Every finding on record at Johnson County Care Center

Based on observation and interview, the facility failed to maintain functioning elevators when on 8/3/26 the front elevator was nonfunctioning impacting all residents who use the elevators for meals and activities. The facility census was 82 residents.1. Observation on 8/3/26 at 10:30 A.M. showed the front elevator of the facility was posted out of service. During an interview on 8/3/26 at 2:00 P.M. the Administrator said:-He/She was aware the elevator being inoperable.-He/She did not know when someone would be there to fix the elevator.-The elevator broke down over the weekend, 8/1/26. Review of Resident #21's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) dated 5/18/26 showed the resident was cognitively intact. During an interview on 8/3/26 at 3:23 P.M. the resident said:-The main elevator was not working and had not been working for about a week.-Everyone has to use the same elevator to get to meals and wherever they needed to go.-The elevator they had to use was smaller than the main one which was not working.-It was a battle to have everyone using one elevator. Review of Resident #3's admission MDS dated [DATE] showed the resident was cognitively intact. During an interview on 8/3/26 at 3:36 P.M. the resident said:-The elevator stopped working over the weekend, 8/1/26.-The elevators were off and on alot. Review of Resident #22's admission MDS dated [DATE] showed the resident was cognitively intact. During an interview on 8/3/26 at 3:47 P.M. the resident said:-The elevators were always going down and constantly stalled.-The front elevator had worked for two days.-All the residents were having to use the one smaller elevator to get to meals and other places. Review of Resident #6's quarterly MDS dated [DATE] showed the resident was moderately cognitively impaired. During an interview on 8/3/26 at 4:33 P.M. the resident said:-The elevator was broken sometimes.-One of the elevators broke and had been broken for four days. During an interview on 8/3/26 at 4:42 P.M. the Maintenance Director said:-The elevators had been broken down since Saturday 8/1/26 due to a hydraulic leak.-He/She called the company to work on the elevator, which was expected to arrive as soon as possible.-He/She was told there was a shortage of staff and as soon as someone was available, they would send someone to fix the elevator.-He/She was expecting an update the following day, until then there would only be the one smaller elevator for use. During an interview on 8/3/26 at 2:16 P.M. the Administrator said:-The main elevator was not functioning at that time.-The elevator stopped working earlier that morning, 8/3/26.-The maintenance director had contacted someone to come fix the elevator.-He/She was not sure when the repairs would be complete. 3104615, 3106863

Based on observation and interview, the failed to ensure residents had a safe, comfortable and homelike environment for three sampled residents (Resident # 1,#11 and #21) and for four other residents who rooms were also affected when their toilets were not functioning properly and door handles were removed making the bathrooms inaccessible out of 22 sampled residents. The facility census was 82 residents1.Observation on 7/30/26 from 4:38 P.M. through 4:43 P.M. showed Room # 309, 314 and 315 had missing door handles to the bathroom and could not be opened. Observation on 7/30/36 at 12:25 P.M. showed room [ROOM NUMBER] and #215 had missing door handles and the doors to the bathroom could not be opened. During an interview on 7/30/26 at 5:51 A.M. the Maintenance Director said:-He/She called the plumber on Monday 7/27/26 and they were supposed to be in the facility on 8/4/26.-He/She said they only use one plumber and chose to wait for the plumber to come to the facility.-He/She removed the door handles from room [ROOM NUMBER] and 315 on the third floor to keep the residents out of the bathroom and prevent the use of the toilets in those bathrooms.-He/She said there were two additional rooms on the second floor, rooms [ROOM NUMBERS], and the door handles were removed for the same reason.-He/She also turned off the water to the sinks in both rooms due to the clogged pipes and flooding in the basement.-He/She did not know why the door handle was missing from room [ROOM NUMBER].-He/She expected staff to submit a work order for missing door handles.-He/She was taking the door handles off the bathroom doors to prevent residents from clogging the toilets.-He/She expected the residents to use the bathroom in the hall shower rooms. Observation on 8/3/26 at 12:52 P.M. showed the Maintenance Director was replacing the door handle to the bathroom door for room [ROOM NUMBER]. During an interview on 8/3/26 at 12:53 P.M. the Maintenance Director said:-He/She was putting the handles back on the doors to the bathrooms.-The plumber instructed him/her to let it flood so that the plumber could see the full impact.-The plumber was on his/her way to the facility. During an interview on 8/3/26 at 1:01 P.M. Certified Medication Technician (CMT) B said:-He/She had been working at the facility for about six months.-room [ROOM NUMBER] had no door handle on the bathroom door for the six months he/she has been working in the facility.-He/She has not been able to open the door to the bathroom.-Resident #2 who resided in one of the affected rooms, urinated and defecated on the floor and in the built-in cabinet in the room, although the resident would use the bathrooms in the shower rooms from time to time.-He/She was told some time ago the reason there was no door handle on the bathroom door was due to something being wrong with the toilet in room [ROOM NUMBER]. During an interview on 8/3/26 at 11:23 A.M. the Administrator said:-The door handle for room [ROOM NUMBER]'s bathroom was put back on.-He/She did not know how long room [ROOM NUMBER]'s door handle had been removed but thought it was a couple of weeks.-He/She was sure the Maintenance Director had taken the door handle to room [ROOM NUMBER]'s bathroom off.-The Maintenance Director was putting door handles back on all the bathroom doors.-The plumber was on the way to the facility to work on the clogged toilets and basement flooding.-The facility used the same plumber for so long no other plumber would come to the facility, so they had to wait for this one to come.-The flooding from the clogged toilets had been going on intermittently for a couple of months.-Resident #11 who resided in one of the affected rooms filled the toilets with paper towels daily, but he/she denied doing it even when he/she was caught doing it. Review of Resident #20's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) dated 6/26/26 showed the resident was cognitively intact. During an interview on 8/3/26 at 2:45 P.M., the resident said:-He/She lived in one of the affected rooms.-The bathroom had been down and without a door handle for about a week.-There had been trouble with the toilet for the last month.-He/She was using the bathroom and the sink in the shower room across the hall. Review of Resident #1's quarterly MDS dated [DATE] showed the resident was cognitively intact. During an interview on 8/3/26 at 3:14 P.M. the resident said:-His/Her toilet doesn't flush half of the time. -He/She had complained about it since he/she arrived at the facility. Review of Resident #21's quarterly MDS dated [DATE] showed the resident was cognitively intact. During an interview on 8/3/26 at 3:23 P.M. the resident said:-He/She lived in one of the affected rooms.-He/She did not have a handle on the bathroom door.-He/She was told they could not use the bathroom due to the drain from the second and third floor not draining.-The bathroom across the hall was very inconvenient, especially during the night.-His/Her roommate was in a wheelchair and could not take him/herself to the bathroom.-The toilet has been out of service twice over the last month. Review of Resident #11's quarterly MDS dated [DATE] showed the resident was severely cognitively impaired. During an interview on 8/3/26 at 4:00 P.M. the resident said:-There was no knob on the bathroom door, and it could not be opened.-There had not been a knob on the door for about a week.-The maintenance man took the doorknob off. 3104615, 3106863

Based on observation and interview, the facility failed to meet the requirement for an operational window to the outside for four sampled residents (Resident #1, #3, #8, and #16) and other affected residents who reside in those rooms out of 22 sampled residents. The facility census was 82 residents.1.Observations on 8/3/26 from 12:11 P.M. through 12:51 P.M., 33 resident rooms had the windows screwed shut. Review of Resident #8's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) dated 7/21/26 showed the resident was cognitively intact. During an interview on 7/30/26 at 12:19 P.M. the resident said:-The windows in his/her room were screwed shut.-He/She did not know why the windows were screwed shut.-The Maintenance Director screwed them shut at the beginning of summer. Review of Resident #1's quarterly MDS dated [DATE] showed the resident was cognitively intact. During an interview on 8/3/26 at 12:40 P.M. the resident said the windows were screwed shut about 4 to 6 months ago by the Maintenance Director. Review of Resident #16's annual MDS dated [DATE] showed the resident was cognitively intact. During an interview on 8/3/26 at 12:41 P.M. the resident said:-The windows were screwed shut.-He/She did not know why or for how long the windows were screwed shut. Review of Resident #3's admission MDS dated [DATE] showed the resident was cognitively intact. During an interview on 8/3/26 at 2:52 P.M. the resident said his/her window had been screwed shut since he/she moved in about two months ago. During an interview on 8/3/26 at 4:42 P.M. the Maintenance Director said:-Almost all windows in the facility were screwed shut.-He/She screwed the windows shut because the residents were opening them.-He/She was told by the Regional Director of Operations the windows could be screwed shut and they did not have to open.-The windows were screwed shut a couple of years ago. During an interview on 8/4/26 at 10:39 A.M. the Regional Director of Operations said: -Two or three years ago he/she was given authorization to screw the windows shut because they were not egress windows and did not need to be operable.-The windows were screwed shut because the residents were opening the windows and creating a temperature control issue.-The windows were screwed shut instead of replacing all the windows, which made them inoperable permanently. During an interview on 8/4/26 at 5:53 P.M. the Administrator said windows were screwed shut to prevent smoking in September. 3104615, 3106863

