactions were through a mobile payment app that allowed users to send and receive money;-Recently RN A was placed on suspension for misappropriation of narcotics (also known as opioids - a class of drugs that interact with opioid receptors in the brain to produce pain relieving properties), which is when he/she felt safe enough to tell another nurse about the money that had been given to RN A;-After telling the nurse, the Former Administrator came and talked with him/her and went through his/her bank statements to determine the amount of money that had been sent to RN A. The determination was $850.00.Review on 09/07/25, at 1:25 P.M., of the resident's mobile payment app history showed the following:-On 04/02/25, the resident sent $100.00 to RN A;-On 04/09/25, the resident sent $100.00 to the RN A ;-On 04/25/25, the resident sent $50.00 to the RN A ;-On 08/06/25, the resident sent $50.00 to the RN A.During an interview on 09/08/25, at 11:52 A.M., RN A said the following:-The resident had given him/her money via a mobile app;-On 04/02/25, the resident sent him/her $100.00;-On 04/09/25, the resident sent him/her 100.00;-On 04/25/25, the resident sent him/her 50.00;-On 08/06/25, the resident sent him/her 50.00;-The resident requested the money be sent to him/her, because the resident's bank account was not working. The resident would send money to him/her and he/she would cash it for the resident and then give it to him/her;-She had asked the resident for gas money before, but that was because he/she was having to transport the resident to an appointment;-She ended up not having to transport the resident to his/her appointment and the transport driver did, so she gave that money, $50.00, to him/her;-General practice is that residents do not have to pay for transportation, that would be the facility's responsibility;-Taking money from residents was not acceptable and having his/her children use/break something of the resident's was not acceptable.During an interview on 09/07/25, at 2:42 P.M., Certified Nursing Assistant (CNA) N said the following:-RN A's children would come into work with her often and would ask the residents as well as staff members for money and/or food;-Recently it had came out that the resident loaned money to RN A;-It was not okay to take money from residents. If someone is alleged of doing so, they should be suspended pending investigation.During an interview on 09/08/25, at 1:11 P.M., Licensed Practical Nurse (LPN) C said it was not okay to take money from residents, if someone is alleged of doing so, they should be suspended pending investigation.During an interview on 09/08/25, at 2:18 P.M., the Administrator said he was not aware of any misappropriation claims.During an interview on 09/09/25, at 12:00 P.M., LPN D said the following:-Misappropriation of resident funds is a type of abuse;-The expectation if someone reports misappropriation of funds, staff are to notify the charge nurse or the Social Services Director (SSD), and the DON and an investigation will begin;-On 09/04/25, RN A was suspended for misappropriation of narcotics;-On 09/04/25, he/she entered the resident's room. The resident asked him/her if RN A was gone. He/she replied yes, and that is when the resident told him/her RN A had taken money from him/her;-He/she immediately reported the allegations to the former Administrator and an investigation began; -He/she felt the resident would have reported it sooner, but was fearful with RN A in the building, so when RN A was suspended for prior allegations, that is when the resident felt comfortable enough to report.During an interview on 09/09/25, at 2:09 P.M., the Former Administrator said the following:-On 09/04/25, RN A was suspended for misappropriation of narcotics, later that night the resident and LPN D came into her office and the resident reported to her that RN A had also taken money from him/her;-RN A would drive the resident to the store and have the resident withdraw money for her, in addition to several mobile cash app transactions;-After seeing the resident's bank statements and app transactions, she determined RN A needed to be terminated and did so on 09/05/25.During an interview on 09/10/25, Certified Medication Technician (CMT) J said the following:-If he/she became aware of any misappropriation allegations, he/she would immediately report it to the charge nurse and then follow up with said charge nurse to ensure that they told the Administrator and reported the allegations to the State Agency within two hours;-The accused staff member should be suspended pending investigation.Review of the Administrator's summary of findings, dated 09/15/25, showed the following:-After review of the investigation completed by the Former Administrator and RN B, and after review of all witness statements and bank statements, it is concluded the allegations are substantiated;-The employee (RN A) has been removed from the facility and his/her employment has been terminated;-He will continue to monitor the resident to ensure he/she feels safe and has no psychosocial effects from the incident;-Education has been provided to all staff on all aspects of abuse and neglect.2. Review of Resident #2's face sheet showed the following information:-re-admission date of [DATE];-Diagnoses included dementia, high blood pressure, Alzheimer's disease, and pain.Review of the resident's care plan, dated 03/23/23, showed staff did not care plan related to the resident's pain or medication to treat pain. Review of the resident's quarterly MDS. dated 06/19/25, showed the following information:-Resident had severe cognitive impairment;-Resident did not take any opioid medications;-Resident was not on a scheduled or as needed (PRN) pain regimen.Review of the resident's August 2025 POS showed the following information:-The resident did not have a routine order for hydrocodone/Acetaminophen 10-325mg tablet;-The resident did not have a PRN order for hydrocodone/Acetaminophen 10-325 mg tablet.Review of the resident's August 2025 MAR showed the resident did not have an order or any administrations of hydrocodone/acetaminophen 10-325 mg tablets.Review of the resident's Controlled Substance Dispense History from the medication dispensing machine showed RN A pulled the following medication for the resident: -On 08/13/25, at 11:00 A.M., two hydrocodone/acetaminophen 10-325 mg tablets;-On 08/14/25, at 10:10 A.M., two hydrocodone/acetaminophen 10-325 mg tablets;-On 08/14/25, at 10:18 A.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 08/15/25, at 11:11 A.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 08/18/25, at 9:44 A.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 08/18/25, at 4:17 P.M., two hydrocodone/acetaminophen 10-325 mg tablets;-On 08/19/25, at 9:43 A.M., six hydrocodone/acetaminophen 10-325mg tablets; -On 08/21/25, at 2:50 P.M., six hydrocodone/acetaminophen 10-325 tablets;-On 08/22/25, at 7:16 P.M., two hydrocodone/acetaminophen 10-325 mg tablets;-On 08/22/25, at 7:25 P.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 08/24/25, at 5:08 P.M., two hydrocodone/acetaminophen 10-325 mg tablets;-On 08/24/25, at 8:00 P.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 08/25/25, at 3:52 A.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 08/30/25, at 7:36 A.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 08/30/25, at 1:27 P.M., two hydrocodone/acetaminophen 10-325 mg tablets;-On 08/31/25, at 11:54 A.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 08/31/25, at 11:57 A.M., two hydrocodone/acetaminophen 10-325mg tablets;-On 09/01/25, at 6:40 A.