Every finding on record at Country Aire Retirement Center

Based on observation, interview, and record review, the facility failed to ensure staff assisted residents, who required assistance with activities of daily living (ADLs), in a way to maintain good personal hygiene and grooming, when staff failed to provide routine bathing for seven residents (Residents #34, #29, #3, #41, #30 #8 and #36), failed to assist one resident (Resident #34) with shaving, failed to provide nailcare for one resident (Resident #30), and failed to provide incontinence care for one resident (Resident #11), in a review of 15 sampled residents. The facility census was 39. Review of the facility policy, Activities of Daily Living (ADL), revised 05/16/25, showed the following:-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;-The policy did not direct staff regarding frequency of residents' showers/baths. 1. Review of Resident #34's face showed the resident's diagnoses included seborrheic dermatitis (a skin condition that causes a rash on the scalp, face and chest), candidiasis (a fungal infection) of skin and nail, and overactive bladder (a sudden and uncontrollable urge to urinate that can cause incontinence and frequency). Review of the undated facility document, Shower List showed staff were to give the resident a shower on Wednesdays and Saturdays. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 05/01/26, showed the following:-Did not reject care;-Required moderate assistance for showering/bathing;-Required set-up assistance for personal hygiene;-Required supervision for lower body dressing. Review of the resident's shower sheets for May 2026 showed the following:-Shower received on 05/06/26;-No documentation the resident refused or received a second shower the week of 05/03/26 through 05/09/26; -Shower received on 05/13/26 (seven days since his/her last documented shower);-Shower received on 05/16/26;-No documentation the resident received or refused a shower on 05/17/26 through 05/31/26. Review of the resident's care plan, revised 06/05/26, showed no care plan to address the resident's ADL needs, including assistance required for showering and shaving. Review of the resident's shower sheets for June and July 2026 showed the following:-No documentation the resident refused or received a shower on 06/01/26 through 06/19/26;-Shower received on 6/20/26 (35 days since his/her last documented shower on 5/16/26);-No documentation the resident refused or received a shower on 06/21/26 through 07/06/26. During an interview on 07/06/26 at 11:04 A.M., the resident said he/she did not get regular showers. He/She would like at least one shower a week, but it would be nice to have more showers. Observation on 07/06/26 at 11:04 A.M. and 1:59 P.M. showed the resident had eight-to-ten whiskers, approximately 1 inch in length, on his/her chin. His/Her hair was disheveled (not combed/brushed) with an oily appearance, and the strands of his/her hair were in clumps. Observation on 07/07/26 at 8:17 A.M. showed the resident had eight-to-ten whiskers, approximately 1 inch in length, on his/her chin. His/Her was disheveled with an oily appearance, and the strands of his/hair were in clumps. During an interview on 07/07/26 at 8:52 A.M., the resident said the following:-He/She had not had a shower in a couple weeks;-Staff usually trimmed his/her whiskers during showers. He/She felt that was appropriate if he/she was receiving his/her scheduled showers; -He/She felt disgusting and not clean;-He/She did not like going multiple weeks without a shower. Observation on 07/08/26 at 9:05 A.M. showed the resident still had whiskers on his/her chin, and his/her hair was oily and disheveled. Observation on 07/09/26 at 9:55 A.M. showed the resident still had whiskers on his/her chin, and his/her hair was oily and disheveled. 2. Review of Resident #29's Care Plan, last revised 03/25/26, showed no documentation or staff direction regarding the resident's ADL needs or need for assistance. Review of the shower book at the nurses' station showed staff were to give the resident a shower on Tuesdays and Fridays. Review of the resident's Shower Sheets, dated 05/01/26 through 07/09/26, showed the following:-On 05/01/26, the resident received a shower; hair not washed; -No documentation the resident refused or received a shower on 05/02/26 through 05/28/26; -On 05/19/26, the resident received a shower (18 days since his/her last documented showed on 05/01/26)); -No documentation the resident refused or received a shower on 05/20/26 through 05/28/26; -On 05/29/26, the resident received a shower (10 days since his/her last documented shower);-No documentation the resident refused or received a shower on 05/30/26 through 06/03/26 -On 06/04/26, the resident received a shower (six days since his/her last documented shower);-No documentation the resident refused or received a shower on 06/05/26 through 06/08/26; -On 06/09/26, the resident received a shower (five days since his/her last documented shower);-On 06/12/26, the resident received a shower; hair not washed; -On 06/16/26, the resident received a shower; -No documentation the resident refused or received a shower on 06/17/26 through 06/29/26;-On 06/30/26, the resident received a shower (14 days since his/her last documented shower on 06/16/26);-No documentation the resident refused or received a shower after 06/30/26. Observation on 07/06/26 at 10:05 A.M. showed the resident's hair appeared disheveled and greasy. During an interview on 07/06/26 at 10:05 A.M., the resident said the following:-He/She had to beg staff to get a shower;-He/She did not always get two showers a week; -He/She would like at least two showers a week. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Did not reject care;-Required partial to moderate assistance for shower/bath;-Occasionally incontinent of bladder. Observation on 07/07/26 at 8:15 A.M., showed the following:-The resident smelled of urine; -The resident's hair appeared disheveled and greasy. During an interview on 07/07/26 at 8:15 A.M., the resident said the following:-He/She had an appointment at 11:00 A.M. with the dentist;-He/She was supposed to get a shower today but probably wouldn't. The facility was always short on help. Observation on 07/07/26 at 9:56 A.M., showed resident's hair appeared disheveled and greasy. Observation on 07/08/26 at 9:05 A.M., showed the resident's hair appeared disheveled and greasy. During an interview on 07/08/26 at 9:05 A.M., the resident said he/she has not had a shower yet. He/She was supposed to have a shower yesterday. Observation on 07/09/26 at 10:10 A.M., showed the resident's hair appeared disheveled and greasy. During an interview on 07/09/26 at 10:10 A.M., the resident said the following:-He/She had not had a shower yet this week;-He/She did not know when his/her last shower was, probably a week ago. 3. Review of Resident #3's face sheet showed his/her diagnoses included need for assistance with personal cares. Review of the undated facility document, Shower List, showed staff were to give the resident a shower on Tuesday and Thursday. Review of the resident's shower sheets showed the following:-The resident received a shower on 05/05/26;-No documentation the resident refused or received a shower on 05/06/26 through 05/16/26;-The resident received a shower on 05/17/26 (12 days since his/her last documented shower);-No documentation the resident refused or received a shower on 05/18/26 through 05/28/26)-The resident received a shower on 05/29/26 (12 days since his/her last documented shower);-No documentation the resident refused or received a shower on 05/30/26 through 06/11/26. Review of the resident's quarterly MDS, dated [DATE], showed the resident required moderate assistance for showering/bathing and personal hygiene. Review of the resident's shower sheets for showed the following:-No documentation the resident refused or received a shower from 06/12/26 through 06/15/26;-The resident received a shower on 06/16/26 (18 days since his/her last documented shower on 05/29/26);-No documentation the resident refused or received a shower on 06/17/26 through 06/26/26;-The resident received a shower on 06/27/26 (11 days since his/her last documented shower). Review of the resident's care plan, revised 06/30/26, showed the following:-Had an ADL self-care performance deficit;-He/She could wash upper body; staff to do lower body. Review of the resident's shower sheets showed the resident received a shower on 07/04/26 (seven days since his/her last documented shower on 06/27/26). During an interview on 07/07/26 at 8:23 A.M., the resident said the following:-He/She was scheduled to get two showers a week on Tuesday and Thursday, but was lucky to get one a week, and usually had to ask;-He/She never refused a shower;-He/She felt dirty and grimy when he/she did not receive a shower and was embarrassed to attend dialysis for fear he/she may stink or look dirty;-He/She thought it had been one or two weeks since his/her last shower. 4. Review of Resident #41's face sheet showed the following:-He/She was his/her own responsible party;-Diagnoses included need for assistance with personal care. Review of the undated facility document, Shower List, showed staff were to give the resident a shower on Wednesday and Saturday. Review of the resident's shower sheets showed the resident received a shower on 05/16/26; Review of the resident's admission MDS, dated [DATE], showed the following:-Dependent on staff for shower/bathing;-Required moderate assistance for personal hygiene. Review of the resident's shower sheets showed the resident received a shower on 05/26/26 (10 days since his/her last documented shower on 05/16/26). Review of the resident's medical record showed he/she was hospitalized from [DATE] to 06/03/26. Review of the resident's shower sheets showed the following:-No documentation the resident refused or received a shower on 06/03/26 (date he/she returned to the facility from the hospital) through 06/09/26;-The resident received a shower on 06/10/26;-No documentation the resident refused or received a shower on 06/11/26 through 06/19/26;-The resident received a shower on 06/20/26 (10 days since the resident's last documented shower on 06/10/26);-The resident received a shower on 06/24/26;-No documentation the resident refused or received a shower on 06/25/26 through 07/03/26;-The resident received a shower on 07/04/26 (10 days since his/her last documented shower on 06/24/26). Review of the resident's care plan, updated 07/06/26, showed he/she was dependent on staff for showering. Observation on 07/06/26 at 11:00 A.M. showed the resident had long hair that was disheveled with an oily appearance. The strands of his/her hair were in clumps. Observation on 07/07/26 at 8:49 A.M. and 12:10 P.M. showed the resident had long hair that was disheveled with an oily appearance. The strands of his/her hair were in clumps. Review of the resident's shower sheets showed no documentation the resident refused or received a shower on 07/05/26 through 07/09/26. 5. Review of Resident #30's quarterly MDS, dated [DATE], showed the following:-Did not reject care;-Dependent on staff for showers, personal hygiene and shower transfers. Review of the shower book at the nurses' station showed staff were to give the resident a shower on Tuesdays and Fridays. Review of the resident's shower sheets, dated 05/10/26 - 07/05/26, showed the following:-On 05/13/26, the resident received a bed bath, and staff washed his/her hair; -No documentation the resident refused or received a shower or bed bath on 05/14/26 through 05/25/26; -On 05/26/26, the resident received a bed bath, and staff washed his/her hair (13 days since his/her last documented bed bath and hair washing);-No documentation the resident refused or received a shower or a bed bath on 05/27/26 through 06/04/26;-On 06/05/26, the resident received a bed bath, and staff washed his/her hair (10 days since his/her last documented bed bath);-No documentation the resident refused or received a shower or bed bath on 06/06/26 through 06/11/26; -On 06/12/26, the resident received a shower, and staff washed his/her hair (seven days since his/her last documented bed bath);-On 06/16/26, the resident received a bed bath, and staff washed his/her hair;-On 06/19/26, the resident refused bathing;-No documentation the resident refused or received a shower or bed bath on 06/17/26 through 06/28/26; -On 06/29/26, the resident received a bed bath, and staff washed his/her hair (13 days since his/her last bed bath on 06/16/26);-No documentation the resident refused or received a shower or bed bath on 06/30/26 through 07/04/26; -On 07/05/26, the resident received a shower and staff washed his/her hair (six days since his/her last documented bed bath). Review of the resident's care plan, last revised 07/05/26, showed the resident required extensive assistance of one staff for showers. During an interview on 07/06/26 at 10:00 A.M., the resident said he/she received showers about once a week, sometimes less, depending on how short staffed the facility was. Observation on 07/06/26 at 10:00 A.M., showed the following:-The resident lay in bed wearing a hospital gown;-His/Her hair appeared disheveled and greasy;-His/Her fingernails were long and had dark colored debris underneath them. During an interview on 07/08/26 at 10:00 A.M., the resident said he/she did not receive a shower yesterday on his/her scheduled shower day. His/Her scheduled days were Tuesday and Friday. Observation on 07/08/26 at 10:00 A.M., showed the following:-His/Her hair appeared disheveled and greasy;-His/Her fingernails were long and had dark colored debris underneath them. Observation on 07/09/26 at 10:05 A.M., showed the resident's hair appeared disheveled and greasy. During an interview on 07/09/26 at 10:05 A.M., the resident said the following:-He/She received a bed bath about a week ago, and staff did not wash his/her hair -He/She hoped he/she could get a shower today or tomorrow. 6. Review of Resident #8's face sheet showed his/her diagnoses included need for assistance with personal care. Review of the undated facility document, Shower List, showed staff were to give the resident a shower on Wednesday and Saturday. Review of the resident's shower sheets for May 2026 showed the following:-The resident received a shower on 05/20/26;-No documentation the resident refused or received a shower on 05/21/26 through 05/26/26;-The resident received a shower on 05/27/26 (seven days since his/her last documented shower);-No documentation the resident refused or received a shower on 05/28/26 through 06/02/26;-The resident received a shower on 06/03/26 (seven days since his/her last documented shower);-No documentation the resident refused or received a shower on 06/04/26 through 06/07/26;-The resident received a shower on 06/08/26 (five days since his/her last documented shower) Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Impairment on one side of lower extremities;-Required moderate assistance for showering/bathing. Review of the resident's shower sheets showed the following:-No documentation the resident refused or received a shower on 06/09/26 through 06/19/26;-The resident received a shower on 06/20/26 (12 days since his/her last documented shower on 06/08/26). Review of the resident's care plan, revised 06/24/26, showed no care plan to address the resident's ADL needs, including assistance required for showering. Review of the resident's shower sheets showed the following:-No documentation the resident refused or received a shower from 06/21/26 through 07/03/26;-The resident received a shower on 07/04/26 (14 days since his/her last documented shower on 06/20/26). During an interview on 07/06/26 at 11:19 A.M., the resident said the following:-He/She was to receive two showers per week on Wednesdays and Saturdays; -He/She was lucky to get one shower a week, and sometimes he/she went longer than a week without a shower;-He/She felt dirty and unclean when he/she did not receive a shower. 7. Review of the undated facility document, Shower List, showed staff were to provide Resident #36 with a shower on Mondays and Thursdays. Review of the resident's Shower Sheets showed the following:-On 05/14/26, the resident received a shower; -No documentation the resident refused or received a shower on 05/15/26 through 05/20/26;-On 05/21/26, the resident received a shower (seven days since his/her last documented shower). Review of the resident's admission MDS, dated [DATE], showed the following:-Did not reject care;-Required supervision or touch assistance for personal hygiene and toileting;-Required partial/moderate assistance for shower/bathing;-Occasionally incontinent of bladder and bowel;-Diagnosis of dementia. Review of the resident's Shower Sheets showed the following:-On 05/25/26, the resident received a shower;-No documentation the resident refused or received a shower on 05/26/26 through 06/03/26;-On 06/04/26, the resident received a shower (nine days since his/her last documented shower); -On 06/08/26, the resident received a shower;-On 06/11/26, the resident refused a shower but was given a partial bath;-On 06/15/26, the resident received a partial bath, and staff washed his/her hair;-On 06/16/26, the resident received a shower;-On 06/20/26, the resident received a shower;-On 06/25/26, the resident received a partial bath. Staff did not wash the resident's hair; -On 06/29/26, the resident received a partial bath. Staff did not wash the resident's hair. Observation on 07/06/26 at 1:37 P.M. showed the following:-The resident's hair appeared disheveled and greasy;-The resident had a strong urine odor. Observation on 07/06/26 at 3:52 P.M showed the following:-The resident lay awake in bed;-There was a strong body and urine odor in the room;-The resident's hair appeared greasy. Review of the resident's Care Plan, dated 07/07/26, showed the following:-The resident had an ADL self-care performance deficit related to cognitive loss;-Do not rely on the resident to request assistance; anticipate care needs and provide routine assistance throughout the day;-The resident required assistance from one staff for bathing. Observation on 07/07/26 at 10:04 A.M. showed the resident's hair appeared greasy. Observation on 07/07/26 at 7:00 P.M. showed the resident's hair appeared greasy. Observation on 07/08/26 at 1:10 P.M. showed the resident's hair appeared greasy, and he/she had body odor. Review of the facility's Shower Sheet binder showed no documentation the resident received, or refused a shower or bathing from 06/30/26 through 07/08/26. During an interview on 07/09/26 at 12:48 P.M. Certified Nurse Assistant (CNA) D said the following:-It was difficult for staff to give showers when there were more nurse assistants (NAs) than CNAs caring for the residents;-The resident was frequently resistive to toileting, and at times refused to take a shower. The resident would agree to partial baths. 8. Review of Resident #11's quarterly MDS, dated [DATE], showed the following:-Dependent on staff for toileting hygiene;-Always incontinent of bowel and bladder. Review of the resident's care plan, last revised 07/06/26, showed the following:-He/She had an activities of daily living (ADL) self-care performance deficit due to weakness, bilateral lower extremity edema;-He/She required assistance of one staff with toileting and toileting hygiene. Observation on 07/08/26 at 10:20 A.M. showed the following:-CNA D and NA E were in the resident's room;-CNA D removed the resident's urine saturated sweatpants and handed them to NA E; -CNA D partially applied a clean incontinence brief and clean sweatpants on the resident and assisted the resident to stand;-CNA D pulled the incontinence brief and sweatpants up and assisted the resident to sit in his/her wheelchair; CNA D did not perform peri-care for the resident. During an interview on 07/08/26 at 10:40 A.M., CNA D said he/she did not provide peri care to the resident. The resident usually provided his/her own peri care. He/She just had to assist the resident to stand. 9. During an interview on 07/08/26 at 10:40 A.M., CNA D said it was difficult for staff to give showers with only three aides, especially when one aide was certified (CNA) and the other two were not certified (NA). During an interview on 07/07/26 at 6:41 P.M., the Assistant Director of Nursing (ADON) said the following:-Residents had not received their two scheduled showers a week for a while. Administrative staff were aware;-She did not feel the inability to complete showers was due to staffing shortage but due to poor time management;-The facility recently implemented the shower sheet system at the beginning of May;-Staff was to complete the shower sheet when they gave a resident a shower or bed bath or when a resident refused. The charge nurse signed to show staff gave the shower or the resident refused the shower on that day; -Staff kept the shower sheets in a binder for administration to review. During an interview on 07/09/26 at 12:00 P.M., the Director of Nursing (DON) said the following:-Staff were to give resident two showers a week as scheduled;-Staff were to shave residents as needed with showers;-She was aware staff were giving the residents their showers; it was an ongoing issue they were working on;-The facility was trying to get new staff and nurse aides trained to help with the problem; -The facility started using shower sheets in May for tracking and accountability During an interview on 07/09/26 at 2:30 P.M., the Administrator said the following:-Staff were to give resident showers as scheduled;-She was not aware staff were not giving the residents their showers on a regular basis. MO3022694