Based on observation and interview, the facility failed to maintain safe and sanitary floors for one sampled resident (Resident #2) out of 22 sampled residents, The facility census was 82 residents.1.During an observation on 7/30/26 at 4:38 P.M. of Resident #2's room showed:-He/she was ambulating in his/her room.-Upon entering the room there was a pungent odor of urine and feces.- The resident was redirected by staff and was non-verbal.-The flooring and built-in cabinets were saturated with urine and fecal material.- The tiles on one side of the room adjoining the wall were pulled up at the corners. During an interview on 7/30/26 at 4:51 P.M. the Maintenance Director said:-The resident's room smelled of urine and feces was due to the resident not using the bathroom in his/her room or the bathroom across the hall.-The room had been in that condition for some time. During an interview on 8/3/26 at 1:20 P.M. the Social Services Designee said:-The resident's room has been like that for some time.-He/She recalled the resident's room was like this for about a month and a half ago and had urine and feces in the cabinets and on the floor.- The resident's behaviors were urinating and defecating on the floor and cabinets. During an interview on 8/3/26 at 1:01 P.M. Certified Medication Technician (CMT) B said:-The resident has been urinating and defecating on the floors and in the cabinets in his/her room for at least six months.-He/She was told the resident was not able to use his/her bathroom because there was something wrong with the toilet.-The resident has been observed using the toilet in the shower room, but it depended greatly on the resident's state of mind.-The room has smelled of urine and feces for the last six months. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) dated 6/30/26 showed the resident was cognitively intact. During an interview on 8/3/26 at 3:14 P.M. the resident said:-Resident #2's smelled of urine really bad.-When the door was opened, the smell of urine took over the hallway and into some of the rooms close by.-The smell of urine had been really bad for the last six months.-The resident pooped all over him/herself and all over the bathroom floor in the shower rooms.-He/She was offended by the smell During an interview on 8/3/26 at 4:42 P.M. the Maintenance Director said:-He/She had removed the toilet in Resident #2's room many times due to the resident filling the toilet with poop and pee and he/she was having to dig it out of the toilet to work on it.-The resident used to go to the shower room to use the bathroom but had stopped.-Even when Resident #2 was using the shower room, he/she would still poop and pee on the floor and cabinets in his/her room.-He/She was not sure how long the pungent odor of urine and feces had been present in Resident #2's room.-The resident had been urinating and defecating in his/her room for about a year.-There was no current plan to clean and/or repair the cabinets and floors the resident's room.-He/She said the resident's aggressive behaviors prevented the staff from cleaning and making the necessary repairs in the room. During an interview on 8/4/26 at 10:39 A.M. the Regional Director of Operations said:-Resident #2 was urinating and defecating on the floors and in the cabinets in his/her room.-There was no current plan for resolution of the flooring and cabinets for the resident's room. During an interview on 8/4/26 at 2:22 P.M. Certified Nursing Assistant (CNA) A said:-He/She was in Resident #2's about a week ago.-While in the room, he/she noticed the flooring was stained with poop and pee and the flooring was pulling up.-He/She noted the room had a strong urine odor.-He/She had taken the resident to his/her room to assist him/her with cleaning and changing the resident after he/she had been incontinent. During an interview on 8/4/26 at 4:12 P.M. Licensed Practical Nurse (LPN) A said:-He/She recalled Resident #2 urinating on the floor almost daily.-He/She oriented the resident to the shower rooms across the hall due to the resident's aggression when entering the resident's room.-The resident's room smelled of urine and the floors had urine on them. During an interview on 8/4/26 at 4:26 P.M. CNA B said:-Resident #2 had been urinating and defecating on the floor for the last couple of months that he/she has been working in the facility.-The staff could not clean the resident due to the resident being aggressive and combative.-The cabinets were in disrepair because the resident ripped them apart and it was common for him/her to use them as a toilet.-The flooring had been peeling up for over two months and had gotten worse over the last month because the resident would not stop urinating on the floor.-The resident's room smelled of urine normally due to the resident urinating on the floor all of the time. During an interview on 8/4/26 at 5:53 P.M. the Administrator said:-Resident #2 has been urinating on his/her floor for some time, maybe three months.-They were getting ready to work on the floor.-The Regional Director of Operations was going to send someone to assess the resident's room and rectify the damage.-There was no official plan in place at that time. 3068752, 3104615 , 3106863

Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Protection (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for three out of three residents (Residents #5, #6, and #7) sampled for infection control with wounds. The facility census was 72 residents.Review of the facility policy enhanced Barrier Precautions dated 2025 showed:-The EBP approach recommended gown and glove use for certain residents during specific high-contact resident care activities.-EBP are indicated for residents with any of the following:--Certain infections.--Wounds and/or indwelling medical devices.--Wounds generally included chronic wounds such as pressure ulcers (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence, resulting from prolonged pressure alone or in combination with shear/friction), diabetic foot ulcers (an open sore or wound, typically located on the bottom of the foot, that occurs in individuals with diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin)), venous stasis ulcers (wounds on your skin that develop because of problems with blood circulation).--Indwelling medical devices such as central lines (flexible tube that is inserted into a vein use them to give medicine, fluids, blood, or nutrition), urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag), feeding tubes (a flexible medical device inserted into the gastrointestinal tract to deliver liquid nutrition, fluids, and medication directly to the stomach or small intestine), and tracheostomies (surgically created hole, in the windpipe that allows air to pass into the windpipe to help with breathing when the usual way of breathing is blocked or reduced).-For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities:--dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, and wound care (any skin opening requiring a dressing) Review of the Centers for Disease Control and Prevention website on 1/28/26 showed:-Facility staff should use Enhanced Barrier Precautions for residents with residents with certain conditions.-Everyone entering the room of these residents must clean their hands before entering and when leaving the resident's room.-Providers and staff must wear gloves and a gown for the following high-contact resident care activities for the residents that require EBP:--Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting.--Device care of use of central lines, urinary catheters, feeding tubes, and tracheostomies.--Wound care for any skin opening requiring a dressing. 1. Review of Resident #5's admission record printed 1/30/26 showed the resident:-admitted to the facility on [DATE].-Had diabetes, a skin infection, and non-pressure chronic ulcer of his/her left foot. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/25 showed the resident was cognitively intact and had a diabetic foot ulcer and a wound infection. Review of the resident's care plan dated 1/9/26 showed:-The resident had skin impairment related to diabetes.-The resident had a chronic wound. Review of the resident's Treatment Administration Record (TAR) dated January 2026 showed a wound treatment order dated 10/30/25 to clean the wound to the resident's left, great toe, pat dry, apply Iodoflex (a sterile, antimicrobial, non-adhesive pad dressing used for chronic, exuding, and infected wounds. It removes debris and exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) while releasing iodine to kill bacteria) to wound, apply dressing one time a day every other day on even days. Review of the resident's wound care provider note dated 1/27/26 showed:-The resident had diabetes.-The resident had a chronic left great toe wound.