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 09/02/25, at 8:51 A.M., six hydrocodone/acetaminophen 10-325 mg tablets;-On 09/02/25, at 5:59 A.M., two hydrocodone/acetaminophen 10-325mg tablets;-On 09/03/25, at 7:17 A.M., six hydrocodone/acetaminophen 10-325 mg tablets.Review of the resident's September 2025 POS showed an order, dated 09/04/25, for hydrocodone/acetaminophen 5-325 mg by mouth every four hours as needed for pain. The order was entered by LPN D.Review of the resident's Electronic Medical Record (EMR) showed an incident report for Diversion of Medications, dated 09/03/25, at 9:00 A.M. The Regional Nurse Consultant (RNC) documented the following information:-On 09/02/25, the former DON/RN A asked the night shift nurses to come in at approximately 3:30 P.M. RN B and LPN C entered the building and noted RN A was not in the building. RN B and LPN C did not receive report and were given the medication cart keys by a non-nurse staff member. At this time, staff noted there had been several narcotic medications that were printed from the medication dispensing machine, that were unaccounted for. No medications were accounted for from med passes on 09/02/25. The process was to dispense the medications for the day and then fill the cart. Not only were medications unaccounted for, but there was also medication that were dispensed that were not ordered for residents. Dispense record indicates that two hydrocodone/acetaminophen 5-325 dispense as scheduled daily, but when RN A was on duty, she was dispensing six hydrocodone/acetaminophen 10-325 mg although there is no reason for them to be dispensed;-RN A provided controlled substance destruction logs, but the Former Administrator noted that RN A scribbled on the paper prior to handing it to her;-There were still at least 26 hydrocodone/acetaminophen tablets that were unaccounted for at this time in the investigation;-RN A was suspended pending investigation.Review of the facility's Controlled Substance Accountability Sheet, showed the following:-An order for hydrocodone/acetaminophen 10-325, dated 08/12/25, for the resident;-On 08/14/25 through 08/31/25, six tablets were destroyed daily by RN A and LPN D;-On 09/01/25 and 09/02/25, six tablets were destroyed by RN A and a medication technician;-On 09/03/25, six tablets were destroyed and did not have signatures for who destroyed the medication.During an interview on 09/07/25, at 1:55 P.M., RN B said the following:-RN A called him/her in to work on 09/02/25 night shift. Once arriving on shift, he/she noted there were a lot of discrepancies with narcotics. He/she immediately reported it to the Former Administrator. RN B then made copies of all the dispensed discrepancies;-After the dispensing record was printed, he/she compared that to the resident's POS, and MAR;-RN A had been dispensing two routine narcotics, for the resident, in addition to six as needed narcotics for the resident. It was questionable and concerning as to why the resident would need 8 narcotics in one day;-After reviewing the resident's MAR and POS, it showed the resident did not have an order for the narcotics. At that point, he/she printed an entire month's worth of dispense sheets, and quickly realized that RN A had been doing this for a while;-Once learning all of this information, he/she assisted the Former Administrator in searching RN A's office where they found multiple open medication packets, and loose pills scattered throughout the office. While they found a lot, not all the medications were recovered and there was no additional record of destructions;-RN A never asked him/her to destroy any medications with her;-There are supposed to be two nurses for destruction of narcotics;-The resident apparently had an order written by the physician on 08/12/25, for hydrocodone/acetaminophen 10-325 mg, and sent the order directly to the pharmacy. RN A did not convert those orders into the resident's EMR.During an interview on 09/08/25, at 11:52 A.M., RN A said the following:-She was fired last week for allegations of misappropriation of narcotics and resident funds;-She pulled all those medications out of the medication distribution system so they could be destroyed, but often did not have the time to destroy them;-The physician sent the script in wrong for the resident, which is why it was not the right medication that she was pulling;-She called the pharmacy a couple of times to get the resident's medication removed from the medication dispensing system as it was the wrong order. They did not. So, she pulled them out to destroy;-The resident had an order, it was just not transcribed into the EMR, so there is no record of it ever existing and/or being administered;-The resident never took pain medication;-She did communicate with the pharmacy and Physician, but has no record of it. She did not document any of the concerns in the resident's progress notes;-She destroyed the narcotics with another nurse, LPN D;-She was not aware there was supposed to be a destruction log. She had not used a destruction log since July 2025, so there is no way of telling what medications were destroyed or not;-She was not sure why the medication kept being dispensed, she called the pharmacy to get this corrected, but did not document it or follow up.During an interview on 09/08/25, at 1:11 P.M., LPN C said the following:-He/she was on shift at work on 09/03/25, and discovered several discrepancies for the resident's narcotics;-The resident did not have an order for the medication that was being dispensed by RN A, and he/she could not find a destruction record for all the medications that had been dispensed;-RN A never asked him/her to destroy any medications with her.-The way the medication dispensing system worked was the nurse on shift had to load a roll of blank packets into the machine. The nurse must enter in the resident name and select which medication they are wanting dispensed. After they are dispensed you either put them in a locked box in the medication cart and log them and/or administer them to the resident;-There are supposed to be two nurses for destruction of narcotics.During an interview on 09/09/25, at 12:00 P.M., LPN D said the following:-There was no log for the destruction of the resident's narcotics that were pulled from the medication dispensing system;-He/she asked RN A why those medications were being dispensed and never got a clear answer other than RN A would be destroying them and she would then take them to her office. He/she was unaware if RN A kept them in a locked box or not;-He/she came to learn the resident did have an order for hydrocodone/acetaminophen but it was never transcribed into the resident's EMR so it was never administered that he/she was aware of;-RN A forged his/her signature on the narcotic sheets. He/she was not in the building on the dates that RN A said that he/she destroyed narcotics with her;-Toward the resident's end of life, he/she did begin to experience pain, and he/she did obtain an order for PRN hydrocodone/acetaminophen 5-325 mg every four hours as needed, on 09/04/25. During an interview on 09/07/25, at 3:46 P.M., the Former Administrator said RN A was placed on suspension pending investigation and was terminated on 09/05/25 after seeing an overwhelming amount of evidence against her for misappropriation of narcotics and resident funds.Complaints #2608924, #2609968, #2609971, #2609989, #2609995, #2610122, #2610146, and #2610229

Based on observation, interview, and record review, the facility failed to ensure all residents were free of significant medication error, when staff failed to administer insulin as ordered for three residents (Resident #5, # 6, and #7). The facility census was 44. Review of the facility policy, titled Medication Administration, revised 06/06/24, showed the following information:-Ensure the six rights of medication administration are followed included right resident, right drug, right dosage, right route, right time, and right documentation;-Administer medication as ordered;-Injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice.1. Review of Resident # 5 face sheet (brief look at resident information) showed the following information:-re-admission date of 06/18/25;-Diagnoses included diabetes.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 06/18/25, showed the following information:-Cognitively intact;-Received insulin injections seven days out of the week.Review of the resident's care plan, revised on 08/18/25, showed the following information:-Accu-Check's (blood glucose monitoring) per physician order;-Administer diabetic medication per physician order;-Rotate insulin injection locations and document as indicated.Review of the resident's September 2025 Physician Order Sheet (POS) showed the following information:-An order, dated 08/07/25, for insulin glargine (Lantus - a long-acting synthetic form of human insulin used to manage blood sugar) subcutaneous (under the skin) solution pen injector 100 unit/milliliter (ml), inject 30 units subcutaneously every morning and at bed time;-An order, dated 08/28/25, for Novolog (a modified type of rapid acting medical insulin used to treat diabetes) FlexPen, inject 10 units subcutaneously three times a day, in addition to sliding scale;-An order, dated 06/24/25, for Novolog FlexPen, inject three times a day per the following sliding scale;-If blood glucose level is 121 mg/dL to 175 mg/dL, administer 4 units of insulin;-If blood glucose level is 176 mg/dL to 225 mg/dL, administer 8 units of insulin;-If blood glucose level is 226 mg/dL to 275 mg/dL, administer 10 units of insulin;-If blood glucose level is 276 mg/dL to 325 mg/dL, administer 12 units of insulin;-If blood glucose level is 326 mg/dL to 425 mg/dL, administer 19 units of insulin and call the physician;-If blood glucose level is 426 mg/dL to 475 mg/dL, administer 21 units of insulin and call the physician;-If blood glucose level is 476 mg/dL to 500 mg/dL, administer 24 units of insulin and call the physician.Review of the resident's September 2025 Medication