Based on interview and record review, the facility failed to have written policies and procedures in place regarding visitation rights, including restrictions placed on two residents' visitation (Resident #2 and #3), in a review of six sampled residents. The facility failed to have a system in place regarding the limitations on visitors and failed to communicate the reasons for those limitations to staff. The facility census was 34. During interview on 9/29/25 at 2:15 P.M. the Administrator said the facility did not have a policy regarding visitation rights. Review of the facility policy Resident Rights, dated 6/10/25 showed the following:-The facility will inform the resident both orally and in writing, in a language a resident understands, of his or her rights and all rules and regulations governing conduct and responsibilities during the stay in the facility;-Prior to admission, the social service designee or designated staff member, will inform the resident and/or resident's representative of the resident's rights and responsibilities;-Information about resident's rights and responsibilities will be given to the resident both orally and in writing. 1. Review of Resident #2's letter of guardianship of an incapacitated person and conservatorship of a disabled person showed the following: -On July 17, 2025, Family Member M was appointed and qualified as guardian of the person and conservator of the estate of the resident, an incapacitated and disabled person;-The above-named guardian and conservator was authorized and empowered to perform the duties of guardian and to perform the duties of conservator as provided by law, under the supervision of the court, having the care and custody of the person and the estate of the above named incapacitated and disabled person. Review of the resident's undated, face sheet showed the following:-The resident admitted to the facility on [DATE];-Diagnoses included Alzheimer's disease, anxiety disorder, and cognitive communication deficit. Review of the resident's Social Service Designee (SSD) note, dated 8/28/25 at 9:57 A.M., showed no one could visit the resident if they had a specific last name. Three other names of individuals were listed as not being allowed to visit the resident. Review of the facility's Resident Rights form, provided to the resident's guardian upon admission, showed the following: -The resident has the right, and the facility must provide immediate access to any resident, subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident;-Subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident;-The guardian signed the form on 8/28/25. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 9/3/25, showed the resident had severe cognitive impairment. Review of the resident's care plan, revised on 9/24/25, showed the following:-The resident had a psychosocial well-being problem related to family discord. There was a list of people who could not have contact with the resident per guardian's wishes (date initiated 9/24/25);-A list of 11 people who could not visit the resident was included on the care plan. Observation on 9/29/25 at 10:00 A.M. showed a sign posted in the nurse's station and that showed the following:-The following people are not to have contact with Resident #2 per his/her guardian's wishes, the list included 11 names, which were also on the resident's care plan;-When visitors come in, please ask for identification and name. If they are on the list inform them they cannot have contact with Resident #2. If they insist, contact the police, administration, and Director of Nurses (DON). During an interview on 9/24/25 at 3:45 P.M. the resident smiled and interacted. The resident said he/she saw Family Member I recently and Family Member G. He/She felt safe and had no concerns with anyone visiting him/her. During an interview on 9/24/25 at 12:30 P.M. Family Member M, Resident #2's guardian said the following:-He/She provided the facility a list of family members who could not visit Resident #2;-Family Member I called the guardian and asked if he/she could visit Resident #2 and he/she was told he/she could not visit the resident; -Family Member I had done some vandalism years ago at the cemetery and wasn't a good person;-Family Member I went to the facility to visit the resident anyway and refused to leave. He/She was on the list the guardian provided to the facility and was not to have contact with the resident; -Family Member G went to visit the resident, he/she was also on the list and not allowed to have contact with Resident #2; -Family Member G had no history of crime. Family Member G did not agree with the guardian that one of the family members had taken advantage of the resident therefore he/she did not want Family Member G around the resident. Also, Family Member I and Family Member G made a comment about reporting the guardian for elder abuse; -He/She was also concerned some of the family members had taken advantage of the resident financially. The resident had a large amount of money in the bank, and it was gone; -There had been no formal charges and he/she had not reported this to law enforcement. The guardian thought he/she knew which family member had taken the resident's money;-Some of the family had taken care of the resident before he/she was named guardian, and he/she felt that the resident was taken advantage of by the family; - He/She was Resident #2's guardian and did not want the other family members around the resident. 2. Review of Resident #3's face sheet undated showed the resident admitted to the facility on [DATE]: Diagnoses included anxiety disorder, depressive disorder, bipolar disorder (a chronic mental health condition characterized by extreme mood swings) and nondisplaced intertrochanteric fracture of right femur (a break in the thigh bone that does not move out of place);-The resident did not have a guardian. Review of the facility's Resident Rights form, provided to the resident's guardian upon admission, showed the following: -The resident has the right, and the facility must provide immediate access to any resident, subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident;-Subject to reasonable restrictions and the residents right to deny or withdraw consent at any time, others who are visiting with the consent of the resident;-The resident signed the form on 9/16/25. Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's undated, care plan showed the resident was very social and attended most group activities and visited with staff and peers. Has frequent visitors, encourage visits. During an interview on 9/24/25 at 9:55 A.M. the resident said the following:-He/She admitted to the facility approximately two weeks ago;-Family member G came to visit him/her at the facility. While at the facility, family member G visited another resident, Resident #2, who was also a family member;-The facility called the police on Family Member G, and Family Member G was told he/she was not allowed to come to the facility anymore; -The resident was upset about family member G not being allowed to visit;-He/She normally saw family member G frequently throughout the week, prior to admission to the facility. During an interview on 9/25/25 at 2:00 P.M. Family Member G said the following:-He/She went to visit his/her family member (Resident #3) at the facility;-He/She called the facility a week or so before and asked a staff member if he/she could also visit with Resident #2 who was also a family member and a resident at the facility. Staff told him/her it was fine to visit Resident #2;-On 9/20/25 he/she visited Resident #3 and Resident #2 at the facility. When he/she was at the facility, staff said he/she could not visit Resident #2;-On the evening of 9/20/25 law enforcement came to his/her home and said he/she was subject to charges if he/she returned to the facility because he/she had visited with a resident he/she was not supposed to;-He/She was very concerned about not being able to visit Resident #3. He/She usually visited Resident #3 routinely prior to admission to the facility. The resident had a history of depression, and he/she was concerned this could affect the resident emotionally. During an interview on 9/25/25 at 10:30 A.M. Law Enforcement Agent H said the following: -The Assistant Director of Nursing (ADON) called the 911 center on 9/20/25. He/She reported Family Member G was causing a disturbance and refused to leave the facility; -When law enforcement arrived, other staff were present and said Resident #2 had not been threatened and family member G had visited Resident #2. Family Member G was no longer at the facility when law enforcement arrived;- A law enforcement agent went to family member G's home and instructed him/her not to return to the facility as he/she had been trespassed (notified he/she was no longer allowed on a particular property and if he/she returned he/she may face legal consequences by management at the facility. During an interview on 9/24/25 at 10:30 A.M. Licensed Practical Nurse (LPN) A said the following:-He/She was unaware Resident #2 had any visitor restrictions until 9/20/25;-Family member G came to the facility on a weekend to visit with Resident #3 (a family member) and while he/she was there, family member G stopped to visit with Resident #2, another family member. The resident was not upset by the visit with family member G;-The Social Service Designee (SSD) called the facility and asked if family member G was at the facility and requested to speak with him/her; -Family member G came to the nurse's station and was upset and said the SSD said the resident's guardian did not want him/her to visit Resident #2;-LPN A and Registered Nurse (RN) B, who was also working at the time, looked through the progress notes to see if there were any notes on visitor restrictions;-He/She found a progress note from admission by the SSD. The note indicated anyone with a specific last name, family member G, and another person's name, could not visit Resident #2;-Law enforcement showed up with the Assistant Director of Nursing (ADON) and questioned staff about family member G;-The ADON was related to Resident #2;-LPN A and RN B told law enforcement that family member G was not threatening anyone and had already left the facility;-LPN A was not sure why family member G could not visit Resident #2. During an interview on 9/24/25 at 11:07 A.M. RN B said the following:-Certified Medication Technician (CMT) C came to him/her on 9/20/25 on his/her break and said Resident #2 had a visitor that was not allowed to have contact with Resident #2;-Family member G was observed visiting Resident #2. The resident was not in distress and did not appear upset;-He/She was not aware of any restrictions on visitors for Resident #2. RN B looked through the chart to see if he/she was able to verify this;-LPN A and RN B found a list from admission on a progress note by SSD. The list included a specific last name, and he/she could not remember if family member G was on the list;-SSD called the facility and asked to speak with family member G. SSD did not speak to the staff working. Family member G said that SSD said he/she was not allowed to visit with Resident #2;-RN B was not sure why family member G could not visit. 3. During an interview on 10/6/25 at 2:45 P.M. the Social Service Designee said the following:-Upon admission, Resident #2's guardian provided him/her with a list of family members that could not visit the resident. The guardian provided a specific last name of family members who were not to visit, and two other family members who were also not allowed to visit, one was family member G;-The guardian mentioned one family member took money from the resident, but he/she did not provide anything official, such as court documents, there was no proof of the allegation. The SSD was unaware of any other reasons the guardian wanted to restrict the resident's visitors;-He/She received two phone calls regarding visitors from the ADON that were not to be visiting Resident #2 recently when he/she was off work; -The ADON said family member G was at the facility and the ADON wanted the SSD to speak with family member G. The SSD asked the ADON if anyone else could help with the situation as he/she was off work and he/she was told no;-The SSD called the facility and staff put family member G on the phone and he/she told family member G he/she could not visit Resident #2; -Family member G was on the restricted visitor list that the guardian provided the SSD with upon admission;-On 9/22/25 the ADON called him/her again when he/she was off work and said family member I was at the facility visiting Resident #2;-Family member I was not on the original list of restricted visitors;-The ADON should have followed the chain of command and discussed the situation with the Registered Nurse in the building or the DON before restricting a resident's visitor. During an interview on 9/24/25 at 2:45 P.M. the ADON said the following:-He/She was related to Resident #2 by marriage;-The resident had Alzheimer's disease and intermittent confusion;-The resident had a guardian, and the guardian had provided the facility with a list of family members who were not allowed to visit the resident;-On 9/20/25 CMT C called him/her at home on the weekend and said someone was sitting with Resident #2 at the nurse's station;-The ADON instructed staff to request the visitor's identification;-The visitor was Family Member G;-The ADON called the SSD (who was also off work) and asked where the list of family members was that could not visit the resident. The SSD said the list was in a progress note. Family Member G was on the list of restricted visitors; -The ADON called the Administrator about a visitor being at the facility who was not to visit Resident #2, and the Administrator instructed him/her to call the police; -When the ADON arrived at the facility, Family Member G had already left. The police went to family member G's home to trespass him/her from coming back to the facility;-On 9/22/25 he/she came out of the morning meeting and saw someone visiting Resident #2. He/She asked the visitor for identification, the visitor was Family Member I. -The ADON was aware Family Member I was on the guardian's list of visitor restrictions. The ADON told Family Member I to move away from the resident. Family Member I latched on to the resident's arm and said, the facility staff was making him/her leave;-He/She yelled for assistance from the Director of Nursing (DON) and was able to get Family Member I away from the resident. During an interview on 9/24/25 at approximately 10:30 A.M. and 9/25/25 at 10:45 A.M. the DON said the following:-Resident #2 and Resident #3 were family members;-Resident #2 had a guardian. On 9/21/25 the DON was made aware of a family feud between the family members. The DON was not aware of a list of family members who could not visit Resident #2;-On 9/20/25 Resident #3's Family Member G came to visit him/her and stopped to visit with Resident #2. A staff member contacted the ADON, and the SSD and notified them of the visitor;-The SSD informed staff Resident #2's guardian did not want Family Member G to have contact with the resident;-Family member G was told by law enforcement he/she could not return to the facility. The DON was not sure who made that decision;-Resident #2 was alert and oriented to self and family members. Staff reported Resident #2 did not seem upset with Family Member G when he/she visited the resident;-On 9/22/25 Family Member I came to visit Resident #2. The ADON yelled for help when he/she saw Family Member I with the resident;-The DON told family member I he/she could not visit the resident because he/she was on the guardian's restricted visitors list;-Until the facility could clear everything up, Resident #3's Family Member G could visit in the resident's room, smoke area or out front of the building, but not near Resident #2;-Family member G did not feel comfortable visiting the resident after the police told him/her not to be on the facility property and Family Member G had not returned to the facility since that time;-The ADON could not restrict family from visiting a resident unless it was at the guardian's direction. That needed to go through the chain of command. During an interview on 9/24/25 at 3:30 P.M and 9/29/25 at 2:15 P.M. the Administrator said the following:-Visitors could come and visit residents anytime. The facility did not have a policy regarding visitation rights.-Resident #2 had a guardian and the guardian had provided a list of family members that he/she did not want visiting Resident #2. The facility staff did not know why the guardian restricted those visitors, but staff would honor the guardian's wishes. Staff had not discussed the rationale for the restricted visitors with the guardian;-On 9/20/25 the ADON called her at home and was concerned about a visitor (Family Member G) who was at the facility visiting Resident #2. She directed the ADON to call the police to assure everyone was safe as she was not at the facility; -The facility was not allowing anyone to visit Resident #2 that was on the list provided by the guardian;-The SSD had put a list in the chart at admission on visitor restrictions for resident #2. Intake 2625783

Based on observation, interview and record review the facility failed to ensure staff followed professional standards of practice when staff removed resident medications from packaging and placed them in medication cups prior to morning medication pass for 13 residents. Also, staff failed to ensure insulin was administered correctly for one resident (Resident#3) in a review of six sampled residents. Staff failed to follow the facility's policy to keep the dose button/plunger of the insulin pen pressed and the needle in the skin for six to ten seconds during administration. The facility census was 34.Review of the facility policy Medication Storage, dated 5/9/25, showed it was the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature light, ventilations, moisture control, segregation, and security. During an interview on 9/29/25 the Director of Nursing said the facility did not have a medication administration policy regarding setting up medications prior to administration.Review of the facility policy Insulin Pen, dated 5/16/25, showed the following:-It is the policy of this facility to use insulin pens to improve the accuracy of insulin dosing, provide increased resident comfort, and service as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge;-Injecting the insulin, while still pressing the plunger, keep the needle in the skin for 6-10 seconds and then remove the needle from the skin. 1. Observation of medication cart one on 9/29/25 at 11:20 P.M. showed Certified Medication Technician (CMT) C opened the medication cart drawer, inside the drawer were three paper medication cups with a resident's first name written on the side of each of the cups. Each cup contained medications that had been removed from the original packaging. The medications cups were not labeled to show what medications were in each cup. 2. Observation of medication cart two on 9/29/25 at 11:40 A.M. showed the following:-CMT C opened the medication cart drawer, inside the drawer were ten medications cups with a resident's first name written on the side of each cup. Each cup contained medications that had been removed from the original packing. The medications cups were not labeled to show what medications were in each cup. 3. Review of Resident #3's undated face sheet showed the following:-The resident admitted to the facility on [DATE];-Diagnoses included diabetes. Review of the resident's physician orders, dated September 2025, showed insulin Aspart (a fast-acting insulin used to treat diabetes) solution 100 units/milliliter (ml) 6 units subcutaneously (under the skin) one time a day before lunch. Review of drugs.com showed the following:-Aspart was a fast-acting insulin; -Insert the needle and start injection;-Press and hold down the dose button until the dose counter showed 0;-Continue to keep the dose button pressed and keep the needle in the skin and slowly count to 6 and remove the needle from the skin. Observation on 9/29/25 at 11:25 A.M. showed the following:-Certified Medication Technician (CMT) C turned the Aspart insulin flex pen dose selector to 6 units;-CMT C injected the needle into the resident's stomach and depressed the plunger, a click was heard and the dose counter showed 0;-CMT C immediately removed the needle from the resident's skin;-CMT C did not continue to press the plunger and keep the needle in the skin for 6 seconds to assure all the medication was administered to the resident. 3. During an interview on 9/29/25 at 11:22 A.M. CMT C said the following:- The medications in the cups were to be administered during his/her medication pass;-CMT C said he/she labeled each cup with the resident's first name and placed them back inside the divided drawer until it was time for the medication pass;-He/She knew medications were not to be removed from packaging until time of administration. He/She had so many medications to pass, preparing all the medications ahead of the medication pass time made it easier and quicker to complete his/her medication pass;-He/She was unaware when administering insulin that he/she was to keep pressure on the plunger and keep the needle in the skin for 6 seconds to assure the resident received the full dose of insulin. During an interview on 9/29/25 at 2:00 P.M. the Director of Nursing said the following:-Staff should not remove medications from the packaging until time of administration; -Preparing all the medications ahead of the medication pass could cause a medication error;-Staff should hold the insulin pen needle in the skin for 10 seconds to assure the resident received the full dose of medication. During an interview on 9/29/25 at 2:15 P.M. the Administrator said the facility should follow the facility's policy on medication pass and insulin administration.