-The resident had been treated with Intravenous (IV)antibiotics in the past for chronic osteomyelitis (an infection in the bone).-The resident saw a surgeon who recommended amputation of the resident's left great toe but the resident declined.-The diabetic wound on the resident's left great toe was acquired 7/1/20.-The measurements were 0.5 centimeters (cm) length x 0.3 cm width x 0.1 cm deep.-The wound was described as a grade one (a superficial wound, meaning the skin is broken, but the ulcer is shallow) diabetic ulcer, small amount of serosanguineous exudate (containing blood and watery drainage) that was red and brown in color, has slough (necrotic/avascular tissue in the process of separating from the viable portions of the body), has a large amount of granulation (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) that was pale pink, and had a small amount of necrotic (dead) tissue that is adherent slough. Observation and interview during wound care with the Director of Nursing (DON) on 1/28/26 at 11:23 A.M. showed:-There were no EHB signs or Personal Protective Equipment (PPE-equipment such as gloves, gowns, masks, respirators, and face shields, that serve as a barrier against infectious materials, protecting both workers and patients) outside the resident's room.-The DON provided wound care on the resident's great toe on his/her left foot.-The DON used gloves and completed hand hygiene during the wound care.-The DON did not wear a gown during wound care.-The DON said they had not talked about EBP at the facility.-The DON said they had not used EBP at the facility. 2. Review of Resident #6's admission Record printed 1/28/26 showed the resident:-admitted to the facility on [DATE].-Had a diagnosis of diabetes. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:-Moderately cognitively impaired.-Diagnosis of diabetes.-Treatments included the application of nonsurgical dressings other than to feet.-Treatments included the application of ointments/medications other than to feet. Review of the resident's care plan dated 1/9/26 showed:-The resident had a diagnosis of diabetes.-The resident had an infection of his/her left, great toe. Review of the resident's TAR dated January 2026 showed:-A physician's order dated 12/24/25-1/22/26 to clean the resident's left, lower extremity wound with wound cleanser, apply calcium alginate (a highly absorbent dressing), cover with foam dressing (highly absorbent wound cover designed to manage moderate-to-heavy exudate while maintaining a moist, protected healing environment) one time a day.-A physician's order dated 1/23/26 to cleanse the resident's left lower extremity wound with wound cleanser, apply calcium alginate cut to size of wound bed, and cover with foam dressing daily until resolved. Review of the resident's skin observation tool dated 1/19/26 showed the resident had abrasions to his/her right and left knee that were both 1.0 cm in length and 1.0. cm in width and 0.0 cm in depth. Review of the resident's skin observation tool dated 1/26/26 showed the resident had a vascular wound to his/her left lower leg that measured 0.5 cm in length and 0.5 cm in width and 0.0 cm in depth. Observation and interview on 1/28/26 at 11:33 A.M. showed:-There were no EHB signs or PPE outside the resident's room.-The resident had dressings on his/her left and right shin.-The DON said they had not talked about EBP at the facility.-The DON said they had not used EBP at the facility. 3. Review of Resident #7's admission Record printed on 1/28/26 showed:-The resident admitted to the facility on [DATE].-The resident had an open wound on his/her left foot and osteomyelitis. Review of the resident's care plan dated 9/4/25 showed:-The resident was at risk for infection related to a wound on his/her foot.-The resident had actual impairment to skin integrity related to a chronic foot wound. Review of the resident's significant change MDS dated [DATE] showed the following staff assessment of the resident:-Cognitively intact.-Had an open lesion(s) on his/her foot.-Had the application of dressings to his/her feet. Review of the resident's TAR dated January 2026 showed:-A physician's order to clean his/her left plantar (a thick, fibrous band of tissue running along the bottom of the foot, connecting the heel bone to the toes) area with wound cleanser, apply A&D ointment to dry areas, apply foam dressing and kerlex (woven gauze that is non-adhesive used to wrap wounds) daily.-A physician's order dated 9/19/24 to cleanse the right foot plantar with wound cleanser, apply foam dressing and kerlex one time a day.-A physician's order dated 10/17/25 to cut Calcium Alginate (a highly absorbent dressing) to wound bed size and apply to wound on right foot daily for open area. Review of the resident's skin observation tool dated 1/24/26 showed the resident had:-A callous on the bottom of his/her left foot that measured 1.0 cm length x 1.0 cm with x 0.0 depth.-A chronic wound on the bottom of his/her right foot that measured 5.0 cm length x 4.0 cm width and 1.0 cm depth. Observation and interview on 1/28/26 at 11:40 AM showed:-There were no EHB signs or PPE outside the resident's room.-The DON said:--The resident had wounds on the bottom of both his/her feet.--They had not talked about EBP at the facility.--They have not used EBP at the facility.-The resident had socks on his/her feet and didn't want to take them off. 4. During an interview on 1/28/26 at 10:10 A.M., Certified Medication Technician A said: -He/She hardly ever saw any of the nurses use gloves when doing wound treatments.-He/She saw nurses doing wound treatments without a gown on.-He/She didn't even know where the gowns were. During an interview on 1/28/26 at 11:23 A.M., the DON said:-They had not talked about EBP at the facility.-They have not used EBP at the facility for any residents. During an interview on 1/28/26 at 12:10 P.M., the Administrator said they had not been doing EBP and he/she did not think they had an EBP policy. During an interview on 1/28/26 at 12:22 P.M., the Infection Preventionist said he/she had never heard of EBP prior to today. During an interview on 1/28/26 at 12:35 P.M., Licensed Practical Nurse (LPN) A said:-The facility administration had not told them to use EBP.-He/She had only been wearing gloves during wound treatments.-He/She had not worn gowns when doing wound treatments. 2692293

Based on interview and record review, the facility failed to provide sufficient proof of the Registered Nurse (RN) eight consecutive hours a day coverage during the Fiscal Year (FY) Quarter Four 2024 Payroll Based Journal (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for all the dates triggered within the quarter equaling nine total days; during FY Quarter One 2025 PBJ for all the dates triggered within the quarter equaling two total days; during FY Quarter Two 2025 PBJ for all the dates triggered within the quarter equaling 18 total days; and during FY Quarter Three 2025 PBJ for all the dates triggered within the quarter equaling 45 total days. This deficient practice had the potential to affect all residents within the facility. The facility census was 75 residents.Review of the facility's undated policy titled Policy for Staffing showed:-Followed the Missouri regulatory requirements at the minimal operation.-RN at least eight hours a day.-Used the services of a RN for at least eight hours a day, seven days a week.1. Review of the facility's PBJ FY Quarter Four 2024 PBJ data report showed the facility had no RN coverage for the following dates:-7/7/24.-7/21/24.-8/3/24.-8/11/24.-8/17/24.-8/31/24.-9/14/24.-9/15/24.-9/28/24.--Requested documentation of RN Coverage for the listed dates and the facility was unable to produce documentation of RN coverage for eight hours per day. 2. Review of the PBJ FY Quarter One 2025 PBJ data report showed the facility had no RN coverage for the following dates:-10/5/24.-7/21/24.--Requested documentation of RN Coverage for the listed dates and the facility was unable to produce documentation of RN coverage for eight hours per day. 3. Review of the PBJ FY Quarter Two 2025 PBJ data report showed the facility had no RN coverage for the following dates:-1/14/25.-1/21/25.-1/31/25.-2/5/25.-2/6/25.-2/7/25.-2/11/25.-2/12/25.-2/13/25.-2/17/25.-2/25/25.-2/26/25.-3/5/25.-3/6/25.-3/11/25.-3/12/25.-3/19/25.-3/25/25.--Requested documentation of RN Coverage for the listed dates and the facility was unable to produce documentation of RN coverage for eight hours per day. 4. Review of the PBJ FY Quarter Three 2025 PBJ data report showed the facility had no RN coverage for the following dates:-4/3/25.-4/8/25.-4/9/25.-4/16/25.-4/22/25.-4/23/25.-4/25/25.-4/30/25.-5/1/25.-5/2/25.-5/6/25.-5/7/25.-5/10/25.-5/11/25.-5/12/25.-5/14/25.-5/15/25.-5/20/25.-5/21/25.-5/23/25.-5/24/25.-5/25/25.-5/26/25.-5/27/25.-5/28/25.-5/29/25.-5/30/25.-6/3/25.-6/4/25.-6/6/25.-6/7/25.-6/8/25.-6/9/25.-6/10/25.-6/11/25.-6/12/25.-6/15/25.-6/17/25.-6/18/25.-6/20/25.-6/21/25.-6/22/25.-6/23/25.-6/27/25.-6/30/25.--Requested documentation of RN Coverage for the listed dates and the facility was unable to produce documentation of RN coverage for eight hours per day. 5. During an interview on 10/14/2025 at 9:50 A.M., the Administrator said:-He/She oversaw staffing at this time, since the Director of Nursing just started about two months ago. -He/She knew that the facility had not met the eight-hour RN requirement. -The facility had been trying to hire RN's.-The facility had just hired a DON two months ago. -It was the policy of management not to use agency staff. -He/She was trying to staff the facility as best as could be, but it was very difficult to hire RN's due to the lack of RN's in the area. -He/She had recently gotten fully staffed for RN's to ensure that there was a RN for eight hours per day seven days a week. During an interview on 10/14/25 at 10:56 A.M. the DON said:-He/She was not doing staffing at this time. -He/She knew that the facility had just gotten fully staffed with RN's.