Every finding on record at Four Seasons Living Center

Based on observation, interviews, and record review, facility staff failed to provide a sanitary and functional environment in the facility's laundry room to store, sort, and return clean laundry to the residents of the facility. The facility census was 231.1. Review of the facility's Handling Clean and Dirty Linen policy, dated 06/26/24, showed staff were directed to not place clean linen on the floor or other contaminated surfaces. The policy did not direct staff on a timeframe to return clean laundry to residents. 2. Observation on 08/03/26 at 1:45 P.M., showed the laundry room floor with multiple plastic bags of clothes stacked approximately five feet high. During an interview on 08/03/26 at 1:45 P.M., the Environmental Service Director said the clothes in the plastic bags on the floor were clean but needed to be sorted and returned to the residents. He/She said the clothes were clean because they were stored in the clean room where the clothes are washed and sorted. During an interview on 08/03/26 at 1:50 P.M., Laundry Staff K said laundry staff have been trying to get caught up with laundry in the laundry room for the past one to two weeks, but laundry staff keep getting pulled to work the floor. During an interview on 08/03/26 at 2:40 P.M., Resident #6 said he/she was missing clothes sent to the laundry room about two weeks prior and questioned if he/she could start washing his/her own personal laundry to ensure he/she had clean clothes to choose from daily. During an interview on 08/04/26 at 9:34 A.M., Resident #8 said he/she is missing several pieces of clothing that were sent to the laundry room at least two weeks prior, and staff told him/her the laundry room is backed up with clothing. During an interview on 08/04/26 at 9:52 A.M., Resident #12 said he/she was missing some clothes that staff took to the laundry room about one to two weeks prior. During an interview on 08/04/26 at 11:39 A.M., Registered Nurse (RN) A said several residents have reported they sent clothes to the laundry room and don't get their clothes back for weeks. The laundry staff seem to not have time to sort, fold, and deliver clothes back to the residents. Observation on 08/04/26 at 12:32 P.M., showed the laundry room floor with multiple plastic bags of clothes stacked approximately five feet high. During an interview on 08/04/26 at 1:01 P.M., Licensed Practical Nurse (LPN) B said some residents have complained about not getting their laundry back for weeks, and staff often have to go to the laundry room to try and find clean clothes for the residents. The laundry staff is responsible for delivering clean linens and personal clothes to the halls a few times per day, but sometimes laundry staff only deliver clean linens to the halls once daily. The LPN is not sure why the laundry room is so backed up with laundry. During an interview on 08/04/26 at 1:28 P.M., the Environmental Service Director said the night shift laundry staff is expected to sort the residents' personal laundry, and the day shift staff delivers the clean laundry to the rooms, but laundry staff are often pulled to the floor which causes them to fall behind and makes it difficult to stay caught up with the laundry. When the laundry staff gets the laundry caught up, laundry staff should have residents' personal laundry washed and returned to the residents within 24-48 hours. During an interview on 08/04/26 at 1:37 P.M., the Director of Nursing (DON) said staff should sort the clothes and return them to the residents within a few days. Laundry staff are rarely pulled to work on the floor and usually only from 6:00 P.M. to 10:00 P.M. when it happens. During an interview on 08/04/26 at 1:38 P.M., the administrator said staff should sort the clothes and return them to the residents within a few days. She has not received any complaints from residents about missing clothes sent to the laundry room. Laundry staff are rarely pulled to work on the floor and usually only from 6:00 P.M. to 10:00 P.M. when it happens. Complaint# 3120692, 3131103

Based on observation, interviews, and record review, facility staff failed to provide protective oversight to ensure one resident (Resident #1) out of 12 sampled residents remained free from physical abuse, when four residents (Residents #2, #3, #4, and #5) who had a history of physical aggression towards other residents assaulted Resident #1 while resident was in bed which resulted in bruising to the right rib area. The facility census was 231. 1. Review of the facility's Abuse and Neglect policy, dated 06/12/24, showed:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physician condition, cause physical harm, pain or mental anguish;-Physical abuse is purposefully beating, striking, wounding, or injuring any resident in any manner whatsoever, mistreating or maltreating a resident in a brutal or inhumane manner. 2. Review of Resident #1's Quarterly MDS, dated [DATE], showed staff assessed the residents with moderate cognitive impairment.Review of the resident's care plan, dated 06/25/26, showed staff implemented an intervention to ensure the resident's environment remains safe.Review of the facility's incident Investigation Summary, dated 08/02/26, showed staff documented they immediately initiated an investigation into allegations Resident #1 was assaulted by other residents on the 100 rehab hall that occurred on 08/01/26. Residents were interviewed and review of video footage showed:-At 10:08 P.M., Resident #2 seen walking in the hall with a sock and soap;-At 10:13 P.M, Resident #1 was moved to the 100 hall;-At 10:13 P.M., Resident #2 and Resident #3 entered Resident #1's room and exited after a minute;-At 10:20 P.M., staff entered Resident #1's room;-At 10:30 P.M., Resident #4 entered Resident #1's room and exited a few seconds later;-At 10:34 P.M., Resident #2 entered Resident #1's room, exited after a few seconds, re-entered Resident #1's room with a broom a few seconds later, and exited the room at 10:35 P.M.;-At 10:35 P.M., Resident #4 entered Resident #1's room with a water pitcher and exited the room a few seconds later;-At 10:37 P.M., Resident #1 exited his/her room to the hallway, Resident #5 threw water at Resident #1 then picked up a chair and tossed it towards Resident #1.Review of the resident's progress notes, dated 08/02/26 at 6:04 P.M., showed staff documented the resident arrived back to the facility approximately 5:40 P.M. from the hospital via facility transportation. No new orders.Review of the resident's hospital Discharge summary, dated [DATE], showed the resident was evaluated after a reported physical assault from three residents at the facility, and was assessed with a bruise on the right lateral rib area as well as over the hip bone on the right. Review showed the hospital documented tenderness to the left lower abdomen. Review of the resident's progress notes, dated 08/03/26 at 7:55 A.M., showed staff documented while Resident #1 was in his/her personal room, Resident #2 and Resident #3 entered Resident #1's room and reported Resident #2 struck Resident #1 in the arms and back before exiting room. Resident #4 enters Resident#1's room and pours water on Resident #1. Resident #1 exited the room into the hallway where Resident #5 threw more water on Resident #1. Resident #1 then returned to his/her personal room. All residents separated with no visible injuries noted, and Resident #1 moved to a different unit.Observation on 08/05/26 at 9:45 A.M., showed the resident with a bluish-purple bruise to his/her right rib, and a greenish-yellow bruise to his/her abdomen.During an interview on 08/04/26 at 2:40 P.M., Resident #3 said Resident #1 hit a couple of staff before they moved him/her to the 100 rehab unit and other residents wanted to beat him/her for hitting the staff. The resident said he/she went to Resident #1's room and tried to prevent the other residents from hitting him/her and someone threw water at Resident #1, but the room was dark, so he/she did not see who threw the water.During an interview on 08/05/26 at 9:45 A.M., the resident said he/she was in his/her room and it was dark, so he/she does not know exactly who did what, but they threw water on him, one of the resident hit him/her with a fist to his/her right rib, and one tried to hit him/her with a broom to his/her back but the broom did not catch him/her. The resident said he/she did not tell staff the residents tried to jump him/her. 3. Review of Resident #2's Annual Minimum Data Set (MDS), a federally mandated assessment, dated 07/09/26, showed staff assessed the resident as cognitively intact and did not exhibit physical or verbal behavioral symptoms towards others. Review of the residents' progress notes, dated 01/01/26 to 08/03/26, showed staff documented:-On 03/09/26 at 11:42 A.M., resident was the aggressor in an incident;-On 08/02/26 at 10:29 A.M., resident was the aggressor in an incident.During an interview on 08/04/26 at 2:47 P.M., the resident said Resident #1 was moved to the 100 hall rehab unit and he/she was upset at Resident #1 for hitting other residents, so he/she hit Resident #1 once with a bar of soap in a sock but did not use a broom to do anything to Resident #1.5. Review of Resident #4's annual MDS, dated [DATE], showed staff assessed the resident with moderate cognitive impairment and did not exhibit physical or verbal behavioral symptoms towards others. Review of the resident's progress notes, dated 01/01/26 to 08/03/26, showed staff documented:-On 05/04/26 at 12:15 P.M, resident was the aggressor in an incident;-On 08/02/26 at 11:40 A.M., resident was the aggressor in an incident.During an interview on 08/04/26 at 2:44 P.M., the resident said Resident #1 was acting up and was moved to the 100 unit, so he/she poured water on Resident #1's chest to calm him down. The resident said Resident #2 hit Resident #1 with a soap.6. Review of Resident #5's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and did not exhibit physical or verbal behavioral symptoms towards others. Review of the resident's progress notes, dated 01/01/26 to 08/03/26, showed staff documented:-On 07/03/26 at 8:10 P.M., the resident was the aggressor in an incident;-On 08/02/26 at 11:32 A.M., the resident was the aggressor in an incident.During an interview on 08/04/26 at 2:55 P.M., the resident said he/she poured water in the hallway and tossed a chair at Resident #1, but he/she did not hit Resident #1.8. During an interview on 08/04/26 at 10:07 A.M., Nursing Assistant (NA) E said shortly after he/she assisted Resident #1 to move to his/her new room on the 100 rehab unit on 08/01/26, Resident #2 and Resident #3 went inside Resident #1's room and exited after about one or two minutes and did not have anything in their hands. He/She went inside Resident #1's room to check on him/her, Resident #1 was covered in bed and said he/she was okay. NA E left the room and went outside to the courtyard to talk to a law enforcement officer about an incident that occurred earlier in the shift. NA E told Certified Medication Technician (CMT) G he/she was stepping outside to talk to the officer and assumed CMT G would remain on the hall until he/she returned from outside. NA E said when he/she returned to the hall, there was a puddle of water on the hallway floor next to the medication cart and did not see CMT G, so he/she cleaned up the water, went to check on the residents who were all in their respective rooms, and Resident #1 said he/she was okay. NA E said he/she was not aware of the incident until 08/03/26 when the Director of Nursing (DON) called him/her for an interview regarding the incident.During an interview on 08/04/26 at 11:39 A.M., Registered Nurse (RN) A said he/she was passing through the dining room on 08/02/26 and overheard Resident #2, #5, and #6 discussing how the prior evening 8/01/26 they had fun educating Resident #1 not to hit other residents by pouring water on Resident #1 and that broom stick thing. RN A said he/she immediately started an investigation, went to talk to Resident #1, assessed him/her, moved him/her to a different hall, notified the physician, guardian, DHSS, sent the resident to the ER for evaluation, and the DON took over the investigation. During an interview on 08/04/26 at 1:37 P.M., the administrator said Resident #2 had not been in any recent altercations, but Resident #3, #4, and #5 have been in altercations within the past six months. She did not consider the incident abuse, but rather staff neglected to provide the protective oversight to monitor and follow up on Resident #2, #3, and #4 entering and leaving Resident #1's room. There should have been at least one staff present on the hall at the time of the incident.During an interview on 08/05/26 at 12:15 P.M., CMT G said on 08/01/26, he/she was back and forth administering medications to residents on three different halls, and NA E was assigned to the 100-hall rehab unit. NA E did not notify him/her he/she was leaving the 100-hall rehab unit for him/her to monitor the residents in NA E's absence. CMT G did not witness the incident and was not aware of the incident until the next day and was in-serviced on the facility's abuse and neglect policy and monitoring residents. Intake# 3131080 and 3131679

Based on observation, interview, and record review facility staff failed to provide a clean, comfortable, homelike environment for residents, when staff did not ensure resident rooms were maintained and cleaned daily. The facility census was 231.1. Review of the facility's Safe and Homelike Environment Policy, dated 06/05/24, showed in accordance with resident rights the facility will provide a safe, clean, comfortable, and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment. 2. Observation on 07/28/26 at 10:52 A.M., showed Resident #9's room with sticky floors, that contained stains and debris. During an interview on 07/28/26 at 10:53 A.M., Resident #9 said his/her room had not been cleaned in a few days. 3. Observation on 07/28/26 at 12:56 P.M., showed Resident #6's sink contained black substance and the floor contained trash. During an interview on 07/28/26 at 12:56 P.M., Resident #6 said his/her room had not been cleaned in a long time. He/She said he/she had to clean his/her floor. 4. Observation on 07/28/26 at 1:29 P.M., showed Resident #10's floor dirty, stained, and with debris. The resident's mattress had a brown substance. 5. Observation on 08/03/26 at 1:17 P.M., showed Resident #15's floor contained dark brown stains next to the bed. ' Observation on 08/04/26 at 9:18 A.M., showed Resident #15's floor contained dark brown stains next to the bed. 6. Observation on 08/03/26 at 1:31 P.M., showed Resident #14's floor with scattered dark brown stains. Observation on 08/04/26 at 9:25 A.M., showed Resident #14's floor with scattered dark brown stains. 7. Observation on 08/03/26 at 1:37 P.M., showed resident #16's wall with dark brown marks, and missing paint/drywall approximately 18 inches by 10 inches next to the air conditioning unit below the window. Observation on 08/04/26 at 9:42 A.M., showed resident #16's wall with dark brown marks, and missing paint/drywall approximately 18 inches by 10 inches next to the air conditioning unit below the window. 8. During an interview on 07/28/26 at 2:09 P.M., Housekeeper H said resident rooms are cleaned once a week. There are only four housekeepers, so they can only clean one unit at a time. During an interview on 07/28/26 at 2:24 P.M., the DON said the residents' rooms should be cleaned daily, and he/she did not know the residents' rooms were not cleaned daily. During an interview on 7/29/26 at 9:44 A.M., the administrator said staff are educated to report environmental and cleanliness concerns to the housekeeping staff or maintenance staff. Resident rooms were cleaned daily. There have been a lot of staff who have called in, and the facility also had housekeeping staff quit and had to hire new staff. During an interview on 08/03/26 at 1:45 P.M., the Environmental Services Director said he/she had been in the position for about two weeks and was working to get the housekeepers back on track with cleaning resident rooms daily. During an interview on 08/04/26 at 12:51 P.M., CNA C said within the past two weeks, he/she submitted a couple maintenance requests via the facility's maintenance app regarding dark stains on the floors in a few of the rooms on the 200 hall to see if they can be stripped and waxed. He/She could not recall the exact rooms. During an interview on 08/04/26 at 1:38 P.M., the administrator said staff should submit maintenance requests via the facility's maintenance app, maintenance staff checks daily to prioritize and address concerns/repairs. Broken stuff and emergency issues are addressed before floor concerns. #3120692, 3131103, 3109564, 3109675

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free of significant medication errors when Registered Nurse (RN) A did not verify admission physician's orders, which resulted in staff not administering diabetic medications and resident hospitalization with Diabetic ketoacidosis (DKA) (a life-threatening complication of diabetes that occurs when the body lacks enough insulin to use blood sugar). The facility census was 224.The administrator was notified on 06/12/26 of Past Non-Compliance which occurred on 06/08/26. The Director of Nursing (DON) investigated, notified the residents' responsible party, counseled RN A, and in-serviced staff regarding medication administration, transcribing physician's orders, medication reconciliation, and the admission process. Staff corrected the deficient practice on 06/08/26. Review of the facility's Medication Reconciliation Policy, dated 05/14/24, showed the facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free from any significant medication errors, and that the facility's medication error rate is less than five percent (%). Review of the facility's admission Process, Assignment of Primary Diagnosis Policy, dated 12/01/22, showed:-If the decision is made to admit the resident, then the admissions coordinator will obtain all pertinent information to ensure that the resident's needs can be met including current drug regimen, diet orders, laboratory orders and any special need items. -The DON/ADON (Assistant Director of Nursing)/RN designee will input the resident's information onto the Resident Diagnosis Sheet;-A Licensed/Registered Nurse will ensure that all admission paperwork including physician orders, medications, diet orders, laboratory orders are followed;-The RN will need to complete a Chart Audit within 24 hours of Admission. Review of the facility's Transcription/Orders/Following Physician's Orders Policy, dated 05/18/24, showed:-Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in resident's electronic medical records in orders section;-The Licensed Nurse will review electronic Medication Administration Records (MARs) and electronic Treatment Administration Records (TARs) on a routine basis to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etcetera;-The Nurse or Certified Medication Technician (CMT) in charge of medication administration must review all their designated MARSs and TARs prior to the end of their shift to ensure that all medications/treatments scheduled to be given on their shifts were administered according to the physician's order and that all necessary interventions were taken in the event of an omission. 2. Review of Resident #1's Face Sheet from the transferring facility, dated 05/20/26, showed the resident with diagnoses of Type I Diabetes Mellitus (a chronic metabolic disorder characterized by persistently high glucose (blood sugar) levels with Hyperglycemia (high blood sugar). Review of the resident's transferring facility's Physician's Orders, dated 05/20/26, showed Insulin Glargine (a long-acting insulin) 100 units/milliliter (U/ml) 20 units subcutaneously (under the skin) one time a day, Insulin Glargine 100 U/ml 30 units subcutaneously at bedtime, Insulin Lispro (a rapid-acting insulin) 100 U/ml four units subcutaneously with meals, Insulin Lispro 100 U/ml inject with meals as sliding scale for blood glucose levels as follows: -0-150-Do not administer;-151-200-two units;-201-250-four units;-251-300-six units-301-350-eight units-351-400-ten units-401-450-12 units-451-500- 14 units-501-550- 16 units and notify physician. Review of the resident's medical record did not contain admission paperwork to include diagnoses, face sheet. Review of the resident's Physician Order Sheet, for June 2026, showed no documentation of medication orders or diabetic medication orders. Review of the resident's MAR, dated June 2026, showed the MAR did not document any orders or that they administered the resident's insulin from 06/06/26 through 06/08/26. Review of the resident's nurse's notes, dated 06/06/26 through 06/08/26, showed the resident admitted to the facility on [DATE]. Review showed the nurses notes did not contain documentation of diagnoses, physician's orders, or documentation staff contacted the physician to clarify or to obtain physician orders for the resident upon admission. During an interview on 06/30/26 at 9:47 A.M., Licensed Practical Nurse B said he/she was not on duty on the weekend of 06/05/26 through 06/07/26. The first interaction he/she had with the resident was on the morning of 06/08/26, so he/she did not know the resident's baseline. When he/she checked on the resident at approximately 8:00 A.M. on 06/08/26, the resident was covered in coffee ground emesis and had loose stool. He/She thought the resident may have an impaction or gastrointestinal (GI) bleed, so he/she sent the resident to the Emergency Department (ED). He/She said there were no physician's orders or diagnoses in the resident's chart, and no documentation the resident was diabetic. Review of the resident's nurse note, dated 06/09/26, showed the DON documented the resident admitted on [DATE] from another facility, and upon admission the RCC (Resident Care Coordinator) entered orders for the resident based on old referral orders instead of his/her current new admission orders brought in with the resident. The RCC did not verify that the orders on the old referral were the correct orders with the physician. Weekend RN (Registered Nurse) did not complete 24-hour RN chart audit. The resident voiced concerns related to medication throughout the weekend. No one addressed his/her concerns. Sent to hospital 06/08/26, admitted for Diabetic Keto-acidosis (DKA). Review of the resident's hospital records, dated 06/08/26, showed hospital staff documented the resident admitted with Diabetic Ketoacidosis with a blood glucose level over 600 (normal levels are 74 to 106). During an interview on 06/15/26 at 2:00 P.M., RN A/Admissions Coordinator said he/she needed to complete five admissions on 06/05/26. The DON sent him/her the referral packet for the resident and he/she was overwhelmed. He/She did not enter insulin orders for the resident or call the physician to verify orders and did not administer medications to the resident before he/she went off duty. He/She did not know if the resident was feeling ill,. He/She should have verified to ensure medication orders were correct. During an interview on 06/18/26 at 2:23 P.M., the DON said he/she was not on duty when RN A admitted the resident to the facility. He/She was on his/her way to the facility on [DATE], when staff notified him/her the resident was having coffee consistent emesis and staff were sending the resident to the hospital. He/She said when hospital staff called the facility to question facility staff regarding the resident's insulin and blood glucose levels, he/she looked at the resident's admission and medical chart and discovered staff had not transcribed the resident's current physician's orders into his/her medical record. He/She said when the facility admits a new resident, either the RCC or the floor nurse will enter admission orders in the resident's electronic medial chart, and the RN on duty should review the information within 24 hours to ensure accurate information. He/She would consider the failure to administer the resident's medication a significant medication error with the potential to cause harm. During an interview on 7/1/26 at 9:15 A.M., the physician said the resident was a brittle type I diabetic who received Lantus and Lispro insulin. The resident had a history of DKA if insulin was not given. The physician said the facility should have had those orders as they had been requested and if not, they should have reached out to clarify the residents' orders. The physician said he/she never got a call from the facility to confirm the details of the residents' orders. The physician said he/she would expect a facility to notify the physician to go over all orders prior to admitting them to assure residents receive significant medications such as insulin. #3040985

Based on observation, interviews and record review, facility staff failed to provide adequate nursing staff, as determined by their facility assessment. The facility census was 239.1. Review of the facility's Facility Assessment Policy and Tools policy, dated 10/31/24, showed the facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)2. Review of the Facility Assessment, dated 08/01/25, showed the average daily census for the last six months of occupied beds as 235. Review showed the assessment based on the resident population and their needs for care and support daily. Review showed direct care staff required to care for their facility census for a twenty-four-hour period should include:-Four Resident Care Coordinator (RCC);-Eight Licensed Practical Nurses (LPN);-Twenty-Four Certified Nurse Aides (CNA);-Nine Certified Medical Technicians (CMT).Review of the facility staffing schedule from 05/10/26 through 05/16/26, with an average daily census of 235, showed: -Sunday, 05/10/26; three RCC's, six LPN, sixteen CNA's and eight CMT's;-Monday, 05/11/26; three RCC's, six LPN, ten CNA's and six CMT's;-Tuesday, 05/12/26; three RCC's, four LPN, fourteen CNA's and seven CMT's;-Wednesday, 05/13/26; three RCC's, four LPN, fifteen CNA's and seven CMT's;-Thursday, 05/14/26; two RCC's, six LPN, sixteen CNA's and seven CMT's;-Friday, 05/15/26; three RCC's, five LPN, fourteen CNA's and five CMT's;-Saturday, 05/16/26; three RCC's, four LPN, fourteen CNA's and six CMT's.During an interview on 06/09/26 at 8:59 AM, the administrator said the staffing coordinator was responsible for updating the staffing schedule. He/She said he/she worked with the Director of Nursing (DON) to ensure there was enough staff per the facility assessment.During an interview on 06/09/26 at 9:04 A.M., the staffing coordinator said he/she was responsible for completing the daily staffing schedules. He/She said he/she would coordinate with the administrator and DON. He/She followed the facility assessment to verify how many staff are required each day. He/She said he/she had a lot of employees who recently quit.#3019426

Based on observation, interview and record review, facility staff failed to update two resident's (Resident #1 and Resident #2) plan of care after the residents consistently pulled the fire alarm. The facility census was 235. 1. Review of the facility's Comprehensive Care Plan, dated 10/31/24, showed the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy showed it did not contain direction for staff regarding updating the resident's plan of care with new interventions after a new or increased behavior.2. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as cognitively intact and did exhibit other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) one to three days during the lookback period.Review of the resident's care plan, dated 03/31/26, showed the resident had a negative behavior of pulling fire alarms. Review showed the care plan did not contain documentation of new interventions related to the pulling the facility fire alarms.Observation on 05/26/26 at 11:03 A.M., showed staff turning off the fire alarm. At this time, the resident said said he/she pulled the fire alarm.During an interview on 05/26/26 at 2:01 P.M., Certified Medication Technician (CMT) A said the resident had a history of pulling the fire alarm. He/She said the resident pulled the alarm when he/she wanted cigarettes, or if he/she was out of cigarettes, and was upset. He/She did not know what interventions were in place for the behavior.During an interview on 05/26/26 at 2:20 P.M., Licensed Practical Nurse (LPN) B said the resident had a history of pulling the fire alarm when he/she did not get his/her way. He/She did not know if the behavior was addressed in the care plan.During an interview on 05/26/26 at 2:55 P.M., Certified Nurse Aide (CNA) C said the resident had a history of pulling the fire alarm.During an interview on 06/09/26 at 8:59 AM, the administrator said staff had recently reported behaviors of the resident pulling the fire alarm.3. Review of Resident #2's comprehensive MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired and did not exhibit other behavioral symptoms not directed toward others during the lookback period.Review of the resident's progress notes, dated 05/25/26, showed staff documented the resident pulled the fire alarm.Review of the resident's care plan, dated 05/26/26, showed staff documented the resident had manifestations of behaviors related to his/her mental illness and behaviors include pulling facility fire alarms. Observation on 05/26/26 at 11:08 A.M., showed the fired alarm went off in the 400 hallway.During an interview on 05/26/26 at 12:08 P.M., the regional nurse said the resident had a history of pulling the fire alarm.During an interview on 05/26/26 at 2:01 P.M., CMT A said the resident had a history of pulling the fire alarm. He/She said the resident just pulled the alarm a day or two ago and pulled the alarm every other day. He/She said the resident pulled the alarm when he/she wanted something. He/She did not know what interventions were in place for the behavior.During an interview on 05/26/26 at 2:55 P.M., CNA C said the resident pulled the fire alarm today. He/She said pulled the alarm on 05/21/26 and had a history of frequently pulling the fire alarm since he/she was admitted to the facility. He/She said he/she did not know what interventions were in place for his/her behaviors. During an interview on 05/26/26 at 2:20 P.M., LPN B said the resident had a history of pulling the fire alarm when he/she wanted cigarettes. He/She did not know if the behavior was addressed in the care plan.During an interview on 06/09/26 at 8:59 AM, the administrator said staff had recently reported behaviors of the resident pulling the fire alarm.4. During an interview on 05/26/26 at 2:20 P.M., LPN B said behaviors of pulling the fire alarm should be addressed in resident's care plan. He/She said new interventions should be addressed in the resident's care plan if the resident was still having the same behavior.During an interview on 05/26/26 at 3:14 P.M., the corporate nurse said he/she would expect to see interventions in the care plan after a change in behavior and new interventions depending on the reason for interventions not working. He/She said the nurse can update resident care plans.During an interview on 06/09/26 at 8:59 AM, the administrator said he/she expected the resident's care plan to include new interventions after the fire alarm was pulled. He/She said the nurses were also able to update the care plans with new interventions after behaviors. He/She said he/she are re-educating the nurses to update the care plans with new interventions and to also update the care plan coordinator when a resident had a new behavior. #3019574

Based on interview, and record review, facility staff failed to report an allegation of sexual abuse for one resident's (Resident #4) within the required two hours to the state agency Department of Health and Senior Services (DHSS). The facility census was 228. 1. Review of the facility's Abuse and Neglect Policy, dated 06/12/24, showed it is the policy of this facility to report all allegations of abuse and are reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames. The facility must ensure that all the alleged violations involving abuse or sexual assault are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse to the State Survey Agency. 2. Review of Resident #4 quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as cognitively intact and admitted on [DATE]. Review of the resident's progress notes, dated 04/02/2026, showed staff documented the resident reported he/she was raped in his/her sleep and wanted to be sent to the hospital to obtain a rape kit. During an interview on 04/03/26 at 1:46 P.M., Licensed Practical Nurse (LPN) A said the resident had reported to staff he/she was raped by someone then later said it was his/her family member. He/She said he/she reported the allegation to the administrator around 5:00 A.M He/She said he/she was told the administrator reported the allegation to DHSS.During an interview on 04/03/26 at 2:20 P.M., the administrator said he/she received a call around 5:30 A.M. regarding the allegation of sexual abuse. He/She said he/she did not file a complaint with DHSS because he/she investigated the allegation of sexual abuse and determined within two hours, the allegation of sexual abuse did not occur. 2972664

Based on interviews and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment) when they did not accurately code a psychiatric/mood disorder diagnosis for three residents (Resident #1, Resident #2 and Resident #3) out of four sampled residents. Facility census was 232.1. Review of the facility's MDS 3.0, Care Assessment Summary and Individualized Care Plans policy, dated 11/06/23, showed to understand the changes presented by Centers of Medicare and Medicaid Services (CMS) for the MDS 3.0 to define the intent of each section of the MDS 3.0 and to ensure that MDS 3.0 sections are completed accurately and in a timely manner by the assigned responsible parties. 2. Review of the resident's diagnosis report, dated 04/30/23, showed staff documented a diagnosis of bipolar disorder.Review of Resident #1's quarterly MDS, dated [DATE], staff assessed the resident as cognitively intact. The assessment did not contain documentation that the resident had a diagnosis of a bipolar disorder.Review of the resident's care plan, dated 3/31/26, showed staff documented the resident had a diagnosis of bipolar and schizophrenia, and exhibited behaviors of hallucinations and delusions. 3. Review of the resident's diagnosis report, dated 06/04/25, showed staff documented a diagnosis of PTSD.Review of Resident #2's quarterly MDS, dated [DATE], staff assessed the resident as cognitively intact. The assessment did not contain documentation that the resident had a diagnosis of Post Traumatic Stress Disorder (PTSD).Review of the resident's care plan, dated 03/28/26, showed staff documented the resident did have a diagnosis of PTSD with interventions in place, but did not contain direction for staff related to PTSD triggers. 4. Review of the resident's diagnosis report, dated 10/15/25, showed a diagnosis of PTSD.Review of Resident #5 quarterly MDS, dated [DATE], staff assessed the resident as cognitively intact. The assessment did not contain documentation that the resident had a diagnosis of PTSD.Review of the resident's care plan, dated 01/15/26, showed staff documented the residents had a history of PTSD.5. During an interview on 04/14/26 at 1:38 P.M., the MDS Coordinator said if a resident had an active diagnosis and was being treated for PTSD or a bipolar disorder, it should be documented on the MDS. He/She said he/she did not know if Resident #2 and Resident #5 had a diagnosis of PTSD or if Resident #1 had a diagnosis of bipolar disorder, since the facility had a large population. 2967099, 2967098, 2967147

Based on interview and record review, facility staff failed to update one resident's (Resident #2) plan of care who experienced suicidal ideation and had a history of self-harm, and facility staff failed to update three resident's (Resident #1, Resident #3 and Resident #5) plan of care after they exhibited increased behaviors. The facility census was 232. 1. Review of the facility's policy, MDS 3.0, Care Assessment Summary and Individualized Care Plans, dated 01/06/23, showed it did not contain direction for staff regarding updating the resident's plan of care with new interventions after a new or increased behavior.2. Review of Resident #1's progress notes, dated 01/27/2026, showed staff documented the resident was an aggressor in a resident-to-resident altercation and reported the holy spirit had taken over his/her body and he/she did not need medication.Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as cognitively intact, and without hallucinations and delusion.Review of the resident's care plan, dated 3/31/26, showed staff did not document new intervention after the altercation on 01/26/26.3. Review of Resident #2's quarterly MDS, dated [DATE], staff assessed the resident as cognitively intact with a diagnosis of depression. The assessment did not contain documentation of the resident having thoughts that he/she would be better off dead, or of hurting self in some way.Review of the resident's care plan, dated 03/28/26, showed staff documented the resident at low risk for suicide. The care plan did not provide guidance for staff in regard to interventions when resident exhibited suicidal ideations, makes self-harm statements, or self-harm attempts.Review of the residents' progress notes showed staff documented:-02/11/2026 the resident expressed to staff that he/she was manic and felt he/she wanted to hurt himself/herself on 02/10/26. -03/09/26, the resident was found with a shoestring around his/her neck.-03/28/26, the resident was transferred to the hospital after staff found the resident with a charger cord tied tightly around his/her neck. 4. Review of Resident #3's progress notes, dated 02/19/26, showed staff documented the resident pushed another resident causing both residents to tumble to the floor and exchanged one punch.Review of the residents quarterly MDS, dated [DATE], staff assessed the resident as cognitively intact and did not exhibit physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually).Review of the resident's care plan, dated 3/19/26, showed staff did not document new intervention after the altercation on 02/19/26, and did not contain guidance for staff in regard to interventions when resident exhibited behaviors.5. Review of Resident #5 quarterly MDS, dated [DATE], staff assessed the resident as cognitively intact, and without physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), and verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others).Review of the resident's care plan, dated 01/15/26, showed staff did not document new intervention after the altercation on 02/06/26 or 03/21/26, and did not contain guidance for staff in regard to interventions when resident exhibited behaviors.Review of the resident's progress notes showed staff documented on 02/06/2026 a call was placed to the guardian because resident had increased behaviors, lashed out towards staff by grabbing a cigarette box and then had a verbal altercation with another resident. 6. During an interview on 4/03/26 at 1:46 P.M., Licensed Practical Nurse (LPN) A said the care plan should be updated with new interventions after a statement of self-harm or behaviors of self-harm or incidents of physical aggression. He/She said there are a lot of resident's with behaviors, and he/she said there could be more information and education for staff to prevent behaviors.During an interview on 04/03/25 at 2:20 P.M., the administrator said he/she would consider new or increased behaviors, including being physically aggressive and causing injury, or statement or behaviors of self-harm to be a significant change. He/She said the MDS Coordinator was responsible for completing a significant change assessment. He/She said the care plan should be updated with new interventions after a new behavior of self-harm or aggression towards other. He/She said nurses would be responsible to update the care plan.During an interview on 04/08/26 at 3:11 P.M., the MDS Coordinator said he/she was responsible for completing the significant change and comprehensive assessment. He/She would consider a new statement of self-harm, or an action of self-harm, or new aggressive behaviors a significant change in condition unless it was documented on the Preadmission Screening and Resident Review (PASAAR). He/She said he/she did not know if the behaviors were on Resident #1, Resident #2, Resident's #3's or Resident #4's PASAAR, since he/she had hundreds of residents to keep up with.2967099, 2967098, 2967147

