Every finding on record at Fair View Health Care Center

Based on interviews and record review, facility staff failed to report an allegation of physical abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility's census was 53.The administrator was notified on 7/6/26 of Past Non-Compliance which occurred on 6/25/26. The administrator and Director of Nursing investigated, notified responsible parties, and in-serviced staff regarding abuse and notifying management, terminated alleged perpetrator and had additional monitoring for the resident. Staff corrected the deficient practice on 6/26/26. 1.Review of the facility Abuse and neglect policy, revised 6/12/24, showed all allegations of abuse and neglect shall immediately be reported to the administrator and to other appropriate agencies in accordance with current state and federal regulations within required timeframes. Notify the appropriate agencies immediately as soon as possible but no later than twenty-four hours after discovery of the incident. In the case of serious bodily injury, no later than two hours after discovery or forming suspicion. Review of the facility's investigation, dated 6/26/26, showed staff documented they were notified of an allegation of physical abuse occurred on 6/25/26 by Certified Nurse Aide (CNA) D when he/she smacked Resident #1's mouth when he/she spat at him/her. CNA D states resident spat at him/her and he/she held his/her hand out to cover spit from him/her and witness CNA A. CNA A documented CNA B quickly stuck her open hand out and made contact with resident's mouth. CNA D is suspended upon investigation. In response, the facility has begun providing in-service education to staff abuse and neglect, and appropriate response to challenging behaviors. Additionally, resident questionnaires are being distributed to determine whether any residents have witnessed or experienced abuse or neglect. Resident was assessed for injuries. No injuries are present. Resident does not recall incident and does not appear to be affected by incident. Guardian notified Physician notified Care Plan updated Law enforcement notified. Review showed the investigation did not contain documentation facility staff contacted DHSS within the two hours required timeframe after CNA A reported the allegations to Licensed Practical Nurse (LPN) C. Review of the DHSS database did not contain a report the facility reported allegations of physical abuse within the two-hour required timeframe. During an interview on 7/6/26 at 10:56 A.M., the administrator said he/she does not know why CNA A or LPN C did not report the allegation immediately. He/She said staff are expected to call administration immediately because it has to be reported in two hours. During an interview on 7/6/26 at 11:03 A.M., the Director of Nursing (DON) said LPN B came to him/her about the allegations on 6/26/26 at 12:15 P.M., asking for an update and that was the first time it had been reported. He/She said he/she started the investigation immediately and reported it to the state agency. He/She said LPN C should have reported the incident immediately and does not know why it was not reported. He/She completed education on notifying management and reporting abuse immediately. During an interview on 7/6/26 at 11:35 LPN B said LPN C told him/her about the alleged incident the next day and he/she thought it had already been reported. He/She said he/she asked CNA A if he/she told anyone about the alleged abuse and he/she said he/she did not know to report it. He/She said there was education done on abuse and neglect and notifying management. During an interview on 7/6/26 at 2:00 P.M., LPN C said he/she believed he/she reported the allegation to the administrator by calling him/her. He/She said he/she does not know if it was documented he/she called the administrator. He/She said he/she knows allegations of abuse must be reported within two hours. During an interview on 7/15/26 at 5:12 P.M., CNA A said he/she witnessed the alleged abuse with Resident #1 and reported the incident to his/her charge nurse LPN C. He/She said LPN C reported the incident to the administrator or to the DON but he/she does not know when it was reported to them. During an interview on 7/16/26 at 9:27 A.M., the Administrator said the allegation was reported to him by LPN C but not until over 24 hours after the incident. Incident 3056588

Based on interview and record review, facility staff failed to ensure the admission policy did not require the resident and/or responsible party to waive facility liability for loss or damage to personal belongings for two residents (Resident #39, and #51) out of three residents. The census was 53.1. Review of the facility's Skilled Nursing Facility Resident Agreement, undated, showed the facility under no circumstances will be held responsible for or have any liability of any nature whatsoever for loss or damage to valuables, personal property or money brought to facility. It is further agreed that no deductions or credits shall be taken from any amount due or owing to facility as a result of any loss suffered or damage done by residents to personal property. 2. Review of Resident #39's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/12/26, showed staff documented the resident admitted to the facility on [DATE]. Review of the resident's Resident Handbook, signed and dated 12/16/24, showed the facility under no circumstances will be held responsible for or have any liability of any nature whatsoever for loss or damage to valuables, personal property or money brought to facility. It is further agreed that no deductions or credits shall be taken from any amount due or owing to facility as a result of any loss suffered or damage done by residents to personal property. 3. Review of Resident #51's Quarterly MDS, dated [DATE], showed staff documented the resident admitted to the facility on [DATE]. Review of the resident's Resident Handbook signed and dated 12/03/25, showed the facility under no circumstances will be held responsible for or have any liability of any nature whatsoever for loss or damage to valuables, personal property or money brought to facility. It is further agreed that no deductions or credits shall be taken from any amount due or owing to facility as a result of any loss suffered or damage done by residents to personal property. 4. During an interview on 04/22/26 at 4:07 P.M., the Director of Nursing (DON) said he/she is new and has not completed an admission contract with any residents since he/she started. He/She said he/she is not familiar with the policy and was not aware of what it said. During an interview on 04/22/26 at 4:16 P.M., the corporate DON said the admissions agreement is created on the corporate level and not a document that he/she participates in creating. He/She said because the document is created on that level and used at other facilities, he/she believed the information to be appropriate, and was not aware that it did not meet regulatory requirements. During an interview on 04/22/26 at 4:52 P.M., the Administrator said the admissions agreement is a standard contract the facility uses. He/She said he/she was just made aware of the wording in the agreement about loss and/or damage to resident property. He/She said he/she believes that statement is not agreeable to regulation.

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services (DFNS) with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 53.1. Review of the facility's Dietary Manager (DM) job description, dated 2023, showed the DM must meet State requirements for food service managers or dietary managers, and also meet one of the following qualification requirements: - Certification as a DM;- Certification as a food service manager;- Has similar national certification for food service management and safety from a national certifying body;- Has an associate's or higher degree in food service management and or in hospitality, if the course of study includes food service or restaurant management, from an accredited institution of higher learning;- Has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than 10/01/23, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. Review of the DM personnel records showed a hire date for the DFNS position as 03/12/26. The record did not contain documentation of prior experience as a DFNS in a nursing facility and certification or other education required for the DFNS position. During an interview on 04/22/26 at 1:36 P.M., the DM said he/she became the DM in mid-March 2026 and he/she did not have a degree or certification related to food service management and had not previously worked as a DM. The DM said the facility's consultant registered dietician (RD) only works part-time and the facility did not have any other clinically qualified nutritional staff employed full-time. During an interview on 04/22/26 at 2:33 P.M., the administrator said the DM had been the DM since March 2026, he/she did not know of the qualifications that the DFNS had to meet by regulation and did not know the DM did not meet the qualifications. The administrator said the facility's RD only works part-time and was not aware of any other clinically qualified nutritional staff employed full-time working at the facility.

Based on observation, interview and record review, the facility failed to maintain the walk-in freezer in a manner to prevent potential food contamination. This failure has the potential to affect all residents. The facility census was 53.1. Review of the facility policies provided showed they did not contain a policy related to maintenance of the walk-in freezer. Observation on 04/19/26 at 10:24 A.M., showed the walk-in freezer door unable to fully seal shut. Observation showed a thick frost accumulation on the freezer walls, evaporator coil cabinet and on most of the food stored inside the freezer. Observation also showed a thick layer of ice on the front and back of the evaporator coil cabinet and on the floor inside the freezer. Observation on 04/20/16 at 10:18 A.M., showed the walk-in freezer door unable to fully seal shut. Observation showed thick frost on most of the stored food items, on the freezer walls, and on the evaporator coil cabinet inside the freezer. Observation showed a thick layer of ice on the freezer floor, on the side of the freezer door, and on the front and back of the evaporator coil cabinet in the freezer. During an interview on 04/21/26 at 3:00 P.M., the maintenance director said he/she began employment at the facility approximately three weeks ago and had just been made aware of the issue with the freezer door not fully sealing. During an interview on 04/22/26 at 12:39 P.M., the dietary manager (DM) said he/she began his/her employment at the facility approximately eight months ago and the door to the walk-in freezer not being able to fully seal shut was already an issue when he/she started and it had never been fixed. The DM said the accumulation of frost and ice within the freezer has gradually gotten worse over the last eight months and he/she knows it is a problem. The DM said he/she reported the walk-in freezer door issue to the previous maintenance director multiple times, but the previous maintenance director never addressed the issue and stopped working at the facility approximately a month ago. During an interview on 04/22/26 at 2:33 P.M., the administrator said he/she did not know about the condition of the walk-in freezer until last week. The administrator said he/she thought the freezer door seal was supposed to be replaced last week and did not know the seal had not been replaced. The administrator said he/she did not know how long the walk-in freezer door had been unable to fully seal shut and did not know how much frost and ice had built up in the walk-in freezer and on the evaporator coil cabinet.

Based on interview and record review, facility staff failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), a complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data for the first and second quarter of 2025. The facility census was 53.1.Review of the facility's Registered Nurse (RN) policy, revised 04/30/24, showed the facility is responsible for submitting timely and accurate staffing data through the CMS PBJ system. 2. Review of the facility's CMS PBJ Staffing Data Report, dated April 17, 2026, did not contain a report for the first and second quarter of 2025. 3. During an interview on 04/22/2026 at 4:07 P.M., the Director of Nursing (DON) said their corporate office is responsible for reporting staffing information to the PBJ. He/She said he/she was not aware the PBJ wasn't reported correctly for 2025. During an interview on 04/22/2026 at 4:52 P.M., the Administrator said he/she was not aware there were issues with the PBJ being reported. He/She said their corporate office handles the final submission to PBJ. During an interview on 4/29/26 at 12:57 P.M., the Regional Human Resource Director said the facility Human Resource Director (HR) keeps a calendar and collects the hours worked information. He/She said that information is then sent to him/her quarterly. He/She said he/she then takes that information, compares it to their system, creates the file to submit to CMS. He/She just took over this position in November 2025 and was not aware of the previous person's process. He/She said he/she knows the importance of submitting to CMS and ensures timely processing.

Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to ensure the two-step purified protein derivative (PPD), a skin test for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) was completed and on file in accordance with the facility policy for five employees (Dietary Aide M, Licensed Practical Nurse (LPN) N, [NAME] O, Certified Medication Technician (CMT) P, and Registered Nurse (RN) E out of 10 employee files reviewed. Staff failed to ensure all residents were screened for TB when staff failed to ensure a two-step PPD and/or annual PPD tests were completed and documented per the facility policy for four residents (Resident #3, #10, #26, and #35) of five sampled residents. Facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease, a serious type of pneumonia (lung infection) caused by Legionella bacteria. This failure has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all facility occupants at risk of exposure which could lead to illness. The facility census was 53.1.Review of the facility's Tuberculosis Testing policy, revised 06/29/23, showed: -Upon hire, a new employee will receive a 2 step PPD skin test. Each employee will also have an annual 1 step TB test to ensure that any possible infections can be triggered proactively to prevent further spread. -Upon admission and readmission, each resident will receive a 2 step PPD skin test as ordered by the physician. Each resident will also have an annual 1 step TB test as ordered by the physician to ensure that any possible infections can be triggered proactively to prevent further spread. If the resident has not been hospitalized for the year, they will receive a signs and symptoms checklist to monitor for communicable diseases. -All TB test and chest x-rays records will be kept on file in the according areas (employee files and resident records). 2. Review of Dietary Aide M's employee file showed: -Hire date of 03/04/26; -First step TB skin test administered on 03/09/26, read date of 03/11/26; -Second step TB administered on 03/23/26, read date of 03/25/26; -Staff documented they administered the first TB test after the date of hire. 3. Review of LPN N's employee file showed: -Hire date of 03/30/26; -First step TB skin test administered on 04/04/26, read date of 04/06/26; -Second step TB administered on 04/18/26, the date of 04/20/26; -Staff documented they administered the first TB test after the date of hire. 4. Review of [NAME] O's employee file showed: -Hire date of 11/11/25; -First step TB skin test administered on 03/22/26, read date of 03/24/26; -Second step TB administered on 04/04/26, read date was 04/06/26; -Staff documented they administered the first TB test after the date of hire. 5. Review of CMT P's employee file showed: -Hire date of 03/14/25; -First step TB skin test administered on 03/01/26, read date of 03/03/26; -Staff did not document the resident received a second-step TB test. 6. Review of RN E's employee file showed: -Hire date of 09/16/25; -First step TB skin test administered on 09/08/25, the record did not contain a date read; -Second step TB administered on 9/18/25, the record did not contain a date read. 7. During an interview on 04/22/2026 at 4:07 P.M., the Director of Nursing (DON) said the human resource manager is responsible to ensure staff TB'S are complete. The DON said he/she's been here a month and unsure why the staff TBs were not complete. He/She said nursing staff give TB tests. During an interview on 04/22/26 at 5:09 P.M., the Administrator said there is a two-part process when new staff's hired. The Business Office Manager (BOM) is responsible for ensuring the information is provided to the DON and ensure the TB step is provided. The Administrator was not aware some new hire TB tests were not administered appropriately. During a phone interview on 05/05/26 at 1:00 P.M., the BOM schedules staff to get their TB tests three days before staff start. He/She said when the first step is completed, he/she places the first step near the nurse's station. The BOM said if the new hire staff miss their tests, it is due to no shows or nurses did not give the tests. He/She is responsible for ensuring tests are complete before contact with residents. 8. Review of Resident #3's medical record showed: -admitted on [DATE]; -The record did not contain documentation the resident received the first or second step TB tests. 9. Review of Resident #10's medical record showed: -admitted on [DATE]; -The record did not contain documentation the resident received the first or second step TB tests. 10. Review of Resident #26's medical record showed: -admitted on [DATE]; -The record did not contain documentation the resident received the first or second step TB tests. 11. Review of Resident #35's medical record showed: -admitted on [DATE]; -The record did not contain documentation the resident received the first or second step TB tests. 12. During an interview on 04/22/26 at 4:40, the Corporate Director of Nursing said residents are expected to have the first step TB test upon admission, and the second step within 14 days after, he/she said they believe the issue is that the information isn't flowing over in the Electronic Medical Record (EMR) system to trigger staff to do the tests. During an interview on 04/22/26 at 4:45 P.M., the Administrator said the DON is ultimately responsible for making sure resident TBs are done, and there has been a lot of change over with the DON position and that might be why it was not done. 13.Review of the Centers for Medicare and Medicaid Services (CMS), QSO-17-30, dated 06/02/17 and revised 07/06/18, showed: -CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.-Facilities must have water management plans and documentation that, at a minimum, ensure each facility:--Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;--Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit;--Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained;--Maintains compliance with other applicable Federal, State and local requirements; --Note: CMS does not require water cultures for Legionella or other opportunistic water borne pathogens. Testing protocols are at the discretion of the provider. Review of the facility's policy titled, Legionella and Legionnaires' Disease Prevention, undated, showed the facility shall operate potable water systems in a manner that reduces the risk of Legionella growth and Legionnaires' disease by: - Maintaining potable water systems in a clean condition and free of excessive sediment and debris; - Controlling hot and cold water temperatures to reduce conditions favorable to Legionella growth; - Minimizing water age and stagnation throughout the system; - Maintaining a measurable disinfectant residual where feasible; - Identify and correct dead legs, low-flow, and low-use conditions; - Performing routine flushing, cleaning, maintenance, and monitoring; - Documenting all monitoring, maintenance, corrective actions, and response measures; - Maintaining documentation of the facility's water system descriptions and maps and annual risk assessments and policy reviews. - This policy shall be reviewed at least annually and revised as needed. Observations on 04/21/26 during the Life Safety Code tour showed the facility equipped with a cooling tower, multiple ice machines and multiple water sources throughout the facility. Observations showed all water sources were not in regular use. Review of the facility's Water Management Program showed the documentation did not contain: -A facility specific risk assessment; -Identification of dead legs, low-flow, and low-use conditions;-Documentation of routine flushing, cleaning, maintenance, and monitoring of water sources. During an interview on 04/22/26 at 10:32 A.M., the regional maintenance director said maintenance staff and facility administration are responsible to develop and implement the water management program. The director said he/she thought the facility had completed a facility specific risk assessment that identified how water was distributed throughout the building and identified risk areas, but he/she could not locate it. The director said the current maintenance director had only worked at the facility for approximately three weeks and he/she does not have documentation of routine flushes, cleaning, maintenance, or monitoring of the facility's water system. The director said the facility is expected to maintain documentation of the facility risk assessment and of routine flushes, cleaning, maintenance, and monitoring of water sources. During an interview on 04/22/26 at 2:33 P.M., the administrator said maintenance staff is responsible for implementing the facility's water management program. The administrator said he/she thought the facility had a risk assessment that showed a diagram of how water is distributed throughout the building and identified areas of risk, but he/she could not locate it. The administrator said he/she expects maintenance staff to perform and document any necessary routine monitoring, maintenance, and cleaning of the facility's water sources and he/she could not provide documentation to show any actions taken by maintenance staff.

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care for four residents (Resident #4, # 5, #10, and #22) out of 16 sampled residents. The facility census was 53.1. Review of the Facility's Comprehensive Care Plan Policy, revised 10/31/24, showed the care planning process will include an assessment of the resident's strengths and needs, and cultural preferences in developing goals of care. The Care plans will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS), a federally mandated assessment tool, assessment. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 2. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Upper and lower extremity impairment on both sides; -Dependent on staff for eating, toileting, shower/bathe, and personal hygiene; -Diagnosis of Cerebral Palsy and Quadriplegia. Review of the Physician Order Sheets (POS), dated April 2026, showed an order to wear bilateral resting hand splints as tolerated during the day. Review of the residents' care plan, dated 04/2026, showed the plan did not address the residents' contractures or interventions. Observation on 04/19/26 at 12:10 P.M., showed the resident in his/her specialized medical wheelchair in the dining room with both hands contracted without interventions place. Observation on 04/20/26 at 12:125 P.M., showed the resident in his/her specialized medical wheelchair in the dining room with both hands contracted without interventions place. Observation on 04/21/26 at 4:00 P.M., showed the resident in his/her bed with both hands contracted without interventions place. Observation on 04/22/26 at 11:00 A.M., showed the resident in his/her bed with both hands contracted without interventions place. 3. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Upper extremity impairment to one side; -Substantial/maximal assistance with toileting hygiene, and shower/bathe; -Moderate assistance with upper body dressing and personal hygiene. Review of the resident's POS, dated April 2026, showed an order for a left upper body brace. Review of the resident's care plan, dated 02/27/26, showed the plan did not address the residents' contracture. Observation on 04/19/26 at 11:36 A.M., showed the resident in his/her wheelchair with left hand contracted without interventions place. Observation on 04/20/26 at 11:20 A.M., showed the resident in his/her wheelchair with left hand contracted without interventions place. Observation on 04/21/26 at 10:25 A.M., showed the resident in his/her wheelchair with left hand contracted without interventions place. Observation on 04/22/26 at 12:25 P.M., showed the resident in his/her wheelchair with left hand contracted without interventions place. 4. Review of Resident #10's annual MDS, dated [DATE], showed staff assessed the resident needs/wants assistance to communicate with doctors and health care staff. Review of resident's Nursing Progress Notes, dated 04/16/26, 04/18/26 and 04/21/26, showed the resident went to medical appointments outside of the facility. Review of the resident's care plan, dated 01/28/26, showed the plan did not reflect the resident's need/want for communication assistance during his/her medical appointments. During an interview on 04/21/26 at 10:40 A.M., the resident said he/she goes to his appointment without communication assistance. The resident said his preference is to have someone with him when he/she attends. During an interview on 04/21/26 at 10:30 A.M., Certified Medication Technician (CMT) J said he/she is unsure if the facility sends communication assistance with the resident. CMT said when the resident is at the facility, he/she assists in communication per the resident's request. During an interview on 04/22/26 at 2:00 P.M., social worker K said there is a med tech at the facility he/she utilizes when communicating with the resident. He/She believes the resident needs communication assistance for each shift to ensure his/her needs are known but he/she does not believe he/she has that at all times. 5. Review of Resident #22's annual MDS, dated [DATE], showed: -Severely impaired cognition; -Upper extremity impairment on both sides; -Dependent of staff for toileting, eating, shower/bathe, on/off footwear, and dressing; -Diagnosis of cerebral palsy. Review of the resident's care plan, dated 2/16/26, showed the plan did not direct staff to use ace wraps for edema and did not address new interventions for edema. Review of the resident's POS, dated April 2026, showed an order for the resident's bilateral lower legs to be ace wrapped daily for edema. Observation on 04/20/26 at 1:39 P.M., showed the resident in his/her wheelchair with swollen bilateral lower legs. The resident did not have bilateral ace wraps on his/her legs. Observation on 04/21/26 at 2:42 P.M., showed the resident in his/her wheelchair with swollen bilateral lower legs. The resident did not have bilateral ace wraps on his/her legs. Observation on 04/22/26 at 1:22 P.M., showed the resident in his/her wheelchair with swollen bilateral lower legs. The resident did not have bilateral ace wraps on his/her legs. 6. During an interview on 04/22/26 at 4:35 P.M., the Director of Nursing (DON) said he/she would expect resident contractures with interventions such as braces and splits to be on the care plan. The DON said language restrictions should be care planned. During an interview on 04/22/26 at 4:40 P.M., the Administrator said care plans should be personalized to each resident's needs and preferences. He/She said they would expect interventions and language restrictions to be on a care plan.

