Every finding on record at Fountainbleau Nursing Center

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice affected one resident (Resident #22) outside of the 22 sampled residents and had the potential to affect all residents in the facility. The facility's census was 105.Review of the facility's policy, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, showed: - Environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard; - Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled; - Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled; - Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled; - Horizontal surfaces will be wet dusted regularly (e.g., daily, three times per week) using clean cloths moistened with an Environmental Protection Agency (EPA)-registered hospital disinfectant (or detergent). The disinfectant (or detergent) will be prepared as recommended by the manufacturer. 1. Observations on 02/09/26 at 11:50 A.M., and on 02/10/26 at 10:30 A.M., of the 300 Hall showed a strong urine odor. 2. Observations on 02/09/26 at 12:10 P.M., and on 02/12/26 at 5:00 P.M., of room [ROOM NUMBER] showed: - A three inch (in.) by three in. circular hole in the bathroom door; - A three in. by four in. area of missing sheetrock with visible screws; - Four one in. by one in. areas of missing sheetrock and a two in. by two in. area of missing sheetrock on the side wall beside the first bed. 3. Observation on 02/12/26 at 2:45 P.M., of the 300/400 Hall shower room showed: - Dirty rags, gloves, a razor, bottles of lotion, a stick of deodorant, and a watch scattered on and around a shower chair; - Opened bottles of shampoo and soap lay on the floor; - An open cabinet to the right of the sink with items scattered on the floor from the cabinet; - An opened backpack and a pair of shoes on the floor in front of the sink; - Dirt, grime, and a brown substance on the shower tile on the floor and walls. 3. Observation on 02/12/2026 from 2:00 P.M. to 2:10 P.M., showed dirt and stains with a musty odor on carpets in resident rooms 102, 103, 104, 105, 108, 110, 112, 116, 205, 208, 209, 210, 213, 214, 215, 301, 302, 304, 307, 310, 312, 401, 410, and 411. During an interview on 02/09/26 at 12:12 P.M., Resident #22 said he/she had lived here a month or so. The holes had been there ever since, and no one had come to fix them. During an interview on 02/12/26 at 6:45 P.M., the Administrator said she would expect the facility to be free from odors and the carpet to be free from stains and odors. She would expect the facility walls to be free from holes and scratches and the shower rooms to be clean, organized, and free from dirt and grime. During a phone interview on 02/20/26 at 8:34 A.M., the Maintenance Director said that he goes in and checks resident rooms about once a week, and if there are any issues found he tries to fix them the same day, depending on the supplies needed. He said typically he can fix a hole in a wall or door in a day. He said staff either call his phone with repairs or they have a tele system where staff can place work orders.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #74) out of 22 sampled residents was free from abuse when an employee knowingly sent inappropriate sexual pictures and text messages to the resident. The facility census was 105.Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed: - Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms;- The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect and exploitation or misappropriation of property by anyone including, but not necessarily limited to, facility staff;- Develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents;- Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior;- Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property;- Protect residents from any further harm during investigations. Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, showed: - All reports of resident abuse (including injuries from unknown origin), neglect, exploitation, or theft/misappropriation or resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported;- The administrator or the individual making the allegation immediately reports his/her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility; the local/state ombudsman, the resident's representative, adult protective services (where state law provides jurisdiction in long term care), law enforcement officials, the resident's attending physician, and the facility medical director;- Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete;- Within five business days of the incident, the administrator will provide a follow-up investigation report;- If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) is terminated. 1. Review of the facility's investigation report, completed on 02/14/26, showed: - The Assistant Director of Nursing (ADON) was made aware of a relationship between Resident #74 and Dietary Aide L on the evening of 02/10/26 by a friend of the resident. Dietary Aide L was suspended pending the investigation;- Resident #74 and Dietary Aide L had been sending each other text messages that were sexual in nature for about a week. The Director of Nursing (DON) reviewed the texts and confirmed they were sexual in nature from both Resident #74 and Dietary Aide L. Resident #74 said the communication was consensual between them. Resident #74 did not want to file a police report and said he/she was not abused physically or mentally. A full body assessment was completed with no concerns;- Dietary Aide L said at first, he/she didn't know he/she was texting Resident #74 because he/she used a dating app and thought he/she was texting someone off the app. After finding out he/she was texting Resident #74, he/she continued to send texts and an explicit photo of himself/herself accidentally to Resident #74. He/She thought the photo was being sent to someone on the dating app;- Dietary Aide L said he/she didn't know how Resident #74 got his/her phone number. About a week ago, he/she wrote his/her number on a piece of paper, and it must have fallen out of his/her pocket;- Dietary Aide L said that the communication was through text only, and no physical contact occurred;- Resident #74 said that two episodes of physical contact occurred about a week ago. Dietary Aide L worked on 02/04/26 and 02/05/26, and the areas where the physical contact was said to have happened were under video surveillance. The video footage was reviewed. Resident #74 and Dietary Aide L were observed talking multiple times on the video footage dated 02/04/26, and there were no interactions between the two on 02/05/26. There were no incidents of Dietary Aide L touching Resident #74 between his/her thighs or putting anything down his/her shirt between his/her breasts;- The Administrator contacted the police and Resident #74 said he/she did not want to file a police report. The police officers told the Administrator the report would only be informational, report #26-0136;- Dietary Aide L was terminated on 02/14/26.Review of Resident #74's medical record showed:- An admission date of 11/26/24;- Diagnoses of end stage renal disease (ESRD - final, permanent stage of kidney failure), morbid obesity (excess body fat that severely affects health), hemiplegia (paralysis of one side of the body), intracranial injury with loss of consciousness (traumatic brain damage to the brain with a period of non-responsiveness), generalized anxiety (persistent worry and fear about everyday situations), major depressive disorder (long-term loss of pleasure or interest in life), need for assistance with personal care, dependence on renal dialysis (process of purifying the blood of a person whose kidneys aren't working normally), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and type two diabetes (a condition that affects the way the body processes blood sugar). Review of the resident's Care Plan, revised 02/10/26, showed:- Actual functional decline, history of left sided hemiparesis (weakness or partial paralysis of one side of the body), uses an electric wheelchair for community/facility locomotion;- Uses antianxiety medications related to anxiety;- Uses antidepressant medications related to depression;- Receives hemodialysis treatments related to ESRD. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility staff), dated 01/13/26, showed no cognitive impairment. During an interview on 02/11/26 at 9:05 A.M., Resident #74 said Dietary Aide L had a crush on him/her and that he/she liked attention. Resident #74 said Dietary Aide L had been working at the facility for a few months and (Dietary Aide L) had asked for Resident #74's phone number so they could text each other. Resident #74 said they traded sexual texts and Dietary Aide L asked for sexual stuff, and to feel parts of his/her body. Resident #74 said that one time he/she was out in the hall by the meal cart, and Dietary Aide L took a piece of paper and stuffed it down the front of his/her outfit (at the neckline), but Dietary Aide L did not touch his/her chest. Resident #74 said there was another time that he/she was by the nurse's station, and Dietary Aide L stuck his/her hand up under Resident #74's clothing and tried to get in between his/her legs but was unsuccessful. Resident #74 said that he/she and Dietary Aide L had only been texting a week and that both things happened a week ago. Resident #74 said Dietary Aide L said, one of these days I'm gonna get ya. Resident #74 said Dietary Aide L asked, where they were going to do it, meaning where were they were going to have sex, and they both said they didn't know, but they couldn't do it at the facility. Resident #74 said the first day they texted, Dietary Aide L sent him/her a picture of his/her genitals and wanted Resident #74 to send him/her pictures of his/her body parts and he/she told Dietary Aide L not until they got to know each other better. Resident #74 said Dietary Aide L told him/her not to tell anyone they were talking because he/she would lose his/her job. Resident #74 told Dietary Aide L they should drop it (end the relationship) before they got into more trouble. Resident #74 said Dietary Aide L kept texting him/her inappropriate texts and he/she would just change the subject. Sometimes this upset him/her because he/she just wanted the relationship over. Resident #74 said Dietary Aide L would also say sexual things to his/her face, and he/she would tell Dietary Aide L to get away from him/her. Resident #74 said he/she just recently told someone about what was going on 02/09/26. Resident #74 said the DON called him/her into the DON's office and questioned him/her about the situation with Dietary Aide L. Resident #74 said he/she lied and told the DON they just sent texts socially and not sexually. Resident #74 said she/he wanted to protect Dietary Aide L. Resident #74 said he/she texted Dietary Aide L yesterday (02/10/26) and told him/her that he/she got called into the DON's office with the Administrator and questioned about what happened between them. Resident #74 said he/she can't text very well and could only use his/her thumb on his/her right hand to text with, so he/she told Dietary Aide L that he/she would talk to him/her and tell him/her the rest of what happened at dinner on 02/10/26. Resident #74 said he/she didn't get a chance to talk to Dietary Aide L face to face because Dietary Aide L went straight to the DON's office and showed his/her phone to them and said, See, Resident #74 keeps texting me and won't leave me alone. Resident #74 said that Dietary Aide L went right to the DON's office and tried to place the blame on him/her. Resident #74 said that was when she told the DON the truth about what was going on between him/her and Dietary Aide L. Resident #74 said the DON told him/her that Dietary Aide L got fired last night (02/10/26). Resident #74 said she had known the DON for a long time because she worked at a different facility before and that he/she had lived there for 17 years prior to coming to this facility. Resident #74 said Dietary Aide L never made him/her feel uncomfortable or unsafe, and he/she had always felt safe at the facility. Resident #74 said he/she did not want to make a police report or press charges. Resident #74 said he/she deleted all the texts and the picture off his/her phone from Dietary Aide L. Resident #74 said when he/she and Dietary Aide L would get done texting for the night, he/she would go back through the texts and delete all of them. Resident #74 said the DON recovered all the texts and the picture of Dietary Aide L's genitals. During an interview on 02/11/26 at 10:00 A.M., with the Administrator, DON, and the Director of Operations present, the Administrator said they were made aware of the situation between Resident #74 and Dietary Aide L yesterday evening (02/10/26) and the communication was mutual. Resident #74 didn't feel abused and wanted the relationship over with. The Administrator said Dietary Aide L was suspended pending the investigation. The Administrator said Dietary Aide L told her that he/she thought he/she was texting someone from a dating app and at first, he/she didn't know it was Resident #74, but after he/she found out it was Resident #74, they continued texting. Dietary Aide L wouldn't admit to how he/she got Resident #74's phone number because Resident #74 didn't have a dating app. The DON said the texting between Resident #74 and Dietary Aide L started on 02/04/26. The DON said that she, the ADON, and the Administrator went through Resident #74's phone with his/her permission and were able to retrieve multiple texts that were sexual in nature and a picture of Dietary Aide L's genitals. Dietary Aide L had Resident #74's phone number saved under a different name, and that was who Dietary Aide L thought he/she was texting on the dating app. Dietary Aide L told the Administrator the relationship between him/her and Resident #74 was over yesterday (02/10/26). The DON said they offered to call the police, but Resident #74 didn't want them called. The DON and the Administrator both said that Resident #74 did not want any of the texts and the picture saved, emailed, screenshot, or sent anywhere. The DON said Resident #74 told her that nothing sexual or physical ever happened. The DON said Resident #74 did not mention to them about the paper being stuffed down the front of his/her outfit at the neckline or that Dietary Aide L placed his/her hand under his/her outfit and tried to get between his/her legs. The DON said Resident #74 came to her this morning (02/11/26) at around 7:00 or 7:30 A.M. and wanted all the texts and the picture erased, and Dietary Aide L's phone number blocked and deleted off of his/her phone, so the DON deleted the texts and picture and blocked and deleted Dietary Aide L's phone number off of Resident #74's phone.During an observation on 02/11/26 at 3:20 P.M., the facility camera footage of the south nursing station, dated 02/04/26, showed:- At 5:58 P.M., Resident #74 in a power wheelchair at the south nurse's station parked beside the hot meal cart talking to Dietary Aide L. Dietary Aide L ripped off a piece of paper, wrote on the paper, and stuck the paper in his/her pocket;- At 6:00 P.M., Dietary Aide L placed a piece of paper on Resident #74's chest area;- At 6:11 P.M., a staff member adjusted Resident #74's foot buddy (cushioned support accessory designed to keep a wheelchair user's feet and calves securely on the footrests) and showed Dietary Aide L assisted the other staff member and touched Resident #74's lower leg area;- At 6:14 P.M., Dietary Aide L gave Resident #74 a hug. During an interview on 02/11/26 at 3:51 P.M., the Administrator said the police told her that the report will be an informative report since they spoke to Resident #74, and he/she didn't want to press charges.Attempts to obtain an interview with Dietary Aide L by phone on 02/11/26 at 1:10 P.M., and 02/13/26 at 3:09 P.M., were unsuccessful.During a phone interview on 02/18/26 at 5:56 P.M., the Administrator said Dietary Aide L was terminated on 02/14/26.The Administrator was notified on 02/11/26 of the Past Non-Compliance which occurred on 02/04/26. On 02/10/26, facility staff started an investigation, completed disciplinary action, and began in-servicing all staff on abuse policies and procedures. The non-compliance was corrected on 02/10/26.

Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for three residents (Residents #3, #67, and #96) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of three sampled residents. The facility's census was 105. The facility did not provide a policy on trauma informed care. 1. Review of Resident #3's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, major depressive disorder (condition characterized by a persistent low mood, loss of interest in pleasurable activities, and fatigue, lasting at least two weeks), bipolar disorder (chronic mental health condition characterized by extreme, often debilitating shifts in mood, energy, and activity levels, alternating between high and low episodes), social phobia (an intense, persistent fear of being watched, judged, or humiliated by others in social or performance situations), and schizoaffective disorder (condition combining schizophrenia symptoms, such as hallucinations, delusions, and disorganized speech, with a major mood disorder). Review of the resident's Preadmission Screening and Resident Review (PASARR - a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 03/20/24, showed diagnoses of schizophrenia, schizoaffective disorder, anxiety disorder, social phobia, personality disorder, bipolar disorder, and PTSD. Review of the resident's Trauma Informed Care assessment, dated 12/08/25, showed: - Resident has experienced something unusually or especially frightening, horrible, or traumatic; - In the past month, the resident had nightmares about the event(s) or thought about the event(s) when he/she did not want to, tried hard not to think about the event(s) or went out of his/her way to avoid situations that reminded him/her of the event(s), and had been constantly on guard, watchful, or easily startled; - Did not address triggers or interventions if the resident is triggered. Review of the resident's Physician Order Sheet (POS), dated 02/12/26, showed: - An order for Benztropine (medication to treat involuntary movements caused by psychiatric drugs) one milligram (mg), one tablet by mouth at bedtime for schizoaffective disorder, dated 10/14/25; - An order for clonazepam (anti-anxiety medication) 0.5 mg, one tablet by mouth three times a day for anxiety for 30 days, dated 02/09/26; - An order for Invega injection (antipsychotic medication - a drug that affects the brain activities associated with mental processes and behavior), 234 mg/1.5 milliliters (ml), inject 1.5 ml every 30 days for schizoaffective disorder, dated 01/15/26; - An order for paliperidone (antipsychotic medication) three mg, one tablet by mouth once a day for schizoaffective disorder, dated 10/14/25; - An order for Trintellix (antidepressant) five mg, two tablets by mouth once a day for schizoaffective disorder, dated 10/14/25. Review of the resident's care plan, revised 02/09/26, showed: - PTSD only mentioned as a diagnosis related to psychotropic medication use; - No triggers listed or interventions regarding how to care for the resident's trauma. Review of the resident's behavioral progress note, dated 07/28/25, showed resident continues to see mice in his/her room and other rooms. No mice observed by staff or other residents. Resident states he/she knows he/she is hallucinating but continues to look for mice around room. During an interview on 02/12/26 at 3:31 P.M. the social worker said Resident #3 has PTSD because he/she accidentally burned his/her house down. The social worker saw how staff talking about similar situations could trigger the resident. 2. Review of Resident #67's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, schizophrenia (a long-term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), major depressive disorder (MDD - long-term loss of pleasure or interest in life), and anxiety disorder (persistent worry and fear about everyday situations). Review of the resident's PASARR, dated 03/25/24, showed diagnoses of PTSD, anxiety disorder, panic disorder, and MDD; Review of the resident's Trauma Informed Care Assessment, dated 03/05/24, showed no information regarding trauma. Review of the resident's POS, dated February 2025, showed: - An order for clonazepam (anticonvulsant medication) 0.5 mg, one tablet by mouth at bedtime for anxiety, dated 12/02/25; - An order for Lexapro (antidepressant) 10 mg, one tablet by mouth once a day for depression, dated 10/16/25; Review of the resident's Care Plan, dated 01/20/26, showed: - MDD and anxiety; - Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. - Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs; - Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift; - Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs being given; - Monitor/document/report as needed adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in activities of daily living ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, n/v, dry mouth, dry eyes; - Did not address PTSD; - Did not address the resident's past trauma or any triggers that would cause the resident to have behaviors. 3. Review of Resident #96's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, schizophrenia, MDD, anxiety disorder, mood disturbance (a mental health condition where there is a disconnect between actual life circumstances and one's state of mind or feeling), and bipolar disorder. Review of the resident's PASARR, dated 12/04/25, showed diagnoses of PTSD, major depressive disorder, anxiety disorders, schizophrenia and bipolar disorder. Review of the resident's Trauma Informed Care Assessment, dated 02/11/26, showed no information regarding trauma. Review of the resident's POS, dated February 2026, showed an order for duloxetine (antidepressant) 60 mg, two capsules by mouth daily for mood, dated 10/14/25. Review of the resident's undated Care Plan showed: - Resident had experienced an event or series of events/circumstances that had a long lasting, negative impact on emotional, mental or spiritual well-being; - No triggers voiced by resident; - Give resident opportunities for choice, control of personal decisions within reason; - Medications as ordered; - Validate resident's feelings and encourage to voice fears or concerns. During an interview on 02/12/2026 at 1:50 P.M. Licensed Practical Nurse (LPN) B said Resident #96 had a diagnosis of PTSD, but he/she did not know of triggers other than the resident would have anxiety when he/she became short of breath due to diagnosis. During an interview on 02/12/2026 at 2:20 P.M., the Director of Nursing (DON) said she did not know what Resident #96's triggers were, but when the resident lived with his/her family for a time, he/she had called the facility and asked to come back because of not receiving medications correctly. The resident sees a counselor at the outpatient clinic. During an interview on 02/12/26 at 11:00 A.M., the MDS Coordinator said she would expect the care plan to be person-centered and to reflect a resident's diagnosis of PTSD or dementia with individualized triggers and interventions. During an interview on 02/12/2026 at 3:18 P.M., the Administrator and Director of Nursing (DON) said Social Services completes the trauma assessments. The assessments do not contain very much information, but that's all that the system shows for the assessment. The social worker will have a conversation with the resident about their trauma, triggers, etc. The social worker will note the conversation in the progress notes and should be updating the care plan; however, the social worker did not know she should be updating the care plan until recently. The administrator said care plans should be customized to each resident. During an interview on 02/12/26 at 3:31 P.M., the social worker said the trauma assessment is very broad, so there is really no way to know what the residents' trauma and triggers are based on the assessment and care plan. There needs to be more noted regarding what happened because there is currently not enough information to know what the residents' trauma involves.