Based on interview and record review, the facility failed to notify one resident's (Resident #1) representative when the resident was started on Rexulti (an antipsychotic medication), in a review of six sampled residents. The facility census was 34.During an email correspondence on 10/9/25 at 10:40 A.M. the Director of Nursing said she was unaware of facility policy regarding family notification for a change of condition. Review of the facility's Resident Rights form provided upon admission showed the following:-Free Choice: The resident has the right to be fully informed about care and treatment and of any changes in that care or treatment that may affect the resident's well-being unless incompetent or otherwise found to be incapacitated under the laws of the state, participate in care and treatment or changes in care and treatment;-Resident Right's under Missouri omnibus nursing home act: each resident admitted to the facility, or his/her guardian or legally qualified representative, shall fully be informed of his/her rights and responsibilities of a resident. 1. Review of Resident #1's consent to treat form, dated 11/17/22, showed it was signed by responsible party/Family Member K. Review of the resident's face sheet, undated, showed the following:-The resident admitted on [DATE];-Diagnoses included Parkinson's disease (a progressive movement disorder of the nervous system), unspecified dementia, history of transient ischemic attack (a stroke that only lasts a few minutes), cerebral infarction (stroke), and cognitive communication deficit. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 5/30/25, showed the following: -Severe cognitive impairment;-Disorganized thinking and inattention continuously present. Review of the resident's physician orders, dated 6/4/25, showed an order for Rexulti (an atypical antipsychotic; reduces agitation, aggression, and other disruptive behaviors in people with Alzheimer's dementia) 1 milligram (mg) by mouth one time a day related to anxiety. Review of the resident's progress notes showed no evidence the facility notified the resident's responsible party of the new medication that was started. Review of the resident's care plan, dated 7/21/25, showed the following:-Administer psychotropic medications as ordered and report any side effects noted, such as nausea and vomiting, over sedation or agitation; -Educate the resident/family/ caregiver regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation and maintenance. Review of the resident's physician orders, dated July 2025, showed an order for Rexulti 1 mg, a half a tablet by mouth one time a day related to anxiety. During an interview on 9/25/25 at 8:15 A.M. the resident's family member K said the following:-The facility notified him/her of other changes involving the resident including falls and other medication changes, but the facility did not notify him/her when Rexulti was started for the resident;-He/She noticed a change in the resident around June to July 2025, noting the resident really did not know the family and was very groggy. The resident's speech was hard to understand also;-When staff were questioned about the resident's change in behavior, family member K was informed about the Rexulti being started. During an interview on 9/25/25 at 11:10 A.M. the resident's family member L said the following:-The facility did not notify the family when the resident was started on Rexulti;-The family questioned the resident's change in behavior and was told the resident had been on Rexulti. During an interview on 9/24/25 at 9:15 A.M. the Director of Nursing (DON) said he/she would expect the facility to notify the resident's responsible party/representative of any new medications. During an interview on 9/29/25 at 2:15 P.M. the Administrator said the resident did not have a guardian and did not have a legal power of attorney (POA). The facility needed to talk to the family about getting POA paperwork. She did not feel the facility was required to notify the family of a new medication if they were not a legal POA. Intake 2612003

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #4) in a sample of six residents, remained free of a significant medication error when staff crushed and administered glipizide 24 hour extended release (used to manage blood sugars, the form of medication is gradually released throughout 24 hours) and metoprolol 24 hour extended release (used to manage high blood pressure, the form of medication is gradually released throughout 24 hours) to Resident #4. The facility census was 34.Review of the facility policy, Crushed Medications, dated 6/10/25, showed the following:-Medications shall be crushed in accordance with standards of practice for safety and accuracy in medication administration;-Medications shall be crushed in accordance with physician orders;-Medications that typically should not be crushed include enteric coated medications and sustained-release or extended-release absorption. Review of drugs.com showed inform patients that glipizide ER tablets should be swallowed whole. Inform residents that they should not chew, divide or crush tablets. Review of drugs.com showed Metoprolol ER tablets were not to be crushed or chewed. 1 Review of Resident #4's undated, face sheet showed the following:-The resident was admitted to the facility on [DATE];-Diagnoses included diabetes and hypertension (high blood pressure). Review of the resident's physician orders, dated September 2025, showed the following:-Glipizide ER 5 milligrams (mg) extended release 24-hour tablet one tablet one time a day for diabetes;-Metoprolol ER extended release 24 hour/25 mg, one tablet one time daily for hypertension. Observation on 9/29/25 at 11:55 A.M. showed the following:-Certified Medication Technician (CMT) C removed a medication cup from the medication cart which contained two tablets. CMT C said one tablet was glipizide and the other tablet was metoprolol;-CMT crushed both tablets and placed the medication in yogurt and administered the medication to the resident. Review of the resident's Medication Administration Record (MAR), dated September 2025, showed the following:-On 9/29/25 CMT C documented he/she administered the resident's glipizide ER 5 mg in the morning;-On 9/29/25 CMT C documented he/she administered metoprolol 25 mg ER in the morning. During an interview on 9/29/25 at 1:40 P.M. CMT C said the following:-He/She was not aware the resident's glipizide and metoprolol was extended release medications;-Extended-release medications should not be crushed because it would be absorbed all at once instead of over 24 hours. During an interview on 9/29/25 at 2:00 P.M. and 3:00 P.M. the Director of Nursing said glipizide extended release and metoprolol extended release should not be crushed because the resident would get too much medication at once instead of over 24 hours, which could affect blood sugar and blood pressure. During an interview on 9/29/25 at 2:15 P.M. the Administrator said staff should follow the medication policy for crushed medications. Intake 2612003

Based on interview and record review, the facility failed to ensure there was an adequate number of licensed nurses on duty to meet resident needs. The Social Service Director (SSD)/Licensed Practical Nurse (LPN) A was pulled from his/her duties as the Social Services Director, and unable to follow up on resident concerns, to work the floor as the charge nurse on multiple occasions. SSD/LPN A worked a total of 36 consecutive hours due to having no licensed nurse coverage. SSD/LPN A slept in a recliner at the nurse's station while on duty during his/her 36 hour shift. Registered Nurse (RN) B said he/she was leaving employment 3/19/25; he/she was unable to measure wounds weekly per policy, complete routine skin assessments, or complete necessary documentation due to staffing. The facility did not have an Infection Preventionist, designated wound nurse, or an Assistant Director of Nurses due to staffing. The facility census was 37. Review of the facility's policy titled, General Staffing, dated 2025, showed the following: -Licensed Nurse (RN/LPN) 24/7 coverage; -Staffing levels will be adjusted based on acuity needs using the facility assessment; -The facility will develop contingency plans for staffing shortage (e.g., internal float pool, as needed (PRN) staff, and agency contracts). 1. Review of the Facility Assessment, dated 7/8/24, showed the following: -Desired workforce profile included Assistant Director of Nursing (ADON)/LPN; -Administrative Staffing information desired number included Social Service Director/ LPN A; -The facility desired five full time RNs; -The facility desired seven full time LPNs; -Two residents with contractures; -One resident with intellectual and/or developmental disability; -Residents with documented signs and symptoms of depression was 19; -Residents with a documented psychiatric diagnosis was one resident; -Residents with a diagnosis of Dementia or Alzheimer ' s disease was 11 residents; -Residents with pressure ulcers indicated was three residents; -Residents receiving preventive skin care was 41; -Residents receiving Hospice services was one; -One resident on dialysis care; -Residents with respiratory treatments was four; -One resident with tracheostomy care; -One resident requiring suctioning; -Six residents received injections; -Five residents received mechanically altered diets; -Ten residents received rehabilitative services. Review of the facility's staffing sheets dated March 2024 showed the following: -On 3/15/25 SSD/LPN A worked 6:00 A.M. to 6:00 P.M. and was the only Licensed Nurse in the building; -On 3/15/25 SSD/LPN A worked 6:00 P.M. to 6:00 A.M. and was the only Licensed Nurse in the building; -On 3/16/25 SSD/LPN A worked 6:00 A.M. to 6:00 P.M. and was the only Licensed Nurse in the building. During an interview on 3/18/25 at 10:15 A.M. Resident #2 said the following: -The facility did not have enough nursing staff (LPNs and RNs); -He/She was concerned because LPN A recently worked 36 hours straight and he/she was not sure if that was safe for someone to work that many hours and care for the residents; -RN B was always doing double shifts because the facility was short staffed and now RN B was leaving: -He/She was not sure who was going to take care of the residents. The resident became tearful during the conversation. During an interview on 3/18/25 at 10:05 A.M. Resident #3 said the following: -The facility did not have enough nurses; -He/She had no one to go to about his/her concerns; - He/She had issues with getting a shower twice a week, his/her sheets hadn't been changed in a month, and his/her oxygen concentrator never had water for humidification like it was supposed to have. During an interview on 3/18/25 at 3:15 P.M. Resident #1 said the following: -The facility did not have enough nurses; -Recently LPN A worked 36 hours, because there was no one else to work; -LPN A was exhausted. During an interview on 3/18/25 at 7:45 P.M. Resident #8's family member said the following: -The facility did not have enough nurses (RNs/LPNs); -Recently, SSD/LPN A worked 36 hours in a row because there was no one to relieve him/her. During an interview on 3/18/25 on 7:15 A.M. Certified Medication Technician (CMT) F said the following: -He/She worked 36 hours in a row recently over a weekend with the SSD/LPN A; -He/She worked to be available if there was an emergency to assist SSD/LPN A; -SSD/LPN A did not get a round well and it would be hard for him/her to get down the halls quickly in case of an emergency; -SSD/LPN A was physically exhausted and slept some in the recliner at the nurse's station during the 36 hours he/she worked. During an interview on 3/18/25 at 9:10 A.M. the Social Service Director/Staffing Coordinator/Licensed Practical Nurse A said the following: -He/She was unable to fulfill his/her role as the Social Service Director due to consistently being pulled to the floor to work as a LPN; -He/She was unable to follow-up on concerns brought to him/her by the residents; -He/She recently worked three 12 hour shifts in a row, 36 hours total, because the facility had no licensed nurses to relieve him/her. He/She had to nap in a chair at the facility while working because of being so exhausted; -He/She notified corporate staff of being short licensed nurses and was told to reach out to a staffing agency, but he/she was unsuccessful; -Today would be ten days in a row he/she had worked at the facility and physically he/she was unable to be on his/her feet for that many days/hours in a row; -The facility had only one full time RN, RN B, and his/her last day was 3/19/25; -The facility had one as needed (PRN) RN once RN B was gone; -The facility had one full time LPN on night shift and a part time LPN on day shift; -The facility had a contract with a staffing agency, but had been unsuccessful with finding any routine RN/LPN coverage; -Currently, there were multiple holes in the schedule for licensed nurses and he/she was not sure how the facility would get the shifts covered. During an interview on 3/18/25 at 12:30 P.M. RN B said the following: -He/She didn't get wounds measured weekly per policy, routine skin assessments weren't completed and charting and documentation didn't get done like it should due to staffing; -The facility did not have an Infection Preventionist, designated wound nurse, or ADON and lot of things were not getting done; -His/Her last day was 3/19/25. During an interview on 3/19/25 at 1:25 P.M. Corporate RN C said the following: -He/She was aware SSD/LPN A worked 36 hours or three, 12 hour shifts in a row, due to a shortage of licensed nurses; -He/She thought LPN A could respond in an appropriate timeframe if there was an emergency after working 36 hours; -The facility had exhausted all solutions of getting the shifts covered for LPN A and there was nothing else they could do; -The facility had a shortage of licensed nursing staff and there was a potential of things not getting done as they should. During an interview on 3/18/25 at 4:35 P.M. and on 3/19/25 at 4:20 P.M. The Administrator said the following: -He started working at the facility on 3/17/25; -He was not aware that RN/LPN coverage was so critical; -He would expect there to be plenty of licensed staff to care for the residents. MO251105 MO251103 MO251172 MO251142 MO251147 MO251138 MO251121 MO251144

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to ensure the facility had a RN designated as the Director of Nursing (DON) on a full-time basis. The facility census was 37. Review of the Facility Assessment, dated 7/8/24, showed the following: -The administrative staff should include a DON; -The facility desired five full time RNs. Review of the facility's Director of Nursing Staffing policy, dated 2025, showed the following: -The facility must employ a full-time DON; -The DON must be a Licensed Registered Nurse; -The DON was responsible for overseeing operations, quality of care, staff recruitment, retention and education. Review of the facility's General Staffing policy, dated 2025, showed the following: -RN coverage eight consecutive hours/day seven days a week; -Licensed Nurse (RN/LPN): 24/7 coverage; -Staffing levels will be adjusted based on the acuity needs using the facility assessment; -The facility will develop contingency plans for staffing shortages to include internal float pool, as needed (PRN) staff and agency staff. 1. Review of the facility staffing schedules, dated March 2025, showed the following: -On 3/15/25 no RN coverage; -On 3/16/25 no RN coverage. During an interview on 3/18/25 at 9:10 A.M. the Social Service Director/Staffing Coordinator/Licensed Practical Nurse A said the following: -The facility was told to put a RN with Corporate down on paper as the DON on and off since December 2024; -The facility did not have a DON; -There was no RN in the building on 3/15/25 or 3/16/25; -The facility only had one full-time RN, RN B, and his/her last day was 3/19/25; -The facility only had one as needed (PRN) RN employee once RN B left; -The facility worked with a staffing agency, but had been unsuccessful with finding any routine RN coverage. During an interview on 3/18/25 at 12:30 P.M. RN B said the following: -He/She worked a lot of extra hours/overtime at the facility due to no RN coverage; -His/Her last day would be 3/19/25; . -The facility had a DON on paper from Corporate he/she was told, but he/she had only seen someone from Corporate, RN D, in the facility one time since December 2024; -He/She did not know how to get in contact with Corporate RN D. During an interview on 3/19/25 at 1:25 P.M. Corporate RN C said the following: -The facility needed a DON; -The facility had a shortage of licensed nursing staff, including RN's; -He/She would expect the facility to have a full-time DON and a RN on duty eight hours a day, seven days a week. During an interview on 3/24/25 at 11:30 A.M. Corporate RN L said the following: -He/She was the facility's DON from 2/24/25 through 3/7/25, he/she worked five days in the facility during that timeframe; -On 3/7/25 he/she was told by Corporate staff that he/she was no longer needed at the facility and that the facility had RN coverage; -On 3/14/25 he/she was asked to be the the facility's DON on paper again; -He/She was basically available by phone but was not onsite at the facility on a full time basis; -Corporate RN C had been in the building some; During an interview on 3/18/25 at 4:35 P.M. and on 3/19/25 at 4:20 P.M. The Administrator said the following: -He started working at the facility on 3/17/25; -He thought there was a Corporate RN filling in as a DON; -The facility should have a RN on duty eight hours a day, seven days a week in the building; -The facility should have a full-time DON. Full-time would be approximately 40 hours a week on average in the building. MO251105 MO251103 MO251172 MO251142 MO251147 MO251138 MO251121 MO251144

