Every finding on record at Fulton Nursing & Rehab

Based on interviews and record review, facility staff failed to complete weekly skin assessments ordered by the physician for three residents (Resident #1, Resident #2, Resident and #3) out of five sampled residents. The facility census was 69.the purpose is prevent and treat further break down of skin or pressure ulcers. Treatment and prevention of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers. 2.Review of Resident #1's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 10/31/25, showed staff assessed the resident as severely cognitively impaired and at risk for developing pressure ulcers.Review of the physician order sheet (POS), dated February 2026 and March 2026, showed the physician ordered weekly skin assessments. Review of the resident's weekly skin assessments showed did not contain documentation staff completed skin assessment for the resident on 2/20/26, 2/27/26, 3/13/26, 3/20/26 and 3/27/26. 3. Review of Resident's #2 Comprehensive MDS, dated [DATE], showed staff assessed the residents as cognitively intact with two stage three pressure ulcers present.Review of the resident's POS, dated January 2026, February 2026 and March 2026, showed a physician ordered for weekly skin assessments.Review of the resident's weekly skin assessments showed did not contain documentation staff completed skin assessment for the resident on 1/20/26, 2/3/26, 2/24/26, 3/3/26, 3/10/26 and 3/17/26.Review of the resident's Comprehensive MDS, dated [DATE], showed staff assessed the resident as cognitively intact with two stage three pressure ulcers present. 4.Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired and at risk for developing pressure ulcers.Review of the resident's POS, dated January 2026, February 2026 and March 2026 showed a physician ordered for weekly skin assessments.Review of the resident's weekly skin assessments showed did not contain documentation staff completed skin assessment for the resident on 1/1/26, 1/8/26, 1/22/26, 1/29/26, 2/5/26, 2/12/26, 2/27/26, 3/6/36, 3/13/26, and 3/20/26. 5.During an interview on 4/9/26 at 11:32 A.M., the Interim director of Nursing (DON) said skin assessments should be done weekly. He/She said licensed nursing staff are required to do skin assessments even if the resident has a wound and is under supervision of wound care. He/She said all skin assessments are kept in the electronic health record under observations. He/She said he/she does not know why they are not getting done besides a heavy workload, he/she said they have recently added more licensed staff to shifts to help.During an interview on 4/9/26 at 12:19 P.M. the administrator said he/she is aware there is an issue with skin assessments being completed weekly. He/She said he/She believe the nurses get busy and they are just not done.

Based on observation, interview and record review, facility staff failed to address and update care plans to address behaviors for three resident (Resident #1, #2 and #3) of three sampled residents and failed to update care plans at least quarterly in conjunction with the required Minimum Data Set (MDS) a federally mandated assessment instrument), to provide interventions to meet individual needs for two residents (Resident #2 and #3) out of three sampled residents. The facility census was 68.1. Review of the facility's policy, Care Plan Comprehensive, undated, showed:-An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being;-Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition;-Applying current standards of practice in the care planning processes;-The interdisciplinary care plan team is responsible for the periodic review and updating of care plan when a significant change in the resident's condition has occurred or when changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment).2. Review of Resident #1's quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and did not exhibit behaviors of physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) during the seven day look back period.Review of the resident's care plan, dated 11/14/25, showed the care plan did not contain direction for the resident's aggressive behaviors towards residents or interventions in place after three altercations with other residents on 12/07/25, 12/21/25 or 12/22/25. Review of the resident's progress notes, dated 12/07/25, showed staff documented the resident threatened to stab another resident with a knife during an evening meal. Review of the resident's progress notes, dated 12/21/25, showed staff documented the resident hit another resident in face with closed fist unprovoked when exiting the dining room. Review of the resident's progress notes, dated 12/22/24, showed staff documented the resident slapped another resident in the mouth. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and did not exhibit behaviors of physical behavioral symptoms directed toward others during the seven day look back period.Review of the resident's care plan, dated 08/28/25, showed it did not contain direction for staff regarding aggressive behaviors towards residents or interventions in place after an altercation with another resident on 12/06/25. The care plan was not updated on a quarterly basis.Review of the resident's progress notes, dated 12/06/2025, showed staff documented the resident kicked another resident in the knee for being in his/her chair in the dining room.4. Review of Resident #3's annual MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and did not exhibit behaviors of physical behavioral symptoms directed toward others during the seven day look back period.Review of the resident's care plan, dated 08/17/25, showed the resident had behaviors of attempting to hit peers and staff, rummaging, making [NAME] sexual comments, throwing insults upon other, or verbal/vocal symptoms like shouting and making disruptive sounds and refusal of care. The care plan did not contain a new intervention for an altercation on 12/07/25 with another resident. Review of the resident's progress notes, dated 12/07/2025, showed staff documented the resident cursing and calling names. Staff documented the resident then had an altercation with another resident on the 200 hall, when he/she was yelling and cursing at the other resident. 5. During an interview on 01/14/26 at 12:42 P.M. Licensed Practical Nurse (LPN) A said he/she would expect to see a new intervention after each behavioral incident. He/She said he/she did not know if the care plans were updated for the resident's after each altercation. During an interview on 01/14/26 at 12:57 P.M., the DON said he/she would expect a new intervention after each incident and documented in the care plan. He/She said the MDS Coordinator was responsible to update the care plan. He/She said he/she was responsible to verify events and interventions were in place, but he/she said he/she was overwhelmed with other task.During an interview on 01/14/26 at 1:58 P.M., the MDS Coordinator said care plans are updated quarterly, annually and after a significant change. He/She said there should be updated with new interventions after aggressive behaviors. He/She said he/she was the only person who worked on revising or updating the care plans, so when he/she was out of the building, no one was working on the resident care plans. He/She said he/she was out sick for an extended period, and he/she was trying to catch up on his/her care plan responsibilities, in addition to other responsibilities in the facility. #2698585

Based on observation, interview and record review, facility staff failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the 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 follow acceptable infection control practices for Covid-19. The facility failed to separate five residents (Resident #1, #3, #7, #10 and #12) who tested positive for COVID-19 from five residents (Resident #2, #4, #8, #9, and #11) who had tested negative for COVID-19, which placed the Covid-19 negative residents at an increased risk of contracting COVID-19 due to prolonged exposure. The facility census was 68. 1. Review of the facility's Outbreak Management: SARS-COV-2 Long Term Facilities policy, revised on 5/15/23, showed staff are directed as follows: -Place a patient with suspected or confirmed SARS-COV-2 infection in a single room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom;-If cohorting, only patients with the same respiratory pathogen should be housed in the same room;-If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-COV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location;-Facilities could consider designating entire units within the facility, with dedicated HCP (healthcare personnel) are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible dur to staffing crisis or a small number of infections;-Limit transport and movement of patients outside the required medically essential purposes.2. Review of Resident #1's COVID test results form, dated 12/21/25 and 12/29/25, showed staff documented the resident with a positive result. Review of Resident #2's COVID test results form, dated 12/29/25, showed a negative result.Observation on 12/30/25 at 11:00 A.M. showed Resident #1 and Resident #2 in the same room and did not wear masks.During an interview on 12/30/25 at 3:12 P.M., Resident #2's durable power of attorney (DPOA) stated he/she was made aware by staff there were residents in the facility who tested positive for Covid -19. He/She stated he/she would want Resident #2 to be kept in his/her room and not exposed to others, including at mealtimes. 3. Review of Resident #3's COVID test results form, dated 12/22/25 and 12/29/25, showed staff documented the resident with a positive result.Review of Resident #4's COVID test results form, dated 12/29/25, showed staff documented the resident with a negative result.During an interview on 12/30/25 at 3:50 P.M., Resident #4 said he/she would not want a room with a sick resident but was not asked if he/she would want to move. 4. Review of Resident #7's COVID test results form, dated 12/22/25 and 12/29/25, showed staff documented the resident with a positive result.Review of Resident #8's COVID test results form, dated 12/29/25, showed staff documented the resident with a negative result.Observation on 12/30/25 at 11:00 A.M. showed Resident #3 and Resident #4 in same room and did not wear masks.Observation on 12/30/25 at 01:50 P.M. showed Resident #7 who tested positive for COVID without a facemask sitting in the hall in a wheelchair within close proximity of staff and various residents walking in the hall. Certified Medication Technician (CMT) D assisted Resident #7 to the 300 hall dining room.During an interview on 12/30/25 at 3:55 P.M., Resident #8 said he/she does not want to be in a room with a sick resident, however no one asked if he/she wanted to mover rooms. 5. Review of Resident #9's COVID test results form, dated 12/20/25 and 12/29/25, showed staff documented the resident with a positive result.Review of Resident #10's COVID test results form, dated 12/29/25, showed staff documented the resident with a negative result.Observation on 12/30/25 at 11:35 A.M. showed Resident #9 and Resident #10 in the same room and did not wear masks.Observation on 12/30/25 at 1:25 P.M. and 4:05 P.M., showed Resident #9 out of his/her room. 6. Review of Resident #11's COVID test results form, dated 12/22/25, showed staff documented the resident tested positive.Review of Resident #12's COVID test results form, dated 12/29/25, showed a negative result. During an interview on 12/30/25 at 2:00 P.M., Resident #11 stated he/she would prefer to move rooms if roommate was sick with Covid. His/Her roommate tested positive for COVID-19 on 12/22/25. 7. During an Interview on 12/30/25 at 12:32 P.M., Certified Nurse Assistant (CNA) C stated there were seven Covid positive residents in the 300 Dining Hall out of 13 total residents.During an interview on 12/30/25 at 12:15 P.M., the Director of Nursing (DON) said they follow the policy regarding resident placement during a COVID-19 outbreak, but some residents refuse to be moved and there are not always rooms available. They have relocated some residents. Families were notified that the facility has residents testing positive for COVID-19.During an interview on 12/30/25 at 10:20 A.M., CMT D said he/she did not know which residents had tested positive for COVID-19, but was aware some were positive. He/She said he/she had not been told during shift change who had COVID-19. CMT D said he/she is new and had only been told to wear a mask. He/She acknowledged wearing it below the nose would not provide protection from the virus, and it should be an N95 mask. During an interview on 12/30/25 at 10:31 A.M., the Assistant Director of Nursing (ADON) said he/she does not know who on Hall 300 is COVID-19 positive or why there is no signage on the door. He/She said staff are probably going in and out of rooms without the proper PPE. The ADON did not know why there were not red bags in the rooms for PPE disposal. The ADON said he/she and the DON are responsible for ensuring staff is compliant with PPE requirements. During an interview on 12/30/25 at12:41 P.M., LPN B said there is a list of COVID-19 positive residents at the nurse's station that is updated every three days. He/She said everyone should know about it and nurses know what PPE to wear. LPN B did not know why there was no signage on the doors; it is the Infection Preventionist's (IP) responsibility.During an interview on 12/30/25 at 12:15 P.M., the Director of Nursing (DON) said a list of positive residents is posted at the nurse's station and all nurses should be aware of it. During an interview on 12/30/25 at 12:45 P.M., the Infection Preventionist said interventions implemented to contain COVID-19 include room trays for residents who test positive, some room changes, masks, handwashing reminders, family notification and cancellation of the Christmas party. The IP said all residents have been asked to wear masks outside their rooms, but many refuse. During an interview on 12/31/25 at 10:40 A.M., the Administrator said the ADON and DON are responsible for educating nurses on the use of PPE and nurses are responsible for compliance. The Administrator said a list of COVID-19 positive residents is posted at the nurse's station and does not understand why staff are saying they do not have the information.Complaint # 2697930

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility's census was 67.1. Review showed the facility did not provide a policy in regard to RN services. Review of the Facility Assessment, revised 08/27/25, showed the facility should staff at least one RN for eight hours per day, seven days a week. Review of the facility's RN Staffing assignments, dated 09/01/25 through 09/30/25, did not contain documentation of RN coverage for eight consecutive hours per day on 09/01/25, 09/05/25, 09/06/25, and 09/21/25. Review of the facility's RN Staffing assignments, dated 10/01/25 through 10/21/25, did not contain documentation of RN coverage for eight consecutive hours per day on 10/04/25, 10/05/25, 10/18/25, and 10/19/25. During an interview on 10/21/25 at 2:29 P.M., the Director of Nursing (DON) said he/she is aware of the requirement to have an RN in the facility eight consecutive hours daily, and the Assistant Director of Nursing (ADON) or the administrator should ensure the requirement is met. He/She said he/she is at the facility five days per week and was not aware that an RN was not at the facility on 9/1, 9/5, 9/6, 9/21, 10/4, 10/5, 10/18, and 10/19. During an interview on 10/21/25 at 3:18 P.M., the administrator said he/she is aware of the requirement to have an RN in the facility eight consecutive hours daily, the ADON does the nursing schedule and should ensure the required RN coverage is provided. The administrator said the facility lost a couple RNs within the past two months which makes it difficult to provide the daily required RN coverage particularly on the weekends, but he/she was not aware there was not an RN at the facility for that many days. The administrator said they just do not have anyone to cover, and he/she is actively trying to hire more RNs. During an interview on 10/22/25 at 10:38 A.M., the ADON said he/she just took over the nursing schedule from the administrator a week ago and he/she is aware of the requirement to have an RN in the facility eight consecutive hours daily. The ADON said he/she was not aware there was not an RN at the facility on 9/1, 9/5, 9/6, 9/21, 10/4, 10/5, 10/18, and 10/19. Complaint # 2644523

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 (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. Facility staff failed to use Enhanced Barrier Precautions (EBP) (an infection control practice that requires staff to wear Personal Protective Equipment (PPE) (gowns, gloves and/or eye protection) and/or failed to have EBP signs posted for 5 residents (Resident #18, #45, #52, #53, and #71), and failed to review Infection Prevention and Control policies annually. The facility census was 62 with a capacity of 100. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: -The bacterium Legionella can cause a serious type of pneumonia called Legionnaire's Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. -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. Review of the facility's building maintenance, inspection and testing records, showed the records did not contain documentation of a complete water management program to monitor the facility's water systems for the growth of waterborne pathogens and prevent LD. Review showed documentation of a Legionella policy guideline which instructed the facility staff to complete a risk assessment and develop procedures to monitor for Legionella in accordance with the Centers for Disease Control guidelines. Review showed the records did not contain documentation of a management team, a water flow description, defined control measures specific to the facility's water systems, and actions to be taken when the specified control limits are not met. During an interview on 06/26/25 at 12:30 P.M., the maintenance director said the administrator oversees the water management program and he/she just completes water management task, such as checking the water temperatures, monthly as outlined on his/her checklist. The maintenance director said he/she could not provide any additional documentation related to the facility's water management program. During an interview on 06/26/25 at 1:45 P.M., the administrator said the maintenance director is responsible for the development and implementation of the facility's water management program. The administrator said he/she just became the administrator in January 2025, he/she could not provide any additional documentation related to the facility's water management program, and he/she did not know the records did not contain all information required. 2. Review of the facility's policy titled Enhanced Barrier Precautions to Infection Control Guidance, dated March 2024, showed the purpose is to prevent broader transmission of Multidrug-resistant organisms (MDRO), a germ that is resistant to many antibiotics, and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed. Residents who require EBP are residents with an indwelling medical device including the following: central venous catheter, urinary catheter, feeding tube, tracheostomy, and residents with a wound, regardless of their MDRO status. Use EBP when providing high-contact resident care activities such as bathing/showering, transferring residents from one position to another, providing hygiene, changing bed linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device, and performing wound care. Gloves and applying and removing of gown are required when conducting high-contact resident care activities that are listed above. Residents that are placed on EBP should have PPE in proximity outside the door and a trash can in residents' room for disposal prior to leaving the room. The policy did not address placement of signs indicating if a resident is on EBP. 3. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/07/25, showed staff assessed the resident as: -Received dialysis; -At risk for skin breakdown; -Diagnosis of End Stage Renal Disease (ESRD) is the final stage of chronic kidney disease, Peripheral Vascular Disease (PVD), a circulatory condition, and Diabetes. Review of the resident's care plan, revised 06/16/25, showed: -Resident required dialysis; -Did not contain direction for Enhanced Barrier Precautions (EBP), and risk for skin breakdown. Review of the resident's physician order sheet (POS), dated 06/24/25, showed orders for dialysis three times a week on Monday, Wednesday, Friday. Observation on 06/24/25 at 10:42 A.M., showed the resident's room did not have a sign to indicate the resident required EBP. Observation showed the resident's lower legs had weeping blisters. Observation showed Registered Nurse (RN) F transferred the resident and did not wear PPE. During an interview on 06/24/25 at 10:42 A.M., RN F said the resident requires dialysis and he/she should have worn PPE to transfer the resident due to the blisters on the resident's legs and need for dialysis, but there was no PPE available. Observation on 06/26/25 at 8:40 A.M., showed the resident's room did not have a sign to indicate the resident required EBP. Observation showed the resident's lower legs had weeping blisters. 4. Review of Resident #45's admission MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired, at risk for pressure ulcers and had one stage one pressure ulcer (non-blanchable redness, intact skin, and localized over a bony prominence). Review of the resident's POS, dated June 2025, showed an order dated 06/16/25 to apply collagen powder (wound treatment) to wound bed on right and left side of buttock, daily. Observation on 06/24/25 at 11:01 A.M., showed the resident's room had an EBP sign outside and did not have PPE within proximity. Observation on 06/25/25 at 8:53 A.M., showed the resident's room had an EBP sign outside and did not have PPE within proximity. Observation on 06/25/25 2:07 P.M., showed Licensed Practical Nurse (LPN) B provided wound care to the resident's bottom and did not wear a gown. During an interview on 06/25/25 at 2:30 P.M., LPN B said he/she should have worn a gown which should be at the door, but the PPE has not been in the hallways for a while. LPN B said the supplies are in the employee bathroom on a large linen cart, that is by the nurses' station. He/she said the supplies are not easily accessible and should be. 5. Review of Resident #52's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Had an indwelling catheter; -Diagnosis of obstructive uropathy (obstructed urine flow), and dementia. Review of the resident's care plan, revised 05/13/25, showed it did not contain direction for catheter care or EBP. Review of the resident's POS, dated 06/24/25, showed: -Foley catheter 20 French (size of catheter tube) with 10 cubic centimeters (cc) balloon; -Catheter care every shift and as needed; -Change catheter each month on the first. Observation on 06/25/25 at 8:17 A.M., showed a sign on the resident's door for EBP use and did not have PPE within proximity. Observation showed the resident had a catheter. Observation on 06/26/25 at 11: 25 A.M., showed a sign on the resident's door for EBP use and did not have PPE within proximity. Observation showed Certified Nurse Aide (CNA) K and Restorative Aide (RA) L performed catheter care and did not wear a gown. During an interview on 06/27/25 at 11:30 A.M., CNA K said he/she is the CNA supervisor and has received education on EBP. CNA K said he/she should have worn a gown and gloves to provide catheter care to the resident and he/she just forgot. 6. Review of Resident #53's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of the resident's care plan, revised 06/22/25, showed: -Catheter care provided routinely and as needed; -Did not contain direction for EBP. Review of the resident's POS, dated 06/24/25, showed: -Catheter 18 French with 10 cc balloon; -Catheter care every shift and as needed; -Change catheter each month on the first. Observation on 06/25/25 at 8:34 A.M., showed an EBP sign on the resident's door and a PPE cart outside the room. Observation showed Certified Nurse Aide (CNA) H transferred the resident to his/her bed and did not wear PPE. Observation on 06/26/25 at 9:48 A.M., showed an EBP sign on the resident's door and a PPE cart at his/her door. Observation showed CNA H, CNA K and Nurse Assistant (NA) M transferred the resident to his/her bed and did not wear a gown. Observation showed CNA K provided catheter care and did not wear a gown. During an interview on 06/26/25 at 10:00 A.M., CNA K said he/she is the CNA supervisor and has received education on EBP. CNA K said all three aides should have worn gowns and gloves to transfer the resident and while providing catheter care. CNA K said he/she realized it after he/she provided the care he/she forgot to put a gown and gloves on. 7. Review of Resident #71's admission MDS, dated 0520/25 showed staff assessed the resident as: -Cognitively intact; -At risk for pressure ulcers; -Surgical wound; -Diagnosis of left below the knee amputation. Review of the resident's care plan, revised 06/16/25, showed: -Had a pressure ulcer; -Had surgical wounds; -Did not contain direction for EBP. Review of the resident's POS, dated 06/24/25, showed: -Apply gauze to left surgical site and wrap with ace wraps daily; -Wound care left buttock pressure ulcer, cleanse with wound cleanser, apply boarder dressing, change daily and as needed. Observation on 06/24/25 at 10:45 A.M., showed the resident's room did not have a information for EBP use and did not have PPE with proximity. Observation showed the residents with a leg dressing. During an interview on 06/24/25 at 10:45 A.M., the resident said he/she had a recent procedure and has a wound on his/her buttock. Observation on 06/26/25 at 2:08 P. M., showed the resident's room did not have a information for EBP use and did not have PPE with proximity. 8. During an interview on 06/27/25 at 8:30 A.M., CNA G said he/she has not received EBP education while at the facility. CNA G said if a resident requires EBP they should have a sign posted on their door to alert staff. CNA G said EBP is to protect the resident from possible contamination or infection during care. CNA G said staff should wear a gown and gloves when providing care for a resident who has an open wound, catheter, and dialysis access site. CNA G said he/she was not aware PPE should be worn during transfers and he/she only thought it was to be worn when providing care. CNA G said PPE is not easily accessible for staff. CNA G said he/she does not know if the facility has gowns for staff to wear. CNA G said he/she does not know which residents require EBP and does not know who is responsible to ensure signs are posted and PPE is readily available. During an interview on 06/27/25 at 11:20 A.M., RA L said if a resident requires EBP they should have a sign posted on their door to alert staff. RA L said staff should wear a gown and gloves when providing care for a resident who has an open wound, catheter, or dialysis access site. RA L said he/she did not wear PPE when assisting with catheter care and should have. RA L said the PPE is not readily available and he/she was in a hurry. During an interview on 06/27/25 at 1:50 P.M., the Interim Director of Nursing (DON) said gowns and gloves for EBP are required when caring for residents with multi-drug-resistant organism infections, wounds, tube feeding, dialysis, and indwelling catheters. Signage should be on the door and removed when no longer applicable. The DON said PPE should be readily available. The DON/Designee is responsible for ensuring signage is posted and PPE is available when appropriate. During an interview on 06/27/25 at 2:20 P.M., the administrator said staff is expected to wear gown and gloves when caring for residents with tube feedings, wound dressing changes, and urinary catheters. He/She said PPE is expected to be available in carts in the hall. The administrator said the Social Services Director (SSD) is currently responsible for placement of EBP signage. 9. Review of the facility's policy titled Infection Prevention and Control Program, undated, shows: -Facility will maintain an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors and healthcare workers; -Conducts surveillance for facility associated infections and/or communicable diseases. Data will be collected by chart review, review of microbiological reports, reports from resident care providers and review of other documents, trended for historical comparison and reported to the infection prevention committee no less than quarterly; -Maintains facility infection prevention/control policy and procedure manuals; -The effectiveness of the infection prevention and control program is reviewed no less than annually with findings reported to the Quality Assurance committee. Review of the IPCP Procedure Manual, undated, showed the manual had not been reviewed annually. Review showed the manual did not contain antibiotic tracking documentation from May 2024 to March 2025. During an interview on 06/25/25 at 10;21 A.M., RN W said he/she was unable to perform the responsibilities of the role and stepped down a few months ago. RN W said he/she had not attended a Quality Assurance meeting for a long time. During an interview on 06/27/25 at1:50 P.M., the DON said policies had not been followed or reviewed annually. During an interview on 06/27/25 at 02:10 P.M., the Administrator said the purpose of the Infection Prevention and Control Program (IPCP) is to track infections in the facility and analyze trends and patterns for the Quality Assurance and Performance Improvement (QAPI) committee's review. He/She said the IP is expected to follow the facility's IPCP policies, and that the Interim DON is rebuilding the IPCP after discovering a period of inactivity between March 2024 and April 2025.