Administration Record ( MAR) showed the following information:-On 09/09/25, staff did not document a blood sugar check at 7:00 A.M.;-On 09/09/25, staff did not document administration of the resident's 7:00 A.M. dose of insulin glargine. Staff noted hold/ see progress notes;-On 09/09/25, staff did not document administration of the resident's 7:00 A.M. dose of scheduled Novolog. Staff noted hold/ see progress notes;-On 09/09/25, staff did not document administration of the resident's 7:00 A.M. dose of sliding scale Novolog. Staff noted hold/ see progress notes.Review of the resident's progress notes, dated 09/09/25, showed staff did not document why the resident's insulin was not administered.Observation and interview on 09/09/25, at 11:15 A.M., showed the resident lay in bed appearing flushed and said the following:-He/she did not receive his/her insulin this morning;-He/she was worried, because his/her blood sugar level had been running high;-He/she asked staff about his/her insulin and it was reported to him/her the nurse did not have access to administer the insulin. The nurse also did not check his/her blood glucose level this morning though he/she believed the nurse does not need access to be able to do that.During an interview on 09/09/25, at 1:30 P.M., the Regional MDS and Care Plan Coordinator said the following:-The resident missed his/her morning dose of insulin;-She had checked the resident at this time, and it was 390 mg/dL resulting in an insulin administration of 10 units plus an additional 19 units of sliding scale.Review of the resident's September 2025 MAR showed the Regional MDS and Care Plan Coordinator administered the resident's insulin on 09/09/25 after the lunch meal. 2. Review of Resident #6's face sheet showed the following information:-re-admission date of 04/22/24;-Diagnoses included diabetes. Review of the resident's MDS, dated [DATE], showed the following information:-Cognitively intact;-Received insulin injections seven days out of the week.Review of the resident's care plan, revised 08/18/25, showed the resident had a nutritional need related to diabetes. Staff did not care plan related to the resident's medication management of the resident's diabetes. Review of the resident's September 2025 POS showed an order, dated 08/15/25, for Lantus Solostar Subcutaneous Solution Pen Injector 100 unit/ml, inject 65 units subcutaneously one time a day at 7:00 A.M. Review of the resident's September 2025 MAR showed the following:-On 09/09/25, staff did not document checking the resident's blood sugar at 7:00 A.M.,-On 09/09/25, staff did not document administration of the resident's Lantus at 7:00 A.M. Staff noted hold/ see progress notes.Review of the resident's progress notes, dated 09/09/25, showed staff did not document why the resident's insulin was not administered.During an interview on 09/09/25, at 11:29 A.M., the resident said the following:-He/she had not received his/her insulin this morning;-The nurse on duty spoke with him/her about it and said that he/she did not have access to the system in order to administer his/her insulin;-His/her blood sugar had not been taken this morning either.3. Review of Resident #7's face sheet showed the following information:-admission date of 05/20/25;-Diagnoses included diabetes.Review of the resident's MDS, dated [DATE], showed the following information:-Moderate cognitive impairment;-Received insulin injections seven days out of the week.Review of the resident's care plan, dated 07/09/25, showed staff did not care plan related to the resident's medication management of diabetes. Review of the resident's September 2025 POS showed the following information:-An order, dated 06/11/25, for insulin lispro injection solution 100 unit/ml, inject before meals and at bedtime as per following sliding scale;-If blood glucose was 150 mg/dL to 175 mg/dL, administer 4 units of insulin;-If blood glucose was 176 mg/dL to 225 mg/dL, administer 8 units of insulin;-If blood glucose was 226 mg/dL to 275 mg/dL, administer 10 units of insulin;-If blood glucose was 276 mg/dL to 325 mg/dL, administer 12 units of insulin; -If blood glucose was 326 mg/dL to 375 mg/dL, administer 16 units of insulin; -If blood glucose was 376 mg/dL to 425 mg/dL, administer 19 units of insulin and call physician;-If blood glucose was 426 mg/dL to 475 mg/dL, administer 21 units of insulin and call physician;-If blood glucose was 476 mg/dL to 500 mg/dL, administer 24 units of insulin and call physician;-An order, dated 07/17/25, for Lantus 100 unit/ml, inject 25 units subcutaneously one time a day, at 8:00 A.M.Review of the resident's September 2025 MAR showed the following information:-On 09/09/25, the resident did not receive Insulin Lispro at 6:30 A.M. Staff noted hold/ see progress notes;-On 09/09/25, the resident did not receive Lantus at 8:00 A.M. Staff noted hold/ see progress notes; - The resident did not get his/her blood sugar checked at 7:00 A.M.Review of the resident's progress notes, dated 09/09/25, showed staff did not document why the resident's insulin was not administered.Observation and interview on 09/09/25, at 11:23 A.M., showed the resident lay in bed appearing to be fatigued by the inability to hold conversation without closing his/her eyes and drifting in and out of sleep. The resident said the following:-He/she was a diabetic and did not get his/her blood sugar checked this morning;-He/she did not receive his/her insulin this morning;-He/she was told the nurse did not have access to give him/her his/her insulin and/or check blood sugar;-He/she was concerned about not getting his/her medication.4. During an interview on 09/09/25, at 9:58 A.M., Licensed Practical Nurse (LPN) F said the following:-He/she was unable to give the residents their medications, this morning (09/09/25), due to not having access to the electronic medical records (EMR); -He/she was unable to give the residents their insulin. He/she believed around 11 residents went without their insulin due him/her having a broken hand and not being able to administer. The facility was aware of this when they asked him/her to work; -He/she typically does not work at the facility and was not provided any access for the EMR system and/or the medication dispensing system;During an interview on 09/09/25, at 4:33 P.M., the facility physician said the following:-He/she would expect nurses to have access to the medication dispensing system prior to starting their shifts;-He/she has not been made aware of any missed medication administrations;-If a resident's order says to notify her regarding blood sugar levels, she expected to be notified.During an interview on 09/10/25, at 9:49 A.M., LPN I said the following:-If a nurse did not have access to the EMR or medication administration system they should call the Director of Nursing (DON), or the Administrator;-Residents should receive their medication per physician's order;During an interview on 09/10/25, at 11:04 A.M., the Medical Director said the following:-He expected nurses to have access to the medication dispensing system prior to starting their shift;-If a resident has an order for insulin, he expected them to receive it.During an interview on 09/10/25, at 11:58 A.M., Certified Medication Technician J said the following:-LPN F did not have any access to the resident's records;-LPN F made several calls in attempts to get access and the ability to pass resident medications; -If a resident had an order for medication, they should be receiving that medication.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-He was not aware residents were not receiving their medication;-He was not familiar with the medication dispensing system, but access should have been provided to the nurses prior to starting their shifts. If the nurses did not have access or the ability to perform their jobs, they should have contacted him.Complaints #2598186, #2609971, #2611677