Based on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation of the controlled medications and to ensure nursing staff signed at the beginning and the end of each shift for four medication carts out of five sampled medication carts. The facility's census was 105.Review of the facility's policy titled, Controlled Substances, revised November 2022, showed:- Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count;- The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.1. Review of the North Nurses' Cart Nurse Count Log, dated February 1 through February 12, 2026, showed:- No signature and/or initials by the nurse for 14 out of 46 opportunities.2. Review of the 200 Hall Certified Medication Technician (CMT) Cart Narcotic Count Sheet, dated February 1 through February 12, 2026, showed:- No signature and/or initials by the nurse or CMT for eight out of 68 opportunities;- The narcotic count sheet was reviewed on February 12, 2026 at 9:30 A.M., and staff had signed as oncoming day shift, as well as already signed for off-going day shift, oncoming evening shift, and off-going evening shift for that date.3. Review of the 300 Hall Medication Cart Narcotic Count Sheet, dated February 1 through February 12, 2026, showed:- No signature and/or initials by the nurse or CMT for nine out of 68 opportunities;- The narcotic sheet was reviewed on 02/12/26 at 9:30 A.M., and CMT A had already signed as the off-going day shift for that date.Review of the Total Card Count Sheet for 300 Hall showed 18 cards total, but the physical card count was 19.4. Review of the 400 Hall CMT Cart Narcotic Count Sheet, dated February 1 through February 12, 2026, showed:- No signature and/or initials by the nurse or CMT for 20 of 68 opportunities;- The narcotic sheet was reviewed on 02/12/26 at 9:30 A.M., and CMT A had already signed as the off-going day shift for that date.During an interview on 02/12/26 at 8:53 A.M., CMT A said he/she was on the cart last night and was trying to find why the 300 Hall total card count was off. He/She failed to add Resident #43's clonazepam (anti-anxiety medication). The medication came about 6:00 P.M., yesterday and he/she forgot to add it to the count sheet. During an interview on 02/12/26 at 8:53 A.M., the Infection Preventionist said regarding the 300 Hall CMT cart, CMT A may have not updated the count sheet this morning yet, but it should be done when they make a change. During an interview on 02/12/26 at 9:06 A.M., CMT A said the night shift nurses sign when the evening shift CMT leaves, and both CMT A and the Infection Preventionist said there should be signatures on all the lines for each count at the change of shift. During an interview on 02/12/26 at 6:45 P.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect off-going and on coming nursing staff to count and sign the narcotic sheet, and they would expect the total count sheet in the book to be updated when medications were added to the cart.

Based on observation, interview, and record review, the facility failed to implement care plans with specific interventions to meet individual needs for three residents (Residents #3, #8, and #67) out of 22 sampled residents and one resident (Resident #36) outside the sample. The facility's census was 105.1. Review of Resident #3's medical record showed: - admission date of 11/14/24; - Diagnoses of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and triggers may bring back memories, intense emotions and physical reactions), major depressive disorder (condition characterized by a persistent low mood, loss of interest in pleasurable activities, and fatigue, lasting at least two weeks), and schizoaffective disorder (condition combining schizophrenia symptoms, such as hallucinations, delusions, and disorganized speech, with a major mood disorder). Review of the resident's care plan, revised 02/09/26, showed: - PTSD only mentioned as a diagnosis related to psychotropic (a drug that affects the brain activities associated with mental processes and behavior) medication use; - Did not address triggers or interventions on how to care for the resident. 2. Review of Resident #8's medical record showed: - admission date of 02/02/24; - Diagnosis of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). Review of the resident's care plan, revised 12/12/25, showed: - Dementia not addressed; - Did not address personalized dementia care or interventions associated to the resident or the dementia diagnosis. 3. Review of Resident #36's medical record showed: - admission date of 09/22/25; - Diagnosis of PTSD. Review of the resident's care plan, revised 02/02/26, showed: - PTSD not addressed; - Did not address personalized triggers or interventions associated to the resident. During an interview on 02/12/26 at 2:54 P.M., the resident said he/she has PTSD, and his/her trigger is anger. 4. Review of Resident #67's medical record showed: - admission date of 09/30/25; - Diagnoses of PTSD. Review of the resident's care plan, dated 01/20/26, showed: - PTSD not addressed; - Did not address triggers or interventions. During an interview on 02/12/26 at 11:00 A.M., the MDS Coordinator said she would expect the care plan to be person-centered and to reflect a resident's diagnosis of PTSD or dementia with individualized triggers and interventions. During an interview on 02/12/2026 at 3:18 P.M., the Administrator and Director of Nursing (DON) said Social Services completes the trauma assessments. They will have a conversation with the resident about their trauma, triggers etc. The social worker will note the conversation in the progress notes and should be updating the care plan; however, she did not know she should be updating the care plan until recently. The administrator said care plans should be customized to each resident. During an interview on 02/12/26 at 3:31 P.M., the social worker said the trauma assessment is very broad, so there is really no way to know what their trauma and triggers are based on the assessment and care plan. There needs to be more noted regarding what happened because there is currently not enough information to know what the residents' trauma involves.

Based on interview and record review, the facility failed to provide the annual competencies of dementia care (care of a resident with an impaired ability to remember, think, or make decisions), and abuse/neglect training and provide at least twelve hours of nurse aide in-service education per year. This affected three of three sampled Certified Nurse Aides (CNAs). The facility census was 105.Review of the facility's policy, In-service Training, Nurse Aide, revised August 2022, showed:- All personnel are required to participate in regular in-service education. Participation in in-service education is considered working time for which personnel are paid their regular wages;- In-service training is based on the outcome of the annual performance review;- Annual in-services: ensure the continuing competences of nurse aides; are no less than 12 hours per employment year; address areas of weakness as determined by nurse aide performance reviews; address the special needs of the residents, as determined by the facility assessment; include training that addresses the care of residents with cognitive impairments; and include training in dementia management and resident abuse prevention;- Nurse Aide participation in training is documented by the staff development coordinator, or his or her designee, and include: the date and time of the training, the topic of the training, the method used for training, a summary of the competency assessment, and the hours of training completed.1. Review of the in-service record for CNA E showed:- A hire date of 10/03/24;- A total of seven in-services, no length of time provided for each in-service;- No documented abuse/neglect or dementia care training.2. Review of the in-service record for CNA D showed:- A hire date of 12/16/24;- A total of 21 in-services, no length of time provided for each in-service.3. Review of the in-service record for CNA F showed:- A hire date of 12/27/24;- A total of 20 in-services, no length of time provided for each in-service;- No documented abuse/neglect or dementia care training.During an interview on 02/12/26 at 5:40 P.M., the Director of Nursing (DON) said they track CNA in-services on a spreadsheet. She was not sure on the specific number of hours required per year and unsure of specific trainings that were required. It would be helpful if the in-services were dated and had the length of time for each in-service.During an interview on 02/12/26 at 6:42 P.M., the Administrator said she would expect all staff to have at least 12 hours of in-service training to include abuse, neglect, and dementia care, and expect trainings to be dated and include the length of time for each in-service.

Based on observation, interview, and record review, the facility failed to wear proper personal protective equipment (PPE) and to maintain infection control practices to prevent the development and transmission of infection during suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen and into the bladder to drain urine outside of the body and into a bag) care for one resident (Resident #5) out of one sampled resident, and during wound care when the marker and scissors weren't cleaned and put back into and taken out of the staff's pocket for one resident (Resident #26) out of one sampled resident. The facility failed to ensure staff maintained appropriate hand hygiene practices during medication pass for three residents (Residents #23, #32 and #35) out of seven sampled residents. The facility's census was 105. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), revised September 2024, showed: - EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents; - EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; - Examples of high contact resident care activities requiring use of gown and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting to toilet, device care or use, (such as urinary catheter, feeding tube) and wound care (any skin opening requiring a dressing). Review of the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, showed: - All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections; - All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors; - Hand hygiene products and supplies are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; - Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task (free from contamination), after touching a resident, after touching the resident's environment, before moving from work on soiled body site to clean body site on the same resident, and immediately after removing gloves. Review of the facility's policy titled, Administering Medications, revised April 2019, showed: - Medications are administered in a safe and timely manner, and as prescribed; - Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 1. Observation on 02/12/26 of the medication administration showed: - At 9:15 A.M., Certified Medication Technician (CMT) C did not wash or sanitize his/her hands prior to or after Resident #32's medication administration; - At 9:18 A.M., CMT C did not wash or sanitize his/her hands prior to or after Resident #23's medication administration; - At 9:23 A.M., CMT C did not wash or sanitize his/her hands prior to Resident #35's medication administration; - At 9:24 A.M., CMT C picked two Tums (a chewable antacid tablet) tablets from the bottle using an ungloved hand, placed them into a medication cup, and administered to Resident #35; - CMT C did not wash or sanitize his/her hands after medication administration. During an interview on 02/12/26 at 9:25 A.M., CMT C said he/she should sanitize his/her hands prior to giving medications and in between residents. CMT C said he/she should not pick up tablets using a bare hand, and he/she usually didn't do that. 2. Observation on 02/12/26 at 10:40 A.M., of Resident #26's wound care showed: - Sign on the resident's door for EBP precautions and PPE in the room; - Licensed Practical Nurse (LPN) H sanitized hands, donned gloves, and failed to don a gown; - LPN H placed a barrier under the resident's feet, cleaned his/her left ankle wound, removed gloves, sanitized hands, donned clean gloves, obtained calcium alginate (highly absorbent medical dressing), and placed it onto the wound; - LPN H removed gloves, sanitized hands, donned clean gloves, cleaned the resident's left foot wound, removed gloves, sanitized hands, donned clean gloves and placed Medihoney (medical-grade, sterilized honey dressing) onto the wound; - LPN H wrapped kerlix (a woven cotton gauze) around the resident's foot and ankle and taped in place, obtained a marker from his/her pocket, dated the dressing, and placed it back into his/her pocket; - LPN H removed gloves, washed hands, and donned clean gloves; - LPN H cleaned the resident's right foot wound, removed gloves, sanitized hands, and donned clean gloves; - LPN H cleaned the resident's right ankle wound, removed gloves, sanitized hands, donned clean gloves, and applied dressing to the wound; - LPN H removed gloves, sanitized hands, donned clean gloves, and placed betadine (solution to prevent skin infections) gauze on right foot wound; - LPN H removed gloves, sanitized hands, donned clean gloves, wrapped the resident's right foot with kerlix, taped in place, obtained scissors, cut gauze, and placed the scissors in his/her pocket; - LPN H removed gloves, took a marker from his/her pocket, dated the dressing, and placed it back into his/her pocket; - LPN H washed hands, donned clean gloves, and cleaned the resident's left buttock wound; - LPN H removed gloves, sanitized hands, donned clean gloves, and placed packing strip (a type of wound dressing) moistened in Dakin's (diluted antiseptic) solution into the wound with a cotton swab; - LPN H removed scissors from pocket, cut the strip, and placed the scissors back into pocket; - LPN H removed gloves, sanitized hands, donned clean gloves, applied the dressing, and removed gloves; - LPN H removed marker from pocket, dated the dressing, and placed it back into pocket; - LPN H removed gloves and sanitized hands in the hallway. During an interview on 02/12/26 at 11:04 A.M., LPN H said he/she forgot PPE because he/she was focused on doing everything correct and should have had it on. The scissors and marker should not have been placed back in his/her pocket prior to being cleaned, and he/she should have removed gloves before getting scissors and marker out of his/her pocket. 3. Observation on 02/12/26 at 4:00 P.M. of Resident #5's suprapubic catheter care showed: - Sign on the resident's door for EBP use and PPE on the back of the door; - Certified Nursing Assistant (CNA) G washed hands, donned gloves, and failed to don a gown; - CNA G cleaned the catheter bag drain spout with an alcohol pad and drained urine into a graduated cylinder (container used to measure liquids); - CNA G removed gloves, washed hands, donned clean gloves, cleaned the spout with alcohol and clamped the spout back; - CNA G emptied the urine into the toilet, rinsed the container, and placed it on a paper towel in the bathroom; - CNA G removed gloves, washed hands, and donned clean gloves; - CNA G lowered the resident's bed, picked up a package of wipes and placed it on the resident's bedside table, removed a stuffed animal, pulled the blanket down, and lowered the resident's pants to access the suprapubic catheter; - With the same gloves, CNA G cleaned around the suprapubic catheter site with his/her right hand, obtained another wipe with his/her left hand, and with the same gloves, repeated five times with five different wipes; - With the same gloves, CNA G cleaned from the insertion site to about three inches down the suprapubic catheter tubing; - CNA G removed gloves, washed hands, donned clean gloves, assessed by touching the catheter to assure it was clean, and with the same gloves, pulled up the resident's pants, blanket, and lowered the bed. During an interview on 02/12/26 at 4:20 P.M., CNA G said he/she should have worn PPE, and had worn it earlier, but just forgot. He/she should have had on clean gloves after touching the resident's pants and bedspread and before cleaning the catheter site. He/she should have put on clean gloves after touching the catheter and before adjusting the blanket and bed when finished. During an interview on 02/12/26 at 6:42 P.M., the Administrator said she would expect staff to sanitize or wash their hands prior to and in between medication administration and would expect staff not to touch medications directly with their bare hands. Staff were expected to wear proper PPE, which was a gown and gloves, for EBP. They should wear it anytime EBP was noted and glove up when providing any type of personal care. Staff should change gloves anytime they were soiled and between residents. She would expect staff to change their dirty gloves prior to touching residents or items in the room. She would expect items used during resident care to be disinfected.