-He/She did not know that the facility was not meeting the RN requirement prior to being hired.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility failed to ensure appropriate hand hygiene was performed during medication administration for one sampled resident (Resident #69) and two supplemental residents (Resident #25 and Resident #68); the facility failed to ensure appropriate hand hygiene was performed during wound care for one sampled resident (Resident #2) out of 18 sampled residents and two supplemental residents; and the facility failed to ensure Tuberculosis (TB a chronic bacterial infection caused by Mycobacterium tuberculosis bacteria) testing was completed following facility policy, Center for Disease Control (CDC) guidelines, and State regulation for eight sampled employees (Employee A, B, D, E, G, H, J, and K) of 10 sampled employees. The facility census was 75 residents with a licensed capacity for 87 residents at the time of the survey 1. Review of the facility's Legionella program paperwork towards the back of a binder entitled Disaster Manual, last reviewed 8/23/24 and provided by the Administrator, showed the following:-There was no 31-page (pg.) Centers for Disease Control (CDC) toolkit including a completed brief 8 question assessment on page 2, with the rest consisting of educational guidelines for creating a water management program with control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.-There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188.-There was a hand-drawn diagram of the facility's water system with no accompanying written explanation of the water flow throughout the facility that identified and indicated specific potential risk areas of growth within the building with assessments of each individual area's potential risk level.-No testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility was present.-There were no facility-specific interventions or action plans for when control limits are not met.-There was no documentation included of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned. Observation on 10/7/25 at 12:47 P.M. during the initial facility Life Safety Code (LSC) kitchen inspection with the Dietary Manager (DM) showed there was a three-sink area, a chemical dish-washing machine, a hand-washing sink, and a steam table (also referred to as a hot food table, is specifically designed to hold food at steady, safe serving temperatures, and not designed to cook or warm foods from a raw state). Observation on 10/8/25 between 10:03 A.M. and 1:33 P.M. during the initial facility LSC walk-through inspection showed the following:-The water main supply entered in the basement and first spread out through their kitchen, ice machine, hot water heater, laundry rooms, bathrooms, boiler room, and Janitor's Closet with a mop hopper (mop hoppers/service sinks are used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water). -On the first floor there were gender specific public restrooms located on the west wall along with a Beauty Shop with a sink.-The second floor contained at least 17 resident rooms with private or shared bathrooms and sinks, two Shower Rooms, a Janitor's Closet with a mop hopper, and a Medication Room with a sink.-The third floor contained at least 17 resident rooms with private or shared bathrooms and sinks, two Shower Rooms, a Janitor's Closet with a mop hopper, and a Medication Room with a sink.-The building was equipped with a complete fire sprinkler system with sprinkler heads located throughout the facility. During an interview on 10/10/25 at 9:51 A.M. the Maintenance Supervisor (MS) said the following:-His/Her responsibilities with the Legionella program included doing the pathogen testing throughout the building.-He/She was trained on the requirements by his/her predecessor. During an interview on 10/10/25 at 10:55 A.M. the Administrator said the following:-The Maintenance Supervisor oversaw the Legionella program.-They learned about the CMS and CDC requirements from corporate staff and other maintenance people. 2. Review of the facility's undated policy titled Medication Management and Monitoring showed staff were to wash hands before and after each administration of medication. Review of Resident #68's admission Record showed he/she admitted to the facility with a diagnosis of Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Observation on 10/9/25 at 9:25 A.M. of the resident's medication administration pass completed by Licensed Practical Nurse (LPN) A showed:-LPN A did not wash or sanitize his/her hands prior to the start of the medication pass.-While popping out the pills into the medication cup, LPN A dropped a pill on the floor.-LPN A picked up the pill from the floor, threw the pill away, and continued popping out pills into a medication cup without washing or sanitizing his/her hands after touching the floor.-LPN A finished putting the pills into the cup, mixed the pills in pudding, and assisted the resident in taking the medication.-LPN A returned to the medication cart without washing or sanitizing his/her hands. 3. Review of Resident #69's admission Record showed he/she admitted to the facility with the following diagnoses:-DM II.-Epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures, which are caused by abnormal, excessive electrical activity in the brain), Intractable (resistant to conventional anti-epileptic drug treatment), With Status Epilepticus (a prolonged or recurrent seizure that lasts for more than five minutes or consists of multiple seizures without regaining consciousness between them). Observation on 10/9/25 at 9:40 A.M. of the resident's medication administration pass completed by LPN A showed:-LPN A did not wash or sanitize his/her hands prior to the start of the medication pass.-LPN A popped the resident's pills into a medication cup, then placed them in a bag to be crushed, crushed the medications, returned the medications to the medication cup, mixed the medications in pudding, and assisted the resident in taking the medications.-LPN A returned to the medication cart without washing or sanitizing his/her hands. 4. Review of Resident #25's admission Record showed he/she admitted to the facility with the following diagnoses:-Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).-Moderate Intellectual Disabilities. Observation on 10/9/25 at 9:46 A.M. of the resident's medication administration pass completed by LPN A showed:-LPN A did not wash or sanitize his/her hands prior to the start of the medication pass.-LPN A popped the resident's medications into a medication cup.-LPN A gave the resident his/her medications and returned to the medication cart without washing or sanitizing his/her hands. During an interview on 10/9/25 at 9:50 A.M. LPN A said he/she would not have done anything differently during the medication pass. 5. During an interview on 10/14/25 at 9:48 A.M. LPN A said:-Hand hygiene should be completed before and after each resident during medication administration.-He/She could not remember if he/she had done appropriate hand hygiene during Resident #68's, Resident #69's, and Resident #25's medication administration.-He/She had been told by some staff person that he/she could not have hand sanitizer on his/her medication cart, which made it hard to remember to perform hand hygiene appropriately.-He/She should have sanitized his/her hands after picking up the dropped pill from the floor and continuing Resident #68's medication pass.-He/She should have sanitized his/her hands before and after each medication pass. During an interview on 10/14/25 at 10:07 A.M. LPN B said:-Hand hygiene should be completed before and after each resident during medication administration.-Hand hygiene should be performed after picking anything up from the floor.-LPN A had not performed appropriate hand hygiene during Resident #68's, Resident #69's, and Resident #25's medication administration.-LPN A should have sanitized his/her hands before and after each resident and after he/she had picked up the dropped pill.-Hand sanitizer was not allowed to be kept on the medication carts.-When staff were not allowed to keep hand sanitizer on the medication carts it made it difficult for staff to remember to perform appropriate hand hygiene. During an interview on 10/14/25 at 12:02 P.M. the Director of Nursing (DON) said:-Hand hygiene should be performed before and after each resident during medication administration.-LPN A had not performed hand hygiene appropriately during Resident #68's, Resident #69's, and Resident #25's medication administration.-LPN A should have washed his/her hands after picking up the pill from the ground and before resuming Resident #68's medication administration.-He/She had not told staff that they could not keep hand sanitizer on the medication carts.-Staff were to keep hand sanitizer in the medication carts in order to perform appropriate hand hygiene during medication administration. 6. Review of the facility's Policy for Handwashing, undated, showed:-All staff must apply proper hand washing before, after, and between care deliveries with the following procedure:--Turn on water.--Wet hands.--Dispense five milliliter (ml) of soap (about the size of a silver dollar) into the palm of one hand.--Rub hands together vigorously for at least 30 seconds. Pay particular attention to nails. Use a nail brush if desired.--Rinse thoroughly under running water, rubbing hands together vigorously.--Dry with a clean paper towel.--Turn off the water using the paper towel as a barrier between the handle and your clean hand.