Based on interview and record review, the facility failed to ensure all residents were free from unnecessary medications when staff administered medications to two residents (Resident #1 and #10) without following physician ordered monitoring. The facility census was 42.Review of the facility policy titled, Medication Administration, revised on 06/26/24, showed the following:-Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. It is the policy of this facility to ensure the safe and effective administration of all medication by utilizing best practice guidelines;-Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside of physician's prescribed parameters;-Sign MAR (medication administration record) after administered. For those medications requiring vital signs, record the vital signs onto the MAR;-Medications requiring vital signs prior to administration includes anti-hypertensives (used to treat high blood pressure). 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information:-Diagnoses including congestive heart failure (CHF - chronic condition where the heart cannot pump enough blood to meet the body's needs) and high blood pressure. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/03/25, showed the following: -Moderate cognitive impairment.-Diagnosis of high blood pressure. Review of the resident's care plan, revised 10/24/25, showed the following:-Independent with activities of daily living (ADL – basic personal care tasks essential for health and safety, such as eating, bathing, dressing, and mobility).-The resident had a communication problem.-The resident had CHF and high blood pressure. -Staff should administer cardiac medications and high blood pressure medications as ordered. Review of the resident's November 2025 Physician Orders showed an order, dated 04/18/25, for metoprolol tartrate (blood pressure medication) tablet 25 milligrams (mg), give a half tablet by mouth one time a day related to CHF. Hold if systolic blood pressure (SBP) is 110 millimeters of Mercury (mm/Hg) or less or heart rate is less than 65 beats per minute (bpm). Review of the resident's November 2025 MAR showed an order, dated 04/18/25, for metoprolol tartrate tablet 25 mg, give a half tablet by mouth one time a day related to CHF. Hold if SBP is 110 mm/Hg or less or heart rate is less than 65 bpm. Staff administered the resident's metoprolol tartrate medication when the resident's heart rate was below the ordered perimeters on the following dates:-On 11/15/25, the resident's heart rate was 50 bpm and staff documented medication was administered.-On 11/17/25, the resident's heart rate was 62 bpm and staff documented medication was administered.-On 11/18/25, the resident's heart rate was 62 bpm and staff documented medication was administered.-On 11/19/25, the resident's heart rate was 61 bpm and staff documented medication was administered.-On 11/21/25, the resident's heart rate was 45 bpm and staff documented medication was administered.-On 11/22/25, the resident's heart rate was 42 bpm and staff documented medication was administered.-On 11/24/25, the resident's heart rate was 49 bpm and staff documented medication was administered.-On 11/25/25, the resident's heart rate was 48 bpm and staff documented medication was administered. 2. Review of Resident #10's face sheet showed the following information:-Diagnoses including CHF and orthostatic hypotension (a condition where blood pressure drops significantly and suddenly when changing positions). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact.-Diagnoses including CHF and orthostatic hypotension. Review of the resident's current November 2025 Physician Orders showed an order, dated 03/05/25, for Entresto (heart failure medication) tablet 24-26 mg, give one tablet by mouth two times a day for CHF. Hold if SBP was less than 100 mm/Hg. Review of the resident's November 2025 MAR showed the following: -An order, dated 03/05/25, for Entresto tablet 24-26 mg, give one tablet by mouth two times a day for CHF. Hold if standing blood pressure (SBP) was less than 100 mm/Hg.-Staff administered the resident's Entresto medication without checking the resident's blood pressure from 11/01/25 through 11/19/25, twice daily at 7:00 A.M. and 3:00 P.M., except on 11/05/25 and 11/18/25 at 7:00 A.M. due to resident's refusal of medication. Review of the resident's vital sign summary for November 2025 showed staff documented the resident's blood pressure was taken one time on 11/11/25. During an interview on 11/24/25, at 12:40 P.M., Certified Medication Technician (CMT) E said the following:-The resident did not need his/her blood pressure checked prior to administering his/her medications.-He/she did not know what the resident's blood pressure that morning was prior to administering his/her medication. 3. During an interview on 11/24/25 at 12:40 P.M., CMT E said the following:-If a medication required a blood pressure or pulse to be taken it would be indicated on the MAR.-The blood pressure or pulse should be checked prior to medication administration to make sure it was within the ordered parameters.-There was no place to document residents' blood pressure on the MAR. During an interview on 11/25/25 at 1:47 P.M., Licensed Practical Nurse (LPN) F said a resident's blood pressure and pulse should be checked prior to administering medication if there are parameters. The vital signs should be documenter on the MAR. During an interview on 11/24/25 at 12:50 P.M., the Director of Nursing said staff should check the resident's blood pressure or pulse if it was indicated on the MAR. There should be a spot to document vital signs on the MAR. During an interview on 11/25/25 at 4:10 P.M., the Administrator said blood pressure and pulse should be listed in the MAR if indicated. Staff should follow physician orders, including any parameters ordered, when administering medication.

Based on observation, interview, and record review, facility staff failed to ensure a clean and homelike environment when multiple resident rooms had pest droppings present on the floor, in cabinets, on window ledges, and on tabletops. The facility had a census of 39. Review of facility records showed the facility did not provide a policy regarding housekeeping. Review of a facility document titled, Housekeeping Deep Cleaning Checklist, not dated, showed the following cleaning instructions:-Strip beds and disinfect mattress on both sides;-Disinfect bed frames, rails, head/foot boards, doorknobs, light switches, outlet covers, paper towel dispensers, soap dispensers, call lights, glove brackets, bedside tables, nightstands, toilet, toilet seat, handrails, and bedside commodes;-Pull out and sweep underneath nightstands and dressers;-Clean windows, windowsills, blinds, sinks, faucets, mirrors, baseboards, and trash can;-Sweep and mop the floors;-Dust from top to bottom (areas not specifically identified);-Remove trash. Review of facility document titled, Everyday Women's/Men's Hall Cleaning List , not dated, showed the following cleaning instructions:-Pick up of all trash;-Wipe all surfaces;-Disinfect beds and remake;-Clean bathroom;-Sweep and mop floors including behind and underneath furniture. 1. Observations on 01/29/26, starting at 10:48 A.M., of [NAME] Oak Hall showed the following: -room [ROOM NUMBER] had multiple dark brown rice grain sized pieces of material consistent with mouse droppings inside the left and right lower cabinet drawers of the built-in cabinet. The left drawer was empty. The right drawer contained incontinence briefs and one package of incontinence wipes. Mouse-like droppings were on top of the briefs. The room had a four-drawer dresser near the resident bed containing various resident belongings including, a puzzle book, cans of tobacco, incontinence briefs, paper towels, and a pillowcase. All four drawers had multiple mouse-like droppings alongside the resident belongings;-room [ROOM NUMBER] had multiple mouse-like droppings inside the right lower cabinet drawer of the built-in cabinet. The resident's socks and underwear were in the drawer;-room [ROOM NUMBER] had multiple mouse-like droppings in the left and right lower cabinet drawers of the built-in cabinet. The drawers contained resident's socks, shoes, and blankets. The room also had a four-drawer dresser with mouse like droppings on one unopened package of incontinence briefs in one drawer. Observation on 01/29/26, at 11:10 A.M., of room [ROOM NUMBER] showed the following: -The room appeared cluttered with various personal items and multiple plants;-A bedside table with various personal items and food crumbs on the top. Mouse-like droppings were also present on the tabletop;-The right lower cabinet drawer of the built-in cabinet had multiple mouse-like droppings;-Mouse-like droppings on the floor in one corner near the corridor door. During an interview on 01/29/26, at 12:58 P.M., Housekeeper I said he/she cleaned rooms daily, but did not clean out resident cabinets or drawers. He/She had not observed mice in the last few weeks. Observations on 01/29/26, starting at 2:34 P.M., of [NAME] Oak Hall showed the following: -room [ROOM NUMBER] had multiple mouse-like droppings inside the top drawer of a dresser near the corridor door. The drawer also contained resident clothing items;-room [ROOM NUMBER] had multiple mouse-like droppings inside the left and right lower cabinet drawers of the built-in cabinet. The left drawer was empty. The right drawer contained incontinence briefs. Mouse-like droppings were on top of the briefs. Multiple mouse-like droppings were also on the windowsill along with holiday decor and cards;-The Activity area at the end of the hall near room [ROOM NUMBER] had multiple mouse-like droppings