Based on observation, interview, and record review, the facility administration failed to ensure operations including staffing and required regulatory systems necessary for the care and safety of residents were provided. The facility failed to have a full time Director of Nursing (DON), Assistant Director of Nursing (ADON), and an adequate number of licensed nurses to meet the residents' needs. The facility also failed to have an Infectionist Preventionist (IP) or antibiotic stewardship program in place,which included tracking of antibiotic use and infections. Vendors were not paid for supplies or services timely. The facility census was 37. Review of the facility's Administrator Job Description, undated, showed the following: -The primary purpose of the position is to direct the day to day functions of the facility in accordance with current federal, state and local standards and guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times; -As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties; -Plan, organize, implement, evaluate and direct the Facility's programs and activities in accordance with guidelines issued by management; -Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility; -Ensure that all employees, residents, family members, visitors, and general public follow the facility's established policies and procedures; -Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the facility; -Review resident complaints and grievances and make written reports of action taken. Discuss such actions with residents and family as appropriate; -Working hours: 40, plus hours a week as needed; -Assist in the recruitment and selection of department directors, supervisors, facility non-licensed staff, consultants, etc. -Must be knowledgeable of reimbursement regulations and nursing practices and procedures, as well as laws, regulations and guidelines pertaining to nursing facility administration. 1. Review of the facility staffing schedules, dated [DATE], showed the following: -On [DATE] no Registered Nurse (RN) coverage; -On [DATE] no RN coverage. 2. The facility provided a list of facility employees and agency staff employees' CPR certification cards that had worked since [DATE]. The staffing sheets were compared with the employees that had valid CPR certifications and review showed the following: -On [DATE], night shift, no CPR certified staff; -On [DATE], night shift, no CPR certified staff; -On [DATE], night shift, no CPR certified staff. 3. Review of the Resident Council Minutes, dated [DATE], showed the following: -Televisions were still too loud in some of the rooms, and food was still an issue; -Never have the right size of incontinence briefs; -No water for the oxygen concentrators; -Can the menu's be changed; -Would like more soup, sandwiches and salad; -The veggies were overcooked; -Would like to have regular fried burgers instead of the ones in water; -Coffee, juice and cornbread was not a snack; -There was no documented response by staff to these concerns. Review of the Resident Council Minutes, dated [DATE], showed the following: -The meals were still coming out cold, the vegetables were cold, and using too much pepper; -Still getting corn bread on the snack cart; -Resident televisions were still too loud; -There was no documented response by staff to these concerns. Review of the Resident Council Minutes, dated [DATE], showed the following: -Concerned with no ice water in the daytime; -Cold food, mostly vegetables; -There was no documented response by staff to these concerns. 4. During an interview on [DATE] at 10:05 A.M. Resident #3 said the following: -The facility was short staffed on nurses; -He/She had no one to go to about his/her concerns; -He/She had issues with getting a shower twice a week, his/her sheets hadn't been changed in a month, and his/her oxygen concentrator never had water for humidification like it was supposed to; -The food at the facility was typically cold. 5. During an interview on [DATE] at 7:45 P.M. Resident #8's family member said the following: -He/She didn't have much interaction with the Administrator and only saw him a couple times at the facility; -The facility did not have a DON; -The facility ran out of medium size incontinence briefs. He/She went to the store and purchased some for the resident to have since there were none available at the facility. 6. During an interview on [DATE] at 10:30 A.M. Nurse Assistant (NA) E said the following: -The facility did not have a DON and the Administrator was never at the facility. He/She had no one to go to with questions except the charge nurses and they were busy; -He/She was currently in Certified Nurse Assistant (CNA) classes but had not received any education at the facility once he/she started working except for watching onboarding videos upon hire; -There was no one to go to with his/her concerns at the facility. 7. During an interview on [DATE] at 2:20 P.M. NA G said the following: -He/She started working at the facility in December of 2024; -He/She was not sure who to go to with questions as the facility didn't have DON and the Administrator was seldom at the facility; -He/She was currently in CNA classes and watched some videos upon hire, but had not received any education from anyone. 8. During an interview on [DATE] at 3:45 P.M. the Human Resource (HR) Director said the following: -The facility had a lot of staff who had either expired certifications or the facility didn't have a current copy of their CPR certifications on file to verify if they were up to date; -The Administrator was responsible for setting up the CPR classes and that had not been done; -He/She had given the Administrator a list of staff who had either no CPR certification or expired CPR certifications. During an interview on [DATE] at 12:47 P.M. a Vendor/Accounts Representative for medical supplies said the following: -The facility was sent out a courtesy letter on [DATE] and had until [DATE] to pay the past due balance of over $5000 dollars or they would be unable to reorder future supplies until it was paid in full; -The facility account balance was past due 120 days. During an interview on [DATE] the Maintenance Supervisor said the following: -He contacted the facility's vendor who was responsible for shredding facility documents and records, as the facility needed items shredded; -He was told the bill was past due and the facility owed approximately $3000 dollars on an outstanding balance and the records couldn't be picked up unless the bill was paid; -He was putting all the records in a shed behind the building and it was getting full; -He was told to switch pest control companies by the Administrator because that bill had not been paid; -The facility had not had a full time DON since the end of [DATE]. During an interview on [DATE] at 9:10 A.M. the Social Service Director/Staffing Coordinator/Licensed Practical Nurse A said the following: -The facility was told to put a RN with Corporate down on paper as the DON on and off since [DATE]; -The facility did not have a DON; -There was no RN in the building on [DATE] or [DATE]; -The facility only had one full-time RN, RN B, and his/her last day was [DATE]; -The facility only had one as needed (PRN) RN employee once RN B left; -The facility worked with a staffing agency, but had been unsuccessful with finding any routine RN coverage; -In the past he/she tried to schedule CPR certified staff each shift. He/She didn't know which staff members had a current CPR certification or an expired certification; -He/She recently worked three 12 hour shifts in a row, 36 hours total, because the facility had no licensed nurses to relieve him/her. He/She had to sleep in a chair at the facility while working because of being so exhausted; -He/She notified corporate staff of being short licensed nurses and was told to reach out to a staffing agency, but he/she was unsuccessful; -Today would be ten days in a row he/she had worked at the facility and physically he/she was unable to be on his/her feet for that many days/hours in a row; -He/She gave all the resident concerns from the monthly Resident Council Meeting to the Administrator, and each department head. Nothing was ever done to address the residents' issues or concerns; -The residents consistently had complaints about the food and the administrator did not address the issues. During an interview on [DATE] at 12:30 P.M. Registered Nurse (RN) B said the following: -He/She had been the Infection Preventionist and he/she resigned from that role around September or October of 2024; -The facility was not tracking infections and also didn't have a current antibiotic stewardship program in place; -The new NAs had no one to go to for training or direction; -Licensed nurses were not receiving any training for the electronic medical system, which caused issues with charting; -He/She tried to measure all pressure ulcers weekly when he/she worked, but it was not done weekly. The facility did not have a designated wound nurse; -He/She asked the Administrator for help from the Corporate office to fill in with some of these roles, but nothing was ever done; -His/Her last day at the facility was [DATE]. During an interview on [DATE] at 2:15 P.M. the Business office Manager (BOM) said the following: -He/She sent any payments that were due through Stampli (an automated software for companies to manage financial workflow and process payments); -The Corporate Business Office Manager made all the payments; -He/She didn't necessarily receive a receipt that something had been paid; -He/She would expect all bills be paid on time. During an interview on [DATE] at 3:00 P.M. the Corporate BOM said he/she was not aware of the outstanding bill until today ([DATE]). During an interview on [DATE] at 11:30 A.M. Corporate RN L said the following: -He/She was the facility's DON from [DATE] through [DATE], he/she worked five days in the facility during that timeframe; -On [DATE] he/she was told by Corporate staff that he/she was no longer needed at the facility and that the facility had RN coverage; -On [DATE] he/she was asked to be the the facility's DON on paper again; -He/She was basically available by phone but was not onsite at the facility on a full time basis. During an interview on [DATE] at 1:25 P.M. and on [DATE] at 3:55 P.M. Corporate RN C said the following: -The facility had a shortage of licensed nursing staff and there was a potential of things not getting done as they should; -He/She wasn't aware the facility didn't have a ADON; -He/She was not aware of any issues with the bills at the facility being paid; -He/She would expect the facility to follow their policies and procedures for infection control; -He/She was not aware the facility didn't have an IP or a IPCP program in place; -He/She could not find any documentation at the facility regarding tracking antibiotic use or infections; -He/She would expect all policies followed and care needs met. During an interview on [DATE] at 4:35 P.M., and on [DATE] at 4:20 P.M., and email correspondence on [DATE] at 10:42 A.M. the Administrator said the following: -He started working at the facility on [DATE]; -He would expect there to be plenty of licensed staff to care for the residents. -Typically either the facility would have a Infections Preventionist or the DON would fill that role; -He thought there was a Corporate RN filling in as a DON. The facility should have a full-time DON. Full-time would be approximately 40 hours a week on average in the building; -A CPR certified staff member should be scheduled on each shift. -Typically the DON or the HR director should assure all staff members have current CPR certifications. -He was not aware of any issues with vendors or credit holds. He would expect bills to be paid; -He would expect the facility to follow policies and procedures and the regulatory guidelines; -He was unable to locate any training documentation for the NAs working at the facility. During an interview on [DATE] at 4:00 P.M. the facility's Medical Director said the following: -The facility had no leadership; -She would expect all of the administrative roles be filled in the facility; -She would expect follow-up on concerns that arise; -She would expect the facility to have antibiotic stewardship program, someone designated to follow wounds and report to her weekly on progress; -She was concerned if the facility was currently able to meet each of the residents' needs. MO251105 MO251103 MO251172 MO251142 MO251147 MO251138 MO251121 MO251144

Based on interview and record review, the facility failed to act promptly upon the grievances and recommendations of the Resident Council concerning issues of resident care and quality of life in the facility, and failed to provide the Resident Council with responses, actions, and rationale taken regarding their concerns. The facility census was 37. Review of the facility's Administrator Job Description, undated, showed the administrator was to review resident complaints and grievances and make written reports of action taken. The administrator was to discuss such actions with residents and family as appropriate. During an email correspondence on 3/31/25 at 10:42 A.M., the Administrator said he/she was not sure if there was a written policy on council meetings. The facility followed the regulations by holding monthly meetings. Review of the Resident Council Minutes, dated 1/14/25, showed the following: -Televisions were still too loud in some of the rooms, and food was still an issue; -Never have the right size of incontinence briefs; -No water for the oxygen concentrators; -Can the menu's be changed; -Would like more soup, sandwiches and salad; -The veggies were overcooked; -Would like to have regular fried burgers instead of the ones in water; -Coffee, juice and cornbread was not a snack; -There was no documented response by staff to these concerns. Review of the Resident Council Minutes, dated 2/11/25, showed the following: -The meals were still coming out cold, the vegetables were cold, and using too much pepper; -Still getting corn bread on the snack cart; -Resident televisions were still too loud; -There was no documented response by staff to these concerns. Review of the Resident Council Minutes, dated 3/19/25, showed the following: -Concerned with no ice water in the daytime; -Cold food, mostly vegetables; -There was no documented response by staff to these concerns. During an interview on 3/18/25 at 10:05 A.M. Resident #3 said the following: -He/She had no one to go to about his/her concerns; -He/She had issues with getting a shower twice a week, his/her sheets hadn't been changed in a month, and his/her oxygen concentrator never had water for humidification like it was supposed to; -The food at the facility was typically cold. Observation on 3/18/25 at 10:06 A.M. showed the resident had oxygen on and there was no water noted in the humidification bottle attached to the concentrator. During an interview on 3/18/25 at 9:10 A.M. the Social Service Director/Staffing Coordinator/Licensed Practical Nurse A said the following: -He/She gave all the resident concerns from the monthly Resident Council Meeting to the previous Administrator, and each department head. Nothing was ever done to address the residents' issues or concerns; -The residents consistently had complaints about the food and the previous Administrator did not address the issues. During an interview on 3/18/25 at 4:35 P.M. and on 3/19/25 at 4:20 P.M. The Administrator said the following: -He started working at the facility on 3/17/25; -He would expect the facility to follow policies and procedures and the regulatory guidelines.

Based on interview and record review, the facility failed to follow professional standards of practice for seven residents (Resident #4, #9, #11, #13, #1, #3 and #2 ). Staff failed to follow the physician's orders for droplet precautions (measures taken to prevent the spread of infections transmitted through respiratory droplets) for four residents (Resident #4, #9, #11 and #13). The facility also failed to ensure staff followed physician's orders for medications for three residents (Resident #1, #3 and #2) in a review of 13 sampled residents. The facility census was 37. Review of the facility's policy and procedure, Physician's Orders, dated 2025, showed the following: -It is the policy of the facility to ensure that all physician orders are obtained, documented, and implemented in accordance with federal and state regulations, professional standards, and facility protocols. All orders must be clear, accurate, and carried out in a timely manner to provide safe and effective care for residents; -Any changes or clarifications must be confirmed with the physician and documented accordingly; -Nursing and other appropriate staff must review and acknowledge all new orders; -Orders must be carried out promptly unless contraindicated; -If an order appears unclear or inappropriate, the nurse must contact the prescriber for clarification before implementation; -Regular audits of physician orders will be conducted by the nursing leadership team; -Any discrepancies, errors or delays in order implementation will be reviewed and addressed through staff education and corrective actions. Review of the facility's Infection Control Policy and Procedure, undated, showed the following: -The facility implements evidence-based infection prevention practices to protect resident's, staff, and visitors; -Staff must wear appropriate Personal protective equipment (PPE, gloves, gowns, masks, goggles) based on the transmission risks; -Droplet precautions (measures taken to prevent the spread of infections transmitted through respiratory droplets): For flu/influenza (a common viral infection of the nose, throat and lungs), Respiratory Syncytial Virus (RSV, a common respiratory virus that can affect people of all ages) utilize surgical masks. 1. Review of Resident #4's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 3/11/25, showed the following: -Severe cognitive impairment; -Diagnoses included pneumonia, heart failure and dementia. Review of the resident's nursing note, dated 3/9/25 at 8:59 A.M., showed the resident was diaphoretic (profuse perspiration) with cough and shortness of breath. Obtained orders for chest X-ray. Review of the resident's Physician Order Summary Report dated March 2025 showed on 3/9/25 an order to obtain a chest X-ray. Review of the resident's radiology report dated 3/9/25 showed the findings included minimal right hazy and patchy pulmonary opacities (areas that appear dense or dark) that may represent infectious/inflammatory (pertaining to infection or response to an infection) process, atelectasis (a condition where part of the lung collapses), or chronic lung condition (a lung condition that is persistent). Review of the resident's Physician Order Summary Report dated March 2025 showed an order on 3/10/25 for droplet precautions until symptoms subside. Review of the Physician Order Summary Report dated 3/11/25 showed an order for Levaquin (antibiotic) 500 milligrams (mg) for seven days for pneumonia. Observation on 3/18/25 through 3/19/25 showed the resident didn't have signage on the door indicating droplet precautions. 2. Review of Resident #9's quarterly MDS dated [DATE] showed the following: -Short and long-term memory impairment; -Cognitive skill for daily decision making was poor; -Diagnoses included dementia and Parkinson's disease (a progressive neurological disorder that affects movement); Review of the resident's progress note, dated on 3/8/25 at 5:36 P.M., showed the resident was noted to have a cough that morning, cough medication administered. Review of the resident's physician's order dated 3/10/25 showed the following: -Droplet precautions until symptoms resolve; -Chest x-ray, Coronavirus Disease 2019 (COVID-19, an acute disease in humans caused by a Coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions. ) and flu test as previously ordered and notify with abnormal results. Review of the resident's physician order summary dated March 2025 showed the facility didn't transcribe the physician's order for droplet precautions onto the order summary sheet. Review of the resident's nursing note, dated 3/10/25 1:27 P.M., showed the resident continues with nonproductive cough. Review of the resident's nursing note, dated 3/14/25 at 2:00 A.M., showed the resident continued with an occasional cough and was diaphoretic. 3. Review of the Resident #11's quarterly MDS, dated [DATE], showed the following: -Short and long-term memory impairment; -Cognitive skill for daily decision making was poor; -Diagnoses included dementia. Review of the resident's nursing note, dated 3/8/25 at 10:22 A.M., showed the resident was noted to have a deep, barky cough. Review of the resident's physician's order dated 3/10/25 showed the following: -Droplet precautions until symptoms resolve; -Chest X-ray, COVID and flu test as previously ordered and notify with abnormal results. 4. Review of Resident #13's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included stroke. Review of the resident's physician order dated 3/10/25 showed the following: -Droplet precautions until cough and congestion resolves; -Chest X-ray, COVID and flu test as previously ordered and notify with abnormal results. Review of the resident's notes dated 3/12/25 at 12:24 A.M. showed staff administered as needed breathing treatment due to the resident having an increased, loose cough. During an interview on 3/19/25 at 7:45 A.M. the Social Service Director/Licensed Practical Nurse (LPN) A said the following: -Earlier that month the facility had several residents who were ill with abnormal respiratory symptoms including cough, congestion and fever; -Medical Director/Physician N gave orders for all the residents to be placed on droplet precautions to prevent it from spreading to other residents; -The previous administer told staff not to worry about following the orders for droplet precautions. During an interview on 3/18/25 at 12:30 P.M. Registered Nurse (RN) B said the following: -On 3/10/25 the facility had multiple residents with a horrible cough, congestion, and shortness of breath; -Medical Director/Physician N gave specific orders to place those residents on droplet precautions while the residents were symptomatic to prevent it from spreading to other residents; -The previous Administrator said not to worry about following droplet precautions because there was no definitive diagnosis; -He/She left the order for droplet precautions on each of the resident's charts, but the facility did not follow the order for precautions; -Resident #4 was diagnosed with pneumonia; 5. Review of Resident #1's quarterly MDS dated [DATE] MDS showed the following: -Cognitively intact; -Diagnoses included diabetes (elevated blood sugar). Review of the resident's Order Summary Report, dated March 2025, showed an order for Lispro insulin (rapid acting insulin), inject 10 units before meals. Review of the resident's Medication Administration Record (MAR) dated March 2025 showed the following: -Lispro insulin 10 units, inject 10 units before meals; -On 3/11/25 at 7:00 A.M., Agency Registered Nurse (RN) M documented he/she administered Lispro insulin 10 units; -On 3/11/25 at 12:00 P.M., Agency RN M documented he/she administered Lispro insulin 10 units. During an interview on 3/18/25 at 3:15 P.M. the resident said the following: -Approximately a week ago when RN M, an agency staff, was working and did not give the resident his/her insulin; -The resident's blood sugar ran high normally, and he/she needed his/her insulin; -He/She reported his/her concerns to the Administrator, and he/she thought RN M was fired. 6. Review of Resident #3's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Diagnoses included stroke, heart failure (the heart is not pumping blood effectively to meet your body's needs) and diabetes (elevated blood sugar). Review of the resident's MAR dated 3/11/25 showed the following morning medications scheduled and documented as administered by RN M: -Aspirin 81 milligrams (mg) one tablet (related to history of a stroke); -Calcitriol 0.25 micrograms (mcg) one tablet (for arthritis); -Cymbalta 60 mg one capsule daily (for depression); -Dapagliflozin 10 mg one tablet (for diabetes); -Multivitamin one tablet (supplement); -ProFe oral capsule give one capsule (for an iron supplement); -Protonix 40 mg delayed release capsule, take one capsule (for reflux disease); -Metoprolol 50 mg give one tablet (blood pressure); -RN M did not document the resident refused any morning medications. Review of the resident's MAR dated March 2025 showed the following: -On 3/11/25, RN M documented he/she administered eight routine morning medications to the resident; -RN M did not document the resident refused any morning medications. During an interview on 3/18/25 at 10:25 A.M. the resident said the following: -An agency staff worked last week, RN M, and RN M brought in the resident's morning medications; -The medications were not correct, and two pills were missing from what the resident normally took in the morning; -He/She questioned RN M about the medications being wrong. RN M got upset with the resident when he/she questioned RN M; -He/She refused his/her medications. He/She told the Administrator about the situation. 7. Review of Resident #2's significant change MDS dated [DATE] showed the following: -Cognitively intact; -Diagnoses included diabetes (elevated blood sugar), and malignant neoplasm of endometrium (cancer in the uterus that can spread). Review of the resident's MAR dated 3/11/25 showed the following morning medications scheduled and documented as administered by RN M: -Acidophilus one capsule (for gastrointestinal); -Amlodipine 10 mg one tablet (for high blood pressure); -Bumex 2 mg one tablet (for swelling in lower extremities); -Cholecalciferol 125 mcg two tablets (supplement); -Ferrous sulfate 325 mg one tablet (iron supplement); -Folic acid one tablet (supplement); -Gemtesa 75 mg one tablet (for overactive bladder); -Liquacel protein gummies (for abnormality of albumin); -Magnesium oxide 200 mg one tablet (for heartburn) ; -Multiple vitamin one tablet (supplement) -Carvedilol 25 mg one tablet (for high blood pressure); -Cephalexin 500 mg one tablet (for wound infection); -Magnesium 400 mg one tablet (supplement for low magnesium); -Gabapentin 400 mg one capsule (for pain); -Zofran 4 mg two tablets (for nausea); -Oxycodone 10 mg one tablet (for severe to moderate pain); -RN M didn't document the resident refused any morning medications. Review of the resident's MAR dated 3/11/25 showed the following: -On 3/11/25 RN M documented he/she administered 14 morning medications to the resident; -RN M did not document the resident refused any medications. During an interview on 3/18/25 at 10:15 A.M. the resident said the following: -RN M, an agency staff member, had worked at the facility a few times; -Last week when he/she worked, RN M attempted to administer him/her medications in the morning and the medications were incorrect; -He/She refused to take the medications from RN M; -He/She was not sure if anything was done about the issue. 8. During an interview on 3/18/25 at 7:15 P.M. Certified Medication Technician (CMT) F said the following: -He/She had multiple complaints from residents about RN M, who was an agency staff member, regarding medication pass on 3/11/25; -The residents said they had missed medications or didn't receive their medications correctly; -The residents who complained were alert and very familiar with their medications. During an interview on 3/19/25 at 7:45 A.M. the Social Service Director/Licensed Practical Nurse (LPN) A said the following: -Resident #1, #2 and #3 reported their medications were administered incorrectly when RN M, an agency staff member, worked at the facility on 3/11/25; -RN M was scheduled to work 3/20/25, 3/21/25 and 3/22/25. During an interview on 3/18/25 at 12:30 P.M. RN B said many of the residents reported concerns with receiving incorrect medications when RN M, an agency staff member, recently worked at the facility. During an interview on 3/19/25 at 1:25 P.M. Corporate RN C said the following: -He/She would expect the facility to follow the physician's orders for droplet precautions, there was a potential for infections to spread if appropriate precautions were not followed; -All medications were to be administered as ordered; -He/She was aware of some concerns that were reported regarding RN M, an agency staff member, that worked at the facility last week during medication pass; -If insulin administration was missed, there was an opportunity for hyperglycemic (high blood sugar) complications. During an interview on 3/19/24 at 12:45 P.M. and 4:20 P.M. the Administrator said the following: -The facility should follow all physician orders; -Staff should follow the facility's policy on physician orders; -He could not locate any documentation of education provided to RN M after the residents complained about getting incorrect medications and/or omission of their medications. During an interview on 3/19/25 at 4:00 P.M. the Medical Director/Physician N said the following: -Recently she .gave orders for droplet precautions for several residents at the facility who had abnormal respiratory symptoms; -She would expect for staff to follow her orders. Precautions were to prevent the spread of any respiratory infections while testing was done for a definitive diagnosis; -She would expect staff to follow physician orders for medications. MO251105 MO251103 MO251104 MO251172