Based on interview and record review, the facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The facility census was 53.1.Review of the Facility's RN policy, revised 4/30/24, showed the facility will utilize the services of a RN for at least eight consecutive hours per day, seven days a week. 2. Review of the facility's RN staff schedule, dated January 2026, showed the facility did not have an RN in the building on: -Saturday, 01/03/26; -Sunday, 01/04/26; -Saturday, 01/17/26; -Sunday, 01/18/26; -Saturday, 01/31/26. 3. Review of the facility's RN staff schedule, dated February 2026, showed the facility did not have an RN in the building on: -Sunday, 02/01/26; -Saturday, 02/14/26; -Sunday, 02/15/26; -Saturday, 02/28/26; -Sunday, 02/29/26. 4. Review of the facility's RN staff schedule, dated March 2026, showed the facility did not have an RN in the building on: -Sunday, 03/14/26; -Saturday, 03/15/26; -Saturday, 03/28/26; -Sunday, 03/29/26. 5. Review of the facility's RN staff schedule, dated March 2026, showed the facility did not have an RN in the building on Saturday 04/11/26 and Sunday 04/12/26. 6. During an interview on 04/22/26 at 4:07 P.M., the Director of Nursing (DON) said the facility is required to have an RN in the building seven days a week for eight consecutive hours a day. He/She said he/she thought they had an RN rotating every other weekend to cover and was not aware there was not an RN scheduled some weekends. He/She said if there are holes for RN coverage the corporate DON and himself/herself cover the shift. During an interview on 04/22/26 at 4:52 P.M., the Administrator said the facility should have an RN on everyday shift, 8 hours consecutively. He/She said he/she had some concerns with RN coverage, and they have been recruiting RN's. He/She said RN coverage has been an issue, and they are working on. He/She said the DON and corporate DON cover shift when needed. He/She said their DON and corporate DON do not clock in to track the RN hours in the building.

Based on interview and record review, facility staff failed to ensure four Nurse Aide's (NA) (NA A, NA B, NA C and NA D) of four completed the nurse aide training program within four months of his/her employment in the facility. The census was 53.1.Review of the facility's policies showed staff did not provide a policy that directed staff on NA qualifications. 2. Review of NA A's Certified Nurse Aid (CNA) report showed a hire date of 09/15/25. The report did not contain documentation NA A completed a nurse aide training program. 3. Review of NA B's CNA report showed a hire date of 08/23/25. The report did not contain documentation NA B completed a nurse aide training program. During an interview on 04/22/26 at 10:51 A.M., NA B said he/she started in August of 2025 and has never worked in any other department. He/She said he/she started classes a few months ago. He/She said before he/she started classes there were issues with not having an instructor. He/She said he/she has completed classes but has not set up any testing dates. 4. Review of NA C's CNA report showed a hire date of 03/06/23. The report did not contain documentation NA C completed a nurse aide training program. 5. Review of NA D's CNA report showed a hire date of 11/21/25. The report did not contain documentation NA D completed a nurse aide training program. During an interview on 04/22/26 at 11:08 A.M., NA D said he/she has worked at the facility for four to five months and before that he/she worked at another one of their homes for seven months as an NA. He/She said he/she completed the classes but has not set up a time to take the test. 6. During an interview on 04/22/26 at 4:07 P.M., the Director of Nursing (DON) said he/she knows the requirement is for the NA to complete the CNA training course within 120 days from the date of hire. He/She said he/she was not aware and is not sure why they have not completed the training. He/She said he/she is new to the facility and has only been the DON for 29 days. During an interview on 04/22/26 at 4:16 P.M., the corporate DON said the facility was sharing the CNA classes with their sister facilities. He/She said he/she was not sure why each of them had not completed the CNA classes in the 120 days but that he/she knows some of the staff were not reliable with going to classes. He/She said human resources helps with the process, but the DON is ultimately responsible for ensuring the NA's complete training timely. During an interview on 04/22/26 at 4:52 P.M., the Administrator said he/she knows that NA's should be certified in 120 days from when they start. He/She said he/she was aware they were having issues with completing the classes timely. He/She said they had a teacher walk out and had to work with their sister facility to get a new trainer and the processes took a long time.

Based on observation, interview, and record review, facility staff failed to ensure medications were stored in a safe and effective manner, when staff failed to ensure medications not in use and expired medications were properly discarded. The facility census was 53.1.Review of the facility's policy, Storage of Medications, dated 05/18/24, showed medications housed in the facility premises and follow in accordance the manufacturer's recommendations related to unused medications. 2. Observation on 04/19/26 at 10:30 A.M., showed the 200 hall medication cart contained: -One bottle of Prednisolone Acetate 1% Ophthalmic Suspension five milliliter (mL) (steroid eye drop) with an expiration date of 04/15/26; -One bottle of Systane Balance Lubricant Eye Drops 0.5%, 10 mL with an expiration date of 02/12/26; - Albuterol inhaler HFA 90 microgram (mcg) (used to open the lung airways) with a use by date of 04/06/26; -Biscodyl 5 milligrams (mg), (a stimulant laxative) with an expiration date of 02/2024. 3.Observation on 04/19/26 at 11:00 A.M., showed the 200 hall overflow medication cart contained: -Levetiracetam 100 mg/mL oral solution (to treat seizure disorders) with an expiration date of 3/16/26; -Lactulose 10 gram/15 mL oral solution (to treat constipation and liver disease) with a use by date 04/11/26; - Valproic acid 250 mg/5 mL (to treat seizure disorders) with a use by date 03/24/26; -Stomach relief Pink Bismuth with an expiration date of March 2026; -Baclofen (muscle relaxer) 10 mg with a use before 04/07/26; -Senexon-S 8.6 -50 mg (stool softener) with a use by date of 2/16/26; - Ondansetron 4mg (to prevent nausea and vomiting) with a use by date of 02/16/26. During an interview on 4/19/26 at 12:00 P.M., the certified medication technician (CMT) J said he/she is responsible to go through his/her medication cart to ensure expired or discontinued medications are discarded. The CMT said we usually go through the carts weekly. The CMT said he/she is unsure if there is a system in place to document or chart med storage completion requirements. The CMT said the director of nursing (DON) is overall responsible to ensure the medication carts are in order. During an interview on 04/22/26 at 3:30 P.M., Registered Nurse (RN) E said he/she is primarily responsible for his/her medication cart. He/She reconciles the medications and ensures there are no expired medications. The CMT's go through the cart and are responsible to dispose of expired or discontinued medications. He/She is unsure if there is a documented process of charting med storage reconciliation/organization of carts. He/She would not place sole responsibility on the DON. He/She has responsibility as the nurse to ensure the medication carts are in order. During an interview on 04/22/26 at 4:07 P.M., the DON said the CMT's go through the carts to ensure the medications are disposed. He/She said to his/her knowledge, there's not a system in place to ensure proper medication storage audits. He/She is responsible for ensuring the carts are in order and to audit each individual cart. He/She said the expectation of this process is to ensure expired or discontinued medications are not used. He/she was not aware there were expired or discontinued medications in the medication carts. During an interview on 04/22/26 at 5:06 P.M., the Administrator said he/she expects proper storage of medications to be utilized. He/She would expect weekly inspections conducted of the medication carts. The administrator said if the medications are expired or discontinued, they should be removed immediately. He/She said the DON is overall responsible to ensure proper medication storage in the medication carts.

Based on observation, interview and record review, the facility staff failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit ( F) or higher upon service to residents who ate in their rooms. The facility census was 53.1. Review of the facility's policy titled, Dietary Food Preparation, dated 07/05/23, showed the temperature of hot food items are expected to be greater than 135 F at the time of service to residents. During an interview on 04/19/26 at 12:50 P.M., Resident #23 said he/she eats in his/her room. The resident said when staff bring his/her food the food is barely warm and he/she prefers his/her food to be hot. During an interview on 04/19/26 at 1:11 P.M., Resident #43 said his/her food is mostly cold when delivered. Review of the facility menus, dated 04/22/26, showed the menu directed staff to provide the residents on a regular diet with rosemary herbed baked chicken, mushroom rice, and cauliflower au gratin at the lunch meal. Observation on 04/22/26 at 1:11 P.M., showed staff served lunch room trays to residents from the 100 hall food cart. Observation of a resident tray from the food cart showed the internal temperature of the rosemary herbed baked chicken and cauliflower au gratin both measured 103 F and the mushroom rice measured 106 F. During an interview on 04/22/26 at 1:13 P.M., Certified Medication Technician (CMT) H said the residents on the 100 hall who choose to eat in their rooms complain nearly every day about the hot food being cold when their meal trays are served. The CMT said the residents who eat in their rooms on the 100 hall are the last residents to be served meal trays. The CMT said he/she had reported the resident's complaints to the previous dietary manager (DM) who stopped working at the facility one or two months ago, but the issue had not improved and he/she still receives complaints from residents. During an interview on 04/22/26 at 1:16 P.M., Certified Nursing Assistance G said residents who choose to eat in their rooms frequently complain about their hot food being cold when they receive the meal trays. During an interview on 04/22/26 at 1:28 P.M., Dietary Aide (DA) I said depending on the day, it can take a while to dish up plates for the meal trays being served to residents who eat in their rooms. The DA said he/she checks the temperature of the food on the steam table before they start service and again approximately mid-way through service. The DA said the residents who eat in their rooms on the 100 hall are the last residents to be served. During an interview on 04/22/26 at 1:36 P.M., the DM said hot food should be served to the residents at 120 F or higher, regardless if they eat in the dining room or receive a room tray. The DM said once the hall cart leaves the kitchen, it is the nurse's responsibility to serve the residents eating in their rooms. During an interview on 04/22/26 at 2:33 P.M., the administrator said the DM is responsible to make sure hot food is served to all residents at 120 F or higher. The administrator said he/she did not know that some residents had complained to staff about their hot food being cold when it is served.