on the floor along the baseboard trim and near the trashcan. Observations on 01/30/26, starting at 11:29 A.M., of Dogwood Hall showed the following: -room [ROOM NUMBER] had multiple mouse-like droppings inside the left and right lower cabinet drawers of the built-in cabinet. The cabinets were empty;-room [ROOM NUMBER] had multiple mouse-like droppings along the baseboard trim at the head and foot of one bed near the window;-room [ROOM NUMBER] had multiple mouse-like droppings inside the left and right lower cabinet drawers of the built-in cabinet. The drawers also contained resident clothing items. Observations on 01/30/26, starting at 11:56 A.M., of [NAME] Oak Hall showed the following: -room [ROOM NUMBER] had multiple mouse-like droppings inside the left and right lower cabinet drawers of the built-in cabinet. The cabinets were empty;-room [ROOM NUMBER] had multiple mouse-like droppings in the same location as previously observed on 01/29/26. The left and right lower cabinet drawers of the built-in cabinet had mouse like droppings. The left drawer was empty. The right drawer contained resident briefs. Mouse-like droppings were on top of the briefs. Multiple mouse-like droppings were also on the windowsill along with holiday decor and cards. The Maintenance Director removed the right and left lower cabinet drawers of the built-in cabinet. A large accumulation of mouse-like droppings and shredded paper were located in the drawer frame area. During an interview on 01/30/26, at 12:05 P.M., the Pest Control Technician said the following: -He/She worked for an outside vendor and serviced the facility for pest control;-He/She visited the facility twice per week to address pest control needs including mice;-He/She was on-site today to address rodent activity;-He/She had not seen new rodent activity for two days;-The facility did have old mice droppings;-He/She informed the facility to clean the old droppings while on-site. During an interview on 02/02/26, starting at 9:58 A.M., Housekeeper J said the following: -Mouse droppings have been an ongoing issue due to cold weather;-Housekeeping staff should check resident rooms daily for signs of droppings including checking drawers, floors, and interior cabinets;-Droppings should be immediately removed and the impacted areas should be sanitized;-Personal items should be removed and sanitized or sent to laundry for cleaning as needed;-Each resident room should be cleaned daily and trash removed;-There have been issues with droppings sticking to edges of flooring. He/She had reported the difficulty cleaning to the Housekeeping Supervisor;-Signs of pests including droppings should be reported immediately to the Housekeeping Supervisor;-Housekeeping staff were responsible for cleaning each assigned hall including rooms. Observations on 02/02/26, starting at 10:19 A.M., of [NAME] Oak Hall showed the following:-room [ROOM NUMBER] had multiple mouse-like droppings inside the top drawer of a dresser near the corridor door. The drawer also contained resident clothing items. The drawer appeared in the same condition as previous observation on 01/29/26;-room [ROOM NUMBER] had multiple crumbs of food items on the floor under the resident bed near the window and trash can. The windowsill had multiple mouse-like droppings consistent with observations on 01/29/26 and 01/30/26. During an interview on 02/02/26, at 10:43 A.M., Housekeeper K said the following: -Each resident room was checked daily during cleaning for signs of mice and other pests;-He/She checked the entire room for signs of pests;-Droppings should be immediately removed and the impacted area should be cleaned and sanitized;-Laundry should be removed from impacted areas and sent to laundry for cleaning;-Mouse droppings have been an issue for one month;-Signs of mice should be reported immediately to the Housekeeping Supervisor;-Housekeeping staff were responsible for cleaning their assigned halls and rooms. During an interview on 02/02/26, at 1:43 P.M., the Housekeeping Supervisor said the following: -Housekeeping staff should fully clean each room daily and check for signs of pests;-Housekeeping staff should check drawers and other common pest areas for signs of activity and report to her immediately if any activity is found;-Areas of pest activity should be cleaned and sanitized immediately. Resident items should be removed, cleaned, and sent to laundry as needed;-She was unaware of any reports of areas with difficulty cleaning of droppings;-Housekeeping staff were responsible for properly cleaning their assigned hall and rooms. During an interview on 02/02/26, at 2:53 P.M., the Administrator said the following: -Housekeeping staff should check resident rooms daily for signs of pests and report to Administrative staff immediately of activity found;-Rooms should be deep cleaned when signs of pests are found;-The deep clean should include cleaning and sanitizing of impacted areas including dressers and drawers, checking the room for entry points of pests, and washing clothing;-Housekeeping staff were responsible for compliance. Complaint 2717249

Based on observation, interview, and record review, the facility failed to prevent a pressure ulcer that progressed from a suspected deep tissue injury to a Stage IV for one resident, Resident # 2. The facility failed to put pressure relieving interventions such as pressure relieving devices and repositioning in place. The facility failed to track and document the progression or deterioration of the wound consistently. The facility did not assess the resident's risk of developing pressure ulcers and did not update and put prevention and healing interventions on the resident's care plan, such as repositioning every two hours, relieving pressure on the heels by floating them, and applying heel protectors. This practice affected one resident out of a sample of 12. The facility census was 50. Pressure ulcer staging according to the U.S. Dept. of Health and Human Services Clinical Practice Guidelines Number 15 showed: -Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is non-blanchable); -Stage II pressure ulcer (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater); -Stage III pressure ulcer (full thickness skin loss involving damage or death of subcutaneous (layer of skin under the top layer of skin that usually contains fatty tissue) tissue that may extend down to but not including the bone); -Stage IV pressure ulcer (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures). Suspected Deep Tissue Injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.) The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) According to the National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org, deep tissue injury is a term to describe a unique form of pressure ulcers. Clinicians described these ulcers for many years with terms such as purple pressure ulcers, ulcers that are likely to deteriorate and bruises on bony prominences. Although it looks like a deep bruise, deep tissue injury is sometimes mistaken for a Stage I pressure ulcer. This can happen if only the color and fact that the skin is intact are noted. NPAUP's proposed definition is a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III. The wound may include undermining or tunneling to a Stage IV. Slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) may be present on some parts of the wound bed. The pressure ulcer often includes undermining and tunneling even with optimal treatment. (NPAUP) Deep tissue injury represents a dangerous lesion due to its potential for rapid deterioration. Record review of the U.S. Dept. of Health and Human Services Clinical Practice Guidelines, Number 15, Treatment of Pressure Ulcers, showed the following information: -Assess the pressure ulcer initially for location, stage, size, tracts, exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury), necrotic tissue (death of tissue in response to disease or injury), and presence or absence of granulation tissue (formation of new tissue, usually pink to red in color) and [MEDICATION NAME] (healing by the growth of epithelium over a denuded surface). -To monitor progress or deterioration, the examiner must accurately measure the length, width, and depth of the ulcer. -Reassess pressure ulcers at least weekly. -Indicators of a deteriorating pressure ulcer include increases in exudate and wound [MEDICAL CONDITION], loss of granulation tissue, and a purulent discharge. -A clean pressure sore should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. Record review of the facility's wound care policy, dated 02/01/11, showed the following information: -Purpose: To prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions; -To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown; -To promote healing of pressure ulcers