Based on interviews and record review, facility staff failed to report an allegation of physical abuse to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe for one resident (Resident #1) of one sampled resident who reported an employee physically abused him/her. The facility's census was 227.1. Review of the facility's Abuse and Neglect policy, dated 06/12/24, showed physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, or sexual assault including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency.2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/06/26, showed staff assessed the resident as cognitively intact, independent with ambulation, and diagnoses to include unspecified impulse disorder (when an individual exhibits harmful behaviors such as extreme aggression, property destruction or dangerous urges), schizoaffective disorder, bipolar type (a mental health condition with symptoms of hallucinations, delusions, bouts of mania and major depression), and Attention-Deficit Hyperactivity Disorder (ADHD). During an interview on 02/18/26 at 12:18 P.M., the resident said the previous night, Certified Nursing Assistant (CNA) A held him/her by his/her coat collar at the neck area with his/her fist and slammed him/her against a wall next to the door to an adjoining unit. The resident said he/she was not injured, and was not sure if anyone witnessed it, but staff knew about the incident. Review of the facility's investigation, dated 02/18/26, showed staff documented Resident #1 reported to staff on 02/17/26 at approximately 7:38 P.M., CNA A physically abused him/her when CNA A grabbed the resident by his/her coat and pushed him/her. The resident was assessed with no injuries, there were no direct witnesses, CNA A was immediately suspended pending the investigation, physician, guardian, law enforcement and DHSS were notified, and the resident was offered counseling services. Review of the DHSS complaint/facility self-report database did not contain documentation the facility reported the allegation of physical abuse towards the resident. During an interview on 02/18/26 at 3:10 P.M., the administrator said all allegations of abuse should be reported to DHSS within two hours. The administrator said Licensed Practical Nurse (LPN) B notified him/her of the resident's allegation approximately 8:00 P.M. on 02/17/26, he/she started an investigation, initiated an online report to DHSS, but closed his/her computer without confirmation the report was successfully submitted. The administrator said he/she was responsible to submit the report to DHSS.Complaint# 2745801

Based on observation, interview, and record review, facility staff failed to ensure the doors on the Tiger Medical Unit, a secured unit, were monitored during a fire alarm test which resulted in one resident (Resident #27) eloping from the facility at approximate 3:00 P.M. In addition, staff failed to complete hourly face checks for the resident, did not check on the resident after he/she missed dinner and smoke breaks, and did not notice the resident was missing until 9:00 P.M. Facility staff further failed to properly complete a thorough head count to ensure all residents were in the facility after the fire drill when staff were made aware two residents (Resident #116 and #112) had left the facility when the unit doors were left unattended and unlocked. Facility staff failed to properly store and lock medications to ensure resident safety for six residents (Resident #163, #211, #233, #74, #86, and #39) of a sample of 45 residents. The facility census was 231.The administrator was notified on 12/5/25 at 6:06 P.M., of an Immediate Jeopardy (IJ) which began on 12/4/25. The IJ was removed on 12/5/25, as confirmed by surveyor onsite verification. Review of the facility's Elopement policy, dated 06/12/24, showed residents who are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The facility is equipped with door locks/alarms. Alarms are not a replacement for necessary supervision. Review of the facility's Fire Drill Policy, dated 12/27/24, showed the policy did not contain staffing assignments during drills for secured units. Further review showed the policy did not address monitoring of doors during fire alarm drills or emergencies. 1.Review of Resident #27's Medicare 5-Day Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident had verbal behaviors towards others, and required supervision or touch assistance with eating, walking, transfers, personal hygiene, and bathing. Diagnoses of Anxiety Disorder, Schizophrenia (a serious brain disorder causing abnormal reality interpretation, with symptoms like hallucinations (hearing voices), delusions (false beliefs), disorganized speech, and impaired thinking), Schizo-affective Disorder (Bipolar Type) (a serious mental illness blending symptoms of schizophrenia (psychosis like hallucinations/delusions) with bipolar disorder (manic highs and depressive lows), where psychotic symptoms occur alongside or even without significant mood episodes), Asthma, and Chronic Obstructive Pulmonary Disease (COPD). Review of the resident's care plan, dated 07/23/25, showed staff documented the resident had explosive anger, extreme emotional swings, fear of being left alone, impulsive, had self-destructive behaviors, concerns for self-harm, and skilled nursing to complete face checks. Review of the resident's Elopement Assessment, dated 11/14/25, showed the resident scored a zero, not at risk for elopement. Review of the facility's surveillance video showed on 12/4/25 at 2:53 P.M., staff for the Tiger Medical Unit could not be observed in the hallway or at the fire exit, during the fire drill. Resident #27 exited his/her room and walked straight out the fire exit door by the Business Office. At 2:53:44 P.M., the exterior camera footage showed the resident crossed the back parking lot of the facility and entered the woods behind the facility.Review of Resident #116's care plan, dated 10/23/25, showed staff documented the resident has a history of behavioral challenges that require protective oversight in a secure setting; is at risk of elopement; and expresses a desire to leave facility. Eloped from his/her personal window on 10/23/25 at 12:24 P.M. Monitor resident's location frequently and initiate face-checks if/when necessary. Review of Resident #116's Quarterly Elopement Assessment, dated 11/5/25, showed staff assessed the resident as a high risk for elopement. Review of Resident 112's Quarterly Elopement Assessment, dated 10/16/25 showed staff assessed the resident as not a risk for elopement. Review of Resident #112's care plan, dated 11/3/25, showed staff documented staff should provide protective oversight and assist where needed. Observation on 12/4/25 at 3:00 P.M., showed Dietary Aide (DA) B yelled out the back dining room door Get back in here. Observation showed Resident #116 held open the exit door attached to the enclosed fence on Tiger Lane and Resident #112 outside the door and fence. Review of Resident #27's hourly face checks, dated 12/04/25, showed face checks were completed at the following times: 00:43 AM, 02:33 AM, 03:32 AM, 04:43 AM, 05:04 AM, and 19:50 (7:50 PM). Six hourly face checks were completed out of a possible 24 checks. One hourly check was documented as competed after the resident eloped from the facility. Review of the resident's Medication Administration Record (MAR), dated December 2025, showed the following for 12/04/25:- Melatonin Oral Tablet 10 milligrams (mg), Give 10 mg by mouth at bedtime related to insomnia, unspecified, at 8:00 P.M., ordered 11/18/25; not administered;- Vitamin D3 Oral Tablet (Cholecalciferol), give 1000 unit by mouth at bedtime for low vitamin D related to vitamin D deficiency, unspecified; at 8:00 P.M., ordered 11/18/25, not administered; - Antipsychotic medication - monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting, lethargy, drooling, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue; document every shift related to schizoaffective disorder, bipolar type, started 9/16/24; review showed staff documented the assessment was completed for the night shift;- Assess for pain every shift every shift, started 09/16/24, review showed staff documented the assessment was completed for the night shift;- Behaviors - monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care, every day shift and night shift; review showed staff documented the assessment was completed for the night shift;- Check mouth after giving medications to observe for cheeking meds every shift, started 09/16/24; review showed staff documented the assessment was completed for the night shift. Review of the resident's progress notes, dated 12/4/25 at 9:12 P.M., showed staff reported the resident did not come to get his/her snack at 9:00 P.M., after a thorough check of the facility the resident could not be found. Another resident reported the resident walked out the door/fire exit around 3:00 P.M. when the fire alarm went off. Staff documented the Administrator, Director of Nursing (DON), Assistant DON, 911, and physician had been notified. Staff documented the guardian could not be reached. Review of the resident's progress notes, dated 12/4/25 at 10:00 P.M., showed staff documented the police were present when the DON arrived at the facility at 10:00 P.M., and confirmed by facility cameras the resident left the facility though the unlocked exit door at approximately 3:00 P.M. The police reported that a citizen called and said they had picked up a man/woman with the same name, who was walking, and gave him/her a ride to the public library. Review of the resident's progress notes, dated 12/5/25 at 1:43 A.M., showed staff documented the resident had been found at 1:33 A.M. and had been taken to the emergency room for psychiatric evaluation, as he/she reported he/she would not go back to the facility because Jesus had given his/her guardianship back. The DON instructed a Certified Nurse Aide (CAN) to take the resident's paperwork to the emergency room and sit with the resident per emergency room staff request. Review of the website https://forecast.weather.gov showed the temperature to be 19 Degrees Fahrenheit on 12/05/25 at 1:45 A.M. During an interview on 12/5/25 at 7:53 A.M., the DON said he/she found Resident #27 around 1:30 A.M. in the downtown area and had approached the resident to get him/her back to the facility. The resident refused to return and was picked up by law enforcement around 1:45 A.M. and transported to the local hospital for psychiatric evaluation and is currently in the hospital. During an interview on 12/5/25 at 9:09 A.M., DA B said there had not been any staff assigned to the doors of the unit that the two residents went out of. He/She said the facility doesn't usually assign staff to the back door or the back gate during fire drills. The DA said he/she knows the doors are unlocked during fire drills. As far as he/she knows, when the fire drill occurred there was not a staff member assigned to watch the back door. He/she happened to be walking down the hall, when he/she heard the residents (#112 and #116) say let's go, and saw them go out the back door, so he/she opened the door and saw the two residents open the door to the fence and start to go through it. He/she yelled at the residents to get back in the building. The DA said a staff member did not come and talk to him/her after the fire drill. The DA said staff did not watch the exterior locked fence exit, just the inside doors. He/she said the administrative staff did not come talk to him/her about the two residents who tried to go through the back gate. The DA said he/she did not know another resident got out as well. He/she did not report to anyone the two residents got out, or that no staff watched the back exits. During an interview on 12/5/25 at 9:35 A.M., Resident #116 said it was him/her and Resident #112 that were at the open door during the fire drill. He/she knew the fence door would unlock during the fire drill. The resident said staff told him/her to come back in the door, so he/she did. The resident said there were not any staff at the dining room door, or at the exit door at the fence when the fire alarm went off. During an interview on 12/5/25 at 9:40 A.M., Resident #112 said it was him/her that went out the fence door when the fire alarm went off. He/she did not see any staff. During an interview on 12/5/25 at 9:45 A.M., Resident Care Coordinator (RCC) HH said the fire drill notification was sent by text and he/she knew about the drill before the alarm sounded. He/She didn't assign a staff member to monitor the exit doors before the alarm went off, but did ask staff to watch the doors while the alarm sounded. The RCC said he/she just started asking people to watch doors and had to use housekeepers and he/she did not assign anyone to watch the dining room door. There was not a staff member available to watch the exit door. The DON did not talk to him/her after the drill. The RCC was not aware Resident #27 was missing until 9:26 P.M., when staff told him/her they could not find the resident to give him/her a snack. Staff did not notify him/her the resident had missed his/her dinner or 8:00 P.M., medications. The RCC said the resident missed his/her smoke breaks last night which was not normal. It was cold last night when the resident walked down the highway without a shoulder. It can be difficult to create a safe and secure environment with two Nurse Aides (NAs) and one Certified Medication Technician (CMT). Staff should have completed hourly face checks on the resident. Staff documented the checks were completed, and they were not, because the resident was not there. During an interview on 12/5/25 at 10:46 A.M., the Receptionist said he/she announced the fire drill on the intercom at 2:45 P.M. on 12/4/25. During an interview on 12/5/25 at 11:00 A.M., the DON said as soon as the state surveyor came and reported the two residents (#112 and #116) outside to him/her, he/she looked at the Medical Records staff and told him/her to complete a head count on the unit. The DON said the medical records staff ran to the unit, completed head checks and told him/her all residents were accounted for. During an interview on 12/5/25 at 11:26 A.M., the Medical Record staff said he/she was not assigned to a door during the drill. The DON came and told him/her to contact the two other residents who tried to go out the back gate. The DON told him/her to lay eyes on the two residents and to do a bit of a count. He/She can't say that he/she went to each individual resident and he/she did not have any other staff count residents with him/her. He/She did not contact RCC HH or the aides on the floor, to see if they had completed a resident count and he/she did not see Resident #27. During an interview on 12/5/25 at 11:17 A.M., the Business Office Manager (BOM) thought he/she had been assigned to the door Resident #27 went out, but did not think he/she got there in time. He/She was not notified before the fire drill happened. Typically the aides on the hall monitor the doors. The BOM did not see any residents go out the doors, but was not down there exactly at that time. He/she got to the area after the fire drill started. During an interview on 12/8/25 at 12:05 P.M., NA D said he/she was the staff over Resident #27's unit, the day of the resident's elopement. He/She went on lunch break and was not on the hall during the fire alarm test. He/She told CMT C and NA W he/she went to lunch, before the fire drill went off. During interviews on 12/5/25 at 11:50 A.M. and 12/8/25 at 12:46 P.M., CMT C said there should be staff by each exit door when a fire alarm drill/test is announced to ensure residents do not try to elope. CMT C said NA D came and asked to take a lunch on 12/4/25 and he/she told the NA to wait for NA W to get back. NA W should have been on the resident's unit if NA D was on break. During the fire drill he/she had to use housekeepers to watch the exits, because there was not enough nursing staff to monitor the exits. During an interview on 12/5/25 at 11:20 A.M., Resident #165 said Resident #27 was in the dining room on the Tiger Lane Medical unit when the fire alarm went off. He/She said after the alarm went off Resident #27 walked out the back door by the offices. The resident said there was not any staff by the exit door while the fire alarm sounded. During an interview on 12/5/25 at 5:21 P.M., the DON said during a true fire drill, staff should monitor the doors and complete a head count afterwards. He/She would have to check on the education provided during orientation, but he/she knows education regarding fire drills is provided throughout the year. The expectation would be to monitor the doors. He/She could understand why staff didn't during this experience. The DON said that since they were just testing to make sure the doors unlock it was not the same as when they run true fire drills where staff have to mock evacuate, get fire extinguishers, etc. He/She expected if the doors are unlocked, they should be monitored. During an interview on 12/5/2025 at 5:24 P.M., the administrator said he/she would expect if a door to a secured unit is unlocked a staff member would be present to monitor the door. He/She doesn't know why staff were not at the door. Staff receive education regarding fire drills, but he/she does not know if the education covers egress doors. He/She could not find a policy for locked secured doors. Staff are expected to ensure doors close, grab a fire extinguisher, evaluate the situation, monitor the doors and complete a head count to make sure everyone was safe. Staff should have gone downstairs and completed a head count and he/she does not know why they did not. The administrator said, We failed, we just failed. 2. Review of the facility's Medication Storage Policy, dated 05/18/25, showed it is the policy of this facility to ensure all medications housed on our premises will be stored in the medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Observation on 12/01/25 at 1:14 P.M., showed an unattended pill cup with several medications sat on the counter in Resident #163's room. Resident #211, #233, #74 & #86 wandered the hall outside the resident's room and Resident #74 and Resident #86 wandered into other residents' rooms. The unattended pill cup contained the following medications:-One 150 milligram (mg) Seroquel (antipsychotic medication);-Two tablets of melatonin three mg (used to induce sleep);-Two tablets of 500 mg Valproic Sodium (mood stabilizer);-One tablet of 200 mg Clozapine (antipsychotic medication);-One tablet of 300 mg Clindamycin (antibiotic);-One tablet of 50 mg Hydroxyzine (anti-anxiety medication);-Two tablets of 325 mg Acetaminophen. During an interview on 12/1/25 at 1:30 P.M., RCC 1 said the medications were from the night shift medication pass. CMT C was the CMT that administered the medications, and he/she documented the resident received them. During an interview on 12/1/25 at 1:43 P.M., CMT C said he/she gave the resident his/her medications last night. He/She never takes medications to the resident's room, he/she catches the resident when he/she goes out to smoke and gives him/her medications then. He/she must watch the resident, because he/she likes to cheek the medications. The CMT said he/she watches the resident swallow his/her medications. If the resident had night medications in his/her room, it was not from last night. During an interview on 12/2/25 at 2:50 P.M., Resident #163 said CMT C left the medications on the sink in his/her room. He/She fell asleep before he/she could take them. During an interview on 12/05/25 at 12:14 P.M., NA I said three residents wander the unit where the pills were found, and two residents go in and out of residents' rooms. Observation on 12/8/25 at 10:37 A.M., showed medications sat on top of the 300 hall medication cart without staff present. Five unidentified residents were around the cart with the following medications:-Dulera (inhaler);-Albuterol (inhaler);-Flonase (nasal spray);-Duloxetine (antidepressant);-Ventolin (inhaler);-Fluticasone (nasal spray). During an interview on 12/8/25 at 10:38 A.M., Resident #39 said staff always leave those medications out for resident's that use inhalers as needed in case of an emergency. That way the residents do not have to wait on staff, and they can grab them themselves. During an interview on 12/8/25 at 10:40 A.M., CMT FF said the medications left out are from the morning medication pass, and he/she just forgot to put them up. During an interview on 12/8/25 at 1:28 P.M., CMT GG said it is important to never leave medications unlocked, because the residents will steal them. During an interview on 12/8/2025 at 2:44 P.M., RCC HH said staff should make sure residents swallow their medications. Staff should make sure the residents don't walk away from the medication cart with the medications. The unit has residents who wander in and out of rooms and it is dangerous to have unattended pills on the hall with residents who wander. During an interview on 12/8/25 at 4:29 P.M., the DON said staff should watch residents take their medications. There is a concern for other residents taking unattended medications. The DON said the unit has wanderers who go in and out of other residents' rooms. During an interview on 12/9/25 at 1:28 P.M., the administrator said he/she expected the CMTs to watch the residents take their medications. Staff should report immediately if they find medication that is unattended. The administrator said that unit does have residents that wander. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint 2685059

Based on observation, interview and record review, facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry to prevent the growth of foodborne pathogens. Facility staff failed to ensure two ice machines, used to supply ice to residents, drained through an air gap to prevent cross-contamination. Facility staff failed to store moist cleaning clothes in sanitizing solution between uses to prevent the growth of bacteria and cross-contamination. Facility staff also failed to maintain kitchen equipment and surfaces in two of two kitchens and one kitchenette in a clean sanitary manner to prevent cross-contamination and the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 231. 1. Review of the facility's policy titled Dietary-Sanitary Procedures, revised 11/06/23, showed: -Hand washing is a priority for infection control;-Hands must be washed prior to beginning work, when working with different food substances, and after contact with any unsanitary surface; -The policy directed staff to place enough hand soap or detergent to build a good lather on a fingernail brush and palms of hands, vigorously scrub and lather both hands and then rinse the lather and soap from hands in flowing warm water when they washed their hands. Observations on 12/03/25 at 6:55 A.M., 7:22 A.M., 7:23 A.M., and 7:28 A.M., showed Dietary Aide (DA) NN washed soiled dishes in the mechanical dishwashing station. Observation showed, without performing hand hygiene, the DA then put away sanitized dishes from the clean side of the station. During an interview on 12/03/25 at 7:28 A.M., DA NN said staff should wash their hands after they touch anything dirty. The DA said he/she rinsed his/hands after he/she put the soiled dishes into the machine, and he/she thought that was good enough. The DA said he/she was trained on proper handwashing procedures and proper handwashing includes the use of soap. The DA said he/she got in a hurry. During an interview on 12/03/25 at 7:30 A.M., the dietary manager (DM) said staff should wash their hands between handling dirty and clean dishes. The DM said DA NN had worked at the facility for a year, was trained on proper hand hygiene procedures upon hire, and he/she had provided the DA with multiple reminders since hire. Observation on 12/03/25 at 11:05 A.M., showed [NAME] PP used his/her cellular phone in the kitchen with his/her bare hands and then washed his/her hands at the handwashing sink. Observation showed the cook scrubbed his/her hands with soap under running water for three seconds and after he/she washed his/her hands, he/she set up meal trays for service to residents at the lunch meal. Observation on 12/03/25 at 11:06 A.M., showed DA OO washed his/her hands at the handwashing sink, he/she scrubbed his/her hands with soap for three seconds, rinsed, and then served food to residents in the Main Street dining room. Observation on 12/03/25 11:20 A.M., showed [NAME] PP lifted the trash can lid with his/her bare hands to dispose of trash and then washed his/her hands at the handwashing sink. Observation showed the cook scrubbed his/her hands with soap under running water for three seconds and after he/she washed his/her hands, he/she continued to prepare food for service to residents at the lunch meal. During an interview on 12/04/2025 at 2:03 P.M., the DM said staff should wash their hands after they touch anything dirty, which would include trash can lids, dirty dishes, and personal items like their cellular phones. The DM said when staff wash their hands, they should scrub their hands with soap, out of the running water, for 20 to 30 seconds. The DM said all staff are trained on proper hand hygiene procedures upon hire and at least annually. During an interview on 12/03/25 at 3:00 P.M., the administrator said staff should perform hand hygiene after they touch anything dirty, which would include trash can lids, dirty dishes, and personal items like their cellular phones. The administrator said when staff wash their hands, they should scrub their hands with soap, out of the running water, for 30 seconds and all staff are trained on proper hand hygiene procedures upon hire. 2. Review of the facility's policy titled Dietary-Equipment Operations, Infection Control, and Sanitation Policy, revised 02/02/24, showed the policy directed staff to air dry dishes after they are properly washed and sanitized. Review of the facility's Daily Dietary Checklist/Cleaning Schedules, dated 12/01/25 through 12/03/25, showed the A.M. and P.M. dietary aides are directed to put dishes away clean and dry. Review showed staff did not document they put the dishes away as directed for the dates of 12/01/25 through 12/03/25. Observation on 12/01/25 at 9:54 A.M., showed 11 metal food service pans stacked together wet on the storge rack in the kitchen. Observations on 12/03/25 at 6:55 A.M., showed 24 plastic service trays, eight black dessert plates and five dessert bowls stacked together wet on the storage rack in mechanical dishwashing station. Observation on 12/03/25 at 7:00 A.M., showed DA NN removed sanitized plates from the clean side of the mechanical dishwashing station while wet, stacked them together and placed them in the plate warmer storage cart. Observation showed five additional plates stacked together wet in the plate warmer storage cart. During an interview on 12/03/25 at 7:15 A.M., the DM said staff should allow clean dishes to air dry before they are put away and staff are trained on this requirement. During an interview on 12/04/25 at 3:03 P.M., the administrator said staff should allow clean dishes to air dry before they are put away and staff are trained on this requirement during their orientation to the dietary department. The DM should monitor for this daily. 3. Review of the facility's policy titled Dietary-Equipment Operations, Infection Control, and Sanitation Policy, revised 02/02/24, showed the policy directed staff to see the manufacturer's instructions for operation of ice machines. Review showed the policy did not contain information related to drain air gaps. Observation on 12/03/25 at 8:00 A.M., showed the drain line to the ice machine in the Main Street dining room beverage station ended inside the floor drainpipe and the machine did not contain an air gap to prevent the backflow of sewage and other contaminates into the ice machine. Observation on 12/03/25 at 9:00 A.M., showed the drain line to the ice machine in the 100 hall clean utility room ended inside the floor drainpipe and the machine did not contain an air gap to prevent the backflow of sewage and other contaminates into the ice machine. During an interview on 12/03/25 at 9:00 A.M., the maintenance director said the facility's contracted service company is responsible for the installation and maintenance of the ice machines and he/she did not know ice machines needed to drain through air gaps. During an interview on 12/04/25 at 2:15 P.M., the DM said the ice machines in the Main Street dining beverage station and 100 hall clean utility room are used to supply ice to residents. The DM said the facility's contracted service company and maintenance staff are responsible for the maintenance of the ice machines and ice machines should drain through an air gap to ensure nothing goes into the machine if the drain backs up. The DM said he/she did not know the ice machine drains did not have an air gap. During an interview on 12/04/25 at 3:17 P.M., the administrator said the maintenance director is responsible to ensure the ice machines drain through an air gap and he/she did not know the ice machines did not drain through air gaps. 4. Review of the facility's policy titled Dietary-Equipment Operations, Infection Control, and Sanitation Policy, revised 02/02/24, showed the policy directed staff to store sanitizing cloths in sanitizing buckets, filled with an appropriate sanitizing solution, when not in use. Observation on 12/03/25 from 7:50 A.M. to 8:05 A.M., showed two wet cleaning clothes on the countertop by the sink in the Main Street dining beverage station. Observation showed staff entered and exited the beverage station multiple times. Observation on 12/03/25 from 10:50 A.M. to 12:45 P.M., showed a wet cleaning cloth on the countertop by the food processor as staff prepared food in the area. Observation on 12/04/25 from 2:15 P.M. to 2:30 P.M., showed a wet cleaning cloth on the countertop by the food processor as staff prepared food in the area. During an interview on 12/04/25 at 2:30 P.M., the DM said staff are to store cleaning cloths in buckets of sanitizer when not in use and staff are trained on this requirement. During an interview on 12/04/25 at 3:14 P.M., the administrator said staff should store wet cleaning cloths in buckets of sanitizer between uses and staff are trained on this requirement. 5. Review of the facility's policy titled Dietary-Equipment Operations, Infection Control, and Sanitation policy, revised on 02/02/24, showed: -The dietary staff shall maintain the sanitation of the dietary department through compliance with written, comprehensive cleaning schedules developed for the facility by the dietary manager;-The dietary manager shall record all cleaning and sanitation tasks for the dietary department;-A cleaning schedule shall be posted with tasks designated to specific positions in the department;-All tasks shall be addressed as to the frequency of cleaning; -The dietary employees should complete the tasks assigned for the day and shift and they should check off tasks as they are completed. If the employee does not accomplish a task, they need to communicate with the dietary manager and place the task on the list for the following day;-The policy directed staff to clean and sanitize:*The insides of tray, dish and utility carts after each meal;*The exterior of the dishwasher after each meal and clean the interior and exterior of the machine with de-liming solution weekly;*The exterior of the ice machine daily;*The steamtables after each meal. Review showed the policy directed staff to remove food from the wells when they clean the steamtables;*The floors daily. Review showed the policy directed staff to dust mop or sweep and mop the floors when they clean them; *Walls and ceilings at least twice a year, but heavily soiled surfaces must be cleaned more frequently and as required;*Equipment daily. 6. Review of the facility's Daily Dietary Checklist/Cleaning Schedules, dated 12/01/25 through 12/03/25, showed the record did not include direction to clean the exterior of the mechanical dishwasher. Observations on 12/01/25 at 9:46 A.M. and 12/03/25 at 8:08 A.M., showed a thick accumulation of yellow and white substances dried on the exterior bottom half of the mechanical dishwasher. Observation showed the dried on substances came off the dishwasher when scraped with a fingernail. During an interview on 12/03/25 at 8:09 A.M., the DM said staff are directed to clean the dishwasher daily and delime the dishwasher weekly. The DM said they had not been able to find a product that would remove the calcium and lime deposits from the dishwasher. The DM said he/she did not think about trying to scrape the deposits off the surfaces. 7. Review of the facility's Daily Dietary Checklist/Cleaning Schedules, dated 12/01/25 through 12/03/25, showed the A.M. and P.M. aide is directed to sweep and mop the floors. Review showed staff did not document they swept and mopped the floors in the main kitchen and Main Street dining beverage station for the dates of 12/01/25 through 12/03/25. Review showed the staff who worked in the Tiger Lane kitchen documented they swept and mopped the floors after each meal for the dates of 12/01/25 through 12/03/25. Observations on 12/01/25 at 9:46 A.M. and 12/03/25 at 8:08 A.M., showed a thick accumulation of a white substance dried on the floor beneath the mechanical dishwasher in the main kitchen. Observation showed the dried on substance came off when scraped with a fingernail. During an interview on 12/03/25 at 8:09 A.M., the DM said staff are directed to clean the floors daily. The DM said they had not been able to find a product that would remove the calcium deposits from the floor. The DM said he/she did not think about trying to scrape the deposits off the floor. Observation on 12/03/25 at 7:59 A.M., showed the Main Street dining beverage station contained an excessive accumulation of dirt, trash and food debris on the floor under and around the ice machine and refrigerator and in the cabinet beneath the sink. Observation on 12/03/25 at 8:21 A.M., showed an accumulation of brown and black substances dried along the perimeter of the floor, which extended approximately three to five inches from the baseboards, in the Tiger Lane kitchen. 8. Review of the facility's Daily Dietary Checklist/Cleaning Schedules, dated 12/01/25 through 12/03/25, showed the A.M. and P.M. aide is directed to clean the kitchen doors and to clean the door frames and walls if needed in the main kitchen and to clean the walls in the Tiger Lane kitchen. Review showed staff did not document they cleaned the doors and walls as directed for the dates of 12/01/25 through 12/03/25. Observation on 12/01/25 at 9:46 A.M. and 12/03/25 at 8:09 A.M., showed the wall by the door to the main kitchen's mechanical dishwashing station covered with dried food debris and brown liquid stains. Observations on 12/03/25 at 8:18 A.M., showed an accumulation of dried food debris on the wall behind the steamtable in the Tiger Lane kitchen. Observation also showed an accumulation of black stains, dried liquid stains and food debris on the interior side of the two doors to the kitchen. During an interview on 12/04/25 at 2:21 PM., the DM said the person who scrapes the dishes after meals is responsible to clean the walls daily, but it did not look like they had done so. 9. Observation on 12/01/25 at 9:50 A.M. and 12/03/25 at 8:07 A.M., showed a thick accumulation of dust and debris on the two ceiling vents and the ceiling in the food preparation and service area by the steamtable in the main kitchen. Observation showed debris hung from the side of the left facing vent. Observation on 12/03/25 at 8:18 A.M., showed an accumulation of dirt on the two vents and surrounding ceiling in the Tiger Lane kitchen. During an interview on 12/04/25 at 2:21 P.M., the DM said maintenance staff are responsible to clean vents and ceilings weekly, but they do not clean them unless he/she puts an order in the computerized maintenance portal. The DM said he/she had put in an order for them to be cleaned a while ago and they had not cleaned them yet. During an interview on 12/04/25 at 3:00 P.M., the administrator said maintenance staff are responsible to clean vents monthly and as needed. During an interview on 12/04/25 at 3:55 P.M., the maintenance director said maintenance staff is responsible to clean the vents and ceilings in the kitchens, but there is not a routine schedule to do so, and staff should put a work order in the computerized maintenance portal when maintenance is needed. The maintenance director said the maintenance department has been short staffed, they complete the work orders when they can, and he/she could not recall if he/she received a work order to clean the vents and ceilings in the kitchens. 10. Review of the facility's Daily Dietary Checklist/Cleaning Schedule, dated 12/01/25, showed the A.M. and P.M. cooks are directed to wipe the steamtables after each meal. Review showed staff did not document they cleaned the steamtables in the Main Street dining room as directed on 12/01/25. Observation on 12/01/25 at 10:20 A.M., showed food debris, which included pieces of chicken and green beans, floated in the water of the wells to the steamtable in the Main Street dining room and a slimy white substance on the bottom of the wells. During an interview on 12/04/25 at 2:21 P.M., the DM said serving staff are responsible to clean the steamtables, which would include the removal of any debris in the wells of the steamtable, after each meal. 11. Review of the facility's Daily Dietary Checklist/Cleaning Schedules, dated 12/01/25 through 12/03/25, showed the record did not include direction to clean the ice machines. Observation on 12/03/25 at 7:59 A.M., showed an excessive accumulation of dirt and an unidentifiable red substance on the exterior of all the water lines to the ice machine and on the outlet behind the ice machine in the Main Street dining beverage station. Observation showed the interior surfaces of the ice machine, filled with ice, contained an accumulation of dirt and an unidentifiable black substance. Observation also showed the scoop to dispense the ice hung uncovered from the side of the ice machine in a metal rack. Observation showed brown stains on the scoop and the rack with an accumulation of dust and rust spots. During an interview on 12/03/25 at 9:00 A.M., the maintenance director said the facility's contracted service company is responsible for the maintenance of the ice machines. During an interview on 12/04/25 at 2:15 P.M., the DM said the ice machine in the Main Street dining beverage station is used to supply ice to residents. The DM said the facility's contracted service company and maintenance staff are responsible for the maintenance of the ice machines, but dietary staff should wipe the exterior of the ice machine and ensure the scoop is cleaned daily. The DM said he/she did not know about the condition of the ice machine or that the ice scoop was not stored properly. 12. During an interview on 12/04/25 at 2:21 P.M., the DM said all staff are responsible for cleaning the kitchens daily and are expected to move equipment that can be moved to clean behind and under it. The DM said they have cleaning schedules for staff to follow and document on every day. The DM said some are not completed and some have signed that they completed the tasks but would say they have not done all the tasks. During an interview on 12/04/25 at 3:00 P.M., the administrator said the dietary staff is responsible to clean the kitchens daily, including the doors, walls, floors and equipment. The administrator said staff should follow the cleaning schedules and document the tasks as completed. The DM is responsible to ensure the kitchens are clean and in good repair and that staff have completed the daily cleaning schedules as assigned.

Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease, a serious type of pneumonia (lung infection) caused by Legionella bacteria. Facility staffs' failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 231 with a capacity of 239. 1. Review of the Centers for Medicare and Medicaid Services (CMS), QSO-17-30, dated 06/02/17 and revised 07/06/18, showed:-CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.-Facilities must have water management plans and documentation that, at a minimum, ensure each facility:--Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;--Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit;--Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained;--Maintains compliance with other applicable Federal, State and local requirements; --Note: CMS does not require water cultures for Legionella or other opportunistic water borne pathogens. Testing protocols are at the discretion of the provider. Review of the facility's Identifying and Investigating Legionnaire's Disease policy and procedure, dated 06/06/18, showed facilities must have water management plans and documentation that, at a minimum, ensure each facility:-Conducts a facility risk assessment;-Implements a water management program that includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing;-Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Environmental Water Testing for Legionnaire's Disease policy and procedure, dated 06/06/18, showed testing of the building's hot and cold-water distribution systems must be performed at least quarterly. Review showed water samples from at least five outlets on the hot water system and at least five outlets on the cold-water system should be taken for each quarterly testing cycle. Review of the facility's Building Water System Description, undated, showed:-In warm climates, water pipes that typically carry cold water may reach a temperature that allows for growth of Legionella;-Decorative fountains and devices such as cooling towers and ice machines may contain areas where cold water can be heated to temperatures that allow Legionella to grow;-If hot water is allowed to sit in pipes (stagnation), it might reach a temperature where legionella can grow and could encourage sediment to accumulate or biofilm to form. Review of the facility's Water Management Program documentation showed the documentation did not contain:-A facility specific risk assessment;-Control measures related to identified risk areas;-Corrective actions to take if control measures are not within specified ranges;-Documentation of quarterly water system testing. Observations on 12/02/25 and 12/03/25 during the Life Safety Code tour showed the facility equipped with a cooling tower, multiple ice machines and multiple water sources throughout the facility. Observation showed all water sources were not in regular use. During an interview on 12/04/2025 at 11:57 A.M., the maintenance director said the facility should have a water management plan, but he/she did not know who was responsible for the plan. The maintenance director said any area with hot water would be a risk area. The maintenance director said he/she took a single Legionella water sample twice a year and he/she was unaware of the facility policy directing ten samples quarterly. The maintenance director he/she flushed water heaters twice a year but did not document the flushes. The maintenance director said he/she cleaned the facility cooling tower but did not document the cleaning. The maintenance director said he/she was not aware of any facility specific water management policies related to control measures or corrective actions. During an interview on 12/04/2025 at 4:13 P.M., the administrator said the facility water management program should include monitoring water temperatures, risk areas, Legionella sample testing and corrective measures for any issues identified. The administrator said he/she was not familiar with facility specific water sampling procedures or control measures. The administrator said he/she was not aware the water management program did not contain facility specific control measures or corrective actions.

Based on observation, interview, and record review, facility staff failed to maintain resident dignity, when residents were required to line up for medication administration outside of the nurse's station door, and required two residents to communicate with staff through a three-inch hole in the enclosed nurse's station glass. Additionally, residents were required to stand in line to get their meal trays and were unable to eat in the dining room due to lack of chairs. The facility census was 231. Review of the facility's policy titled, Resident Rights, dated 07/5/23, showed each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality including privacy in treatment. Review of the facility's policy titled Promoting/Maintaining Resident Dignity, dated 09/21/25, showed every resident has a right to be treated with dignity and respect. All staff will speak to and treat all residents with dignity and respect. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 1. Observation on 12/2/25 at 8:33 A.M., showed Certified Medication Technician (CMT) CC in the enclosed nurse's station at the medication cart. The CMT had pre-popped 18 cups of medications. Residents stood in a line at the closed nurse's station door to receive their medications. CMT CC would take one pill cup off the medication cart at a time, open the nurse's station door, hand the medication cup to the resident at the front of the line, close the door to the nurse's station and return to the medication cart. Resident Care Coordinator (RCC) HH went in and out of the nurse's station door during the medication administration. 2. Observation on 12/2/25 at 10:25 A.M., showed CMT CC and RCC HH in the enclosed nurse's station with the door closed. An unidentified resident bent over to talk to the CMT through an approximately three-inch circular hole in the plexiglass, at the front of the nurse's station. The resident stuck his/her ear to the hole in the glass to hear the CMTs responses to his/her questions. Observation on 12/3/25 at 12:06 P.M., showed CMT CC sat in the enclosed nurse's station with Resident #89 bent over at the waist to talk to him/her through the small circular hole in the plexiglass. During an interview on 12/2/25 at 10:29 A.M., Resident #58 said the residents having to talk to staff through the hole at the nurse's station, That is pretty much jail. During an interview on 12/2/25 at 11:12 A.M., Resident #165 said the nurse's station was completely closed in with glass and they must talk to staff through a small hole. The resident said he/she has been in other nursing homes and those homes do not have enclosed nurse's stations. The resident said, It is not homelike, to be honest it is more prison like. During an interview on 12/8/25 at 11:55 A.M., Nursing Assistant (NA) A W said residents talking through the hole at the nurse's station is not dignified. During an interview on 12/8/25 at 12:46 P.M., CMT C said it is not dignified for residents to have to speak to nursing staff through the small hole on the nurse's station glass. During an interview on 12/8/25 at 2:44 P.M., RCC HH said it's not dignified for staff to talk to resident through hole in nurse's station glass. 3. During an interview on 12/8/25 at 4:29 P.M., the Director of Nursing (DON) said it not dignified for residents to have to talk through hole in nurse's station to staff. The DON said staff should not be passing resident's medications from the nurse's station. During an interview on 12/9/25 at 1:28 P.M., the administrator said it is not dignified for residents to talk through the hole in the nurse's station glass. He/She said staff should not be administering medications from behind the nurse's station. 4. Observation on 12/3/25 at 12:17 P.M., showed six unidentified residents stood in a line in the Tiger Lane dining room as they waited for staff to serve their lunch trays from a kitchen window. There were not any staff in the dining room to serve the residents at the tables. Observation on 12/3/25 at 12:29 P.M. showed six unidentified residents in the Tiger Lane dining room stood in a line waiting for food. During an interview on 12/3/25 at 12:39 P.M., Resident #216 said there is not enough chairs in the Tiger Lane dining room for staff to serve residents during meals and that was why they must wait in line. The resident said even if there were enough chairs there are not enough staff to serve the residents at the dining room tables. Observation on 12/4/25 at 12:14 P.M., showed Residents # 72, #183, #216, and seven unidentified residents stood in a line in the Tiger Lane dining room as they waited for staff to serve their lunch trays from the kitchen window. Further observation at 12:40 P.M., showed the same 10 residents continued to stand in a line at the kitchen window, waiting to be served lunch. During an interview on 12/4/25 at 12:42 P.M., Resident #183 said it bothers him/her to stand in line for food, he/she would rather be served at the table, but there are not enough chairs in the dining room. He/She said it was frustrating standing in line, and it puts everyone in a mood. He/She said sometimes they wait a long time in line before they are given their tray. During an interview on 12/4/25 at 12:44 P.M., Resident #72 said there was not enough chairs in the dining room. The resident said he/she can't even sit down and wait for his/her food. Observation on 12/5/25 at 11:50 A.M., showed 44 residents on Tiger Lane and showed nine dining room chairs in the Tiger Lane dining room. During an interview on 12/8/25 at 11:55 A.M., NA W said residents having to stand in line to get their food was not dignified. During an interview on 12/5/25 at 12:14 P.M., NA I said he/she does not think it is dignified to have residents stand in line to get their food, it was just easier to have the residents stand in line than to serve them. During an interview on 12/8/25 at 12:46 P.M., CMT C said some residents prefer to sit at a table and be served their food. The CMT said the facility used to serve all the residents at the tables. CMT C said residents shouldn't have to line up to get their meals but said it would take at least two staff to serve the residents, and they don't have enough staff to do that. During an interview on 12/8/2025 at 2:44 P.M., RCC HH said all the residents stand in a line to get their food and since he/she started this past February, there has always been a lack of chairs in the dining room. The RCC said some residents will pull up chairs, because they can't stand in that line that long. During an interview on 12/8/25 at 4:29 P.M., the DON said he/she thinks the residents prefer standing in line because they get their food faster. The DON said the facility would have to order more chairs, and the dietary department would need to send staff to assist, for residents to be able to sit and be served. During an interview on 12/9/25 at 1:28 P.M., the administrator said residents should not have to stand in line, it should be a choice for them, if they wanted to go get their tray. The administrator said staff should serve residents, if the residents want to sit down. The administrator said the facility would have to get more staff down there to serve the residents at the tables.

Based on observation, interview, and record review, facility staff failed to provide reasonable accommodations for residents when they failed to provide sufficient dining room chairs in four dining rooms to ensure residents were able to sit down and eat their meals. The facility census was 231. Review of the facility's policy titled Promoting/Maintaining Resident Dignity, dated 09/21/25, showed each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. 1.Observation on 12/2/25 at 11:15 A.M., showed 17 residents residing on the Tiger Medical Unit. The dining room contained two tables and three chairs. Observation on 12/3/25 at 12:47 P.M., showed the Tiger Medical Unit dining room with three tables and one chair at each table occupied. Observation showed dietary staff delivered a cart with lunch trays. Observation showed Resident #149 stood in the hallway with his/her food tray in one hand and ate his/her meal because there were no available chairs. Observation showed Resident #133 left the dining room table and Resident #74 sat down. Observation showed Resident #165 placed his/her lunch tray at the end of an occupied table and stood to eat because there were no available chairs. Observation on 12/4/25 at 12:37 P.M., showed the Tiger Medical Unit dining room with three tables and one chair at each table occupied. Observation showed Resident #74 placed his/her lunch tray at a dining room table and ate as he/she stood because there were no available chairs. During an interview on 12/3/25 at 12:39 P.M., Resident #216 said there was not enough chairs in the Tiger Lane dining room, and he/she thinks it's because residents take the chairs to their rooms. Observation on 12/5/25 at 11:50 A.M., showed 44 residents on Tiger Lane and showed nine dining room chairs in the Tiger Lane dining room. During an interview on 12/5/25 at 12:03 P.M., Resident #19 said there are not a lot of chairs in the Tiger Lane dining room. He/She likes to eat in the dining room, but there are not always enough chairs. During an interview on 12/5/25 at 11:46 A.M., Resident #115 said he/she would like more chairs in the Tiger Lane dining room. He/She used a wheelchair and would like to transfer from his/her wheelchair into a regular dining room chair to eat, but there were not enough chairs. During an interview on 12/5/25 at 11:52 A.M., Resident #195 said he/she eats in his/her room due to the lack of chairs in the Tiger Lane dining room. During an interview on 12/5/25 at 12:08 P.M., Resident #171 said the lack of chairs in the Tiger Lane dining room was a problem and he/she had seen residents standing to eat. Resident #171 said he/she usually ate in his/her room, but if the dining room had more chairs, he/she could eat in the dining room. He/she said it was not an option now. During an interview on 12/5/25 at 12:14 P.M., nursing assistant (NA) I said there are only three dining room chairs in the Tiger Medical dining room, because residents take the chairs to their rooms. The NA said it was not dignified for residents to have to stand and eat. Observation on 12/5/25 at 12:20 P.M., showed all nine dining room chairs occupied and all other residents carried their meal tray to their rooms. During an interview on 12/8/25 at 12:05 P.M., NA D said he/she noticed only three chairs in the Tiger Medical dining room, he/she does not know where the chairs are going, and he/she has not reported the missing chairs to anyone. The NA said he/she could use a few extra chairs for residents to eat. During an interview on 12/8/25 at 12:45 P.M., CMT C said some of the dining room chairs in Tiger Lane and Tiger Medical were broken and he/she thought the facility was supposed to be ordering more chairs but said that was around three to four months ago. 2. Observation on 12/8/25 at 1:41 P.M., showed seven chairs in the men's behavioral dining room. During an interview on 12/8/25 at 1:42 P.M., certified nursing assistant (CNA) DD said there are only seven chairs on the men's unit for 20 residents, he/she said because there are not enough chairs it causes residents to not eat, or they go to their room to eat, and it causes cleanliness issues. 3. Observation on 12/8/25 at 1:43 P.M., showed five chairs in the women's behavioral dining room. During an interview on 12/8/25 at 1:43 P.M., CNA T said there are five chairs in the women's dining room with 16 residents. He/She said there are not enough chairs and sometimes the residents are upset because they all want to eat together. 4. During an interview on 12/8/25 at 2:44 P.M., residential care coordinator (RCC) HH said there always has been a lack of chairs in the dining rooms, at least since he/she started in February. The RCC said occasionally residents have said things about not getting to sit in the dining room, because there aren't enough chairs. The RCC said sometimes he/she has seen residents stand and eat, the residents will put their tray on a table and stand, due to a lack of chairs. RCC HH said he/she thought the facility ordered more chairs a few months ago and doesn't know why they have not arrived. During an interview on 12/8/25 at 4:29 P.M., the director of nursing (DON) said property damage by residents is probably a big part of not having many chairs. The DON said he/she was not aware; residents were standing to eat. The DON said it is not dignified for the residents to stand and eat. He/She said the residents should be able to sit down and eat their meals. The DON said he/she believes the administrator has put in an order, but it has not been approved. During an interview on 12/9/25 at 1:28 P.M., the administrator said a lot of chairs have been broken, and he/she put in a capital expense request for new chairs around four to five months ago and had it had not been approved yet. The administrator said it is not dignified for residents to have to stand and eat.

Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to clean and maintain resident room and common area walls, doors, windows, floors, toilets, air conditioning (A/C) units, bathroom vents, and furniture. Facility staff failed to ensure residents had access to clean clothes and linens in a timely manner and failed to assist residents with laundry as needed. The facility census was 231 with a capacity of 239. 1.Review of the facility policy titled Safe and Homelike Environment Policy, dated 06/5/24, showed the facility will provide a safe, clean, comfortable and homelike environment. The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment. The facility will provide and maintain bed and bath linens that are clean and in good condition, the facility will provide sufficient individual closet space in each resident room. General considerations include to minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department; report any furniture in disrepair to Maintenance promptly; and report any unresolved environmental concerns to the Administrator. Review of the facility policy titled Housekeeping - Deep Cleaning, dated 06/29/23, showed deep cleaning is to be completed as scheduled, this includes complete pull outs of furniture in rooms, wall cleaning, floor cleaning (scrubbing and waxing included), restrooms to be cleaned and disinfected, cob webs removed, beds and rails to be cleaned, sprinkler heads to be cleaned, windows to be cleaned. All areas should be monitored daily, and all resident living areas and non-living areas should be clean and odor free. Daily cleaning includes dust mop or sweep floor; surfaces are to be cleaned including wall smudges, side tables, and windows; and clean shower rooms inside the shower, around the shower, and the base boards in the room. All resident rooms will be deep cleaned once monthly or more often if needed, as in the case of heavy care rooms. Bathroom floors will be swept and mopped, and any dirt, grime or stains will be hand scrubbed with stiff brush or other equipment suitable for removing surface dirty from the entire floor; if the stain is not removable then housekeeper will notify Maintenance department with a Maintenance Request Form; and necessary wall washing to remove smudges and spots will be done with disinfectant cleaner. Review of the facility's policy titled Exhaust Fan Maintenance, revised 02/3/25, showed maintenance is responsible for repair and testing of the ventilation systems. Maintenance employees shall inspect the ventilation system including the vent covers, ductwork and fan operation during quarterly preventive maintenance room audits. Observation on 12/2/25 and 12/3/25 during the Life Safety Code tour showed:-Bathrooms adjacent to resident rooms 104, 408, 417, 424, and 505 did not contain covers to the bathroom exhaust fans;-Bathrooms adjacent to resident rooms 122, 129, 412, and 518 did not contain toilet tank lids;-The bathroom adjacent to resident room [ROOM NUMBER] contained a bowed ceiling tile and a two- and one-half inch gap which exposed the space above the ceiling;-The bathroom adjacent to resident room [ROOM NUMBER] contained a bowed ceiling tile and a four-inch gap which exposed the space above the ceiling;-Resident room [ROOM NUMBER] had large holes in the wall which exposed the wall cavity;-The bathroom adjacent to resident room [ROOM NUMBER] had a rusted baseboard heater;-The corridor handrails near resident rooms 102, 412 and 415 were missing end caps, which exposed sharp metal edges;-Resident room [ROOM NUMBER] was missing hallway door trim; -Resident room [ROOM NUMBER] had torn bathroom door trim and the bathroom door did not contain a doorknob; -Resident room [ROOM NUMBER] contained a broken hallway door frame which caused the door to stick which prevented the door from latching; -Resident room [ROOM NUMBER] was missing hallway door trim on the left side of the door. During an interview on 12/4/25 at 11:57 A.M., the maintenance director said all staff, residents, and visitors can enter work orders when issues are identified. Facility staff completed 99 work orders this week and they still have 25 open work orders. He/She was not aware of every wall issue since they were so frequent. He/She was not aware of the missing handrail end caps. The maintenance director said toilet tanks should have lids, and he/she was not sure why they were missing. He/She needed more staff to keep up with building maintenance and repairs. Observation on 12/01/25 at 11:40 A.M., showed the following around the Tiger Lane dining and nurse's station areas: -Exterior exit door missing paint and covered in dirt and debris;-Handrails in the dining room between columns have peeled and missing paint on four handrails;-Missing base trim and exposed unpainted drywall; -Missing paint and drywall on corners of columns and metal brackets on corners of columns exposed; -Four drywall patches on dining room walls, sanded and not painted;-A/C wall unit had broken vents, covered in thick dirt and debris, and missing trim around unit; -500 Hall nurses station missing paint and drywall on corners, one large drywall patch, unpainted;-Door to the vending machine room with a crack across the bottom of the door. Observation on 12/1/25 at 11:42 A.M., showed the handrails by resident rooms [ROOM NUMBERS] with chipped and missing paint. Observation on 12/1/25 at 11:58 A.M., showed the Tiger Lane hallway light fixture by the dry utility room without a cover. Observation on 12/1/25 at 12:47 P.M., showed resident occupied room [ROOM NUMBER] with the bed not made, belongings piled on the bed and on the floor under the bed, a laundry basket, and an open box of prepackaged noodles. Observation on 12/2/25 at 9:09 A.M., showed resident occupied room [ROOM NUMBER] in the same condition, bed was not made, personal belongings piled on the bed and on the floor under the bed, and an open box of prepackaged noodles. Observation on 12/1/25 at 12:49 P.M., showed resident occupied room [ROOM NUMBER] with a rolled-up, stained blanket in front of the dresser by the sink and under the sink; missing/damaged floor tiles under the sink, and the nightstand between the resident beds had the two top drawers broken. Observation on 12/1/25 at 12:52 P.M., showed resident occupied room [ROOM NUMBER]'s bathroom with a brown stain and water leakage around the base of the toilet. During an interview on 12/1/25 at 12:52 P.M., the resident said his/her toilet had been leaking for a month. Staff were aware and it had not been fixed yet. It was not sanitary and posed a fall risk. Observation on 12/3/25 at 3:46 P.M., showed resident occupied room [ROOM NUMBER]'s bathroom with a brown stain and water leakage around the base of the toilet. Observation on 12/4/25 at 9:05 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom with a brown stain and water leakage around the base of the toilet. During an interview on 12/5/25 at 11:27 A.M., housekeeper BB said he/she had not noticed the resident's toilet leaking in room [ROOM NUMBER] and said it did not appear to be leaking when he/she cleaned the bathroom. Housekeeper BB said if he/she had noticed it leaking he/she would notify maintenance to repair it because it could be a fall risk to residents. Observation on 12/1/25 at 12:53 P.M., showed the dresser in resident occupied room [ROOM NUMBER] A missing the front of the top drawer and exposed nails. The floor was dirty with scattered trash. Observation on 12/01/25 at 12:54 P.M., showed a strong odor of urine when entering the Tiger Medical unit. Observation showed the handrails on both sides of the hall on Tiger Medical unit with missing paint and two large drywall patches on the wall between resident rooms [ROOM NUMBERS] that were not sanded or painted. Observation on 12/01/25 at 12:59 P.M., showed 13 cracked tiles in the Tiger Medical dining room floor and showed the A/C unit had broken vents and the A/C unit cover hanging forward of off the unit. Observation on 12/01/25 at 1:00 P.M., showed resident occupied room [ROOM NUMBER] had debris scattered around the bed and a dark substance on the floor in front of and went under the bed. Observation on 12/02/25 at 2:30 P.M., showed resident occupied room [ROOM NUMBER] with debris scattered around the bed and a dark substance on the floor in front of and went under the bed. Observation on 12/03/25 at 9:38 A.M., showed resident occupied room [ROOM NUMBER] with debris scattered around the bed and a dark substance on the floor in front of and went under the bed. Observation on 12/04/25 at 2:40 P.M., showed resident occupied room [ROOM NUMBER] with debris scattered around the bed and a dark substance on the floor in front of and went under the bed. Observation on 12/05/25 at 11:42 A.M., showed resident occupied room [ROOM NUMBER] with debris scattered around the bed and a dark substance on the floor in front of and went under the bed. Observation on 12/01/25 at 1:04 P.M., of resident occupied room [ROOM NUMBER] showed bed B missing a mattress and the wire frame exposed with visible rust. Further observation showed unpainted drywall patches on the wall next to the room sink, damaged drywall at bed height across the back of the wall where the beds are located along the length of the wall. The left side window of the double window had three screws through the window frame and unable to open the window, and the screen was missing; the right-side window was cracked open, unable to be fully closed, with a torn screen on the bottom edge; with a few leaves on the inside of window frame. Also on the wall near bed A was large letters scribbled on the wall spelling Howdy with a brown and black waxy like substance. Observation on 12/02/25 at 9:27 A.M., showed resident occupied room [ROOM NUMBER] remained without a mattress on bed B, left side window remained screwed shut with missing window screen; right side window remained cracked open along bottom edge, unable to shut with moderate amount of force. During an interview on 12/8/25 at 12:53 P.M., Licensed Practical Nurse (LPN) E said he/she did not notice the windows in room [ROOM NUMBER] and tried to report an issue when he/she sees it. LPN E said he/she was not sure how long the unoccupied bed did not have a mattress. During an interview on 12/8/25 at 1:04 P.M., Certified Nurse Aide (CNA) H said he/she did not notice the window in room [ROOM NUMBER], he/she tries to report every concern he/she sees and was not sure how long the bed has not had a mattress. Observation on 12/01/25 at 1:05 P.M., showed resident occupied room [ROOM NUMBER] with debris on the floor and in the windowsills. The floors and walls have a dark substance on them and the sheets and bedding were dirty. Observation on 12/02/25 at 2:40 P.M., showed resident occupied room [ROOM NUMBER] with the same debris on the floor and in the windowsills. Resident bed A's floor and wall had a dark substance splattered on it and dirty linens on the bed. Observation on 12/03/25 at 9:45 A.M., showed resident occupied room [ROOM NUMBER] with the same debris on the floor and resident bed A's floor and wall had a dark substance splattered on it and dirty linens on the bed. Observation on 12/04/25 at 2:50 P.M., showed resident occupied room [ROOM NUMBER] with the same debris on the floor and resident bed A's floor and wall had a dark substance splattered on it and dirty linens on the bed. Observation on 12/05/25 at 11:50 A.M., showed resident occupied room [ROOM NUMBER] with the same debris on the floor and resident bed A's floor and wall had a dark substance splattered on it and dirty linens on the bed. During an interview on 12/05/25 at 11:53 A.M., the resident said the toilet has been broken for about a week. Staff have been in and out of the room looking at the toilet all week and was unsure what the dirty linens are on the bathroom floor. He/She was unsure how they got there and who was supposed to take care of them. Observation on 12/01/25 at 1:06 P.M., showed a large area of peeled paint that exposed the drywall by the emergency eye wash kit at the end of the 400 hall. Observation on 12/01/25 at 1:25 P.M., showed resident occupied room [ROOM NUMBER]'s bathroom showed the vent without a cover and approximately three sheets of toilet paper in the vent. Observation on 12/05/25 at 9:43 A.M., showed the floor in resident occupied room [ROOM NUMBER] dirty with debris. Observation on 12/01/25 at 1:30 P.M., showed the bathroom in room [ROOM NUMBER] with the vent uncovered and showed the bathroom floor dirty with a black substance in front of the toilet. Observation on 12/01/25 at 1:32 P.M., showed occupied room [ROOM NUMBER] B with a dirty and stained privacy curtain. Observation showed the headboard attached to the resident's bed broken and without approximately one-fourth of the headboard. Observation on 12/01/25 at 1:38 P.M., showed a crack in the oxygen storage room door by room [ROOM NUMBER]. Observation on 12/01/25 at 2:15 P.M., showed resident occupied room [ROOM NUMBER]'s bathroom floor with brownish stains on the left side of the toilet. Observation showed a black substance around the base of the toilet, and a flat piece of wood stuck out from under the toilet. Further observation showed cracked, chipped, and stained floor tiles along the baseboard and underneath the resident's bed. Observation on 12/01/25 at 2:20 P.M., showed the inner door frame of resident occupied room [ROOM NUMBER] had missing trim that exposed the space between the door frame and dry wall. The bathroom floor had a chipped tile in front of the toilet and one missing tile two tiles away from the front of the toilet. Observation on 12/01/25 at 2:25 P.M., showed resident occupied room [ROOM NUMBER] with approximately three feet of missing paint on the wall. The bathroom floor had a black substance on the floor tiles close to the toilet. Observation on 12/01/25 at 3:22 P.M., showed resident occupied room [ROOM NUMBER] with bed frame A with a thick layer of dirt and debris. Observation on 12/03/25 at 7:40 P.M., showed resident occupied room [ROOM NUMBER] A with two large pieces of feces and urine on the floor in front of the resident's dresser and showed areas of feces on the front of the dresser. Observation on 12/03/25 at 8:07 P.M., showed two large pieces of feces remained on the floor in resident occupied room [ROOM NUMBER] visible from the hallway. Further observation showed certified medication technician (CMT) C walked into Tiger Lane Medical and tried to get the resident back into his/her room, but did not do anything to address the two large pieces of feces on the resident's floor. Observation on 12/03/25 at 8:40 P.M., showed two large pieces of feces remained on the floor in resident room [ROOM NUMBER] visible from the hallway. Observation on 12/04/25 at 8:35 A.M., showed resident room [ROOM NUMBER] room smelled of urine and the floor was sticky and had a brown outline of where the feces had been. Dried feces remained on the front of the resident's dresser. Observation on 12/02/25 at 8:48 A.M., showed resident occupied room [ROOM NUMBER] with a brown substance splattered on the window blinds and showed the floors around the baseboard trim with a black thick unknown substance. The bathroom door had gouges and the A/C unit was covered in dirt and debris. The bathroom had missing baseboards that exposed damaged drywall. During an interview on 12/02/25 at 8:52 A.M., the resident said he/she was not sure how often housekeeping cleans his/her room and said the floors are stained. Maintenance was very limited on the time they had to fix holes in the walls, as they have a lot of stuff to fix on other halls in the facility. Observation on 12/02/25 at 9:05 A.M., showed resident occupied room [ROOM NUMBER] had unpainted patched drywall under the bathroom vent. Observation on 12/02/25 at 9:11 A.M., showed resident occupied room [ROOM NUMBER] had food debris and dirt in the middle of the room and under bed A. Observation on 12/02/25 at 9:30 A.M., showed resident occupied room [ROOM NUMBER] A had brown splatter on the walls around the bed and showed dirt and debris on the floors. Observation showed damage to the drywall by the bed's headboard, a buildup of black grime around the rubber of the baseboard trim and showed white splatter on the privacy curtain. Observation on 12/02/25 at 10:29 A.M., showed the shower room on Tiger Lane with a black unknown substance scattered on the ceiling. Further observation showed the walk-in shower had a thick black unknown substance on the tile along the base boards. During an interview on 12/08/25 at 3:49 P.M., the environmental supervisor said the facility previously had issues with mold build up in the Tiger Lane shower room and had painted the ceiling at that time but recently noticed the areas on the ceiling coming back. Observation on 12/02/25 at 10:35 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom vent had a large accumulation of dust. Observation on 12/02/25 at 2:33 P.M., showed a resident on Tiger Lane medical urinated on the floor, pulled his/her pant leg up and dropped feces on the floor. Observation showed housekeeper M came to the unit picked up the feces and did not clean up the urine or mop/sanitize the floor where the feces was. Observation on 12/02/25 at 2:35 P.M., showed resident occupied room [ROOM NUMBER] had a broken dirty toilet and dirty linens on the bathroom floor. Resident bed C had clothes and shoes all over his/her floor around the bed, and a plate of food on the bed side table. Observation on 12/03/25 at 9:40 A.M., showed resident occupied room [ROOM NUMBER]'s toilet consistently running and had dirty linens on the bathroom floor. Resident bed C had clothes and shoes all over his/her floor around the bed and a plate of food on the bed side table. Observation on 12/04/25 at 2:45 P.M., showed resident occupied room [ROOM NUMBER] had dirty linens on the bathroom floor. Resident bed C had clothes and shoes all over his/her floor around the bed and a plate of food on the bed side table. Observation on 12/05/25 at 11:46 A.M., showed resident occupied room [ROOM NUMBER] had dirty linens on the bathroom floor. Resident bed C had clothes and shoes all over his/her floor around the bed and a plate of food on the bed side table. During an interview on 12/05/25 at 11:53 A.M., the resident said the toilet has been broken for about a week. Staff had been in and out of the room looking at the toilet all week and was unsure what the dirty linens are on the bathroom floor. The resident said he/she doesn't know why the staff haven't picked them up. The resident said it was his/her responsibility to keep things picked up in his/her own space. During an interview on 12/05/25 at 11:55 A.M., Certified Medication Technician (CMT) LL said there was only one staff member on the unit. The residents do all their own cleaning, sweeping, mopping and linen changes. CMT LL said staff should encourage residents to do these things and help if needed. CMT LL said residents are told to aim for having these things done by 10 o'clock in the morning so they have the rest of the day free. The CMT said he/she is unsure if room checks are done but thinks maybe the upper management might do it. Observation on 12/02/25 at 3:10 P.M., showed the floor in resident occupied room [ROOM NUMBER] dirty with dirt and debris. Observation on 12/02/25 at 3:13 P.M., showed the Tiger Lane hallway floor by room [ROOM NUMBER] and room [ROOM NUMBER] with various black stains. Observation on 12/02/25 at 2:46 P.M., showed resident occupied room [ROOM NUMBER]'s right side of the bathroom door frame was missing trim and had exposed nails between the door frame and drywall and the bathroom door handle was missing. Observation showed the floor was dirty with dirt and debris and showed the A/C unit covered in dirt and debris. The tiles around the toilet were stained and discolored and had missing caulk around base of the toilet. The window did not have blinds and showed the resident's bedsheet was stained and had brown debris. Observation on 12/03/25 at 11:20 A.M., showed the floor in resident occupied room [ROOM NUMBER] was dirty and had dirt and debris and had brown splatter on the walls around the resident's bed and door. Observation on 12/04/25 at 8:40 A.M., showed the floor in occupied room [ROOM NUMBER] was sticky and covered with dirt and debris. During an interview on 12/02/25 at 2:50 P.M., the resident said his/her bathroom door had been like that for approximately three months when he/she first moved into the room. Observation on 12/03/25 at 11:12 A.M., showed the Tiger Medical hallway light fixture by room [ROOM NUMBER] without a cover. Observation on 12/04/25 at 11:53 A.M., showed resident occupied room [ROOM NUMBER] with a broken PTAC unit and showed it would not turn on, and the PTAC vents were covered in dirt and debris. During an interview on 12/04/25 at 11:55 A.M., the resident said his/her PTAC unit did not work and it had not worked for over a week. He/She did not want to be cold and said all he/she had to keep warm was his/her blanket. He/She told staff the PTAC unit was not working but could not remember which staff he/she told. Observation on 12/04/25 at 12:23 P.M., showed the outlet on the right side of the Tiger Lane kitchen service window did not have a cover and a light switch in the Tiger Lane dining room did not have a cover. Observation on 12/05/25 at 9:10 A.M., showed the double windows in the 100-hall dining room leaked cold air. The frame of the double windows was screwed into the window casing; a sheet of glass was attached/glued by a white substance to the window frame. Observation on 12/05/25 at 9:40 A.M., showed the privacy curtain in resident occupied room [ROOM NUMBER] B with various brownish stains. Observation on 12/08/25 at 1:38 P.M., showed multiple ceiling tiles in the hallway near rooms [ROOM NUMBERS] with small to large brown stains and some areas of the tiles were missing and the corners of the tiles appeared torn, with the brown core exposed. During an interview on 12/08/25 at 12:05 P.M., nursing assistant (NA) D said the resident rooms on Tiger Medical were not in good condition because residents tear up their rooms to get back at staff if they don't feel like staff are treating them well. NA D said staff can get on the radio and request extra cleaning for resident rooms and said there was scheduled deep clean days. The NA said there are Quick Response Codes (QR Code - a matrix barcode sorting data like URLs (Uniform Resource Locator -a web address that functions like a physical address) on the back of doors to resident rooms that staff can scan for maintenance requests. During an interview on 12/08/25 at 12:31 P.M., housekeeper KK said housekeeping staff are assigned to a hall to clean every day and said they are expected to clean the resident's toilets, sinks, floors, change linens, and whatever else is needed. The housekeeper said the housekeeping department had been short staffed for a while, but they now have five housekeepers, although they are supposed to have six, and said most of the housekeeping staff are new. During an interview on 12/08/25 at 12:46 P.M., CMT C said the facility has been short housekeepers and maintenance is not doing anything. There was a form on the computer for staff to fill out for maintenance requests. The housekeeping supervisor was on leave the last few months and the housekeeping went downhill. CMT C said sometimes residents urinate on the floors. During an interview on 12/8/25 at 12:53 P.M., LPN E, said for any maintenance concerns he/she calls the maintenance director directly. A few months ago the facility started using a code he/she had to scan with his/her personal phone, and he/she does not like to do that, so he/she will just call. There used to be a maintenance book staff could put requests in, but they do not have that anymore. He/She did not notice the windows in room [ROOM NUMBER] and tries to report an issue when he/she sees it. He/She will also notify housekeeping if there is something that needs to be cleaned, but sometimes he/she is focused on caring for residents and does not notice. During an interview on 12/8/25 at 1:04 P.M., CNA H said there is a QR code that he/she must scan with his/her personal phone to submit a maintenance request. He/she said there used to be a maintenance book but switched to the QR code a couple of months ago. He/she does not like using his/her personal phone as they are not supposed to be on their phones while working and if someone does not have a smart phone, they can't scan it. He/She did not notice the window in room [ROOM NUMBER] and he/she tries to report every concern he/she sees. Staff will fix things, but then it gets broken again. Sometimes he/she is focused on resident care and may not notice things. CNA H said rooms should be clean and in good repair because it is the residents' home. During an interview on 12/8/25 at 2:44 P.M., Residential Care Coordinator (RCC) HH said there has been a lack of housekeepers. If an NA sees a room not cleaned appropriately, they can come to him/her and he/she would go to the environmental supervisor. The RCC said the NA's also know where to find the cleaning supplies. During an interview on 12/8/25 at 3:48 P.M., the environmental supervisor said he/she had been on leave the last few months and supervising the housekeepers was an issue. He/She expects the housekeeping staff to thoroughly clean all resident rooms and common areas and said each housekeeping staff is supposed to deep clean one resident room each day. Maintenance staff are responsible to clean and maintain A/C units and said he/she has noticed how dirty some of them are. During an interview on 12/9/25 at 1:28 P.M., the administrator said the housekeeps call in, and there is a lot of turnover which makes it difficult to adequately train new staff. They had a period when the housekeeping supervisor was on leave, and they were all trying to cover his/her position. If staff finds things that need to be fixed, they are supposed to put in work orders and maintenance is supposed to follow up with those orders. He/She was not sure why staff are doing that. The facility was also down a maintenance staff and he/she does not have an answer for why staff are not putting in work orders. The administrator said he/she is responsible to make sure maintenance is maintaining the building and said they do a weekly environmental round and go in each room. Maintenance is responsible for cleaning the air conditioners and should check the units monthly and at a minimum twice a year. During an interview on 12/17/25 at 11:22 A.M., the maintenance director said staff members and residents can use the QR code in the rooms to report maintenance issues. Maintenance staff is responsible to sand and repaint repaired areas, but it's been difficult to keep up due to not enough maintenance staff. Maintenance staff is responsible to clean and maintain the air conditioning units and said the units are cleaned at least annually and typically in nicer weather. He/She had replaced a lot of floor tiles in the last few months, but didn't realize there were more areas that were chipped and broken. Covers should be on all the overhead light fixtures and said all the outlets and light switches should have covers. Maintenance is also responsible to address broken furniture and he/she was not aware there were broken headboards or dressers. He/She was not aware of any resident rooms with missing door trim and said he/she expects staff to report these issues because he/she has a stock of materials and supplies on hand for these issues. 2. Review of the facility's policy titled Handling Clean and Dirty Linen Policy, dated 06/26/24, showed it is the policy of the facility to handle, store, process and transport clean and soiled linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Linen can become contaminated with pathogens from contact with intact skin, body substances, or from environmental contaminants. Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons; and used or soiled linen shall be collected at the bedside (or point of use, such as dining room) and placed in a linen bag or designated lined receptacle. Soiled linen shall not be kept in the resident's room or bathroom. Observation on 12/02/25 at 3:03 P.M., showed a medium sized pile of clothes in the corner of Resident #19's room. During an interview on 12/02/25 at 3:05 P.M., Resident #19 said the washer on the Tiger Lane unit has been broken for a while and staff did not get clean clothes back to the residents timely. The resident said he/she currently did not have any clean pants, underwear, or socks. During an interview on 12/08/25 at 12:03 P.M., Resident #19 said it can take around two to three weeks to get clean clothes back from laundry. He/She said he/she did not have enough clothes to wait that long, so he/she has had to wear dirty clothes. Observation on 12/02/25 at 10:20 A.M., showed a large pile of cloths on the floor by Resident #26's bed and showed the resident's bed without a bed sheet or a pillowcase on the pillow. During an interview on 12/02/25 at 10:22 A.M., Resident #26 said if his/her bed sheet gets dirty he/she was supposed to go get a clean one from the linen closet but said there was usually not any clean sheets available. He/She would like to sleep with a bed sheet and pillowcase. Observation on 12/03/25 at 10:57 A.M., showed a large pile of clothes on the floor by Resident #26's bed and showed the resident's bed without a bed sheet and without a pillowcase. Observation on 12/05/25 at 9:43 A.M., showed a large pile of clothes on the floor by Resident #26's bed and showed the resident without a bed sheet and without a pillowcase. During an interview on 12/05/25 at 9:45 A.M., Resident #26 said he/she did not know what to do with his/her dirty laundry and said he/she was tired of wearing dirty clothes. He/She has not had a bed sheet or pillowcase all week and staff have not checked to see if he/she wants one. Observation on 12/01/25 at 1:30 P.M., showed Resident #38's room with a large pile of clothes on the floor in front of the bed. During an interview on 12/01/25 at 1:32 P.M., Resident #38 said his/her dirty clothes have been piled up like that for four to five days. The resident said it can take laundry at least a week to get clean clothes back to residents. During an interview on 12/05/25 at 12:22 P.M., Resident #38 said he/she still does not have any clean clothes and said he/she had to wear dirty clothes. Observation on 12/02/25 at 9:27 A.M., showed Resident #46 wore a hospital gown. During an interview on 12/02/25 at 9:30 A.M., Resident #46 said he/she was wearing the hospital gown until he/she can get a clean shirt. He/She did not have any clean underwear or socks and said the items have been in laundry a long time. During an interview on 12/03/25 at 12 P.M., Resident #177 said it can take two to three weeks to get clean clothes back from the laundry. During an interview on 12/02/25 at 2:47 P.M., NA D said the washer in Tiger Lane was broken. NA D said the new washer had been installed about a month ago but broke after a couple of days. Residents are supposed to put their dirty clothes in the laundry bin and staff takes the bin to the main laundry room. It has been a while since he/she has seen laundry bring the residents clean clothes, he/she cannot remember the last time they brought clean clothes. He/She must go upstairs to get clean clothes for the residents. During an interview on 12/08/25 at 10:40 A.M., the laundry lead said he/she was the only staff working in laundry during the day. The washer in Tiger Lane has been broken for a month or two. Staff are supposed to put the resident's dirty clothes in a bag, label the bag with the resident's name and bring it to the laundry room, but staff are not consistently doing it. He/She only has two functioning washing machines in the main laundry room and the other two are curre