Based on record review and interviews, facility staff failed to maintain an Antibiotic Stewardship Program (the monitoring for appropriate antibiotic use and effectiveness to improve outcomes and prevent development of antibiotic resistance). The facility census was 62.1. Review of the facility's policy titled, Antibiotic Stewardship Program, undated, showed:-The Infection Preventionist (IP) will be the hub of the program and have the knowledge and expertise to develop, implement and monitor the Antibiotic Stewardship Program;-The IP/Designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription;-The IP/Designee will be responsible for auditing of the completeness of antibiotic prescribing documentation to include dose, route, start date, end date, days of therapy and indication;-The IP/Designee will track C. difficile (inflammation of the colon caused by bacteria Clostridium difficile resulting in severe diarrhea), and antibiotic resistant infections; and develop a quarterly report for the Quality Assurance meeting.2. Review of the Antibiotic Stewardship program, dated June 2024 to April 2025 did not contain documentation staff tracked antibiotic and infection.During an interview on 06/25/25 at 10:21 A.M., Registered Nurse (RN) W said he/she was the designated IP for the past year until stepping down a few months ago. RN W said he/she was unable to perform the responsibilities of the role and had not tracked infections or performed antibiotic surveillance. RN W said he/she works a lot of shifts and could not keep up with it all. RN W said he/she had not gone to a Quality Assurance and Performance Improvement meeting for a long time.During an interview on 06/27/25 at 1:50 P.M., the Interim Director of Nursing (DON) said he/she is aware the Antibiotic Stewardship Program had not been active. The Interim DON said he/she came to the facility two months ago and discovered infection tracking and antibiotic surveillance had not been done prior to his/her arrival. During an interview on 06/27/25 at 2:33 P.M., the administrator said she is a new administrator, but believes the purpose of Antibiotic Stewardship is tracking who is on antibiotics and making sure it is given the full length of time and that infection is going away. The administrator is aware the program has not been active, but is now getting on track. The administrator expects the IP to manage the program according to Centers for Disease Control guidelines and facility policy.

Based on interview and record review, facility staff failed to delegate an Infection Preventionist (IP) with qualifications by education, training, experience or certification to perform the role. The facility census was 62.1. Review of the facility's policy titled Infection Prevention and Control Program, undated, showed the IP is qualified to conduct infection control and prevention activities as a result of education, training and experience. He/She will complete the Centers for Disease Control (CDC) Long Term Care Infection Preventionist training module.Review Registered Nurse (RN) W's, personnel records showed he/she completed two of 19 continuing education units of the CDC Long Term Care Infection Preventionist training module on 05/15/24.During an interview on 06/25/25 at 10:21 A.M., RN W said he/she began the IP role May of 2024 and stepped down a few months ago because he/she was unable to fulfill the responsibilities of the role. RN W said he/she does not recall if he/she completed the CDC certification training. RN W said the Interim Director of Nursing (DON) is now the IP. During an interview on 06/27/25 at 1:50 p.m., the Interim DON said he/she began overseeing the IP program in May of 2025 but he/she is not certified. He/She said RN W has been helping though he/she did not know he/she had not completed the CDC training. During an interview on 06/27/25 at 2:33 P.M., the administrator said the purpose of the Infection Prevention and Control program is to track infections in the facility. He/She said the IP must be certified and she believed RN W had completed the training. He/She is aware the Interim DON is not certified.

Based on interview and record review, facility staff failed to consistently document the code status as Do Not Resuscitate (DNR) or Full Code - Cardiopulmonary resuscitation ((CPR) an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing and heartbeat) on the care plan, and/or Physician Order Sheet (POS) for four residents (Resident #18, #35, #47, and #53) out of 25 sampled residents. The facility census was 62. 1. Review of the facility policy titled Advance Directive, undated, showed upon admission of a resident, the social services designee (SSD) will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident with moderate cognitive impairment.Review of the resident's face sheet (a summary document that provides essential patient information), undated, showed staff documented the resident's code status as DNR.Review of the resident's POS, dated [DATE], showed a physician order for full code status dated [DATE].Review of the resident's medical record showed a signed DNR form dated [DATE].Review of the resident's care plan, revised [DATE], showed staff documented the resident's code status as DNR.3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment.Review of the resident's face sheet, undated, showed staff documented the resident's code status as full code.Review of the resident's care plan, revised [DATE], showed staff documented the resident's code status as full code.Review of the resident's POS, dated [DATE], showed the resident did not have a physician order for code status.4. Review of Resident #47's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired, and admitted to the facility on [DATE].Review of the resident's face sheet, undated, showed staff documented the resident's code status as full code.Review of the resident's POS, dated [DATE], showed the resident did not have a physician order for code status.Review of the resident's care plan, dated [DATE], showed staff did not document the resident's code status.5. Review of Resident #53's Quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment.Review of the resident's face sheet, undated, showed staff documented the resident's code status as DNR.Review of the resident's POS, dated [DATE], showed a physician order for full code dated [DATE].Review of the resident's medical record showed a signed DNR form dated [DATE].Review of the resident's care plan, revised [DATE], showed staff did not document the resident's code status.6. During an interview on [DATE] at 10:27 A.M., the administrator said the facility has a morning meeting each day and that is when code status changes should be discussed. The administrator said the SSD is responsible to ask about code status when a resident is admitted to the facility. The administrator said once the facility received a signed DNR order from the physician, the SSD is responsible to update the face sheet, the charge nurse is responsible to update the orders, and the MDS coordinator is responsible to update the care plan. The administrator said the face sheet, orders, and care plan should all match so staff are able to quickly know what a resident's code status is in an emergency. The Administrator said if they do not match this could lead to confusion and poor outcome for the resident. The resident could receive CPR if they did not want to, or not be resuscitated if they wanted to be a full code.During an interview on [DATE] at 11:50 A.M., the SSD said he/she is responsible to obtain the resident's code status upon admission. The SSD said if a resident chose to be a DNR the SSD or administrator are responsible to get the orders. The SSD said once the order is received he/she updates the charge nurse and they are responsible to update the resident's orders, and he/she alerts the MDS coordinator who is responsible to update the care plan. The SSD said the face sheet, orders, and care plan need to match to avoid confusion when an emergency arises. The SSD said he/she does not know why the code statuses did not match for each resident.During an interview on [DATE] at 1:50 P.M., the Director of Nursing (DON) said he/she expects each resident to have a code status order, and it should match the face sheet and care plan. The DON said the SSD is responsible to obtain the resident code status and enter it on the face sheet, the charge nurse is responsible to change the orders in the resident's chart, and the MDS coordinator is responsible to update the care plan. The DON said the face sheet, orders, and care plan should match to avoid staff confusion in an emergency. The DON said if they don't match the staff won't know what to do and it could lead to adverse outcomes for the resident. The DON said having the wrong code status or missing code status could cause a delay in care or staff providing the wrong care. The DON did not know about the code status discrepancies for the residents.During an interview on [DATE] at 2:00 P.M., the MDS Coordinator said he/she has only been at the facility for two to three months, and there were not any care plans completed or updated from [DATE] to now. The MDS Coordinator said he/she has been winging it and trying to get caught up on the care plans and MDS assessments, but he/she has been working on the floor as well. He/she said code statuses should be on the care plan and it should match the physician orders.