in cost efficient and timely manner; -Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers; -Risk identification and assessment: -The purpose of the assessment is to collect enough information to evaluate the resident's general condition, characterize a pressure ulcer, and identify related causes and complications; -A Braden Scale should be completed for all residents upon admission, readmission, when a significant change of condition occurs, and with each Minimum Data Set (MDS) (a federally mandated resident assessment tool completed by facility staff) assessment; -Residents with a Braden score of 12 or less should be considered to be at high risk for pressure ulcer development; -Findings from the weekly skin assessment should be documented by the licensed nurse on a Weekly Skin Assessment form; -Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, on the Wound Evaluation Flow Sheet; -Documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis (dead tissue) odor, tunneling, or undermining; -The PUSH Tool 3.0 and Pressure Ulcer Healing Chart should be completed in conjunction with these weekly wound assessments; -At the direction of the facility Quality Assurance (QA) Committee, a Weekly Wound Report should be completed by the Director of Nurses (DON), or designee, on a weekly basis for review and monitoring by the QA Committee to assure objectives of this policy and protocols are being met. According to Elizabeth A. Ayello, PhD, RN, CS, CETN at Medscape.com, Pressure ulcers are serious problems that occur frequently in hospitalized , community-dwelling and nursing home older adults, accounting for 3-11% in acute facilities, and 24% in long-term facilities. Once they occur, pressure ulcers in the older adult may lead [MEDICAL CONDITION] and death. A key to prevention is early detection of at-risk patients with a valid and reliable pressure ulcer risk assessment instrument. T he Braden Scale for Predicting Pressure Sore Risk is among the most widely used tools for predicting the development of pressure ulcers. Clinicians typically use the tool to assess six risk areas for developing pressure ulcers: sensory perception, skin moisture, activity, mobility, nutrition and friction/shear. Each risk area is assigned a score ranging from one (highly impaired) to three/four (no impairment). All risk areas are then added and the total overall risk, ranging from 6 to 23 is determined. Those scores at or below 16 indicate high risk, while scores above 16 indicate moderate to no risk. 1. Record review of Resident # 2's face sheet showed the following information: -Initial admission date of [DATE], with admission [DIAGNOSES REDACTED]. -Readmission date of [DATE], with a new [DIAGNOSES REDACTED]. Record review of the resident's admission-data collection form, dated 05/20/16, showed the only skin condition recorded was a scar from previous heart surgery. Record review of the resident's Braden Scale, staff completed on 05/24/16, showed the resident had a risk factor score of 17. Record review of the resident's admission MDS, dated [DATE], showed the following: -Brief Interview of Mental Status (BIMS) score of 14, which indicated a high level of cognitive functioning; -Staff did not identify the resident at having a high risk for developing pressure ulcers; the resident had no pressure ulcers; -The resident required extensive assistance of one staff with transfers, dressing, personal hygiene, bathing, and locomotion in and out of the room; -The resident walked with extensive assistance of one staff person; -The resident was continent of bowel and bladder; -The resident did not resist cares. Record review of the resident's summarized care plan (identified by staff as the resident's current care plan) showed the following information: -Resident admitted [DATE], and care plan last updated 06/08/16; -Pressure ulcer risk due to a stroke, left sided weakness and inability to move around much on own; -Please check skin during showers and personal care for any red areas and please report them to the charge nurse; -Please, use any skin interventions that the physician thinks is appropriate; -Pain, needs help from staff to reposition in bed; -The care plan did not include interventions such as heel protection devices, floating the heels, repositioning the resident at least every two hours, Podus Boot (suspends the heel to provide pressure relief), or weekly wound documentation. Record review of the weekly skin assessments, dated 08/04/16 through 08/18/16, prior to the heel wound discovery, and filled out by the charge nurses, showed the skin as being intact. Record review of the nurse's notes showed the following information: -On 09/21/16, the resident's left hip x-ray showed a fracture and the resident transferred to the hospital; -On 09/27/16, at 7:15 P.M., the resident returned to the facility. Record review of the resident's admission-data collection form, dated 09/27/16, showed the resident admitted with multiple bruises to both arms, two incisions on the left hip, and redness to the buttocks with a pressure ulcer to the coccyx (tailbone) area. Record review of the weekly skin assessments, showed an entry dated 09/28/16 that the skin was not intact, and indicated a possible suture line on the left hip drawn on the body diagram on the form. Staff did not document anything on the form showing any pressure ulcers. The documentation did not include any information regarding the coccyx wound that was on the readmission data-collection form on 09/27/16. During an interview on 04/07/17, at 7:57 A.M., Certified Nursing Assistant (CNA) C said staff should reposition residents with mobility issues at least every two hours. Resident #2 had mobility issues and was a lot more stiff when he/she returned from the hospital on [DATE], after acquiring a [MEDICAL CONDITION], and had been reluctant to move his/her legs at all. The CNA had put pillows between the resident's legs, but the resident did not like them. The resident had had a pressure ulcer on his/her heel prior to going to the hospital with the [MEDICAL CONDITION], but it had not been that bad. He/she had also had some type of boot on his/her heel prior to the [MEDICAL CONDITION]. He/she was unsure what kind it was. Staff started using Podus Boot sometime after hip surgery. The resident had also had some type of dressing on that heel prior to the hip surgery. The resident had rubbed his/her heels into the bed since he/she had been admitted to the facility, and a nurse had told staff to apply heel protectors and keep them on at all times, but that nurse no longer worked at the facility full-time. The CNA would become upset upon arriving at work and finding the other staff had not floated the resident's heels. Some staff members had known how to float a resident's heels and others had not. The resident was much less mobile since he/she had hip surgery, and was starting to have contractures. Staff used to be able to stand/pivot the resident, but due to the heel wound, staff have had to use a Hoyer lift (A mechanical device with a sling for totally lifting a resident that does not allow for weight-bearing) for transfers. During an interview on 04/06/17, at 10:55 A.M., the DON said the resident used to be able to stand and pivot-do anything on his/her own really. When the resident returned from the hospital after the [MEDICAL CONDITION], he/she did not like staff to mess with him/her. The resident would kick pillows out of the bed. He/she developed a deep tissue injury to the left heel that progressed to being an unstageable wound. (Full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue)). Record review of the resident's quarterly MDS, after the resident's re-admission after the [MEDICAL CONDITION] repair, dated 10/02/16, showed the following information: -BIMS score of 4 (which indicated a low level of cognitive functioning); -Staff did not identify the resident was at risk or high risk for developing pressure ulcers; -Staff did not identify that the resident had any unhealed pressure ulcer(s) at Stage I or higher. -The resident required extensive assistance of one staff with transfers, bed mobility, dressing, personal hygiene, bathing, and locomotion in and out of the room; -Did not walk; -Continent of bowel and occasional incontinence of bladder; -Did not resist cares. -The staff coded some physical and mental functioning and decline for the resident that would present as risk factors for developing pressure ulcers (according to the Braden Scale), although staff wrote on the same document that the resident was not at risk. Record review of the resident's medical record showed staff did not document completion of a Braden Scale assessment since the one they completed on 5/24/16, to show if the resident's risk of pressure ulcers had changed. Record review of a nurse's