Based on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures for residents in three rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 105. The facility did not provide a policy for overbed lighting safety. 1. Observation on 02/09/26 at 1:36 P.M. of room [ROOM NUMBER] showed a framed photo collage on top of the light fixture above the bed by the window. 2. Observation on 02/09/26 at 1:40 P.M. of room [ROOM NUMBER] showed a poster, a license plate, and a framed picture on top of the light fixture above the bed by the window. 3. Observation on 02/12/26 at 9:15 A.M. of room [ROOM NUMBER] showed three stuffed animals on top of the light fixture above the bed by the window. During an interview on 02/12/26 at 10:20 A.M., Certified Nurse Assistant (CNA) J said he/she tries not to put things on top of the lights in the resident rooms and tries to keep them clear. He/she knows there are some residents that put things on them because they want items on them. During an interview on 02/12/26 at 5:30 P.M., the Administrator said she knew there were a couple of residents who did this, and she had housekeeping checking it. During an interview on 02/12/26 at 6:45 P.M., the Administrator and Director of Nursing (DON) said items should not be placed on the light fixtures due to possible hazards.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice affected two residents (Resident #13 and #23) outside of the 19 sampled residents and had the potential to affect all residents in the facility. The facility census was 95. The facility did not provide a policy regarding environment. 1. Observation on 09/24/24 at 11:44 A.M. of the 300 and 400 halls showed the halls with a strong urine odor. 2. Observation on 09/26/24 at 3:45 P.M. of the south shower room showed: - A used razor on the shower room floor; - A brown slimy substance caked around the shower drain; - Part of the shower room floor rotten with exposed layers of subfloor showing; - Dingy tile with dirty, black grout under the hand rail; - The shower room door scratched with missing and chipped paint on the bottom half of the door. 3. Observation on 09/26/24 at 4:05 P.M. of the north shower room showed: - Five brown spots of varying sizes on the ceiling; - A dirty shower chair with a red substance and two flies on the seat; - Multiple used wet linens on the floor; - The majority of the surface of the shower floor brown, stained, and dingy; - The shower floor peeling up around the shower drain; - A brown slimy substance caked around the shower drain; - The wall immediately to the right upon entering the shower room with dents, scratches, and exposed corner bead and drywall; - The sink basin detached from the wall leaving caulking exposed. 4. Observations on 09/27/24 from 9:40 A.M. to 10:00 A.M. showed dirt and stains with a musty odor on carpets in the following resident rooms: 102, 103, 106, 112, 201, 202, 205, 207, 208, 209, 210, 211, 212, 213, 214, 215, 217, 304, 305, 308, 311, 312, and 416. 5. Observation on 09/27/24 of room [ROOM NUMBER] showed the light fixture above the bed cracked with a baseball-sized hole in the front. During an interview on 09/27/24 at 12:35 P.M., Resident #23 said that the carpets are rough on his/her feet and staff throw soiled briefs on the floor. He/She is unhappy with all the paint colors and patches on the wall. During an interview on 09/27/24 at 12:44 P.M., the Housekeeping Manager said he/she does not clean the carpets as part of the regular rotation of cleaning. He/She will clean them if the residents complain about them or if housekeepers report they need cleaned. There are several rooms that are on a list to have the carpet replaced. During an interview on 09/27/24 at 12:48 P.M., Resident #13 said he/she is bothered by the carpet in his/her room. He/she always wears shoes in the room because he/she doesn't want to get anything from the floors. During an interview on 09/27/24 at 2:40 P.M., the Administrator said he/she would expect resident rooms to be free from dirt, debris, stains, and odors. 46555 49754

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This affected four residents (Resident #17, #45, #73 and #88) out of 19 sampled residents and three residents (Resident #25, #69, and #199) outside the sample and had the potential to affect all residents. The facility's census was 95. Review of the facility's policy entitled, Pest Control, revised July 2023, showed: - The facility shall maintain an effective pest control program; - This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents; - Windows are screened at all times; - Only approved Food and Drug Administration (FDA) and Environmental Protection Agency (EPA) insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas; - Garbage and trash are not permitted to accumulate and are removed from the facility daily; - Maintenance services assist, when appropriate and necessary, in providing pest control services. 1. Observation on 09/24/24 at 11:47 A.M. showed two flies buzzing around Resident #45 as he/she sat in a wheelchair in his/her room. During an interview on 09/27/24 at 10:10 A.M., Resident #45 said the flies are worse in the summer, and he/she hasn't seen as many lately. 2. Observation on 09/24/24 at 12:01 P.M. showed Resident #199 lay in bed with a fly buzzing around in the room. 3. Observation on 09/24/24 at 12:11 P.M. showed a fly buzzing around in room [ROOM NUMBER] near Resident #69, who had a cover over his/her head. 4. Observation on 09/24/24 at 1:30 P.M. showed a fly buzzed Resident #73's head and face while he/she sat in a wheelchair in the hallway. 5. Observation on 09/25/24 at 3:45 P.M. showed a fly on the resident's bed in room [ROOM NUMBER]. 6. Observation on 09/25/25 at 4:00 P.M. of the north shower room showed two flies on the shower chair seat. 7. Observation on 09/26/24 at 11:15 A.M. showed two flies on the nurse's shoe at the med cart on 400 hall. 8. Observation of room [ROOM NUMBER] showed: - On 09/24/24 at 2:21 P.M., three flies flying around and landing on Resident #25 while he/she tried to take a nap. Resident #25 covered his/her head with a blanket in an attempt to keep the flies from crawling on his/her face; - On 09/25/24 at 2:11 P.M., two flies buzzed around the room while Residents #25 and #17 tried to nap; - On 09/27/24 at 9:30 A.M., five flies flew around, landed, and crawled on surfaces in the room while Resident #25 watched television. 9. Observation of room [ROOM NUMBER] showed: - On 09/24/24 at 9:36 A.M., two flies buzzed around Resident #17; - On 09/25/24 at 2:11 P.M., three flies flew around the resident's divider curtain and bed. During an interview on 09/24/24 at 2:20 P.M., Resident #25 said he/she will sometimes sleep with the blanket over his/her head to try and prevent flies from crawling on his/her face. The flies bother him/her and wake him/her up, preventing the resident from getting restful sleep. During an interview on 09/24/24 at 2:21 P.M., Resident #17 said there has been ongoing issues with flies at the facility and they have been particularly bad over the last two months. They are a big nuisance. 10. Observation of the hallways showed: - On 09/24/24 at 11:44 A.M., a fly buzzed around in the 400 hall between rooms [ROOM NUMBERS]. - On 09/25/24 at 2:13 P.M., two flies buzzed about in the 300 hall outside room [ROOM NUMBER]; - On 09/27/24 at 9:40 A.M., a fly in the hallway by the entrance to room [ROOM NUMBER]; - On 09/27/24 at 9:42 A.M., a fly near the nurses station by the entrance to the 300 hallway; - On 09/27/24 at 9:46 A.M., a fly buzzed around residents in the seating area near the nurses station by the 200 hallway; - On 09/27/24 at 10:15 A.M., a fly flew around 100 and 200 hall. 11. Observation on 09/26/24 at 9:53 A.M. showed: - A fly buzzing around in the hall and near the treatment cart as the nurse prepared wound dressings for Resident #88; - A fly buzzed around the room as the nurse performed wound care for Resident #88. During an interview on 09/24/24 at 09:36 A.M., Resident #88 said there's a ton of flies. It bothers the crap out of him/her. Half the time he/she has to turn the light off to try and get them to leave the room. During an interview on 09/27/24 at 12:44 P.M., the Housekeeping Supervisor said the pest control company comes once a month to spray for pests. There is a log in his/her office staff can complete if they see pests. The pest control company will come more than once a month if needed. There have been residents complain about flies because they are always harder to control from the doors being open to go outside during warmer months. During an interview on 09/27/24 at 2:40 P.M., the Administrator said he/she would expect the facility to be free from flies and other pests.