--Dispose of paper towel in the trash can.-Hand hygiene is the primary means of preventing the transmission of infection. Situations that require hand hygiene include:--Before and after assisting a resident with personal cares.--Before and after changing a dressing.--Upon and after coming into contact with a resident's intact skin.--After handling soiled or used linens, dressings, bedpans, catheters, and urinals-Alcohol-based hand rubs can be used when hands are not visibly soiled for routine decontamination of hands. Review of Resident #2's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified wound, left foot, and osteomyelitis (infection of the bone tissue, often leading to inflammation, pain, and damage to the bone). Review of the resident's Wound care plan, initiated 10/13/19, showed:-The resident was at risk for infection related to foot wound(s).-The resident would receive daily dressing changes as ordered.-Nurses would report signs and symptoms of infection such as elevated temperature, loss of appetite, flushed or pale appearance, nausea, vomiting, or foul odor from wounds. Review of the resident's Physician's Orders dated July, 2025 showed:-Clean the right foot plantar (bottom/sole of foot) area with wound cleanser. Apply foam dressing and Kerlex (gauze bandaging with a crinkle weave) daily starting on 9/19/24.-Clean the left foot plantar area with wound cleanser. Apply A & D ointment (a topical skin protectant used to soothe minor skin irritations, and protect chafed or chapped skin. It is available over-the-counter and is characterized by its thick, emollient, and moisture-sealing properties. to dry areas) Apply foam dressing and Kerlex daily for foot dryness starting 10/10/24. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 9/12/25 showed the resident:-Was cognitively intact.-Had a venous or arterial ulcer (a sore that develops, typically on the feet or lower legs, due to poor blood flow in the veins and/or arteries).-Had other open lesions (damaged tissue) on the foot.-Received dressings to the feet. During an interview on 10/8/25 at 12:00 P.M. the resident said:-He/She had been diagnosed with osteomyelitis several years ago and had very poor circulation which caused him/her to have lots of wounds off and on to both feet.-He/She had infected wounds on his/her feet over the past several years but currently was not taking any antibiotic for his/her wounds. Observation on 10/9/25 at 3:03 P.M of the resident's wound care. showed:-Items to be used during wound care were sitting on a table next to LPN B who was sitting at the foot of the resident's bed.-Prior to starting the wound care LPN B applied hand sanitizer to his/her hands and put on exam gloves.-He/She took socks off the resident's left and right feet and threw them onto the floor.-LPN B picked up scissors and cut the Kerlex wrap off the resident's left foot and then touched the resident's left foot with both gloved hands.-With the same gloved hands and without sanitizing the scissors LPN B cut and then removed the Kerlex from the resident's right foot. -Observation of the right foot showed black eschar (a layer of dead, crusty tissue that forms over a wound) approximately 1/3 inch thick. There was puffiness and a reddish pink coloring to the inside of the resident's right ankle and foot with two open areas approximately 1/4 inch in size on the swollen portion of the foot and ankle. There was an open area approximately ¾ inch in diameter in the mid-section of the arch on the right foot.-LPN B said the foot looked about like it did the last time he/she saw it over two months ago, but he/she hadn't seen the open area on the resident's arch and didn't know when that started because he/she normally didn't do the resident's wound care.-LPN B removed and discarded the exam gloves, used hand sanitizer and put on clean exam gloves.-LPN B applied wound cleanser to a pad and cleaned the eschar on the resident's right foot. -LPN B took off his/her gloves, used hand sanitizer, and put on a new pair of exam gloves before placing a padded foam dressing over the eschar.-LPN B discarded his/her gloves, used hand sanitizer and put on clean gloves before opening a package of calcium alginate (a highly absorbent fiber derived from seaweed, primarily used for moderate to heavily oozing wounds). He/She cut a piece of calcium alginate to fit the mid-arch wound without sanitizing the scissors. He/She placed the dressing into the open wound on the mid-arch section of the right foot.-Without sanitizing his/her hands LPN B used Kerlex to wrap the bandaging in place on the right foot. -LPN B took off and discarded his/her gloves and used tape to secure the Kerlex and then put on gloves without first using sanitizer and opened the second padded foam bandage which he/she placed on the left foot and then wrapped the left foot with Kerlex.-LPN B took off and discarded his/her gloves and used tape to secure the Kerlex on the left foot.-LPN B applied hand sanitizer, sanitized the scissors and placed socks on each of the resident's feet.-LPN B said the resident's room sink didn't work and normally he/she would wash his/her hands before starting wound care and before leaving the room.-The resident said the sink had been dripping over the past several months. Maintenance had fixed it a couple of times, but it was dripping so he/she turned it off with the valve below the sink. The water couldn't be turned on at the faucets because it was turned off under the sink.-LPN B did not sanitize his/her hands after putting on the resident's socks or wash his/her hands before leaving the room. During an interview on 10/9/25 at 3:20 P.M. LPN B said:-Nurses were supposed to wash their hands before starting and after finishing wound care, but the water was turned off to the resident's faucet so he/she used hand sanitizer and put on gloves before doing wound care for Resident #2.-Nurses were supposed to sanitize their hands before and after cleaning and dressing wounds and to sanitize equipment before and after using it.-Nurses should sanitize their hands after touching skin and after any dirty step in the wound care process. During an interview on 10/10/25 at 1:04 P.M. LPN A said:-Nurses were supposed to wash their hands before and after doing wound care, but the resident's sink had not worked for the three weeks he/she had been employed there, so he/she used hand sanitizer before starting and after finishing the resident's wound care.-Nurses should sanitize their hands before and after cleaning, treating, and dressing wounds and after each dirty step in the wound care process or after touching anything that could be dirty. During an interview on 10/14/25 at 10:18 A.M. the DON said:-He/She expected nurses to wash their hands before and after wound care.-Nurses should always use hand sanitizer after each dirty task in the wound care process and before cleaning, treating, and dressing wounds. During an interview on 10/14/25 at 12:20 P.M. the MDS Coordinator, also the Infection Control Nurse, said:-Nurses should wash their hands before and after completing wound care.-Nurses should sanitize their hands after touching anything that could potentially be dirty and after every dirty task in the wound care process. During an interview on 10/14/25 at 1:00 P.M. the Maintenance Supervisor said:-Resident #2 kept turning the faucets off in his/her room with too much force. That had caused the valve stems to go bad more than once in the past several months. -He/She always tried to keep multiple valve stems on hand at the facility, and had recently ordered several, but it was taking longer for the parts to arrive from overseas.-The resident's sink could be turned on and off by the valve below the sink. 7. Review of the facility's Policy for TB-Employee Version, undated, showed:-To ensure early detection of tuberculosis for potential employees, all potential employees shall be asked to participate in TB testing or a chest X-ray for possible infection.-If a potential employee has no documentation of a prior two-step Mantoux Tuberculin Skin Test (TST), administer the first step at least two to three days prior to employment. -The previous two-step TB test is acceptable if performed no longer than six months from the hire date.-Read results of the first tuberculin injection within 48 to 72 hours of injection. Results must be read and documented in millimeters (mm) prior to or on the employee start date.-If results are negative, administer second step within one to three weeks of the first TST administration and read results within 48 to 72 hours.-A chest X-ray should be provided for employees whose skin test reactions indicate positive results. Treatment for TB infection should be provided according to results. Review of the Centers for Disease Control (CDC) website on 10/10/25 showed:-A person who does not return within 72 hours after administration of tuberculin will need to be rescheduled for another skin test.-Induration (hard, raised swelling at injection site) of five or more millimeters (mm) is considered positive for individuals with compromised autoimmune systems or those on immunosuppressive therapy; those with recent contact with an infectious TB case; or those with fibrotic changes on a chest X-ray consistent with past TB.-Induration of 10 mm or more is positive for people coming from countries where TB is common; those who misuse drugs; workers, including health care workers, and residents in high risk congregate settings; and individuals with clinical conditions like diabetes, kidney failure and certain cancers. Review of employee files who were hired within the past year and still currently employed as of 10/9/25, showed: -Review of Employee A's file showed he/she:--Was hired as a Nurse Assistant (NA) on 4/16/25.