Based on observation, interview, and record review, facility staff failed to maintain resident dignity, when staff stood over four residents (Resident #4, #22, #23 and #34) while assisting the residents to eat. The facility census was 53.1. Review of the facility's Promoting/Maintaining Resident Dignity policy, revised 09/21/25, showed all staff will speak to and treat all residents with dignity and respect, all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights, and when interacting with a resident, pay attention to the resident as an individual.2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 02/04/26, showed staff assessed the resident as severely impaired cognition, upper extremity impairment on both sides and dependent on staff for eating.Review of the resident's care plan, dated 02/16/26, showed the plan did not direct staff on how to assist the resident with meals.Observation on 04/20/26 at 12:33 P.M., showed Nurse Aide (NA) F stood over the resident as he/she fed him/her. 3. Review of Resident #22's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely impaired cognition, upper extremity impairment on both sides, and dependent on staff for eating.Review of the resident's care plan, dated 02/16/26, showed the resident is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits.Observation on 04/19/26 at 12:26 P.M., NA B stood over the resident as he/she fed him/her.Observation on 04/20/26 at 12:22 P.M., NA F stood over the resident as he/she fed him/her.Observation on 04/22/26 at 12:19 P.M., Certified Nurse Aide (CNA) G stood over the resident as he/she fed him/her.During an interview on 04/22/26 at 12:30 P.M., CNA G said facility staff receive education on assisting residents to eat. He/She said staff are allowed to stand while feeding residents, and that it is staff preference to either stand or sit. 4. Review of Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely impaired cognition, upper extremity impairment on both sides and dependent on staff for eating.Review of the resident's care plan, dated 12/29/25, showed the resident with dysphagia (difficulty swallowing) needs assistance and encouragement with meals and fluids.Observation on 04/20/26 at 12:21 P.M., showed NA F stood over the resident as he/she fed him/her. 5. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely impaired cognition and requires substantial maximal assistance with meals.Review of the resident's care plan, dated 12/29/25, showed the resident does not feed himself/herself and requires staff assistance and encouragement.Observation on 04/20/26 at 12:33 P.M., showed NA F stood over the resident as he/she fed him/her.6.During an interview on 04/22/26 at 4:07 P.M., the Director of Nursing (DON) said he/she expects his/her staff to sit at eye level when assisting residents with meals. He/She said sitting at eye level is important to maintain dignity and respect for the resident. He/She said he/she was not aware staff were not sitting with the residents during meals. He/She said his/her staff should know better and are educated about not standing during meal assistance.During an interview on 04/22/26 at 4:52 P.M., the Administrator said it is his/her expectation that staff sit at the same level as the resident while assisting residents with meals. He/She said it is good for dignity and for the residents to not feel rushed through the process. He/She said he/she was not aware staff were standing while assisting residents to eat.

Based on observation, interview, and record review, facility staff failed to complete or post required nurse staffing information in an area readily accessible to residents and visitors. The facility census was 53.1. Review of the facility's policy titled, Nurse Staffing Posting Information Policy, reviewed 06/26/24, showed the nurse staffing sheet will be posted on a daily basis and will contain: -Facility Name; -Current date; -Facility current resident census; -The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directedly responsible for resident care per shift: -Registered nurses (RN); -Licensed Practical Nurses (LPN)/Licensed Vocational Nurses (LVN); -Certified nurse aides (CNAs). -The facility will post the Nurses Staffing Sheet at the beginning of each shift. -The information posted will be presented in a clear and readable format and in a prominent place readily accessible to residents and visitors. 2. Observation on 04/19/26 10:30 A.M., showed facility staff did not post the nurse staff posting sheet in an area readily accessible to residents and visitors. Observation on 04/20/26 11:00 A.M., showed facility staff did not post the nurse staff posting sheet in an area readily accessible to residents and visitors. Observation on 04/21/26 5:10 P.M., showed facility staff did not post the nurse staff posting sheet in an area readily accessible to residents and visitors. Observation on 04/22/26 3:04 P.M., showed facility staff did not post the nurse staff posting sheet in an area readily accessible to residents and visitors. During an interview on 04/22/26 at 4:07 P.M., the Director of Nursing (DON) said the daily staff schedule should be posted at the nurse station. He/She said it is the responsibility of the staffing coordinator to post it daily. He/She said he/she was not aware it was not being posted with the correct information. During an interview on 04/22/26 at 4:17 P.M., the corporate DON said the daily staffing should be posted at the nurse station. He/She said it should have the total hours worked per day/per shift for each direct care staff and include the census for the day. He/She was not aware it was not being posted. During an interview on 04/22/26 at 4:52 P.M., the administrator said he/she knows the daily staffing numbers should be posted daily where residents and visitors can see it. He/She said he/she was not aware it was not being posted.

Based on interview and record review, facility staff failed to have a Registered Nurse (RN) for eight consecutive hours a day that was not the Director of Nursing (DON) with a facility census over 60 residents. The facility was 64.1. Review of the facility's Registered Nurse Policy, revised 4/30/24, showed staff are directed the DON may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents. 2. Review of the facility census and staffing sheets, dated 7/15/25 to 7/31/25, showed the following: -7/20/25 showed a facility census of 61, and DON worked as a charge nurse;-7/24/25 showed a facility census of 61, and DON worked as a charge nurse;-7/29/25 showed a facility census of 61, and the DON worked as a charge nurse. 3. Review of the facility census and staffing sheets, dated 8/1/25 to 8/20/25, showed the following: -8/1/25 showed a facility census of 63, and DON worked as a charge nurse;-8/2/25 showed a facility census of 62, and DON worked as a charge nurse;-8/6/25 showed a facility census of 61, and DON worked as a charge nurse;-8/7/25 showed a facility census of 61, and DON worked as a charge nurse;-8/11/25 showed a facility census of 63, and DON worked as a charge nurse;-8/12/25 showed a facility census of 64, and DON worked as a charge nurse;-8/14/25 showed a facility census of 65, and DON worked as a charge nurse;-8/15/25 showed a facility census of 64, and DON worked as a charge nurse;-8/16/25 showed a facility census of 64, and DON worked as a charge nurse;-8/17/25 showed a facility census of 64, and DON worked as a charge nurse;-8/20/25 showed a facility census of 64, and DON worked as a charge nurse. During an interview on 8/20/25 at 9:00 A.M., the Administrator said the DON has been working as the RN charge nurse at nights for a few weeks because they do not have another RN. During an interview on 8/20/25 at 9:13 A.M., the staffing coordinator said the DON has been working the floor as the RN charge nurse because they only have one other RN on staff. During an interview on 8/20/25 9:43 A.M., the Administrator said he/she is aware that the DON can not be the floor nurse once the census is over 60, he/she said he/she only has one other RN on staff that takes turns with the DON to cover RN hours. He/She said there are add on indeed for nurses in their area. During an interview on 8/20/25 at 10:23 A.M., the DON said he/she is aware that he/she can not count as the RN and the DON but he/she does not have another RN due to staffing issues. He/She said he/she has been working as the floor RN charge nurse for about a month. Complaint # 2590461

Based on observation, interview, and record review, facility staff failed to meet professional standards when staff did not complete weekly skin assessments and did not document they provided physician ordered wound treatments for three residents (Residents #1, #2, and #3) out of six sampled residents. The facility census was 61. 1. Review of the facility's Skin Assessment Policy, dated 6/26/24, showed licensed or registered nurse will conduct a full body, or head to toe, skin assessment upon admission, or re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/5/25, showed staff assessed the resident as: -Cognitively intact; -Diagnosis of stroke, pressure ulcer of sacral region (region of the lower back) stage two (partial thickness skin loss), and chronic non pressure ulcer of the right calf with fat layer exposed; -At risk for pressure ulcers. Review of the resident's care plan, dated June 2025, did not contain documentation in regard to the resident's skin breakdown. Review of the resident's physicians order sheets (POS), dated June 2025, showed physician's orders directed staff as follows: -Weekly skin assessments; -Xeroform (type of special gauze used in wound care) to right lower leg and cover with ace once daily in the morning; -Zinc Oxide External Ointment 20% apply to affected areas topically every shift for skin breakdown. Cleanse with wound cleanser. Pat dry. Apply to coccyx (bottom of spine). Review of the resident's medical record, dated 4/1/25 through 4/30/25, did not contain documentation staff completed a weekly skin assessement the weeks of 4/7/25, 4/14/25, 4/21/25 or 4/28/25. Review of the resident's medical record, dated 5/1/25 through 5/31/25, did not contain documentation staff completed a weekly skin assessment the weeks of 5/5/25, 5/12/25, and 5/26/25. Review of the resident's Treatment Administration Record (TAR), dated 5/1/25 through 5/31/25, showed staff did not document they provided the resident wound care as ordered on 5/3/25, 5/10/25, 5/11/25, 5/15/25, 5/23/25, 5/27/25, 5/28/25, or 5/29/25. 3. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of Parkinson's disease with dyskinesia (involuntary muscle movements); -Impairment to both sides, upper and lower extremities. Review of the resident's care plan, dated June 2025, showed staff assessed the resident with a potential for pressure ulcer development related to immobility. Staff are directed to administer treatments as ordered and monitor for effectiveness and to follow facility policies and protocols for prevention and treatment of skin breakdown. Review of the resident's POS, dated June 2025, showed physician orders directed staff as follows: -Weekly skin assessments; -Barrier cream cleanse perineal area and buttocks after each incontinence episode, then apply barrier cream every shift. Review of the resident's medical record, dated 4/1/25 through 4/30/25, did not contain documentation staff completed a weekly skin assessment for the weeks of 4/1/25, 4/21/25, or 4/28/25. Review of the resident's medical record, dated 5/1/25 through 5/31/25, did not contain documentation staff completed a weekly skin assessment for the weeks of 5/5/25 or 5/12/25. Review of the resident's TAR, dated 5/1/25 through 5/31/25, showed staff did not document they provided the resident wound care as ordered on 5/10/25, 5/11/25, 5/15/25, 5/24/25, 5/25/25, 5/27/25, and 5/28/25. Review of the resident's TAR, dated 6/1/25 through 6/9/25, showed staff did not document they provided the resident wound care as ordered on 6/2/25 and 6/3/25. 4. Review of Resident #3's MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -Diagnoses of Pressure ulcer of buttocks stage three (full thickness skin loss) and nonchronic ulcer of lower leg; -Dependent for toileting and transfers; -Indwelling urinary catheter; -Incontinent of bowel; -At risk for pressure ulcers. Review of the resident's care plan, dated June 2025, showed staff assessed the resident as had a pressure ulcer of the buttock. Staff are instructed to complete weekly treatment with documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (mass cells and fluid that has seeped out of blood vessels or an organ) and any other notable changes or observations. Review of the resident's POS, dated June 2025, showed physician orders direct staff as follows: -Cleanse open area on buttocks, apply xeroform, cover with island dressing (non-adherent wound dressing). Change every day and as needed until healed daily; -Cleanse open areas on lower right extremity and left lower extremity, apply xeroform and non adhesive dressing, wrap with kerlix (bulky gauze used for wound care) every day and as needed until healed one daily per wound nurse; -Nystatin External Ointment 100,000 unit/Gram apply to affected areas topically every morning and at bedtime for fungal treatment. Review of the resident's medical record, dated 4/1/25 through 4/30/25, did not contain documentation staff completed a weekly skin assessment for the weeks of 4/1/25, 4/7/25, 4/14/25, 4/21/25, or 4/28/25. Review of the resident's medical record, dated 5/1/25 through 5/31/25, did not contain documentation staff completed a weekly skin assessment for the weeks of 5/5/25 or 5/15/25. Review of the resident's TAR, dated 5/1/25 through 5/31/25, showed staff did not document they provided the resident wound care as ordered on 5/4, 5/8/25, 5/11/25, 5/15/25, 5/16/25, 5/19/25, 5/24/25, 5/25/25, 5/26/25, 5/27/25, 5/28/25, and 5/29/25. During an interview on 6/9/25 at 1:18 P.M., Licensed Practical Nurse (LPN) A said skin assessments are to be completed weekly by the nurse. LPN A said he/she thinks the Director of Nursing (DON) would be responsible for making sure they are completed and documented in their electronic health records. He/She said the charge nurse is responsible for wound care and treatments. LPN A said if there was a hole in the TAR it would mean the treatment was not completed. He/She said the DON and Administrator are responsible for making sure the TAR is signed off on by the nurses. During an interview on 6/9/25 at 1:35 P.M., LPN D said skin assessments are done at least once weekly and more often for residents with wounds. He/She said assessments are documented in the residents electronic health records and the nurse on duty is responsible to complete them. He/She said the DON would be responsible for making sure they are completed. He/She said the charge nurse is responsible for treatments and wound care. Staff are to sign off on the TAR after completion and if there was not a signature it would mean the treatment had not been completed. He/She believes the Regional consultant nurse is responsible for making sure this is completed. During an interview on 6/9/25 at 2:12 P.M., the DON said skin assessments should be completed weekly by the charge nurse. He/She said he/she is responsible for making sure they are completed. The DON said he/she was made aware the nurses were not doing these as they were supposed to. He/She said the charge nurses are responsible for wound care and treatments. Staff are to sign off on the TAR when the treatments are completed. If there was a hole in the TAR it would mean the treatment was not completed. He/She said he/she is responsible for making sure this is completed and was not aware there were holes in the TAR. During an interview on 6/9/25 at 2:20 P.M., the Administrator said skin assessments should be completed weekly by the charge nurse and when showers are completed. He/She said the DON is responsible for making sure this is completed. He/She said if there was a hole in the TAR it would mean a treatment wasn't completed or it was not signed off on. He/She said the DON is responsible for making sure the TAR is signed off on. MO00254921