Based on interview and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating, consisting of chest compressions and artificial respirations) certified staff were scheduled 24 hours a day seven days a week, failed to develop and implement a policy addressing CPR requirements for staff, and failed to maintain documentation of CPR certifications for staff members. The facility had 13 residents with full code status (residents requested to have full resuscitation efforts/CPR in the event of cardiac arrest). The facility census was 37. During an email correspondence on [DATE] at 12:56 P.M., the Administrator said the facility did not have a policy specific to CPR training or certification. The facility would follow the regulatory requirements. 1. Review of the facility's code status report, dated [DATE]/,d+[DATE], showed 13 residents designated as full code status. The facility provided a list of facility employees and agency staff employees' CPR certification cards that had worked since [DATE]. The staffing sheets were compared with the employees that had valid CPR certifications and review showed the following shifts without a staff member who was CPR certified: -On [DATE], night shift; -On [DATE], night shift; -On [DATE], night shift. During an interview on [DATE] at 3:45 P.M. the Human Resource (HR) Director said the following: -The facility had a lot of staff who had either expired certifications or the facility didn't have a current copy of their CPR certifications on file to verify if they were up to date; -The Administrator was responsible for setting up the CPR classes and that had not been done; -He/She had given the previous Administrator a list of staff who had either no CPR certification or expired CPR certifications. During an interview on [DATE] the Social Service Director/Staffing Coordinator/LPN A said the following: -He/She made out the schedule for each shift; -In the past she tried to schedule CPR certified staff each shift. She didn't know which staff members had a current CPR certification or an expired certification; -A CPR certified staff member should be scheduled on each shift. During an interview on [DATE] at 4:20 P.M. the Administrator said the following: -A CPR certified staff member should be scheduled on each shift. -Typically the DON or the HR director should assure all staff members have current CPR certifications.

Based on interview and record review, the facility failed to assure an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use was in place. The facility also failed to have a designated Infection Preventionist (IP). The facility census was 37. Review of the facility's Infection Control Policy and Procedure, dated 2025, showed the following: -The facility implements evidence-based infection prevention practices to protect residents, staff, and visitors; -The facility maintains an Infection Prevention and Control Program (IPCP) overseen by a designated Infection Preventionist (IP) who was trained in infection control; -The IPCP includes: -Surveillance of infections; -Prevention strategies (e.g., hand hygiene, personal protective equipment (PPE, gloves, gowns, masks, goggles use); -Education for staff, residents, and visitors; -Antibiotic stewardship; -Resident with contagious infections are placed on isolation precautions as needed; -Signs are posted outside rooms to indicate precaution levels; -The facility follows an antibiotic stewardship program to prevent antibiotic overuse and resistance; -Antibiotic use is reviewed regularly for appropriateness. During an interview on 3/18/25 at 12:38 P.M. Registered Nurse (RN) B said the following: -The facility currently did not have a functioning antibiotic stewardship program or an IP; -He/She was the IP and was responsible for the program until approximately September 2024; -He/She was the only full time day shift RN and was working multiple hours and could not designate time as the IP and do all of his/her other duties along with overtime hours; -The facility was not currently tracking infections or antibiotic use. During an interview on 3/19/25 at 1:25 P.M. and on 3/31/25 at 3:55 P.M. Corporate RN C said the following: -He/She would expect the facility to follow their policies and procedures for infection control; -He/She was not aware the facility didn't have an IP or a IPCP program in place; -He/She could not find any documentation at the facility regarding tracking antibiotic use or infections. During an interview on 3/19/25 at 4:20 P.M. the Administrator said the following: -He started working at the facility on 3/17/25; -He would expect the facility to have a designated IP or if the facility had a full time Director of Nursing (DON) that could be his/her role; -Part of the DON's role would be to assure the facility had a IPCP in place; -He thought a Corporate RN was filling in as the DON prior to him starting at the facility; -The facility should follow it's policy and procedures regarding infection control in conjunction with the Centers for Disease Control and Prevention (CDC) guidelines.

Based on observation, interview, and record review, facility staff failed to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) for one resident (Resident #2), who had three Stage IV pressure ulcers (Stage IV pressure ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location) and was identified at risk for pressure ulcers in a review of 13 sampled residents. The facility census was 37. Review of the facility policy, Wound Prevention and Treatment Documentation, dated 2022, showed the following: -Chart weekly the wound assessment including measurements and description of wound during rounds. This could be on the weekly wound observation tool on electronic medical records (EMR) or on a paper assessment form; -Make a weekly wound progress note for each resident's wounds. Unless the following items have been documented on the assessment form: Include wound status, wound treatments that are ordered, if the resident was having pain and what treatment for pain is, what nutritional and equipment interventions are in place; -Create, or review and revise the wound plan of care weekly; -Log each wound on the wound report weekly, or utilize assessment reports in the EMR; -There must be a system for nurses and direct care staff to report and document new possible skin issues. Assign nurses to complete a weekly skin check and document it, if you have a wound care nurse it is in his/her job description to assist with monitoring them and the bathing sheets for any new areas of skin breakdown. Staff may utilize bath sheets, EMR charting, stop and watch, or report sheets, just make sure that whichever system you use that there is documented notification and follow through of any changes including pain or other signs and symptoms of infection or non-healing issues; -If a new skin issue is noted, charge nurse informs the physician, gets treatment order written and added to administration record; -Pressure wounds are monitored weekly and as needed by the Director of Nursing (DON) or a designee in collaboration with wound consultant teams. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage I pressure ulcer is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) erythema (redness). Presence of blanchable erythema changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure ulcer is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure ulcer is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage IV pressure ulcer is full-thickness tissue loss with exposed bone, tendon, or muscle, and may include slough or eschar, and often includes undermining and tunneling. 1. Review of Resident #2's Braden Scale Score (a score for evaluating the risk of pressure ulcers to be completed quarterly), dated 10/18/24, showed the resident scored a 16, which indicated the resident was at risk for pressure ulcers. Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/26/24, showed the following: -The resident had one Stage III pressure ulcer and it was present upon admission; -The resident had one Stage IV pressure ulcer and it was present upon admission; -The resident had one unstageable pressure ulcer and it was present upon admission. Review of the resident's significant MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for toilet hygiene. -Required partial to moderate assistance from staff to roll from left to right and to change from a sitting to lying position and from lying to sitting on the side of the bed; -Dependent on staff to safely come to a standing position from a lying position and with a chair/bed to chair transfer; -The resident had an indwelling catheter; -The resident was always continent of bowel; -The resident had a stage one pressure ulcer or greater, a scar over bony prominence, or nonremovable dressing; -The resident was at risk for pressure ulcers; -The resident had one or more Stage I pressure ulcer (s) or higher; -The resident had no Stage I, Stage II or Stage III pressure ulcers; -The resident had three Stage IV pressure ulcers, and these pressure ulcers were present upon admission; -Pressure care treatment provided. Review of the resident's care plan, revised 2/25/25, showed the following: -The resident was admitted with multiple pressure ulcers (initiated 1/31/24); -The resident was at risk for poor healing and infection related to diabetes and incontinence (revised on 1/31/24) -Encourage the resident to frequently shift weight (revised on 1/31/24); -Dietary consult monthly until wounds are resolved (revised on 1/31/24); -Notify provider of no signs of improvement on current wound regimen (revised 1/31/24) -Pressure reducing cushion in chair and air mattress on bed (revised on 1/31/24); -Wound Care consultant agency to follow as needed (PRN), (revised on 1/31/24); -Notify charge nurse promptly of any new red areas or breakdown who will assess and notify the physician (revised on 1/31/24); -Check resident every two hours and assist with toileting as needed (revised on 1/31/25) -Perform objective pressure ulcer risk took such as Braden quarterly and with a significant change (4/3/24). -The resident was able to transfer with assistance of two staff members and a sit to stand device (revised 7/24/24); - The resident had an indwelling urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine) related to a stage four pressure ulcer on the coccyx and a history of bladder incontinence (revised on 7/24/24); -Resident can move side to side with assist of mobility bars (revised on 10/30/24) -Presence of wounds on the left and right buttock and right heel (revised on 1/28/25); -The resident will not drink liquid protein when attempts were made by staff (revised on 1/28/25); -The resident had been using an over-the-counter protein drink mix ice cream daily for protein support (revised on 1/28/25); -Liquacel gummies (for abnormal albumin) ordered one gummy per day (revised 1/31/25); Review of the resident's Physician Order Summary Report, dated March 2025, showed the following: -Diagnoses included pressure ulcer to right buttock Stage IV, pressure ulcer of unspecified location of the skin, Stage III, local infection of the skin and subcutaneous tissue, unspecified, malignant neoplasm of the endometrium (cancer in the uterus that can spread); -Cephalexin (antibiotic) 500 mg one tablet daily for seven days for wound infection (start date 3/10/25); -Cleanse left ischium (the lower and back part of hip bone) with Dakins solution (used to treat skin and tissue infections). Apply skin prep to surrounding skin, apply Santyl (a topical enzyme medication used to remove damaged skin aiding the growth of healthy skin) to wound bed nickel thick, pack with calcium alginate (absorbent non-adhesive dressing used for moderate to heavy drainage), cover, change daily and as needed (order date 2/27/25); -Cleanse right ischium with Dakins solution. Apply skin prep to surrounding skin, apply Santyl to wound bed nickel thick, pack with calcium alginate, cover, change daily and as needed (order date 2/27/25); -Wound gel apply to right heel topically as needed to dry wound bed (order date 12/30/24). Review of the resident's Treatment Administration Record (TAR), dated March 2025, showed the following: -Cleanse right heel with Dakins solution. Apply skin prep to surrounding skin, apply Santyl to wound bed nickel thick, cover with calcium alginate, cover with a nonstick pad, wrap with kerlix change daily and as needed, (No start dated indicated); -Staff documented a daily dressing change. Review of the resident's nursing note, dated 3/16/25 at 8:50 A.M., showed the resident had an extreme amount of wound pain. Pain medication administered. Review of the resident's nursing note, dated 3/17/25 at 3:18 A.M., showed the resident remained on an antibiotic for a wound infection. Odor noted. The resident had increased pain, more then normal. Observation on 3/19/25 at 10:12 A.M. showed the following: -Dressings were not in place to the resident's wounds. Registered Nurse (RN) B said staff removed them earlier due to drainage; -The resident lay on a air mattress; -The resident's buttocks were noted to have red creases/ imprints from the bed linens; -RN B washed his/her hands and put on gloves; -RN B cleaned the resident's left ischium wound with a gauze pad soaked with Dakins solution, RN B applied Santyl to the wound bed with a cotton applicator, and cut strips of calcium alginate and packed gently into the wound, followed by a 4x4 and secured with tape; -RN B washed his/her hands and put on gloves; -RN B cleaned the resident's right heel with a gauze pad soaked in Dakins' solution, RN applied Santyl to the wound bed with a cotton applicator, and cut in strips to fit over wound, followed by a nonstick pad, 4x4 gauze pad and secured with tape; -RN B washed his/her hands and put on gloves; -RN B cleaned the resident's right ischium wound with a gauze pad soaked with Dakins solution, RN B applied Santyl to the wound bed with a cotton applicator, and cut strips of calcium alginate and packed gently into the wound, followed by a 4x4 gauze pad and secured with tape; -There was no odor noted to the wounds; -RN B did not measure the wounds; -The resident's skin was noted to have red creases/ imprints of the bed linens to the resident's buttocks area. Review of the resident's nursing notes and skin assessments from 11/5/24 through 3/19/25, showed there was no evidence staff measured the wounds weekly or skin assessments were completed for the resident. During an interview on 3/18/25 at 12:15 P.M. Licensed Practical Nurse (LPN) H said the following: -He/She didn't measure wounds on any of the residents; -He/She thought RN B tried to measure the wounds weekly During an interview on 3/18/25 at 12:30 P.M. and 3/19/25 at 10:30 A.M. RN B said the following: -The nurses are supposed to do weekly skin assessments and wound measurements, but it didn't get done; - He/She couldn't find any wound measurements on Resident #2 in the resident's medical record; -The licensed nurses were short staffed, and charting and other things didn't get done like they were supposed to; -The resident usually stayed in his/her wheelchair most of the day or in his/her recliner. Staff offered to lay the resident down during the day; -Staff assist the resident with repositioning; -The resident refused having an outside wound care company follow him/her. The resident had them follow him/her briefly, but felt the wounds got worse with their care; -The resident was started on an antibiotic recently because the found had a foul odor and increased drainage. During an interview on 3/19/25 at 1:25 P.M. and 3/31/25 at 3:55 P.M. Corporate RN C said he/she would expect all policies and procedures be followed and resident care needs be met. During an interview on 3/19/25 at 4:20 P.M. the Administrator said the following: -He/She started working at the facility on 3/17/25; -He/She wasn't aware the facility didn't have a designated wound nurse; -He/She would expect the staff to follow the facility policy on wound prevention; -Staff should measure all wounds to monitor progress of the wounds and to assure the treatment in place was effective; -He/She would expect communication with the physician regarding wound status; -He/She thought the corporate nurse was filling in as the DON at the facility; -The DON would be responsible for monitoring to assure wounds were being monitored. During an interview on 3/19/25 at 4:00 P.M. and 4/1/25 at 3:30 P.M. the resident's Physician/Medical Director said the following: -She would expect the facility to measure and assess the status of all wounds weekly; -Measurements of a wound was a very important part of monitoring the status of a wound; -She would expect the facility to send him/her a weekly report on the status of all wounds in the facility to ensure the treatment was effective and no changes were needed on wound care; -The facility currently didn't provide him/her with any wound documentation or weekly wound reports on the resident; -She would expect the facility to follow the wound care policy.