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital and failed to send a copy of the notice of transfer and/or discharge for eight residents (Resident #4, #7, #9, #12, #91, #93, #100, and #150) out of eight sampled to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. The facility census was 231. 1. Review of the facility's policy titled Bed Hold, revised 06/12/2025, showed: -Before a resident is transferred or discharged , the facility must: -Notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand; --Notify a representative of the Office of the State Long-Term care Ombudsman; --A copy of the discharge/transfer notice shall be sent to the Ombudsman at least 30 days in advance of a discharge or as soon as possible; --In the case of an emergency or immediate discharge, copies shall be sent to the Ombudsman. This notice shall be sent when practicable and a monthly list is acceptable and should include if the resident's return is expected. 2. Review of Resident #4's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 09/30/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party and did not notify the Ombudsman of the transfers/discharges. 3. Review of Resident #7's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 08/18/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party and did not notify the Ombudsman of the transfers/discharges. 4. Review of Resident #9's medical record showed staff documented the resident discharged from the facility to the hospital and returned to the facility on the following dates: 10/07/25 through 10/09/25; 10/25/25 through 10/29/25 and 10/30/25 through 11/04/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party and did not notify the Ombudsman of the transfers/discharges. 5. Review of Resident #12's medical record showed staff documented the resident discharged from the facility to the hospital and returned to the facility on the following dates: 04/15/25 through 05/13/25; 05/27/25 through 06/04/25; 06/22/25 through 06/29/25, 09/14/25 through 09/20/25, and 11/04/25 through 11/05/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party and did not notify the Ombudsman of the transfers/discharges. 6. Review of Resident #91's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 07/19/25. Review showed the resident discharged from the facility to the hospital on [DATE] and returned on 08/09/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party and did not notify the Ombudsman of the transfers/discharges. 7. Review of Resident #93's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 02/24/25. Review showed the resident discharged from the facility to the hospital on [DATE] and returned on 11/13/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party and did not notify the Ombudsman of the transfers/discharges. 8. Review of Resident #100's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party and did not notify the Ombudsman of the transfers/discharges. 9. Review of Resident #150's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 11/24/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party and did not notify the Ombudsman of the transfers/discharges. 10. Review of email correspondence from the Ombudsman, dated 11/25/25, showed the Ombudsman said he/she had not received transfer/discharge logs since last year around this time. During an interview on 12/8/25 at 12:53 P.M., Licensed Practical Nurse (LPN) E said if the resident is their own responsible person, the nurse would give the bed hold to them, if it has to go to their guardian, he/she was not sure who would be responsible, maybe the Social Services Director (SSD), otherwise the nurse gives it to the resident on the way out of the door. LPN E said he/she was not sure if the bed holds were issued to the residents consistently. During an interview on 2/08/25 at 2:14 P.M., the SSD said the Administrator issues the bed holds; if it is on a weekend or night shift staff tells the Administrator, and he/she does not do them. The SSD said he/she had only been told one time since the previous SSD left at the end of October about notifying the Ombudsman of the transfers/discharges but was unclear on the frequency. He/she did not know that the Ombudsman was not being notified of the transfers/discharges. During an interview on 12/08/25 at 3:18 P.M., the Administrator said the charge nurse should issue the bed hold; if he/she is in the office, he/she will issue the paperwork, but the charge nurse should. The Administrator said he/she did not know staff were not doing them until the bed holds were requested. He/she said the team oversees they are being done, but the SSD and himself/herself should ensure they are completed. The Administrator said he/she would expect the Ombudsman notified at least monthly of transfers/discharges, and if an emergency discharge is completed, they should be notified as soon as possible. He/she did not know the Ombudsman notifications were not being done, and the SSD should be the one sending the notifications. During an interview on 12/08/25 at 4:29 P.M., the Director of Nursing (DON) said charge nurses are responsible for issuing the bed holds, and the SSD can assist within 24 hours if the resident is sent out emergently. The DON said when he/she looked at the system, he/she realized the process had changed six months or so ago and were not auto populated any longer in the system. The DON did not know they were not being done until they were requested, and that is when he/she realized the issue. He/she said some of the bed holds did not even populate for completion. The DON said the SSD should send a monthly report to the Ombudsman, and he/she did not know it was not being done. He/she said the previous SSD was working until about a month ago, so they should have been sent.

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care for ten residents (Resident #12, #19, #57, #58, #76, #82, #91, #117, #185, and #211) out of 45 sampled residents with changes in the resident's needs. The facility census was 231.1. Review of the facility policy titled Comprehensive Care Plans, dated 10/31/24, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe resident specific interventions that reflect the resident's needs and preferences and will be prepared by an interdisciplinary team. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS – a federally mandated assessment tool) assessment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 2. Review of Resident #12's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired, at risk for pressure ulcers, one Stage III pressure ulcer (a bedsore that involves full-thickness skin loss, extending through the top layers into the fatty tissue), and diagnoses of high blood pressure, end stage renal failure with dialysis (the kidneys have permanently failed requiring dialysis to filter waste and fluid from the blood), and diabetes. Review of the resident's Physician Order Sheet (POS), dated December 2025, showed an order for Venelex bordered foam (a prescription topical ointment wound dressing) to coccyx every shift and as needed every day and night shift for abscess, effective 10/16/25. Review of the resident's progress notes, dated 12/02/25, showed the facility Nurse Practitioner identified the wound as a stage III pressure ulcer acquired on 10/13/25, and to cleanse wound with cleanser, apply Alginate (used to manage moderate to heavily draining wounds) to wound bed, cover wound with bordered foam dressing to be changed daily and for soiling and/or saturation. Review of the resident's care plan, dated 08/20/25, showed staff did not update the plan to include the resident's pressure ulcer or interventions. 3. Review of Resident #19's Quarterly MDS, dated [DATE], showed the resident with a diagnosis of Psoriasis (a chronic autoimmune disease causing rapid skin cell buildup, leading to itchy, scaly, red patches (plaques) on elbows, knees, scalp, and elsewhere). Review of the residents POS, dated December 2025, showed the following orders:- Ketoconazole Shampoo (a medicated shampoo to treat scalp conditions) 2% three times weekly;- Prednisone (used to help reduce inflammation) 10 milligram (mg) tablet one time daily to treat Psoriasis;- Revised order on 12/01/25 for dermatology consult for severe Psoriasis and need for medication change. Observation on 12/01/25 at 2:09 P.M., showed the resident's scalp, face, and neck area with a significant amount of dry and flakey skin. Review of the resident's care plan, dated 08/29/25, showed staff did not update the plan to include the resident's diagnosis of Psoriasis or interventions. 4. Review of Resident #57's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, no behaviors, and did not wander. Review of the resident's Quarterly Elopement Assessment, 09/26/25, showed staff assessed the resident at risk for elopement/wandering. Review of the resident's care plan, dated 08/29/25, showed staff documented diagnoses of dementia with behavioral disturbance, and history of traumatic brain injury (damage to the brain from an external force). Review showed staff did not update the plan to include the resident's elopement/wandering risk with interventions. 5. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's POS, dated 12/01/25, showed an order for Almond Milk (a dairy-free, plant-based milk made from ground almonds and water) instead of regular milk, due to intolerance of regular milk, started 04/28/25. Review of the resident's care plan, dated 06/25/25, showed staff did not update the plan to include the resident's dietary requirements with interventions. Observation on 12/03/25 at 12:47 P.M., showed staff did not provide an alternative to regular milk to the resident. The resident asked staff about his/her Almond Milk and staff said, you know the kitchen only has half of what they need down here on the unit. Observation on 12/08/25 at 12:35 P.M., showed staff did not provide an alternative to regular milk to the resident. During an interview on 12/01/25 at 3:51 P.M., the resident said he/she hasn't been getting his/her Almond Milk, he/she was lactose intolerant. During an interview on 12/03/25 at 9:48 A.M., the resident said staff try to give him/her regular milk and when he/she explains, he/she needs Almond Milk, the staff won't give it to him/her. During an interview on 12/08/25 at 12:05 P.M., Nurse Aide (NA) D said he/she knows the resident cannot drink regular milk, but not sure why the facility was not getting Almond Milk down here. During an interview on 12/08/25 at 4:29 P.M., the Director of Nursing (DON) said dietary interventions should be on a resident's care plan. During an interview on 12/09/25 at 1:28 P.M., the administrator said dietary restrictions and interventions should be on care plan. 6. Review of Resident #76's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, behaviors of rejection of care, had no hallucination, had no delusions, no physical behavior towards others, had no feelings of little interest or pleasure in doing things in the last two weeks, had no feelings of down/depressed/hopelessness in the last two weeks. Review of the resident's health status note, dated 10/03/25, showed staff documented they responded to code green (a facility-specific emergency alert for a behavioral/mental health crisis) where they found the resident with a shirt tied around his/her neck. The staff reported it took three staff members to remove the shirt from his/her neck. Staff reported the resident stated he/she was homicidal/suicidal. The resident was sent out for psychiatric evaluation. Review of the resident's behavioral note, dated 10/27/25, showed staff reported that resident attempted to place items around his/her neck stated, I want to die and the voices are telling me to kill myself. Staff reported the resident said he/she needed to go to the hospital again and the last time he/she went he/she wasn't honest about how he/she was feeling. Staff reported the resident said the voices were getting worse and tell him to harm himself/herself and make him/her want to put things around my neck. The resident was sent out for psychiatric evaluation. Review of the resident's current care plan that was in use, dated 09/09/25, showed staff did not update the plan to include the resident's behavior of suicidal ideation with risks and interventions. During an interview on 12/08/25 at 4:29 P.M., the DON said suicidal ideation and attempts should be updated on the care plan, but it was not true suicidal ideation. He/She would expect the behaviors to be on the care plan. The DON said a new suicidal ideation assessment was not done because the resident denied suicidal ideation, did not want to harm himself/herself, and was just upset in the moment and the resident had some delusions involved. 7. Review of Resident #82's Significant Change in Status (SCSA) assessment, dated 10/01/25, showed staff assessed the resident as unable to assess cognitive status, short and long-term memory issues, received hospice services, and diagnoses of non-traumatic brain injury, high blood pressure, Alzheimer's Disease (dementia), seizure disorder, and depression. Review of the resident's POS, dated December 2025, showed an order for hospice consult, dated 09/4/25, and hospice services, dated 09/16/25. Review of the resident's care plan, dated 10/16/25, showed staff did not update the plan to include the resident's hospice with interventions. 8. Review of Resident #91's Annual MDS assessment, dated 10/01/25, showed staff assessed the resident as moderately cognitively impaired, had weight loss of five percent or more in the last month or ten percent or more in the last six months; not on physician prescribed weight-loss regimen, with diagnoses of high blood pressure, diabetes, Alzheimer's disease, dementia, anxiety, depression, psychotic disorder (a loss of contact with reality with symptoms like hallucinations, delusions, and unusual behavior), and schizophrenia (a serious, chronic brain disorder that disrupts how a person thinks, feels, and behaves). Review of the resident's monthly weights, showed on 05/05/2025, the resident weighed 183.2 lbs. On 11/08/2025, the resident weighed 160 pounds which was a 12.66% loss. Review of the resident's care plan, dated 11/03/25, showed staff did not update the plan to include the resident's recent significant weight loss. 9. Review of Resident #117's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, had no behaviors and no wandering, with diagnoses of anxiety, depression, and schizophrenia. Review of the resident's Reentry Elopement Assessment, dated 10/18/25, showed the resident scored a one and was at risk for elopement/wandering. Review of the resident's care plan, dated 10/28/25, showed diagnosis of borderline personality disorder (a serious mental health condition marked by unstable emotions, self-image issues, and chaotic relationships, leading to impulsive actions, and unstable moods). Review showed staff did not update the plan to include the resident's elopement/wandering risk with interventions. 10. Review of Resident #185's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, has edema (fluid retention, swelling, the buildup of fluid in the body's tissue) and received multiple diuretics. Observation on 12/02/25 at 2:30 P.M., showed both resident's hands to be swollen, tight and red in color. Review of the resident's medical record showed a diagnosis of edema. Review of the resident's care plan, dated 03/12/25, showed the care plan did not contain the resident's edema. 11. Review of Resident #211's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired, did not identify weight loss of five percent or more in the last month, weighed 189 pounds, and had diagnoses of dementia and traumatic brain injury. Review of the resident's monthly weights, from September 2025 through November 2025, showed staff documented on 09/16/25 the resident weighed 190 pounds, on 10/20/25 weighed 188.6 pounds and on 11/21/25 weighed 176.2 pounds, which constituted a significant weight loss for one month from October to November in the amount of 7% weight loss in a month. Review of the resident's care plan, dated 11/20/25, showed staff did not update the plan to include the resident's weight loss or interventions to prevent future weight loss. During an interview on 12/08/25 at 12:05 P.M., NA D said he/she did not know the resident had weight loss. The NA said if a resident had weight loss, it should be on the resident's care plan. During an interview on 12/08/25 at 4:29 P.M., the DON said weight loss and interventions for a resident should be care planned. During an interview on 12/09/25 at 1:28 P.M., the administrator said weight loss and interventions should be on resident's care plan. 12. During an interview on 12/8/25 at 12:53 P.M., Licensed Practical Nurse (LPN) E, said hospice status, skin issues such as psoriasis and edema, significant weight loss, diet orders, pressure ulcers, and elopement risks should be on the care plans. LPN E said residents with behaviors, especially suicidal ideation should have that updated on the care plan, so staff know what behaviors to watch for in the resident. LPN E said he/she does not update care plans, and believes the two MDS people do it, and maybe the Resident Care Coordinator (RCC), but was not sure about that one. LPN E said floor nurses do not update the care plans, and that staff should know what interventions should be in place or what behaviors to watch out for. During an interview on 12/8/25 at 1:04 P.M., Certified Nurse Aide (CNA) H said he/she uses care plans when he/she needs to look and see specific information. He/she said information such as hospice status, psoriasis, edema, weight loss and diet orders, pressure ulcers, and suicidal ideation should be on the care plan, as well as elopement risk. CNA H said it is so staff know what to look out for, or what interventions to do like posey boots, cushions, needing assistance with meals, behaviors to monitor. He/she did not know who was responsible for updating care plans. During an interview on 12/08/25 at 3:25 P.M., RCC HH said care plans should address elopement risks, hospice, skin conditions like psoriasis and edema, pressure ulcers, weight loss, special diet orders, behaviors and suicidal ideation. RCC HH said he/she believes the MDS person updated the care plans, but he/she and floor nurses do not update the care plans. He/she said those areas should be on the care plan so that staff know what to do for the residents. The RCC said he/she was not sure of the process of letting the person in charge of care plans know when there were changes that needed to be made. During an interview on 12/08/25 at 4:29 P.M., the DON said anyone can update the care plans, they should be able to, and they should know that, otherwise the Care Plan Coordinator updates the care plans. The DON said he/she would expect weight loss, hospice, pressure ulcers, skin conditions such as edema or psoriasis, elopement risks, and behaviors as well as any new suicidal ideation to be on the care plans. He/she said the care plans should be updated so that staff know the plan of care for the resident, and that NAs and CNAs have access to the care plans, they should be looking at the care plans, and it is in the same system they do charting. During an interview on 12/09/25 at 1:51 P.M., the MDS Coordinator said he/she does not actually update the care plans, but another staff who is the Care Plan Coordinator updates them. The MDS Coordinator said himself/herself and the Care Plan Coordinator cover two buildings, this one and a sister facility. He/she said the comprehensive, annual and significant change assessments should trigger Care Area Assessments (CAAs) to flow into updating the care plans. He/she said hospice should be on the care plan after a significant change in status assessment is completed. He/she said it is a lot to cover for two buildings doing MDS assessments or care plans. During an interview on 12/09/25 at 2:40 P.M., the Care Plan Coordinator said he/she has been in charge of care plans since November 2024 but was assigned to two facilities in June or July of this year. He/she said sometimes it is a lot to cover both buildings. The Care Plan Coordinator said he/she currently reviews the care plans every three months and compares the POS and progress notes and the resident's medical records to make any changes that are needed, like new or discontinued medications, or new diagnoses. He/she said the charge nurses and DON should be able to update the care plans, especially when it is something more immediate or acute such as falls, or behaviors, resident to resident interactions and suicidal ideation. He/she said the staff should do it, but they do not. He/she said communication could be better, there is not currently a process to inform him/her when there are changes or updates that need to be made. He/she said communication would really help, because unless someone sends him/her an email with a change, he/she does not find out about it until he/she does the three-month review, so even an email would help him/her know when the care plan should be updated. The Care Plan Coordinator said hospice, weight loss, special diet orders or requirements, pressure ulcers, elopement risks, suicidal ideation, behaviors and skin conditions such as psoriasis and edema should be on the care plan, especially if they are ongoing or more chronic issues. He/she said he/she is typically in the building on Tuesdays and Thursdays and covers the sister facility on Wednesdays and Fridays. During an interview on 12/09/25 at 10:28 A.M., the Administrator said the Care Plan Coordinator is primarily responsible for revising and updating the care plans, but said nursing staff can also update care plans as needed. He/she would expect hospice services, weight loss, pressure ulcers, elopement risk and actual elopements, skin conditions such as Psoriasis, and edema to all be included on the resident's care plan. The Administrator said he/she would also expect for significant behaviors to be included on resident care plans, such as suicidal ideation so staff understands the resident's behaviors and interventions.