Based on interview and record review, facility staff failed to update their Facility-Wide Assessment, an assessment completed by facility staff to determine what resources are necessary to care for its residents competently during day-to-day operations and emergencies as necessary. The facility census was 59. 1. Review of the facility's Assessment Tool, dated 9/5/24, showed the purpose of the assessment is to evaluate the resident population and determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Staff are directed as follows: -Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually and as necessary, per the above requirement; -Use evidence-based, data driven methods that focus on ensuring that each resident is provided care that allow the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being. The tool is organized in three parts: -Resident profile including numbers, diseases/conditions, physical/behavioral health needs, cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care; -Services and care offered based on resident needs; -Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and system, a facility-based and community-based risk assessment, and other information that you may choose. Review of the Facility's Assessment Tool, dated 9/13/24 showed the assessment tool did not contain: -The persons involved in completing the assessment; -The dates the facility assessment was reviewed with QAA/QAPI committee; -The resident profile section for the last quarter average number of occupied beds; -The acuity section for the accurate number of resident's acuity levels that help to understand potential implication regarding the intensity of care and services needed over the past year or during a typical month; -The Special treatments and conditions section for an accurate number, average, or range of residents; -The Assistance with activities of daily living (ADL's) section for an accurate number for residents who are independent, one to two person assistance, or dependent on staff; -The mobility section for an accurate number of residents; -The average daily facility staffing plan, based on the resident population and their needs for care and support for an accurate number of staff needed. During an interview on 6/2/25 at 1:00 P.M., the Director of Nursing (DON) said he/she thought the administrator was responsible for updating the facility census. He/She said he/she doesn't think the administrator knew how often to update the facility assessment. He/She said the administrator was responsible for making sure the staffing quota was met for the facility's acuity. During an interview on 6/2/25 at 1:16 P.M the interim administrator said the administrator is responsible for updating the facility assessment yearly and on an as needed basis. He/She does not know why this has not been done. He/She said the facility assessment should be updated if there is an change in administration, DON, staffing requirements, resident acuity, and census changes. MO00255114

Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered baseline care plan to meet the resident's medical, nursing, mental and psychosocial needs for one resident (Resident #1) out of two sampled residents. The facility's census was 52. 1. Review of the facility's Baseline Care Plan Policy, dated 5/18/24, showed the baseline care plan will be developed in 48 hours of a resident's admission. It should include the minimum healthcare information necessary to properly care for a resident. The admitting nurse, or supervising nurse on duty, shall gather infoamtion form the admission physical assessment, hospital transfer information, physicain orders, and discussion with teh residnt and resident representative. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 2. Review of Resident #1's Entry Minimum Datat Set (MDS), a federally mandated assessment tool, dated 3/27/25, showed the resident admitted to the facility 3/27/25. Review of the resident's clinical admission assessment, dated 3/28/25, showed staff assessed the resident as follows: -Severe cognitive impairment; -Diagnosis of acute respiratory failure, tracheostomy status, angelman syndrome (a genetic disorder causing developmental disabilities and nerve-related symptoms), and encounter screening for autism; -Tracheostomy; -Urinary catheter; Review showed it did not contain documentation related to gastrostomy tube. Review of the resident's baseline care plan, dated 3/27/25, did not contain staff direction in regard to resident's tracheostomy, gastrostomy tube, or urinary catheter. During an interview on 4/4/25 at 12:16 P.M., the Director of Nursing (DON) said the MDS cordinator was responsible for baseline careplans, but they do not have a MDS cordinator right now so he/she has been responsible for completing them. The DON said he/she would expect to see the resident's tracheostomy, gastrostomy tube, and urinary catheter addressed on the baseline care plan. He/she said it wasn't put on the baseline care plan because she didn't do it. The DON said he/she is trying to work on care plans as he/she can. During an interview on 4/4/25 at 12:24 P.M., Licensed Practical Nurse (LPN) D said nurses have access to care plans and can update them if needed. LPN D said he/she is unsure of who is responsible for baseline care plans or for checking them. He/She said a resident should have a baseline care plan within 48 hours and would expect a resident's tracheostomy, gastrostomy tube, and urinary catheter to be addressed on the baseline care plan. During an interview on 4/4/25 at 2:45 P.M., LPN A said he/she has access to the care plans but is not sure how to access them as he/she has only been working part time. He/She said a resident should have a baseline care plan within 48 hours of admission and would expect for the resident's tracheostomy, gastrostomy tube, and urinary catheter to be addressed in the baseline care plan. He/She does not know who is responsible for completing the baseline care plan and thinks the DON would be responsible for making sure they were completed by staff. During an interview on 4/4/25 at 2:54 P.M., the adminsitrator said baseline care plans are to be comleted within 48 hours of the residents admission and the nursing staff is responsible. The DON is responsible for making sure the baseline care plans are completed. MO00252016

Based on interview and record review, facility staff failed to meet professional standards when staff did not obtain orders for a urinary catheter (flexible tube used to drain the bladder when someone cannot urinate on their own), catheter care, for a tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe), tracheosyomy care, and did not obtain orders for a Gastrostomy (a surgical procedure creating an opening through the abdominal wall into the stomach, allowing for the insertion of a gastrostomy tube for feeding) tube, Gastrostomy tube flushes, or Gastrostomy tube care for one resident (Resident #1) out of five sampled residents. The facility census was 52. 1. Review of the facility's admission process, assignment of primary diagnosis policy, dated 12/1/22, showed a licensed or registered nurse will ensure all admission paperwork including physician orders, medications, diet orders, laboratory orders are obtained and followed. Review of the facility's Medication order policy, dated 5/18/24, showed written transfer orders staff are to implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order witht the current attending physicina before medications are adminsitered. The nurse should document verification on the admission order record by enter the time, date, and signature. 2. Review of Resident #1's Entry Minimum Data Set (MDS), a federally mandated assessment tool, date 3/27/25, showed the resident was admitted on [DATE]. Review of the resident's Clinical admission assessment, dated 3/28/25, showed staff assessed the resident as follows: -Severe cognitive impairment; -Diagnoses of acute respiratory failure, tracheostomy status, angelman syndrome (a genetic disorder causing developmental disabilities and nerve-related symptoms), and encounter screening for autism; -Tracheostomy; -Urinary catheter. Review showed it did not contain documentation related to gastrostomy tube. Review of the resident's baseline care plan, dated 3/27/25, showed staff assessed the resident at risk for impaired communication, had limited physical mobility and requires one to two assist at time, and at risk for falls. Staff were instructed to provide gentle range of motion as tolerated with daily care, provide supportive care, assistance with mobility as needed, and document assistance as needed. Review of the Physician's Order Sheet (POS), dated March 2025, showed it did not contain orders for the resident's tracheostomy, tracheostomy care, catheter, catheter care, gastrostomy tube, gastrostomy tube care, or gasttrostomy tube flushes. During an interview on 4/2/25 at 1:15 P.M., Licensed Practical Nurse (LPN) A said the resident is a new admission and has not been at the facility long. He/She said the resident has a tracheostomy, urinary catheter, and gastrostomy tube. LPN A said he/she was not aware there were not orders in the system for the resident's tracheostomy, catheter, or gastrostomy tube. LPN A said he/she knew how to care for the resident because of caring for residents with same tubes in the past and his/her nursing knowlegde. He/She said the charge nurse is responsible for entering in orders on new admissions and the Director of Nursing (DON) is resposible to make sure they are put in correctly. During an interview on 4/2/25 at 2:15 P.M., LPN D said the charge nurse is responsible to put orders in on a new admission. He/She said the nurses are receiving training on how to do this. LPN D said he/she put some of the resident's orders in but is not sure of the process from start to finish. He/She said the DON would be responsible for making sure all the information was in correctly. LPN D said he/she is not very familiar with the resident, but would expect there to be orders for the resident's tracheostomy, urinary catheter, gastrostomy tube, and cares for all of those listed on the physician's orders. LPN D said he/she was not aware the orders were not in the system and said he/she knew what care to provide through his/her nursing knowledge. During an interview on 4/2/25 at 3:50 P.M., the DON said he/she was not aware the orders were not in the system. He/She said they used to have a corporate person who helped with admissions. He/She said the charge nurses will be responsible for putting in orders for new admissions and he/she is responsible for making sure they are put in correctly. He/She said the orders were not put in due to a lack of knowledge on the nurses part. Nurses are currently in training. During an interview on 4/4/25 at 2:54 P.M., the administrator said the nursing staff are responsible for putting in orders for new admissions and the DON is responsible for making sure the nurses complete this task. MO00252016