Based on observation, interview, and record review, facility staff failed to develop a comprehensive person-centered plan of care to meet the resident's medical, nursing, mental and psychosocial needs for 10 residents (Resident #11, #18, #42, #45, #52, #53, #56, #58, #64, and #71) out of 25 sampled residents. The facility census was 62. 1. Review of the facility's policy titled Care Plan Comprehensive, undated, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS); -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; -The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS and Care Area Assessment (CAAs)); -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: When a significant change in the resident's condition occurs; -At least quarterly; -When changes occur that impact the resident's care. Review of the facility's policy titled Care Panning, Interdisciplinary Team, undated showed the facility care plan team is responsible for the development of an individualized comprehensive care plan for each resident. The resident, resident's family, and/or legal representative are encouraged to participate in the development and revisions of the resident's care plan. 2. Review of Resident #11's Quarterly MDS, a federally mandated assessment tool, dated 05/05/25, showed staff assessed the resident as: -Severe cognitive impairment; -Used a cane or wheelchair for mobility; -Received antipsychotic medications; -Received antidepressant medications; -Received opioid medications; -Required pain management. Review of the CAAs section blank. Review of the resident's care plan, revised 06/12/25, showed staff documented the resident is allowed to walk the halls to the dining area. Review showed staff did not document direction for psychotropic, opioid medication use, pain management or use of walker. Review of the resident's Physician's Order Sheet (POS), dated 06/24/25 showed: -Chlorpromazine (antipsychotic medication) 25 milligrams (mg) twice a day dated 03/14/25; -Trazadone (antidepressant medication) 50mg daily dated 03/14/25; -Hydrocodone/Acetaminophen (opioid pain medication) 5/325 mg every six hours as needed (prn) dated 03/14/25; -Invega Sustenna syringe (antipsychotic medication) 234mg/1.5 milliliters (ml), give 1.5ml intramuscularly (IM) every three weeks on Friday dated 06/06/25. Observation on 06/25/25 at 8:19 A.M., showed the resident ambulated with a walker in the hall independently. 3. Review of Resident #18's admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Used a walker for mobility; -Received dialysis; -Received oxygen; -Received insulin; -Received antipsychotic medication; -At risk for skin breakdown. Review of the resident's CAAs showed staff documented the resident triggered for cognitive loss, nutrition, pressure ulcer risk, and psychotropic drug use. Review of the resident's care plan, revised 06/16/25, showed the care plan did not contain direction for cognitive status, nutrition, insulin use, antipsychotic medication, oxygen use, ADL assistance, Enhanced Barrier Precautions (an infection control strategy to reduce transmission of multidrug resistant organisms (EBP)) due to resident being on dialysis, and having open wounds, risk for skin breakdown or the resident's wishes to not have a bed. Review of the resident's POS, dated 06/24/25, showed: -Insulin Lispro (medication used to control blood sugar) per sliding scale dated 04/24/25; -Lurasidone (antipsychotic medication) 80mg at bedtime dated 04/24/25; -Olanzapine (antipsychotic medication) 5mg at bedtime as needed dated 04/24/25; -Quetiapine (antipsychotic medication) 50mg every six hours as needed dated 04/24/25; -Left foot blisters apply skin (a protective skin barrier) prep two times a day dated 05/15/25; -Oxygen at 4 liters minute per (LPM) nasal cannula (N/C) continuously dated 04/24/25; -Dialysis (way to remove waste and excess fluid from the blood when kidneys don't perform adequately) three times a week on Monday, Wednesday, and Friday dated 04/24/25. Observation on 06/24/25 at 10:42 A.M., showed the resident's legs wept (fluid) from blisters. Observation showed the resident wore oxygen. Observation showed the resident's room did not have EBP signage. Observation on 06/24/25 at 2:00 P.M., showed the resident in a recliner and wore oxygen. Observation on 06/25/25 at 8:30 A.M., showed the resident in a recliner and wore oxygen. Observation showed the resident did not have a bed in his/her room. Observation on 06/25/25 at 11:20 A.M., showed the resident wore oxygen. Observation on 06/26/25 at 8:40 A.M., showed the resident wore oxygen. Observation showed the resident did not have a bed in his/her room. Observation on 06/27/25 at 8:50 A.M., showed the resident sat in a recliner an wore oxygen. Observation showed the resident did not have a bed in his/her room. 4. Review of Resident 42's Quarterly MDS, dated [DATE] showed staff assessed the resident as cognitively intact, did not have a pulmonary (lung) diagnosis, utilize a Continuous Positive Airway Pressure (CPAP), non-invasive ventilation that delivers a continuous flow of pressurized air to keep the airway open during sleep, or oxygen use. Review of the resident's care plan, dated 04/19/25, showed the care plan did not contain direction for staff in regard to pulmonary conditions or CPAP use. Review of the resident's POS, dated 05/08/25, showed an order for oxygen at two to four LPM per N/C while in bed and as needed. The POS did not contain orders for a CPAP. Observation on 06/24/25 at 11:34 A.M. showed the resident in bed with a CPAP mask on. The oxygen compressor is attached to the CPAP device and set to deliver oxygen at five liters. Observation on 06/25/25 at 10:02 A.M. showed resident in bed with a CPAP mask on. The oxygen compressor is attached to the CPAP device and set to deliver oxygen at five liters. Observation on 06/26/25 10:39 A.M. showed resident in bed with a CPAP mask on. The oxygen compressor is attached to the CPAP device and set to deliver oxygen at five liters. Observation on 06/27/25 10:20 A.M. showed resident in bed with a CPAP mask on. The oxygen compressor is attached to the CPAP device and set to deliver oxygen at five liters. Observation on 06/27/26 at 08:32 A.M. showed the resident's oxygen compressor on and set to give LPM. The CPAP mask is on the bed. During an interview on 06/27/25 at 08:33 A.M., Resident Assistant (RA) L said the resident maintains and sets up the CPAP machine himself/herself. Nursing is responsible to bag the tubing when not in use. He/She was not familiar with the resident's care plan. During an interview on 06/27/25 at 08:30 A.M., Licensed Practical Nurse (LPN) Q said he/she was not familiar with the resident's care plan and was not able to locate an order for CPAP. During an interview on 06/27/25 at 08:39 A.M., LPN T said the resident came with his/her own CPAP machine. He/She did not know the current respiratory care orders for the resident and did not realize there was not a CPAP order, or that the oxygen order did not match what was administered. He/She said it is everyone's responsibility to ensure orders are accurate, but there have been a lot of staff changes lately. He/She said he/she gets resident information he/she needs during shift change report. During an interview on 06/27/25 at 10:14 A.M., Certified Nurse Assistant (CNA) U said he/she does not do anything with the resident's CPAP. He/She receives information about resident care during shift report and doesn't look at care plans. 5. Review of Resident #45's admission MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired, with diagnoses of atrial fibrillation (an irregular and often rapid heart rate that commonly causes poor blood flow), high blood pressure, peripheral vascular disease (PVD), a circulatory condition where blood vessels narrow and reduce blood flow to the limbs and organs, acid reflux, renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes, arthritis, anxiety, and depression. Review of the resident's CAAs showed the following areas should be addressed on the care plan: Cognitive Loss/Dementia, Visual Function, ADLs - Functional/Rehabilitation Potential; Urinary Incontinence and Indwelling Catheter; Nutritional Status; and Pressure Ulcer. Review of the resident's medical record did not contain a comprehensive care plan. During an interview 06/25/25 at 8:53 A.M., the resident's spouse said the resident gets urinary tract infections (UTI), a common infection affecting the urinary system, including the bladder, urethra, and kidneys, often, and the resident gets more confused. The spouse said the resident has good and bad days with their mental status; and does currently have a pressure ulcer that is getting better. The spouse said the resident had a stroke in the past and favors his/her left side so does need assistance with transfers and other activities of daily living, and it also affects the resident's memory. 6. Review of Resident #52's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and had an indwelling urinary catheter (plastic tube inserted directly in the bladder to drain urine). Review of the resident's CAAs showed staff left the section blank. Review of the resident's care plan, revised 05/13/25, showed the care plan did not contain direction for urinary catheter care and infection risk, ADL assistance, or EBP. Observation on 06/25/25 at 8:07 A.M., showed the resident wore a catheter leg. Observation on 06/26/25 at 11:25 A.M., showed CNA K performed catheter care for the resident. 7. Review of Resident #53's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required set up assistance for meals; -Required maximum assistance for transfers; -Dependent on staff for dressing and hygiene; Review of the resident's care plan, revised 06/22/25, showed it did not contain direction for ADL assistance or EBP. Observation on 06/24/25 at 10:52 A.M., showed the resident had a fall mat on the floor next to his/her bed and a urinary catheter hung at his/her bedside. Observation showed the resident had an EBP sign and PPE outside his/her door. Observation on 06/25/25 at 8:34 A.M., showed CNA H transferred the resident to bed and put a fall mat on the floor. Observation on 06/26/26 at 8:40 A.M., showed a catheter bag hung under the resident's wheelchair. Observation on 06/26/25 at 9:48 A.M., showed CNA K performed catheter care on the resident. 8. Review of Resident 56's Quarterly MDS, dated [DATE]. showed staff assessed the resident as: -Cognitively intact; -Diagnoses of bipolar disorder, dementia, PVD and atrial fibrillation; -Received antipsychotic and anticoagulation (blood thinner) medication. Review of the resident's care plan, dated 01/22/25, showed the care plan did not contain direction for staff in regard to antipsychotic and anticoagulant medication use. Review of the resident's POS, dated 01/10/25, showed orders for aripiprazole (an antipsychotic medication) 5 mg daily and rivaroxaban (anticoagulant), 2.5 milligrams twice daily. 9. Review of Resident #58's admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required moderate assistance for meals, dressing, and transfers; -Dependent for hygiene, and bathing; -Uses a wheelchair for mobility; -Received insulin; -Received antidepressant medications; -Received antipsychotic medications; -At risk for pressure ulcers. Review of the resident's CAAs showed the resident triggered for cognitive loss, activities, and psychotropic drug use. Review of the resident's care plan, revised 06/16/25, showed: -Resident at risk for falls related to cognition; -Resident is a full code; -Resident has a pressure ulcer on left buttock; -Did not contain direction for cognitive loss, activities, insulin use, antidepressant medication, antipsychotic medication, ADL assistance, or EBP due to resident wounds. Review of the resident's POS, dated 06/24/25, showed: -Admelog Solostar insulin (medication used to control blood sugar) per sliding scale four times a day dated 04/09/25; -Bupropion (antidepressant medication) extended release 450 mg every day dated 04/15/25; -Lantus insulin (medication used to control blood sugar) 14 units (U) at bedtime dated 04/09/25; -Quetiapine 25 mg as needed dated 4/09/25; -Quetiapine 75 mg every day dated 04/11/25; -Trazadone 50 mg at bedtime dated 04/09/25; -Wound care left lower buttock pressure ulcer, cleanse with wound cleaner, apply skin prep to peri-wound (around the wound), apply hydrogel (a wound treatment medication) to wound bed, cover with boarder gauze, change daily until healed; -Wound care coccyx pressure ulcer, cleanse with wound cleaner, apply skin prep to peri-wound, apply hydrogel to wound bed, cover with boarder gauze, change daily until healed. Observation on 06/24/25 at 11:05 A.M., showed the resident in a wheelchair. Observation on 06/26/25 at 7:58 A.M., showed the resident in the dining room in a wheelchair as Nurse Assistant (NA) I served his/her breakfast and assisted the resident to cut food up. Observation on 06/26/25 at 8:50 A.M., showed RN E performed wound care on the resident's left buttock. Observation showed staff used EBP during wound care. 10. Review of Resident # 64's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of aphasia (a language disorder that affects the ability to communicate) weakness, a neurological condition, and obvious or likely cavity or broken teeth. Review of the resident's care plan, dated 06/17/25, showed the care plan did not contain dental problems or restorative nursing care. Review of the resident's POS, dated 05/08/25, showed an order for Physical Therapy evaluation, one session for establishment of Restorative Nursing Program. Established and implemented. Review showed a dental consult as needed ordered on 05/26/25. Review of the resident's progress notes, dated 05/20, 05/29, 06/10 and 06/24/25, showed restorative nursing services provided Review of the resident's progress notes, dated 06/03/25, showed staff documented the resident was seen by the physician and asked for a dental consult. To be seen by dental clinic at facility. During an interview on 06/24/25 at 11:40 A.M., the resident said he/she had a stroke that affected his/her speech, right arm and legs. Resident believed he/she would be in the facility for rehabilitation for about two months. Resident said he/she has been having tooth pain since admission in May and has asked multiple times to see a dentist but is still waiting. Observation on 06/24/25 at 2:48 P.M. showed the resident winced in pain from the left side of his/her mouth during interview. Observation showed the lower left side of face noted to be swollen. During an interview on 06/25/25 at 2:40 P.M., the Social Services Designee (SSD) said dental issues should be care planned. He/She was not aware he was complaining of pain or jaw was swollen. The SSD said the resident arrived at the facility after the last Dental Clinic and will be seen at the next one now that he has been approved for Medicaid. The SSD said they did not pursue an outside appointment until I questioned them. He/She said the waiting lists are very long. 11. Review of Resident #71's admission MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Required set up assistance for meals, hygiene, dressing -Required supervision for bathing; -Required moderate assistance for transfers; -Used a wheelchair for mobility; -Received insulin; -Received antidepressant medications; -Resident is a smoker; -At risk for pressure ulcers; -Has a surgical wound. Review of the resident's CAAs showed the resident triggered for ADLs, and psychotropic medication use. Review of the resident's care plan, revised 06/16/25, showed: -Resident has a pressure ulcer; -Resident has surgical wounds due to left below the knee amputation -Did not contain direction for antidepressant medications, diabetes mellitus, smoking, ADL assistance, or EBP. Review of the resident's POS, dated 06/24/25, showed: -Duloxetine (antidepressant medication) 60 mg every day dated 05/14/25; -Lispro insulin (medication used to control blood sugar) 5 U before meals dated 05/14/25; -Lispro insulin sliding scale with meals dated 06/12/25; -Lantus insulin (medication used to control blood sugar) 22 U at bedtime dated 06/12/25; -Apply gauze to left stump and wrap with ace wraps daily; -Wound care left buttock pressure ulcer, clean with would cleanser, apply boarder dressing, change daily and as needed. Observation on 06/24/25 at 10:45 A.M., showed the resident had a left below the keen amputation. Observation showed the resident transferred himself/herself to a wheelchair and propelled himself/herself in the hall. Observation showed the resident went outside to smoke. 12. During an interview on 06/27/25 at 1:50 P.M., the Director of Nursing (DON) said he/she has only been at the facility two weeks, so he/she is not sure what the care plans are like. The DON said the MDS coordinator is responsible to complete the MDS, CAAs, and care plans on each resident in the facility. The DON said each resident should have an individualized accurate care plan that matches the orders and sections triggered on the MDS in the CAAs. The DON said the initial comprehensive care plan should be completed within 21 days of admission. The DON said he/she would expect a care plan to address things such as falls and interventions, skin issues such as surgical sites or blisters, pressure ulcers, oxygen use, smoking, catheters and if the resident uses a urinary leg bag, how much assistance the resident needs for all ADL's, any nutritional needs or weight loss, and certain medications such as antidepressants, antianxiety, antipsychotic, and anticoagulants, restorative nursing care and dental issues. During an interview on 06/27/25 at 2:30 P.M., the Administrator said he/she is aware the facility care plans are not appropriate for each resident. The Administrator said the facility did not have an MDS coordinator for a length of time and the current MDS coordinator is working to catch up. The Administrator said the MDS coordinator is responsible to update the care plans, but the charge nurse has access to update as well. The Administrator said the care plan should be individualized for each resident, be accurate, and match the resident's orders and sections triggered on the MDS in the CAAs. During an interview on 07/01/25 at 2:00 P.M., the MDS Coordinator said comprehensive care plans should be completed within 14 days after the comprehensive MDS assessment is completed. He/she said any CAAs triggered should typically be addressed on the care plan unless the concern only occurred during the look back period of the assessment and is not ongoing. The MDS Coordinator said he/she has been working on the care plans since January 2025 to get them caught up and had been training another nurse to help but he/she was unable to finish due to health reasons. The MDS Coordinator said he/she just does not have the help, and must work the floor often, and that corporate does come out one to two times a month to help when they can, but he/she has only been at the facility for about 2.5 months, and they were just not being done prior to him/her starting at the facility. The MDS Coordinator said nutrition and diet orders, all medications including antidepressants, antipsychotics, anticoagulants, insulin, antibiotics and opioids should be on the care plan. He/she said CPAP and oxygen use with any respiratory diagnoses, long standing dental concerns, restorative nursing cares, ADL needs, skin concerns, pain, and diabetes should be on the care plan as well. The MDS coordinator said smoking should be on the care plan to address if they need supervision or an apron for safety; as well as any infections and if the resident requires EBP, has a foley catheter, or cognitive loss/dementia. The MDS coordinator said he/she likes to make care plans that are individualized so that anyone could pick out the resident from reading the care plan.

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care for three resident's (Resident #15, #41, & #47) out of 25 sampled residents with changes in the resident's needs. The facility census was 62.1. Review of the facility policy titled Care Plan Comprehensive, undated, showed an individualized care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable, mental and psychosocial well-being. The comprehensive care plan will be based on a thorough assessment that includes but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool. Assessment of each resident is an ongoing process, and the care plan will be revised as changes occur in the resident's condition. The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment MDS and Care Area Assessment (CAAs), process used to further investigate potential problems identified during a comprehensive resident assessment. The interdisciplinary care plan team is responsible for the periodic review and update of care plans when a significant change in the resident's condition has occurred; at least quarterly; and when changes occur that impact the resident's care (i.e. change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 2. Review of Resident #15's Annual MDS assessment, dated 04/01/25, showed staff assessed the resident as severely cognitively impaired with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and seizure disorder. The MDS did not contain documentation of a swallowing disorder, or that the resident received a mechanically altered diet. Review of the resident's POS, dated June 2025, showed a diet order level six bite sized (a diet where food is soft, tender and cut into small, bite sized pieces) started 04/09/25. Review showed the resident's peg tube (a feeding tube inserted through the abdominal wall directly into the stomach) discontinued November of 2024. Review of the resident's care plan, dated 11/28/24, showed staff documented the resident diet mechanical soft (a diet that includes foods that have been chopped, ground, or pureed) with regular liquids, received all medications via peg tube, and only received boluses of tube feeding at bedtime if he/she ate less than 50% of meals. The care plan did not address the removal of the resident's peg tube or the current diet order. Observation on 06/24/25 at 12:17 P.M., showed the resident served a regular diet, and an unknown staff member cut the served turkey into bite sized pieces. 3. Review of Resident #41's MDS assessment, dated 04/01/25, showed staff assessed the resident as severely cognitively impaired, received hospice services, received antidepressants and opioids, and had diagnoses of dementia, malnutrition, anxiety, depression and unspecified pain. Review of the resident's POS, dated June 2025, showed orders for: -Trazodone tablet (antidepressant); 50 milligrams (mg), take 1/2 tablet 25 mg at bedtime with a start date of 04/18/25 for unspecified depression; -Zoloft (antidepressant) tablet; 50 mg; take 50mg; daily with a start date of 04/18/25 for unspecified depression; -Fentanyl - Schedule II patch 72 hour; 12 micrograms (mcg)/hour; 1 patch transdermally (on the skin) Special Instructions: once a day every three days with a start date of 04/18/25 for unspecified pain; -Morphine concentrate - Schedule II solution; 100 mg/5 milliliter (mL) (20 mg/mL); amt: 0.25 mL; Special Instructions: every one hour as needed for unspecified pain. Review of the resident's care plan, dated 05/21/25, showed the care plan did not address the resident's hospice status or use of antidepressants and opioids. 4. Review of Resident #47's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired with diagnoses of heart failure, dementia, urinary tract infection (UTI), a common infection affecting the urinary system, including the bladder, urethra, and kidneys, anxiety, overactive bladder, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), atrial fibrillation, acid reflux, and generalized muscle weakness. Review of the resident's admission MDS, dated [DATE], showed the Care Area Assessment (CAA), process used to further investigate potential problems identified during a comprehensive resident assessment, showed the following areas should be addressed on the care plan: Cognitive Loss/Dementia, Activities of Daily Living (ADLs) - Functional/Rehabilitation Potential; Urinary Incontinence and Indwelling Catheter; Falls; Pressure Ulcer, Psychotropic drug use, and pain. Review of the resident's POS, dated June 2025, showed orders as follows: -02/28/25 meloxicam tablet; 7.5 mg, take 0.5 tab oral once a day for chronic pain; -02/27/25 tylenol tablet; 500 mg; take two tabs for a total of 1000 mg oral; may give three times a day as first line for pain, for chronic pain. Review of the resident's care plan, dated 06/16/25, showed staff did not address Cognitive Loss/Dementia, ADLs, urinary incontinence, falls, pressure ulcer and pain. 5. During an interview on 06/27/25 at 8:37 A.M., the MDS Coordinator said the care plans are a year behind in getting done, and that he/she had only started working at the facility a few months ago, and had been trying to get caught up, but had been pulled to work the floor a lot. The MDS Coordinator said the corporate nurse had been helping and was trying to prioritize new admissions, those receiving skilled services, and that the person who was in the position before was so behind that he/she is doing all he/she can do to get caught up. During an interview on 06/27/25 at 1:50 P.M., the Director of Nursing (DON) said he/she has only been at the facility two weeks, so he/she is not sure what the care plans are like. The DON said the MDS coordinator is responsible to complete the care plans on each resident in the facility. The DON said each resident should have an individualized accurate care plan that matches the resident's orders and sections triggered on the MDS. The DON said he/she would expect a care plan to address things such as hospice, pressure ulcers, urinary incontinence, how a resident transfers, mobility, if the resident uses a wheelchair or walker, how much assistance the resident needs for all ADL's, any nutritional needs or weight loss, dementia needs, pain, infections and the use of antibiotics, and certain medications such as antidepressants, antianxiety, antipsychotic, and anticoagulants. During an interview on 06/27/25 at 2:30 P.M. the administrator said he/she was aware the facility care plans were not appropriate for each resident. The administrator said the facility did not have a MDS coordinator for a length of time and the current MDS coordinator is working to catch up. The administrator said the MDS coordinator is responsible to update the care plans, but the charge nurse has access to update as well. The administrator said the care plan should be individualized for each resident, be accurate, and match the resident's orders and sections triggered on the MDS in the CAAs. The administrator said said he/she would expect a care plan to address things such as falls and interventions, hospice, pressure ulcers, pain, dementia, how a resident transfers, mobility, how much assistance the resident needs for all ADL's, any nutritional needs or weight loss, and certain medications such as antidepressants, antianxiety, antipsychotic, and anticoagulants. During an interview on 07/01/25 at 2:00 P.M., the MDS Coordinator said any areas triggered on the MDS should be addressed on the care plan unless it was only occurring during the look back period of the assessment and is not an ongoing concern. The MDS Coordinator said he/she has been working on the care plans since January 2025 to get them caught up and has been training another nurse to help but he/she was unable to finish due to health reasons. The MDS Coordinator said he/she just does not have the help, and must work the floor often, and that corporate does come out one to two times a month to help when they can, but he/she has only been at the facility for about 2.5 months, and they just were not being done prior to him/her starting at the facility. The MDS Coordinator said hospice, psychotropic medications, ADLs transfers/mobility, pressure ulcers including the risk for pressure ulcers, urinary incontinence, dementia, diet orders and nutritional status, and pain should be on the care plans. The MDS coordinator said the care plans should match the orders in place for the residents as well.