Based on observation, interview, and record review facility staff failed to provide care, to maintain personal hygiene, grooming, bathing and nail care for four residents (Residents #211, #233, #149, and #77) out of a sample of 45 residents. The facility census was 231.Review of the facility's policy titled Activities of Daily Living (ADLs), dated 05/18/24, showed a resident who is unable to carry out ADLs will receive the necessary services, to maintain good nutrition, grooming and personal hygiene. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on comprehensive assessment. The facility will maintain individual objectives of the care plan and periodic review and evaluation. 1. Review of Resident #233's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/5/25, showed staff assessed the resident as:-Severe cognitive impairment;-Rejection of care not exhibited;-Required moderate assistance from staff members for personal hygiene, bathing, and toileting hygiene;-Required supervision or touch assistance from staff members for dressing and eating;-Diagnoses of Parkinson's Disease (a progressive nervous system disorder causing tremors, stiffness, slow movement (bradykinesia), and balance problems), Alzheimer's Disease and Dementia. Review of the resident's care plan, dated 06/10/25, showed staff documented the resident had an ADL self-care performance deficit due to Alzheimer's disease. When bathing staff should check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. When dressing staff should assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. Review of the facility's Point of Care documentation, dated 12/1/25 through 12/5/25, showed staff documented the following:-12/1/25 nail care did not occur and staff did not document the resident refused nail care;-12/2/25 personal hygiene had been provided. -12/5/25 staff documented the resident had been offered a shower and refused. Staff did not document how or when the resident had been reapproached. Review of the facility's Staffing Schedule, dated 12/3/25, showed the night shift aide documented the resident refused a shower, the aide was the only documented staff on the locked unit with 17 residents with behaviors. Review of the resident's Progress Notes, dated 12/1/25 through 12/5/25, showed staff did not document the resident refused care. Observation on 12/2/25 at 9:24 A.M., showed the resident wore the same gray sweatshirt and blue sweatpants as he/she wore the previous day. The resident's hair was oily and unkempt, and he/she had a strong body odor. The resident's nails were long with debris under them. Observation on 12/3/25 at 12:55 P.M., showed the resident shuffled to the dining room with the same gray sweatshirt and blue sweatpants he/she had on the past three days with long dirty fingernails and the resident's hair was oily and unkempt. Observation on 12/4/25 at 11:50 A.M., showed the resident wore the same clothes as the previous three days, had jagged fingernails full of debris, with body odor and greasy unkempt hair. Observation on 12/5/25 at 8:06 A.M., showed the resident wore the same clothes as the previous four days. His/her hair was oily and unkempt, and his/her fingernails were long and had a build up black and brown debris under them. The resident had a strong body odor. During an interview on 12/5/25 at 12:14 P.M., Nursing Aide (NA) I said the residents should not eat with fingernails that look like the resident's nails. The NA said he/she had not told the Resident Care Coordinator (RCC) or Certified Medication Technician (CMT) this week about the resident's fingernails. During an interview on 12/8/25 at 12:05 P.M., NA D said staff have a hard time getting the resident's clothes changed, because they have to go get another resident who speaks the resident's language to translate. The NA said he/she had to negotiate with the resident to get the resident to let him/her change his/her clothes. The NA said he/she does not remember the resident refusing showers this week. During an interview on 12/8/25 at 2:44 P.M., RCC HH said he/she doesn't know why the resident did not get a shower last week. The RCC said staff have not reported to him/her, the resident refused his/her shower. The RCC said staff have not come to him/her in the last week about this resident's fingernails. RCC HH said he/she tries to do residents nails and the CNA can if they are certified, just not for diabetics. The RCC said residents nails should be checked daily, nails should be cleaned before and after meals especially on the medical side, and no staff had come to him/her about the resident's fingernails. The RCC said staff should ask for help reapproaching residents for showers. 2. Review of Resident #149's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Moderate cognitive impairment;-Rejection of care not exhibited;-Required supervision or touch assistance from staff members for bathing, dressing and personal hygiene;-Diagnoses of Diabetes, Dementia, and Traumatic Brain Injury (TBI). Review of the resident's care plan, dated 11/3/25, showed staff documented the resident has an ADL self-care performance deficit due to TBI. When dressing resident, staff should assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. Staff should monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Review of the facility's Point of Care documentation, dated 12/1/25 through 12/5/25, showed staff documented the resident did not refuse nail care, bathing or personal hygiene. Staff documented the resident had been offered a bath. Review of the resident's Progress Notes, dated 12/1/25 through 12/5/25, showed staff did not document any refusals of ADL cares by the resident. Observation on 12/3/25 at 12:52 P.M., showed the resident wore stained clothing in the dining room. The resident's hair was unkempt and oily. The resident's fingernails were long and full of brown debris and the resident had a strong body odor. Observation on 12/4/2025 at 12:01 P.M., showed the resident wore the same clothes as the previous day that were stained. The resident's hair was oily and disheveled. The resident's fingernails were long and had brown debris under them. Observation on 12/5/25 at 8:11 A.M, showed the resident wore the same clothing the previous two days. The resident had strong body odor and long dirty fingernails. The resident's hair was oily and unkempt. During an interview on 12/5/25 at 12:14 P.M., NA I said the residents should not eat with fingernails that look like the resident's. The NA said he/she had not told the RCC or CMT this week about the resident's fingernails. During an interview on 12/8/25 at 2:44 P.M., RCC 1 said he/she doesn't know why the resident did not get a shower last week. The RCC said staff have not reported to him/her the resident refused his/her shower. The RCC said staff have not come to him/her in the last week about this resident's fingernails. 3. Review of Resident #211's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Moderate cognitive impairment;-Rejection of care not exhibited;-Required moderate assist from staff members for personal hygiene, bathing, toileting hygiene and oral hygiene;-Supervision of touching assistance from staff members for dressing;-Occasional incontinence of bowel and bladder;-Diagnoses of Dementia, Major Depressive Disorder, Adjustment Disorder, Antisocial Personality Disorder and TBI. Review of the resident's care plan, dated 11/20/25, showed staff documented the resident had impaired cognitive function/dementia, ADL self-care performance deficit due to disease process Hereditary Ataxia (a neurological symptom causing poor muscle coordination, leading to clumsy movements, balance issues, slurred speech, and difficulty with tasks like writing or eating), impaired balance and limited mobility. During showering staff should check nail length and trim and clean on bath day and as necessary. Required limited assistance from one staff to dress with personal hygiene and toileting. Review of the facility's Point of Care documentation, dated 12/1/25 to 12/5/25, showed staff documented the resident did not refuse nail care, bathing, or personal hygiene. Review showed staff did not document the resident had been offered a bath or shower. Review of the resident's Progress Notes, dated 12/01/25 through 12/05/25, showed staff did not document the resident refused cares. Observation on 12/1/25 at 3:22 P.M., showed the resident walked the hall in blue pants and blue shirt with stains on it. The resident had an odor of urine, his/her fingernails were long with brown debris, and the resident's hair was oily. Observation on 12/2/25 at 9:06 A.M., the resident wandered up and down the hall without shoes or socks and had long, thickened toenails which curled downwards over his/her toes and a thick layer of black substance on the bottoms of his/her feet. The resident's fingernails were long and full of brown debris and his/her hair was oily and disheveled. The resident wore the same light blue shirt with food debris down the front of it and the same stained blue sweatpants as the day before. Observation on 12/3/25 at 11:14 A.M., showed the resident in his/her bed. The resident wore the same blue shirt and sweatpants he/she had worn for three days. The resident's bare feet were covered in a thick black substance. The resident had a strong body odor and urine smell. His/her hair continued to be oily, and fingernails were long and full of brown debris. Observation on 12/3/25 at 1:02 P.M., showed Certified Medication Technician (CMT) N delivered a meal tray and placed it on the resident's two drawer dresser, then left room. The resident stood up from the bed and fed him/her self with his/her hands with long brown fingernails. The resident ate food off the tray with his/her fingers and placed his/her dirty fingers and fingernails in his/her mouth with the food. Observation on 12/3/25 at 7:40 P.M., showed the resident in bed, in the same soiled blue pants and shirt. The resident's fingernails were long and full of brown debris and the resident's hair was oily. Observation on 12/4/25 at 11:44 A.M., showed the resident in bed, with the same blue shirt and sweatpants on with a circular wet spot on the buttocks of his/her pants. The resident's fingernails were long and full of a brown substance. The resident had on yellow non-skid socks and the bottoms were covered in a black substance. Observation on 12/5/25 at 8:13 A.M., showed the resident in bed with a yellow non-skid sock on his/her left foot and a bare right foot covered in a black substance. The resident's hair was oily and unkempt. The resident's fingernails were long and full of brown debris. During an interview on 12/5/25 at 12:14 P.M., NA I said the resident had worn the same clothes all week. The NA said the black substance on the resident's feet was from him/her walking around the unit bare foot. The NA said he/she worked the hall on 12/1/25 and 12/2/25 and did not shower the resident. The NA said sometimes the resident does smell of body odor. The NA said the resident's fingernails are a little long and crusty on the inside and the resident should not eat with his/her hands with fingernails that dirty. The NA said he/she has not told the CMT or RCC this week about the resident's fingernails. During an interview on 12/8/25 at 2:44 P.M., RCC HH said he/she doesn't know why the resident did not get a shower last week. The RCC said staff have not reported to him/her, the resident refused his/her shower. The RCC said staff have not come to him/her in the last week about this resident's fingernails. 4. Review of Resident #77's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Moderate Cognitive impairment;-Rejection of care not exhibited;-Range of Motion (ROM) impairment to both sides of lower extremities;-Used a wheelchair;-Required moderate assistance from staff members for personal hygiene, bathing and toileting hygiene;-Diagnoses of Alzheimer's Disease, Dementia and Psychotic Disorder. Review of the resident's care plan, dated 06/25/25, showed staff documented the resident required supervision and care assistance at all times related to vascular dementia. The resident was reliant on staff for meeting emotional, intellectual, physical, and social needs due to disease process and physical limitations. When bathing staff should check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Staff should provide sponge bath when a full bath or shower cannot be tolerated. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time. If resident resists with ADLs, staff should reassure resident, leave and return five to ten minutes later and try again. Review of the facility's Point of Care documentation, dated 12/1/25 through 12/5/25, showed staff documented the resident did not refuse nail care, bathing, or personal hygiene. Review of the resident's Progress Notes, dated 12/1/25, showed staff did not document any refusals of ADL cares, by resident. Observation on 12/3/25 at 1:13 P.M., showed NA D stood by the resident as he/she ate at the dining room table. The resident's fingernails were long with debris and the resident ate with his/her fingers at times. The resident's hair was oily and unkempt and the resident had a foul body odor. Observation on 12/3/25 at 7:49 P.M., showed NA P entered the resident's room to provide incontinence care. Observation showed the resident's fingernails were long and with debris under them. The NA exited the resident's room after incontinence care and did not clean the resident's fingernails. Observation on 12/5/25 at 8:09 A.M., showed the resident's fingernails were long with brown debris under the nails, the resident's hair was oily and unkempt, and the resident had a foul body odor. During an interview on 12/5/25 at 12:14 P.M., NA I said the residents should not eat with fingernails that look like the resident's. The NA said he/she has not told the RCC or CMT this week about the resident's fingernails. NA I said it could be a risk for infection eating with dirty fingernails. During an interview on 12/08/25 at 2:44 P.M., RCC HH said he/she doesn't know why the resident did not get a shower last week. The RCC said staff have not reported to him/her, the resident refused his/her shower. The RCC said staff have not come to him/her in the last week about this resident's fingernails. 5. During interviews on 12/2/25 at 10:39 A.M. and 12/5/25 at 12:14 P.M., NA I said he/she has 17 residents on his/her unit, and he/she is the only staff right now. The NA said CMTs usually trim and clean the residents fingernails, he/she does as much care as he/she can. NA I said it is usually him/her for staff on the unit, when he/she has to do ADL care for residents, he/she has to get the CMT or RCC from the other unit. The NA said he/she keeps the resident's shower schedule in his/her head. The NA said he/she knows not to cut any resident's fingernails. The NA said the foot doctor comes once a month and cuts the resident's nails. The NA said after working down on the unit, he/she has become nose blind. During an interview on 12/8/25 at 12:05 P.M., NA D said he/she needs another staff on the hall when he/she completes resident showers, that is the problem, the staff from the other side can't come over and watch the hall and if they do, it leaves a CMT on the other unit with forty something residents to monitor and administer medications. One CMT for forty something residents is not enough. The NA said if residents need their fingernails clipped, staff grab the clippers, if the resident is diabetic, staff tells the nurse. During an interview on 12/8/25 at 12:46 P.M., CMT C said the facility should have two staff members on the unit, so if a staff completes showers the unit is not left unsupervised. The CMT said there used to be a CNA down on Tiger and Tiger Medical that would do rounds and cut the residents fingernails every week. The RCC would cut the diabetic residents nails. The CMT said since that CNA changed positions five to six months ago, the facility has not had a CNA come down to these units and cut the residents' fingernails. The CMT said the staff should check the cleanliness of resident fingernails before the resident eats, but the staff do not. The CMT said if a resident refuses care it should be documented in the notes and on the resident's care plan. During an interview on 12/8/25 at 2:44 P.M., RCC 1 said sometimes residents can't shower because there are not any clean towels or washcloths. The RCC said the NA is responsible for assisting residents with changing clothes, if the resident needs it. The RCC said a NA should assist residents with showering, if they need the assistance. The RCC said staff can write in the system, if a resident refuses care. The RCC said he/she tries to clean and trim the residents' fingernails. The RCC said staff should ask for help with reapproaching residents for showers, if the resident refuses. The RCC said staff should check the residents' fingernails daily. The RCC said staff should clean the residents' fingernails before and after meals, especially on this unit. During an interview on 12/8/25 at 4:29 P.M., the Director of Nursing (DON) said staff did not document refusals for ADL cares for these residents. The DON said nail care should be on shower days and refusals should be documented and on the care plan. During an interview on 12/9/25 at 1:28 P.M., the administrator said he/she did not have a good answer for why these residents wore the same clothes, had body odors, and had dirty fingernails all week. The administrator said nursing staff should cut the residents' fingernails, unless they are diabetic, it would have to be a licensed nurse.

Based on interview and record review, facility staff failed to ensure nine Nurse Aides (NA) (NA D, NA I, NA P, NA V, NA W, NA X, NA Y, NA Z, and NA AA) out of nineteen sampled staff, completed the nurse aide training program within four months of his/her employment in the facility. The facility census was 233.1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications.2. Review of NA D's CNA report showed a hire date of 04/28/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.3. Review of NA I's CNA report showed a hire date of 08/26/24. Review showed the file did not contain documentation the NA completed a nurse aide training program.4. Review of NA P's CNA report showed a hire date of 07/15/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.5. Review of NA V's CNA report showed a hire date of 06/16/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.6. Review of NA W's CNA report showed a hire date of 07/21/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.7. Review of NA X's CNA report showed a hire date of 02/24/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.8. Review of NA Y's CNA report showed a hire date of 04/21/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.9. Review of NA Z's CNA report showed a hire date of 07/22/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.10. Review of NA AA's CNA report showed a hire date of 03/24/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.During an interview on 12/12/25 at 8:19 A.M., NA V said he/she did work the week of survey as a NA. NA V said he/she was in the middle of Certified Nurse Assistant (CNA) classes when the instructor quit, he/she believes it was in October 2025. NA V said he/she has been waiting to find out what he/she was supposed to do next, but has not heard anything until recently when the facility got a new instructor. The NA said he/she continued to work as an NA, because the facility needed staff. During an interview on 12/05/25 at 3:45 P.M., the Director of Nursing (DON) said the CNA instructor was at a sister facility and quit abruptly so it left the NAs unable to complete the program. The DON said he/she was aware the NAs should be certified in 120 days, however there was no other option but to leave them working as NAs as the facility needed the coverage. During an interview on 12/08/25 at 12:30 P.M., the Administrator said he/she was aware of the 120-day time frame for NA training completion, however the instructor quit which delayed the process. The administrator said other than that he/she would not know why it would not be completed within the time frame. The administrator said the DON and Human Resources (HR) are responsible for making sure the time frames are met. During an interview on 12/10/25 at 3:30 P.M., HR said reason the NAs were not certified within the time frame is because the instructor quit. He/She said they would typically try to move the aides to a different position in the facility not related to nursing until they are able to become certified. However, the NAs continued to work as NAs due to shortage of staff.

Based on interview and record review, facility staff failed to ensure three residents (Resident #5, #6, and #7) out of seven sampled residents remained free from physical abuse when Resident #8 who had a history of physical aggression towards other residents willfully hit the residents in the head. The facility's census was 234.1. Review of the facility's Abuse and Neglect policy, dated 06/12/24, showed abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physician condition, cause physical harm, pain or mental anguish. Physical abuse is purposefully beating, striking, wounding, or injuring any resident in any manner whatsoever. Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his/her safety, as well as the safety of other residents and employees in the facility. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/19/25, showed staff assessed the resident as cognitively intact and did not exhibit physical or verbal behavioral symptoms towards others. Review of the resident's care plan, revised 07/03/25, showed staff assessed the resident as has a history of being verbally and physically aggressive towards staff and peers due to his/her Autism and mild intellectual disabilities. Resident has ineffective coping skills, poor impulse control, and may have crying spells, throwing fits and melt downs, where he/she will yell at staff, threaten to hit or smack others, and at times he/she may then become uncooperative with care and redirection. Review showed staff documented on 7/3/25 a physical altercation with a peer on 07/01/25 with intervention the resident to be educated on anger management in easy-to-understand communication from staff and resident to do conflict resolution with the other resident. Review of the resident's progress notes, dated 04/01/25 to 07/31/25, showed staff documented:-On 04/04/24 at 9:34 A.M., the resident initiated physical contact with peer when the resident struck another resident several times open-handed to the head after a verbal altercation occurred between them, residents were immediately separated, assessed for injuries, guardians, local authorities, Nurse Practitioner notified.-On 05/16/25 at 3:02 P.M., resident was the aggressor in an altercation; -On 06/10/25 at 2:50 P.M., resident was the aggressor in an altercation; -On 06/11/25 at 2:47 P.M, resident was the aggressor in an altercation; -On 06/22/25 at 11:05 P.M., resident charged at another resident and struck him/her several times in the head and pulled his/her hair, redness and scratches noted to the other resident's neck, the other resident transported to the hospital. Guardians notified for both residents, medical and Nurse Practitioner notified, and local authorities dispatched with EMS for hospital transport;-On 07/02/25 at 10:15 P.M., resident charged at his/her roommate, swatted him/her open-handed on the top of the head and grabbed his/her hair, after his/her roommate admitted to using his/her body wash without permission, staff separated both resident, the roommate was moved to a different hall, guardian notified, medical and Nurse Practitioner notified, and dispatch notified-On 07/31/25 at 2:12 P.M., Resident #8 in altercation with Resident #5, #6, and #7 today. guardian contacted along with administration. Review of the facility's incident Investigation Summary, dated 08/01/25, showed staff documented:-On 07/31/25, Resident #8 involved in a physical altercation with Resident #5. Resident #8 became upset with Resident #5, after he/she witnessed Resident #5 slapping at a staff member, the resident got up from the table, walked around staff and slapped the top of Resident #5's head and pulled his/her hair. The altercation was not accidental and was not preventable. Reward card initiated for Resident #8, Resident #8 educated and encouraged to not interfere with other resident's behaviors. Resident #8 agreed to conflict resolution and has apologized to Resident #5.-On 07/31/25, Resident #8 involved in a physical aggression with Resident #6 and Resident #7. Resident #8 knocked on Resident #6's door and asked to use his/her bathroom, Resident #6 said no, Resident #8 pushed the door, Resident #6 yelled at Resident #8 to get out, then Resident #8 slapped Resident #6 to the face. During the altercation, Resident #6 tripped and fell to the floor hit his/her head. Resident #7 entered Resident #6's room, told Resident #8 to stop, staff responded, and Resident #7 returned to his/her room. Resident #8 ran to Resident #7's room and slapped Resident #7 to his/her head and pulled his/her hair. The altercation was not accidental and was not preventable. Staff documented Resident #8 with one small scratch to his/her left upper cheek, Resident #6 with three small scratches to his/her right upper cheek and raised area to the right side of back of head, Resident #7 not injured. Resident #8 placed one-one with staff for de-escalation time and reflection and re-educated on keeping hands to self when upset. Resident #8 wishes to do conflict resolution with other residents. Resident #6 moved to separate unit, wishes to do conflict resolution with Resident #8. Resident #7 moved to separate unit, educated on seeking staff assist when having issue with other resident and not interfere with other residents' behaviors.During an interview on 08/01/25 at 3:19 P.M., Nurse Practitioner F said he/she is aware of the incidents involving Resident #8 on 07/31/25, but staff did not request any medication changes or request an as needed medication from him/her.During an interview on 08/01/25 at 3:24 P.M., Certified Medication Technician (CMT) B said the resident has a history of hitting other residents but had not been in an altercation with anyone for a while. During an interview on 08/01/25 at 4:15 P.M., the administrator said the resident has a history of altercations with other residents, but he/she had not had to do a detailed investigation involving the resident since approximately 04/04/25. He/she said staff are aware to routinely monitor the resident, assess the resident's coping skills, re-direct resident if he/she starts to show signs of anger, offer support pillow, and call the administrator if needed to intervene in escalating situations. 3. Review of Resident #5 Electronic Medical Record (EMR), dated 08/01/25, showed staff documented the resident admitted to the facility on [DATE].Review of the resident's care plan, dated 07/28/25, showed staff were directed to ensure the resident's environment is safe.Review of the resident's progress notes, dated 07/31/25, showed staff documented Resident #5 in altercation with Resident #8, non-injury, guardian contacted along with all other appropriate parties. During an interview on 08/01/25 at 3:28 P.M., the resident said he/she had only been at the facility for a few days and was in the dining room the day prior, when Resident #8 hit him/her in the head. He/She said his/her head hurt, and requested something from pain from CMT B.4. Review of Resident #6's admission MDS, a federally mandated assessment tool, dated 07/08/25, showed staff assessed the resident admitted on [DATE] and cognitively intact.Review of the resident's care plan, revised 07/15/25, showed staff were directed to ensure the resident's environment is safe, and keep his/her environment safe from actual or perceived judgement and physical or perceived danger.Review of the resident's progress notes, dated 07/31/25, showed staff documented Resident #6 in altercation with Resident #8.Review of the resident's Physician Order Sheet (POS), dated 07/31/25 to 08/01/25, showed the physician ordered an x-ray of the resident skull due to trauma on 07/31/25, and on 08/01/25, an order for skull, complete, minimum 4 views- sent for imaging. Observation on 08/01/25 at 11:01 A.M., showed the resident with scratches to his/her cheek and complained of a headache.During an interview on 08/01/25 at 11:06 A.M., CMT B said the resident had an altercation with Resident #8 the day prior and has a goose egg to the backside of his/her head. During an interview on 08/01/25 at 3:01 P.M., the resident said Resident #8 hit him/her in the head and scratched him/her below his/her left eye. The resident said he/she was moved to a different unit after the incident and staff has offered him/her ice packs for treatment.During an interview on 08/01/25 at 3:24 P.M., CMT B said when he/she responded to the resident's room, Resident #8 had the resident on the floor, and he/she assisted Resident #8 from over the resident and escorted Resident #8 from the resident's room. 5. Review of Resident #7's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.Review of the resident's care plan, revised 03/17/25, showed staff were directed to ensure and provide the resident with a safe environment. Review of the resident's progress notes, dated 07/31/25, showed staff documented resident in altercation with Resident #8, non-injury, all appropriate parties notified.During an interview on 08/01/25 at 3:03 P.M., the resident said Resident #8 ran into his/her room the day prior and tried to fight him/her. The resident said he/she was not injured. Staff separated the residents and Resident #7 was moved to a different unit.During an interview on 08/01/25 at 3:24 P.M., CMT B said he/she escorted Resident #8 from Resident #6's room after an altercation, and Resident #8 went over to Resident #7's room and hit him/her in the head. Staff separated the residents and Resident #7 was moved to a different unit.6. During an interview on 08/01/25 at 1:47 P.M., the administrator said after the incidents involving Resident #8, Residents #5, #6, and #7 were moved to a different unit and Resident #8 was kept on his/her unit because he/she does not do well on the other units and was placed one on one with staff for de-escalation and reflection. The administrator said the residents had agreed to participate in conflict resolution, but staff had to allow some time to do so. During an interview on 08/01/25 at 3:24 P.M., CMT B said after a resident-to-resident altercations, staff usually separate the residents, keep a closer eye on the residents, a resident may get moved to another hall, and sometimes the resident may get sent to the hospital for an evaluation if they were injured. The CMT said whenever Resident #8 has been involved in an altercation with another resident, staff always moved the other resident and leave Resident #8 on his/her unit. The CMT said after the altercations on 07/31/25, staff were verbally directed to closely monitor Resident #8, but it was difficult to do so with only three staff assigned to two locked units, especially when the residents were exhibiting physical behaviors towards each other. During an interview on 08/01/25 at 4:15 P.M, the Director of Nursing (DON) said staff initiated appropriate interventions by moving Residents #5, #6 and #7 to a different unit after Resident #8 hit all three residents on 07/31/25. The DON said staff had plans to sit Resident #8 down with the other residents for conflict resolution after at least 24 hours. The DON said staff had no way of predicting Resident #8 would hit the residents when he/she did, so after the resident had calmed down, he/she returned to 15-minute checks from staff.During an interview on 08/17/25 at 12:01 P.M., CMT B said prior to the altercations on 07/31/25, the last altercation he/she can recall Resident #8 involved in was about three to four weeks ago. The CMT said staff were directed by the resident's care plan if the resident starts getting angry/upset, remove him/her from situation, offer him/her tablet for coping skills, and color/sketch pads. The CMT said after the altercations on 07/31/25 Residents #5, #6, and #7 were moved to a different unit, Resident #8 was one-on-one with staff until he/she calmed down, and then staff were verbally directed to maintain close supervision of Resident #8 with 15- minute checks. During an interview on 08/17/25 at 12:10 P.M., Nursing Aide (NA) G said prior to the altercations on 07/31/25, the last altercation he/she can recall Resident #8 involved in was about a month ago. The NA said he/she was not at facility on 07/31/25, but staff verbally reported to him/her on 08/01/25 that Resident #8 was involved in more than one altercation the day prior, Residents #5, #6, and #7 were moved to a different unit, and the current intervention was to conduct 15-minute checks on Resident #8 and ensure he/she had his/her tablet for use. Intake # 2577272 and 2577436

Based on interview and record review, the facility staff failed to provide supervision of one resident (Resident #1) who has a history of inserting foreign objects into his/her colostomy bag (a bag that collects stool) and stoma (an opening in the body) which resulted in the resident being transfered to the hospital. The facility census was 232. 1. Review of the facility's policy titled, Incidents and Accidents Policy, dated 05/18/24, showed staff were directed to assure appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/18/24, showed staff assessed the resident as cognitively intact and used a colostomy bag. Review of the resident's Physician Order Summary, undated, showed an order for a colostomy bag. Review of the resident's medical record showed staff documented: -On 06/23/24 at 1:34 P.M., the resident sent to the hospital due to shoving a paperclip in his/her stoma; -On 07/03/24 at 12:39 P.M., the resident sent to the hospital due to shoving a fork in his/her colostomy bag; -On 09/10/24 at 10:47 A.M., the resident sent to the hospital due to placing foreign objects in his/her stoma; -On 09/17/24 at 2:55 P.M., the resident sent to the hospital due to shoving a spoon and fork in his/her stoma. Review of the resident's care plan, dated 08/27/24, showed staff documented the resident used a colostomy bag. Staff documented the resident exhibited behavior's of inserting foreign objects into his/her colostomy bag. Review of the care plan showed staff documented on 02/23/24 resident has behavior of inserting foreign objects. The care plan did not contain interventions for the resident inserting foreign objects. Review of the resident's hospital paperwork, dated 09/18/24, showed the resident admitted to the hospital due to insertion of a foreign object in his/her ostomy, which required a procedure to examine the lower part of the colon and rectum to assist with removal of the foreign object surgically. During an interview on 09/25/26 at 2:16 P.M., Charge Nurse A said the resident had a history of inserting foreign objects into his/her colostomy bag. He/She said he/she did not know if there were interventions after each incident, but he/she said there should be and it should be documented in the care plan. During an interview on 09/25/24 at 2:40 P.M., the Director of Nursing (DON) said the resident had a history of inserting foreign objects in his/her colostomy bag. He/She said staff did not attempt interventions after each incident of inserting foreign objects in his/her colostomy bag. He/She said staff should have attempted interventions and addressed the interentions in the care plan. During an interview on 10/02/24 at 8:24 A.M., the DON said if staff did attempt interventions after each incident, it could have potentially prevented future incidents of the resident's inserting foreign objects in his/her colostomy bag. He/She said staff did not have interventions in place to monitor the silverware prior to the resident leaving the table after meals. During an interview on 09/25/24 at 2:40 P.M., the administrator said the resident had a history of inserting foreign objects in his/her colostomy bag. He/She said staff did not attempt interventions after each incident of inserting foreign objects in his/her colostomy bag. He/She said staff did not have interventions in place to monitor the silverware prior to the resident leaving the table after meals. MO00242343

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to separate residents who tested positive for Covid-19 from residents who had tested negative for Covid-19 or had only been exposed to Covid-19 for seven resident (Resident #2, #4, #6, #8, #10, #12, #15, #17, and #18) at an increased risk of contracting Covid-19 due to prolonged exposure. The facility census was 233. The administrator was notified on 12/07/22 at 4:30 P.M., of an Immediate Jeopardy (IJ) which began on 12/01/22. The IJ was removed on 12/14/22 as confirmed by surveyor onsite verification. 1. Review of the Centers for Disease Control (CDC)'s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated Sept. 23, 2022, showed a resident with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room. The door should be kept closed (if safe to do so). Ideally, the resident should have a dedicated bathroom. If cohorting, only residents with the same respiratory pathogen should be housed in the same room. Facilities could consider designating entire units within the facility, with dedicated health care professional (HCP), to care for residents with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means HCP are assigned to care only for these residents during their shifts. Limit transport and movement of the residents outside of the room to medically essential purposes. Communicate information about residents with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities. Review of the facility's Pandemic Coronavirus (COVID-19), revised 1/19/22, showed when a resident tests positive for the Coronavirus they will be placed in isolation. Review showed the facility did not have a policy that directed staff in regards to cohorting residents. 2. Review of Resident #1's COVID test results form, dated 12/1/22, showed staff documented a positive result for the resident. Review of Resident #2's COVID test results form, dated 12/1/22 and 12/5/22, showed staff documented the resident tested negative for COVID on 12/1/22 and on 12/5/22. Observation on 12/7/22 at 9:30 A.M. showed Resident #1 who tested positive for COVID in a room with Resident #2 who tested negative for COVID. During an interview on 12/9/22 at 9:30 A.M., Resident #2's guardian said the facility notified him/her they had positive COVID cases, but never mentioned the resident was exposed to COVID. He/She said the facility staff called after the Department of Health and Senior Services (DHSS) staff had tried to call him/her and not at all prior to that. He/She said they did not educate him/her of risks for the resident to stay in the room and he/she would not have given consent for that. The guardian said once they notified him/her Resident #2 was directly exposed, he/she gave permission for him/her to be moved. 3. Review of Resident #3's COVID test results form, dated 12/5/22, showed staff documented a positive result for the resident. Review of Resident #4's COVID test results form, dated 12/1/22 and 12/5/22, showed staff documented the resident tested negative for COVID on 12/1/22 and on 12/5/22. Observation on 12/7/22 at 9:35 A.M. showed Resident #3 who tested positive for COVID in a room with Resident #4 who tested negative for COVID. During an interview on 12/13/22 at 2:09 P.M., Resident #4's guardian said he/she was not notified by the facility the resident was in contact with a resident who tested positive for COVID-19, and said he/she would not have given consent for him/her to stay in a room with a resident who tested positive for COVID. He/She said the facility did not educate him/her on the risks to the resident, but that he/she knows the risks. Further review on 12/16/22 of Resident #4's COVID test results form showed Resident #4 tested positive for COVID on 12/12/22. 4. Review of Resident #5's COVID test result form, dated 12/2/22, showed staff documented a positive result for the resident. Review of Resident #6's COVID test result form, dated 12/1/22 and 12/5/22, showed staff documented the resident tested negative for COVID on 12/1/22 and on 12/5/22. Observation on 12/7/22 at 9:40 A.M. showed Resident #5 who tested positive for COVID in a room with Resident #6 who tested negative for COVID on 12/1/22 and on 12/5/22. During an interview on 12/7/22 at 1:45 P.M., Resident #6's guardian said he/she was not called and notified Resident #6 was in contact with a resident who tested positive for COVID-19, and said he/she would not have given consent for him/her to stay in a room with a resident who tested positive for COVID. He/She said the facility did not educate him/her on the risks to the resident, but that he/she knows the risks. 5. Review of Resident #7's COVID test results form, dated 12/5/22, showed staff documented a positive result for the resident. Review of Resident #8's COVID test result form, dated 12/1/22 and 12/5/22, showed staff documented the resident tested negative for COVID on 12/1/22 and on 12/5/22. Observation on 12/7/22 at 9:45 A.M. showed Resident #7 who tested positive for COVID in a room with Resident #8 who tested negative for COVID on 12/1/22 and on 12/5/22. During an interview on 12/7/22 at 2:00 P.M., Resident #8's guardian said he/she was not notified by the facility the resident was in contact with a resident who tested positive for COVID-19, and said he/she would not have given consent for him/her to stay in a room with a resident who tested positive for COVID. He/She said the facility did not educate him/her on the risks to the resident, but that he/she knows the risks. 6. Review of Resident #9's COVID test results form, dated 12/4/22, showed staff documented a positive result for the resident. Review of Resident #10's COVID test result form, dated 12/1/22 and 12/5/22, showed staff documented the resident tested negative for COVID on 12/1/22 and on 12/5/22. Observation on 12/7/22 at 9:47 A.M., showed Resident #9 who tested positive for COVID in a room with Resident #10 who tested negative for COVID on 12/1/22 and on 12/5/22. 7. Review of Resident #11's COVID test results form, dated 12/5/22, showed staff documented a positive result for the resident. Review of Resident #12's COVID test result form, dated 12/1/22 and 12/5/22, showed staff documented the resident tested negative for COVID on 12/1/22 and 12/5/22. Observation on 12/7/22 at 10:15 A.M. showed Resident #11 who tested positive for COVID in a room with Resident #12 who tested negative for COVID on 12/1/22 and 12/5/22. During observation and interview on 12/7/22 at 10:17 A.M., showed Resident #12 in his/her room without a mask on. The resident said he/she does not have COVID, but that his/her roommate did. Resident said they did not offer him/her to move and did not educate him/her on risks of him/her to remain in the room. 8. Review of Resident #13's COVID test results form, dated 12/5/22, showed staff documented a positive result for the resident. Review of Resident #14's COVID test results form, dated 12/5/22, showed staff documented a positive result for the resident. Review of Resident #15's COVID test result form, dated 12/1/22 and 12/5/22, showed staff documented the resident tested negative for COVID on 12/1/22 and 12/5/22. Observation on 12/7/22 at 10:20 A.M. showed Resident #13 and Resident #14 who tested positive for COVID in a room with Resident #15 who tested negative for COVID on 12/1/22 and 12/5/22. During an interview on 12/7/22 at 2:10 P.M., Resident #15's guardian said the facility notified him/her they had positive COVID cases, but never mentioned the resident was in contact with a resident who tested positive for COVID-19. The guardian said he/she would not have given consent for him/her to stay in a room with a resident who tested positive for COVID. He/She said the facility did not educate him/her on the risks to the resident, but that he/she knows the risks. 9. Review of Resident #16's COVID test results form, dated 12/1/22, showed staff documented a positive result for the resident. Review of Resident #17's COVID test result form, dated 12/1/22 and 12/5/22, showed staff documented the resident tested negative for COVID on 12/1/22 and 12/5/22. Review of Resident #18's COVID test result form, dated 12/1/22 and 12/5/22, showed staff documented the resident tested negative for COVID on 12/1/22 and 12/5/22. Observation on 12/7/22 at 10:25 A.M. showed Resident #16 who tested positive for COVID in a room with Resident #17 and Resident #18 who tested negative for COVID on 12/1/22 and on 12/5/22. During an interview on 12/7/22 at 2:18 P.M., Resident #18's guardian said he/she was not notified related to COVID. He/She said he/she did not want the resident in a room with a resident who tested positive for COVID-19 and if he/she was in a room would want him/her moved. During an interview on 12/7/22 at 2:27 P.M., Resident #17's guardian said he/she was not notified by the facility the resident was in contact with a resident who tested positive for COVID-19, and said he/she would not give consent for him/her to stay in a room with a resident who tested positive for COVID. He/She said the facility did not educate him/her on the risks to the resident, but that he/she knows the risks. 10. During an interview on 12/7/22 at 11:37 A.M., the Director of Nursing (DON) said they did not change any of the rooms,they made the 200 and 300 halls COVID halls with barriers at the entrance, but since it was COVID halls when they received positive results for the residents they did not make any room changes. The DON said he/she would have to check with management related to the expectation on residents who are positive as to if they are supposed to be in the same room with negative residents. During an interview on 12/7/22 the Administrator said he/she had the Social Worker and the Customer Service Coordinator call all the guardians of positive residents and they were in agreement with them shutting down the units and leaving the positive residents in the rooms with the negative residents since they had all already been exposed at that point they did not make any room changes. At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00210823, MO00211071, MO00210708, MO00211000