Based on observation, interview, and record review, facility staff failed to perform hand hygiene and/or wash hands to prevent the spread of infection during medication pass for five residents (Residents #3, #20, #29, #41, and #48) of six sampled residents, and during perineal care for two residents (Resident #22 and #38) of two sampled residents. Facility staff failed to follow infection control protocols for cleaning/disinfecting the glucometer (a device used to measure blood sugar levels) when staff tested four residents (Resident #23, #26, #31, and #58) of four sampled resident blood sugar levels. Facility failed to ensure the two-step purified protein derivative ( (PPD) skin test for Tuberculosis (TB) ) was completed in accordance with their policy and on file for six employees (Registered Nurse (RN) E, Nurse aide (NA) D, housekeeping aide I, Maintenance J, Certified nurse aide (CNA) K, and Licensed Practical Nurse (LPN) S) out of ten employee files reviewed. Facility staff failed to have and maintain transmission-based precautions for one resident (Resident #56) in order to prevent the transmission of clostridium difficile ((C-diff) a germ that causes diarrhea and an inflammation of the colon) infection and failed to post guidance on contact precaution actions for staff and visitors. Facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff/other providers of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for three (Resident #22, #35, and #38) of three sampled residents. Facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's cooling tower to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD-a serious type of pneumonia (lung infection) caused by Legionella bacteria). Failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 53. 1. Review of the Facility's Hand Hygiene policy, dated June 2024, showed: -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Alcohol based hand rubs with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom; -Soap and water: -When hands are visibly dirty; -Exposure to c. diff. is suspected or likely; -Either soap and water or alcohol-based hand rub (ABHR is preferred): -Between resident contacts; -After handling contaminated objects; -Before applying and after removing PPE, including gloves; -Before preparing or handling medications; -For conditions involving a resident, or the resident's environment, who is isolated for c diff or other infectious diarrhea, handwashing with soap and water is required. Review of the facility's Peri-Care Policy, dated 06/29/23, showed staff are directed as follows: -Ensure resident genital area is kept clean and proper techniques are used to prevent skin breakdown, infections, or any other impairments that can be caused from not using proper aseptic technique; -Peri-care prevents skin breakdown, itchning burning, odor, and infections; -Always wear gloves when giving peri-care to protect yourself and the resident; -Wash hands and put gloves on; -Remove and dispose of gloves, and wash hands. 2. Observation on 08/26/18 at 11:20 A.M., showed Certified Medication Technician (CMT) A did not perform hand hygeine after he/she prepared and administered medication to Resident #41 or before he/she adminsitered medication to Resident # 3. Observation on 08/26/18 at 11:23 A.M., showed CMT A did not perform hand hygeine after he/she prepared and administered medication to Resident #3 or before he/she adminsitered medication to Resident #20. Observation on 08/26/18 at 11:28 A.M., showed CMT A did not perform hand hygeine after he/she prepared and administered medication to Resident #20 or before he/she adminsitered medication to Resident #29. Observation on 08/26/18 at 11:35 A.M., showed CMT A did not perform hand hygeine after he/she prepared and administered medication to Resident #29 or before he/she adminsitered medication to Resident #48. Observation on 08/26/18 at 11:45 A.M., showed CMT A prepared Resident #48's medication and took the medication to the resident. CMT A did not wash his/her hands and returned to the medication cart to. CMT A did not perform hand hygiene in a manner to prevent the spread of infection while administering medication. During an interview on 08/28/23 at 10:34 A.M., CMT A said he/she knows he/she should perform hand hygiene after each resident. He/She said he/she was not sure why he/she did not use hand sanitizer after passing resident medication. He/She said he/she just forgot because of nerves. He/She said he/she typically uses hand sanitizer between residents but washes his/her hands after the second or third resident. He/She said to his/her knowledge the facility does not provide any other reeducation for medication pass other than the new employee education. During an interview on 08/28/24 at 11:01 A.M., the infection Preventionist (IP) said it is his/her expectation staff use hand sanitizer from one resident to the next during medication pass. He/She said staff should be educated on hand hygiene during new employee training and yearly. During an interview on 08/28/24 at 1:51 P.M., the Director of Nursing (DON) said it is his/her expectation that staff perform hand hygiene between each resident's medication pass to prevent the spread of infections. He/She said he/she was not aware staff were not performing hand hygiene during medication pass. He/She said staff are educated on hand hygiene and should know the policy. During an interview on 08/29/24 at 4:05 P.M., the administrator said it is his/her expectation staff perform hand hygiene before entering and exiting resident rooms and between each resident's medication pass. He/She said he/she expects staff to perform hand hygiene when removing gloves. He/She said he/She was not aware staff were not performing hand hygiene between passing resident medications. 3. Review of Resident #22's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/29/24, showed staff assessed the resident as severe cognitive impairment, had an indwelling catheter, dependent with personal hygiene, and toileting. Observation on 08/28/24 at 12:09 P.M., showed CNA W and CNA X entered the resident's room to provide care. CNA W and CNA X did not wash his/her hands before he/she applied gloves.CNA X cleaned the bowel movement (BM) from the resident's buttock, provided peri-care/catheter care, changed gloves, cleaned BM from the resident's hip, placed a clean disposable pad underneath the resident, and both CNAs removed gloves. The CNAs did not perform appropriate hand hygiene before or during, peri-care to prevent the spread of infection. During an interview on 08/28/24 at 12:20 P.M., CNA X said he/she should have washed his/her hands before peri-care, and after removing his/her gloves, and he/she just did not. 4. Review of Resident #38's quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, had an indwelling catheter, dependent with personal hygiene, and toileting. Observation on 08/28/24 at 3:06 P.M., showed NA P and NA Q entered the resident's room, retrieved gloves from their pockets, put gloves on, transferred the resident via hoyer lift from chair to bed, and removed his/her brief. Observation showed the resident incontinent of BM. NA P performed incontinence care, wiped the catheter tubing and assisted NA Q to place a clean brief on the resident, both NAs removed their gloves, and transferred the resident back to his/her chair from the bed via mechanical lift. NA Q secured the resident's catheter bag to his/her chair and propelled him/her out the room. The NAs did not perform appropriate hand hygiene during, or after peri-care to prevent the spread of infection. During an interview on 08/28/24 at 3:25 P.M., NA P said he/she should have sanitized or wash his/her hands after cares. The NA said he/she should have changed gloves and at least sanitize hands after cleaning the resident's bowel movement, but he/she just forgot. The NA said he/she carried the gloves in his/her pockets because gloves are usually stored on walls outside the residents' rooms, and not always available inside a resident's room. During an interview on 08/29/24 at 4:35 P.M., the DON said it is not appropriate for staff to transport gloves in their pockets because of the risk for contamination, and he/she was not aware staff was transporting gloves in their pockets for use. The DON said staff should wash hands/sanitize after glove changes, and between clean and dirty tasks. 5. Review of the Facility's Glucometer Disinfection policy, dated April 2024, showed: -The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use; -The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against Human immunodeficiency virus (HIV), Hepatitis C and Hepatitis B virus; -Procedure:Retrieve two disinfectant wipes from container,using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer,after cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. Review of the facility glucose monitoring system manual, undated, showed the manual directs staff as follows: -To clean meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas id the meter or lancing device including both front and back surfaces until visibly clean; -To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. Other Environmental Protection Agency (EPA) registered wipes may be used for disinfecting the system, however these other wipes have not been validated and could affect the performance of your meter; i.Dispatch hospital cleaner disinfectant towels with bleach; ii. Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol; iii.Clorox Healthcare Bleach Germicidal and Disinfecting Wipes; iv. Medline Micro-Kill Bleach Germicidal Bleach Wipes; -Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time on the wipe's directions for use. Review of the Super Sani-Cloth Germicidal Disposable Wipes General Guidelines for use, dated 2021, showed staff are directed to disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for full two minutes. For heavily soiled surfaces, use wipe to pre-clean prior to disinfecting. Let air dry. 6. Observation on 08/27/24 at 7:57 A.M., showed LPN B entered Resident #23's room and obtain his/her blood sugar. LPN B did not clean/disinfect the glucometer before he/she placed the glucometer back in the top drawer of the medication cart. Observation on 08/27/24 at 11:01 A.M., showed LPN B did not clean the glucometer with an approved EPA registered healthcare disinfectant after he/she obtained Resident #26's blood sugar or before he/she obtained Resident #58's blood sugar. Observation on 08/27/24 at 11:23 A.M., showed LPN B did not clean the glucometer with an approved EPA registered healthcare disinfectant after he/she obtained resident #31's blood sugar or before he/she obtained resident #23's blood sugar. During an interview on 08/27/24 at 8:05 A.M., LPN B said he/she wipes down the glucometer with an alcohol wipe to clean after each resident. He/She said the facility does not provide any other wipes. He/She said he/she should have wiped it down after use and before he/she put it away. He/She said he/she just forgot. During an interview on 08/28/24 at 11:01 A.M., Infection Preventionist (IP) said the facility's policy is for staff to clean glucometers with a Sani-wipe, place it on a barrier or clean napkin and let it air dry for 5 minutes in between residents. His/She expectation is that staff follow the policy for cleaning the glucometer. He/She said he/she used to oversee new employee education, but the process has changed since the new company has taken over. He/She is not sure who is providing the new employee infection control education upon hire. During an interview on 08/28/24 at 1:51 P.M., the DON said it is his/her expectation staff are cleaning glucometers in between residents. He/She said staff should be cleaning glucometers with Sani-cloths and placing them on a clean barrier while they dry for three minutes. He/She said he/she was not aware staff were using alcohol wipes to clean the glucometers. He/She said disinfecting the glucometer is important for ensuring there is not cross contamination of blood. During an interview on 08/29/24 at 4:05 P.M., the administrator said it is his/her expectation staff clean/disinfect glucometers after each use, with a sani-wipe. He/She said staff should wipe down the glucometer thoroughly then allow it to dry for five minutes or until dry. He/She said alcohol wipes do not kill blood borne pathogens and should not be used to disinfect glucometers. He/She said he/she was not aware staff were using alcohol wipes to clean glucometers. 7. Review of the Facility's Tuberculosis Testing policy, dated June 2023, showed upon hire, a new employee will receive a 2-step purified protein derivative skin test. Review of the Center for Disease Control and Prevention's, Clinical Testing Guidance for TB: TB Skin Tests, Dated May, 14, 2024, showed: -Two-Step testing; -If the first skin test is negative, a second TB skin test should be done 1to 3 weeks later; -If the second TB skin test result is positive, it is probably a boosted reaction; -Interpreting test results; -The skin test reaction should be read between 48-72 hours after administration by a health care worker trained to read TB skin results. 8. Review of RN E's employee file showed: -Hire date of 11/27/23; -The file did not contain documentation staff administered the first step PPD and second step PPD test. Review of NA D's employee file showed: -Hire date of 01/31/24; -The file did not contain documentation staff administered the first PPD and second PPD test. Review of Housekeeping I's employee file showed: -Hire date of 11/17/23; -Staff documented the first step PPD administered on 11/17/23 and read on 11/20/23; -Staff documented the second step PPD administered on 11/28/23 five days after the 24-72 time. Review of maintenance J's employee file showed: -Hire date of 01/05/24; -Staff documented the first step PPD administered on on 01/02/24 and read on 01/04/24; -Second step PPD was administered on 01/04/24. Staff did not wait seven-21 days after the first dose, before administering the second step PPD. Review of CNA K's employee file showed: -Hire date of 07/26/23; -Staff documented the first step PPD administered on 07/26/23 and read on 07/29/23; -The file did not contain documentation a second step PPD dose administered. Review of LPN S's employee file showed: -Hire date of 06/30/23; -Staff documented the first step PPD administered on 03/03/23 and read on 03/06/23; -The file did not contain documentation a second step PPD dose administered. During an interview on 08/28/24 at 11:01 A.M., the IP said he/she oversees new employee TB's along side human resourses (HR). He/She said HR notifies him/her when they hire a new employee and he/she gives them their TB and directs them to return to have them read in two-three days. He/She said they require two step TB's upon hire. He/She said staff are directed to return to him/her in two-three weeks from the first TB, to get the second step. He/She said if staff do not return for their TB, he/she tries to reach out to the person. He/She said if he/she cannot get ahold of the staff member he/she notifies HR. He/She said he/she is not aware of any active staff members who did not receive the two step TB's. He/She said the second step should never be given the day the TB is read. He/She was not aware there were any staff who received the second step the same day the first step was read. During an interview on 08/28/24 at 1:51 P.M., the DON said the IP and HR work together to make sure all new employees have the two step TB's completed. He/She said the IP gives a list to him/her weekly of staff who need TB's read or given with deadlines. He/She tries to reach out to those staff members if he/she sees them. He/She said he/she was not aware there were staff who did not complete the two step TB's or who had them too close together. He/She said he/she is new and just started at the end out July. He/She said not having TB's completed puts their resident population at risk for TB expose due to their susceptibility. During an interview on 08/29/24 at 4:05 P.M., the administrator said when someone comes in for an interview and they have decided to hire them either the infection preventionist, DON or himself/herself perform the initial TB test. He/She said it is the responsibility of the IP to make sure staff complete the first step and the second step TB. He/She said TB's should be read between 48-72 hours and there should be 2-3 weeks in between the first and second step. He/She said he/she is not sure why the staff member was given the second step the same day as the first step was read. 9. Review of facility's Management of C-Difficile Infection Policy, dated 05/14/24, showed the purpose is to implement facility-wide strategies for the prevention and spread of Clostridioides difficile infections. Facility staff were directed as follows: -Contact precautions shall be implemented in accordance with a physician's order and facility policy for transmission-based precautions; -All staff are to wear gloves and a gown upon entry into the resident's room and while providing care for the resident with C. difficile infection; -Hand hygiene shall be performed by handwashing with soap and water; -Maintain contact precautions for the duration of illness, but no less than 48hrs after diarrhea has resolved; -A private room with a dedicated toilet is preferred. Review of facility's policy Transmission-Based Isolation Precautions, dated 06/26/24, showed: -Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment; -Transmission based precautions refer to actions implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections; -Facility staff will apply Transmission-based precautions, in addition to standard precautions, to resident who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission; -Signage that includes instructions for use of specific PPE will be places in a conspicuous location outside the resident's room, wing, or facility wide; -The CDC category of transmission-based precautions or instructions to see the nurse before entering will be included in the signage; -The Facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into he environment of a resident on transmission-based precautions; -Healthcare professional caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment; -Donning PPE upon entry and discarding before exiting the room is done to contain pathogens, especially those that that been implicated in transmission through environmental contamination (e.g. C. difficile). 10. Review of Resident #56's Temporary Care Plan, dated 08/20/24, showed the following: -Cognitively intact; -Diagnosis of C-Diff; -Independent with transfers and ADLS. Review of the resident's nurses admission assessment, dated 08/20/24, showed the resident is being treated for C-Diff and has seven days of antibiotic left to take. Observation on 08/26/24 at 9:27 A.M., showed the resident's room did not contain precaution signage, PPE inside or outside of the room. Observation on 08/27/24 at 8:09 A.M., showed the resident's room did not contain precaution signage, PPE inside or outside of the room. Observation on 08/27/24 at 10:34 A.M., showed LPN M did not wear a gown when he/she entered the residents' room to administer the resident's intravenous (within a vein) antibiotics. The resident room did not contain precaution signage, PPE inside or outside the room. During an interview on 08/27/24 at 10:43 A.M., LPN M said resident has red bin outside of door because resident is on C-Diff precautions. He/She said make sure and wear gloves going in and hand wash after removing gloves. He/She said no gown or goggles are needed, just gloves and handwashing. Observation on 08/28/24 at 9:19 A.M., showed CNA O did not wear a gown or gloves when he/she changed the resident's bed sheets. The resident room did not contain precaution signage, PPE inside or outside the room. During an interview on 08/29/24 at 10:50 A.M., CNA O said the resident has red bin outside of door for C-Diff precautions. He/She said to make sure and wear gloves going in room and to wash hands after removing gloves. He/She said he/she is unsure if there should be a sign outside of door due to privacy, but maybe a sign that says see charge nurse before entering resident room. He/She said he/she failed to wear gloves when changing bed sheets because, he/she was busy and honestly can't think of why he/she did not wear gloves, he/she should have worn gloves. He/She said not wearing gloves is a risk of getting sick and transferring the infection to another resident. During an interview on 08/29/24 at 8:50 A.M., CMT A said resident is on precautions for C-Diff. He/She said they were told to wear gloves when entering the room and remove gloves, put in red bin, and wash hands. He/She said he/she was not told he/she needed a gown. He/She would expect a sign on the door that says please see charge nurse before entering due to privacy. During an interview on 08/29/24 at 11:01 A.M., the Infection Preventionist said resident was admitted with C-Diff and was finishing up antibiotic here in facility. He/She said PPE for C-Diff should be gloves and hand washing or sanitizing after leaving room. He/She was not aware that gowns should be worn as a precaution for C-Diff when entering the room. He/She said there should have been a sign on the door to alert staff/visitors on precautions, but he/she just forgot. During an interview on 08/29/24 at 4:31 P.M., the DON said the resident was admitted with C-Diff from hospital. He/she said the resident should have proper PPE outside of resident's room to use when entering room. He/She said he/she expects a sign on door to ask nurse about precautions before entering the room. He/She said C-Diff precautions should be gloves and gown when caring for resident. He/She said gloves should be removed and hands should be washed and not sanitized when leaving the room. During an interview on 08/29/24 at 4:41 P.M., the administrator said he/she was not aware of resident's diagnosis upon admission that day until he/she saw the red bin outside of his/her door. He/She said he/she expects a sign outside of door to see the charge nurse before entering room. He/She expects PPE to he gloves, gown, and hand washing with soap and water. He/She said not using appropriate PPE is a risk for spreading infection to other residents. 11. Review of the facility's Enhanced Barrier Precautions Policy, dated 05/18/24, showed staff are directed as follows: -EBP uses PPE and recommends gown and glove use for certain residents during specific high-contact resident care activities associated with multidrug-resistant organisms (MDRO) transmission; -EBP (gown and gloves) must be used for high-contact resident care activities with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -High-contact resident care activities include, but are not limited to, dressing, transferring, providing hygiene, changing briefs, indwelling device care or use; -Indwelling medical devices include, but are not limited to, central lines, urinary catheters, feeding tubes, and tracheotomies; -Make gowns and gloves available immediately near or outside of the resident's room; -All staff receive training on EBP upon hire and at least annually, and are expected to comply with all designated precautions; -The Infection Preventionist (IP) will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education; -EBP are intended to be placed for the resident's entire stay in the facility or until discontinuation of the indwelling device that placed them at higher risk; -Facility should ensure all staff and other health care providers (doctors, therapy providers, etc.) know which residents require EBP; -The facility's IP is responsible for the enforcement of the policy. 12. Review of Resident #22's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Upper extremity (shoulder, elbow, wrist, hand) impairment on both sides; -Uses a feeding tube for nutrition; -Has a trach (a catheter inserted into the windpipe to help a person breathe); Observation on 08/26/24 at 11:35 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation 08/27/24 at 9:22 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 08/27/24 at 12:21 P.M., showed LPN B did not wear a gown when he/she administered the resident's medications, water flushes, and feeding via peg tube. The LPN re-entered the resident's room and did not wear a gown or gloves when he/she administered a nebulizer treatment via the resident's trach mask. The LPN did not use appropriate PPE as an EBP during cares. Observation on 08/28/24 at 11:51 A.M., showed Occupational Therapist (OT) V did not wear a gown when he/she performed hand exercises with the resident. The OT did not use appropriate PPE as an EBP during the therapy session. During an interview on 08/28/24 at 11:51 A.M., OT V said he/she has not been notified or made aware of any extra precautions or requirements to use additional PPE/EBP during therapy sessions with the resident. 13. Review of Resident #35's quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, and uses a feeding tube for nutrition. Observation on 08/26/24 at 11:35 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation 08/27/24 at 9:22 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 08/27/24 at 11:48 A.M., showed LPN B did not wear a gown when he/she administered the resident's medications, feeding, and water flushes via peg tube. The LPN did not use appropriate PPE as an EBP during care. During an interview on 08/27/24 at 2:40 P.M., LPN B said he/she was not aware of any protocol to use EBP for residents with medical devices such as a peg tube or trach. 14. Review of Resident #38's quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, had an indwelling catheter, dependent with personal hygiene, and toileting. Observation on 08/28/24 at 3:06 P.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. NA P and NA Q did not wear a gown when they transferred the resident via mechanical lift, performed incontinence care and catheter care. The NAs did not use appropriate EBP during transfers and incontinence/catheter care. During an interview on 08/28/24 at 3:25 P.M., NA P said he/she was not aware of any extra PPE such as gowns required for use with catheter care. During an interview on 08/28/24 at 12:32 P.M., the IP said he/she was not officially made aware of a CDC recommendation/guideline regarding EBP. The IP said he/she was told by a friend, and he/she consulted with the Administrator, but did not implement a policy. The IP said the facility did not currently have a protocol for EBP. During an interview on 08/29/24 at 4:35 P.M., the DON said he/she was aware of EBP required PPE for residents with wounds/devices such as peg tube, catheter, and trach from a previous job. The DON said he/she noticed there were residents in the facility that met the criteria, and he/she spoke with the IP regarding implementing a policy, but they just did not get to it yet. During an interview on 08/29/24 at 4:46 P.M., the administrator said he/she knew of EBP requirements for catheters/peg tubes but was not fully aware previously for extra PPE to be used with a trach or wound. The administrator said the facility had a policy for EBP, but staff did not implement it. The administrator said the policy should have been implemented prior to help with infection control. 15. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the Centers for Disease Control and Prevention (CDC) and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environm[TRUNCATED]