--Received his/her first Mantoux TST injection on 4/14/25. It was read with negative results on 4/16/25.--Received the second Mantoux TST more than 21 days later, on 5/28/25. There was no date documented for results.-Review of Employee B's file showed he/she:--Was hired as a NA on 1/30/25.--Received his/her first TST months later, on 5/10/25. It was read with negative results on 5/12/25.--Received the second TST more than 21 days later, on 7/2/25. It was read on 7/5/25 with negative results.-Review of Employee D's file showed he/she:--Was hired as a Certified Medication Technician (CMT) on 5/19/25.--Received his/her first TST on 5/16/25. It was read with negative results on 5/19/25.--Received the second TST more than 21 days later, on 6/19/25. It was read more than 72 hours later, on 6/25/25.-Review of Employee E's file showed he/she:--Was hired as a Certified Nursing Assistant (CNA) on 9/18/25.--Received his/her first TST on 9/17/25. It was read with negative results on 9/19/25.--Received the second TST on 10/1/25. There was no documentation of results.-Review of Employee G's file showed he/she:--Was hired as a Registered Nurse (RN) on 2/17/25.--Received his/her first TST on 2/19/25. It was read with negative results on 2/21/25.--Received the second TST on 3/7/25. There was no documentation of second step results.-Review of Employee H's file showed he/she:--Was hired as a Dishwasher on 9/23/25.--Received his/her first TST on 9/19/25. It was read with negative results on 9/22/25.--Received the second TST on 10/1/25. There was no documentation of second step results.-Review of Employee J's file showed he/she:--Was hired as a Transportation Driver on 7/7/25.--Received his/her first TST on 7/7/25. It was read with negative results less than 24 hours later, on 7/8/25.--Received the second TST on 7/21/25. It was read more than 72 hours later, on 7/30/25.-Review of Employee K's file showed he/she:--Was hired as a Housekeeper on 6/12/25.--Received his/her first TST on 6/12/25. There was no documentation of first step results.--Received the second TST on 6/25/25. It was read on 6/27/25 with negative results. 8. During an interview on 10/9/25 at 11:50 A.M. the Business Office Manager said:-He/She was responsible for new employee background screenings and the DON and LPN D were responsible for TB testing for newly hired and current staff.-TB documentation was kept in the nursing office until the employee no longer worked at the facility and then their TB information was given to him/her to be placed in the employee's file. During an interview on 10/14/25 at 10:18 A.M. the DON said:-LPN D was responsible for keeping track of when staff were due for their two-step and annual TB tests.-Either he/she or LPN D administered the first step Mantoux TST on the employee's first day of orientation. -New employees were told when the first step needed to be read, when the second step would be done, and that they couldn't work on the floor until results of the first TST step had been read.-Results should be recorded on the Employee TST form kept on LPN D's desk.-Either he/she or LPN D usually administered the second step TST when due. The employees were told any nurse could read it and it needed to be read in two to three days. -The nurse who read it should record the second step results on the Employee TST form.-He/She tried to read the TB results Monday through Friday and other nurses read the results on evenings, and weekends.-Nurses have been told where to go to record results of the TST tests.-He/She tried to have the second step done one week after the first step if possible-He/She was new to the facility within the past few months and noticed the TB results were either read too late or weren't read at all and needed to be started all over again.- He/She, as the DON, was responsible for auditing and ensuring TB tests were completed according to facility policy.

Based on interview and record review, the facility failed to have parameters listed in the medication orders for Acetaminophen (a widely used over-the-counter medication that relieves pain and reduces fever) containing medications for three sampled residents (Resident #1, #6, and #78) of out of 18 sampled residents. The facility census was 75 residents. Review of policy entitled Medication Management and Monitoring dated 2019 showed that it was the responsibility of nursing professionals was to be aware of action, correct dosage and route, frequency, and other considerations as required for the administration of medications.1. Review of Resident #78's admission Record showed the resident was admitted to the facility on [DATE].Review of Medication Review Report dated 2/29/24 showed the following order:-Acetaminophen 325 milligram (mg) give two tablets by mouth every four hours as needed for pain or increased body temperature. -The order failed to have the parameters of not to exceed three grams of Acetaminophen in 24 hours from all sources. 2. Review of Resident #6's admission Record showed the resident was admitted to the facility on [DATE]. Review of Medication Review Report dated 3/4/25 showed the following orders:-Acetaminophen Extra Strength 500 mg tablet give two tablets by mouth every six hours as needed for pain. -The order failed to have the parameters of not to exceed three grams of Acetaminophen in 24 hours from all sources. 3. Review of Resident #1's admission Record showed the resident was admitted to the facility on [DATE]. Review of Medication Review Report dated 2/29/24 showed the following orders:- Acetaminophen 325 mg give two tablets by mouth every six hours as needed for pain.-The order failed to have the parameters of not to exceed three grams of Acetaminophen in 24 hours from all sources. 4. During an interview on 10/14/2025 at 9:22 A.M., Licensed Practical Nurse (LPN) B said: -Acetaminophen should have had parameters of not to exceed 3 grams (g) in 24 hours from all sources.-If the order did not have the parameters, he/she would have called the doctor and gotten the parameters.-He/She was unsure who audited the orders to ensure medications that needed parameters had them. -All orders with Acetaminophen should have had parameters. -The parameters were needed to be on the order because too much Acetaminophen could be toxic. During an interview on 10/14/2025 at 9:26 A.M., LPN A said: -Acetaminophen should have had parameters of no to exceed 3 g in 24 hours from all sources.-If the order did not have the parameters, he/she would have called the doctor and gotten the parameters.-He/She was unsure who audited the orders to ensure medications that needed parameters had them. -All orders with Acetaminophen should have had parameters. During an interview on 10/14/25 at 11:25 A.M., the Director of Nursing (DON) said:-It was his/her expectation that all orders that contained Acetaminophen would have the parameter of not to exceed 3 g of Acetaminophen in 24 hours from all sources. -It was his/her expectation that all nurses would have ensured that this parameter was added to all orders that contained Acetaminophen. -It was his/her expectation that when the parameter was missing on an order the nurse that discovered it would have contacted the doctor and received the order to add the parameter. -It was ultimately his/her responsibility to ensure that all medications that contained Acetaminophen had the parameter on all the orders.-He/She had only been a DON for two months. -He/She though pharmacy audited all the medications.-He/She would audit all medications with Acetaminophen to ensure parameters were in place.

Based on interview and record review the facility failed to ensure 10 Nurse Assistants (NA A, NA B, NA C, NA D, NA E, NA F, NA G, NA H, NA I, and NA J) out of 24 were not Certified Nursing Assistants (CNAs) within four months of hire. The facility census was 75 residents.A policy on NA training was requested but was not received from the facility. 1. Review of an undated hire record sheet showed:-NA A was hired on 2/6/25.-NA B was hired on 4/16/25.-NA C was hired on 3/17/25.-NA D was hired on 3/2/25.-NA E was hired on 6/11/24.-NA F was hired on 1/30/25.-NA G was hired on 2/27/24.-NA H was hired on 3/31/25.-NA I was hired on 1/3/25.-NA J was hired on 4/18/25.During an interview on 10/10/2025 at 2:23 P.M., NA A said:-He/She had started CNA class last week. -He/She was hired in February 2025. -The class was an on-line class and nurses observed him/her and did the checkoffs for the skill being observed.-He/She and three other NA's were in the class (NA F, NA H, and NA J)During an interview on 10/14/2025 at 9:50 A.M., the Administrator said:-He/She oversaw staffing and the NA program.-A NA could only be an NA for four months. -If a NA was not a CNA after four months that person should have been moved to a different department or terminated. -Some were NA's longer than four months due to lack of staff. -He/She should have done audits and tracked the status of the NA's. -He/She was trying to hire more staff to include NA's and CNA's but it was difficult due to the availability of qualified people.During an interview on 10/14/25 at 10:10 A.M., NA H said:-He/She had worked at the facility for nine months. -He/She was a NA, not a CNA. -He/She had been in the CNA class for a couple of weeks. -No one at the facility had ever said why it had taken so long to get in the class to become certified.During an interview on 10/14/25 at 10:35 A.M., the Director of Nursing (DON) said:-He/She was not in charge of the NA program at this time.-He/She had only been the DON for two months.-He/She was unaware of how many NA's had been NA's longer than four months.-He/She did not know that NA's could only be NA's for four months before they had to become certified, moved to another department, or terminated.