Based on observation, interview, and record review, facility staff failed to document the required fall documentation and neurological assessments (an assessment completed to determine if the nervous system is impaired) for five residents (Resident #11, #35, #53, #58, and #71) out of 25 sampled residents. The facility census was 62. 1. Review of the facility's policy titled Resident Condition Change, undated, showed: -The purpose is to observe, record, and report any condition change to the physician so that proper treatment can be implemented;-After all resident falls, injuries, or changes in physical or mental function, monitor the following: observe for lacerations, swelling, discoloration, convulsions, pain, personality changes, alterations in consciousness, incontinence, sensory disorder, weakness, speech disorder, balance, reflexes, bleeding, unequal pupils, dyspnea, flushing or cyanosis, abduction/adduction/shortening of extremities;-Obtain vital signs;-Have someone stay with the resident while the nurse calls the physician if necessary;-Notify the resident's responsible party;-Monitor resident's condition frequently until stable;-Notify the physician of condition changes, need for treatment, or medications. Review of the facility's policy titled Event Investigation, undated, showed: -The purpose is to investigate the cause of all marks, discolorations, skin breaks, and injuries which have not been witnessed to identify injuries after a sustained event;-Obtain vital signs;-Complete an assessment to observe skin, any pain, redness, swelling, edema, tenderness, breaks, palpate pulses, perform range of motion to all joints, assess mental and cognitive status, observe neurological signs;-Interview the resident to determine the cause;-Interview any witnesses to determine the cause;-Notify the resident's physician;-Notify the resident's representative;-Attempt to determine the cause;-Implement preventative measures;-Complete an event form. Review of the facility's policy titled Charting and Documentation, undated, showed: -The purpose is to provide a complete account of the resident's care, treatment, response to the care, signs and symptoms, as well as the resident's progress;-Chart all pertinent changes in the resident's condition, reactions, as well as routine observations;-Documentation pertaining to accidents or incidents involving residents should include: -Circumstances surrounding the incident; -Where the incident took place; -Date and time of the incident; -Name of any witnesses and their account of the incident; -Residents account of the incident; -Time the physician was notified; -Date and time the family was notified; -The condition of the resident; -Disposition of the resident (i.e. Transferred to the hospital, put to bed, etc.) -All pertinent observations; -Signature and title of the person documenting.;-Documentation of follow up notes should include: -A summary of the resident's condition all shifts until stabilized; -Documentation that the resident condition has stabilized; -Signature and title of the person documenting. 3. Review of Resident #11's Quarterly Minimum Data Sett (MDS) a federally mandated assessment tool, dated 05/05/25, showed staff assessed the resident as: -Severe cognitive impairment;-Required moderate assistance for transfers, hygiene, dressing, toileting, and ambulation;-Had falls prior to admission and after admission;-Had falls with injury. Review of the resident's care plan, revised 06/12/25, showed staff documented the resident is at risk for falls and had falls. Review of the resident's medical record showed: -01/30/25: resident had an unwitnessed fall with no injury;-Did not contain documentation of an initial fall note, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -02/6/25: resident had an unwitnessed fall with no injury;-Did not contain documentation of a completed event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -02/18/25: resident had a witnessed fall with no injury;-Did not contain documentation of a completed event report, vital signs, or follow up documentation each shift for 72 hours. -03/18/25: resident had an unwitnessed fall with complaints of hip pain, sent to the emergency room (ER), returned the same day;-Did not contain documentation of a completed event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -04/09/25: resident had an unwitnessed fall with right extremity pain, x-ray completed;-Did not contain documentation of an initial fall note, neurological assessment, or follow up documentation each shift for 72 hours. -04/16/25: resident had an unwitnessed fall with right hip pain, sent to the ER, returned the same day;-Did not documentation of a neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -05/21/25: resident had an unwitnessed fall with a laceration to his/her left eye, sent to the ER, returned the same day;-Did not contain documentation of a neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -05/25/25: resident had an unwitnessed fall with no injury;-Did not contain documentation of vital signs or follow up documentation each shift for 72 hours. -06/08/25: resident had an unwitnessed fall with left arm pain, sent to the ER, returned the same day;-Did not contain documentation of a neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -06/11/25: resident had an unwitnessed fall with no injury;-Did not contain documentation of a completed event report, vital signs, or follow up documentation each shift for 72 hours. 4. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and required moderate assistance for transfers, hygiene, dressing, toileting, and bathing. Review of the resident's care plan, revised 06/13/25, showed: -Resident required assistance with Activities of Daily Living (ADL's) and mobility;-At risk for falls and injury;-06/07/25: Fall occurred while in the dining room, staff to provide reminders and cues for safety;-Did not contain an intervention for the fall on 06/21/25. Review of the resident's medical record showed: -06/07/25: resident had an unwitnessed fall with no injury;-Did not contain documentation of follow up charting each shift for 72 hours. Review of the resident's medical record showed: -06/21/25: resident had an unwitnessed fall with no injury;-Did contain documentation of a neurological assessment, vital signs, physician notification, responsible party notification, or follow up documentation each shift for 72 hours. 5. Review of Resident #53's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment;-Required moderate assistance for bed mobility;-Required maximum assistance for transfers;-Dependent on staff for dressing, and hygiene;-Uses a wheelchair for mobility. Review of the resident's care plan, revised 06/22/25, showed: -Cognitive deficit;-Required assistance for mobility;-At risk for falls;-Did not contain an intervention for the fall on 06/11/25. Review of the resident's medical record showed: -06/11/25: resident had witnessed fall with no injury;-Did not contain documentation a completed fall event report, vital signs, or follow up documentation each shift for 72 hours. 6. Review of Resident #58's admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment;-Required moderate assistance for dressing, and transfers;-Dependent on staff for hygiene, and bathing;-Uses a wheelchair for mobility. Review of the resident's care plan, revised 06/16/25, showed at risk for falls related to cognition. Review of the resident's medical record showed: -04/10/25: resident had an unwitnessed fall with no injury;-Did not contain a completed fall event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -04/15/25: resident had an unwitnessed fall, hit his/her head, right shoulder, and right hip pain, sent to the ER, returned the same day;-Did not contain an initial fall note, a completed fall event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -04/20/25: resident had a witnessed fall hitting his/her head with a nickel size raised bump, sent to the ER, returned the same day;-Did not contain a neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -04/23/25: resident had a witnessed fall with no injury hitting his/her head with a small, raised bump on his/her right side, sent to the ER, returned the same day;-Did not contain a neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -04/26/25: resident had an unwitnessed fall with no injury;-Did not contain a completed fall event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -04/29/25: resident had a witnessed fall, unable to determine if resident hit his/her head or had any injuries;-Did not contain an initial fall note, a completed fall event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -05/06/25: resident had an unwitnessed fall with no injury;-Did not contain a completed fall event report, vital signs, or follow up documentation each shift for 72 hours. -05/13/25: resident had an unwitnessed fall with no injury;-Did not contain a completed fall event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -05/17/25: resident had an unwitnessed fall with no injury;-Did not contain a completed fall event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -05/28/25: resident had a witnessed fall with no injury;-Did not contain a completed fall event report, vital signs, or follow up documentation each shift for 72 hours. -05/30/25: resident had an unwitnessed fall with no injury;-Did not contain a completed fall event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -05/30/25: resident had an unwitnessed fall hitting his/her head, laceration to the forehead and half dollar size raised bump;-Did not contain a completed fall event report, neurological checks, vital signs, or follow up documentation each shift for 72 hours. -06/11/25: resident had an unwitnessed fall with no injury;-Did not contain a neurological assessment, vital signs, or follow up documentation each shift for 72 hours. -06/22/25: resident had an unwitnessed fall with no injury;-Did not contain a completed fall event report, neurological assessment, vital signs, or follow up documentation each shift for 72 hours. 7. Review of Resident #71's admission MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact;-Required moderate assistance for transfers. Review of the resident's care plan, revised 06/16/25, showed: -At risk for falls due to a left below the knee amputation;-Did not contain direction for ADL assistance, transfers, or mobility. Review of the resident's medical record showed: -06/15/25: resident had an unwitnessed fall with no injury;-Did not contain a neurological assessment, vital signs, or follow up documentation each shift for 72 hours. 8. During an interview on 06/27/25 at 11:00 A.M., Licensed Practical Nurse (LPN) Q said if a resident falls it is the responsibility of all staff to report it to the charge nurse immediately. LPN Q said the charge nurse is responsible to complete a head-to-toe assessment of the resident to assess for injuries, complete vital signs, notify the responsible party, notify the physician, and notify the administration team. LPN Q said the charge nurse is responsible to complete a fall report in the computer and chart a nurse's note including details of the fall. LPN Q said the charge nurse is responsible to enter follow up notes each shift for 72 hours after every fall. LPN Q said if a resident has an unwitnessed fall or hits their head, the charge nurse is responsible to initiate neurological assessments on the resident and complete them. LPN Q said he/she is not sure what the facility policy is regarding the frequency of the neurological assessments after a fall because they have a paper form and a computer form. LPN Q said the paper form instructs staff to complete a neurological assessment every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, then every four hours for 24 hours. LPN Q said the computer chart is not the same time frequency and lasts for 72 hours after a fall. LPN Q said staff all complete the neurological assessments differently. LPN Q said the assessment frequency is not clear to all the charge nurses. During an interview on 06/27/25 at 1:50 P.M., the DON said he/she expects when a resident falls for the charge nurse to complete the proper documentation. The DON said when a resident falls staff are to notify the charge nurse who is responsible to complete a head-to-toe assessment of the resident to assess for injuries, complete vital signs, notify the responsible party, notify the physician, and notify the administration team. The DON said the charge nurse is responsible to create an event in the resident's chart and make a nurse's note with details of the fall (date, time, witnessed/unwitnessed, hit their head, any injuries, vital signs, who was notified, and any new orders). The DON said if the resident has an unwitnessed fall, or they hit their head staff are to complete neurological assessments as well. The DON said all falls are to be documented on each shift for 72 hours. The DON said he/she was not aware the staff were using a paper form and the computer to complete the neurological assessments, nor was he/she aware the documentation frequency was different. The DON said he/she expects staff to use the computer to chart and document the neurological assessment there for 72 hours for unwitnessed falls or residents who hit their head. The DON said if a resident is not monitored after a fall it could lead to harm for the resident. During an interview on 06/27/25 at 2:30 P.M., the administrator said the charge nurse is responsible to document all falls in the facility. The administrator said he/she expects the charge nurse to complete an assessment of the resident, vital signs, assess and triage any injuries noted, notify the responsible party, notify the physician, and notify the Administrator and DON. The administrator said he/she expects the charge nurse to document the details of the fall in the nurse's notes, and to complete follow up charting each shift for 48 hours on all falls. The administrator said staff are to complete neurological assessments on any resident who hits their head or has an unwitnessed fall, but he/she was not sure of the frequency the assessment should be completed. The administrator said he/she expects staff to document in the computer, but he/she knows they use a paper form sometimes. The administrator said if staff don't monitor a resident after a fall it could lead to a resident having a major injury, brain bleed, or even death. The Administrator said if a resident goes to the ER after a fall, he/she expects staff to complete neurological assessments upon return to the facility for the rest of the time frame. The administrator said the DON is responsible to monitor falls and ensure staff document correctly.

Based on interview and record review, facility staff failed to educate and provide influenza immunizations for two residents (Resident #42 and #50) and pneumococcal immunizations for three residents (Resident #42, #50 and #56) of five sampled residents. The facility census was 62.1. Review of the facility policy titled Immunization Recommendations for Long Term Care Facilities, undated, showed the resident's physician will be consulted and determine the level of risk and need for the vaccinations. Influenza vaccination is recommended annually for all residents. Pneumococcal vaccination will be administered according to state guidelines when determining vaccination status. Requirements for administering vaccinations include a physician order, consent and an information sheet with general information, risks and side effects.Review of the Centers for Disease Control (CDC), Adult Immunization Schedule by Age | Vaccines & Immunizations | CDC, dated 05/29/25, showed vaccines are recommended for those age [AGE] years or older who have:-Not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21;-If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition (condition that weakens the immune system making one more susceptible to illness),* cochlear implant (device that stimulates the nerve in the ear), or cerebrospinal fluid leak (condition where fluid that protects the brain and spinal cord leaks through a tear in the tissue);-Previously received only PCV7: follow the recommendation above;-Previously received only PCV13: 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PCV13 dose;-Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose;-If PCV15 is used, no additional PPSV23 doses are recommended;-Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age [AGE] years or older: 1 dose PCV20 or 1 dose PCV21 at least 5 years after the last pneumococcal vaccine dose;-Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose;-Immunocompromising conditions include chronic renal failure, nephrotic syndrome (kidney disorder causing too much protein to be excreted in the urine), immunodeficiencies (system unable to defend the body from abnormal cells), iatrogenic immunosuppression (weakend immune system caused by medical treatments), generalized malignancy (cancer that has spread), Human immunodeficiency virus (HIV) infection (a virus that attacks the immune system), Hodgkin disease (cancer of the immune system), leukemia (cancer that affects the blood and bone marrow), lymphoma (cancer that affects the lymphatic system), multiple myeloma (cancer that forms in a type of white blood cell called a plasma cell), solid organ transplant, congenital or acquired asplenia (absence of spleen function), or sickle cell disease (inherited blood disorders) or other hemoglobinopathies (inherited blood disorders that impact the production of the protein that carries oxygen in the blood).2. Review of Resident #42's medical record showed:-Date of admission [DATE];-Resident age [AGE];-The record did not contain documentation the resident received, refused or been offered the influenza vaccination for the current influenza season and the pneumococcal vaccine.3. Review of Resident #50's medical record showed:-Date of admission [DATE];-Resident age [AGE];-The record did not contain documentation the resident received, refused or been offered the influenza vaccination for the current influenza season and the pneumococcal vaccine.4. Review of Resident #56's medical record showed:-Date of admission [DATE];-Resident age [AGE];-The record did not contain documentation the resident had received, refused or been offered a pneumococcal vaccine.5. During an interview on 06/27/25 at 1:50 P.M., the Interim Director of Nursing (DON) said he/she took over the Infection Prevention and Control program in May of 2025. He/She said documentation cannot be provided to show the resident's are receiving their immunizations consistently and per facility policy. The Interim DON said the previous Infection Preventionist (IP) stepped down in May, 2025.During an interview on 06/27/25 at 2:33 P.M., the administrator said he/she expects the resident immunization policy to be followed by the IP and the DON. He/She was not sure it has been done for the past year by the previous IP who stepped down a few months ago. He/She said the risk of not educating and offering vaccinations to residents is illness and spread of disease. The administrator said he/she did not know whether residents were not offered vaccines or the documentation is missing.

Based on interview and record review, facility staff failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated resident assessment tool, for two residents (Resident #41 and #35) out of 25 sampled residents who were admitted to hospice services. The facility census was 62.1. Review of the policies provided by the facility did not show a policy for completion of a SCSA.Review of the Resident Assessment Instrument (RAI) manual version 3.0, dated October 2024, Omnibus Budget Reconciliation Act (OBRA), required Assessment Summary showed assessment time frames as follows:-A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing. 2. Review of Resident #41's Annual MDS assessment, dated 04/01/25, showed staff assessed the resident as severely cognitively impaired and received hospice services. Review of the resident's census report (a report that provides information into resident occupancy and related data) showed staff documented the resident received hospice services with a start date of 10/31/24.Review of the resident's medical record showed staff did not complete a required SCSA assessment after the resident admitted to hospice services on 10/31/24. Review of the resident's care plan, dated 05/21/25, showed staff did not address hospice services. During an interview on 06/26/25 at 11:20 A.M. the Social Services Director (SSD) said the resident had been kicked off hospice services and started the services again on 10/31/24. The SSD did not know staff had not completed the required SCSA assessment. 3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and did not receive hospice services. Review of the resident's care plan, revised 06/13/25, showed staff did not address hospice services. Review of the resident's face sheet (a summary document that provides essential patient information) showed staff documented the resident received hospice services. Review of the resident's hospice care service logs showed hospice staff signatures dated back to 06/09/25.Review of the resident's medical record showed staff did not complete a required SCSA after the resident admitted to hospice services. During an interview on 06/25/25 at 8:50 A.M., Licensed Practical Nurse (LPN) B said the resident was admitted to hospice services in June 2025, but he/she did not know the exact date. During an interview on 06/25/25 at 1:02 P.M., the BOM said he/she obtained the resident's hospice admission date from the hospice company. The BOM said the resident was admitted to hospice services on 06/05/25. During an interview on 07/01/25 at 2:00 P.M., the MDS Coordinator said said he/she just happened to find out Resident #35 was on hospice when he/she was reading through stuff; but he/she could not pinpoint the exact date the resident admitted to hospice services. During an interview on 06/27/25 at 10:27 A.M., the Administrator said the MDS coordinator is responsible to ensure residents' MDS's are completed timely, and the care plans are updated with changes. The Administrator said the facility has a morning meeting to discuss changes in the residents' conditions. The Administrator said if a resident is admitted to hospice services it should be discussed in the meeting so all staff are made aware. The Administrator said he/she does not know why staff were not informed of the resident's admission date to hospice services. 4. During an interview on 06/27/25 at 1:50 P.M., the Director of Nursing (DON) said a SCSA should be completed stops or starts hospice services. The DON said he/she did not know the SCSA were not completed for the two residents. He/she said the MDS Coordinator is responsible for completing the MDS assessments. During an interview on 06/27/25 at 2:31 P.M., the Administrator said SCSA should be completed when a resident starts or stops hospice services and the MDS Coordinator is responsible for completing the assessments. goes onto or off hospice and the MDS Coordinator is responsible for completing those. He/she said there was not an MDS Coordinator for a long time, and the new MDS Coordinator started about three months ago. The Administrator said corporate had been coming in one to two times a month to help get caught up on assessments and care plans, but the MDS Coordinator also works on the floor as a nurse. During an interview on 07/01/25 at 2:00 P.M., the MDS Coordinator said said he/she did not know that a SCSA had not been completed for Resident #41 because as long as he/she has been at the facility the resident has received hospice services. During an interview on 07/01/25 at 2:00 P.M., the MDS Coordinator said SCSA should be completed as soon as a resident starts or stops hospice services. The MDS Coordinator said he/she is so far behind on everything, when he/she started 2.5 months ago there was nothing done, and he/she is trying to catch up. He/she said the problem is communication because sometimes he/she does not know if a resident goes onto hospice. The MDS Coordinator said he/she has been working the floor as a nurse which makes it hard to get caught up on MDS assessments and care plans, he/she said there really was no excuse, it was really bad and now he/she is trying to catch up.