Based on interview and record review, the facility failed to follow their background screening policy regarding screening staff members for the Family Safety Care Registry (FCSR), Employee Disqualification List (EDL), Criminal Background Check (CBC), and Nurse Aide (NA) Registry prior to the employment start date for three out of ten employees reviewed. The facility census was 95. Review of the facility's policy titled, Nurse Aide Registry Verification, revised August 2022, showed: - Certified nurse aide (CNA) licenses shall be verified through the state registry of nurse aides before individuals may serve as nurse aides or nursing assistants; - The Human Resources (HR) director, or other designee, is responsible for contacting the state nurse aide registry to determine the validity of the individual's certification status from every state registry that the facility believes will include information concerning the individual. Review of the facility's policy titled, Background Screening Investigations, revised 08/23/24, showed: - The facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents (direct access employees) prior to the employment start date; - The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. These checks include but are not limited to Criminal Background Check (CBC) or Office of Inspector General (OIG), Family Care Safety Registry (FCSR), and Employee Disqualification List (EDL); - The director of personnel, or designee, checks the state nurse aide registry to determine if any finding of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file on all potential direct access employees and contractors prior to the employment start date. 1. Review of NA A's personnel file showed: - A hire date of 12/28/23; - The facility failed to conduct the CBC until 02/23/24. 2. Review of CNA B's personnel file showed: - A hire date of 01/02/24; - The facility failed to conduct the CBC until 01/05/24. 3. Review of the Assistant Director of Nursing (ADON) C's personnel file showed: - A hire date of 12/26/23; - The facility failed to conduct the NA Registry check. During an interview on 09/27/24 at 1:10 P.M., the Director of Nurses (DON) said that the HR/Business Office Manager checks the NA registry and does background checks upon hire and quarterly. During an interview on 09/27/24 at 2:40 P.M., the Administrator said she would expect the NA Registry to be run on all new hires and that the CBC, EDL, and/or FCSR should be completed upon hire.

Based on observation, interview, and record review, the facility failed to follow a new physician's order for one resident (Resident #1) resulting in the resident missing 28 days of a chemotherapy (medication used to treat cancer) medication. The facility census was 85. The facility did not provide a policy regarding physician's orders after a resident's visit to the physician's office. 1. Review of Resident #1's medical record showed: - admitted [DATE]; - Cognition intact; - Diagnoses of malignant neoplasm (cancer spread to other areas) of the right female breast, iron deficiency anemia (a condition of too little iron in the body), chronic kidney disease stage 3 (chronic condition with mild to moderate damage to the kidneys), diabetes mellitus (a disorder of carbohydrate metabolism characterized by impaired ability to produce or respond to insulin), morbid obesity, major depressive disorder (a mood disorder that causes a persistent feeling of sadness or loss of interest), gastro-esophageal reflux disease (GERD) (a digestive disease in which stomach acid irritates the food pipe lining); - The resident's Oncologist's (a physician that treats cancer) After Visit Summary, dated 05/18/23, showed an order to start taking Arimidex (a chemotherapy medication) and a notation to pick up the medication at a specific pharmacy; - No documentation of any cancer related medication changes after the resident's oncologist visit on 05/18/23; - An order for Arimidex 1 milligram (mg) one tablet by mouth daily related to malignant neoplasm of the right female breast with an order date of 06/14/23 and a start date of 06/15/23 on the resident's July 2023 Physician Order Sheet (POS). Review of the facility's Pharmacy Consolidated Delivery Sheets, dated 05/25/23, showed the 28 tablets of Arimidex was delivered to the facility on [DATE] and signed for by the facility staff. Observation on 7/5/23 at 1:25 P.M., showed the medication Arimidex 1 mg tablets in the facility's medication cart. Review of the resident's May 2023 Medication Administration Record (MAR) showed: - No order for Arimidex 1 mg daily, dated 5/18/23; - The resident did not receive Arimidex; - The resident missed 14 days of Armidex for May 2023. Review of the resident's June 2023 MAR showed: - An order for Arimidex 1 mg daily with an order date of 06/14/23; - The resident received the Arimidex daily starting on 06/15/23; - The resident missed 14 days of Arimidex for June 2023. During an interview on 7/5/23 at 2:30 P.M., the Director of Nursing (DON) said she did a chart audit of the resident's chart in mid-June 2023 and found the missed order for the Arimidex. She said it was faxed to the pharmacy on 06/15/23, the medication arrived on 06/16/23, and the resident started getting the medication on 06/16/23. During an interview on 7/5/23 at 3:10 P.M., the Administrator said that she had very recently started and she was only made aware of the issue with this resident's chemotherapy medication this morning when a family member complained to her. She does expect the physician's orders to be checked and implemented when residents return from physician visits. The DON did one on one education with the nurse on duty when the medication order was missed. She had an in-service scheduled for 07/07/23. During a phone interview on 07/13/23 at 12:20 P.M., Pharmacy Tech B said the pharmacy filled a prescription for Arimidex on 05/24/23 and delivered it to the facility. The pharmacy had a signed delivery sheet that showed the medication was delivered and signed for by facility staff. During a phone interview on 07/13/23 at 12:28 P.M., LPN A said he/she did not specifically recall the day of 05/18/23 when the resident returned from the oncologist appointment. He/She knew the resident went to the oncologist a couple times in May 2023. He/She talked to the DON and the Assistant Director of Nursing (ADON) about this matter and they pulled up the physician's discharge packet from the oncologist visit for the day of 05/18/23. He/She never signed the discharge packet so he/she didn't see the Arimidex order. When a resident returns from a physician's visit, he/she reviewed the discharge packet and signed off to show that he/she reviewed it. During a phone interview on 07/13/23 at 1:48 P.M., the DON said the chemotherapy medication for the resident might have been delivered by the pharmacy on 05/25/23, but the script was sent to the pharmacy automatically from the physician's office. The problem was the order for the chemotherapy medication was not transcribed into the facility's system, so if the medication was delivered, it was likely returned because there was no matching order. She had no way to tell for sure because due to privacy concerns, the certified medication technicians shred the medication labels. She did not know why no one checked for an order when the medication was delivered. Complaint #MO220903

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 82. Record Review of the facility's Guideline & Procedure Manual, dated 2016, showed: - Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions; - Items cleaned after each use include can opener, small food preparation equipment (e.g. blender, food processor), slicer, kettles and utensils, mixers, cutting boards, work tables and counters, beverage table, coffee urns, pots and pans, dishes, dining room tables and chairs; - Items cleaned daily include stove top, grill, kitchen and dining room floors, kitchen towels and cloths, toaster, microwave oven, mop and buckets, steam table, hand washing sink, food carts, pot and pan sink, exterior of large appliances; - Items cleaned weekly include hoods, filters, trash barrels, garbage disposals; - Cleaning Rotation includes coffee machine, storerooms, drawers, cleaning closet, shelves, oven, cupboards; - Items cleaned monthly include refrigerators, freezers, ingredient bins, ice machines, food containers, walls; - Items cleaned annually include ceilings and windows. 1. Observations of the walk-in refrigeration units on 06/06/23 at 10:34 A.M. showed: - One full milk crate with single serve half-pint containers stacked on the floor; - Twenty-four uncovered fruit cups with mandarin oranges inside walk-in refrigerator; - Metal wire shelving inside walk-in refrigerator with a brown substance and black grime build up; - Walk-in freezer with twelve 1 inch (in.) diameter (dia.) frost formations on the ceiling; - Walk-in freezer with a 1 foot (ft.) x 2 in. ice formation attached below ventilation unit; - Walk-in freezer with six 1 in. dia. ice formations on the floor. 2. Observations of the dry food storage area on 06/06/23 at 10:45 A.M. showed: - One dented 6 pound (lb.) 9 ounce (oz.) can of diced carrots; - One unlabeled 6 lb. 9 oz. can; - One heating, ventilation, and air conditioning (HVAC) return air grill with gray grime between louvers; - Eight cardboard boxes stacked in the corner between food shelving labeled as holiday decorations. 3. Observations of the kitchen on 06/06/23 at 10:50 A.M. showed: - One commercial can opener with a sticky brown substance and removable knife with a black substance; - The gas range with black grime build-up on the back splash and burners; - The floor below the gas range with oil, dust and food debris; - The griddle with brown grime build-up and food debris. 4. Observations of the dining room serving area on 06/06/23 at 12:14 P.M. showed: - Two floor-standing commercial ice machines with white grime build-up on interior and exterior surfaces, interior plastic surface with brown build-up; - Floor beneath ice machines with white grime build-up and debris; - One ice machine drain pipe attached over an open floor drain with brown grime build-up and no air gap. 5. Observations of the dry food storage area on 06/07/23 at 9:03 A.M. and 10:30 A.M. showed: - Thirty-five various food boxes stacked on the floor. During an interview on 06/07/23 at 2:44 P.M., the Dietary Manager said a Dietary Aide had stacked the food items that were on the floor onto the shelves around 10:50 A.M., the food boxes had been delivered around 6:00 A.M. this morning. The baking pans have carbon build up and are difficult to clean. The range hood is in need of cleaning and an outside steam cleaning service should be here on 6/13/23. The range has black grime build-up inside and out and needs to be replaced. The microwave does not work properly and needs to be replaced. 6. Observations of the kitchen on 06/07/23 at 2:50 P.M. showed: - A section of partially repaired wall 4 ft. x 4 ft. unsanded and unpainted near the front entrance to the serving area; - Eighteen 26 in. x 18 in. x 1 in. baking pans with black grime on the surfaces and brown grime build-up in the corners; - Fourteen 16 in. x 12 in. x 1 in. baking pans with black grime on the surfaces and brown grime build-up in the corners; - Three 24 cup and two 12 cup muffin baking pans with black grime on the top surfaces; - Two 12 in. frying pans with black coating peeled away; - Deep fryer with brown and black grime build-up along the top edge; - Range hood with brown build-up around filtration area; - Interior range surfaces with brown build-up; - Floor area between range and deep fryer with brown build-up; - Microwave oven with food debris and grime build-up on interior surface. During an interview on 06/09/23 at 11:14 A.M., the Administrator said originally there was an outside company that cleaned the ice machine, but the ice machines should be cleaned immediately by kitchen staff. The machine should have an appropriate air gap. The other kitchen appliances should be clean, but the range may be replaced. The walls should be clean and intact in the kitchen. Food should not be in contact with the floor and the floor should be clean. During an interview on 06/09/23 at 11:50 A.M., the Maintenance Director said the walk-in freezer has heavy frost build up on the back side near a seam. Ice formations should not be there and special insulated tape has been added to prevent condensation. There should not be ice formations on the floor of the freezer. The shelves should be clean. The unpainted wall section in the kitchen near the entrance to the dining area should be repaired, plumbing was accessed through the wall during an update six months ago. The HVAC equipment and vents should be clean. The range hood should be clean.