Based on observation, interview and record review, the facility failed to ensure the resident environment was free from accident hazards, for one resident (Resident #1) when staff allowed the resident to smoke a cigarette with his/her oxygen on. The facility census was 235. The administrator was notified on 9/15/2021 at 5:00 P.M. of an Immediate Jeopardy (IJ) which began on 9/15/21. The IJ was removed on 9/17/21 as confirmed by surveyor onsite verification. Review of the facility's Smoking Safety Regulations, last reviewed and approved on 7/9/2021, showed staff are educated as follows: -The facility will post No Smoking signs with the international symbol for no smoking for any room, ward or compartment where flammable liquids, combustible gases or oxygen is used or stored and in any other hazardous location; -The facility will provide direct supervision for smoking by patients classified as not responsible. Review of the facility's Fire Safety-Oxygen Storage Policy, last revised on 5/25/2019, showed staff were directed as follows. Oxygen cylinders shall be stored in a proper storage area free of any flammable storage practices. Review of Resident #1's, quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/15/21, showed staff assessed the resident as follows: -Cognitive; -Independent with all activities of daily living. Review of the resident's Physician Order Sheet (POS), dated September of 2021, showed the physician ordered Oxygen 2-4 Liters Per Minute (LPM) by nasal cannula, continuous every day and night shift. Review of the resident's Care Plan, dated as initiated on 1/24/21 and revised on 9/15/21, showed staff were directed to care for resident as follow: -Oxygen via nasal cannula as ordered; -Instruct resident about facility policy on smoking locations, times, safety concerns; -Notify Charge Nurse if suspect the resident violated facility smoking policy. Observation on 9/15/21 at 11:23 A.M., showed Nurse Assistant (NA) A sat next to the resident outside while they smoked a cigarette. The resident had his/her oxygen (O2) tank on the back of his/her wheelchair with his/her nasal cannula on and connected to the O2 tank. The oxygen was on at two liters per minute continuous flow. The resident said his/her O2 was on and the Department of Health and Senior Service worker alerted Certified Medication Technician (CMT) B of the resident smoking with his/her oxygen on. The CMT went to the door, said the resident is smoking with his/her O2 on and then said to the resident you know better. The CMT went and gathered additional cigarettes for other residents. NA A did not remove, shut off the O2 or extinguish the resident's lit cigarette. Observation 9/15/21 at 11:27 A.M., showed the resident finished his/her cigarette with his/her O2 on and the NA assisted the resident to the 100 hall. During an interview on 9/15/21 at 11:36 A.M., Resident #1 said he/she knows not to take oxygen to the smoking area. The resident said he/she forgot about his/her oxygen and also said he/she does not always go out to smoke. During an interview on 9/22/21 at 9:54 A.M., Resident #2 said he/she is not able to go outside anymore, because he/she has oxygen and it's a smoking area. During an interview on 9/15/21 at 11:28 A.M., CMT B said they are not supposed to take oxygen tanks outside to smoke. He/She said oxygen tanks are supposed to be left inside the building. He/She said the aides are supposed to check to make sure residents don't have oxygen tanks on them. The CMT said I should have intervened and told him/her to bring the tank back inside and put out the cigarette. Sometimes we forget and we are not supposed to forget. During an interview on 9/15/21 at 11:33 A.M., NA A said this is the first time the oxygen has been out there since he/she has been here. The NA said the resident had not taken a smoke break since last week. The NA said he/she usually takes it before he/she goes out and set it by the door. He/She said I really forgot. The NA said oxygen is not supposed to be around smoke or fire, it can cause it to blow up. During an interview on 9/15/21 at 12:25 P.M., Licensed Practical Nurse (LPN) C said staff are supposed to take residents' oxygen off and leave it inside, so it does not ignite, to protect residents from harm. He/She said he/she would expect staff to immediately take the oxygen off or extinguish the cigarette. The LPN said, It is just common sense he/she would think. During an interview 9/15/21 at 1:46 P.M., NA A said he/she lights all their cigarettes and he/she said he/she lit Resident #1's cigarette. During an interview 9/15/21 at 2:28 P.M., NA A said the lighter is his/her. At this time, the NA showed his/her lighter. Observation showed the lighter had an open flame. During an interview on 9/15/21 at 1:50 P.M., the Director of Nursing said staff are educated on safe smoking practices and oxygen storage during the employee's orientation. During an interview on 9/15/21 at 1:50 P.M., the Assistant Administrator said he/she expects staff to educate residents about smoking and oxygen. He/She said if a resident is smoking, their oxygen tank should stay inside. He/She said residents are not supposed to take the oxygen outside. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 382

Based on interview, and record review, facility staff failed to ensure four residents (Resident #1, #2, #3, and #4) remained free from abuse when Housekeeper A brought methamphetamines (an illegal synthetic stimulant drug) into the facility and sold the drug to four residents (Resident #1, #2, #3 and #4) for their use. The facility census was 231. On 07/16/21 at 12:10 P.M., the administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 06/10/21. On 06/10/21, the administrator identified the housekeeper brought methamphetamines into the facility to sell to the residents. Upon discovery, staff suspended the employee pending investigation, conducted an investigation, and notified appropriate parties. Facility staff reviewed their abuse and neglect policies, and inserviced staff on abuse and neglect. The IJ was removed and corrected on 06/10/21. 1. Review of the facility's policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated July 2020, showed the facility is committed to protecting residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual. Review showed the policy of this facility every resident has the right to be free from any physical, or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Review showed every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. Additional review showed: -Mistreatment, neglect, or abuse of residents is prohibited by the facility; -Class I neglect, failure of an employee to provide reasonable and necessary services to maintain the physical and mental health of any consumer when that failure presents imminent danger to the health, safety, or welfare of a consumer, or a substantial probability that death or physical injury would result; -Class II neglect, failure of an employee to provide reasonable or necessary services to a consumer according to the individualized treatment/rehabilitation plan, if feasible, or according to acceptable standards of care. This includes action or behavior, which may cause psychological harm to a consumer due to intimidating, causing fear or otherwise causing undue anxiety. 2. Review of the facility investigation, dated 06/10/21, showed staff documented a staff member went to the Human Resource Director (HRD) and said a resident informed him/her they received [MEDICATION(S)] from Housekeeper A approximately three days ago. Review showed the Director of Nursing (DON) and administrator were notified of the incident. Review showed staff documented the resident was upset because the other residents did not help pay for it. Review showed the resident was interviewed. Review showed staff interviewed the accused staff member, drug tested the staff member and suspended the staff member pending the investigation. Review showed staff documented they drug tested the residents and started assessments on the residents. Review showed staff sent the residents to the local emergency for room for follow up and returned to the facility without negative outcome. Review showed staff terminated Housekeeper A. 3. Review of the housekeeper's drug test results, dated 6/10/21, showed results were positive for methamphetamines. 4. Review of Resident #1's Minimum Data Set (MDS), a federally mandated tool used to assess residents, dated 6/23/21, showed staff assessed the resident as follows: -Cognitively intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's drug screen, dated 6/10/21, showed the resident tested positive for methamphetamines. During an interview on 6/16/21 at 9:37 A.M., the resident said he/she did use methamphetamines with three other residents. He/She said the drug was brought into the facility to one of the residents by a housekeeper. The resident said he/she would not provide the names of any of the residents or the staff member. 5. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's drug screen, dated 6/10/21, showed the resident tested positive for methamphetamines. During an interview on 6/16/21 at 9:57 A.M., the resident said he/she did use methamphetamines with three other residents. He/She said the drug was brought into the facility by Housekeeper A to Resident #1. The resident said he/she was not going to answer any more questions. 6. Review of Resident #3's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's drug screen, dated 6/10/21, showed the resident tested positive for methamphetamines. During an interview on 6/16/21 at 9:37 A.M., the resident said they used methamphetamines a couple of days ago. He/She could not remember the exact day, but that it had been brought into the facility by a housekeeper, but he/she couldn't remember his/her name. The resident said the housekeeper had brought it in to Resident #1 and then the four of them used it together. 7. Review of Resident #4's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's drug screen, dated 6/10/21, showed the residents drug test results positive for methamphetamines. During an interview on 6/16/21 at 9:48 A.M., the resident said he/she did use methamphetamines with three other residents, but that he/she did not know who brought it in or how it was obtained. He/She said he/she refuses to give names of the other residents who used the drugs with him/her. 8. During an interview on 6/16/21 at 10:37 A.M., the Regional Nurse (RN) said when he/she questioned Housekeeper A, he/she said he/she and his/her spouse used methamphetamines the night before, but said he/she did not bring any drugs into the facility. The RN said the employee was suspended immediately and terminated after investigation. During an interview on 6/30/21 at 3:10 P.M., the HRD said an employee had come to him/her anonymously to report Resident #2 told him/her he/she was upset because he/she bought methamphetamines from an employee and the resident was upset because the other residents who used the methamphetamines had not paid for their portion. He/She said he/she reported it to the DON and Administrator. During an interview on 6/30/21 at 3:23 P.M., the Administrator and DON said they were notified by the HRD about the resident paying a staff member for [MEDICATION(S)] and selling to other staff. They said they immediately began an investigation. The administrator and DON said they called the hotline in within 2 hours, notified the Sheriff's Department who came onsite, and notified guardians. The administrator said the residents all tested positive for methamphetamines and were taken to the hospital then were cleared and sent back so they sent them to a second hospital which also cleared them and sent them back. The administrator and DON said staff were in-serviced on abuse policy and reporting abuse/neglect. The administrator and DON said the employee was immediately suspended until completion of the investigation and was terminated on 6/17/21. MO 549 MO 805

Based on observation, interview, and record review, facility staff failed to provide supervision for two residents (Resident #59 and Resident #74) with a known history of aggressive behavior. While unsupervised, the residents had a physical altercation that put both residents at risk for injury. Furthermore, facility staff failed to complete neurological checks and initiate interventions to prevent further falls for one resident (Resident #75) following two falls, one requiring sutures (stitches holding a wound together) and one resulting in a fracture, failed to safely transfer the resident, and failed to complete an investigation following the fall that resulted in the fracture. The facility census was 229. 1. Facility staff did not provide a policy in regards to resident to resident altercations, as well as, direction for staff after an altercation occurs. 2.Review of Resident #59's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Had delusions (misconceptions or beliefs that are firmly held, contrary to reality); -Physical symptoms directed towards others (e.g., hitting, kicking, pushing, cratching, grabbing, abusing others sexually) occurred ,[DATE] days out of the last 7 days; -Verbal behavioral symptoms towards others (e.g., threatening, screaming, cursing) occurred ,[DATE] days out of the last 7 days; -[DIAGNOSES REDACTED]. -Independent with activities of daily living (ADLs). Review of Resident #74's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Short and long term memory OK; -Decisions consistent and reasonable; -Physical and verbal behavioral symptoms were not exhibited; -Independent with ADLs; -[DIAGNOSES REDACTED]. During an interview on [DATE] at 3:30 P.M., the Director of Nursing (DON) said Resident #59 and Resident #74 had a resident to resident altercation. The residents shared a room, on a secured unit. He/she said Resident #74 picked on Resident #59 all morning, and Resident #59 had buddied up with another resident. He/she said Resident #74 walked up to Resident #59 in the dining room, shoved him/her, and told him/her to keep his/her friend out of their room. He/she said resident #74, reported, Resident #59 then came after him/her and hit him/her in the shoulder. He/she said Resident #74 then hit Resident #59 with his/her fist in the arm/shoulder area and that was when staff separated the residents. He/she went on to say both residents were placed on a 1:1 (staff to resident ratio) and Resident #74 was given [MEDICATION NAME] (an anitpsychotic medication used to treat mental/mood disorders) and [MEDICATION NAME] (an antianxiety medication used to treat anxiety). He/she said Resident #74 was to be moved to a different unit. Furthermore, he/she added Resident #59 had a history of [REDACTED].#74 last weekend because of aggressive ideations, and Resident #74 had said he/she was leaving if he/she had to bust out windows or take chairs to people. During an interview on [DATE] at 3:45 P.M., Certified Nursing Assistant (CNA) Q said he/she was assigned to the locked unit Resident #59 and #74 resided on. Furthermore, he/she said he/she did not know what happened because he/she was on break at the time of the incident. During an interview on [DATE] at 3:55 P.M., Certified Medication Technician (CMT) R said he/she did not witness the altercation between the residents. He/she thought the Code Green, in response to the altercation, was called by CNA Q, because CNA Q was covering the floor. During an interview on [DATE] at 4:00 P.M., the Assistant Director of Nursing (ADON) said he/she was not on the unit when the altercation occurred, and CNA S should have been on the unit. He/she said CNA Q was on the unit when he/she left but did not think CNA Q was in the vicinity at the time of the altercation. Additionally, he/she said he/she did not know who called the code. During an interview on [DATE] at 4:02 P.M., CNA S said he/she was on the adjoining locked unit, when he/she heard Resident #74 yelling. He/she said he/she heard something being thrown, and he/she called the code. Additionally, he/she said he/she did not go to the other unit, where the altercation was, because he/she had to stay on the locked unit he/she was assigned to. During an interview on [DATE] at 4:30 P.M., CNA Q said maintenance staff were completing 1:1's with the residents when he/she arrived back on the unit. Additionally, he/she went on to say the ADON, CMT R, and CNA S were covering the unit while he/she was on break. During an interview on [DATE] at 4:20 P.M., Resident #59 said, on [DATE], Resident #74 kicked him/her out of his/her room. He/she said Resident #74 was talking like he/she wanted to hurt him/her and then they got into it. He/she went on to say he/she hit his/her eye on a table, and both of them hit the tables. Furthermore, he/she said staff did not come in and split them up. During an interview on [DATE] at 4:40 P.M., Resident #74 said, on [DATE], he/she had moved Resident #59's bed away from the heater, told him/her not to put it back, and went to the dining room. He/she said both residents exchanged words in the dining room. Furthermore, the resident said he/she stood up but did not advance towards Resident #59. The resident went on to say Resident #59 charged him/her, and they both fell . He/she said he/she hit the wall, hit his/her shoulder, and jammed his/her finger. Additionally, he/she said Resident #59 hit him/her in the left eye and right arm. The resident said he/she was back on his/her feet, and Resident #59 was walking down the hall when staff got to the dining room. During an interview on [DATE] at 10:35 A.M., CMT R said there is supposed to be someone on both adjoining, locked units at all times. He/she said staff are expected to verbally communicate with each other when they go on breaks. He/she went on to say our communication was bad the day the residents got into an altercation. Furthemore, he/she said staff failed to let each other know when they were leaving the unit for breaks. During an interview on [DATE] at 2:45 P.M., the DON said there should always be a staff member on each of the adjoining locked units, and he/she expected the CNAs to communicate with the nurses and CMTs to coordinate break times. Furthermore, he/she said he/she did not know who was on the unit when the resident's got into an altercation because the staff who were supposed to be there were not the ones who intervened. He/she said the staff on the adjoining locked unit had to call the Code Green. He/she said there should absolutely have been someone on the unit, and there should always be someone on the unit in case something goes on. He/she went on to say the incident may not have escalated to the point it did if there had been a staff member on the unit. During an interview on [DATE] at 11:15 A.M., the ADON said there is one CNA on each of the two secured units. He/she said the CNAs are supposed to rotate breaks and are assigned either break one, two, or three, which is on their daily CNA sheet. He/she said when one gets back they let the other know so there is always someone on the hall. He/she was not certain of the times of the breaks but knew they were after the resident's meals. During an interview on [DATE] at 1:00 P.M., the DON said he/she keeps the CNA sheets that have the assigned break times on them in his/her office and would have them for [DATE] if they had been completed. He/she said he/she would send those to the surveyor. The facility did not provide the surveyor with the completed CNA sheets for [DATE]. 3. Review of the facility's Post Fall Protocol, dated ,[DATE], showed the Protocol directed the staff as follows: -Immediate vital signs are to be taken and include: temperature, respirations, pulse, blood pressure, oxygen saturations and neurological assessment (if fall was unobserved, if resident hits any part of head or if resident is cognitively impaired). Neurological assessments (neuro checks) include assessment of Level of Consciousness, movement of extremities, hand grasps, pupil size, pupil reaction, and speech; -Documentation of a resident fall must be completed in the medical record and includes but is not limited to incident details, description of injuries, actions taken, residents condition at time of the incident, including but not limited to medications taken in the last eight hours, other current conditions and co-morbidities, usual mobility and mental status, restraints if any, side rails if any, and bed height is applicable, details of the incident including but not limited to a narrative of the incident, injury if any, actions taken to minimize reoccurrence, immediate actions taken, witness statements, and resident's account of the incident; -Continue neuro checks and vital signs every 15 minutes for one hour, every 30 minutes for one hour, every four hours until follow-up complete. Progress along this time schedule only if signs are stable, any abnormalities are to be reported to the physician within 15 minutes; -Update care plan to include individualized interventions with the date, refer to therapy department with screens and if needed, evaluation and treatment to prevent reoccurrence; -DON/RN/designee to complete medical record review within 24 hours of falls and incidents; -Reassess FRAPP (focused risk assessment plan scope and severity) level and interventions for falls. Review of the facility's FRAPPS levels showed the following: -Level 1 is minimal risk with a score of ,[DATE]. Interventions include intensive monitoring/15 minute checks, environmental assessment to ensure the floor and pathways are free of clutter and spills, lighting is adequate, and clothing and footwear is assessed for appropriate size; -Level 2 is potential for more than minimal harm with a score of ,[DATE] and 1 fall with no significant injury. Interventions include doctor and guardian notified of interdisciplinary interventions, therapy assessment completed and interventions placed for assistive devices, gait and positioning assessed by therapy, appropriate footwear assessed, rule out any medical antecedents, obtain lab work for medications, intensive monitoring; -Level 3 is the potential for actual harm with a score of ,[DATE] and 2 or more falls with no significant injury. Interventions include intensive monitoring/five minute face checks, dietary and pharmacist consult if determined by interdisciplinary team, high priority list, physician and guardian notified of interdisciplinary interventions, DON/designee to assess care plan and interventions, Therapy to evaluate and implement interventions for assistive devices, MDS/CPC to address plan of care for the resident, in-servicing to all direct care staff on plan of care for resident's needs related to falls; -Level 4 is immediate jeopardy with a score greater than 35 and two or more falls with one significant injury. Interventions include hospitalization , 30 day discharge, immediate discharge, high priority list, physician and guardian notified of interdisciplinary interventions, therapy director to review therapy interventions, family care plan and/or discharge notice if facility is unable to meet the resident's needs, administrator/designee and DON/designee to review care plan and interdisciplinary interventions, 1:1 initiated while awake, bed alarm and individualized interventions while sleeping. Review of Resident #75's care plan, dated [DATE], showed the resident had a history of [REDACTED]. The care plan instructed the staff as follows: -Stand by assist for all ambulation; -Required one person limited assistance with all ambulation; -Required two person extensive assist usually with bed mobility; -Required two person extensive assist with all transfers, had been using a hoyer (mechanical) lift at prior facility; -Required two person assist with repositioning to avoid skin friction/shearing; -Used mechanical lift to avoid skin friction/shearing; -And the care plan did not include side rail, or chair and bed alarm use. Review of the resident's Certified Nursing Assistant (CNA) care card, undated, instructed the staff as follows: -The resident required assist of two for turning and repositioning, and routine toileting; -Mechanical lift left blank; -Adaptive devices including body alarm, chair alarm, and bed alarm was left blank; -Assistive devices including side rails, positioning devices, low bed, floor mat, and padded side rails was left blank; -And FRAPSS fall risk, level 1 (minimal risk for falls). Review of the resident's nurse's notes showed staff documented the following: -On [DATE] at 10:35 A.M., at approximately 9:35 A.M. the resident was observed on the floor after the bed alarm was heard. Upon entering the room, the resident was lying on the right side of the bed between the bed and the nightstand with his/her body on the fall mat and head on the floor. The resident had blood coming from the left side of his/her head. Pressure was applied to the area and EMS (emergency medical services) were contacted. The resident was transported to the hospital for evaluation; -On [DATE] at 4:59 P.M. the resident returned from the hospital at approximately 2:30 P.M. with three sutures by the left eyebrow. Neuro checks were intitiated upon return. Facility staff did not provide the completed neuro check forms for the fall on [DATE], when requested by the survey staff. Further review of the resident's care plan and CNA care card showed staff did not update them with new interventions, following the fall, with injury, on [DATE]. Additional review of the medical record showed an order, dated [DATE], for bilateral upper half side rails to bed, due to safety awareness and mobility assistance. Review of the resident's nurse's notes showed staff documented the following: -On [DATE] at 6:21 A.M., at 3:30 A.M. the nurse responded to an alarm going off on the resident's hallway. The resident was lying on the floor, half on the floor and half on the mat on his/her back. He/she had rolled out of the bed. The resident complained of pain in his/her left elbow and was unable to straighten it. Range of Motion (amount of movement around a specific joint or body part) (ROM) in left arm was limited. The resident was assisted to bed and neuro checks were initiated; -On [DATE] at 3:58 P.M., mobile X-ray was on site at approximately 2:00 P.M. Preliminary photos were concerning to the staff. The family nurse practitioner (FNP) was notified and the resident was transported to the hospital for further X-rays; -On [DATE] at 5:43 A.M., the resident returned to the facility during dinner last evening. He/she had a 90 degree hard splint for a [MEDICAL CONDITION] radial (long bone of lower arm) and ulna (long bone of the lower arm) head deformity. It was wrapped with an ACE wrap (elastic bandage) and secured with a sling (a flexible strap used to support weight). The resident kept saying he/she was trying to get up and that could be how he/she fell . He/she had rails on his/her bed now but was a strong, independent resident; -On [DATE] at 4:23 P.M., alarms were in use for the bed and chair. The resident had increased confusion; -On [DATE] at 10:33 P.M., the resident was very confused and staff were unable to keep the resident in bed. The resident was currently in the hallway in a wheelchair with the alarm on. The resident continued to try to get up. The resident was in bed for a short while but continued to try to get up. Facility staff did not provide the completed neuro check forms for the fall on [DATE], when requested by the survey staff. Further review of the resident's care plan and CNA care card showed staff did not update them with new interventions following the fall, with injury, on [DATE]. Observation on [DATE] at 3:55 P.M. showed the resident up in his/her wheelchair in his/her room watching T.V. Elevating leg rests were in the seat of a chair across from the resident. Further observation showed the resident's feet rested on the floor. He/she had regular socks on with no shoes. The wheelchair alarm was in position on the wheelchair but was not turned on. Observation on [DATE] at 1:42 P.M. showed the resident in a wheelchair at the dining room table with his/her eyes closed. Further observation showed elevating leg rests were on the wheelchair, but the resident's legs were between the leg rests, and his/her feet were on the floor. Additional observation showed the resident wore regular socks with no shoes. The chair alarm was in position but not turned on. Staff were in and out of the dining room, leaving the resident unsupervised for up to two minutes at a time. Observation on [DATE] at 1:50 P.M. showed CNA H and CNA I took the resident to his/her room. CNA H placed a gait belt on the resident. The CNAs stood on each side of the resident, hooked their arm closest to the resident under the resident's axilla (armpit), and held onto the gait belt with the hand furthest away from the resident. The CNAs lifted the resident from the chair and pivot transferred (a transfer were one or both legs bears some weight to help spin from one surface to another) the resident to the edge of the bed. During the transfer the resident did not lift his/her feet and CNA H released his/her hand from the gait belt and used only his/her arm under the resident's axilla to lift the resident onto the bed. CNA I said the resident did not bear very much weight and did not pick up his/her feet. The chair alarm did not sound when the resident was lifted out of the chair but did alarm after CNA H turned it on. CNA I said therapy had gotten the resident up. Further observaton, showed the CNAs pulled up bilateral full side rails before they left the room. During an interview on [DATE] at 3:45 P.M., CNA H said when staff use gait belts for transfers they should hold onto the side of the belt and the back of the belt. He/she said staff should not lift a resident under the arms during a transfer. Additionally, he/she said he/she did not notice he/she had lifted the resident under his/her arms during the previous transfer. During an interview on ,[DATE] 21 at 6:35 P.M., LPN G said neuro checks are documented on paper and go in the resident care coordinator's (RCC) box along with the fall packet after they are completed. He/She said staff are supposed to complete neuro checks after unwitnessed falls. He/she went on to say the resident had side rails, a chair alarm, and staff would lower the bed to help prevent falls. Additionally, he/she said he/she did not realize the resident was a fall risk. During an interview on [DATE] at 6:40 P.M., CNA F said interventions in place to prevent the resident from falling were using a gait belt, and the side rails on the bed. He/she went on to say staff used to use fall mats, but now they use the side rails. He/she said he/she lowers the bed in case the resident would come out of the bed. During an interview on [DATE] at 2:10 P.M., LPN D said he/she was passing medications, on a different attached unit, when the resident fell on [DATE]. He/she said when he/she entered the room the resident was lying with his/her body on the mat and head on the floor. LPN D said the resident tried to get up sometimes when he/she was not supposed to. He/she went on to say, there were no side rails on the bed at the time of the fall but they were put on that day. During an interview on [DATE] at 2:45 P.M., the DON said after a fall, staff should implement new interventions immediately, and the interventions should be added to the care plan. He/she said bed and chair alarms do not prevent falls, but residents with chair alarms should have them turned on when they are up. He/She said when the resident fell on [DATE], side rails were on the bed but he/she did not know if they were up or not. He/she said he/she thought the ADON completed the investigation. During an interview on [DATE] at 11:15 A.M., the ADON said either he/she or the DON are responsible for completing fall investigations. He/she said if he/she had completed a fall investigation for the [DATE] fall it would be in the computer, and it was not. During an interview on [DATE] at 1:00 P.M., the DON said the resident had multiple falls at home and prior facility. He/She went on to say, the resident had no safety awareness, and thinks he/she should be able to get up. He/She said CNAs are made aware of alarm and side rail use by the CNA care card, and Licensed nurses are made aware by relaying it in report and the care plan. During an interview on [DATE] at 6:00 P.M., LPN C said on [DATE] the resident was found lying on his/her left side and had rolled off the bed. He/she said the bed was in the normal bed position. He/she said the resident did not have side rails on the bed at the time of the fall but they were put on afterwards as a safety precaution. He/she said he/she was not aware the resident had an order for [REDACTED]. Furthermore, he/she said the resident had a bed alarm because he/she moved about a lot and reached for things while he/she was in bed, and a chair alarm because staff did not want him/her to get out of the chair. Additionally, he/she said the resident had never fallen out of the chair.