notes dated 10/04/16, at 11:35 A.M. showed a Stage II wound was on the sacrum and on redness on the buttocks in addition to surgical incisions from the [MEDICAL CONDITION] repair. Record review of the resident's medical record showed no other documentation regarding a pressure ulcer on the resident's sacrum. During an interview on 04/07/17, at 8:15 A.M., the MDS Coordinator said the resident had a decline in his/her abilities after his/her [MEDICAL CONDITION]. The resident had already had a stroke prior to the [MEDICAL CONDITION], and may have had another stroke since admission to the facility. The resident was very stiff, pressed his/her heels into the bed and would not leave pillows under his/her heels. The resident had begun to develop contractures within the last two months. He/she had tried placing a Podus Boot on the resident and elevating the heel, but resident would kick it off the boot. He/she would sometimes find the resident in bed without the boot and was unsure why. The resident's heels were fine before he/she went to the hospital with the [MEDICAL CONDITION]. The resident developed a deep tissue injury on 10/06/16. It had looked like a bruise at first. He/she was unsure if staff put interventions in place on the resident's care plan for the deep tissue injury or the unstageable wound once the deep tissue injury opened. Pressure ulcers should be on the MDS and the care plan. A resident's pressure ulcer risk should also be determined and coded on the MDS. Risk for pressure ulcers was determined by assessing the resident's mobility; if the resident could reposition his/herself; if the resident was continent or incontinent; and if the resident had pain. She looked the resident's Braden score, but found the nurses did not always complete the Braden Scale assessments. He/she would consider the deep tissue injury and the unstageable wound information that should be on the resident's care plan, and staff should put any changes in a wound on the care plan. A resident at high risk for pressure ulcers should have had interventions place on the care plan such as proper positioning; repositioning at least every two hours; using pillows, heel protectors, cushions in wheelchairs, air mattresses for fractures, and floating heels off of surfaces. If a resident refused cares and interventions, he/she would have expected the information to be on the care plan, and documented in the nurse's notes. He/she had arrived on the day shift and observed that staff had not floated Resident # 2 heels floated off of the bed. Record review of a condition change form dated 10/07/16, at 2:00 P.M. showed the resident's left heel appeared necrotic (death of cells in living tissue, that unless removed may delay healing of a wound), with an area measured to be 4.8 centimeters (cm) by 6.5 cm. Record review of the resident's medical record showed no other staff documentation regarding necrotic tissue on the resident's at that time. During an interview on 04/07/17, at 11:45 A.M., the DON said for a resident that had mobility issues, which she considered high, risk for pressure ulcers, she would have expected the staff to put interventions in place. Those interventions should include turning and repositioning the resident at least every two hours, and more frequently if needed. If a resident would or could not move him/herself, then use pillows, heel protectors, and any other interventions ordered by the physician. The DON said staff should have charted the interventions for the resident. They had tried heel protectors once on the resident, but he/she had not liked them. The facility started using the Podus Boot after he/she acquired the deep tissue injury the left heel. Staff tried to reposition the resident with pillows, but he/she did not like anything touching his/her feet. They would have to sweet talk the resident into turning. She would have expected staff to document the resident's refusal of care in order to protect staff, and would have expected staff to add the information to the resident's care plan. She did not recall the resident having had issues with his/her heels before hospitalization . She thought the pressure ulcer stemmed from the [MEDICAL CONDITION] and him/her refusing to float his/her heels, and the heels sat on the bed too long. The staff could have possibly administered stronger pain medication to the resident before attempting to reposition him/her. The resident liked to stay on his/her back. Staff should have updated the resident's care plan after the resident returned from the hospital. The interventions from that time should have included such things as repositioning, decline in functioning abilities, behaviors, wounds, and pressure ulcers. Record review of the physician's orders [REDACTED]. -10/07/16: Cleanse the left heel wound with wound cleanser and pat dry; Place hydrogel gauze in wound bed; Cover with foam and secure with rolled gauze and tape; Change Tuesday and Friday and as needed until healed. Podus Boot to left lower extremity at all times except to shower; Protein powder three times a day with meals to promote healing; Record review of the nurse's notes in the resident's medical record did not show any resistive behaviors to repositioning from 09/27/16 to 04/04/17. The notes showed the resident needed extensive assistance of one to two staff with activities of daily living such as repositioning in bed, transfers, personal hygiene, and bathing. The nurses did not document floating the resident's heels or use of any type of protective device for the heels until the physician ordered the Podus Boot on 10/07/16 after the staff discovered the resident had developed the deep tissue injury. Record review of the physician's orders [REDACTED]. -10/12/16: Apply skin prep to left heel and cover with foam; Secure with gauze roll and tape; Change daily and as needed until resolved; Record review of the resident's wound/skin records showed staff documented the resident's left heel wound weekly from 10/7/16 through 11/01/16. Each week the staff described the wound, they wrote the type of wound, and the size of the wound. They wrote whether or not they notified the physician and whether the physician changed the treatment. On 11/01/16, staff wrote the deep tissue injury had become unstageable with hard eschar; was 4.5 centimeters (cm) by 6.5 cm; the wound bed was black/brown (eschar); the wound deteriorated. Staff notified dietary, the physician, and the resident's family. Staff did not document any entries regarding the left heel wound from 11/01/16 until 12/13/16. On 12/13/16, staff wrote the wound had increased in size from 4.5 centimeter (cm) by 6.5 cm to 6.2 cm by 7.8 cm. Staff did not make any entries on the record until 1/18/17. Staff wrote an entry on that date that showed the wound was 4.5 cm by 5.5 cm. It was improved; it had no exudate, no odor, and had a wound bed of black/brown eschar. During an interview on 04/10/17, at 2:12 P.M., the DON said staff had not assessed the wound after 11/01/17 until 12/13/16. Surveyors noted staff did not assess the wound after 12/13/16 until 01/18/17 as well. The DON said she had done a chart audit and had noticed the staff had not measured the wounds. She said at that time, the wound nurse had been filling in as the MDS coordinator and had asked the charge nurses to fill in and cover the wound assessments. She said the charge nurses had denied that the MDS Coordinator had asked them to assess the wounds. She had given an in-service to all of the charge nurses that covered the wound assessments as soon as the charge nurses could all get together. Record review of the resident's medical record showed the staff preformed weekly skin assessments for resident during the weeks they did not make entries on the resident's wound/skin records from 11/4/16 through 1/12/16. Staff wrote the resident's skin was not intact. The resident had a wound on the coccyx, one on the right buttock and one on the left heel. Staff did not document descriptions of the wounds, the sizes of the wounds, but did write that they used pressure relieving devices, a pressure reduction mattress and a cushion in the wheelchair. On 01/05/17, staff wrote they implemented the use of a pressure relieving boot (Podus). Record review of the resident's Pressure Ulcer Scale for Healing (PUSH) Tool 3.0 and used by the facility showed the staff did utilize the tool for the resident 10/07/16 through 11/01/16 and 01/18/17 through 04/04/17. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -BIMS score of 4 (cognitively impaired); -The MDS did not show the resident was at risk for developing pressure ulcers; -Staff assessed the resident did not have any unhealed pressure ulcer(s) at Stage I or higher. -Resident required extensive assistance of one staff with bed mobility, dressing, personal hygiene, bathing, locomotion in and out of the room (in wheelchair), and extensive assistance of two staff for transfers, did not walk; -Occasionally incontinent of bowel and frequently incontinent of bladder; -Did not resist cares. -The staff coded some physical and mental functioning and decline for the resident that would present as risk factors for developing pressure ulcers (according to the Braden Scale), although staff wrote on the same document that the resident was not at risk. Review of the resident's medical record showed staff did not document completing a Braden Scale assessment since the one they completed on 5/24/16, to determine whether the resident's risk of pressure ulcer had increased. Record review of the resident's wound/skin healing records showed the following weekly assessments of the left heel: -On 01/25/17; staff documented an unstageable deep tissue injury; 4.5 cm by 5.5 cm; the wound bed was black/brown eschar; the wound remained unchanged with no response to treatment. Staff did not document notification of the physician or updating the care plan. -On 02/01/17; staff documented an unstageable wound; 4.6 cm by 5.5 cm; the wound bed was black/brown (eschar); the wound was unchanged with no response. The staff did not document notification of the physician or update of the care plan. Record review of the physician's orders [REDACTED]. He/she wrote to cleanse left heel wound with wound cleanser, pat dry, and apply skin prep to peri-wound area. Apply Santyl (an ointment that helps to debride dead skin tissue such as slough and dead tissue) to wound bed and cover with foam gauze and tape; Change twice a day and as needed; Obtain a culture and sensitivity (a test for bacteria and antibiotics that are appropriate to treat the bacterial infection) of the left heel wound; During an interview on 04/07/17, beginning at 8:15 A.M., the MDS Coordinator said the wound had started shrinking at one time. He/she was unsure of what happened, but the area ballooned up, and it probably became infected or something. The wound started seeping, so the physician ordered Santyl ointment for the wound. Record review of the resident's wound/skin healing records showed the following weekly assessments of the left heel: -On 02/08/17; staff wrote the wound was unstageable; was 5.0 cm by 5.6 cm; had exudate (drainage) purulent (contained pus); and had a sight odor. The exudate amount was small; the wound bed was black/brown eschar; and staff sent a culture of the wound to the lab for testing. The wound had not responded to treatment and had deteriorated. Staff notified the physician and updated the care plan. Record review of the physician's orders [REDACTED]. Secure with Kerlix (gauze roll) and tape; Change every three days; Administer [MEDICATION NAME] (an oral antibiotic) 300 milligrams (mg) twice a day for ten days. Record review of a wound culture and sensitivity report, dated 02/11/17, showed the left heel wound was infected with Proteus Mirabilis (bacteria) and [MEDICAL CONDITION] Resistant Staphylococcus (drug resistant bacteria) organisms; Record review of the resident's wound/skin healing records showed the following weekly assessments of the left heel: -On 02/15/17; staff wrote the wound was unstageable; was 5.0 cm by 6.5 cm and had a wound that bed black/brown (eschar). The exudate from the wound was serosanguinous (blood and clear fluid). (Staff wrote the wound remained unchanged and had no response to treatment, but the wound measurements staff documented were larger than staff had last documented on 02/08/17.) The resident continued on two antibiotics for wound infection; Staff did not document notification of the physician or update of the care plan. -On 02/22/17, staff wrote the unstageable wound was 4.0 cm by 5.0 cm and the exudate was a small amount of serosanguinous fluid. The wound had a slight odor. The wound bed had slough and black/brown (eschar); the wound had responded to treatment and improved. -On 03/01/17, staff wrote the unstageable wound was 4.0 cm by 5.0 cm and exudate was a small amount of serosanguinous fluid. The wound had a slight odor; the wound bed had slough and black/brown (eschar); the wound had not responded to treatment and had deteriorated. Staff did not document notification of the physician or update of the care plan. During an interview on 04/07/17, beginning at 8:15 A.M., the MDS Coordinator said wound specialist had seen the resident at the wound clinic, and initially had thought the resident had osteo[DIAGNOSES REDACTED] (infection of the bone). The wound specialist had ordered soft gauze bandage for it, and there had been [MEDICATION NAME] between the wound and the gauze. Record review of the nurse's notes dated 03/01/17 at 5:55 P.M. showed the resident went to the wound clinic for assessment of the left heel wound. The physician reportedly thought the wound needed debridement (the removal of dead tissue from a wound; it may be done by chemicals or surgery). Record review of the physician's orders [REDACTED]. -03/01/17: Discontinue Santyl dressing to the left heel wound; Clean left heel wound with wound cleanser; Pat dry; Cover with [MEDICATION NAME] (a medicated mesh dressing formulated prevent adherence to the wound) then a ABD (large sterile absorbent pad that resist moisture) pad; Secure with rolled gauze and tape; Change daily or when soiled; -03/10/17: 0.125 % Dakin's (a hypochlorite (bleach) solution used to kill germs in a wound) moistened gauze packing to heel wound daily; Wrap with thick bulky gauze football wrap; Keep weight off affected left heel at all times; Keep in Podus Boot at all times; the resident's heel should not touch any surface at any time; -03/11/17: Hold daily dressing change to left heel until Dakin's solution arrives from pharmacy. Record review of a nurse's note dated 03/14/17, showed the resident saw the wound surgeon on 03/10/17 and the physician wrote new orders. Record review of the medical showed staff wrote no further documentation regarding a debridement or surgical procedure. Record review of a nurse's note, dated 03/11/17, the day shift nurse wrote the resident had a surgical dressing on the left heel. Record review of the resident's wound/skin healing records showed the following weekly assessments of the left heel: -On 03/15/17, the unstageable wound was 4.0 cm by 4.5 cm and now had a depth of 2.5 cm; the wound purulent exudate purulent with a foul odor. The wound bed had slough and black/brown (eschar). Staff wrote the wound had responded to treatment and had improved. -On 03/22/17, the wound was 4.0 cm by 5.5 cm, had a depth of 2.8 cm. The purulent exudate was a copious (large) amount. The wound had a foul odor and the wound bed had slough. The wound had deteriorated. The physician ordered a [DEVICE] assisted closure (vac) (the use of vacuum-assisted drainage to remove blood or serous fluid from a wound). Staff documented update of the care plan. Record review of the nurse's note showed the resident went to the wound clinic on 03/22/17. Record review of the physician's orders [REDACTED]. Continue Dakin's solution treatment for one week then start wound vac at 125 millimeters of mercury (mmHg) pressure continuous; Change three times weekly; Record review of the resident's wound/skin healing records showed the following weekly assessments of the left heel: -On 03/28/17; staff wrote the wound was 4.0 cm by 5.0 cm and had a depth 2.8 cm; it had moderate amount of serosanguinous exudate, with no odor. The wound bed had [MEDICATION NAME] and granulation tissue (sign of healing); the wound was improved. Record review of the physician's orders [REDACTED]. to left heel 125 mmHg; change three times weekly. Record review of the resident's wound/skin healing records showed the following weekly assessments of the left heel: -On 04/04/17; the wound was 3.5 cm by 4.5 cm with a depth of 2.8 cm; the serosanguinous exudate was a scant amount; it had no odor; the wound bed had granulation tissue (growth of new healthy tissue). The wound had improved. During an observation on 04/04/17, at 2:38 P.M., Resident # 2 sat in a wheelchair with wound vac tubing from the left foot area; a Podus boot protected the heel from surface pressure. During observation and interview on 04/05/17, at 9:28 A.M., Licensed Practical Nurse (LPN) A and the MDS Coordinator prepared to change the wound vac dressing on the resident. The MDS Coordinator said he/she thought the left heel wound started as an unstageable pressure wound with eschar, but looked like a bruise when it first started. He/she thought the reason the wound developed was probably due to the resident breaking his/her hip. The wound started around October 2016 and had debridement in March 2017. The physician ordered a wound vac after the debridement. LPN A and the MDS coordinator removed the