Based on interview and record review, the facility failed to maintain quarterly Quality Assurance Performance Improvement (QAPI) committee meetings with the required members. The facility's census was 82. Record review of the facility's QAPI Program policy, revised February 2020, showed: - This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; - The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements; - The QAPI committee reports directly to the administrator; - The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. Record review of the facility's 2023 QAPI Plan showed: - Aspects of service and care are measured against established performance goals. Key monitors are measured and trended on a quarterly basis; - The Governing Body assures adequate resources exist to conduct QAPI efforts, and fosters a culture where QAPI is a priority by ensuring policies are developed to sustain QAPI despite changes in personnel and turnover; - On a quarterly basis, data will be collected and reported to the QAPI Steering Committee from the following areas: input from caregivers, residents, families, and others; adverse events; performance indicators; survey findings; and complaints; - The PDSA (Plan, Do, Study, Act) cycle outcomes will be reported to the QAPI Steering Committee at least quarterly. Record review showed the facility did not maintain the minimum required quarterly QAPI meetings in the past year. During an interview on 06/09/23 at 8:39 A.M., the Administrator said she just started in February and had a QAPI meeting on 4/19/23, and she hasn't been able to find any additional information regarding past QAPI meetings except for 11/11/22. The prior administrator should have been doing them quarterly.

Based on interview and record review, the facility failed to electronically transmit significant change and quarterly Minimum Data Set assessments (MDS - a federally mandated assessment instrument completed by the facility) in a timely manner and in accordance with guidelines for three residents (Resident #5, #7, and #49) of 18 sampled residents and ten residents outside the sample (Resident #2, #6, #28, #45, #47, #52, #54, #61, #63, and #71). The facility's census was 82. Record review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual for assessment transmission showed the following: - Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date (V0200C2+14 days); - Entry tracking records must be transmitted electronically no later than the entry date + 14 days; - All other MDS assessments must be submitted within 14 days of the MDS completion date (Z0500B+14 days). 1. Record review of Resident #2's medical record showed: - An entry MDS tracking record, dated 7/15/22 and completed 7/15/22; - The entry MDS tracking record transmitted and accepted 8/25/22; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date. 2. Record review of Resident #5's medical record showed: - An entry MDS tracking record, dated 4/22/23 and completed 4/25/23; - The entry MDS tracking record transmitted and accepted 5/11/23; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date. 3. Record review of Resident #6's medical record showed: - An entry MDS tracking record, dated 9/26/22 and completed 10/3/22; - The entry MDS tracking record transmitted and accepted 10/14/22; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date. 4. Record review of Resident #7's medical record showed: - A comprehensive significant change in status MDS assessment, dated 2/9/22, and completed 2/20/22; - Care plan decisions for the comprehensive significant change in status MDS assessment completed 2/25/22; - The comprehensive significant change in status MDS assessment transmitted and accepted 3/23/22; - The facility failed to ensure the comprehensive significant change MDS assessment was transmitted electronically within 14 days of the care plan completion date; - A comprehensive significant change in status MDS assessment, dated 3/31/22, and completed 5/16/22; - Care plan decisions for the comprehensive significant change in status MDS assessment completed 7/22/22; - The comprehensive significant change in status MDS assessment transmitted and accepted 8/26/22; - The facility failed to ensure the comprehensive significant change MDS assessment was transmitted electronically within 14 days of the care plan completion date. 5. Record review of Resident #28's medical record showed: - An entry MDS tracking record, dated 4/26/22 and completed 5/2/22; - The entry MDS tracking record transmitted and accepted 5/25/22; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date; - A quarterly MDS assessment, dated 8/3/22 and completed 8/3/22; - The quarterly MDS assessment transmitted and accepted 9/8/22; - The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the MDS completion date. 6. Record review of Resident #45's medical record showed: - An entry MDS tracking record, dated 6/16/22 and completed 6/17/22; - The entry MDS tracking record transmitted and accepted 7/8/22; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date; - A quarterly MDS assessment, dated 9/29/22 and completed 11/8/22; - The quarterly MDS assessment transmitted and accepted 11/23/22; - The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the MDS completion date. 7. Record review of Resident #47's medical record showed: - A comprehensive annual MDS assessment, dated 3/3/22 and completed 6/20/22; - Care plan decisions for the comprehensive annual MDS assessment completed 6/20/22; - The comprehensive annual MDS assessment transmitted and accepted 8/26/22; - The facility failed to ensure the comprehensive annual MDS assessment was transmitted electronically within 14 days of the care plan completion date; - A quarterly MDS assessment, dated 6/1/22 and completed 6/20/22; - The quarterly MDS assessment transmitted and accepted 7/8/22; - The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the MDS completion date; - An entry MDS tracking record, dated 11/11/22 and completed 2/3/23; - The entry MDS tracking record transmitted and accepted 2/3/23; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date. 8. Record review of Resident #49's medical record showed: - A quarterly MDS assessment, dated 2/2/22 and completed 2/7/22; - The quarterly MDS assessment transmitted and accepted 5/12/22; - The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the MDS completion date; - A comprehensive significant change in status MDS assessment, dated 8/5/22, and completed 8/5/22; - Care plan decisions for the comprehensive significant change in status MDS assessment completed 8/5/22; - The comprehensive significant change in status MDS assessment transmitted and accepted 9/8/22; - The facility failed to ensure the comprehensive significant change MDS assessment was transmitted electronically within 14 days of the care plan completion date. 9. Record review of Resident #52's medical record showed: - An entry MDS tracking record, dated 6/22/22 and completed 6/23/22; - The entry MDS tracking record transmitted and accepted 7/8/22; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date; - A comprehensive admission MDS assessment, dated 7/5/22, and completed 7/5/22; - Care plan decisions for the comprehensive admission MDS assessment completed 7/5/22; - The comprehensive significant change in status MDS assessment transmitted and accepted 8/10/22; - The facility failed to ensure the comprehensive admission MDS assessment was transmitted electronically within 14 days of the care plan completion date; - A quarterly MDS assessment, dated 10/5/22 and completed 11/8/22; - The quarterly MDS assessment transmitted and accepted 11/23/22; - The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the MDS completion date. 10. Record review of Resident #54's medical record showed: - An entry MDS tracking record, dated 11/24/21 and completed 12/6/21; - The entry MDS tracking record transmitted and accepted 12/23/21; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date; - A quarterly MDS assessment, dated 12/4/21 and completed 12/8/21; - The quarterly MDS assessment transmitted and accepted 3/24/22; - The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the MDS completion date; - A comprehensive annual MDS assessment, dated 6/4/22 and completed 6/20/22; - Care plan decisions for the comprehensive annual MDS assessment completed 6/20/22; - The comprehensive annual MDS assessment transmitted and accepted 7/8/22; - The facility failed to ensure the comprehensive annual MDS assessment was transmitted electronically within 14 days of the care plan completion date; - A comprehensive significant change in status MDS assessment, dated 9/4/22, and completed 10/13/22; - Care plan decisions for the comprehensive significant change in status MDS assessment completed 11/8/22; - The comprehensive significant change in status MDS assessment transmitted and accepted 11/23/22; - The facility failed to ensure the comprehensive significant change MDS assessment was transmitted electronically within 14 days of the care plan completion date; - A discharge - return anticipated MDS, dated [DATE] and completed 11/8/22; - The discharge - return anticipated MDS transmitted and accepted 11/23/22; - The facility failed to ensure the discharge - return anticipated MDS assessment was transmitted electronically within 14 days of the MDS completion date; - An entry MDS tracking record, dated 10/30/22 and completed 11/8/22; - The entry MDS tracking record transmitted and accepted 11/23/22; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date. 11. Record review of Resident #61's medical record showed: - An entry MDS tracking record, dated 5/10/22 and completed 6/9/22; - The entry MDS tracking record transmitted and accepted 7/8/22; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date; - A comprehensive admission MDS assessment, dated 5/23/22, and completed 7/5/22; - Care plan decisions for the comprehensive admission MDS assessment completed 7/5/22; - The comprehensive significant change in status MDS assessment transmitted and accepted 8/10/22; - The facility failed to ensure the comprehensive admission MDS assessment was transmitted electronically within 14 days of the care plan completion date. 12. Record review of Resident #63's medical record showed: - A quarterly MDS assessment, dated 3/20/22 and completed 3/29/22; - The quarterly MDS assessment transmitted and accepted 5/25/22; - The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the MDS completion date; - A quarterly MDS assessment, dated 6/20/22 and completed 6/20/22; - The quarterly MDS assessment transmitted and accepted 7/8/22; - The facility failed to ensure the quarterly MDS assessment was transmitted electronically within 14 days of the MDS completion date. 13. Record review of Resident #71's medical record showed: - An entry MDS tracking record, dated 9/21/22 and completed 10/3/22; - The entry MDS tracking record transmitted and accepted 10/14/22; - The facility failed to ensure the entry MDS tracking record was transmitted electronically within 14 days of the entry date. During an interview on 6/7/23 at 1:00 P.M., the MDS Coordinator said he/she has only been here a short time, but knew there were issues and he/she was trying to get caught up. During an interview on 6/9/23 at 1:50 P.M., the Administrator and Director of Nursing said they would expect the RAI Manual to be followed for completion and submission of every MDS. They would also expect every MDS to be completed and submitted in a timely manner.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility) within the required time frames for one resident (Resident #7) out of 18 sampled residents and 10 residents outside the sample (Resident #2, #6, #28, #45, #47, #54, #61, #63, #67, and #71). The facility's census was 82. Record review of the facility's policy, Resident Assessments, revised March 2022, showed: - A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements; - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: OBRA required assessments - conducted for all residents in the facility: Admission Assessment (comprehensive); Annual Assessment (comprehensive); and Significant Change in Status Assessment (SCSA) (comprehensive); - The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments; - A comprehensive assessment includes: completion of the MDS; completion of the care area assessment (CAA) process; and development of the comprehensive care plan. Record review of the RAI Manual showed: - For the Admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600); - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment; - For the Admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later than than 13 days after the Entry Date (A1600); - For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300). 1. Record review of Resident #2's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 10/5/22, and MDS completion date of 10/5/22; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 calendar days of admission. 2. Record review of Resident #6's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 11/22/22, and MDS completion date of 11/8/22; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 calendar days of admission. 3. Record review of Resident #7's medical record showed: - An admitted [DATE]; - A comprehensive significant change MDS assessment with ARD of 2/9/22 and MDS completion date of 2/20/22, and CAA completion date of 2/25/22; - No CAAs completed within 14 days of the ARD; - A comprehensive significant change MDS assessment with ARD of 3/31/22 and MDS completion date of 5/16/22, and CAA completion date of 5/16/22; - No CAAs completed within 14 days of the ARD; - The comprehensive Significant Change in Status MDS assessment was not completed by the 14th calendar day after the determination that a significant change had occurred; - A comprehensive significant change MDS assessment with ARD of 8/12/22 and MDS completion date of 10/3/22, and CAA completion date of 10/3/22; - No CAAs completed within 14 days of the ARD; - The comprehensive Significant Change in Status MDS assessment was not completed by the 14th calendar day after the determination that a significant change had occurred. 4. Record review of Resident #28's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 6/27/22, and MDS completion date of 6/27/22; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 calendar days of admission. 5. Record review of Resident #45's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 6/30/22, and MDS completion date of 6/30/22; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 calendar days of admission. 6. Record review of Resident #47's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with a completion date of 3/5/21; - A comprehensive annual MDS assessment with a completion date of 6/20/22, and CAA completion date of 6/20/22; - No comprehensive MDS assessment completed within 366 calendar days of the last comprehensive MDS assessment. 7. Record review of Resident #54's medical record showed: - An admitted [DATE]; - A comprehensive significant change in status MDS assessment with a completion date of 6/4/21; - A comprehensive annual MDS assessment with a completion date of 6/20/22; - No comprehensive MDS assessment completed within 366 calendar days of the last comprehensive MDS assessment; - A comprehensive significant change MDS assessment with ARD of 9/4/22 and MDS completion date of 10/13/22, and CAA completion date of 10/17/22; - No CAAs completed within 14 days of the ARD; - The comprehensive Significant Change in Status MDS assessment was not completed by the 14th calendar day after the determination that a significant change had occurred. 8. Record review of Resident #61's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 7/5/22, and MDS completion date of 7/5/22; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 calendar days of admission; - A comprehensive significant change MDS assessment with ARD of 8/19/22 and MDS completion date of 10/14/22, and CAA completion date of 10/14/22; - No CAAs completed within 14 days of the ARD; - The comprehensive Significant Change in Status MDS assessment was not completed by the 14th calendar day after the determination that a significant change had occurred. 9. Record review of Resident #63's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 9/22/21; - A comprehensive annual MDS assessment with a completion date of 11/22/22, and CAA completion date of 11/22/22; - No comprehensive MDS assessment completed within 366 calendar days of the last comprehensive MDS assessment. 10. Record review of Resident #67's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 11/30/22, and MDS completion date of 11/30/22; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 calendar days of admission. 11. Record review of Resident #71's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 11/22/22, and MDS completion date of 11/22/22; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 calendar days of admission. During an interview on 6/7/23 at 1:00 P.M., the MDS Coordinator said he/she has only been here a short time, but knew there were issues and he/she was trying to get caught up. During an interview on 6/9/23 at 1:50 P.M., the Administrator and Director of Nursing (DON) said they would expect the RAI Manual to be followed for completion and submission of every MDS. They would also expect every MDS to be completed and submitted timely.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for three residents (Resident #5, #25, and #39) out of 18 sampled residents. The facility census was 82. Record review of the facility's policy, Preparing the Resident for Transfer or Discharge, revised December 2016, showed: - Residents will be prepared in advance for discharge; - Business office is responsible for informing the resident, or his/her representative of our facility's readmission appeal, rights, bed-holding policies and etcetera; - Nursing services is responsible for completing a discharge note in the medical record and directing the resident or representative to the business office prior to the transfer or discharge. 1. Record review of Resident #5's medical record showed: - Transferred and admitted to the hospital on 04/20/23 and readmitted to the facility on [DATE]; - No documentation that the resident or representative was informed in writing of the transfer/discharge to the hospital at the time of transfer. 2. Record review of Resident #25's medical record showed: -Transferred and admitted to the hospital on 05/11/23 and readmitted to the facility on [DATE]; -No documentation the resident or representative was informed in writing of the transfer/discharge to the hospital at the time of transfer. 3. Record review of Resident #39's medical record showed: -Transferred and admitted to the hospital on 05/13/23 and readmitted to the facility on [DATE]; -No documentation the resident or representative was informed in writing of the transfer/discharge to the hospital at the time of transfer. During an interview on 6/9/23 at 10:00 A.M., the Director of Nursing (DON) said he/she would expect the nursing staff to inform the resident and/or resident representative of the resident's transfer to the hospital. The DON said that he/she inserviced the staff on providing this education and written documentation, as they are not taking credit for what they are verbally doing. During an interview on 6/9/23 at 1:50 P.M., the Administrator said that he/she would expect a transfer/discharge notice to be initiated and signed when a resident is transferred out to the hospital. 46460