Based on observation, interview, and record review facility staff failed to ensure scheduled narcotic pain medication was available for two residents (Resident #41 and #76), failed to document the reason the residents missed doses and the effects on the residents, and failed to document measures they took to obtain the medications. Furthermore, facility staff failed to control the resident's pain while the medication was unavailable. The facility census was 229. 1. Review of the facility's Ordering and Ensuring Scripts are Provided to Pharmacy policy, dated 7/2014, instructed staff as follows: -The director of nursing (DON) will assign a Licensed Nurse (LPN) or Registered Nurse (RN) to be responsible during business hours, of monitoring all narcotics (drugs that dull the sense of pain and cause drowsiness) in the facility for the need to obtain a written prescription to ensure availability of the narcotic medication; -The LPN/RN nurse will review all routine and as needed (PRN) narcotic medication orders with the available mediation in the facility, daily, to ensure that at least three days' worth of the medication is available; -In the event the narcotic medication has three days remaining, the LPN/RN will reorder the medication from the pharmacy. If the medication requires a written, signed prescription from the prescribing physician, the LPN/RN will contact the physician during office hours. The LPN/RN will ensure the prescription has been received by the pharmacy within 24 hours; -All routine and PRN narcotic pain medications that are ordered by the LPN/RN will be checked within 24 hours, to ensure they were delivered to the facility; -If the narcotic medication was not delivered to the facility, the LPN/RN will re-order the medication and contact the pharmacy directly to verbally confirm its arrival to the facility; -The LPN/RN will ensure all residents who are taking routine or PRN medication for pain have an emergency PRN pain medication in the event the primary/routine pain medication is not available. The LPN/RN will notify the Primary Care Physician (PCP)/prescribing physician of the request for an emergency pain medication until the primary pain medication arrives; -And at any time a medication is not available in the facility, the charge nurse/certified medication technician (CMT) will notify the resident care coordinator (RCC)/designee, DON/assistant DON/RN/designee, Administrator/designee, Legal Guardian and PCP/prescribing physician. Any further orders will be followed. 2. Review of Resident #41's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff), dated 11/13/20, showed staff assessed the resident as: -Cognitively intact; -[DIAGNOSES REDACTED]. -Had been on a scheduled pain medication regimen in the last 5 days; -Had not received PRN pain mediation in the last 5 days; -Had not received non-medication interventions for pain in the last 5 days; -And received no opioids (controlled substance used for pain such as [MEDICATION NAME]) in the last 7 days. Review of the resident's Medication Administration Record [REDACTED].M.), noon, and evening (P.M.). Review of the resident's Individual Patient Narcotic Records showed: -On 7/23/20 at 10:30 A.M., staff removed one tablet of [MEDICATION NAME]/APAP 5/325mg and zero tablets remained; -On 7/30/20 at 2:00 A.M., seven days after the last dose was available, [MEDICATION NAME]/APAP 5-325mg, 90 tablets, arrived from the pharmacy. During the investigation staff could not provide documentation they received the resident's narcotic pain medication from the pharmacy or documentation they removed the medication from the facility's StateSafe from 7/23/20 to 7/30/20, when 90 tablets of [MEDICATION NAME]'/APAP 5-325mg, arrived from the pharmacy, seven days after the resident's last reconciled dose. Review of the resident's care plan, dated 8/14/20, showed staff documented the resident experienced constant pain due to a history of multiple fractures. Staff were directed to evaluate pain daily, administer pain medication as ordered, assist with diversional activities and changing positions slowly, teach distraction techniques, and monitor for worsening of pain symptoms, and report to physician. Review of the resident's MAR, dated 10/15/20-11/14/20, showed the following: -an order for [REDACTED]., noon, and P.M.; -Staff did not document they they administed [MEDICATION NAME]/APAP 5-325mg on 10/29 for the resident's P.M. dose, 11/2 for his/her noon and P.M. doses, 11/8 for the noon and P.M. doses, and 11/12 for the noon and P.M. doses. -Staff circled [MEDICATION NAME]/APAP 5-325mg as not administered on 10/30 for the resident's A.M., noon, and P.M. doses, 10/31 and 11/1 for his/her noon and P.M. doses, 11/2 for his/her A.M. dose, 11/3 for his/her noon and P.M. doses, 11/4-11/7 for his/her A.M., noon and P.M. doses, 11/8 for his/her A.M. dose, and 11/9-11/11 for his/her A.M., noon, and P.M. doses. Additional review, showed staff did not document the reason for the missed doses; -[MEDICATION NAME] (non-narcotic pain medication) 325mg two tablets were given on 11/8/21 at 10:30 A.M. for resident complaint of a headache. Further review showed, staff documented the [MEDICATION NAME] were ineffective; -And from 10/29/20 to 11/11/20 staff did not assess the resident's pain on the night shift on 10/29, 11/3, and 11/8. Furthmore, the MAR indicated [REDACTED]. Review of the resident's Individual Patient Narcotic Records showed the following: -On 10/29/20 at 4:00 P.M., staff signed out [MEDICATION NAME]/APAP 5-325mg, one tablet, and zero tablets remained; -On 11/2 at 8:00 A.M. the resident received [MEDICATION NAME]/APAP 5-325mg, 4 tablets, were signed out 11/2 at 8:00 A.M., 12:00 P.M., and 4:00 P.M. and 11/3 at 12:00 P.M.; -And on 11/12/20 at 3:00 A.M. [MEDICATION NAME]/APAP 5-325mg, 90 tablets, arrived from the pharmacy. During the investigation staff could not provide documentation they received the resident's narcotic pain medication from the pharmacy or documentation the medication had been removed from the facility's StateSafe from 10/29/20 to 11/2/20. On 11/2 staff documented the resident received 4 tablets of [MEDICATION NAME]/APAP 5-325mg. Three tablets were given on 11/2 and one on 11/3. Staff could not provide documentation they received the resident's narcotic pain medication from the pharmacy or documentation the medication had been removed from the facility's StateSafe for the 4 doses. Further staff could not provide documentation they received the resident's narcotic pain medication from the pharmacy or documentation the medication was pulled from the Statsafe from 11/3/20 to 11/12/20, 9 days after the resident's last reconciled dose. Review of the resident's social service note, dated 11/9/20, showed the resident ambulated independently with a steady gait but complained of constant pain in his/her back from injuries in his/her younger life. During an interview on 1/19/21 at 11:25 A.M. the resident said he/she takes scheduled pain pills three times a day and he/she rated his/her pain a 7, on a scale of 1-10, with 10 being the worst pain felt. Additionally, he/she said the facility ran out of his/her [MEDICATION NAME]/APAP for a week and a half. He/she said his/her pain got up to a 10, and was very, very bad. During an interview on 1/26/21 at 4:40 P.M., CMT B said staff get narcotic pain medication from the StatSafe (a locked cabinet provided by the pharmacy that contains stock medications for resident use) when a resident runs out of it until they get a prescription. Sometimes the nurse is able to get two days' worth. He/She said staff pull the reorder sticker on the medication card when it gets to number eight and send it to the pharmacy. The pharmacy sends a fax to the facility if they cannot refill a medication. The pharmacy usually calls the physician to get prescriptions. It usually takes a couple of days but has taken longer to get the prescriptions. His/her initials were circled on Resident #41's MAR because the resident was out of the [MEDICATION NAME]/APAP and there were not any in the StatSafe. He/she should have written the reason for the missed dose on the back of the MAR. 2. Review of Resident #76's Physician order [REDACTED]. -[DIAGNOSES REDACTED]. -an order for [REDACTED].>-[MEDICATION NAME] 325mg take two tablets by mouth every four hours as needed for pain or fever; -And [MEDICATION NAME] (medication used to relieve moderate to moderately severe pain) 50mg take one tablet by mouth every six hours as needed for pain. Review of the resident's MAR, dated 10/15/20-11/14/20, showed: -Pregabalin 200 mg A.M. dose was circled as not administered on 11/3-11/6, further review showed the MAR indicated [REDACTED] -Pregabalin 200 mg HS dose was circled as not administered on 11/4-11/6, further review showed the MAR indicated [REDACTED] -And the resident's [MEDICATION NAME] and [MEDICATION NAME] were not administered from 11/1/20-11/6/20. Review of the resident's Individual Patient Narcotic Records showed: -On 10/31/20, staff removed a dose of Pregabalin 200 mg from the A.M. card and zero tablets remained; -On 11/1/20, staff removed a dose of Pregabalin 200 mg at 8:00 A.M. from the P.M. card and two tablets remained; -On 11/1/20 and 11/2/20, staff removed a dose of Pregabalin 200 mg from the P.M. card and zero tablets remained; -And on 11/7/20, the facility received an A.M. and P.M. card of Pregabalin 200 mg. During an interview on 1/29/21 at 11:15 A.M., LPN A said when staff reorder medications they are to pull the sticker off of the medication card and fax it to the pharmacy that day. He/She said staff are supposed to call the pharmacy or get the medication from the StatSafe if the resident is completely out. He/she said staff are supposed to call the pharmacy if the resident runs out of a narcotic pain medication. Furthermore, he/she said the pharmacy is responsible for getting the prescription from the physician. He/she said when resident #41 ran out of [MEDICATION NAME]/APAP, last November, He/she said the physician was aware. He/she went on to say the physician was not made aware of Resident #76 running out of his/her Pregabalin. Additionally, He/she said medication errors were not completed for the missed doses for either resident and the CMTs should circle their initials and write the reason for the missed dose on the back of the MAR. During an interview on 1/29/21 at 2:45 P.M., the DON said when staff reorder medications they should pull the reorder sticker from the medication card five days before the resident runs out. He/she went on to say if a resident runs out of a narcotic pain medication, he/she would expect staff to get it from the StatSafe. He/she said if the StatSafe runs out of the medication, staff should call the pharmacy to get it refilled. He/she said the nurses on the unit should call the physician to let them know if a prescription is needed, and the nurse or RCC on the unit is responsible for obtaining the prescription. Furthermore, he/she said medication errors should absolutely be completed, and the physician notified when doses of a medication are missed; and staff should document the missed medication in the nurse's notes. Additionally, he/she said he/she would expect the CMT to notify the charge nurse when a resident is out of a medication and document it on the back of the MAR. During an interview on 2/3/21 at 1:00 P.M., the DON said the nurses should call the physician before a resident runs out of pain medication in order to get a prescription. He/she said the facility calls the pharmacy to fill the StatSafe but that can be an issue if there is more than one resident who runs out of that medication. Furthermore, he/she said the nurses should notify the physician when a resident runs out of pain medication, because they are not following physician orders [REDACTED]. During an interview on 2/22/21 at 11:20 A.M., the residents' physician said he/she did not know what happened with the medications. He/she was only able to see when a prescription was generated. The facility staff are supposed to notify the pharmacy three days before the resident is out of a medication, the pharmacy notifies him/her, and a prescription is generated on-line. He/she went on to say if that did not happen in 24 hours, he/she would expect the facility to contact the office to find out why they did not receive the ordered medication. He/she said if a resident is completely out of a medication he/she would expect the facility to contact the office to get permission to remove the medication from the E-kit (StatSafe) and that would generate another prescription. MO 179, MO 947, and MO 007

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) was free from physical abuse. Review of facility surveillance video showed Resident #1 and the administrator in a physical altercation that resulted in the administrator pushing the resident about 15 feet, then taking down the resident to the floor. The facility census was 235. Review of the facility abuse policy, revised 08/28/18, showed every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Review showed the policy of the facility is every resident has the right to be from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. Review showed the policy defines physical abuse as purposefully beating, striking, wounding, or injuring any consumer or any manner whatsoever mistreating or maltreating a consumer in a brutal or inhumane manner. Physical abuse includes handling a consumer with any more force than is reasonable for a consumer's proper control, treatment or management. Review of the facility's Crisis Alleviations Lessons & Methods (CALM) Workbook, showed the most effective and safe crisis intervention techniques occurs during the early verbal stages. Review showed the CALM workbook directs staff to: -Look for a win-win solution during verbal de-escalation; -First sign in any situation where someone is threatening, get help; for self protection, staff should block and move and look for an exit; -When creating a crisis response team, it should ideally be made up of 6-8 people; -During a five person take down the team leader is responsible for maintaining the safety of the resident's head, the next two people responding are responsible for the clients arms, and the last two people are responsible for the client's legs. After a five person take down there should be a debriefing that focuses on staff and client well being. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/08/19, showed staff assessed the resident as follows: -Cognitive; -Has delusions; -Other behavioral symptoms not directed towards others; -[MEDICAL CONDITION]; -[MEDICAL CONDITION]. During an interview on 02/07/19 at 9:24 A.M., the administrator said he was sitting one-on-one with the resident on 02/04/19 due to a previous incident. The administrator said the resident asked for a cigarette. The administrator said he told the resident, I can't get you a cigarette. Why should I give you a cigarette, when you pulled the fire alarm and tried to elope? The administrator said the resident said something about killing everybody. The administrator said the resident then pushed the administrator to the wall. The administrator said he pushed the resident away from him, grabbed the resident's arms and around the resident's waist and they went to the floor. Review on 02/06/19 of the facility surveillance video for 02/04/19 showed the resident and the administrator walked in the hallway of the unit by the nurse's station. Review showed the resident and administrator continued to walk past the nurse's station and the resident then pushed the administrator up against the wall next to the nurse's station. Review showed the administrator pushed the resident on his/her chest with his hands and continued to push the resident backwards into the hallway across from the nurse's station (approximately 15 feet). Review showed the administrator placed his arms around the resident's shoulder and under the arm and then put the resident on the floor. Additional review showed the administrator continued to hold the resident on the floor while additional staff approached them. During an interview on 02/06/19 at 3:02 P.M., certified nursing assistant (CNA) C said he/she was in the hallway, at the nurses' station and turned around to call a Code Green (request more staff assistance), then turned back around and witnessed the administrator take down the resident. CNA C said the resident pushed the administrator and then the administrator grabbed the resident. The CNA said it wasn't a normal takedown, but the resident is so strong, he/she could have hurt someone. The CNA said the administrator was bear hugging the resident to keep him/her from hitting. The CNA said he/she didn't know what to do with the administrator holding him/her in the air, so he/she went for the resident's legs. During an interview on 02/07/19 at 2:32 P.M., the director of nursing (DON) said five staff members then held the resident down, injected [MEDICATION NAME] (Antipsychotic) and [MEDICATION NAME] (used to relieve anxiety), and they did not release the resident until he/she was calm about fifteen minutes later. During an interview on 02/08/19 at 1:01 P.M., CNA H said the resident was freaking out, which he/she was doing all night. The CNA said the administrator stepped into the resident's face and the resident became agitated and pushed the administrator into the wall. The CNA said he/she saw the administrator grab the resident's hands and the resident said, get off, and was trying to push the administrator off him/her. The CNA said the administrator kept picking the resident up to put the resident on the ground. The administrator tried to take the resident to the ground by himself. The administrator picked the resident up and they ended up on the other side of the hall. The CNA said there was not five people for the takedown. The CNA said what he/saw was abusive. During an interview on 02/08/19 at 4:53 P.M., resident aide (RA) J said he/she heard what sounded like someone getting pushed up against wall. The RA said he/she was in the kitchen at the time. The RA said he/she came out and the administrator had the resident and was taking him/her down. The RA said it looked like the administrator had him/her in some kind of lock, and the administrator took the resident down himself. The RA said none of the nurses were doing anything. The RA said once the resident was down, other staff came to help. The RA also said the staff was holding the resident down, when they gave him/her a shot. During an interview on 02/06/19 at 11:05 A.M., RA A said there is a five man takedown and a nurse has to be present. Other than that you really can't touch a resident. During an interview on 02/06/19 at 11:22 A.M., licensed practical nurse (LPN) B said it takes five staff to take a resident down. Staff should not take a resident down by themselves. During an interview on 02/06/19 at 11:29 A.M., the unit director said there has to be five people to put hands on a resident for a take down, if you have four you can't do it. The unit director said he/she teaches staff to call 911 if there is not enough people. One person should never restrain a resident. During an interview on 02/06/19 at 11:43 A.M., the DON said at least five staff members have to be there to perform a takedown. She said staff are not to do a takedown by themselves. She said staff would be disciplined if they did not have five people, because they could hurt themselves and the resident. That is against CALM She said we absolutely do not teach headlocks in our restraint class. During an interview on 02/06/19 at 3:20 P.M., the DON said it wasn't until he/she watched the video, he/she saw the headlock. The DON said they are not suppose to put a resident in a headlock. The DON said he/she did not see abuse. The DON said the technique the administrator used was not by the book and said they should not take residents down with one staff. During an interview on 02/06/19 at 12:20 P.M., the unit director said he/she did not teach takedowns like the one the administrator did to the resident as shown on the surveillance video. He/She said in the video there was not adequate staff to put hands on a resident. He/She said the technique the administrator used in the video is not proper technique. He/She said if a resident pushed him/her against a wall, he/she would try to escape or call for help, not put the resident in a choke hold. He/She said a head lock is never okay. During an interview on 2/6/19 at 12:50 P.M., the social service director (SSD) said he/she is a CALM instructor. The SSD said he/she does not teach what is shown on the video of the resident and the administrator. The SSD said there is not enough people there to do a five point takedown. He/She said if staff can get away from an aggressive resident, they should try to get away. The SSD also said they are trained to release a resident as quickly as possible. It's not a one on one. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility suspended the administrator and started in-servicing staff on the Abuse/Neglect, Grievance Policy and Procedure. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 553

Based on interview and record review, the facility failed to implement interventions known to help de-escalate two resident's behavior (Resident #1 and #2) when the residents had increased agitation. Facility staff planned to allow Resident #1 to smoke when his/her behaviors escalated in an effort to calm the resident. However, staff instead removed smoke breaks as a result of escalating behaviors for the resident. The resident's behavior escalated over several days and resulted in the facility staff taking down and injecting antipsychotic and antianxiety medication into the resident prior to sending the resident out for an inpatient psychiatric evaluation. Facility staff planned to allow Resident #2 to smoke when his/her behaviors escalated in an effort to calm the resident. However, staff instead decreased the resident's smoke times, when staff believed the resident intentionally exhibited behaviors to increase his/her smoke times. The facility census was 235. Review of the Crisis Alleviations Lessons & Methods (CALM) Workbook, undated, showed direction for staff that the most effective and safe crisis intervention techniques occur during early verbal stage. It further instructs staff to be client focused, respectful, allowing personal space. When approaching a crisis, focus on crisis de-escalation and a successful outcome. Look for a win-win solution. The listener should practice active listening. Look for crisis turning point events, this occurs when a situation increases stress to an unmanageable level. The very same crisis neurochemistry that exists in the client when they are escalating out of control, exists in you. Maintain a rational response, and use your team to keep you centered and focused. The first sign in any situation where someone is threatening, is to get help. This part of the process is identified by the facility as Code Green (request for additional staff), or notification system for staff to respond to crisis situation. Look for an exit. 1. Review of Resident #1's face sheet showed the resident's [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 10/09/18, showed the plan directed staff to care for the resident as follows: -Resident is able to make needs known without difficulty; -Ask the resident his/her preferences; -Resident can make daily decisions; -Provide a quiet distraction free environment for discussing important subjects; -Allow resident to verbalize how he/she may be feeling in a nonjudgmental manner; -Attempt to redirect any inappropriate behavior, do not argue with resident; -Assist resident to remove himself/herself from the situation as he/she may need. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Brief Interview of Mental Status (BIMS) score of 15 (indicating cognitively intact); -No verbal or physical behaviors exhibited; -Independent with all activities of daily living; -[DIAGNOSES REDACTED]. -Received Antipsychotic and Antidepressant medications seven days of the seven day look back period. During an interview on 02/07/19 at 10:55 A.M., the house supervisor said they took the resident out for cigarette breaks and verbal de-escalation to deal with the resident's increased behaviors. During an interview on 02/07/19 at 10:31 A.M., the [MEDICAL CONDITION] (TBI) unit manager said interventions to help the resident de-escalate included speaking to the administrator or unit manager on the phone. Review of the resident's nurses' notes, dated 10/16/18, showed staff documented the resident noted to be in a peer's room during hourly checks. Staff documented the resident was asked to leave the room per unit guidelines and the resident became verbally loud and abusive towards staff and peers. Staff documented the resident threw an ice chest in the common area, and all linens off of clean linen cart. Staff did not document any behavioral interventions to address the resident's behavior. Review of the resident's nurses' notes, dated 11/02/18, showed staff documented the following: -4:50 P.M., resident became verbally aggressive with staff and threatening to hurt others. Notified director of nursing (DON) and administrator. Monitor resident for further disruptive behavior; -4:55 P.M., resident verbally aggressive with staff and peers. Attempted to redirect resident without success. Resident continued with verbal aggression. Resident pacing the halls with verbal outbursts throughout the unit. Resident entered room and exited with his/her footboard. Phoned physician for PRN (As Needed) order. Oral [MEDICATION NAME] (Used to relieve anxiety) 2 milligrams (mg) and [MEDICATION NAME] (Antipsychotic) 5 mg administered at this time. Resident without verbal outbursts after [MEDICATION NAME]/[MEDICATION NAME] administered. -5:10 P.M., resident pacing halls with verbal outbursts at this time. Resident requesting other medications to ease his/her thoughts of hurting self and others. Encouraged resident to go sit down and relax for awhile. -5:20 P.M., resident entered the halls verbally aggressive with staff and became physically aggressive with staff. Code green called at this time. The nurse entered unit and administered [MEDICATION NAME] (Antipsychotic) 10 mg injection to resident. -5:40 P.M., resident reapproached writer requesting [MEDICATION NAME] (Antipsychotic), [MEDICATION NAME] (Used to relieve Anxiety), or [MEDICATION NAME] scheduled or PRN. Informed the resident to speak with charge nurse Monday for the psychiatrist to be notified. Further review showed staff did not document they utilized non-pharmacological interventions known to work for the resident prior to administering antipsychotic medications. Review of nurses' notes, dated 12/18/18, showed staff documented the following: -At 12:40 A.M., staff documented the resident up in the hallway yelling/cursing, demanding a cigarette, was told No. Resident continued yelling and cursing, and staff called a code green. -At 1:10 A.M., staff documented the resident continued to yell and curse. The resident removed his/her shirt in the dining room. The resident head-butted another resident and staff called a Code Green. Attempted to take resident down. Resident began hitting other residents. [MEDICATION NAME] 5 mg with [MEDICATION NAME] 2 mg given IM. Additional review of the nurses notes showed staff did not document they attempted non-pharmacological interventions known to work for the resident prior to calling a code green or administering as needed medication. Review of the resident's nurses' notes, dated 01/31/19 at 1:00 A.M. (late entry), showed staff documented the resident was yelling/kicking doors. The resident requested to go outside to smoke. Staff told the resident, Due to current temperature, cannot go out right now. Resident took a fire extinguisher to his/her room and said, it will be fun. Resident took staff's personal belongings, cigarettes, went to his/her room and smoked in the bathroom. He/she said he/she used a battery and paperclip to light the cigarette. Review of the resident's nurses' notes, dated 01/31/19 at 10:39 A.M., showed staff documented around 7:50 A.M., the resident walked down the hallway and kicked the bedside table a few times and then threw linen on the floor. Staff did not document any interventions to address his/her behavior. Review of the resident's nurses' notes, dated 01/31/19 at 9:43 A.M., showed staff documented the resident pushed over a linen cart in the hallway. Additional review showed staff did not document they attempted non-pharmacological interventions known to work for the resident. Review of the resident's nurses' notes, dated 02/01/19 at 10:10 A.M., showed staff documented the resident paced the halls and put cigarette butts in his/her pocket to take to his/her room. Staff did not document any interventions to address the resident's behavior. Review of the resident's nurses' notes, dated 02/04/19 at 10:02 A.M., showed staff documented the resident was pacing the hall and dug through the cigarette butt can. Staff did not document any interventions to address the resident's behavior. Review of the resident's nurses' notes, dated 02/05/19 at 12:21 A.M., showed staff documented at 11:04 P.M. on 02/04/19, the resident pulled the fire alarm and ran out the door. Staff returned the resident to the facility and placed him/her on one-on-one staff monitoring. During an interview on 02/06/19 at 3:31 P.M., house supervisor/licensed practical nurse (LPN) D said after the resident pulled the fire alarm on 02/04/19, they called the administrator in to the facility to sit one-on-one with the resident. During an interview on 02/07/19 at 9:24 A.M., the administrator said on 02/04/19 when he came to sit one-on-one with the resident, the resident asked for a cigarette. The administrator said he told the resident, I can't get you a cigarette. Why should I give you a cigarette when you pulled the fire alarm and tried to elope? The administrator said the resident said something about killing everybody. The administrator said the resident then pushed him to the wall. The administrator said he pushed the resident away from him, grabbed the resident's arm and around the resident's waist and they went to the floor. The administrator said once the resident calmed down the resident was released from the take down and then we took him/her out to smoke. During an interview on 02/07/19 at 2:32 P.M., the DON said on 02/04/19 after the administrator got the resident on the floor, five staff members held the resident down, administered [MEDICATION NAME] and [MEDICATION NAME], and they did not release the resident until he/she was calm about 15 minutes later. During an interview on 02/07/19 at 2:45 P.M., LPN D said on 02/04/19 staff administered [MEDICATION NAME] and [MEDICATION NAME] to the resident, while the resident was still on the floor, according to their protocol. It took about 10 minutes before staff released the resident, and he/she was still struggling. Review of the resident's nurses' notes, dated 02/04/19 at 11:40 P.M., showed staff documented they received an order to send the resident to a psychiatric hospital for evaluation and treatment. During an interview on 02/07/19 at 9:47 A.M., certified nursing assistant (CNA) [NAME] said he/she worked the day shift before the incident occurred. The resident paced and said he/she wanted to go hit the punching bag. The resident kept saying something about a book and acted like he/she was opening a book, but there was nothing in front of him/her. During an interview on 02/08/19 at 11:28 A.M., CNA G said he/she worked during a previous takedown of the resident. CNA said the resident was yelling he/she wanted a cigarette. CNA G said he/she did not think staff took the resident out for a cigarette. The resident started to bang on the nurse's station and they called a Code Green. Two male staff stood by the resident. The resident got in the face of one of the male staff, but did not touch the staff. The staff called for a takedown of the resident. Staff administered an injection while staff held the resident down. CNA G said, I do think Code Green's agitate people, because you have all these people standing in a circle around you, wondering what you are going to do. During interview on 02/07/19 at 4:52 P.M., the facility psychiatrist said staff did not contact him/her regarding the resident's behaviors escalating. 2. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -BIMS score of 15; -Physical and verbal behaviors occurred one to three days of the seven day look back period; -Independent with all activities of daily living; -No range of motion impairments to upper and lower extremities. Review of the resident's plan of care, dated 11/9/18, showed staff are directed to care for the resident as follows: -Redirect resident with conversation, activities of choice, or assist the resident to another area if he/she is upset; -Allow the resident to voice his/her concerns; -Provide a quiet, distraction free environment for important discussions. Review of nursing notes, dated 12/16/18, showed staff documented the resident angry with staff, because roommate slept through both smoke breaks and staff wouldn't allow him/her to go out. Staff documented the resident was reeducated on unit rules regarding smoke times. Staff documented the resident became more angry and stated their rights are being ignored. Resident was reminded of rules again and informed that a smoke break is coming up in 20 minutes. Staff documented the resident said that is not good enough, you will need to take him out now, if you don't, he/she is going to start breaking things and throwing things. Staff documented this writer once again stated the rules to the resident and reminded him/her that I'm required to enforce the rules and that it wouldn't be fair to the other residents if I let his/her roommate go out now and again in 30 minutes. Staff documented the resident continued to threaten staff and flipped the table. Staff documented a code green was called. Review of social services note, dated 12/24/18, showed the social service director (SSD) documented the resident said his/her coping skills are smoking and playing his/her game when he/she is upset. Review of nursing notes, dated 01/15/19, showed at around 2:10 P.M. resident came to the nurse's station wanting to smoke. Staff documented they informed the resident he/she was too late, but could smoke at the next smoke time which is 4:00 P.M. The resident became verbally aggressive and punched at computer, code green called and resident verbally redirected at this time. Review of nursing notes, dated 01/26/19 at 9:49 P.M., showed staff documented the resident up at nurse's station yelling at nurse and medication technician. Staff documented the resident appears upset and stated, if I don't get a cigarette right now I am going to get angry. Staff documented he/she attempted to verbally de-escalate resident, resident then encountered in verbal altercation with another resident. Staff documented the other resident swung at this resident, but no contact was made, staff intervened. Staff documented resident redirected to another room and taken out to smoke by staff at smoke time. Review of nursing notes, dated 01/30/19, showed staff documented a code green was called due to resident yelling and screaming, because he/she could not smoke. Staff documented the resident threatened staff, destroyed the television in the day room and the computer at the nurse's station. Staff documented the resident broke the book shelf and was throwing various objects around the nurse's station. Staff documented the resident made several statements he/she just wants to be dead and he/she should just commit suicide. The resident continued to yell and ram the medication cart into the clean utility room door. Staff documented they attempted to redirect resident without success. Staff documented a five man takedown had to be used on resident. Staff documented they administered [MEDICATION NAME] 5 mg with 2 mg [MEDICATION NAME] mixed dose per the physician direction to the resident. Review of nursing notes, dated 01/31/19, noted late entry for 01/30/19 at 10:00 P.M., showed staff documented the resident verbal, loud towards staff, demanding to go outside and smoke. Staff attempted to verbally de-escalate resident. Resident then damaged facility property. Staff documented a code green called for assistance. During an interview on 02/8/19 at 10:55 A.M., the resident said since the new administrator came to the facility staff are calling a lot of code greens on us for language. During an interview on 02/8/19 at 12:09 P.M., the resident said when staff call a code green, a bunch of staff come and they all stand around him/her. The resident said if he/she busts anything up, they take him/her down. The resident said staff took him/her down for breaking a television and knocking over a book shelf. The resident said he/she wasn't even physically aggressive with staff or residents. The resident said things changed a lot since the new administrator came here. He/She said when staff circle around him/her, it puts him/her in fight mode. He/She said he/she tells staff if they come close to him/her, they are going to get hit. During an interview on 02/08/19 at 12:49 P.M., LPN D said when the resident gets agitated, we try to redirect, allow to verbally vent, let of the unit or go outside for fresh air. During an interview on 02/22/19 at 2:40 P.M., LPN D said there were times staff would let the resident go out and smoke as an intervention, usually it would work, but then tried different things, because he/she would start having behaviors to be able to go out and smoke more. He started taking advantage of that, he/she caught on. We had a facility Ninetendo DS that helped with the behaviors, but when the resident moved downstairs, the resident slammed it on a table and it broke. NOTE: At the time of the abbreviated survey, the violation was determined to be at immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. During the onsite visit, the facility created a corrective action plan. The plan included inservice training to staff which included: recognizing escalating behaviors and applying appropriate behavioral modification interventions; updating residents' care plans with new interventions after each behavioral episode; not allowing punitive interventions; and not limiting smoke breaks when part of a resident's behavioral intervention. At the time of the exit, administrative staff continued to complete inservice training for staff prior to their shifts until they trained all staff. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 553

Based on observation, interview and record review, facility staff failed to promote healing of existing pressure ulcers, when they did not follow physician orders, failed to correctly stage and assess a pressure ulcer, failed to follow the plan of care, failed to obtain a dietary consult related to a new pressure ulcer and failed to complete pressure ulcer documentation for one resident (Resident #4). The facility census was 232. 1. Review of the National Pressure Ulcer Advisory Panel, dated September 2016, showed the following definitions: -Stage 1 pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness). Presence of blanchable [DIAGNOSES REDACTED] and changes in sensation, temperature, or firmness may precede visual changes; -Stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage 3 pressure injury is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage 4 pressure injury is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure injury is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury is intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or stage 4 pressure injury). 2. Review of the facility's Wound Care Policy, dated April 2017, showed the staff are directed as follows: -The Resident Care Coordinator (RCC) (a nurse designated by the facility to be in charge of a hall) is to monitor all abnormal skin conditions weekly; -The RCC will complete a weekly wound report and give a copy to the Administrator, Director of Nursing (DON), Minimum Data Set (MDS)/Care Plan Coordinator and Medical Records Director for weekly review; -The physician/wound consultant will be notified by the RCC when new skin integrity issues are found; -A dietary consult will be requested upon the time of a new area reported. 3. Review of Resident #4's annual MDS, a federally mandated assessment tool completed by staff, dated 08/22/17, showed staff assessed the resident as follows: -Cognitively impaired; -Required extensive assist of two staff members for bed mobility, transfers, toileting, personal hygiene and bathing; -Always incontinent of bowel and bladder; -At risk for pressure ulcers; -A stage 4 pressure ulcer, that measured 3.5 centimeters (cm) long by 3.5 cm wide by 3.0 cm deep, with the most severe tissue type being granulation; -Required a pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, and pressure ulcer care. Review of the resident's plan of care, dated 9/18/17, showed staff are directed as follows: -Provide an air mattress to bed to reduce pressure; -Assist the resident to turn every two hours while in bed and as needed; -Staff are to use paper incontinence pads while the resident is in bed; -Apply treatment to coccyx (tailbone) wound as ordered according to the physician's orders [REDACTED]. Review of the resident's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Dependent on one staff for bed mobility, dressing, eating, toileting, personal hygiene, and bathing; -Dependent on two staff for transfers; -Indwelling catheter (tube inserted into the bladder to drain urine); -Always incontinent of bowel. Review of the resident's weekly skin assessment, dated 8/15/17, showed staff documented a reddened area remained 30 minutes after pressure reduction, and an open ulcer to the resident's coccyx. Further review showed calmo (a barrier cream used to repel moisture) written in the comments section of the weekly skin assessment. Review of the resident's nurses' notes showed staff did not document an open area to the resident's coccyx or an assessment of the open area on 8/15/17. Review of the POS [REDACTED].M., to cleanse the resident's coccyx with wound cleanser, apply hydrogel (a gel wound dressing) and foam, and change the dressing daily. Review of the physician's progress notes, dated 8/16/17, showed the Nurse Practitioner (NP) DD, documented the following: -Coccyx wound; -Discolored dark pink/black; -May have started as a Deep Tissue Injury (DTI) that is now open; -Calmo ([MEDICATION NAME]) BID (twice daily) and prn (as needed); -Low air loss mattress; -And roho cushion (a cushion used for pressure relief) in the wheelchair. Review of the resident's Registered Dietician (RD) consult on 8/17/17, for weight loss, showed the RD did not document any information related to the resident's coccyx wound, as directed by facility policy. Review of the resident's POS's dated 8/15/17 to 9/14/17, showed the following orders received on 8/18/17: -Turn patient side to side to offload coccyx wound; -Roho cushion for wheelchair; -[MEDICATION NAME] to coccyx BID; -Low air loss mattress. Review of the resident's physician's progress note, dated 8/22/17, showed NP DD documented the resident did not have [MEDICAL CONDITION]. Review of the resident's POS, dated 8/15/17 to 9/14/17, showed an order received, 8/22/17, for hydrogel and foam to the left ankle to be changed two times a week and as needed. Review of the resident's nurse's notes, dated 8/23/17, showed staff documented the resident's coccyx treatment order changed to 25% Dakins Solution (a solutions used to treat and prevent infections), with wet to dry dressing. Further review showed the staff member documented that the resident had an order for [REDACTED]. Review of the resident's weekly skin assessment, dated 8/26/17, showed staff documented a wound to the resident's coccyx. Further review showed the skin assessment did not contain documentation related to the resident's open area to his/her right ankle. Review of the resident's nurses notes, dated 8/28/17, showed RN AA documented the resident's coccyx wound measured 3.5 cm long by 3.5 cm wide, and staff provided a Dakins wet to dry dressing that was to be completed BID or PRN. Staff did not document any information related to the resident's right ankle wound. Review of the resident's POS, dated 8/15/17 to 9/14/17, showed the following orders, dated 8/30/17: -[MEDICATION NAME] (an antibiotic) 1 gram (gm) Intramuscularly (IM) (injected into the muscle) every eight hours for five days; -Discontinue foam dressing to right ankle; -Apply Duoderm (wound treatment) to right ankle and change twice a week; -Fluff (dry gauze) dressing to coccyx and change twice a day; -And comfort measures if guardian agrees. Review of the Physician's Progress notes, dated 8/31/17, showed NP DD assessed the resident's wounds as follows: Coccyx wound: -3.5 cm long by 2.2 cm wide by 0.9 cm- worsened; -Undermined at 12 o ' clock 1.1 cm, undermined at 3 o ' clock 0.9 cm, undermined at 6 o ' clock 1.5 cm, undermined at 9 o ' clock 2.5 cm; -May have started as a DTI, now open; -100% slough. Right Ankle Wound: -1.5 cm long by 2 cm wide; - And 50% eschar. Review of the resident's Pre-Transfer Skin Assessment, completed on 8/31/17, showed staff documented the following: -Pressure ulcer to coccyx 3.5 cm long by 3.5 cm wide, dressing changed today; -Open area to right ankle 2.5 cm long by 2.5 cm wide, dressing changed today. During an interview on 10/3/17 at 10:54 A.M., Registered Nurse (RN) AA said the resident had a stage four pressure ulcer to his/her coccyx. RN AA said the resident had been discharged from the facility to the hospital related to an infection that the resident had to his/her coccyx wound. RN AA further said that the resident was admitted to the hospital for approximately three weeks and had returned a couple of weeks ago. Review of a progress note, dated 9/20/17, showed the Social Services Director (SSD) documented the resident was discharged from the facility on 8/31/17 to Bothwell Regional Health Center related [MEDICAL CONDITION] (infection) and [MEDICAL CONDITION] (an abundance of sodium in the blood). Further review showed staff documented the resident returned to the facility on [DATE]. Review of the Braden Risk Assessment Report (an assessment to determine pressure ulcer risk), dated 9/18/17, and signed by an unidentified Licensed Practical Nurse (LPN) on 9/19/17, showed staff did not complete the assessment. Review of the resident's Physical Assessment, dated 9/18/17, showed staff documented the resident had a coccyx Decubitus (wound) that measured 3.5 cm long by 3 cm wide, a dime sized ulcer to his/her right ankle, and a scabbed over round small area on his/her right heel. Review of the resident's progress notes, dated 9/19/17, showed RN AA documented the resident with slough to an unidentified wound bed, and that the wound measured 4.5 cm long by 4 cm wide by 1 cm deep. Further review of the progress note showed it did not contain documentation related to the resident's right ankle ulcer, or scabbed over round small area on right heel. Review of the Physician's progress note, completed by NP DD, dated 9/19/17, showed the following: -Coccyx Wound; -4.5 cm x 4 cm x 1 cm- worsened; -75% Slough; -Treatment order of wet to dry dressing with gauze, moistened in NS (Normal Saline); -Turn side to side to offload wounds; -[DIAGNOSES REDACTED]. -Right Ankle Wound; -1.5 cm x 2 cm; -And hydrogel and foam dressing. Review of the resident's wound assessment, completed on 9/19/17, showed the Assistant Director of Nursing (ADON) documented the resident with a wound to his/her sacrum that was unstageable. Review of the resident's Treatment Administration Record (TAR), dated 9/14/17 to 10/14/17, showed a treatment order for wet to dry dressing with gauze and NS, change BID. Further review showed staff did not document they completed the treatment as ordered on [DATE], 9/21/17, 9/22/17, 9/24/17, 9/25/17, 9/27/17, 9/28/17, 9/29/17, 10/2/17, and 10/3/17. Observation on 10/4/17 at 1:27 P.M., showed RN AA entered the resident's room to provide wound care. The RN removed the dressing from the resident's coccyx which revealed a wound with the wound bed completely covered in slough. At this time the RN said the wound was 50% covered in slough, and 50% granulation tissue. RN AA said the wound was a stage 3 pressure ulcer, and said he/she could no longer see the resident's bone. (According to NPUAP guidelines, a wound covered in slough is unstageable) Observation showed the resident lay on a cloth pad with a large round ring of brown fluid on the pad. RN AA said the brown substance was drainage from the wound. RN AA said the staff was completing a Dakin's solution treatment prior to the resident going to the hospital due to infection. Furthermore, RN AA said the staff is instructed to use paper chucks (paper incontinence pads) for pressure relief because the air mattress is not effective with a cloth pad. During an interview on 10/4/17 at 2:29 P.M., RN AA said it is appropriate to downstage the stage of a wound as it heals. Furthermore, he/she said he/she did not know why the cloth pad was on the resident's bed. During an interview on 10/5/17 at 11:44 A.M., the Assistant Director of Nursing (ADON) said the RCC's didn't do anything on the 300 hall in regards to wound assessments. He/She also said he/she completed the last two wound assessments after the resident returned from the hospital. Observation on 10/5/17 at 5:00 P.M. showed the resident in his/her bed on his/her back and slightly to the left. Staff did not turn the resident side to side as directed by the NP. Observation on 10/6/17 at 9:19 A.M., showed the resident in his/her bed on his/her back. Staff did not turn the resident side to side as directed by the NP. During an interview on 10/4/17 at 11:08 A.M., RN AA said the resident is unable to turn himself/herself in bed. Observation on 10/6/17 at 9:25 A.M., showed RN I entered the resident's room to provide wound care. Further observation showed RN I removed the dressing to the resident's right ankle. Additional observation showed the right ankle with a wound covered in yellow slough. RN I said the wound to the right ankle is a stage 2 pressure ulcer. (According to the NPUAP guidelines, a stage 2 pressure ulcer does not contain slough.) During an interview on 10/6/17 at 9:46 A.M., CNA M said staff are expected to turn and reposition all residents every two hours. Furthermore, he/she said the CNA's are responsible to reposition the residents but that everyone helps. During an interview on 10/6/17 at 12:05 P.M., RN I said if a wound is found the staff is directed to contact the RCC, or the NP. Furthermore, he/she said staff should obtain a treatment order the day staff identify the wound. RN I said he/she does not measure wounds, he/she said he/she lets the RCC do the measuring and the previous RCC fell through and did not complete the assessments. Furthermore RN I said he/she does not measure but uses terms like dime size and quarter size. RN I further said a wound should be assessed every one to two weeks, and we just didn't have a nurse to do that. He/She said that he/she expects staff to turn and reposition all residents every two hours. During an interview on 10/6/17 at 3:20 P.M., the Director of Nursing (DON) said he/she expects the staff to document on every wound, and notify the NP and physician. Furthermore, he/she said the documentation should include the measurements, type of drainage, depth of the wound, appearance of the wound bed, and if there are any odors. He/She said staff should document wound assessments weekly and document completed treatments on the MAR/TAR. He/she said he/she was unaware this was not being completed for the resident. He/She said he/she expects the staff to follow the resident's turn schedule and to use the paper incontinence pads per the care plan. Additionally, he/she said if the RCC did not complete the wound assessments, he/she would expect the ADON to do so. During an interview on 10/13/17 at 12:46 P.M., NP DD said the resident's wound to his/her coccyx started as a deep tissue injury in July. He/She said the resident spent a lot of time in his/her wheelchair due to being a slow eater. NP DD said if the wound bed is completely covered in slough the wound is considered to be unstageable. Furthermore he/she said if the resident is not turned and repositioned appropriately or if the treatments are not being completed as ordered that it could contribute to the wound getting worse.