Based on interview and record review the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to ensure the facility had a RN designated as the Director of Nursing (DON) on a full time basis. The facility census was 44. Review of the Facility Assessment, dated 7/8/24, showed the following: -The administrative staff should include a DON; -The facility desired two full time RNs. Review of the facility's undated Director of Nursing Services policy showed the following: -The nursing services department is under the direct supervision of a registered nurse; -The nursing services department is managed by the Director of Nursing Services. The director is a registered nurse; -The DON is employed full time ( 40 hours per week); -The DON is responsible for recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care needs of each resident. Review of the facility's undated Staffing policy showed the following: -The facility provides adequate staffing to meet needed care and services for the resident population; -The facility maintains adequate staffing on each shift to ensure that the resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. 1. Review of the facility staffing schedules, dated December 2024, showed the following: -On 12/4/24 RN coverage for three hours from 6:00 A.M. until 9:00 A.M.; -On 12/5/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/6/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/7/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/8/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/9/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/15/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/16/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/21/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/22/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/28/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/30/24 no RN coverage. Review of the facility staffing schedules, dated 1/1/25 through 1/8/25, showed the following: -On 1/1/25 no RN coverage; -On 1/5/24 no RN coverage. During an interview on 12/30/24 at 10:18 A.M. and 10:43 A.M. and 1/8/24 at 4:05 P.M. the Administrator in Training (AIT) said the following: -The facility's Director of Nursing (DON) quit on 12/29/24; -There was no Registered Nurse (RN) in the building on 12/30/24; -She called a RN to come in but was not sure if he/she would be able to due to childcare issues; -The one full time RN had worked a lot of hours since the DON quit and he/she would get burnt out if they could not find more RNs to hire. During an interview on 12/30/24 at 10:20 A.M. and 1/8/25 at 4:10 P.M. the Administrator said the following: -The facility currently had one full time RN and two RNs worked as needed; -On 12/30/24, there was no RN on duty; -The facility worked with two staffing agencies to try to get RNs hired but had not had any response; -The facility was associated with a corporation but the corporation hadn't sent any help to fill the RN/DON position; -On the days the facility was without a RN on duty in the building, the corporation had a RN available by phone if the facility needed them. The corporate RN was never in the building, only available by phone; -The facility should have a RN on duty eight hours a day, seven days a week in the building; -The facility should have a full time DON; -The facility did not have a policy that directed RN staffing specifically. The facility followed Centers for Medicare and Medicaid Services guidelines. MO244361 MO245027 MO246664 MO246688 MO246744

Based on interview and record review, the facility failed to ensure two residents, (Resident #1 and Resident #2), in a review of eight sampled residents, were free from misappropriation of property, when Registered Nurse (RN) A/Former Assistant Director of Nursing (ADON) misappropriated the residents' narcotics. RN A/Former ADON signed as receiving the residents' narcotic medications from the pharmacy. There was no documentation the narcotic medications were administered or destroyed. The narcotic medications were not found in the facility after RN A/Former ADON received the narcotic medications from the pharmacy. The facility census was 39. On 09/09/24 at 4:05 P.M., the administrator was notified of the past noncompliance which began on 07/06/24. On 08/31/24, the Director of Nursing became aware of the violation of misappropriation of resident's narcotic medication. Upon discovery, the facility conducted an investigation, notified appropriate parties, suspended RN A/Former ADON and all facility staff were educated on the facility misappropriation policy. RN A/Former ADON was suspended on 09/02/24. The deficiency was corrected on 09/03/24 after all staff had been inserviced and RN A/Former ADON was no longer employed with the facility. Review of the facility policy titled, Controlled Substances, revised December 2012, showed the following: -Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled medications (medications with a high potential for abuse) maintained on premises; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record; -All keys to controlled substance containers shall be on a single key ring that is different from any other keys; -Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing. Review of the facility policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised April 2017, showed the following: -Residents have the right to be free from theft and/or misappropriation of personal property; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 1. Review of Resident #1'sface sheett showed the following: -Re-admit to the facility on [DATE]; -Diagnoses included complete traumatic amputation at level between knee and ankle, right lower leg. Review of the resident's individual narcotic record, dated 07/03/24, showed the resident returned with 32 tablets oxycodone-acetaminophen (Schedule II narcotic pain medication) 5-325 milligrams (mg). Review of the resident's Physician's Order Sheet (POS), dated July 2024, showed an order for oxycodone-acetaminophen 5-325 mg, give one tablet by mouth every four hours as needed for pain. Review of the resident's Medication Administration Record (MAR) dated July 2024 (07/03/24 through 07/05/24) showed no documentation staff administered oxycodone-acetaminophen 5-325 mg for pain. (the resident should of had 32 tablets remaining). Review of the resident's Order Audit Report, dated 07/05/24, showed RN A/Former ADON re-ordered the resident's oxycodone-acetaminophen 5-325 mg. Review of a pharmacy delivery receipt, dated 07/06/24 at 3:14 A.M., showed the following: -The pharmacy delivered oxycodone-acetaminophen 5-325 mg, 60 tablets for Resident #1; -Signed by RN A/Former ADON as received. Review of the nurses' cart narcotic sign in log, dated 06/26/24-07/19/24, showed no documentation on 07/06/24, that RN A/Former ADON signed the resident's oxycodone-acetaminophen 60 tablets into the narcotic count/lock box. Review of the resident's Order Audit Report, dated 07/17/24, showed RN A/Former ADON re-ordered the resident's oxycodone-acetaminophen 5-325 mg. Review of the resident's MAR, dated July 2024 (07/05/24 through 07/17/24) showed no documentation staff administered oxycodone-acetaminophen 5-325 mg for pain. (the resident should of had 92 tablets remaining). Review of a pharmacy delivery receipt, dated 07/18/24 at 2:59 A.M., showed the following: -The pharmacy delivered oxycodone-acetaminophen 5-325 mg 60 tablets for Resident #1; -Signed by Licensed Practical Nurse (LPN) G as received. Review of the nurses' cart narcotic sign in log, dated 06/26/24-07/19/24, showed on 07/18/24 LPN G signed the resident'soxycodonee-acetaminophen 60 tablets into the narcotic count/lock box. Review of the resident's MAR, dated July 2024 (07/17/24 through 07/31/24), showed no documentation staff administered oxycodone-acetaminophen 5-325 mg for pain. (the resident should of had 152 tablets remaining). Review of the resident's POS, dated August 2024, showed an order for oxycodone-acetaminophen 5-325 mg, give one tablet by mouth every four hours as needed for pain. Review of the resident's MAR, dated August 2024, (08/01/24 through 08/14/24), showed no documentation staff administered oxycodone-acetaminophen 5-325 mg for pain. (the resident should of had 152 tablets remaining). Review of the resident's Order Audit Report, dated 08/14/24, showed RN A/Former ADON re-ordered the resident's oxycodone-acetaminophen 5-325 mg. Review of the pharmacy delivery receipt, dated 08/15/24 at 2:09 A.M., showed the following: -The pharmacy delivered oxycodone-acetaminophen 5-325 mg 60 tablets for Resident #1; -Signed by RN A/Former ADON as received. Review of the nurses' cart narcotic sign in log, dated 07/19/24-08/19/24, showed no documentation on 08/15/24 that RN A/Former ADON signed Resident #1's oxycodone-acetaminophen 60 tablets into the narcotic count/lock box. At that time, the resident should of had 212 tablets of oxycodone-acetaminophen at the facility. During an interview on 09/05/24 at 11:55 A.M., Resident #1 said the following: -He/She had occasional pain on the right side of his/her stump; -He/She does not complain of pain to staff, had not asked for, or received pain medication. 2. Review of Resident #2's POS, dated August 2024, showed an order for hydrocodone-acetaminophen (Schedule II narcotic pain medication) 5-325 mg, one tablet by mouth every 12 hours as needed for hand pain. Review of the resident's August 2024 MAR showed no documentation staff administered hydrocodone-acetaminophen 5-325 mg for pain. Review of the resident's Order Audit Report showed the following: -On 08/13/24, RN D/IP (Infection Preventionist) re-ordered the resident's hydrocodone-acetaminophen 5-325 mg; -On 8/14/24, RN A/Former ADON discontinued the resident's hydrocodone-acetaminophen 5-325 mg order in the computer system. Review of a pharmacy delivery receipt, dated 08/15/24 at 2:09 A.M., showed the following: -The pharmacy delivered hydrocodone-acetaminophen 5-325 mg 14 tablets for Resident #2. -Signed by RN A/Former ADON as received. Review of the nurses' cart narcotic sign in log, dated 07/19/24 - 08/19/24, showed no documentation on 08/15/24 that RN A/Former ADON signed Resident #2's hydrocodone-acetaminophen 14 tablets into the narcotic count/lock box. During an interview on 09/05/24 at 9:53 A.M., Resident #2 said the following: -He/She does not have much pain; -He/She does not ask for or take anything for pain; -If he/she has pain, he/she doesn't complain about it or request medication for pain. 3. Review of the facility investigation dated 09/02/24 showed the following: -It was reported by RN D/IP and LPN E that there was a missing card of oxycodone-acetaminophen 5-325 for Resident #1; -It was reported that on the previous day there were two cards of oxycodone-acetaminophen 5-325 in the narcotic box and now there was only one card; -This narcotic (oxycodone-acetaminophen for Resident #1) was delivered on 05/20/24 (this card was still located in the narcotic box), 07/18/24, and 08/14/24, and documented into the building by LPN G; -The delivery sheets for these medications were missing from the manifest book along with the sign out sheets for the narcotic and resident daily flow sheets; -It was noted in Resident #1's MAR Resident #1 had not taken this medication in the last two months; -This medication supply had been exhausted three times and reordered three times by RN A/Former ADON; During this investigation two other incidents were noted to have occurred: -On the night shift of 08/14/24, RN A/Former ADON worked the night shift. He/She clocked in at 5:32 P.M. and left at 8:45 A.M. the next morning. RN A/Former ADON received a pharmacy delivery 08/15/24 at 2:09 A.M. and signed for this delivery. Two medications that were included in this delivery were not signed in on the narcotic count sheet. This included a card of Resident #1's oxycodone-acetaminophen 60 tablets and a card of Resident #2's hydrocodone-acetaminophen 14 tablets. The original paperwork showing this delivery had not been located at this time. Duplicates were obtained from the pharmacy; -On the night shift of 07/05/24, RN A/Former ADON clocked in at 5:51 P.M. and left the following morning at 8:16 A.M. RN A/Former ADON received a pharmacy delivery at 3:14 A.M. and signed for this delivery. One medication that was included in this delivery was not signed in for on the narcotic card count sheet. This included a card of Resident #1's oxycodone-acetaminophen 60 tablets. The original paperwork showing this delivery has not been located at this time. Duplicates were obtained from the pharmacy; -Upon investigation the residents involved had not taken any pain medication for several months. The missing narcotics had been ordered in the system only by RN A/Former ADON. Review of RN D/IP's written statement dated 09/05/24 at 3:23 P.M. showed the following: -On Saturday (morning) 08/31/24, he/she counted the nurse cart (held the narcotic medications) with RN A/Former ADON; -He/She noticed that Resident #1 only had one card of oxycodone-acetaminophen with 31 tablets when he/she believed the resident previously had two cards of oxycodone-acetaminophen, of which the first card had 31 tablets and the second card had 60 tablets; -After completion of the narcotic count and report, he/she took LPN E aside and asked if he/she knew why the other card of oxycodone-acetaminophen was gone, LPN E said he/she did not know; -He/She looked through the narcotic manifest and the narcotic destruction binder and found no record of the card of Resident #1's oxycodone-acetaminophen 60 tablets. During an interview on 09/05/24 at 3:08 P.M., RN D/IP said the following: -RN A/Former ADON worked Friday night shift 08/30/24; -Saturday morning (8/31/24), he/she told LPN E something wasn't right with the narcotic count; -Usually Resident #1 had two cards of oxycodone-acetaminophen, but that morning (8/31/24) the resident only had one card in the medication cart/lock box; -LPN E was in charge of the narcotic medications on day shift 08/30/24; -LPN E counted narcotics at change of shift (days to night) with RN A/Former ADON on 08/30/24; two cards of oxycodone-acetaminophen were in the narcotic box for the resident at that time; -RN A/Former ADON was the only nurse with access to the medications (including the narcotics) on Friday night 08/30/24. -She didn't ask RN A/Former ADON about the missing card at the time of the count because she wanted to confirm the second card with LPN E before tipping off RN A/Former ADON. During an interview on 09/05/24 at 3:22 P.M., LPN E said the following: -He/She was the charge nurse on day shift, Friday 08/30/24 and had the keys to the narcotic medications; -RN A/Former ADON was the charge nurse on night shift, Friday 08/30/24; -RN D/IP was the charge nurse on day shift, 08/31/24; -After RN A/Former ADON left the facility the morning of 08/31/24, RN D/IP told him/her the narcotic count wasn't correct; -RN D/IP said he/she did not think the count was correct because when she counted the narcotic medications with RN A/Former ADON on Saturday morning, 08/31/24, there was only one card of Resident #1's oxycodone-acetaminophen in the medication cart/lock box; she was confirming with him/her that there had been two cards previously; -Resident #1 had two cards of oxycodone-acetaminophen in the medication cart/narcotic lock box for a long time; -When he/she counted with RN A/Former ADON on Friday night, 08/30/24, the narcotic count was correct, and Resident #1 had two cards of the medication in the cart/lock box; -When RN D/IP counted with RN A/Former ADON on Saturday morning, 08/31/24, there was only one card of Resident #1's oxycodoneacetaminophenn in the medication cart/lock box. During an interview on 09/05/24 at 4:10 P.M., the Administrator in Training (AIT) said the following: -The pharmacy delivered 60 tablets of -oxycodone-acetaminophen for Resident #1 on 08/15/24. This medication is not accounted for in the narcotic book or in the medication cart. RN A/Former ADON signed he/she received the medication but the medication is not in the facility. RN A/Former ADON ordered Resident #1's oxycodone-acetaminophen four times and the resident doesn't take the medication; -RN A/Former ADON ordered and received hydrocodone-acetaminophen, 14 tablets for Resident #2, and the medication was not in the facility; -RN A/Former ADON ordered Resident #1 and Resident #2's narcotic medications and took the medication from the facility; -Stealing residents' medications was misappropriation of resident property. Review of the DON's written statement, dated 09/05/24 at 3:30 P.M. showed the following: -On 09/01/24, during her investigation, she continued to see RN A/Former ADON had been the only nurse to order medication for Resident #1 (Oxycodone-Acetaminophen); -She looked at Resident #1's MAR and there wasn't any/sufficient documentation to warrant the continued ordering of this medication; -She met with the AIT on 09/02/24. They printed RN A/Former ADON's time cards and pharmacy receipt logs and went through the documentation; -RN A/Former ADON would order Resident #1's oxycodone-acetaminophen on a night shift he/she would work and take the narcotic after signing it in from pharmacy; -RN A/Former ADON would then destroy the documentation and not chart the narcotic into the narcotic flow sheet; -This instance occurred on the night shift of 08/14/24 and 07/05/24; -On 08/30/24, RN A/ADON received a delivery of a narcotic medication (hydrocodone-acetaminophen 84 tablets) for another resident (Resident #9) with two cards of the medication received; -On 08/30/24, RN A/Former ADON only logged in one card of Resident #9's narcotic medication and was able to take Resident #1's card of oxycodone-acetaminophen; -On 08/14/24, RN A/Former ADON also took a card of hydrocodone-acetaminophen 5-325 mg 14 tablets for Resident #2. During an interview on 09/05/24 at 2:30 P.M., the Director of Nursing said the following: -She got a phone call from RN D/IP on Saturday morning 08/31/24. RN D/IP told her something didn't look right in the narcotic box; -Both RN D/IP and LPN E thought Resident #1 had another oxycodone-acetaminophen card but the narcotic count was correct; -She received documentation from the pharmacy and compared pharmacy delivery tickets to RN A/Former ADON's time cards; -On 07/06/24 and 08/15/24, RN A/Former ADON electronically signed for two cards of oxycodone-acetaminophen (120 tablets) for Resident #1 and one card of hydrocodone-acetaminophen 14 tablets for Resident #2; -RN A/Former ADON took Resident #1's Oxycodone-Acetaminophen and Resident #2's Hydrocodone-Acetaminophen and the corresponding pharmacy delivery tickets; -RN A/Former ADON was the only nurse/employee on duty on night shift, 08/30/24, that had access to all residents' medications. MO 241498