Based on interview and record review, facility staff failed to check the Employee Disqualification List (EDL) (a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident), criminal background check (CBC), and Family Care Safety Registry (FCSR) prior to hire in accordance with their facility policy for nine (Registered Nurse (RN) E, Nurse Aide (NA) D, Certified Medication Technician (CMT) F, Dietary Aide G, laundry aide H, housekeeping aide I, maintenance J, Certified Nurse Aide (CNA) K, and CNA L) out of ten sampled employees. The facility census was 53. 1. Review of the Facility's Screening- Applicant, Employee, Volunteer and Vendor (Missouri) policy, Revised May 2024, showed: -HR staff will conduct the following screens on potential employees prior to hire; -Criminal history- Using the request for Criminal Record Check, a criminal background check should be done through Missouri Highway Patrol's Missouri Automated Criminal History Site; -FCSR; -EDL list. 2. Review of RN E's personnel record showed the employee with a hire date of 11/27/23. The personnel record did not contain documentation staff completed a FCSR or CBC/ EDL check prior to his/her hire date. 3. Review of NA D's personnel record showed the employee with a hire date of 01/31/24.The personnel record did not contain documentation staff completed a FCSR or CBC/ EDL check prior to his/her hire date. 4. Review of CMT F's personnel record showed the employee with a hire date of 09/28/23. The personnel record did not contain documentation staff completed a FCSR or CBC/ EDL check prior to his/her hire date. 5. Review of Dietary aide G's personnel record showed the employee with a hire date of 11/07/23. The personnel record did not contain documentation stafff completed a FCSR or CBC/ EDL check prior to his/her hire date. 6. Review of Laundry aide H's personnel record showed the employee with a hire date of 08/18/23. The personnel record did not contain documentation staff completed a FCSR or CBC/ EDL check prior to his/her hire date. 7. Review of Housekeeping aide I's personnel record showed the employee with a hire date of 11/17/23. The personnel record did not contain documentation staff completed a FCSR or CBC/ EDL check prior to his/her hire date. 8. Review of maintenance J's personnel record showed the employee with a hire date of 01/05/24. The personnel record did not contain documentation staff completed a FCSR or CBC/ EDL check prior to his/her hire date. 9. Review of CNA K's personnel record showed the employee with a hire date of 07/26/23. The personnel record did not contain documentation staff completed a FCSR or CBC/ EDL check prior to his/her hire date. 10. Review of CNA L's personnel record showed the employee with a hire date of 06/13/23. The personnel record did not contain documentation staff completed a FCSR or CBC/ EDL check prior to his/her hire date. 11. During an interview on 08/26/24 at 3:30 P.M., Human Resources (HR) said he/she has been in this position for two weeks. He/She said he/she is responsible for doing the on-boarding of all new employees. He/She does the new employee criminal background checks and EDL's. He/She said the regional staff does all new empoyee FCSR's because he/she does not currently have access to do them yet. He/She said he/she will be responsible for doing them in the future. He/She said he/she is not sure about any employees hired prior to his/her start date. He/She said the previous business office manager (BOM) was responsible for the new employee CBC and EDL checks but he/she is no longer employed at the facility and his/her position was eliminated when the facility was bought out as of June 1, 2024. He/She knows all FCSR/EDL/CBC's should be completed before hire. He/She said he/she was not aware that any the staff previous to his/her employment did not have the CBC/ FCRS/EDLS completed prior to starting. During an interview on 08/28/24 at 1:51 P.M., the Director of Nursing (DON) said HR is responsible for ensuring all backgrounds are completed before someone is hired. He/She said he/she does the interview and then walks them over to HR to complete the paperwork if he/she decided to hire them. He/She said he/she was not aware there were staff who had not completed the required background screenings prior to hiring them. He/She said hiring staff without having the background screenings completed first, puts the residents at risk for being exposed to people who are on the disqualifying list. During an interview on 08/29/24 at 4:03 P.M., the Administrator said before new ownership in June, he/she and the BOM would collaborate on completing the EDL/CBC/FCSR checks with new hires. He/She said with new ownership it is HR's responsibility to ensure EDL/CBC/FCSR's are completed. He/She said he/she was unaware both the EDL and CBC or the FCSR had to come back prior to hire. He/She said he/she thought it was okay to hire as long as the EDL was completed. He/She was unaware the EDL/CBC/FCSR's were not being completed on time before hire.