Based on observation, interview and record review, facility staff failed to check and date oxygen tubing for one resident (Resident #18) and failed to provide orders for one resident (Resident #42), who received continuous positive airway pressure, (CPAP- a treatment that keeps the airway open during sleep). The facility census was 62.1. Review of the facility's policy titled Oxygen Administration, undated, showed at regular intervals, check and clean oxygen equipment, masks, tubing, and cannulas; and place cannula tubing in a plastic bag attached to the concentrator when not in use. 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/07/25, showed staff assessed the resident as: -Moderate cognitive impairment; -Received oxygen; -Diagnoses of sleep apnea (disorder characterized by interruptions in breathing during sleep), asthma, and respiratory failure (occurs when the lungs can't adequately oxygenate). Review of the resident's care plan, revised 06/16/25, showed the care plan did not contain direction for oxygen use. Review of the resident's Physician's Order Sheet (POS), dated 06/24/25, showed: -Oxygen four liters per minute (LPM) via nasal cannula continuously; -Change oxygen tubing weekly on Wednesday during the night shift; -Amoxicillin (an antibiotic used to treat infection) 500 milligrams (mg) twice a day for 10 days to treat pneumonia started on 06/23/25 with a stop date of 07/02/25. Review of the resident's Medication Administration Record (MAR), dated 06/01/25 through 06/26/25, showed night shift staff documented on 06/04/25 and 06/11/25 that they did not change the resident's oxygen tubing due to the tubing being specialized. Staff documented they notified the Director of Nursing (DON). Observation on 06/24/25 at 10:42 A.M., showed the resident wore oxygen, oxygen tank on his wheelchair undated and unbagged oxygen tubing. Observation on 06/25/25 at 8:30 A.M., showed the resident wore oxygen, oxygen tank on his wheelchair undated and unbagged oxygen tubing. Observation on 06/26/25 at 8:40 A.M., showed the resident wore oxygen, oxygen tank on his wheelchair with undated and unbagged oxygen tubing. The oxygen tubing touched the floor. Observation on 06/27/25 at 8:50 A.M., showed the resident wore oxygen, oxygen tank on his/her wheelchair. The oxygen tubing on his/her wheelchair undated and placed on his/her wheelchair cushion with crumbs. During an interview on 06/27/25 at 11:02 A.M., Licensed Practical Nurse (LPN) Q said the resident has pneumonia and has not felt good this week. LPN Q said the night shift charge nurse is responsible to change oxygen tubing weekly. LPN Q said oxygen tubing should be dated when it is changed and if not in use should be kept in a bag. LPN Q said if staff find the oxygen tubing not in a bag, they should replace it. During an interview on 06/27/25 at 1:50 P.M., the Director of Nursing (DON) he/she expects oxygen tubing to be stored in a bag when not in use. The DON said the night shift nurse is responsible to change the oxygen tubing weekly, and he/she expects the tubing to be dated at that time. The DON said oxygen tubing should not be on the floor or in a wheelchair with a dirty cushion, and if staff find it that way, he/she expects them to replace it. The DON said he/she did not know the resident had pneumonia or needed the specialized oxygen tubing ordered. 3. Review of the facility's policy titled CPAP/Bi-level Positive Airway Pressure (BiPAP), non-invasive mechanical ventilation, undated, showed: -Check physician's order for pressure setting and method of administration; -Fill humidifier with sterile water to appropriate level; -Clean or change filter at the air intake of the machine to keep internal parts from accumulating dust; -Tubing should be changed every 90 days or as needed; -The mask and nasal pillow connection can be wiped daily. Change mask every 90 days; -Clean the humidifier holding tank weekly. 4. Review of Resident #42's Quarterly MDS dated [DATE], staff assessed the resident as: -Brief Interview of Mental Status (BIMS), cognitive status assessment, not completed; -Diagnoses of atrial fibrillation (heart condition), anxiety and depression. -No respiratory treatments or shortness of breath. Review of the resident's care plan, revised 03/19/25, showed it did not include CPAP or oxygen use. Review of the resident's POS, dated 05/07/25, showed an order for oxygen at two to four LPM via nasal cannula while in bed and as needed. Observation on 06/24/25 at 11:34 A.M., showed the resident in bed with his/her CPAP on. Observation showed the resident's oxygen set to five LPM and connected to the CPAP device. The water in the humidifier tanks is below the fill line. Observation on 06/25/25 at 10:02 A.M., showed the resident in bed with his/her CPAP on. Observation showed the resident's oxygen set to five LPM and connected to the CPAP device. The water in the humidifier tanks is below the fill line. Observation on 06/26/25 at 10:39 A.M., showed the resident in bed with his/her CPAP on. Observation showed the resident's oxygen set to five LPM and connected to the CPAP device. The water in the humidifier tanks is below the fill line. Observation on 06/27/25 at 08:30 A.M., showed the resident in bed with his/her CPAP on. Observation showed the resident's oxygen set to five LPM and connected to the CPAP device. The water in the humidifier tanks is below the fill line. During an interview on 06/27/25 at 08:30 A.M., LPN Q said he/she was unable to find an order for CPAP or cleaning and maintenance of equipment. He/She said that needs to be fixed. LPN Q said the risk of not cleaning the CPAP device and equipment is infection. During an interview on 06/27/25 at 10:28 A.M., the DON said an order is expected for residents using CPAP and nursing is responsible for cleaning and maintaining the equipment. He/She said if there was an order, a cleaning schedule would appear on the MAR, but since there is not an order, this task is not being documented if done. The DON said he/she was not aware the water reservoir has been empty all week. He/She said orders are reconciled daily by the DON with a report comparing notes and orders. He/She said the missing orders for this resident was missed prior to his/her taking the DON position. During an interview on 06/27/25 at 01:27 P.M., Resident # 42 said he/she cleans the CPAP machine with dish soap, but the tubing cannot be cleaned. He/She said the mask is due to be changed soon because it is leaking. He/She said staff never clean the device or supplies. The resident said he/she changed the filter three days ago from a supply he/she keeps in the drawer. During an interview on 06/27/25 at 2:30 P.M., the administrator said the charge nurse is responsible to change oxygen tubing weekly on the night shift. The administrator said he/she expects the nurse to date the tubing when changed. The administrator said oxygen tubing should not be on the floor or in a dirty wheelchair cushion when not in use. The administrator said oxygen tubing should be kept in a plastic bag when not in use to prevent contamination. The administrator said if staff find oxygen tubing not in a bag he/she expects them to change the tubing. The administrator said he/she did not know the resident had pneumonia and required antibiotics. The administrator said residents using CPAP should have an order; if an order is not present, staff should contact the physician. He/She said nursing staff is responsible for ensuring CPAP is delivered per orders and equipment/supplies are cleaned and maintained to prevent infection.

Based on observation, interview, and record review, facility staff failed to maintain ongoing communication with the dialysis facility (a healthcare facility that provides dialysis treatment to individuals with kidney failure) and failed to document completion of dialysis care for one resident (Resident #18) of one sampled who received dialysis services. The census was 62. 1. Review of the facility's policy titled Dialysis, Care of a Resident Receiving, undated, showed staff were directed to: -Care for the Artery Vein shunt/fistula/graft (a surgical connection between the artery and vein): -Keep the area clean and dry; -Feel for the thrill (a vibration that can be felt when you place your fingers over the fistula site) sensation daily and document in the resident record, if no thrill, notify the physician; -Inspect access for redness, swelling, or warmth; -Avoid excessive pressure on the puncture site after dialysis; -Watch for bleeding after dialysis and monitor for signs of infection;-Communication between the facility and dialysis unit: -The dialysis communication record will be sent with the resident on each dialysis visit; -All care concerns in the last 24 hours will be addressed, including last medications given and the facility contact person; -The dialysis unit will complete the lower portion of the report to include weight prior to and after dialysis, any labs completed, medications given, follow up information, and any new physician orders; -The lower portion will be signed by the dialysis nurse and returned to the facility; -These records will be maintained in the medical record. Review of the facility's policy titled Charting and Documentation, undated, showed staff were directed to: -Used to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, etc. as well as the resident's progress;-Chart all pertinent changes in the resident's condition;-Follow up notes should include a summary of the residents' condition;-Treatment notes should include date and time, name of the person administering the treatment, and signature of the person recording the data;-Weight documentation should include date and time, name of the person obtaining the weight, reason for any weight variation, all pertinent observations, and signature of the person recording the data;-Documentation should include anytime a physician or family is called about the resident as well as their response, when appointments are canceled, and any changes in level of care. 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/07/25, showed staff assessed the resident as: -Moderate cognitive impairment;-Received dialysis;-Diagnosis of end stage renal disease (ESRD). Review of the resident's care plan, revised 06/16/25, showed: -Resident required dialysis;-Assess for fluid, and weight gain;-Monitor and record weight as ordered, notify physician of weight gain or fluid volume excess;-Monitor lab work, if performed at the dialysis clinic request copies for the facility medical record. Review of the resident's physician order sheet (POS), dated 06/24/25, showed orders for: -Check artery vein sight for thrill and bruit (a whooshing sound heard with a stethoscope) every shift;-Check artery vein sight for signs and symptoms of infection every shift;-Dialysis three times a week on Monday, Wednesday, Friday, complete dialysis communication form and send with resident, upload completed form to resident's chart;-Document dialysis post weight under vital signs on dialysis days. Review of the resident's medical record showed the record did not contain a communication record used on dialysis days. Review of the resident's Medication Administration Record (MAR), dated 04/24/25 through 04/30/25, showed: -Did not contain a staff signature for check artery vein sight for thrill and bruit every shift on 04/27/25 day shift;-Did not contain a staff signature for check artery vein sight for signs and symptoms of infection every shift on 04/27/25 day shift;-Did not contain a document dialysis post weight under vital signs on 04/30/25 day shift. Review of the residents MAR, dated 05/01/25 through 05/31/25, showed: -Did not contain a staff signature for check artery vein sight for thrill and bruit every shift on 05/13/25 and 05/20/25. -Did not contain a staff signature for check artery vein sight for signs and symptoms of infection every shift on 05/10, 05/13, and 05/20/25. -Did not contain a staff signature for dialysis three times a week on Monday, Wednesday, Friday, complete dialysis communication form and send with resident, upload completed form to resident's chart on 05/21/25;-Did not contain a documented dialysis post weight under vital signs for all shifts on 05/12, 05/16, 05/19, 05/21, and 05/30/25. Review of the residents MAR, dated 06/01/25 through 06/26/25 showed: -Did not contain a staff signature for check artery vein sight for thrill and bruit every shift on 06/18, 06/22, 06/23, 06/24, and 06/26/25. -Did not contain a staff signature for check artery vein sight for signs and symptoms of infection every shift on 06/22, 06/23, 06/24, 06/26/25. -Did not contain a staff signature for dialysis three times a week on Monday, Wednesday, Friday, complete dialysis communication form and send with resident, upload completed form to resident's chart on 06/18 and 06/23/25. -Did not contain a documented dialysis post weight under vital signs for 06/04, 06/06, 06/09, 06/16, 06/18, 06/23, and 06/25/25. Observation on 06/25/25 at 11:20 A.M., showed the resident sat in the lobby and waited for dialysis transport. During an interview on 06/25/25 at 8:34 A.M., Licensed Practical Nurse (LPN) B said the resident leaves mid-morning for dialysis on Monday, Wednesday, and Friday each week. During an interview on 06/26/25 at 11:35 A.M., Registered Nurse (RN) E said the facility had a dialysis communication binder for the resident at one point, but he/she said they have not been able to find it for quite some time. RN E said he/she was not sure how long the binder had been missing. RN E said the Social Service Designee (SSD) is responsible for the communication binder. RN E said the nurses should have access to the communication binder to know what the resident's status is and if he/she had any issues while at dialysis. RN E said dialysis communication between the facility and dialysis center should occur each time the resident goes to dialysis and returns. RN E said he/she has not called the dialysis center to get a resident update since the communication binder went missing. RN E said staff are supposed to assess the resident's artery vein fistula and obtain weights per orders. RN E said if something is not documented then it can't be considered completed by the staff and should have been. During an interview on 06/26/25 at 11:55 A.M., the SSD said he/she is not responsible for the dialysis communication book. The SSD said the charge nurse is responsible to ensure the dialysis form is completed and sent with the resident each dialysis day, along with ensuring it is returned and kept in the resident's medical record. The SSD said the facility had a communication book for the resident and he/she was not aware it was missing or that it had been missing for quite some time. During an interview on 06/26/25 at 3:05 P.M., the Director of Nursing (DON) said said he/she was not aware the resident's communication book was missing until he/she was informed by the SSD. The DON said the communication form between the facility and the dialysis clinic should be completed with each dialysis day to ensure the resident receives the care he/she needs. During an interview on 06/27/25 at 11:02 A.M., LPN Q said he/she is aware the facility had a communication book prior, but he/she said it had been missing for a while. LPN Q said the communication between the facility and dialysis is important to ensure the resident gets the proper care. LPN Q said the charge nurse is responsible to send a communication form with the resident each time he/she goes to dialysis and responsible to ensure it is returned and any new orders documented on the resident's medical record. LPN Q said if something does not get documented then there is no proof it was completed. During an interview on 06/27/25 at 1:50 P.M., the DON said staff are expected to send a communication form with the resident each time he/she goes to dialysis. The DON said the charge nurse is responsible to ensure this is done, along with ensuring the form is returned from dialysis and orders are followed. The DON said the communication form sent between the facility and the dialysis unit is important to ensure the resident receives consistent oversite and care. The DON said the form shows how much fluid was removed with dialysis, if the resident had any issues while at dialysis, any labs completed, and if there are any new orders. The DON said he/she expects the staff to follow physician's orders and to document each time they are completed. The DON said if something does not get documented there is no way to know if it was completed or not. During an interview on 06/27/25 at 2:30 P.M., the administrator said the charge nurse is responsible to send a communication form with the resident each time he/she goes to dialysis. The administrator said the form is to be filled out by the charge nurse prior to the resident leaving the facility and the charge nurse is responsible to ensure the form is returned from dialysis and filed in the resident's medical record. The administrator said he/she was not aware this was not being completed or that the communication binder was missing. The administrator said he/she expects staff to follow up on the communication with the dialysis clinic to ensure the resident receives the proper care. The administrator said the communication form is used to track the resident's health and condition. The administrator said the charge nurse is responsible to obtain and enter new orders for residents. The administrator expects staff to follow physician's orders and to sign the MAR showing orders were completed. The administrator said if orders are not followed it could lead to a bad outcome or harm to a resident. The administrator said if something isn't charted there is no way to know if it was completed or not.

Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility staff failed to keep the required daily staffing records for eighteen months. The facility census was 62.1. Review of the policies provided by the facility showed they did not contain a policy for the Nurse Staff posting. 2. Review of the facility's daily nurse staffing records showed the record did not contain 18 months of nurse staff posting.3. Observation on 06/24/25 at 10:43 A.M., showed a sign on the wall, next to the medication storage room behind the nurses desk read Nursing Please fill out midnight census worksheets. Observation on 06/24/25 at 11:35 A.M., showed facility staff did not post the required nurse staff information in the facility. Observation on 06/25/25 at 10:35 A.M., showed facility staff did not post the required nurse staff information in the facility. Observation on 06/26/25 at 7:45 A.M., showed facility staff did not post the required nurse staff information in the facility. Observation on 06/27/25 at 7:47 A.M., showed facility staff did not post the required nurse staff information in the facility. 4. During an interview on 06/27/25 at 10:27 A.M., the administrator said the nurse staff posting should be filled out by the night shift nurse and should list all nursing staff working that day and how many hours worked. The posting should be placed in a book at the nurse's station and kept for 18 months. The administrator said the postings were not being kept until the new Social Services Designee (SSD) started. The administrator said the posting should be displayed somewhere visible for everyone to see. During an interview on 06/27/25 at 10:36 A.M. the SSD said the daily nurse posting should have the facility census and the number of licensed staff, nurses, Certified Nurse Aides (CNA) and Certified Medication Technicians (CMTs) and their total hours worked. The SSD said the night shift nurse is responsible for filling out the posting and the Director of Nursing (DON) is responsible for ensuring it is completed. The SSD said the posting should be kept for 18 months, and he/she did not know staff were not completing the staff posting. During an interview on 06/27/25 at 10:39 A.M., the DON said the nurse staff posting should include the facility census, the number of licensed staff such as Registered Nurses (RN), Licensed Practical Nurses (LPN), CMT's and CNAs, and how many hours and total hours they work for a shift. The DON said the night shift nurse is responsible for filling out the posting and it should be kept for 18 months. He/She said he/she did notice this morning that the positing had not been posted. The DON said it is his/her responsibility to ensure the forms are completed correctly and are available for everyone to see.

Based on interview and record review, facility staff failed to contact one resident's (Resident #3's) responsible party after the resident had a change in condition. The facility census 61. 1. Review of the facility's Notification of Physician policy, undated, showed staff are directed to immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member when there is a significant change in resident's physical, mental, or psychosocial status or a decision to transfer or discharge the resident form the facility. 2. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/22/25, showed staff assessed the resident as follows: -Severe cognitive Impairment; -Diagnoses of dementia with agitation, Senile degeneration of brain, Schizoaffective disorder bipolar type, Vascular dementia with anxiety, and personal history of traumatic brain injury. Review of the resident's care plan, dated 2/3/25, showed staff assessed the resident exhibits significant behaviors towards himself/herself and others. Staff are directed to keep the resident's family and hospice informed of any changes in condition. Review of the resident's medical record showed the resident has an active Durable Power of Attorney (DPOA). Review of the nurses's notes, dated 1/30/25 at 3:10 P.M., showed Licensed Practical Nurse (LPN) B documented the physician ordered a psychiatric evaluation at a Psychiatric Center for agitation and physical behaviors toward other residents. Resident is being monitored one on one, continues to pace up and down the hallway, rocking back and forth. Behaviors change in a moments notice. Review of the nurse's notes, dated 1/31/25 at 5:50 A.M., showed the Social Service Director (SSD) documented the resident's family called this morning to check on resident, states he/she was not informed the resident went out. Staff talked to family and let them know the resident was sent to the hospital yesterday afternoon. During an interview on 5/14/25 at 10:34 A.M., the family member said he/she was not notified of the resident being transferred to the hospital on 1/30/25. He/She said he/she spoke with SSD and found out the resident had been sent to the hospital. He/She said he/she was the active DPOA. During an interview on 5/14/25 at 11:30 A.M., the SSD said when a resident is transferred to the hospital the nurse should notify the family and document it in the system. He/She said he/she is not sure who's responsibility it is for making sure this is completed. During an interview on 5/14/25 at 12:23 P.M., the Director of Nursing (DON) said nurses are expected to notify family when a resident is transferred to the hospital. He/She the nurses are expected to document this in the system in the progress notes. He/She said he/she is responsible for making sure this is completed. During an interview on 5/14/25 at 12:50 P.M., the administrator said when a resident is transferred to the hospital it is the nurses responsibility to notify the family. He/She said the DON is responsible for making sure this is completed. During an interview on 5/14/25 at 2:37 P.M., LPN B said he/she was sure he/she notified the family of the residents transfer to the hospital but must have forgotten to chart it in the system. He/She said typically a progress note is made and he/she must have forgotten to add it. He/She said the DON would be responsible for making sure this is completed. MO00253661

Based on interview and record review, facility staff failed to keep Resident #1 free from physical abuse when floor technician E aggresively pulled the residents wheelchair which resulted in the resident falling out of the wheelchair and on to the ground. The facility census was 58. The administrator was notified on 4/30/25 of past Non- Compliance, which occurred on 4/22/25, when staff reported the allegation. Staff immediately suspended floor technician E, assessed the resident for physical and psychological harm, conducted an investigation, in-serviced staff on abuse and neglect, and terminated the employee on 4/30/25. 1. Review of the abuse, neglect, exploitation, and misappropriation of property fact sheet, dated 2017, showed abuse is the deliberate inflection of injury, unreasonable confinement, intimidation, or punishment, which results in physical harm, pain, or mental anguish. This includes verbal, sexual, physical, or mental abuse, as well as abuse enabled through the use of technology. Examples include scolding, ignoring, ridiculing, or cursing a resident and rough handling during care giving or moving a resident. 2. Review of the facility's investigation, dated 4/22/25, showed Certified Nurses Aide (CNA) F notified notified the administrator floor technician E roughly moved Resident #1's wheelchair, causing the resident to fall to the ground. The floor technician was immediately suspended pending the investigation and terminated on 4/30/25. The resident was assessed without injury and all necessary parties were notified. 3. Review of the Resident #1's Minimum Data Set, a federal mandated assessment tool, dated 3/12/25, showed staff assessed the resident as follows: -Cognitively intact; -Impairment to both lower extremities; -Utilized a manual wheel chair. During an interview on 4/30/25 at 10:28 A.M., the resident said CNA A took him/her out and floor technician E started yelling at him/her and wouldn't let him/her have a cigarette. He/She said floor technician E grabbed his/her wheelchair and moved it roughly causing him/her to fall to the ground. He/She said CNA A and a house keeper helped him/her back to his/her wheelchair. He/She said it hurt and made him/her feel bad and not want to go outside anymore. During an interview on 4/30/25 at 10:43 A.M., CNA D said he/she witnessed the floor technician E yell and refused to allow the resident to smoke because the resident was cursing at the staff. He/She said floor technician told the resident he/she was going to take him/her back inside because of his/her behaviors. He/She said floor technician grabbed the resident's wheelchair he/she was sitting up in and roughly moved it backwards, causing the resident to fall to the ground. He/She said floor technician E did not help the resident up. During an interview on 4/30/25 at 11:02 A.M., Dietary Manager (DM) said he/she was in his/her office when a dietary staff member told him/her, he/she may want to go outside they think a manager is needed. He/She said he/she went outside to find floor technician E yelling at the resident, while the resident was on the ground in front of his/her wheelchair. During an interview on 4/30/25 at 11:15 A.M., the housekeeper F said he/she and CNA A helped the resident back into his/her wheelchair with a gait belt. During an interview on 4/30/25 at 11:17 A.M., CNA A said he/she took the resident out to smoke because no one had come to get him/her. He/She said he/she pushed the resident up to the table and went to go back inside when he/she heard the resident and floor technician E yelling at each other. He/She said the resident and floor technician were cursing at each other and floor technician forcefully grabbed the resident's wheelchair causing the resident to fall to the ground. He/She and the housekeeper assisted the resident back to his/her wheelchair, made sure he/she was safe, and went to report the incident to the administrator. During an interview on 4/30/25 at 11:28 A.M., the administrator said he/she was notified by the DM and CNA A, floor technician E had been yelling. He/She said floor technician was immediately pulled from the floor and suspended pending their investigation. He/She said the resident was assessed without injury, all necessary parties were contacted, and staff were inserviced on abuse and neglect and resident rights on 4/25/25. He/She said the floor technician was terminated on 4/30/25. During an interview on 5/6/25 at 2:00 P.M., floor technician E said he/she went out with the resident's to smoke. He/She said the resident came outside cursing at him/her and calling him/her a bitch. He/She said he/she told the resident he/she couldn't behave that way and was going to take the resident back inside due to his/her behaviors. He/She said the resident then threw himself/herself to the ground when he/she tried to wheel him/her back inside. He/She said he/she was suspended. He/She said the resident is always acting crazy and cursing people out. MO00253114