Based on observation, interview, and record review, the facility failed to maintain the range hood free of a buildup of grease and debris; failed to maintain the air conditioner and microwave free of a buildup of debris; failed to ensure food items were labeled, dated, covered and discarded when expired; failed to ensure a water dispenser and a water dispensing unit was free of a buildup of debris; failed to ensure staff utilized safe food handling practices when preparing ready to eat food items; failed to ensure staff handled ready to eat foods safely; failed to ensure staff wore hair restraints properly; and failed to ensure the ice machine was equipped with an appropriate air gap to prevent back siphonage. The facility census was 43. 1. Review of the undated facility policy, Cleaning Instructions: Hoods and Filters, showed stove hoods and filters will be cleaned according to a cleaning schedule or at least monthly. Observation on [DATE] at 10:18 A.M. and on [DATE] at 7:49 A.M. showed the range hood had three filters that protected the stove, griddle and fryer. The filters had a heavy buildup of black and dark brown fuzzy debris with yellow and dark brown grease accumulation. The fire suppression system had a buildup of shiny yellow grease with drip formations on the nozzle caps. A sticker on the outside of the range hood showed the hood had been professionally cleaned on [DATE]. During interview on [DATE] at 11:15 A.M., the Dietary Manager said she was unaware dietary was responsible for cleaning the hood filters. The professional company did not clean the filters when they were onsite in February. She had worked in the dietary department for a year and had been the manager for six months. The filters needed to be cleaned. During interview on [DATE] at 2:10 P.M., the Maintenance Supervisor said he was unsure when the range hood filters were last cleaned. It had probably been a while since this had been done. 2. Observation on [DATE] at 10:25 A.M. and on [DATE] at 7:49 A.M. showed an air conditioner sat in the window frame in the kitchen. The exterior vents had a heavy buildup of dark colored fuzzy debris. The cool air blew through the vents towards the microwave and metal food preparation counter. An open plastic container that held large blocks of butter sat uncovered on a tray with the toaster on the metal preparation counter. Observation on [DATE] at 10:26 A.M. and on [DATE] at 7:49 A.M. showed a microwave sat on a metal preparation counter. Rust-colored debris was visible inside the microwave around the bottom edges of the unit. A large rust-colored area on the top inside center portion of the microwave appeared to have exposed metal and peeling/chipped areas. 3. Review of the facility policy, Food Receiving and Storage, revised [DATE], showed the following: -Foods shall be received and stored in a manner that complies with safe food handling practices; -All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date); -Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements; -All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Observation on [DATE] at 10:31 A.M. inside the upright home-type freezer in the kitchen showed the following: -Three black bowls of vanilla ice cream sat uncovered; -A plastic bag of burritos were open to air and not sealed; -An open plastic bag of hamburger patties was open to air and not sealed. Observation on [DATE] at 10:40 A.M. inside the reach-in refrigerator showed the following: -A container of macaroni salad was loosely covered with tinfoil and had a resident's first name and room number written on the foil. The item was not dated; -Two small Styrofoam cups contained a white substance and were not labeled or dated; -A large Ziploc bag contained several peanut butter/jelly sandwiches. The bag was not dated; -A bottle of soda had been opened, but was not labeled with anyone's name; -A large plastic pitcher of dark colored liquid was labeled Cran and was dated ,d+[DATE]. Observation on [DATE] at 10:42 A.M. above the water dispenser on the metal shelf showed an open packet of low calorie drink mix that was open to air and unsealed. Observation on [DATE] at 7:49 A.M. showed a 2-ounce packet of punch drink mix was open to air and sat upright next to the water dispenser. The mix was open and unsealed. Observation on [DATE] at 10:45 A.M. of the triple door reach-in refrigerator showed the following: -A large clear container with a red lid was labeled Chicken noodle ,d+[DATE]; -A clear plastic pouch/bag of scrambled egg mix was closed with a metal binder clip. The bag was not dated; -A large clear container with a red lid contained shredded cheese and was not dated; -A plastic grocery sack held two egg cartons stacked on top of each other and four loose eggs sat on top of the top carton. The sack of eggs/carton sat on the second to bottom shelf directly over a container of cheese and a cantaloupe. Observation on [DATE] at 11:53 A.M. showed the Dietary Manager reheated the chicken noodle in the container dated ,d+[DATE] and placed it on a resident's hall tray for the lunch meal. Observation on [DATE] at 11:05 A.M. showed a metal shelf above the top of the steam table. The shelf contained the following: -The lid on a 16-ounce container of paprika was open and unsealed; -The lid on a 12-ounce container of basil was open and unsealed; -The lid on a 12.5-ounce container of ginger was open and unsealed; -The lid on a 16-ounce container of pumpkin pie spice was open and unsealed. 4. Observation on [DATE] at 10:41 A.M. and on [DATE] at 7:49 A.M. showed a tall upright water dispenser sat on the metal preparation counter. The dispensing spout had a buildup of dark colored crusty debris on the edges of the dispenser. A water filter and water line were connected to the unit. The water filter was labeled install [DATE] with a black marker. During interview on [DATE] at 8:20 A.M., the Dietary Manager said the following: -The water dispenser was cleaned with lime remover once a week; -She was not sure who was responsible for changing the water filter connected to the water dispenser. During an interview on [DATE] at 12:32 P.M., the Maintenance Supervisor said the facility purchased and installed the water dispenser in [DATE]. He was unsure why the filter had a different date on it. 5. Review of the undated facility policy, Bare Hand Contact with Food and Use of Plastic Gloves, showed the following: -Single-use gloves will be worn when handling food directly with hands to ensure that bacteria are not transferred from the food handler's hands to the food product being served. Bare hand contact with food is prohibited; -Staff will use clean barriers such as single-use gloves, tongs, deli paper and spatulas when handling food; -Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Observation on [DATE] at 11:10 A.M. showed the Dietary Manager removed some butter from the open container near the toaster and placed the butter in a skillet on the stovetop. Without washing his/her hands, she put on gloves, and removed two pieces of bread from a loaf. She used a knife to butter one slice of bread and placed it face down in the skillet on the stove. She buttered a second slice of bread and placed the slice of bread on the edge of the stove top. She wore the same gloves, opened the refrigerator door by the handle, and brought a container of cheese slices to the preparation counter. Using the same gloves, she removed a cheese slice from the container and placed the cheese on top of the bread slice in the skillet. She then removed the bread slice from the edge of the stove top and placed it on top of the cheese and bread in the skillet. 6. Review of the undated facility policy, Personal Hygiene and Health Reporting, showed hair should be neat and clean. Hair restraints must be worn around exposed foods, in the kitchen or food services areas and dining rooms. Observation on [DATE] during the lunch meal service between 11:53 A.M. and 1:01 P.M. and at 2:15 P.M. showed Dietary Staff L placed beverages, nutritional supplements and dessert items on each meal tray. He/She wore a hair restraint; however, the hair restraint did not contain his/her bangs and longer strands of hair on the sides of his/her face that were loose outside of the hair restraint. Observation on [DATE] at 7:49 A.M. showed Dietary Staff M wore a hair restraint; however, not all his/her hair from the back and sides of his/her head was contained inside the hair restraint. Dietary Staff M prepared drinks in the kitchen, placed the drinks on breakfast trays and carried the breakfast trays to the kitchen door for facility staff to deliver to residents in the dining room. 7. Observation on [DATE] at 2:44 P.M. and on [DATE] at 8:04 A.M. of the facility ice machine located in the staff breakroom, showed the approximately 2-inch drain pipe was not equipped with an air gap. The pipe sat down inside the drain and did not have adequate spacing for the required air gap. 8. Observation on [DATE] at 2:15 P.M., in the facility kitchen showed the cover over a four-bulb four bulb fluorescent light fixture located above the microwave and food preparation table was cracked and had a 3-inch by 3-inch hole in the cover. During an interview on [DATE] at 3:04 P.M., the Maintenance Director said the following: -He was responsible for monitoring the facility light fixtures and covers; -He checks light fixtures and covers on an ongoing basis; -He was unaware of the identified cracked cover with a 3-inch by 3-inch hole; -He expected facility light fixtures and covers to be maintained and without damage. 9. During interview on [DATE] at 8:20 A.M., the Dietary Manager said the following: -If family brought in food, snacks or drinks for residents, the food items should be separated from facility foods and labeled/dated; -She was unaware the range hood filters needed to be cleaned. She had just learned this task was dietary's responsibility; -Maintenance staff changed the air conditioner filter and dietary staff cleaned the vents and outside cover either weekly or monthly; -Staff cleaned the microwave every shift. She will look closer at the inside to check the rust color inside. She was unaware of any damage inside the microwave; -Leftovers were good for three days, the date on the label is the date food was placed/stored in the refrigerator; -Pre-packaged foods that have not been opened goes by the manufacturers expiration date, salad dressing and condiments go by expiration date on bottle, if poured into dispensing container it is good for three days; -Shredded cheese was used quickly (usually in two to three days after opening) and she was unsure of how long shredded cheese lasted; -The cooks and aides checked the refrigerators for food labeling dates twice a week; -The four loose eggs were leftover from breakfast yesterday and the carton had been thrown away; -Freezer items should be sealed and dated; -Spice lids should not be open; -Opened drink packets should be sealed; -Any employee that entered the kitchen should wear a hair restraint and all hair should be covered; -She was unaware the ice machine did not have an air gap; -Gloves and handwashing should be performed when touching food items, should switch gloves in between different food items, and after touching dirty items, such as door handles, counter tops, etc. During an interview on [DATE] at 12:32 P.M., the Maintenance Supervisor said the following: -Dietary staff were responsible for cleaning the range hood baffle filters regularly and he would assist them if needed; -Dietary staff were responsible for cleaning the air conditioner monthly. He replaced the filters when needed; -He was unaware the microwave had possible rust/debris inside; -He was unaware the ice machine did not have an air gap. 49528

Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #40 and #293), in a review of 16 sampled residents, and one additional resident (Resident #35), were treated in a manner to promote dignity and respect, when the facility failed to cover a urinary catheter (a tub inserted into the bladder that drains urine from the bladder into a collection bag outside of the body) collection bag. The facility census was 43. Review of the facility policy, Quality of Life-Dignity, dated August 2009, showed the following: -Each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered. 1. Review of Resident #40's significant change Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, dated 06/03/24, showed the following: -He/She was cognitively impaired; -He/She was dependent for toileting needs; -He/She had a urinary catheter. Review of the resident's undated Care Plan showed the following: -He/She had a urinary catheter for urinary retention; -Ensure urinary catheter bag cover is used for dignity. Observation on 07/08/24 at 10:35 A.M. showed the resident sat in his/her wheelchair in the common area. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/08/24 at 12:35 P.M. showed the resident sat in his/her wheelchair at a dining room table, eating lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 8:41 A.M. showed the resident sat in his/her wheelchair in the common area. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/10/24 at 8:44 A.M. showed the resident sat in his/her wheelchair in the common area. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/11/24 at 10:39 A.M. showed the resident sat in his/her wheelchair in the common area. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. 2. Review of Resident #293's Baseline Care Plan, dated 06/28/24, showed the following: -He/She required minimal assistance with mobility; -He/She had a urinary catheter. Review of the resident's admission MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She was independent for toileting needs; -He/She had a urinary catheter. Observation on 07/08/24 at 12:28 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/08/24 at 1:34 P.M. showed staff pushed the resident from the dining room to his/her room in his/her wheelchair. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 6:27 A.M. showed Certified Nurse Assistant (CNA) B pushed the resident in his/her wheelchair to the dining room. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 7:11 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating breakfast. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 1:49 P.M. showed therapy staff walked with the resident in the hallway. The resident's urinary catheter bag, which contained urine, hung from the resident's walker. The catheter bag was not covered with a dignity cover. Observation on 07/10/24 at 11:45 A.M. showed Nurse Aide (NA) C pushed the resident in his/her wheelchair to the dining room. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/10/24 at 12:18 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/11/24 at 11:55 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, waiting for lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. 3. Review of Resident #35's quarterly MDS, dated [DATE], showed the following: -He/She was cognitively impaired; -He/She required substantial to maximum assistance for toileting needs; -He/She had a urinary catheter. Review of the resident's undated Care Plan showed he/she had a urinary catheter. Observation on 07/08/24 at 12:34 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 07:31 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating breakfast. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/11/24 at 9:21 A.M. showed two staff transferred the resident from his/her wheelchair to a recliner in the common room, where other residents were present. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. 4. During an interview on 07/11/24 at 11:06 A.M. Nurse Aide (NA) E said urinary catheter bags should always have a dignity cover on them. During an interview on 07/11/24 at 11:11 A.M. CNA F said urinary catheter bags should always have a dignity cover. During an interview on 07/11/24 at 2:51 P.M., the Infection Preventionist/Registered Nurse A said urinary catheter bags should always be in a dignity cover. During an interview on 07/11/24 at 2:42 P.M., the Director of Nursing (DON) said she expected urinary catheter bags to have dignity cover. She was aware of this issue and the facility did not currently have enough dignity covers for all residents with urinary catheters.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 25 residents. The census was 43. Request for a facility policy regarding the reconciliation of the resident funds account was made and none provided. 1. Record review of the reconciliation of resident funds, provided by the Business Office Manager (BOM), showed no reconciliation for the full resident trust account. 2. Record review of the Corporate Accountant's attempted reconciliation of the resident trust account, for accounts ending in #370665 and #342130, for the period 06/2023 through 06/2024, showed no reconciliations. During an interview on 07/10/24 at 3:37 P.M., the BOM said she only reconciled the petty cash accounts. Corporate staff reconciled the bank accounts. During an interview on 7/11/24 at 9:46 A.M., the Corporate Accountant said the facility BOM reconciled the petty cash only. They only reconciled the two bank accounts. During an interview on 07/16/24 at 9:55 A.M., the BOM said Corporate transfers $1,500 each month to the resident trust account so the account does not go into a negative. During an interview on 07/15/24 at 11:48 A.M., the Facility Management Company Staff said the operating account transfers $1,500 monthly to the resident trust account so there were no negative issues. The reconciliation does not deduct out the amount the facility transfers and the reconciliation does not have a $0 difference/balance. The resident petty cash may have been started with facility funds but no documentation can be located to verify if the petty cash funds start up funds were from the facility or the resident funds. During an interview on 7/16/24 at 2:48 P.M., the Administrator said he expected the resident funds account to be reconciled correctly.

Based on observation, interview and record review, the facility failed to accurately complete comprehensive assessments for three residents (#25, #2, #18) in a review of 16 sampled residents. The facility census was 43. Review of the undated facility policy titled, Minimum Data Set (MDS), Completion and Submission Timeframes, showed the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy did not address accuracy. Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.18.11, October 2023, showed the following: -The Omnibus Budget Reconciliation Act (OBRA) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents; -The RAI process is the basis for the accurate assessment of each resident; -The treatments, procedures and programs listed in Item O0110, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity and quality of life; -Code peritoneal or renal dialysis which occurs at the nursing home or at another facility. -Section I shows for physician diagnoses, include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound). 1. Review of Resident #25's quarterly MDS dated [DATE] showed no documentation the resident received dialysis. Review of resident's POS dated July 2024 showed an order for renal dialysis scheduled Tuesday, Thursday Saturday with a start date 11/13/23. Review of resident's undated Care Plan showed the resident received hemodialysis three times weekly. Observation and interview with resident on 07/08/24 at 11:16 A.M. showed the following: -He/She had been on dialysis for about three years; -He/She goes to dialysis treatment three times weekly. (The resident's MDS completed on 6/20/24 was not accurate and did not identify the resident received dialysis.) 2. Review of Resident #2's physician progress note, dated 6/30/21, showed the resident had diagnoses that included severe intellectual disability (mental retardation). Review of the resident's quarterly MDS, dated [DATE], showed under section A, no documentation the resident had diagnoses that included severe mental illness, mental retardation or other related conditions. Review of the resident's physician progress note, dated 5/22/24, showed his/her diagnoses included severe intellectual disability (mental retardation). During an interview on 7/9/23 at 1:24 P.M., the MDS coordinator reviewed the resident's Physician Progress Note, dated 5/22/24, and said she did not know the resident had intellectual disability (mental retardation) and the MDS was inaccurate. 3. Review of Resident #18's summarization of episode note (entry for readmission information) showed the resident was readmitted to the facility, from the hospital, on 5/30/24. Review of the resident's nursing admission screening/history, dated 5/30/24, showed staff documented the resident had the following: -Left buttocks- two stage II pressure ulcers; -Coccyx (small triangular bone at the base of the spinal column) - one stage II pressure ulcer. Review of the resident's significant change/ five day MDS, dated [DATE], showed the resident had three stage III pressure ulcers that were present upon admission/entry or reentry. Review of the resident's medical record showed no evidence to support the resident's buttocks or coccyx wounds worsened from a stage II to a stage III. During an interview on 7/10/24 at 1:18 P.M., the MDS coordinator said after reviewing the resident's nursing admission screening/history, dated 5/30/24, the MDS was inaccurate. The resident's pressure ulcers were all stage II and not stage III. 4. During an interview on 07/11/24 at 1:03 P.M., the MDS coordinator said the following: -She was responsible for accurately completing all MDS assessments and used a combination of nursing notes, resident interviews, and visual assessments to complete; -She followed the RAI manual; -Missing Resident #25's dialysis was a complete oversight and error on her part. During an interview on 07/11/24 at 2:42 P.M., the Director of Nursing (DON) said the following: -She was responsible for signing off on the MDS as being completed and she expected the MDS to be accurate; -She expected the MDS to be completed per the RAI manual guidelines and to reflect current resident conditions and diagnoses. 50675

Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures for hand hygiene to prevent the spread of bacteria or other infectious causing contaminates for one sampled resident (Resident #18) and one additional resident (Resident #35); failed to ensure urinary catheter (tube inserted into the bladder to drain urine) drainage bags did not touch the floor for three residents (Residents #35, #40, and #293); failed to utilize the appropriate personal protective equipment (PPE), including gowns, when providing care for residents who required Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission ofmulti-drugg-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) for six sampled residents (Residents #11, #12, #24, #25, #143, and #293) and one additional resident (Resident #35); and failed to ensure soiled washcloths used to provide incontinence care were disposed in a sanitary manner for one resident (Resident #18), in a review of 16 sampled residents. The facility census was 43. Review of the facility policy, Hand Washing, dated July 2019, showed the following: -It is the policy of this facility that hand hygiene is the primary means to prevent the spread of infection; -The use of gloves does not replace proper handwashing; -Employees must wash their hands for at least 20 second using antimicrobial or non-antimicrobial soap and water under the following conditions: -When hands are visibly soiled (handwashing with soap and water); -Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); -Before and after assisting a resident with personal care; -Upon and after coming in contact with a resident's intact skin; -Before and after assisting a resident with toileting (hand washing with soap and water); -After contact with a resident's mucous membranes and body fluids or excretions; -After handling soiled or used linens, dressings, bedpans, catheters and urinals; -After handling soiled equipment or utensils; -After removing gloves or aprons. Review of the undated facility policy titled, Enhanced Barrier Precautions, showed the following: -EBPs are utilized to prevent the spread of MDROs to residents; -EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs to residents; -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); c. Face protection may be used if there is also a risk of splash or spray; -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: c. Transferring; d. Providing hygiene; f. Changing briefs or assisting with toileting; g. Device care or use (central line, urinary catheter,feedingg tube, tracheostomy/ventilator, etc.) and h. Wound care (any skin opening requiring a dressing); --EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; -EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; -Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE; -PPE is available outside of the resident rooms. Review of the undated facility policy titled, Urinary Catheter Care, showed the following: -The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections; -Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility policy, Catheter Care, dated 9/2014 showed to place soiled linen in designated container. 1. Review of Resident #12's physician's orders, dated July 2024, showed the following: -Right stump open area: Apply betadine (antiseptic) and cover with abdominal (ABD) pad cut to fit; -Change daily until healed (start date 7/10/24). Review of the resident's undated care plan showed the following: -Blister opened to right stump; -Apply betadine and ABD until healed. Observation on 7/10/24 at 3:03 P.M. showed the following: -The resident sat on his/her bed; -The Assistant Director of Nursing (ADON) entered the resident's room; -No signage was on the resident's room or door regarding EBP; -The ADON washed her hands and applied gloves; -The ADON did not apply a gown; -No additional PPE other than gloves was noted in the resident's room; -The resident removed the soiled dressing from his/her stump; -The dressing was soiled with yellow-tan drainage and had an odor; -The open wound was approximately the size of a quarter; -The wound bed was moist and mostly covered with yellow slough; -The ADON applied betadine to the wound bed; -The ADON removed her gloves, applied alcohol based hand rub and applied clean gloves; -The ADON applied a clean, dry dressing and secured the dressing with tape. Observation on 7/11/24 at 8:41 A.M. in the resident's room showed the following: -No signage was on the resident's room or door regarding EBP; -No additional PPE other than gloves was noted in the resident's room. During an interview on 7/11/24 at 1:36 P.M. Housekeeper N said the following: -Nursing tells housekeeping when the PPE cart is needed in the resident room then housekeeping puts the cart in the resident's room; -Housekeeping does not put the EBP sign on the resident's room/door; -The resident does not have an EBP sign on his/her door or a PPE cart in his/her room. During an interview on 7/11/24 at 1:35 P.M. the Infection Preventionist/Registered Nurse A (IP/RN A) said the following: -The red EBP signs are available at the nurses' station; -Any nurse can put up the red EBP signs but currently the ADON is responsible and eventually she will be the one responsible. 2. Review of Resident #143's admission care plan dated 7/3/24 showed the following: -Cognitively intact; -Two unstageable pressure ulcers (obscured full-thickness skin and tissue loss) with suspected deep tissue injury in evolution; -Pressure ulcer care. Review of the resident's undated care plan showed the following: -Documented pressure ulcer on right heel; -Use gown and gloves with dressing, bathing, transfers, changing linens, providing hygiene, changing briefs or when caring for wound in his/her room. Review of the resident's physician's orders, dated July 2024, showed an order to cleanse wound to right heel, pat dry, Calmoseptine (barrier cream) to periwound (area around the wound), pack wound with silver alginate (wound dressing with antibacterial silver for moderate to highly exudating (the fluid that is secreted from a wound during the healing process) wounds)) (place inside the wound, do not cover good skin only apply to wound bed) cover with gauze and wrap with Kerlix gauze twice daily (original order dated 6/19/24). Observation on 7/10/24 at 8:30 A.M. in the resident's room showed the following: -The resident sat on his/her bed; -There was a red EBP sign on the wall outside the resident's room; -The wound care consultant and the Assistant Director of Nursing (ADON) entered the resident's room; -The wound care consultant washed his/her hands and applied gloves; -The wound care consultant did not wear a gown; -The wound care consultant assessed the open wound on the resident's right heel; -The wound care consultant cleansed and debrided (process of removing dead tissue) the wound bed; -There was yellow slough (dead cells that accumulate in the wound exudate) present in the wound bed; -There was a moderate amount of bleeding with and after the debridement; -With gloved hands, the ADON applied a dry dressing to the resident's right heel wound and placed the resident's right foot on a disposable pad (the wound continued to bleed); -The ADON did not wear a gown when providing the treatment to the resident's wound. Observation on 7/10/24 at 9:06 A.M. in the resident's room showed the following: -The resident sat on his/her bed; -There was a red EBP sign on the wall outside the resident's room; -IP/RN A entered the room, washed his/her hands and applied gloves; -IP/RN A did not apply a gown; -IP/RN A removed the gauze dressing and cleansed the wound with wound cleanser; -There was a moderate amount of dried blood on and surrounding the wound; -IP/RN A removed her gloves, used alcohol based hand rub and applied clean gloves; -IP/RN A cut the silver alginate (wound treatment preparation), packed it into the wound, covered the wound with a gauze pad and secured the dressing with Kerlix gauze and tape; -IP/RN A removed her gloves and washed her hands. During an interview on 7/10/24 at 3:08 P.M. the ADON said she forgot to wear a gown while performing wound care on Resident #12 and Resident #143. 3. Review of Resident #18's Summary of Episode (readmission information), dated 7/11/24, showed his/her diagnoses included acute kidney failure (when the kidneys suddenly can't filter waste products from the blood) and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Observation on 7/10/24 at 11:48 A.M., showed the following: -Certified Nursing Assistant (CNA) G and Nursing Assistant (NA) C donned Personal Protective Equipment (PPE-gown and gloves) and entered the resident's room; CNA G and NA C did not perform hand hygiene (wash hands with soap and water or use hand sanitizer) before donning PPE; -NA C filled a plastic wash basin with warm water and CNA G performed pericare, including the cleaning of the resident's urinary catheter insertion site, with warm water, body wash and wash cloths; -CNA G placed each soiled cloth on the bedside nightstand. No barrier was used between the nightstand and the cloths; -CNA G dried the resident's peri area with a dry towel and placed the towel on top of the soiled cloths on the nightstand; -CNA G, still wearing soiled gloves, went to a cloth bag hanging on the resident's bathroom door and reached in the bag for a clearplasticc bag; he/she placed the soiled wash cloths and towel in the bag; -CNA G doffed his/her gown and gloves, and without performing hand hygiene with soap and water or using hand sanitizer, went to the resident to adjust his/her bedding; -CNA G and NA C left the room and did not clean the resident's bedside nightstand. Interview on 7/10/24 at 1:30 P.M., showed CNA G said he/she did not realize that he/she had not completed hand hygiene before and after care, before touching the resident or items after procedure. While he/she was doing the care, he/she did not have anywhere to put the soiled items except the nightstand. During an interview on 7/10/24 at 2:38 P.M., the Director of Nursing said she expected the staff topreparee for catheter care by getting the bags for soiled items and barriers prepared and to use hand hygiene before staff begancatheterd care. 4. Review of Resident #25's quarterly MDS, dated [DATE], showed he/she had moisture associated skin damage (MASD). Review of the resident's undated care plan showed the following: -Potential for impaired skin integrity; -Provide skin care per facility guidelines and as needed (PRN). Review of the resident's Physician Order Sheet (POS), dated July 2024, showed the following: -An order for house barrier (a topical cream applied directly to the skin surface to help maintain the skin's physical integrity) to bilateral buttocks every shift and PRN every shift for skin care (original order dated 09/13/23); -An order for collagenase powder (an enzyme derived product used to help the healing of burns and skin ulcers), apply to right gluteal fold topically every day shift for MASD to right gluteal fold, mix collagen powder with A&D ointment apply to area cover with a dressing daily may discontinue when area is healed (original order dated 09/22/23). Observation on 07/08/24 at 11:16 A.M. showed no signage for EBP on or near the resident's room door or wall. No PPE supply cart was available inside or outside the resident's room. Observation on 07/10/24 at 8:51 A.M. showed IP/RN A wore gloves and applied house barrier (collagenase powder and A&D ointment) to the resident's bilateral gluteal fold and crease, where MASD was observed. The resident's skin was blanchable, with an area of maceration along the bilateral gluteal clefts. IP/RN A identified two new open areas on the resident's buttock, one on the right inner thigh, below the gluteal fold, and one on the lower right buttock, above the gluteal fold. Both open areas were bleeding. IP/RN A did not wear a gown when providing care to the resident. 5. Review of Resident #11's quarterly MDS, dated [DATE], showed suctioning and tracheostomy (an opening into the trachea, or windpipe, from outside the neck, to help air and oxygen reach the lungs) were required. Review of the resident's undated care plan showed the following: -At risk for infection related to laryngectomy (a surgery to remove part or all of your larynx, or voice box); -Difficulty with communication related to tracheostomy; -Use gown and gloves with dressing, bathing, transfers, changing linens, providing hygiene, changing briefs or when caring for tracheostomy in his/her room; -Use universal precautions as appropriate. Review of the resident's POS, dated July 2024, showed the following: -Remove laryngectomy tube and clean daily with toothbrush and replace same tube every day and evening shift for secretions (original order dated 02/26/24); -Replace tracheostomy inner cannula every day shift every Wednesday (original order dated 06/05/24); -Replace tracheostomy outer cannula every day shift every 30 days (original order dated 06/12/24); -Suction tracheostomy every six hours to maintain airway (original order dated 04/29/24). Observation on 07/09/24 at 05:30 A.M. showed Licensed Practical Nurse (LPN) H prepared the resident for a breathing treatment when the resident coughed up secretions. LPN H, did not wear gloves or a gown, and cleaned the secretions from the resident's tracheostomy with a tissue. LPN H did wash his/her hands after cleaning the secretions from the resident, and starting the resident's breathing treatment. EBP signage was posted on the wall next to the resident's door and EBP PPE cart was available in the resident's room, under the sink. 6. Review of Resident #40's significant change MDS, dated [DATE], showed he/she had a urinary catheter. Review of the resident's undated Care Plan showed the following: -He/She had a urinary catheter for urinary retention; -The urinary catheter will remain without signs and symptoms of infection; -Ensure the bag isn't touching the floor from the bed or wheelchair placement. Observation of resident's room on 07/08/24 at 10:43 A.M. showed no EBP signage on or near the room door or wall, as directed by facility policy for resident's on EBP. Observation on 07/08/24 at 10:35 A.M., 12:17 P.M. and 12:35 P.M. showed the resident sat in his/her wheelchair in the dining room. The urinary catheter bag hung under the resident's wheelchair and touched the floor. Observation on 07/08/24 at 1:54 P.M. showed the resident lay in bed. The urinary catheter bag was hooked on the side of the resident's bedframe and lay directly on the floor. Observation on 07/09/24 at 5:11 A.M. showed the resident lay in bed. The urinary catheter bag lay directly on the floor. Observation on 07/10/24 at 8:44 A.M. showed resident sat in his/her wheelchair in the common area. The urinary catheter bag hung under the resident's wheelchair and touched the floor. 7. Review of Resident #293's Baseline Care Plan, dated 06/28/24, showed the following: -Active diagnoses of urinary tract infection; -He/She required minimal assistance with mobility; -He/She had a urinary catheter. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Had a urinary catheter. Observation on 07/08/24 at 11:46 A.M. showed EBP signage was posted on the wall beside the door outside the resident's room. Observation on 07/08/24 at 12:28 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. The urinary catheter bag hung under the resident's wheelchair and touched the floor. Observation on 07/09/24 at 6:27 A.M. showed Certified Nurse Assistant (CNA) B pushed the resident in his/her wheelchair to the dining room. The resident's catheter bag hung under the wheelchair and dragged on the ground. Observation on 07/09/24 at 7:11 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating breakfast. The urinary catheter bag hung under the resident's wheelchair and touched the floor. Observation on 07/09/24 at 8:52 A.M. showed the resident sat in a recliner in his/her room. The resident's catheter bag was hooked on the side of the footrest and touched the floor. Observation on 07/09/24 at 2:09 P.M. showed no easily accessible PPE in or around the resident's room. Observation on 07/10/24 at 10:16 A.M. showed CNA I emptied the resident's urinary catheter bag. He/She wore gloves but did not wear a gown. No PPE supply cart was available in or outside of the resident's room. Observation on 07/10/24 at 11:45 A.M. showed NA C pushed the resident in his/her wheelchair to the dining room. The resident's catheter bag hung under his/her wheelchair and dragged on the floor. Observation on 07/10/24 at 12:18 P.M. showed the resident sat in his/her wheelchair at the dining room table, eating lunch. The resident's catheter bag hung under his/her wheelchair and touched the floor. Observation on 07/11/24 at 11:55 A.M. showed the resident sat in his/her wheelchair at the dining room table. The resident's catheter bag hung under this/her wheelchair and touched the floor. 8. Review of Resident #24's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent for toileting needs; -Intermittent catheterization. Review of the resident's POS, dated July 2024, showed the resident had a urinary catheter. Review of the resident's undated Care Plan showed the following: -He/She had a urinary catheter for retention, placing him/her at risk for UTI; -Use gown and gloves with dressing, bathing, transfers, changing linens, providing hygiene, changing briefs or when performing straight catheter in his/her room. Observation on 07/08/24 at 11:20 A.M. showed EBP signage hung on the wall outside the resident's room, and a PPE cart sat in the hallway below the signage. Observation on 07/09/24 at 8:58 A.M. showed the following: -The resident lay in bed. His/Her catheter bag was hooked on the side of his/her bed frame; -CNA B and CNA J assisted to dress the resident. CNA B wore full PPE (gown, gloves, face shield), while CNA J only wore gloves; -Once the resident was dressed, CNA B emptied the resident's urinary catheter bag; -CNA B and CNA J removed their gloves and washed their hands, assisted to transfer the resident from his/her bed to the wheelchair with a mechanical lift, and then changed the resident's shirt. Neither CNA wore gloves or a gown while transferring or putting on the resident's shirt. -CNA B did not wear gloves and placed the resident's urinary catheter into the dignity bag; -NA K, who was also in the room, stripped the resident's bed, wearing only gloves. 9. Review of Resident #35's quarterly MDS, dated [DATE], showed the following: -Cognitively impaired; -Substantial to maximum assistance for toileting needs; -Has a urinary catheter. Review of the resident's undated Care Plan showed the following: -At risk of UTI due to a urinary catheter for neurogenic bladder; -He/She will be free of signs and symptoms of infection; -Use gown and gloves with dressing, bathing, transfers, changing linens, providing hygiene, changing briefs or when caring for catheter in his/her room. Observation on 07/08/24 10:40 A.M. showed EBP signage was on the wall outside the resident's room door, and a PPE cart was located in the resident's room under the sink. Observation on 07/08/24 at 12:34 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. The resident's catheter bag hung under the wheelchair and touched the ground. Observation on 07/09/24 at 5:09 A.M. showed the resident lay in his/her bed. The resident's catheter bag was hooked on the side of the bed frame and lay directly on the floor. Observation on 07/09/24 at 5:33 A.M. showed LPN H, did not wear gloves or a gown, and placed the resident's urinary catheter bag in a pink basin. He/She did not wash his/her hands before or after handling the urinary catheter bag. Observation on 07/09/24 at 07:31 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. The urinary catheter bag hung under the resident's wheelchair and touched the floor. Observations on 07/10/24 at 10:13 A.M. and 11:15 A.M. showed the resident lay in bed. The resident's urinary catheter bag was hooked on the side of the bed frame and lay directly on the ground. During an interview on 07/11/24 at 11:06 A.M., NA E said the following: -EBP are for residents with tracheostomies, catheters, and infections; -Staff should wear gown, gloves, and mask/goggles, when providing direct care for residents on EBP: -Catheter bags should never touch the ground due to the risk for infection. During an interview on 07/11/24 at 11:11 A.M., CNA F said the following: -EBP are for residents with catheters and infections, like COVID-19; -When providing direct care for residents on EBP,staff shouldd wear gown and gloves, and a mask if needed; -Catheters should never touch the ground; -He/She received a brief one-on-one training about EBP. During interviews on 07/10/24 at 4:04 P.M. and 07/11/24 at 2:51 P.M., the IP/RN A said the following: -She took over as the Infection Preventionist on 6/1/24; -When providing direct care for a resident on EBP, staff should always wear gowns and gloves and staff should use a face shield if there is a potential for body/contaminated fluid exposure, like when emptying a catheter or irrigating a wound; -She had not provided any additionaltrainings for staff since she became the infection preventionist; the Director of Nursing (DON) provided a training prior to this; -She expected staff to change gloves and wash hands if the gloves were soiled, or if staff touched dirty items, before going back to clean items; -She considered providing perineal (the area between the tops of the thighs) care a dirty activity and expected staff to change gloves and wash hands; -Catheter bags should never touch the ground; -For the few residents who had a very low bed due to fall risks, staff should put the catheter in a pink basin as a barrier to the ground; -She made a mistake when providing wound care for two residents and forgot to wear a gown and mask; she remembered when she exited the second room; -She expected all staff to know and follow the appropriate PPE guidelines for EBP. During an interview on 07/11/24 at 2:42 P.M., the DON said the following: -Catheter bags should always be kept off the floor; -She provided EBP training just a few months ago and would expect all staff to know and follow the appropriate PPE guidelines. 50189 50675