Based on observation, interview and record review, the facility failed to assess, provide interventions, and/or notify the physician of uncontrolled pain for one resident (Resident #3) out of 11 sampled residents. The facility census was 42 . 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by facility staff, dated 11/15/16, showed the facility assessed the resident as follows: -Cognitively impaired; -Complaints of pain almost constantly; -Difficulty sleeping at night due to pain; -Limits his/her day to day activities due to pain; -Pain rated as severe. Review of the resident's significant change MDS Assessment, dated 12/13/16, showed the facility assessed the resident as follows: -Cognitively impaired; -Complaints of pain almost constantly; -Difficulty sleeping at night due to pain; -Limits his/her day to day activities due to pain; -Pain rated as severe. Review of the resident's plan of care, dated 2/3/17, showed staff are directed to: -Administer medications as ordered by the resident's doctor; -Monitor for behaviors, this could be a good indication that pain is not being controlled, if resident was not able communicate this; -There may be times when resident has break through pain (pain felt after receiving scheduled pain medications) and will need a PRN (as needed) in between scheduled medication, please give it to resident, the doctor would not have ordered it if resident couldn't take it as ordered; -If the medication does not seem to be controlling pain, please consult with doctor so can try something more effective; -Assess for pain each day and offer PRN (as needed) medication and then assess for effectiveness of the medicine. Review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME] (medication used to relieve pain) 100 micrograms (mcg) per hour, apply one patch topically (to skin) every 72 hours, start date of 3/21/16; -[MEDICATION NAME]-APAP (medication used to relieve pain) 10/325 milligrams (mg) every six hours as needed for pain, start date of 2/26/15; -Tylenol (medication used to relieve pain) 325 mg two tablets (650 mg) PO every four hours as needed for pain/fever, start date of 11/30/10. Review of the residents nurses's notes dated 2/3/17, at 10:50 A.M., showed Registered Nurse (RN) K documented the following: Resident is up in wheelchair, with complaints of pain all over related to chronic pain, resident has no grimacing or guarding to left side. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's nurse's notes dated 2/4/17, at 11:00 A.M., showed an unidentified nurse documented the following: Complaints of general pain at breakfast when awake, unable to rate or locate pain. Review of the resident's MAR, dated 2/2017, showed facility staff did not document they administered as needed pain medication. Review of the resident's nurse's notes dated 3/11/17, at 9:30 A.M., showed an unidentified nurse documented: complaints of pain while changing dressing, but not at rest. Review of the resident's MAR, dated 3/2017, showed facility staff did not document they administered as needed pain medication. Review of the resident's nurses's notes dated 3/11/17, at 1:00 P.M., showed an unidentified nurse documented: when lower legs moved resident complained of pain, unrated. Review of the resident's MAR, dated 3/2017, showed facility staff did not document they administered as needed pain medication. Further review of the resident's nurses' notes showed staff did not document they notified the resident's hospice provider or physician of the resident's complaints of unrelieved pain. Observation on 3/21/17, at 9:00 A.M., showed the resident sat in a recliner in his/her room. Further observation showed the resident yelled out, please tell the nurse I hurt everywhere, please hurry. During an interview on 3/21/17, at 9:00 A.M., Licensed Practical Nurse (LPN) A said he/she would reposition the resident. The LPN said staff had administered all the medication the resident had orders for. Observation on 3/21/17, at 9:39 A.M., showed the resident in his/her room in a recliner. Further observation showed the resident yelled out, help me, please help me. Review of the resident's Medication Administration Record, [REDACTED]. Observation on 3/22/17, at 11:43 A.M., showed LPN A and an unidentified hospice nurse entered the resident's room to perform skin treatments. Further observation showed the resident with complaints of pain with movement, cleansing of his/her coccyx, and during a dressing change to the right calf. The resident yelled out It hurts so bad, and oh please. The resident also said I sure hurt, as LPN A removed his/her sock. During an interview on 3/23/17, at 7:26 A.M., Certified Nursing Assistant (CNA) I said the resident has complaints of pain frequently. The CNA said he/she informs the charge nurse immediately when the resident complains of pain. During an interview on 3/23/17, at 7:30 A.M., CNA J said the resident has complaints of pain a lot, and he/she reports the pain to the charge nurse. During an interview on 3/23/17, at 8:54 A.M., RN K said the resident has days where he/she is hurting quite a bit, he/she has scheduled and as needed medications. Furthermore RN K said it would be appropriate to administer an as needed medication if the resident had complaints of pain after a scheduled pain medication was given. RN K said he/she would notify the primary care physician if the resident's scheduled and as needed medications were not effective for his/her pain relief. During an interview on 3/23/17, at 12:51 P.M., LPN A said he/she did not know the resident had an order for [REDACTED]. LPN A also said staff are expected to complete pain assessments for the resident daily, and said the assessments are not being completed. LPN A said he/she does not know why the assessments are not completed. During an interview on 3/23/217, at 2:14 P.M., the Director of Nursing (DON) said he/she expects the staff to check the MAR for possible as needed medications to give to a resident in pain. Furthermore the DON said he/she would expect the staff to contact the resident's hospice nurse or physician in regards to unrelieved pain. The DON also said he/she expects staff to complete the pain assessments.