Based on observation, interview and record review, the facility failed to ensure consistent and accurate wound assessments by a trained professional and failed to obtain a physician's order prior to treatment of an open wound for one sampled resident (Resident #2) out of 18 sampled residents. The facility census was 75 residents.Review of the facility's Skin Integrity Management policy, dated 2007 showed:-Ulcers and wounds will be assessed accurately to determine the wound or ulcer type.-Non-pressure ulcers will be assessed weekly. All wounds will be documented using the Wound Tracking form.-After assessing a wound proper documentation is necessary to include the resident's name, vital signs, wound location and size, and description of any drainage, odor, necrotic tissue, infection, and any follow-up.-Do not stage (a system used by healthcare providers to classify the depth of tissue damage caused by pressure) a non-pressure ulcer.Review of the Missouri Nurse Practice Act (NPA), updated 8/28/24, showed:-A Licensed Practical Nurse (LPN) can't perform the initial, comprehensive wound assessment.-An LPN can't independently modify care plans or wound care treatments.-Wound care must be done under the supervision of a Registered Nurse (RN) or licensed prescriber.-An LPN can collect data and document information about the wound such as size, appearance, and the presence of any drainage; monitor for change; implement the care plan; and perform wound care according to physician orders.-LPNs require specialized training and certification to perform comprehensive wound care.Review of the National Pressure Ulcer Advisory Panel website on 10/14/25 showed:-The term unstageable was used to describe a type of PU with full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.-The term was not used to describe a wound caused by poor blood circulation. 1.Review of Resident #2's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified wound, left foot and osteomyelitis (infection of the bone tissue, often leading to inflammation, pain, and damage to the bone). Review of the resident's Wound care plan, initiated 10/13/19, showed:-The resident was at risk for infection related to wound(s) on the foot.-The resident would receive daily dressing changes as ordered.-Licensed nurses will document feet wounds with dressing changes, related to appearance, measurements, drainage, and odor and notify the physician as needed.-Nurses will report signs and symptoms of infection such as elevated temperature, loss of appetite, flushed or pale appearance, nausea, vomiting, or foul odor from wound.-Weekly wound assessments will be conducted by a wound clinic or clinical nurse as the resident allows.Review of the resident's July, 2025 physician orders showed:-Clean his/her right foot plantar (bottom/sole of foot) with wound cleanser. Apply foam dressing and Kerlix (gauze bandaging with a crinkle weave) daily starting on 9/19/24.-Clean his/her left foot plantar area with wound cleanser. Apply A & D ointment to dry areas. Apply foam dressing and Kerlix daily for foot dryness starting 10/10/24.Review of the resident's electronic medical record (EMR) showed no initial, comprehensive assessments completed by an RN or a physician for any wounds and no documentation showing the dates when any wounds were initially discovered.Review of the resident's Weekly Wound Tracking form, for 7/2/25 through 7/9/25 showed:-On 7/2/25 the resident:--Had a stasis ulcer (chronic, open wound on the lower leg due to poor blood circulation) on his/her right plantar measuring 3.5 centimeters (cm) by 3.2 cm. The wound was also marked as unstageable and was described as starting to granulate (tissue that fills in when a wound starts to heal). There was no date showing when the wound was first identified. --The resident also had a callus on his/her left plantar foot area measuring 1.0 cm by 1.0 cm, also marked as unstageable. It was described as dry skin and treatment consisted of foam dressing and Kerlix, no date was indicated for when the left foot callus was first identified. -On 7/9/25 the right plantar wound measured 3.2 cm by 3.0 cm with dark granulation. It was treated with foam dressing and Kerlix. A second wound (wound #2), measuring 1.5 cm by 1.5 cm was documented for the right plantar. Edges had granulation. Treatment consisted of Calcium Alginate and foam dressing. The date it was first identified was not indicated. -On 7/9/25 the left plantar measurements, description and treatment had not changed from the previous week.-There was no documentation of wound assessment due on 7/16/25.Review of the resident's nursing notes for 7/15/25 through 7/17/25 did not show why the resident did not have the wound assessment.Review of the resident's Weekly Wound Tracking for 7/24/25 through 7/30/25 showed:-On 7/24/25:--The resident only had one wound which was reclassified from stasis to callus and continued to be identified as unstageable. There was no documentation for wound #2 or documentation that wound #2 had healed. --On 7/24/25 The left plantar measurements, wound description, and treatment had not changed from the previous week. --On 7/24/25 a second wound was documented on the left foot. There was no documentation when the second left foot wound was first identified. It was classified as a callus and also as unstageable. It measured 1.5 cm by 1.2 cm and was described as being dry skin. Treatment consisted of foam dressing and Kerlix wrap.-On 7/30/25 the right plantar wound increased to 3.0 cm by 3.0 cm by 0.5 cm deep. It was described as dark and the treatment consisted of foam dressing and Kerlix.-On 7/30/25 the left plantar documentation showed the resident had two wounds similar to the previous week's wound type, size, description and treatment.Review of the resident's EMR on 10/10/25 showed there was no further wound tracking documentation after 7/30/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 9/12/25 showed the resident:-Was cognitively intact.-Rejected cares daily.-Had no pressure ulcer or diabetic foot ulcer.-Had a venous or arterial ulcer (a sore that develops, typically on the feet or lower legs, due to poor blood flow in the veins and/or arteries).-Had other open lesions (damaged tissue) on the foot.-Received dressings to the feet.Observation on 10/8/25 at 11:58 A.M. showed:-The resident was in bed with socks covering dressings to both feet. The inside of the resident's right sock appeared stained with an approximate one-half to one inch stain as if the wound could have seeped.-When asked why his/her feet were bandaged the resident replied he/she had been diagnosed with osteomyelitis several years ago and he/she had very poor circulation which caused him/her to have lots of wounds to the feet.Observation during the resident's wound care on 10/9/25 at 3:03 P.M. showed:-Black eschar (a layer of dead, crusty tissue over a wound) approximately 1/3 inch thick on the right foot metatarsalgia pad (padded area just below the toes). The inner right foot was puffy and pinkish red. There were two tiny open areas on the inside of the resident's right foot.-LPN B said the eschar was not something new and the inside of the resident's foot and ankle was always swollen.-The resident had an approximately three-fourths inch open wound to the mid arch area of his/her right foot.-LPN B said the mid-arch open wound was new since he/she last treated the wound a couple of months ago, so he/she didn't know how long it had been there. He/She would use calcium alginate (a highly absorbent fiber derived from seaweed used for medical dressings for wounds with a steady discharge) and will get the physician's order as soon as he/she was done with the treatment.-LPN B opened the calcium alginate packet after cutting it to fit the wound and placed it into the wound and used Kerlix wrap to secure it.During an interview on 10/9/25 at 3:20 P.M. LPN B said:-He/She was texting the doctor now for the calcium alginate order.-The physician just wanted nurses to go ahead and treat any new wounds when they were doing wound treatments and then get the order instead of having to wait to get the order and have to redress the resident's wounds. -He/She had been responsible for doing weekly wound assessments, but hadn't done them since August, 2025 or before. -He/She had been measuring wounds weekly, writing a description of the wounds, and documenting the treatments, but had stopped doing the wound care assessments because he/she was told it put him/her into too much overtime. -RNs at the facility did not do wound care assessments.-He/She did not have any specialized training related to wound care.-The resident has had wounds on his/her feet for several years and he/she thought the resident came into the facility with them. The resident stopped going to the wound care clinic about three or more years ago. -He/She didn't know what the cause of the wounds were.