Based on observation, interview and record review, facility staff failed to prevent the development of a stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) pressure ulcer for two residents (Residents # 4 and # 20) and the development of an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough, a layer or mass of dead tissue separated from surrounding living tissue, and/or eschar, dead tissue, in the wound bed) pressure ulcer for one resident (Resident # 21) out of thirty sampled residents. Facility staff failed to provide necessary care and services to promote healing for one resident's (Resident # 2's) Stage III facility acquired pressure ulcer and for one resident's (Resident # 21's) unstageable pressure ulcer. Facility staff failed to follow physician's orders to treat one resident's (Resident # 4's) Stage III pressure ulcer. Furthermore, licensed staff failed to follow the facility's policy to perform weekly skin assessments for four sampled residents (Residents # 2, #4, #20, and #21) who developed facility acquired pressure ulcers. The facility census was 237. 1. Review of the facility's Pressure Ulcer Policy and Procedure, dated September 2012, showed staff are directed to do the following: - Upon admission weekly and as needed a licensed nurse personnel/designee will perform a skin assessment; - If a skin integrity issue is noted, staff will notify the interdisciplinary team. 2. Review of Resident # 20's Admission Minimum Data Set (MDS), a resident assessment instrument, dated 05/06/13, showed facility staff assessed the resident as follows: - Cognitively intact; - Refuses care four to six days a week but not daily; - Dependent on two or more staff for bed mobility and transfer; - Dependent on one staff for toilet use, dressing, personal hygiene, and bathing; - Limited range of motion of upper and lower limbs on one side of the body; - Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) pressure ulcer on the sacrum. Review of the resident's comprehensive care plan, dated 05/10/13, showed facility staff are directed as follows: - Wears immobilizer to right lower extremity at all times; - Heel protectors on bilaterally when in bed; - Wound clinic visits weekly; - Turn every two hours and as needed; - Total assist with daily care and transfers; - Can be resistant to care. Review of the resident's Discharge Assessment/Summary Report from the hospital, dated 04/23/13, showed the resident discharged with a splint type immobilizer to the right leg. Review of the resident's admission Physician Order Sheet (POS) dated 04/23/13 through 05/14/13, showed no physician orders regarding the immobilizer. Review of the resident's Norton Plus Pressure Ulcer Scale (a tool used to determine pressure ulcer risk), dated 06/06/13, showed facility staff assessed the resident at moderate risk for pressure ulcers. Review of the resident's weekly skin assessments showed the most recent skin assessment documented by staff dated 06/19/13, did not include information related to the resident's right lower leg or foot. Review of the resident's bath sheets showed the most recent Certified Nursing Assistant (CNA) bath sheet/skin assessment documented by staff dated 07/05/13, did not include information related to the resident's right lower leg or foot. Review of the facility's Abnormal Skin Assessment form dated 07/15/13, showed facility staff documented an open area to the resident's right ankle. Review showed the open area measured 3.0 centimeters (cm) in length, 1.0 cm in width, and 0.3 cm in depth with yellow and gray drainage. Review also showed pain and odor present with the wound. Review of the facility's wound nurse's notes dated 07/15/13, showed the wound nurse documented an open area to the resident's right lateral ankle that measured 3.0 cm in length, 1.0 cm in width and 0.3 cm in depth. The wound nurse documented the wound bed contained ninety percent tan slough with a moderate amount of tan drainage. Further review showed the wound nurse documented the open area "lies along where the immobilizer attaches." Review of the wound clinic nurse's notes dated 07/17/13, showed the wound clinic nurse documented "new area of ulcer noted when immobilizer removed." The wound clinic nurse also documented the open area as a stage III pressure ulcer to the right lateral ankle with measurements of 3.0 cm in length, 1.3 cm in width, and 0.2 cm in depth. Review also showed the wound clinic nurse documented the wound bed contained fifty percent yellow slough and fifty percent pink granulation tissue with a moderate amount of serous drainage, intact peri wound tissue and a strong wound odor. Observation on 07/17/13 at 3:15 P.M. showed the facility's wound nurse removed a dressing from the resident's right outer ankle. Observation showed an open area at the resident's right outer ankle with yellow and pink tissue and a foul odor. Observation on 07/17/13 at 3:30 P.M. showed the resident lay in bed with his/her right lower leg and outer ankle lying directly on the mattress. Further observation showed a foam dressing covering the right outer ankle. Observation on 07/17/13 at 9:50 P.M. showed the resident lay in bed with his/her right lower leg and outer ankle lying directly on the mattress. Further observation showed a foam dressing covering the right outer ankle. Observation on 07/18/13 at 8:30 A.M. showed the resident lay in bed with his/her right lower leg in an immobilizer. Observation showed a pillow under the resident's right lower leg with the resident's right outer ankle lying directly on the mattress. Further observation showed a foam dressing covering the right outer ankle visible at the lower end of the immobilizer. During an interview on 07/17/13 at 3:15 P.M., the facility wound nurse said staff noted drainage on the immobilizer and removed it. The facility wound nurse said when staff removed the immobilizer they "found" the wound. She also said the resident had the immobilizer on since his/her discharge from the hospital on [DATE]. During an interview on 07/17/13 at 7:10 P.M., Licensed Practical Nurse (LPN) B said he/she "had no idea" the the resident had a pressure ulcer under the immobilizer. The LPN said staff were told "not to remove it." The LPN said staff did not remove the immobilizer for bathing or hygiene but "put a bag over it" when bathing the resident. The LPN said staff did not remove the immobilizer because "we didn't have a doctor's order to remove it." During an interview on 07/17/13 at 8:05 P.M., the Resident Care Coordinator (RCC) said the resident was "adamant" staff not remove the immobilizer. The RCC also said she expects staff to open and/or remove the immobilizer during weekly skin assessments to assess the resident's skin under the immobilizer. The RCC also said she expects staff to call the physician upon the resident's admission to obtain orders regarding care of the immobilizer. During an interview on 07/17/13 at 8:20 P.M., LPN W said he/she noted "reddish, possibly bloody" drainage on the resident's immobilizer and bed linens during his/her night shift 07/15/13. The LPN said he/she removed the immobilizer at that time and found the open area on the resident's right outer ankle. The LPN said he/she documented the findings on the Abnormal Skin Assessment form. During an interview on 07/17/13 at 8:45 P.M., the RCC said she expects staff to adhere to the schedule of weekly skin assessments for each resident. The RCC also said she expects staff to document resident refusal of skin assessments and bathing. During an interview on 07/18/13 at 8:20 A.M., CNA L said staff are expected to turn and reposition residents every two hours, use pillows or positioning devices to ensure residents stay off pressure areas, keep residents clean and dry, and be sure any dressings are intact. During an interview on 07/18/13 at 8:25 A.M., CNA I said staff are expected to notify the nurses of any issues or changes related to the residents' skin. During an interview on 07/18/13 at 8:50 A.M., the RCC said she expects staff to use pillows or positioning devices to relieve any pressure points or areas of pressure ulcers that residents already have. The RCC also said the immobilizer "probably" contributed to the pressure ulcer's development and that she expects staff to look under any removable devices and perform complete skin assessments. During an interview on 07/18/13 at 9:00 A.M., the facility wound nurse said the immobilizer caused the pressure ulcer. The facility wound nurse said she expects staff to remove the immobilizer during the weekly skin assessment or follow the physician's order if the order is different. During an interview on 07/18/13 at 2:50 P.M., the Director of Nursing(DON) said she expects staff to obtain orders for care of devices such as immobilizers upon a resident's admission to the facility. She also said she expects staff to call the physician and clarify orders if staff are unable to find orders related to the immobilizer. The DON also said she expects staff to assess residents' skin under devices such as immobilizers that can be removed. The DON also said she expects staff to document skin assessments because "if it's not charted, we can't count it as done." During an interview on 07/23/13 at 10:00 A.M., the physician who prescribed the immobilizer for the resident said his "typical orders" for a patient going home with an immobilizer are that the immobilizer may be removed once daily for hygiene and skin assessment. The physician also said he expects staff to call and clarify orders if the facility did not receive discharge orders related to the immobilizer or if the staff were unsure about any orders received. 3. Record review of Resident #21's MDS, dated [DATE], showed staff assessed the resident as: -Memory problem; -Required extensive assistance for bed mobility; -Required total assistance for transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing; -Always incontinent of urine and bowel; -Did not reject care; -At risk for pressure ulcers; -No unhealed pressure ulcers; -No pressure ulcers on prior assessment. Review of the resident's, "Norton Plus Pressure Ulcer Scales," dated 03/26/13 and 06/18/13, showed licensed staff documented the resident's assessment score of 10, a high risk for pressure ulcer development. Review of the resident's "Shower Sheets," dated 06/26/13, 07/13/13 and 07/15/13, showed certified staff documented the resident's skin showed "no red/open areas" and "no changes." Review of the resident's weekly "Skin and Body Assessment" sheet, dated 07/04/13, showed licensed staff documented the resident's "peri-rectal area reddened and buttocks with reddened areas." Further review of the sheet showed staff failed to document the resident's weekly "Skin and Body Assessment" after 07/04/13 through 07/17/13, as directed per the facility's pressure ulcer policy and procedure. Review of the resident's nurse's notes, dated 07/07/13, showed licensed staff documented the resident's right posterior thigh had two dime-sized open areas, with pink wound beds. Review of the resident's nurse's notes, dated 07/08/13, showed licensed staff documented the resident's two right "thigh" ulcers measured 0.4 cm x 0.4 cm x 0.1 cm with an onset date of 07/07/13. Review of the resident's nurse's notes, dated 07/17/13, showed licensed staff documented "open area noted to the resident's right buttock." Review of the resident's nurse's notes, dated 07/17/13, showed a different licensed staff person documented the resident's right buttock "presents as stage II pressure ulcer." Review of the resident's nurse's notes, dated 07/17/13, at 3:45 P.M., showed licensed staff documented the resident's right "buttock area with 90-100% yellow-tan slough covered with pink edges" and "area not stage II." Further review of the nurse's note showed licensed staff documented the resident's "right posterior thigh healed." Review of the resident's nurse's notes, dated 07/17/13, at 4:00 P.M., showed licensed staff documented the resident's right "buttock" ulcer measured 2.5 cm x 1.0 cm. Review of the resident's plan of care, updated 06/25/13, showed staff documented the resident at risk for skin breakdown due to his/her limited mobility and bowel and bladder incontinence. Review of the resident's plan of care showed staff documented the resident required extensive to total assistance with all care, hygiene and transfers. Review of the resident's plan of care showed staff documented the resident's goal to have warm, dry and intact skin through the next 90 days. Further review of the resident's plan of care showed staff documented, on 07/08/13, the resident had "2 small opens areas" to his/her "right thigh" with an "onset" date of 07/07/13. Additional review of the resident's plan of care showed staff planned the following interventions to promote wound healing and minimize risk of further breakdown: -Pressure reducing mattress to bed; -Pressure reducing cushion to wheelchair; -Assist with turning and repositioning; -Assess skin condition weekly. Report any abnormalities; -Total assist needed with peri-care after any incontinent episode; -Total assist with all cares and hygiene; -Assist of 1-2 staff with all transfers using Hoyer lift (a mechanical lift). Review of the resident's POS, dated 07/15/13 through 08/14/13, showed the resident's physician directed staff to turn the resident every two hours. Further review of the resident's POS, showed, on 07/07/13, the resident's physician directed staff to cleanse the resident's right posterior thigh with wound cleanser and apply a dry dressing daily and as needed. Review of the resident's Treatment Administration Records (TARs), dated 06/15/13 through 07/14/13 and 07/15/13 through 08/14/13, showed the resident's physician directed staff, on 07/07/13, to cleanse the resident's right posterior thigh with wound cleanser and apply a dry foam dressing daily and as needed. Review of the resident's POS, dated 07/15/13 through 08/14/13, showed the resident's physician directed staff to turn the resident every two hours. Further review of the resident's POS, showed, on 07/17/13, the resident's physician directed staff to perform the following: -Cleanse the resident's right buttock with wound cleanser, apply [MEDICATION NAME] (a skin cream that provides a barrier to prevent irritation from moisture and to promote healing. It is used for skin irritations from incontinence, feeding tube leakage, wound drainage, and perspiration. It can also be used for diaper rash and [MEDICAL CONDITION] scrapes) and cover with foam daily and as needed until healed; -Discontinue treatment to the resident's healed right thigh. Review of the resident's TAR, dated 07/15/13 through 08/14/13, showed the resident's physician directed staff, on 07/17/13, to cleanse the resident's right buttock area with wound cleanser, apply [MEDICATION NAME] to the area and cover with foam daily and as needed until healed. Observation on 07/17/13 at 3:43 P.M. showed the resident lay in bed, on his/her back, and the facility's wound nurse turned him/her onto his/her left side. Observation showed the resident's right buttock with an irregular bordered, open area, covered with yellow slough and measured approximately 1 inch (in.) x 1/2 in.. During an interview, at this time, the facility's wound nurse said the open area on the resident's right buttock, is "covered with slough, so it's unstageable." Observation showed the facility wound nurse cleansed the resident's right buttock open area and then covered it with a foam dressing. The facility's wound nurse said the resident is incontinent, dependent on staff for his/her care and has history of pressure ulcers. The facility's wound nurse said the resident "does not sit in a chair very long." Additionally, the facility's wound nurse said he/she did not know how the resident developed an open, unstageable pressure ulcer on his/her right buttock. Observation on 07/17/13 at 7:08 P.M. showed the resident sat in his/her wheelchair in a common dining room. Further observation showed the resident sat in this position until 9:36 P.M., when staff put him/her to bed. The resident sat for 2 hours and 28 minutes in his/her wheelchair, without staff assistance to reposition him/her as directed in his/her plan of care. Observation on 07/17/13 at 9:36 P.M. showed CNAs F and G transferred the resident from his/her wheelchair to his/her bed with a mechanical lift. Observation showed the resident's right buttock pressure ulcer without a dressing. Urine and stool covered the pressure ulcer on the resident's buttock. During an interview on 07/17/13 at 9:50 P.M., LPN W said staff are expected to care for residents, who require total assistance, at least every two hours in order to provide them with incontinence care and repositioning. During an interview on 07/18/13 at 8:10 A.M., Registered Nurse (RN) J said he/she did not know how the resident developed a right buttock pressure ulcer and a healed right posterior thigh pressure ulcer. The RN said the resident is "dependent on" staff "to turn and reposition" him/her " every two hours." During an interview on 07/18/13 at 8:30 A.M., CNA L said he/she is unsure how the resident developed an open area to his/her right buttock. The CNA said the resident "gets them really easy." Furthermore, the CNA said the resident is incontinent and the urine irritates his/her skin. Additionally, the CNA said the resident is dependent on staff for his/her care. During an interview on 07/18/13 at 8:45 A.M., the facility's wound nurse said he/she did not know how the resident developed an unstageable right buttock pressure ulcer. The facility's wound nurse said the resident has "a lot of health issues" and he/she is "dependent on staff." The facility's wound nurse said the resident is incontinent and staff turn and reposition him/her "at least every two hours." The facility's wound nurse said the resident's plan of care did not have an approach to show he/she be the last resident out of bed for meals, and the first resident put to bed after meals. The facility's wound nurse said he/she told staff the resident needs to be returned to bed "immediately after meals and to not get him/her out of bed for meals until right before the meal starts." During an interview on 07/18/13 at 10:00 A.M., the 300 Hall RCC said CNAs assess resident's skin for redness and/or open areas during the showers, and then document the information on the "shower sheets." The RCC said licensed staff are expected to review the residents "shower sheets." Furthermore, the RCC said licensed staff, who work night shifts, are responsible and expected to perform residents' head-to-toe skin assessments weekly and document their findings on residents' "Skin and Body Assessment" sheets. The RCC said he/she monitors licensed staff to ensure they complete and document residents' weekly skin assessments. The RCC said he/she did not have any of the resident's documented "Skin and Body Assessment" sheets since 07/04/13. The RCC said he/she did not know why licensed staff failed to document the resident's skin and body assessments since 07/04/13. The RCC said "if it's not documented, it didn't occur." During an interview on 07/18/13 at 2:55 P.M., the DON said staff are expected to reposition residents and provide incontinence care to them at least every two hours. The DON said licensed staff are expected to perform head-to-toe weekly skin assessments on each resident. Additionally, the DON said the RCC is responsible to ensure licensed staff complete and document each resident's head-to-toe weekly skin assessment. 4. Review of the Resident # 4's MDS, dated [DATE], showed staff assessed the resident as follows: - Cognitively intact; - Totally dependent on staff for transfers, dressing, and toilet use; - Required limited assistance from staff for bed mobility, personal hygiene, and bathing; - diagnosed with [REDACTED]. - Two stage III pressure ulcers. Review of the resident's Norton Plus Pressure Ulcer Scale, dated 2/3/13, showed staff assessed the resident to score 15 on the scale (ten or less equals high risk). Review of the resident's care plan, dated 2/21/13, showed staff documented the following: - The resident's mobility is severely limited and he/she with no feeling to the lower torso; - The resident had a stage III pressure ulcer on the left buttock; - Staff were directed to assess the resident's skin weekly and as needed; - 4/4/13 - Pressure ulcer to the left heel. Foam dressing; - 4/10/13 - Treatment changed to silver Alginate (is calcium Alginate (topical medication used to maintain a therapeutic wound environment for wet wounds) infused with silver which gives it an anti-infective property) and foam; - 4/18/13 - Dressing change to heel increased to twice daily due to drainage; - Podus boots (boots that offer protection for heel wounds) at all times. Review of licensed nurse weekly skin assessments showed the licensed staff documented a weekly skin assessment on 5/30/13, 7/4/13, 7/8/13, and 7/15/13. Review showed staff did not perform a weekly skin assessment as directed by facility policy. Review showed the first weekly skin assessment licensed staff documented for the year 2013 was on 5/30/13, after the resident developed the stage III pressure ulcer on his/her left heel. Review of the facility's wound assessment note for the resident, dated 4/5/13, showed staff documented the following: - The resident with a new pressure ulcer on the left heel that measured 4.0 cm by 5.0 cm by 0.2 cm deep, gray in color and unstageable. Off load with pressure reducing heel boot. On schedule for wound clinic to assess next week. Review of the resident's POSs showed the following physician orders: - 4/4/13 - Cleanse the left heel wound with wound cleanser and apply a foam dressing and change daily and as needed until heeled. Heel protectors when in bed; - 4/10/13 - Discontinue previous wound treatment. Cleanse left heel wound and cover with silver Alginate and foam and change daily and as needed. Heel boots on at all times; - 4/18/13 - Change dressing to left heel twice daily; - 5/29/13 - Discontinue previous heel treatment. Cleanse with wound cleanser and apply Santyl (an enzymatic [MEDICATION NAME] ointment that works by breaking down dead skin), silver Alginate, and foam and change daily and as needed. Review of the POS [REDACTED]. Review showed the POS did not contain the most recent left heel wound order from 5/29/13 that included silver Alginate. Review of the TAR dated 6/15/13 through 7/14/13, showed an order for [REDACTED]. Review of the POS [REDACTED]. Review showed the POS did not contain the most recent left heel wound order from 5/29/13 that included silver Alginate. Review of the TAR, dated 7/15/13 through 8/14/13, showed an order for [REDACTED]. Review of the resident's weekly wound assessments documented by the wound clinic nurse showed the following: - 4/10/13 - Unstageable pressure ulcer to the left heel that measured 5.0 cm by 4.0 cm by 0.3 cm with 100 % gray slough. Debrided (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) the wound with scissors; - 4/24/13 - Stage III pressure ulcer to the left heel that measured 6.0 cm by 7.0 cm by 0.2 cm with 50 % yellow slough. Debrided the wound with scissors; - 5/15/13 - Debrided left heel wound with scissors; - 5/29/13 - Stage III pressure ulcer to the left heel that measured 4.0 cm by 3.5 cm by 0.2 cm with 75 % gray slough; - 6/5/13 - Stage III pressure ulcer to the left heel that measured 4.0 cm by 4.0 cm by 0.2 cm with 50 % yellow and gray slough. Debrided the wound with curette (a surgical instrument that can be used to scrape dead tissue from a wound); - 6/19/13 - Stage III pressure ulcer to the left heel that measured 3.5 cm by 2.5 cm by with 25 % gray slough. Debrided the wound with scissors. Additional review showed the pressure ulcer improved in size, however, continued to be a stage III and required debridement. Review of the wound assessments documented by the facility's wound nurse showed on 7/10/13 the nurse did not include staging information in her assessment. Observation on 7/16/13 at 3:15 P.M., showed LPN B performed a dressing change to the resident's left heel. the LPN removed the old dressing, cleansed the wound with wound cleanser, applied Santyl with a q-tip, applied calcium alginate, and then applied an adhesive foam. LPN B did not use silver alginate, as directed in the most recent left heel wound order from 5/29/13. Observation on 7/17/13 at 2:20 P.M., showed the wound clinic nurse measured the resident's left heel pressure ulcer to be 4.0 cm by 3.0 cm. Observation showed the wound bed to be pinkish red in color. During an interview on 7/18/13 at 9:50 A.M., the RCC for the 300 hallway said the night nurse should document a full skin assessment for the resident weekly. The RCC said staff are supposed to ensure the resident has on heel boots at least every two hours. The RCC said the resident can not put on or remove the heel boots without assistance. During an interview on 7/18/13 at 2:10 P.M., the RCC for the 300 hallway said she and other staff are responsible to ensure orders are carried over from old to new POSs and TARs. During an interview on 07/18/13 at 2:10 P.M., the DON said the RCC's are responsible to complete the monthly change over for physician orders. The DON said she expects staff to correctly transcribe physician orders. During an interview on 7/18/13 at 2:15 P.M. the facility wound nurse said: - He/she did the wound assessments last week when the wound clinic nurse was unavailable and documented the assessment them in the residents' chart; - In his/her wound assessment documentation, he/she includes the wound size, appearance, order changes, and other interventions. He/she "sometimes" stages the wound- in the initial wound documentation. He/she said if he/she is not sure what stage the wound is, he/she will wait for the resident's physician or the wound clinic nurse to stage it. During an interview on 7/18/13 at 2:50 P.M. the DON said: - Licensed staff are directed to perform weekly head to toe skin assessments and to document the findings in the treatment book; - The facility wound nurse is expected to stage the wound in the weekly wound assessment documentation. During an interview on 7/26/13 at 1:45 P.M., the facility wound nurse said the following: - She wrote the 5/29/13 order on the POS for staff to apply silver alginate to the resident's left heel pressure ulcer at the recommendation of the wound clinic nurse; - She ordered silver alginate for the resident, but can't be sure that's what the facility's nurses always used on the wound; - She thinks the calcium alginate was a transcription error staff made from month to month on the POSs and TARs. The resident is supposed to get silver Alginate and that's what should be on the POS and TARs. Silver alginate was ordered for the resident's wound because it has antimicrobial (anti-infective) properties that calcium alginate does not have. 5. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 4/24/13, showed staff assessed the resident as: - Severely impaired cognitive skills for daily decision making; - Total dependence on one person physically assist with bed mobility, personal hygiene, and bathing; - Total dependence on two plus persons physically assist with transfers; - Always incontinent of bowel, indwelling catheter (a tube used to drain urine from the bladder); - Has one stage III facility acquired pressure ulcer, with slough present. Review of the resident's plan of care, dated 4/30/13, showed the following: - Stage III pressure ulcer to sacral area. Acquired. Mobility severely limited. Incontinent of bowel. Has a Foley catheter; - Treatment changed to [MEDICATION NAME] Blue (a specialized wound dressing that inhibits the growth of bacteria). Increased drainage on 6/19/13. Dressing changed to BID (twice a day); - Assess skin weekly and PRN (as needed); - Wound clinic visits weekly; - Last one up. First down; - Side to side turn every two hours. Review of the resident's Norton Pressure Ulcer Scale, dated 4/24/13, showed staff assessed the resident to score 11 on the scale (ten or less equals high risk). Review of the resident's POS, dated 7/15/13 to 8/14/13, showed the physician ordered the following: - Resident to wear heel protectors at all times when in wheelchair and in bed; - Palm protectors(to protect skin due to clenched fist); - [MEDICATION NAME] Blue- wound dressing. Apply daily to sacral wound after cleansing the wound with wound cleanser. Cover with foam, change daily. Review of licensed nurse weekly skin assessments showed the licensed staff documented a weekly skin assessment on 10/8/12, 10/20/12, 11/15/12, 11/17/12, 12/15/12, 1/20/13, 1/27/13, 6/22/13, 6/29/13, and 7/6/13. Further review showed the licensed nursing staff did not document a weekly skin assessment as directed by facility policy. Review of the resident's weekly wound assessments from the wound clinic showed: - 5/15/13 sacral pressure ulcer, 0.7 cm by 2.5 cm, "improving"; - 5/22/13 sacral pressure ulcer, stage III, 3.8 cm by 3.5 cm, new open area lateral; - 6/19/13 sacral wound, stage III pressure, 2.5 cm by 2.5 cm by 0.2 cm.. Peri-wound tissue macerated (skin damaged by prolonged moisture exposure). Yellow slough present in less than 25% of the wound base. History of present illness: Wound slow to heal. Increased maceration. Getting e-stim (electrical stimulation wound treatment). Assessment/Plan: No change. Increased maceration. Change dressing BID and PRN. Review of wound assessments by the facility's wound nurse showed on 6/28/13 and 7/10/13 the nurse did not include staging information in his/her wound assessment. Review of the resident's medical record showed on 5/22/13 when the wound was noted to have a new open area lateral to the original wound, staff did not document any new interventions were implemented to promote healing of the resident's stage III pressure ulcer. Further review of the resident's POS and TAR showed staff did not address the recommendation of the wound center nurse to change the treatment to BID instead of once a day on 6/19/13, to promote healing of the resident's stage III pressure ulcer. The physicians orders continued to direct staff to change the treatment once a day. Observation on 7/16/13 at 8:26 A.M. showed the resident sat in a wheelchair at a table in the 300 hall dining room. He/she did not have heel protectors on to prevent additional skin breakdown as ordered by the resident's physician. The resident sat at the table during breakfast without heel protectors on until 9:58 A.M. when staff wheeled the resident to his/her room. Observation on 7/16/13 at 9:58 A.M. showed CNAs E and D wheeled the resident to his/her room. CNAs E and D used a mechanical lift to transfer the resident to bed. CNAs E and D provided perineal care to the resident, who had been incontinent of bowel. The resident did not have a dressing over his/her sacral wound. During an interview conducted at the time of the observation, CNA E said the residen