Based on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: Medicare requires SNFs to issue a SNF ABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for two residents (Resident #34 and #185) out of three sampled residents who remained in the facility when benefits were not exhausted, and failed to issue a CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 at least two days before coverage ended for two residents (Resident #34 and #185) out of three sampled residents. The facility's census was 82. 1. Record review of Resident #34's NOMNC and SNF ABN forms showed: - The resident's skilled Medicare Part A services started on 2/13/23, ended on 2/24/23, and the resident remained in the facility; - The facility failed to get verbal consent or provide the resident's representative with the SNF ABN and the NOMNC forms at least two days prior to services ending. 2. Record review of Resident #185's NOMNC and SNF ABN forms showed: - The resident's skilled Medicare Part A services started on 2/6/23, ended on 2/24/23, and the resident remained in the facility; - The facility failed to get verbal consent or provide the resident's representative with the SNF ABN and NOMNC forms at least two days prior to services ending. During an interview on 6/9/23 at 10:10 A.M., the Director of Nursing (DON) said he/she would expect the SNF ABN and NOMNC forms to be completed and signed appropriately. During an interview on 6/9/23 at 1:50 P.M. , the Administrator said he/she would expect the SNF ABN and NOMNC forms to be completed and signed prior to a resident's discharge from skilled Medicare services. The facility did not provide a policy.

Based on interview and record review, the facility failed to maintain the bond amount for at least one and one-half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from May 2022 to April 2023. The facility census was 82. Record Review of the facility's Resident Trust Fund Bond Policy, undated, showed: - A Nursing Facility or Resident/Patient Trust Fund Bond is required by long-term care facilities, including nursing homes and assisted living facilities, along with businesses that offer at-home care; - The surety bond protects long-term care patients and their families by ensuring that the facility complies with state laws and regulations and administers patient trust funds in an ethical and financially responsible manner; - The surety bond is obligated per Section 483.10(c)(7) of the Code of Federal Regulations for operators of long-term care facilities to ensure faithful security for all personal funds of residents deposited with the facility; - Assurance of compliance with this obligation rests with the state of domicile of the facility; - The surety bond is conditioned upon proper safeguarding and accounting for all funds of residents of the facility which are deposited with the principal while this bond is in effect; - The Surety Bond is required to be in an amount equal to one and one half times the average monthly balance or average total balances, rounded to the nearest one thousand dollars in the residents' personal funds accounts for the previous twelve months. (Section 198.0961, RSMo) 1. Record review of the residents' personal funds account for the last twelve consecutive months from May 2022 to April 2023 showed: - The facility's current approved bond amount equaled $90,000.00; - The average monthly balance for the residents' personal funds equaled $69,000.00; - An average monthly balance of $69,000.00 required a bond of at least $103,500.00. During an interview on 06/09/23 at 1:50 P.M., the Administrator said she would expect the facility surety bond to be at least one and one-half times the twelve month average resident fund amount as per the facility policy.

Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility) within the required timeframe for two residents (Resident #7 and #49) out of 18 sampled residents and six residents (Resident #2, #28, #45, #47, #52, and #54) outside the sample. The facility's census was 82. Record review of the facility's policy, Resident Assessments, revised March 2022, showed: - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: OBRA required assessments - conducted for all residents in the facility: Quarterly Assessment; - The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. Record review of the RAI (Resident Assessment Instrument) Manual showed: - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of previous OBRA assessment (Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment) + 92 calendar days); - The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. 1. Record review of Resident #2's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 1/31/23; - A quarterly MDS assessment with a completion date of 5/23/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 2. Record review of Resident #7's medical record showed: - An admitted [DATE]; - A comprehensive significant change MDS assessment with a completion date of 10/3/22; - A quarterly MDS assessment with a completion date of 2/1/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 3. Record review of Resident #28's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 8/3/22; - A quarterly MDS assessment with a completion date of 1/2/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 4. Record review of Resident #45's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 6/30/22; - A quarterly MDS assessment with a completion date of 11/8/22; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 5. Record review of Resident #47's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 6/20/22; - A quarterly MDS assessment with a completion date of 10/5/22; - A quarterly MDS assessment with a completion date of 1/17/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 6. Record review of Resident #49's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 2/7/22; - A comprehensive annual MDS assessment with a completion date of 7/22/22; - A comprehensive significant change MDS assessment with a completion date of 8/5/22; - A quarterly MDS assessment with a completion date of 12/30/22; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 7. Record review of Resident #52's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 7/5/22; - A quarterly MDS assessment with a completion date of 11/8/22; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 8. Record review of Resident #54's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 3/9/22; - A comprehensive annual MDS assessment with a completion date of 6/20/22; - A comprehensive significant change MDS assessment with a completion date of 10/13/22; - A quarterly MDS assessment with a completion date of 1/17/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. During an interview on 6/7/23 at 1:00 P.M., the MDS Coordinator said he/she has only been here a short time, but knew there were issues and he/she was trying to get caught up. During an interview on 6/9/23 at 1:50 P.M., the Administrator and Director of Nursing (DON) said they would expect the RAI Manual to be followed for completion and submission of every MDS. They would also expect every MDS to be completed and submitted timely.