Based on record review and interview, facility staff failed to ensure two residents (Resident #1 and Resident #2) remained free from sexual abuse when Resident #1 raised his/her shirt, and Resident #2 touched his/her chest inappropriately. The facility census was 34. The administrator was notified on 10/15/24 of past Non-Compliance which occurred on 9/30/24. On 9/29/24, Certified Medication Technician (CMT) B, notified Registered Nurse (RN) A he/she witnessed Resident #1 in Resident #2's room. He/She reported he/she observed Resident #1 with his/her shirt raised, and Resident #2 touched Resident #1's chest inappropriately. Staff immediately separated the residents, assessed the residents for injuries, moved Resident #1 to a secured unit, and notified the required parties and agencies. The Director of Nursing (DON) inserviced all staff on duty, and all staff prior to working, on new interventions, assessing residents for the ability to consent to sexual activity, and abuse and neglect policies and procedures. 1. Review of the facility's Abuse, Neglect, and Misappropriation Policy, undated, showed it is the policy of the facility to prevent abuse by providing residents, families, and staff information on how and to whom to report concerns and grievances without fear of reprisal or retribution. Review showed the facility will establish a safe environment that supports, to the extent possible, a resident's sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to sexual contact will be made, and where the documentation will be recorded. Review showed staff directed to identify, assess, care plan appropriate interventions, and monitor residents with behaviors that include sexually aggressive behavior such as saying sexual things and inappropriate touching/grabbing. Review showed: - Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish; - Willful is defined as the individual acting deliberately, not that the individual intended to inflict harm or injury; - Sexual abuse includes, but is not limited to unwanted sexual attention touching, or sexual touching of the body of a resident who cannot make decisions for themselves. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/10/24, showed staff assessed the resident with impaired cognition. Review of the resident's face sheet showed the resident is his/her own responsible party, with diagnoses of Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the resident's plan of care, updated 9/30/24, showed staff documented on 9/30/24, staff moved the resident to the special care unit of the facility, and staff are directed to monitor him/her closely, and redirect unwanted behaviors. Review of Resident #1's nurses' notes, dated 9/29/24, showed RN A documented staff observed Resident #1 in Resident #2's room with his/her shirt raised, with his/her chest exposed. Staff documented Resident # 1, was allowing, Resident #2 to touch his/her chest inappropriately, and he/she was, shocked and quickly pulled his/her top down. 3. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/29/24, showed staff assessed the resident with impaired cognition. Review of the resident's face sheet showed the resident has an active Durable Power of Attorney (DPOA), and diagnoses of Unspecified Dementia, anxiety disorder, and Alzheimer's Disease. Review of the resident's plan of care, updated 9/30/24, showed staff documented to conduct frequent checks on the resident to ensure the resident did not have the opposite gender in his/her room. When the resident talks to staff or other residents in a sexual manner, staff will redirect him/her and remind him/her this is not acceptable. Review of Resident #2 nurses' notes, dated 9/29/24, showed RN A documented staff observed Resident #2's door closed. Staff knocked and asked to enter Resident #2's room, Resident #2 had his/her hands on Resident #1's chest. 4. Review of the facility's investigation summary, dated 9/30/24, showed staff documented staff reported Resident #1 in Resident #2's room. He/She had his/her shirt up, and Resident #2's hands were on Resident #1's chest. Review showed staff documented both residents with cognitive impairment, and neither resident recalls the incident. Review showed Certified Nurse Aide (CNA) C documented he/she and Certified Medication Technician (CMT) B knocked on Resident #2's door, and upon entrance observed Resident #2 on Resident #1's bed with his/her chest exposed. Review showed CMT B documented he/she knocked on Resident #2's door and witnessed Resident #1 sitting on the bed with his/her shirt up and Resident #2 in between Resident #1's legs, touching Resident #1's chest inappropriately. During an interview on 9/30/24, at 3:35 P.M., the administrator said RN A notified the Director of Nursing (DON) staff observed Resident #2 touching Resident #1's chest inappropriately in Resident #2's room. During an interview on 9/30/24, at 3:40 P.M., the DON said staff notified him/her staff observed Resident #2 touching Resident #1's chest inappropriately in Resident #2's room. He/She said both residents are alert and oriented with some confusion. He/She said when he/she contacted Resident #1's next of kin, the next of kin said the incident did not surprise him/her, and the resident's behaviors are consistent with the resident's personality. The DON said when staff notified Resident #2's spouse regarding the incident, the resident's spouse was upset. During an interview on 9/30/24, at 3:50 P.M., CMT B said he/she knocked on Resident #2's door and witnessed Resident #1 sitting on the bed with his/her shirt up and Resident #2 in between Resident #1's legs, touching Resident #1's chest inappropriately. He/She said he/she immediately notified RN A who separated the residents. During an interview on 10/02/24 at 2:32 P.M., RN A said CMT B and CNA C notified him/her they observed Resident #2 touching Resident #1's chest inappropriately in Resident #2's room. He/She said he/she went to Resident #2's room, both residents appeared shocked, but not distraught, and Resident #1 lowered his/her shirt. RN A said he/she immediately separated the residents, and began his/her investigation and report. During an interview on 10/04/24 at 8:03 A.M., CNA C said he/she and CMT B went into Resident #2's room. He/She said he/she looked over CMT B's shoulder and observed Resident #1 with his/her shirt raised, exposing his/her chest. He/She said he/she did not see Resident #2 physically touch Residnet #1. He/She said he/she and CMT B immediately reported the situation to RN A. CNA C said he has not observed either resident be physically inappropriate with any other residents. MO00242810

Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to perform appropriate hand hygiene during medication administration for two (Resident #4 and #21) of five sampled residents. The facility staff failed to ensure all employees were screened for Tuberculosis ((TB) a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) and annual PPD tests completed and documented as per policy and state law for three employees ( Dietary Aide O, Certified Nurses Aide (CNA) E , and Certified Medication Technician (CMT) P) out of 10 sampled employees . The facility census was 44. 1. Review of the facility's Medication, Administration Guidelines, showed the guidelines did not address hand hygiene between administration of medication between one resident and another resident, pouring tablets or pills out from a medication bottle, or eye drops. Review of the facility's Instillation of Eye Medication Guidelines, showed the guidelines did not address infection control during administration of eye medication. Review of the facility's Infection Prevention and Control Program policy, undated, showed the policy did not address hand hygiene between administration of medication between one resident and another resident, pouring tablets or pills out from a medication bottle, or administration of eye drops. 2. Observation on 04/30/24 at 8:51 A.M., showed CMT A did not perform hand hygiene after he/she administered medication to a resident, used a keyboard, prepared medication, lowered a computer screen, and before he/she administered medication to Resident #21. 3. Observation on 04/30/24 at 09:05 A.M., showed CNA A removed Resident #4's Tylenol tablets from a bottle into his/her bare hand, placed the tablets in into a medication cup and administered the medication. 4. Observation on 04/30/24 at 9:09 A.M., showed CMT A did not perform hand hygiene or put on gloves before he/she administered eye drops to Resident #4. 5. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said during medication administration when pouring tablets from a bottle, the tablets should be poured and measured in the cap of the bottle, then placed in the resident's medication cup. When the CMT instills eyedrops, hand hygiene should be completed, and gloves put on before administering the eyedrops. The DON said hand hygiene should be done between every resident. During an interview on 05/02/24 at 11:12 A.M., the administrator said during medication administration, hand hygiene should be done before and after anything is touched, and pills should never be in the bare hands of staff. During an interview on 05/14/24 at 2:30 P.M., CMT A said hand hygiene should be performed between each resident, and pills should not be poured into bare hands. If eyedrops are administered, staff should perform hand hygiene and put on gloves. CMT A said he/she didn't realize he/she missed performing hand hygiene every time needed, and said staff had a recent in-service on how to put in eyedrops. 6. Review of the facility's policies showed staff did not provide a policy for Catheter Care. 7. Review of Resident #251's Admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 03/27/24, showed staff assessed the resident as follows: -Had an indwelling catheter -Diagnosis of benign prostatic hyperplasia (when the prostate and surrounding tissue expands, can place pressure on the bladder and the urethra, which is the tube that urine passes through. This may cause: difficulty starting to urinate or a frequent need to urinate). 8. Review of Missouri state regulations 19 CSR 20-20.100 Tuberculosis (TB) testing for residents and workers in long-term care facilities showed: -Long-term care facilities shall screen their residents and staff for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit test (TST). Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -All employees are required to obtain Mantoux PPD two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; -If the resident's or employee's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -Employees with an initial zero to nine mm TB two step test shall have one step tuberculin testing annually and the results recorded in a permanent record; -All positive findings shall require a chest X-ray to rule out active pulmonary disease; -Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. Review of the facility's Guideline for screening for tuberculosis in long term care facilities, undated, showed it is important for each facility to have tuberculosis control program in place. This must include the documentation of the tuberculosis status of each resident, staff member, and volunteer of each long-term care facility. Provide a tuberculin skin text (Mantoux, five tuberculin units (TU) of purified protein derivative (PPD) to all employees during pre-employment procedures, unless a previous reaction >10 millimeters (mm) is documented. If the initial skin test results is 0-9mm, a second test should be given at least one week and no more than three weeks after the first test. The results of the second test should be used as the baseline in determining treatment and follow up of these employees. 9. Review of CNA E's personnel file, showed a hire date of 06/09/23. The file did not contain documentation a two-step TB test was completed 10. Review of CMT P's personnel file, showed a hire date of 07/24/23. The file did not contain documentation a two-step TB test was completed 11. Review of Dietary Aide O's personnel file, showed a hire date of 12/12/23. The file did not contain documentation a two-step TB test was completed During an interview on 05/1/24 at 11:47 A.M., the administrator said the charge nurses and MDS Coordinator are responsible for administering and reading the TB tests. He/She said the results were put into a binder. He/she said they have not had a MDS coordinator and could not find the TB binder. He/She said he/she has started a binder and has started over since he/she is overseeing it for the time being. During an interview on 5/1/24 at 12:02 P.M., RN G said the charge nurse and MDS are responsible to administer and read new hire and annual TB tests. He/She said there is a folder where they are logged. He/She said they currently do not have a MDS coordinator and he/she does not know who is in charge of making sure this is completed by the nurses or why it has not been done. 43010 43327

Based on observation, interview, and record review, facility staff failed to follow standard precautions during the performance of routine testing of blood glucose for one resident (Resident #5). The facility failed to ensure hand hygiene was performed and clean gloves applied after potential exposure to blood during blood glucose testing and prior to taking glucose monitoring test strips out of a container used for multiple residents. This failure created an immediate jeopardy to resident health by potentially exposing residents who required blood glucose testing to the spread of blood borne infections in the facility. Furthermore, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility water systems to inhibit growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). Facility staff also failed to practice appropriate hand hygiene measures with regard to appropriate facemask usage. The facility census was 38. The administrator was notified on 4/21/21 at 2:10 P.M. of an Immediate Jeopardy (IJ) which began on 4/20/21. The IJ was removed on 4/21/21, as confirmed by surveyor onsite verification. 1. Review of the manufacturer's users guide for [MEDICATION(S)] Evencare G3 (Blood Glucose Monitoring System), undated, showed staff are directed as follows: -Do not milk or squeeze around the puncture site; -When the blood drop icon appears on the screen, gently bring the test strip to the test site and touch the drop of blood; -Do not touch the sampling end of the test strip; -Do not smear the blood drop on the sampling end; -When there is an insufficient blood sample, the strip icon and the message Err will appear. -Eject and discard the used test strip. Repeat the test with a new strip and discard into a proper waste container. 2. Review of the facility's Universal Precautions (Standard Precautions) Policy, dated March 2015, showed staff are directed as follows: -Body Fluids to which universal precautions apply: blood, and body fluids containing blood; -Gloves are to be used for glucometer or accucheck testing; -Waste Management- Infectious waste is handled and stored accordingly to facility guidelines and immediate and thorough washing of hands and other skin surfaces which come in contact with visible blood, body fluids containing visible blood, or other body fluids to which universal precautions apply must be observed. Review of the facility's Gloves Policy, dated March 2015, showed staff are directed as follows: -Wear Gloves when it can be reasonably anticipated that hands will be in contact with moist body substances (blood or items/surfaces soiled with these substances); -Gloves must be changed between residents and between contacts with different body sites of the same resident. -Gloves are not a cure-all. Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands; -Handling medical equipment and devices with contaminated gloves is not acceptable. Review of the facility's Hand Cleanser (antiseptic) Policy, dated March 2015, showed staff are directed as follows: -Place the container of antiseptic solution on the medication cart or in a secure area not accessible to residents. 3. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff to assess the needs of the resident, dated 4/13/21, showed staff assessed the resident as: -Severe Cognitive Impairment; -Required extensive assistance from two staff members for bed mobility and transfers; -Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Received an injection seven out of the seven days included in the look back period (period of time used to assess the resident). Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the medication was ordered per sliding scale (SS) (the amount of insulin given to the resident was dependent on his/her blood glucose reading), and staff had to obtain the resident's blood glucose before the medication was administered. Observation on 4/20/21 at 11:21 A.M., showed Registered Nurse (RN) A enter the resident's room to obtain his/her blood glucose level. RN A used a lancet to obtain a sample of blood from the resident's finger. RN A squeezed the resident's finger, swiped the glucometer test strip across the resident's finger, which flung blood to an unseen location, and used an alcohol pad to clean blood from the resident's finger. Observation showed blood soaked through the alcohol pad the nurse held in his/her fingers. RN A received an error code on the glucometer. He/She then removed the used test strip from the glucometer, left the resident's room, and returned to the medication cart, where he/she reached into a container of new glucometer test strips, with his/her same soiled gloves on. RN A returned to the resident's room, obtained the resident's blood glucose level, and then went back to the medication cart. He/She then removed his/her gloves and started to push the medication cart to the next resident's room. At this time, survey staff stopped him/her. During an interview on 4/20/21 at 11:31 A.M., RN A said there is only one container of glucometer test strips for the whole facility. He/she said multiple residents use the strips. He/She said he/she changes his/her gloves after each patient, but he/she does not change them at any point during a blood glucose check, or subsequent administration of insulin. Furthermore, he/she said he/she uses hand sanitizer when he/she changes his/her gloves. Observation on 4/20/21 at 11:37 A.M., showed RN A looked in the medication cart for hand sanitizer. The medication cart did not contain hand sanitizer. During an interview on 4/20/21 at 11:39 A.M., RN A said he/she prepares his/her supplies, enters the resident's room, puts the test strip into the glucometer, and checks the resident's blood glucose level. He/she said after he/she obtains the blood glucose level he/she leaves the room, and prepares the resident's insulin for administration. He/She said he/she does not change his/her gloves between checking a resident's blood glucose, and administering their insulin. RN A went on to say, if he/she gets and error code on the glucometer, he/she leaves the room, and changes the testing strip. He/She said there is a chance that blood came into contact with his/her gloves prior to him/her reaching into the test strip container that is used for all residents. Additionally, he/she said he/she is unable to say there was no blood on his/her gloves. During an interview on 4/20/21 at 11:41 A.M., the Assistant Director of Nursing (ADON)/Facility Infection Control Preventionist (ICP) said if a staff member was checking a resident's blood glucose and received and error message, he/she would expect the staff member to remove their gloves and sanitize their hands before they got a new test strip out of the test strip container. He/she said he/she would have them change their gloves before getting a new strip because there is a chance of contaminating the strips in the container. Furthermore, he/she said the residents who get their blood glucose checked all share the same container of testing strips. 4. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of [CONDITION(S)] was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct 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; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify 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 building maintenance, inspection and testing records, showed the records did not contain documentation of a complete water management program to monitor the facility's water systems for the growth of waterborne pathogens and prevent LD. Review showed documentation of a Legionella policy guideline which instructed the facility staff to complete a risk assessment and develop procedures to monitor for Legionella in accordance with the Centers for Disease Control guidelines. Continued review showed the records did not contain documentation of a risk assessment, management team, or developed procedures to monitor and inhibit the growth of Legionella and other waterborne pathogens. During an interview on 04/21/21 at 8:40 A.M., the administrator said he/she did not have any additional documentation to provide regarding a water management program and he/she knew the program was incomplete. The administrator said with the pandemic and difficulty in maintaining a maintenance director some things just fell behind and did not get done. 5. Observation on 4/20/21 at 10:30 A.M., showed Cook D and Dietary Aide E stood in the kitchen, less than six feet apart. Cook D wore a facemask, but it did not cover his/her nose and mouth. Observation on 4/20/21 at 11:15 A.M., showed Cook D prepared lunch. Cook D wore a facemask, but it did not cover his/her nose or mouth. Cook D adjusted his/her facemask several times during the meal preparation with his/her bare hand to the front of the facemask. Cook D did not perform hand hygiene after touching his/her facemask and before touching various kitchen equipment. During an interview on 4/21/21 at 7:50 A.M., the Dietary Manager (DM) said the facility has a face mask policy and staff have been trained on it. The DM said staff are expected to wear their facemask at all times, and they should perform hand hygiene immediately after touching or adjusting their facemask. During an interview on 4/21/21 at 11:00 A.M., the administrator said the facility does not have a face mask policy. The administrator said staff are expected to wear their facemask at all times, and the facemask should cover their nose and mouth. The administrator said staff are expected to perform hand hygiene after touching or adjusting their facemask. 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 F 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).

Based on observation, interview, and record review, facility staff failed to promote healing of existing pressure ulcers and prevent the development of new pressure ulcers when they did not follow physician orders, failed to implement interventions, and failed to correctly stage, assess and monitor a pressure ulcer, failed to follow the care plan, failed to complete assessments as directed by facility policy, and when they failed to identify new pressure ulcers, notify the physician, and obtain new orders for treatment for one resident (Resident #2). Staff also failed to prevent the development of pressure ulcers and failed to identify pressure ulcers, notify the physician, obtain orders for treatment, failed to complete assessments as directed by facility policy, and failed to follow the care plan for one resident (Resident #11). The facility census was 61. 1. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage I 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] changes in sensation, temperature, or firmness may precede visual changes; -Stage II 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, pink or red, moist, and may also present as an intact or ruptured serum-filled blister, and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure 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 IV 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 an 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 Protocol, dated 2009, directs staff: -Stage I Pressure Ulcer is intact skin with non-blanchable redness of a localized area usually over a bony prominence, the area may be painful, firm, soft, warmer or cooler as compared to tissue; -Stage II Pressure Ulcer is partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink, wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister; -Stage III Pressure Ulcer is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendons, or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling; -Stage IV Pressure Ulcer is full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable is full thickness tissue loss in which the base of the ulcer is covered with slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and /or eschar is removed to expose the base of the wound, the true depth, and therefore stage, can not be determined. Stable eschar on the heels serves as the body's natural biological cover and should not be removed. -Suspected Deep Tissue Injury is purple or maroon localized area of discolored intact skin, or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Additional review of the policy showed it did not direct staff what to do if a new wound is found, who should be notified, when to obtain physician orders, required documentation, or assessment guidelines. 3. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 5/10/17, showed facility staff assessed the resident as the following: -Severe cognitive impairment; -Did not reject care; -Extensive physical assistance of two staff members with bed mobility,dressing, hygiene, and toileting; -dependent with physical assistance of two staff members with transfer; -dependent with physical assistance of one staff member with bathing; -frequently incontinent of bowel; -an indwelling catheter (tube inserted to drain the bladder); -at risk for pressure ulcers; -unhealed pressure ulcers; -one Stage IV pressure, two Stage II pressure ulcer; -pressure ulcer care; -pressure reducing device for chair and bed; -turning/repositioning program; -nutrition or hydration intervention to manage skin problems; -application of dressings and ointment/medications. Review of the resident's Braden assessment (an assessment to evaluate risk of pressure ulcers), dated 7/17/17, showed staff assessed the resident with a score of 15, at risk. Review of the resident's Care Plan, last reviewed/revised 7/20/17, showed it directed staff: -Wound vac (negative pressure wound therapy- NPWT), to run continuous at 125 mmHg (millimeters of mercury), change every 48-72 hours; -assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and [MEDICATION NAME] daily; -avoid friction and shearing forces during transfer, and position changes; -conduct a systematic skin inspection weekly, report any further signs of breakdown; -encourage fluids at meals and in between meals; -give [MEDICATION NAME] mixed in eight ounces of clear soda or water twice daily until wound healed; -keep clean and dry as possible, minimize skin exposure to moisture; -keep linens clean, dry, and wrinkle free; -keep weight off buttocks, up in chair for maximum of one hour for meals; -observe and report signs of [MEDICAL CONDITION]; -observe and report signs [MEDICAL CONDITION]; -provide incontinence care after each incontinent episode; -specialty bed/mattress for pressure reduction-low loss mattress; -treatment to buttock wound-cleanse with wound cleanser, wet to dry dressing with normal saline daily; -turn and reposition every two hours avoid direct pressure over wound site while limiting side lying position to 30 degree tilt and/or head of bed up to 30 degrees; -use lifting device (lift sheet, etc.) to move resident in bed, use mechanical lift to transfer from bed to chair; -use air filled cell (ROHO) cushion in wheelchair at all times when up. Review of the resident's admission assessment, dated 10/31/16, showed staff documented an open wound to right buttock; open wound coccyx (tailbone) blister length 1 centimeter (cm), width 0.5 cm, 0 cm depth; blister length 2.7 cm, width 1 cm, 0 cm depth; third blister length 1.9 cm, width 2.5 cm, 0 cm depth; and soggy heels. Review of the resident's wound reports, dated 10/31/16-12/11/16, showed staff documented: -Staff did not document a wound assessment from 11/3/16 to 11/29/16; -11/2/16 Right buttock, Stage IV pressure, length 9.5 cm, width 3.3 cm, depth 6.5 cm, tunneling present; coccyx Stage II pressure length 3.0 cm, width 1.4 cm, depth 0.0 cm, red wound bed with red margins; additional note 11/4/16 Negative Pressure Wound Therapy discontinued and 11/5/16 started wet to dry Dakins 0.25% (solution of saline with diluted bleach); -11/30/16 Right buttock, Stage IV pressure, length 7.0 cm, width 6.0 cm, depth 5.8 cm, pink wound bed; reposition, offload use of pillows, indwelling catheter, keep weight off sacrum (tailbone); -12/5/16 Coccyx, Stage IV pressure, length 7.0 cm, width 3.0 cm, depth 3.0 cm, Wound Clinic #1 following wound. Review of the resident's census, showed the staff documented discharge to the hospital on [DATE]. Review of the resident's readmission assessment, dated 12/12/16, showed the staff documented right buttock wound length 8.0 cm, width 5.0 cm, and depth 4.8 cm. Review of the resident's wound reports, dated 12/12/16-4/26/17, show staff documented: -12/14/16 Right buttock, Stage IV pressure, length 6.0 cm, width 5.0 cm, depth 3.5 cm, wet to dry with normal saline two times daily; -Staff did not document a wound assessment from 12/15/16 to 1/2/17; -1/3/17 Coccyx, Stage IV pressure, length 5.0 cm, width 3.0 cm, depth 3.0 cm, granulating wound, Dakins 0.25% daily with dry gauze covering, side to side every 2 hours, limit time up in wheelchair; -1/10/17 Coccyx, Stage IV pressure, length 5.0 cm, width 3.0 cm, depth 3.0 cm, wet to dry dressing saline two times daily, resident prefers right side, support of ROHO cushion in wheelchair, pillows; -1/16/17 Coccyx, Stage IV pressure, length 4.0 cm, width 2.5 cm, depth 2.8 cm, pink tissue, no odor, skin pin surround; -Staff did not document a wound assessment from 1/17/17-1/26/17; -1/27/17 Coccyx, Stage IV pressure, length 3.0 cm, width 2.0 cm, depth 2.0 cm; -1/30/17 Coccyx, Stage IV pressure, length 2.8 cm, width 2.0 cm, depth 2.0 cm, soft pink tissue with granulation evident; -2/7/17 Coccyx, Stage IV pressure, length 1.8 cm, width 2.4 cm, depth 1.8 cm; new left heel Stage II blister length 2.0, width 2.0, and depth 0 cm, the resident is non compliant with floating heels or protective boots; -2/13/17 Coccyx, Stage IV pressure, length 1.8 cm, width 2.5 cm, depth 2.5 cm; left heel Stage II blister length 2.7, width 2.4, and depth 0.5 cm, with [MEDICATION NAME] (an absorbent fiber dressing) and a dry dressing, resident using heel protecting boots; -2/21/17 Coccyx, Stage IV pressure, length 1.5 cm, width 2.5 cm, depth 0.8 cm deep pink wound bed, soft pink tissue surround; left heel Stage II pressure length 1.8, width 2.8, and depth 0.2 cm, dressing changed to skin prep; -3/1/17 Coccyx, Stage IV pressure, length 2.5 cm, width 2.0 cm, depth less than 0.5 cm, health pink tissue with wound now closed in to lower coccyx, no drainage; -3/7/17 Coccyx, Stage IV pressure, length 3.0 cm, width 2.0 cm, depth 2.0 cm; new left side Stage II shear length 1.0 cm, width 2.0 cm, and depth 0.4 cm; Wound Clinic #2 following; -3/16/17 Coccyx, Stage IV pressure, length 3.0 cm, width 1.4 cm, depth 2.0 cm; -Staff did not document a wound assessment from 3/17/17-3/29/17; -3/30/17 Coccyx, Stage IV pressure, length 2.0 cm, width 2.2 cm, depth 1.8 cm, granulating tissue with soft pink wound bed, Dakins 0.25% for seven days then normal saline gauze with dry dressing covering daily; -4/4/17 Coccyx, Stage IV pressure, length 2.2 cm, width 2.2 cm, depth 1.8 cm, wound bed pink with slight odor,normal saline gauze and dry dressing two times daily; -4/9/17 Coccyx, Stage IV pressure, length 1.0 cm, width 3.0 cm, depth 3.0 cm, wound bed pink, debridement (removal of dead tissue) on 4/3/17; new left hip Stage II bruise dark purple discoloration length 5.5 cm, width 5.5 cm, depth 0.0 cm (NPUAP guidelines classify as deep tissue injury), [MEDICATION NAME] with gauze to cover, area appears to be from lift pad; -4/17/17 Coccyx, Stage IV pressure, length 1.0 cm, width 1.0 cm, depth 3.0 cm, pink wound bed; left hip Stage II shear length 5.0 cm, width 5.0 cm, depth 0.0 cm, dark scabbed area with slight fluctuance ; new left arm shear length 0.5 cm, width 2.0 cm, depth 2.0 cm, cleanse and dry dressing; several red areas on buttocks; -Staff did not document a wound assessment from 4/18/17-4/25/17; -4/26/17 Coccyx, Stage IV pressure, length 1.2 cm, width 1.4 cm, depth 2.0 cm, pink tissue; left hip Stage II skin tear 4.0 cm, width 4.0 cm, depth 0.0 cm scab with pink surrounding tissue; left chest Stage II, length 0.5 cm, width 1.8 cm, depth 0.0 cm, normal saline and gauze dressing. Review of the resident's Wound Clinic Progress Note, dated 4/27/17, showed the wound clinic staff documented: -Right buttock Stage IV pressure ulcer- length 2.2 cm, width 1.5 cm, and depth 2.2 cm, small amount of serosanguineous (blood and yellowish) drainage, 19% [MEDICATION NAME] (new skin), 76-100% granulation tissue (viable healing tissue), periwound with excoriation; -Left hip Unstageable pressure ulcer- length 4 cm, width 5 cm, 0 cm depth, small amount of serosanguineous drainage, 76-100% eschar; -left lateral chest acute Stage III pressure ulcer- length 1 cm, width 2.2 cm, depth 1.4 cm, moderate serosanguineous drainage, 51-75% slough, 1-19% granulation tissue; -left, lateral, inferior hip acute Stage III pressure ulcer- length 1 cm, width 2.5 cm, depth 0 cm, serosanguineous drainage, 1-19% granulation tissue; -physician's orders [REDACTED]. with meals, roho cushion to wheelchair at all times when up, low loss air mattress, seat lift in chair every 15 minutes, turn every two hours, avoid direct pressure over wound site while limiting side lying position to 30 degrees tilt and/or head of bed elevation to 30 degrees in bed, and bed baths. Review of the resident's Treatment Administration Record (TAR), dated 4/11/17-5/2/17, showed staff documented the treatments as follows: -Right buttock: cleanse with wound cleanser, apply wet to dry dressing with saline, two times daily; -Left hip wound: apply [MEDICATION NAME] two times daily and cover with gauze; -Left lateral chest: staff did not document a dressing; -Left lateral inferior hip: staff did not document a dressing. Review of the resident's TAR, dated 5/3/17-5/10/17, showed staff documented the treatments as follows: -Right buttock: cleanse with wound cleanser, apply wet to dry dressing with Dakins 0.25%, two times daily; -Left hip wound: apply [MEDICATION NAME] two times daily and cover with gauze; -Left lateral chest: wet to dry dressing with Dakins 0.25% cover with clear transparent film and gauze two times a day; -Left lateral inferior hip: staff did not document a dressing. Additional review showed staff did not document the implementation of the orders on 4/27/17 until 5/3/17, and the staff did not document the implementation of left lateral inferior hip wound orders. Review of the resident's wound reports, dated 4/28/17-5/9/17, showed staff documented: -4/28/17 Right buttock, Stage IV pressure, length 2.2 cm, width 1.5 cm, depth 2.2 cm, pink granulating tissue; left hip Unstageable/Deep Tissue Injury 4.5 cm, width 5.0 cm, depth 0.0 cm, changed to Dakins 0.25% dressing two times daily; left chest Stage II length 1.0 cm, width 2.2 cm, depth 1.4 cm, wet to dry with Dakins 0.25%; new left hip inferior Stage II shear length 1.0 cm, width 2.5 cm, depth 0.0 cm; -5/2/17 Coccyx, Unstageable pressure, length 1.4 cm, width 1.4 cm, depth 2.0 cm, granulating tissue at edges with soft pink wound base; left hip Stage II scab 3.5 cm, width 4.0 cm, depth 0.0 cm, scab with moderate softness and fluctuance in the center; left chest Stage II skin tear, length 0.5 cm, width 1.5 cm, depth 0.0 cm, with granulating tissue; (documentation did not include the left hip inferior wound); -5/9/17 Coccyx, Stage IV pressure, length 1.4 cm, width 1.4 cm, depth 2.0 cm; left hip Stage II scab 3.0 cm, width 4.0 cm, depth 0.0 cm, scab is brown with slight fluctuance; left chest Stage II skin tear, length 0.5 cm, width 1.0 cm, depth 0.0 cm; (documentation did not include the left hip inferior wound); Review of the resident's Wound Clinic Progress Note, dated 5/12/17, showed the wound clinic staff documented: -Right buttock Stage IV pressure ulcer- length 1.6 cm, width 1.2 cm, and depth 1.8 cm, moderate amount of serosanguineous drainage, 19% [MEDICATION NAME] (new skin), 76-100% granulation tissue, periwound with excoriation; -Left hip Unstageable pressure ulcer- length 4.5 cm, width 4.7 cm, 0 cm depth, small amount of serosanguineous drainage, 76-100% eschar; -Left lateral chest acute Stage III pressure ulcer- length 0.3 cm, width 0.5 cm, depth 0.5 cm, small amount of serosanguineous drainage, 76-100% granulation tissue; -Left, lateral, inferior hip acute Stage III pressure ulcer- length 0.5 cm, width 0.8 cm, depth 0.1 cm, small amount of serosanguineous drainage, 76-100% granulation tissue; -physician's orders [REDACTED]. Review of the resident's wound reports, dated 5/15/17-5/31/17, showed staff documented: -5/15/17 Coccyx, Stage IV pressure, length 3.0 cm, width 1.5 cm, depth 2.0 cm, had debridement at wound clinic; left hip Stage II scab 5.0 cm, width 4.5 cm, depth 0.2 cm, scab with dark black center; left chest Stage II, length 1.0 cm, width 0.1 cm, depth 0.0 cm; -5/23/17 Coccyx, Stage IV pressure, length 3.0 cm, width 1.8 cm, depth 2.2 cm, soft pink wound bed; left hip Stage II scab 4.5 cm, width 4.5 cm, depth less than 0.5 cm, scabbed area loose, fluctuant at center; -5/25/17 Coccyx, Stage IV pressure, length 1.2 cm, width 1.2 cm, depth 1.2 cm; left hip Unstageable/Deep Tissue Injury 3.3 cm, width 4.2 cm, depth 0.0 cm, scabbed area boggy; -5/31/17 Coccyx, Stage IV pressure, length 3.0 cm, width 2.0 cm, depth 2.0 cm; left hip Stage II scab 4.5 cm, width 4.5 cm, depth 0.5 cm, scabbing is loose with open edges. Review of the resident's Wound Clinic Progress Note, dated 6/1/17, showed the wound clinic staff documented: -Right buttock Stage IV pressure ulcer- length 1.9 cm, width 1.2 cm, and depth 0.5 cm, moderate amount of serosanguineous (blood and yellowish serum) drainage, 51-75% [MEDICATION NAME], 76-100% granulation tissue, periwound with excoriation; -Left hip Unstageable pressure ulcer- length 4.3 cm, width 4.3 cm, 0 cm depth, small amount of serosanguineous drainage, 20-50%slough, 51-75% eschar; -physician's orders [REDACTED]. Review of the residents TAR, dated 5/11/17-6/10/17, showed staff documented the treatments as follows: -Right buttock: continued as ordered; -Left hip wound: continued as ordered (TAR did not show staff changed the dressing ordered on [DATE]); -Left lateral chest: wet to dry dressing with Dakins 0.25% cover with clear transparent film and gauze two times a day, (TAR did not show staff changed the dressing ordered on [DATE]); -Left lateral inferior hip: staff did not document a dressing. Review of the resident's wound reports, dated 6/6/17-6/27/17, showed staff documented: -6/6/17 Coccyx, Stage IV pressure, length 2.5 cm, width 2.0 cm, depth less than 0.3 cm; left hip Stage II scab 4.5 cm, width 4.0 cm, depth 0.0 cm, scab is darkened and soft; -6/13/17 Coccyx, Stage IV pressure, length 2.5 cm, width 2.0 cm, depth 0.8 cm; left hip Stage II scab 4.5 cm, width 4.5 cm, depth less than 0.5 cm, scab darker; -6/21/17 Coccyx, Stage IV pressure, length 2.5 cm, width 1.5 cm, depth 0.8 cm; left hip Stage II scab 4.0 cm, width 4.0 cm, depth 0.5 cm; -6/27/17 Coccyx, Stage IV pressure, length 2.5 cm, width 1.5 cm, depth 1.0 cm, granulation; left hip Stage II scab 4.0 cm, width 4.0 cm, depth 0.5 cm, scab off wound staying moist, scab off and yellow cast to tissue; Review of the resident's Wound Clinic Progress Note, dated 6/29/17, showed the wound clinic staff documented: -Right buttock Stage IV pressure ulcer- length 1 cm, width 1.5 cm, and depth 1.2 cm, deteriorating, moderate amount of serosanguineous drainage, 20-50% slough, 51-75% granulation tissue, periwound with excoriation; -Left hip Stage III- length 2.6 cm, width 3.5 cm, 0 cm depth, small amount of serosanguineous drainage, 20-50% slough, 51-75% eschar, post debridement measurements length 2.6 cm, width 3.5 cm, and depth 1 cm; -physician's orders [REDACTED]. Review of the resident's wound reports, dated 7/6/17-7/10/17, showed staff documented: -7/6/17 Coccyx, Stage IV pressure, length 2.0 cm, width 2.0 cm, depth 1.5 cm, deep raspberry pink color to wound bed; left hip Stage II scab 3.0 cm, width 3.0 cm, depth 1.0 cm, soft spongy wound bed with eschar covering, slight redness, changed dressing to Dakins 0.25% and dry dressing daily; MRI scheduled; -7/10/17 Coccyx Stage IV pressure did not contain measurements, staff documented question tunneling, left hip Stage II scab, staff documented circular debridement by wound clinic, and did not contain measurements. Review of the resident's Wound Clinic Progress Note, dated 7/13/17, showed the wound clinic staff documented: -Right buttock Stage IV pressure ulcer- length 1.5 cm, width 1.5 cm, and depth 2 cm, deteriorating, moderate amount of serosanguineous drainage, 20-50% slough, 76-100% granulation tissue, periwound with excoriation; -Left hip Stage IV- length 2.2 cm, width 2.4 cm, 8 cm depth, small large amount of yellow drainage, 76-100% slough, 51-75% eschar, undermining 3 cm; -physician's orders [REDACTED]. Review of the resident's census, showed the staff documented discharge to the hospital on [DATE]. Review of the resident's Operative Notes, dated 7/14/17, showed the physician documented debridement of left hip wound. Additional review showed the physician documented, 3 cm diameter open wound over the left femoral head, with frankly necrotic subcutaneous tissue. The necrotic tissue in the left hip/femoral wound, after debridement was 3 cm diameter and 3 cm deep, but the wound cavity extended superiorly for 5 cm. Review of the resident's readmission assessment, dated 7/17/17, showed the staff documented the presence of pressure ulcers to left hip and coccyx. Additional review show the staff did not document, a stage, measurements, drainage, or a description of the wound bed. Review of the facility's bedside In-Service for placement and use of NPWT, dated 7/18/17, showed the wound consultant reviewed: -Setting the pressure to the prescribed setting; -Review of the manual; -Contraindications: Blood drawing into tubing/canister, remove NPWT, notify primary care physician; more than 20% slough, or necrosis. Review of the resident's wound reports, dated 7/18/17-7/30/17, showed staff documented: -7/18/17 readmission Coccyx Stage IV pressure, staff did not document measurements, normal saline and dry dressing; Left hip debridement of previous scabbed area, NPWT at 125 mmHg, change every three days, use of antimicrobial [MEDICATION NAME] for sponge; -Staff did not document a wound assessment from 7/18/17-7/30/17. Review of the resident's Wound Clinic Progress Note, dated 7/27/17, showed the wound clinic staff documented: -Right buttock Stage IV pressure ulcer- length 1 cm, width 1 cm, and depth 1.2 cm, deteriorating, moderate amount of serosanguineous drainage, 20-50% slough, 76-100% granulation tissue, periwound with excoriation; -Left hip Stage IV- length 2 cm, width 2.4 cm, 7 cm depth, large amount of serosanguineous drainage, 1-19% slough, 76-100% pink granulation tissue, excoriation of the periwound; -physician's orders [REDACTED]. Review of the resident's wound reports, dated 7/31/17-8/14/17, showed staff documented: -7/31/17 Coccyx, Stage IV pressure, length 1.0 cm, width 1.6 cm, depth 1.8 cm; left hip Stage IV surgical 2.0 cm, width 2.0 cm, depth 5.0 cm, tunneling present, scant tan drainage, NPWT at 125 mmHg; -Staff did not document a wound assessment from 8/1/17-8/13/17; -8/14/17 Coccyx, Stage IV pressure, length 1.5 cm, width 1.0 cm, depth 2.8 cm, Dakins 0.25% and dry dressing; left thigh Stage IV surgical 2.0 cm, width 2.0 cm, depth 3.5 cm, NPWT at 125 mmHg. Review of the resident's Wound Clinic Progress Note, dated 8/14/17, showed the wound clinic staff documented: -Right buttock Stage IV pressure ulcer- length 1.4 cm, width 0.8 cm, and depth 1.3 cm, no change, moderate amount of serosanguineous drainage, 76-100% granulation tissue, periwound with excoriation; -Left hip Stage IV- length 1.2 cm, width 0.8 cm, 1.3 cm depth, moderate amount of serosanguineous drainage, improving, 76-100% pink granulation tissue, excoriation of the periwound; -physician's orders [REDACTED]. Review of the resident's physician's orders [REDACTED]. Reduce rate on NPWT to 80 mmHg, as directed by wound supplies company representative (an LPN with the equipment company providing the equipment) to the director of nursing (DON). Additional review did not show the physician approved the order. Review of the resident's Progress Nursing Notes, dated 8/18/17-8/23/17, showed staff documented the resident's NPWT goal pressure set at 80 mmHg (10 entries). Review of the resident's Progress Nursing Notes, dated 8/23/17-8/26/17, showed staff documented the resident's NPWT goal pressure set at 115 mmHg (8 entries). Review of the resident's wound reports, dated 8/21/17, showed staff documented the coccyx, Stage IV pressure, length 1.5 cm, width 1.2 cm, depth 2.0 cm, Dakins 0.25% and dry dressing; left thigh Stage IV surgical 2.0 cm, width 2.0 cm, depth less than 3.0 cm, NPWT at 125 mmHg. Observation on 8/28/17, at 10:32 A.M., showed the resident in bed, with a NPWT pump set with a goal pressure of 115 mmHg. Observation showed the resident on a foam style mattress with raised edges, and the resident's heels rested directly on the mattress. Observation on 8/28/17, at 11:20 A.M., showed certified nurse assistant (CNA) E, and CNA F transfered the resident with a mechanical lift to his/her wheelchair. Observation showed staff positioned the resident in the wheelchair with the mechanical lift and the wheelchair did not have a cushion in the seat. Observation on 8/28/17, at 2:15 P.M., showed the resident did not have a cushion in his/her wheelchair, and the NPWT with the pressure set at 115 mmHg. Observation on 8/28/17, at 3:27 P.M., showed the resident at the nurses station in his/her wheelchair. Observation showed the resident did not have a cushion in his/her wheelchair, and the NPWT pump with the pressure goal set at 115 mmHg. Observation on 8/28/17, at 3:50 P.M., showed the resident in bed, and LPN A provided wound care to the coccyx wound. LPN A said the wound measured length 1.3 cm, width 0.6 cm, and depth 2.6 cm, and the wound had maceration around the edges, pink tissue, and slough. Observation showed the LPN removed the NPWT dressing from the resident's left hip. Observation showed under the tubing secured to the residents leg with a transparent dressing showed a fluid filled blister, and a small red open area. Observation showed a rectangular open area with yellow wound base lateral to the wound on the left hip. The director of nursing (DON) measured the wounds and said the original wound measured length 2.5 cm, width 1.8 cm, depth 0.6 cm with tan gray tissue, less than 5% visible pink tissue, and 75% slough. The DON measured the new wound lateral to the original wound and said the length measured 1.8 cm, width 0.5 cm, and depth a q-tip edge, and the wound bed is 90% slough, and said he/she thinks the suction cap caused it because it is very firm. The DON measured the new fluid filled blister and said the length measured 1 cm, width 2.5 cm, and wound is raised. The DON measured the new red open area and said the length measured 0.5 cm, width 0.5 cm, and had no depth. The DON said the fluid filled blister and the red open area were caused from the tubing and transparent dressing. LPN A replaced the NPWT dressing and set the pressure to 125 mmHg. LPN A said the resident's parent refuses his/her wheelchair cushion because it slides, so staff only use it when he/she is not here. Observation on 8/29/17, at 8:15 A.M., showed the resident in his/her bed on his/her back, with the NPWT pump set at 125 mmHg. Observation on 8/29/17, at 12:37 P.M., showed the resident at the dining room table in his/her wheelchair without a cushion in the wheelchair seat. Observation on 8/30/17, at 12:10 P.M., showed the resident in his/her wheelchair with a foam wheelchair cushion, the resident did not have a ROHO cushion as ordered by the wound clinic physician. During an interview on 8/30/17, at 11:28 A.M., LPN A said the resident does not use any wheelchair cushion unless his/her parent is not here because his/her parent said it makes him/her slide, he/she did not know if another cushion had been tried. He/She said prolonged sitting without a cushion could make his/her wounds worse. He/She is not on a low air loss mattress, and he/she did not know about a physician order, or the mattress listed in the care plan. He/She did not think a low air loss mattress had been tried. He/She said he/she did not report the new wounds found on 8/28/17 because he/she thought the DON reported them to the (NPWT) wound consultant from the equipment company. He/She said he/she thinks he/she might work with the resident's physician but is not sure. He/She did not know if the family or the physician had been notified of the three new wounds, or the slough covered hip wound. He/She said the resident's target pressure started at 125 mmHg, it lowered to 80 mmHg, then last week it went back to 125 mmHg. He/She did not know why. During an