Based on observation, interview and record review, the facility failed to identify, assess and notify the resident's physician to obtain a treatment for [REDACTED]. Of those three, two had pressure ulcers and problems were found with one. (Resident #2) The resident developed a facility acquired pressure sore. The census was 95. Review of Resident #2's hospital discharge notes, dated 7/23/14, showed the following: -Skin: Warm, dry. No rashes or other [MEDICAL CONDITION]; -[DIAGNOSES REDACTED]. -No evidence of a pressure ulcer; -Weight of 128 pounds (lbs) and 15.5 ounces, on 7/21/14. Review of an admission nurse's note, dated 7/23/14 (time of entry not indicated), showed the resident arrived to the facility at 5:00 P.M. after a hospital stay for severe [MEDICAL CONDITION]. He/She was alert and oriented to person and disoriented to time and place, required the assistance of one to two persons depending on his/her mood and had no current skin issues and was free of ulcers or scratches. Completed a head to toe assessment, refer to admission assessment (Resident-Data Collection" form). Review of the resident's "Resident-Data Collection" form, dated 7/23/14, showed the following: -Diagnoses: [REDACTED]. -Skin condition: No problems identified; -Alert and oriented to person only. Review of the resident's "Braden Scale - For Predicting Pressure Sore (ulcer) Risk", dated 7/23/14, showed a score of 13, or a moderate risk to develop pressure ulcers. Review of the facility "Weekly Skin/Wound Report", dated 7/24/14 through 7/25/14, showed no entry for the resident. Review of the resident's "Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review" form, dated 7/27/14, showed no skin irregularities. Review of the facility "Weekly Skin/Wound Report", dated 7/31/14 through 8/1/14, showed no entry for the resident. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/31/14, showed the following: -admission date of [DATE]; -Understood; -Sometimes understands; -Memory problem; -Disorganized thinking: Behavior present, fluctuates (comes and goes, changes in severity); -Rejection of care: Not exhibited; -Extensive assistance of one person required for bed mobility, dressing and personal hygiene; -Extensive assistance of two (+) persons required for transfers and toilet use; -Walking in room/corridor did not occur; -Total dependence of one person for locomotion on/off the unit; -Limited assistance of one person required for eating; -No impairment of the upper/lower extremities; -Mobility device: Wheelchair; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Height of 62 inches; -Weight of 129 pounds (lbs); -Not at risk of developing pressure ulcers; -No unhealed pressure ulcers. Review of the resident's weight review completed by the Restorative Aide (RT), showed the resident weighed 118 lbs on 7/31/14, a weight loss of over 10 lbs since 7/23/14. Review of the resident's "Skin Monitoring: Comprehensive CNA Shower Review" form, dated 8/2/14, showed the resident had two old bruises, a scabbed and red area on the lower left extremity, but no pressure ulcers. Review of the resident's physician assessment form, dated 8/4/14, showed no skin irregularities. Review of the resident's nurse's notes, dated 8/6/14 at 9:00 P.M., showed staff sent the resident to a local hospital due to a fever and the need for further evaluation. Review of the resident's hospital emergency department (ED) records, showed the following: -8/6/14 at 9:48 P.M.: Arrived at the emergency department; -8/6/14 at 10:12 P.M., Pressure ulcer to the buttocks documented; -8/7/14 at 3:09 A.M., admitted to the hospital with [REDACTED]. Review of the resident's hospital wound care consultation, dated 8/7/14 at 9:00 A.M., showed the following information about the resident's pressure ulcer: -Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling); -Location: Coccyx; -Length: 4.2 centimeters (cm); -Width: 1.1 cm; -Depth: unable to determine; -Wound bed: 100% light yellow slough (non-viable or dead tissue) covered with granulation buds (new tissue beginning to replace the dead tissue) throughout the slough; -Wound care suggestion: Pressure relief, barrier paste ([MEDICATION NAME] (absorbent) based); -Wound care goals: Barrier and granulation. Review of the resident's nursing facility nurse's note, dated 8/12/14 at 5:00 P.M. and completed by Nurse E, showed the resident was readmitted with slight maceration (soft white tissue, usually due to moisture) to the coccyx, but no pressure ulcer. Review of the resident's "Resident-Data Collection" form, dated 8/12/14 and completed by Nurse E, showed the following: -Skin condition: Maceration to coccyx. Review of the resident's medical record, for 8/12/14, showed no physician notification regarding the maceration or a pressure ulcer. Review of the resident's "Braden Scale - For Predicting Pressure Sore (ulcer) Risk", dated 8/12/14, showed a score of 13, or a moderate risk to develop pressure ulcers. Review of the resident's physician's orders [REDACTED]. Observation on 8/13/14 at 6:50 A.M., showed the resident lay in bed sleeping. Observation on 8/13/14 from 7:50 A.M. until 9:00 A.M., showed the resident sat up in a geri-chair (mobile reclining chair) in the sitting area across from the nurse's station. During an interview on 8/13/14 at 10:30 A.M., Nurse A said he/she was present on 8/6/14, when the resident was sent to the hospital. He/She did not know of a pressure ulcer on the resident at that time. Review of a "Licensed Nurse Weekly Skin Assessment" form, dated 8/13/14 (time of entry not indicated) and completed by Nurse A, showed the resident had a pressure ulcer identified on his/her coccyx, measuring 3.5 cm (long) by 0.8 cm (width) by 0.1 cm (depth). No other description was noted. During an interview on 8/13/14 at 11:30 A.M., Nurse A said he/she completed the "Licensed Nurse Weekly Skin Assessment" that morning and was not aware the resident had a pressure ulcer until then. Observation on 8/13/14 at 11:40 A.M., showed the resident lay in bed. Nurse A and Nurse B stood at the bedside to complete a skin assessment. The resident had an uncovered pressure ulcer on his/her coccyx with a moderate amount of white and yellow slough covering the ulcer. Nurse A assessed the pressure ulcer as a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister). The wound care nurse from the wound care company was scheduled to come the next day and he/she would have the wound care nurse assess the resident's pressure ulcer tomorrow. During an interview on 8/13/14 at 12:45 P.M., CNA C said he/she had worked at the facility for two months, and was familiar with the resident. The resident was incontinent of bowel and bladder and needed assistance to reposition, transfer and dress. He/She was assigned to the resident on 8/3/14 and the resident had the pressure ulcer at that time. The CNA showed CNA D the pressure ulcer and informed either Nurse A or Nurse E about the pressure ulcer that day. He/She saw the resident's pressure ulcer today 8/13/14, and it looked very similar to what he/she saw on 8/3/14. During an interview on 8/13/14 at 1:00 P.M., CNA D said the resident was incontinent of bowel and bladder and required assistance to reposition, transfer and dress. He/She said CNA C showed him/her the resident's pressure ulcer on 8/3/14. CNA D did not tell a nurse about the resident's pressure ulcer because he/she thought CNA C informed the nurse. During an interview on 8/13/14 at 1:15 P.M., Nurse A said he/she did not recall CNA C telling him/her about the pressure ulcer on 8/3/14. Had he/she known, he/she would have assessed the pressure ulcer and called the resident's physician. He/She did notify the resident's physician today, 8/13/14, and received an order to treat the pressure ulcer with [MEDICATION NAME] ointment (anti-bacterial) daily. During a telephone interview on 8/22/14, Nurse E said he/she could not recall CNA C telling him/her the resident had a pressure ulcer on 8/3/14, but he/she can't guarantee that he/she didn't. If they report something and he/she does not have a piece of paper to write it down on at the time, he/she sometimes forgets. Review of the wound company's documentation, dated 8/14/14, showed the following: -Location: Coccyx; -Stage III pressure ulcer; -Duration: Chronic; -Size: 1.8 cm by 0.7 cm by 0.2 cm; -Exudate (drainage): Moderate serous (clear or slightly yellow drainage); -Yellow slough %: 80%; -Peri-wound (edges of the pressure ulcer): Clear; -Treatment: Santyl (an ointment that containing an enzyme that removes dead tissue), [MEDICATION NAME] and Calcium Alginate (absorbent dressing that absorbs exudate), cover with a dry dressing every day and as necessary; -Recommend an indwelling urinary catheter (tube inserted into the bladder, urine is collected in a bag) for wound healing; -Recommend Prostat (protein supplement) 30 milliliters two times a day for wound healing. Review of the facility "Pressure Ulcer Risk Assessment", dated 2001 and revised on 2010, showed the following: -The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers; -If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident and often times become infected; -Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc), decline in nutrition and hydration status acute illness and/or decline in the resident's physician and/or mental condition; -Once a pressure develops, it can be extremely difficult to heal; -Pressure ulcers are a serious skin condition for the resident; -Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown; -Immediately report any signs of a developing pressure ulcer to the supervisor; -A pressure ulcer risk assessment will be completed upon admission, with each additional assessment, quarterly, annually and with significant changes; -Nurses will conduct skin assessments at least weekly to identify changes; -A resident at risk can develop a pressure ulcer with two to six hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers; -[DIAGNOSES REDACTED]. During an interview on 8/13/143 at 1:10 P.M., the Director of Nurses said he/she saw the resident's pressure ulcer today, 8/13/14 and it was at least a Stage II pressure ulcer. She did not know the resident had a pressure prior to then. If the CNAs had informed a nurse on 8/3/14, the nurse should have assessed and measured and contacted the resident's physician for a treatment order. All of this should have been documented. During a telephone interview on 8/26/14 at 9:15 A.M., the resident's physician said he was not aware the resident had a pressure ulcer, on 8/3/14. He was not informed until after the resident's hospitalization . If the facility identified a pressure ulcer on 8/3/14, someone should have notified him. He would have ordered a treatment and referred the resident to the wound nurse that comes to the facility. MO 351