Based on interview and record review, facility staff failed to investigate an allegation of abuse in a timely manner, and failed to remove all alleged perpetrators from working directly with residents. On 5/2/13, a staff member reported a Licensed Practical Nurse (LPN) F, Certified Nurse Aide (CNA) D, and CNA F forced Resident #1 to take a whirlpool bath against his/her will. In addition, the staff members put the resident in the whirlpool with his/her clothes on. Administrative staff failed to immediately investigate the allegation. Administrative staff suspended LPN F, but allowed the two nurse aides with alleged involvement in the abuse to continue to work with residents until at least 05/10/13. The facility census was 63. 1. Review of Resident #1's face sheet (undated), showed [DIAGNOSES REDACTED]. Review of the resident's psychiatric progress note, dated 1/31/13, showed the resident's psychiatrist documented the resident was "impatient, belligerent, cursing, no physical aggression, refuses to be interviewed." Review of the residents plan of care, updated 2/12/13, showed staff planned the following interventions: - praise resident when behavior is appropriate; - maintain a calm, slow, understandable approach with the resident; - maintain a calm environment and approach the resident; - allow resident to have control over situations, if possible; - immediately report any incidents to nursing administration. The care plan did not provide interventions related to the resident's refusal of care. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/15/13, showed staff assessed the resident as follows: - Cognitively intact decision making skills; - Required extensive assistance of two staff members with bed mobility, transfers, dressing, toilet use, and hygiene; - Did not ambulate. During an interview on 05/09/13 at 12:00 P.M., Certified Nurse Aide (CNA) A said the resident had refused showers before because he/she wanted to watch a ball game or because he/she wanted to wait for a specific staff member to assist him/her with the shower. During an interview on 05/09/13, at 3:15 P.M., CNA B said the resident liked to choose "certain staff" to assist with his/her showers. CNA B said when the resident refused showers, they "reapproached" him/her later. During an interview on 05/09/13 at 2:00 P.M., Licensed Practical Nurse (LPN) C said on 4/27/13, the resident refused his/her whirlpool. LPN C discussed this with the resident and he/she agreed to take a whirlpool after the baseball game he/she was watching. LPN C reported this to CNA D, CNA E, and LPN F. During an interview on 05/09/13 at 11:15 A.M., Resident #1 said LPN F, CNA D, and CNA E "forced me in the whirlpool with my clothes on and then they took my clothes off while I was soaked in the whirlpool. I fought them as long as I could." He/she said "they made me miss the last two innings. I don't want that to ever happen again. They had no right. They were too physical with me and made me do it. It is always her (LPN F) way or no way." During an interview on 05/09/13 at 2:15 P.M., CNA E said the resident refused to take a whirlpool on 04/27/13. He/she reported that to LPN F. The LPN told the resident he/she "had to" take a whirlpool. CNA E said they put the resident in the whirlpool with his/her clothes on. CNA E said the resident was "yelling and cursing and trying to hit at us" as they administered the whirlpool. The resident said, "I don't want to." During an interview on 05/09/13 at 2:00 P.M., LPN C said after she discussed waiting for the ball game to finish with the resident he/she heard the resident "screaming and cursing and yelling obscenities" in the hallway. During an interview on 5/10/13 at 3:10 P.M. CNA D said the resident was on the list to get a shower. CNA D said the resident wanted to watch a game, but would take a shower later. CNA D reported this to LPN F and LPN F said "oh, no". CNA D said the game was still on and LPN F told the resident the DON and Administrator said the resident had to take a bath. LPN F instructed CNA D and CNA E to put the resident in the bath fully clothed. CNA D said the resident "fought them the whole way", and was cursing. Staff used the Hoyer (mechanical) lift to place the resident in the whirlpool. CNA D said the incident was "uncomfortable". CNA D just wanted LPN F to leave the shower room so the resident would calm down. CNA D said as soon as LPN F left the shower room, the resident "deflated" and continued with the bath "no problem". CNA D felt LPN F was abusive to the resident, and if they didn't obey her they would get fired. During an interview on 05/09/13 at 11:00 A.M., the administrator said she was "still investigating" the incident. She said the resident had some behaviors, but was a "fairly good historian." On 5/2/13, an employee reported to her LPN F forced the resident to shower with his/her clothes on and was directed to do so by the administrator and director of nursing (DON). The administrator said the incident occurred "several days earlier." The administrator said she suspended LPN F, but was still investigating and had not interviewed the resident or staff. The administrator requested staff working at the time of the incident to write statements, but said, "I really haven't had a chance to look through all these papers." Reviewed of the DON's signed statement, dated 05/02/13 (no time) showed the DON documented during an interview with the resident, he/she said he/she wanted to finish watching the ball game. The resident said LPN F came in and said, "we are doing your shower." The resident said he/she requested to finish watching the ball game. He/she said LPN F came back with another staff member and took him/her to take a whirlpool. The resident said, "I was so mad. I have never hit a woman in my life, but I feel I could have." The DON documented the resident said, "they got me wet with my clothes on." Review of the DON's "witness statement", dated 05/02/13 at 2:00 P.M., showed the DON documented "while it is not the intent to cause conflict during care, it is not harmful to a resident to have or wear clothing if they bathe." During an interview on 05/09/13 at 1:15 P.M., the DON said they gathered staff members' statements on 05/08/13 and did not interview CNA D, CNA E or other staff working at the time of the incident. When asked if she thought the incident rose to the level of abuse, the DON said, the resident was more upset about missing the game than staff forcing him/her into the whirlpool. The DON said the resident was "usually accurate" with his/her statements. During an interview on 05/09/13 at 2:35 P.M., the administrator said she did not interview staff working at the time of the incident because "they worked nights." She said she had been trying to get the staff to write statements. The administrator said she was not sure of CNA D and CNA E's involvement in the incident, so she did not suspend them. The administrator said CNA D worked 05/08/13 and she "was sure" CNA E had also since staff reported the incident to her. She said she suspended LPN F after she started the investigation. She said LPN F "was driving the bus" so she felt residents were safe after she suspended her. The administrator said she was not done with her investigation and did not know she needed to report the allegation to the state agency (Department of Health and Senior Services-DHSS). The administrator said she would not instruct staff to put any resident in a whirlpool with their clothes on and said, "that's horrible." MO 222

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J." A monitoring visit was completed on May 24, 2013. 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. The facility implemented changes including inservicing staff on abuse/neglect reporting and interviewing residents regarding bathing preferences and treatment during bathing assistance. Staff were continuing to provide inservice training regarding abuse/neglect and resident choices at the time of the revisit. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "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 violations.

Based on interview and record review, facility staff failed to provide a specialized diet as ordered for one of three sampled residents with orders for special diets. Staff failed to ensure one confused resident (Resident #1) with a history of choking on a snack item received a pureed snack as ordered by the resident's physician, which resulted in the resident choking a second time. The resident again ate a regular consistency snack item while unsupervised and choked, requiring the Heimlich maneuver to clear his/her airway. The facility census was 56. 1. Review of Resident #1's plan of care, showed staff added an intervention on 1/14/10 to address the resident's risk of choking. Review showed the plan directed staff to encourage the resident to eat slower and swallow frequently. Review of the resident's physician's orders [REDACTED]. - Obtain a swallow study this week due to repeated episodes of choking with aspiration (accidental sucking in of food particles or fluids into the lungs.) Review of the Speech Therapy Swallowing Evaluation, dated 2/19/10, showed the Speech Therapist (ST) assessed the resident as: - Severely cognitively impaired due to "advanced Alzheimer's" disease; - Mild to moderate impairment of oral residue/pocketing; - Moderate impairment of oral awareness/sensitivity; - Moderate coughing/choking. Additional review of the Speech Therapy Swallowing Evaluation, dated 2/19/10, showed the ST documented the resident as "not able to follow directions, took large bites, ate quickly, and did not always chew his/her food thoroughly." The ST also documented the resident as "very impulsive and does not follow directions well." Review of an e-mail to the resident's physician, dated 2/23/10, showed facility staff documented the speech therapist recommended staff provide a pureed diet to the resident. Review showed the physician approved the order for a pureed diet. Review of the resident's plan of care, dated 2/21/09, showed staff did not change the resident's plan of care to provide direction for staff regarding the resident's new order for a pureed diet. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/25/10, showed staff assessed the resident with the following: - Short and long term memory problems; - Moderately impaired cognitive skills for daily decision making; - Easily distracted; - Periods of restlessness; - Required extensive assistance of two or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; - Required extensive assistance of one staff with eating; - No chewing or swallowing problems; - Did not require a mechanically altered diet; - On the Alzheimer's/dementia special care unit. Review of the MDS showed staff did not assess the resident with swallowing problems or a mechanically altered diet. Review of the resident's Nurse's Notes, dated 6/3/10 at 3:45 P.M., showed staff documented the resident "choked on a danish." Staff documented they performed the Heimlich maneuver and dislodged the danish. During an interview on 9/8/10 at 2:55 P.M., Certified Medication Technician (CMT) A said the resident picked up a danish "set out for other residents" for a snack and put it in his/her mouth. CMT A said he/she performed the Heimlich maneuver on the resident and dislodged the danish. Review of the resident's care plan showed staff did not plan a new intervention to address the resident's choking incident on 6/3/10 to provide direction for staff when providing snacks to prevent the resident from choking again. Review of the resident's Nurse's Notes, dated 8/8/10 at 11:00 A.M., showed the Administrator documented CMT B called her to the Special Care Unit (SCU). The Administrator documented the resident "was sitting up in a chair" and "was cyanotic" (bluish discoloration of the skin and mucous membranes due to not enough oxygen in the blood) "and without airway sounds". The Administrator documented she performed the Heimlich maneuver without success. The Administrator documented staff placed the resident on the floor and the Administrator performed two abdominal thrusts, which dislodged the food item. The Administrator documented, "color returned to the resident's face with respirations present." During an interview on 9/8/10 at 10:20 A.M., the Administrator said the resident "is on a pureed diet." The Administrator said the resident obtained a muffin and choked on it on 8/8/10. The Administrator said she performed the Heimlich maneuver on the resident. During an interview on 9/10/10 at 10:12 A.M., CMT B said on 8/8/10 the Administrator brought snacks to the SCU consisting of donuts or muffins, and then left the SCU. CMT B said the Administrator did not notify CMT B or the other staff member on the SCU that she passed snacks to the residents. CMT B said the other staff member on the SCU entered the dining room and saw the resident choking. CMT B ran out of the SCU and yelled for assistance. CMT B said the Administrator responded and performed the Heimlich maneuver on the resident. CMT B said eventually the food became dislodged. CMT B said after the Administrator dislodged the food the Administrator said she did not know the resident could not have a donut. CMT B said the resident required a pureed diet. During an interview on 9/10/10 at 10:35 A.M., the Administrator said she took snacks to the SCU on 8/8/10. The Administrator said she did not remember if she handed the muffin/donut to the resident or if she placed the tray of snacks on the counter. The Administrator said she did not know each resident's dietary restrictions/orders. The Administrator said staff who consistently worked in the kitchen or on the SCU knew each residents' diet order. MO 852