-It was best practice to do weekly wound assessments to make sure staff were tracking the wounds to see if they were getting better or worse, but nobody was assessing the resident's wounds lately because the resident refused to go to the wound care clinic and he/she had been told to not come in on his/her day off to do the assessments.Note: At 3:33 P.M. during the interview LPN B's phone dinged. LPN B said he/she just got the physician approval for the calcium alginate.During an interview on 10/10/2025 at 10:45 A.M. the Director of Nursing (DON) said:-LPN B was doing all the weekly wound care assessments on residents. -The resident refused to go to the wound care clinic and wasn't cooperative with his/her treatment. -He/She told LPN B not to come in anymore on his/her day off to do the wound assessments. He/She didn't mean LPN B shouldn't do them. He/She expected LPN B to have been doing wound assessments on the days he/she worked unless the resident refuses the assessment. -The Weekly Wound Tracking showed wounds were unstageable as well as stasis ulcers. -He/She had only been at the facility a couple of months and wasn't sure what the wounds were.During an interview on 10/10/2025 at 1:04 P.M. LPN A said:-He/She was newer to the facility and noticed an open area on the resident's foot as well as eschar the one time he/she provided the resident's wound treatment. The resident refused most of his/her treatments. -He/She didn't fully assess wounds because he/she was an LPN and it was out of his/her scope of practice to classify them. He/She could measure the wound and describe the tissue condition, but a nurse had to identify the type of wound and document if it was healed. -The resident's foot was nowhere near being healed.The RNs have the credentials to classify wounds and stage pressure ulcers.-He/She didn't know what type of wounds the resident had. The Weekly Wound Tracking form showed the resident had unstageable wounds. He/She didn't know if that was a PU or another type of wound.-He/She thought wound assessments had to be done weekly and nurses were to look at the wound daily during treatments, but the resident refused more than half of them.During an interview on 10/10/2025 at 1:38 P.M. LPN B said:-A year ago the resident had an open area on his/her foot pad.-He/She marked it as unstageable because it wasn't a stage I, 2, 3, or 4. -He/She hadn't received any training on staging PU or classifying wounds. -The previous DON went over the Weekly Wound Assessment form over a year ago. He/She thought he/she was told if it wasn't a PU it was unstageable. -The right foot had a callus on the foot pad with no depth or drainage in Sept, 2024. He/She thought it also was from poor circulation. -The residents' feet frequently had open wounds related to poor circulation.There was now depth to the eschar on the right foot. -The left foot had gotten better since a year ago. The right foot was worse due to the open area and the tiny pinhole spots on the side of his/her foot. -The right foot swelling has been there for many years. -He/She might have called the wounds unstageable since they were just calluses and you can't stage calluses. Weekly skin assessments were completed on the Treatment Administration Record (TAR). The resident usually had his/her feet bandaged up so staff can't see them unless the resident was getting wound care.-Assessing wounds was within the scope of practice of an LPN.During an interview on 10/10/2025 at 2:14 P.M. Nurse Aide (NA) A said he/she had never filled out a shower sheet for the resident because the resident leaves his/her feet bandaged when he/she sponge bathes. During an interview on 10/14/2025 at 10:18 A.M. the DON said:-He/She was unable to find any skin assessments for the resident where it showed skin areas of concern on a body diagram. He/She asked nurses about it and they said they just mark the skin assessments weekly on the TAR for the skin they are able to see as the resident's feet were always bandaged. He/She couldn't find any wound assessments that showed a body diagram and the exact location of wounds on the resident's feet. It would be best to have a diagram to show the location on the foot of all new wounds.-The first of August he/she told LPN B not to come in on his/her day off to do wound assessments and LPN B thought he/she wasn't supposed to assess the resident any longer. -He/She didn't realize LPN B wasn't assessing the resident's wounds. He/She expected LPN B to do the assessment on his/her regular work day. There should not be any gaps in doing the resident's weekly wound assessments.-Since 7/30/25 he/she had conversations with nurses about the resident's feet, but LPN B didn't mention the area that he/she found open when doing wound care on 10/9/25. He/She realized the nurses needed more oversight in regards to wound treatments and assessments.-He/She didn't think it was out of an LPNs scope of practice to do skin assessments. One nurse should do the assessments for consistency and they should be done weekly. Staging is for PUs. LPN B didn't see the wounds as pressure ulcers. They are stasis ulcers. Unstageable means it isn't a PU. It doesn't meet the Stage 1 through 4 criteria used for PUs.-Either he/she or the MDS coordinator should be designated to audit wound assessments to ensure they are being done.

Based on interview and record review, the facility failed to complete thorough and timely fall investigations and failed to update care plans for two sampled residents (Resident #3 and #19) who fell multiple times out of 18 sampled residents. The facility census was 75 residents. Review of the facility's undated policy titled Fall Policy and Procedure showed:-The purpose of the policy was to ensure appropriate medical and multi-disciplinary assessment of falls and fall risk factors; to coordinate management of acute and recurrent falls; and to provide measures to help prevent falls.-The licensed nurse performed an assessment within a time frame appropriate to the clinical circumstance, right after the fall occurred and coordinated other indicated evaluation and management of injuries or underlying causative conditions.-Licensed nurses were responsible for providing adequate documentation of evaluation and management of the fall.-The incident report was for internal management only and should not be considered as part of the resident's medical record.-The safety committee coordinated fall risk assessments and fall managements.Review of the facility's undated policy titled Policy and Procedures for Fall Investigation showed licensed nurses completed the fall investigation form upon each fall on the provided form.Review of the facility's undated policy titled Upon a Fall Incident showed:-Staff were to conduct an immediate investigation of the accident/incident.-The investigation report was to be submitted to the Director of Nursing (DON) no later than 24 hours after the occurrence of the accident/incident.-The Quality Assurance (QA) team completed a summary of investigation for unwitnessed falls that addressed the following:--What happened.--Physical and mental assessments.--Interviewing process that included all potential witnesses.--Reviewing the pattern and history.--Summary for determining the causation and developing the interventions.-Staff were to complete an incident report for witnessed falls that included the following:--The surroundings of the occurrence including medical devices or equipment that may have been involved in the incident.--The causation of the witnessed incident.--Time that the attending physician was notified and response.--Date and time that the resident's family or responsible party was notified.--The condition of the injured resident including the resident response and reaction.--The disposition of the injured resident.--Signature and title of the person completing the report.--The date, time, and place the accident/incident took place.1. Review of Resident #19's admission Record showed he/she admitted to the facility with the following diagnoses:-Parkinsonism (a clinical syndrome characterized by a group of movement disorders that mimic Parkinson's Disease (a progressive neurological disorder that affects movement, balance, and coordination), Unspecified.-Tremor, Unspecified.-Hallucinations, Unspecified.Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 7/7/25 showed:-The resident was cognitively intact.-The resident did not have any falls since admission or the prior assessment.Review of the resident's care plan dated 9/5/25 showed:-The resident had potential for falls related to repeated falls.-The resident had to be reminded to not use the wheelchair as a walker.-The resident had poor balance and was unable to ambulate at times.-The resident had poor safety awareness.-The resident had been having increased hallucinations and medications were changed which caused him/her to be more unsteady on his/her feet.-The interventions that were in place included:--Monitor for medication side effects and keep the physician informed of any problems.--No foot pedals on wheelchair.--Ensure the resident had shoes on the right feet.--The resident was to only ambulate with the restoration aide (RA) due to decline.--The resident was to work with the RA for ambulation and strengthening.-NOTE: The care plan was not updated to show the resident had falls on 9/23/25 and 9/28/25 with new interventions as of 10/13/25.Review of the resident's Incident Audit Report dated 10/9/25 showed:-The report was created on 10/9/25.-The resident had an unwitnessed fall on 9/23/25.-The nurse had been called to the hallway outside of the resident's room.-The Nursing Assistant (NA) saw the resident stand at the foot of his/her bed and then left his/her room and started running down the hall.-The resident tripped over his/her feet and fell to the floor.-The resident had a laceration above his/her left eye.-The resident had been sent to the local hospital.-The resident returned to the facility with five stitches to his/her injury above his/her left eye.-The immediate action taken was the resident was sent to the hospital.-The resident had poor safety awareness and needed to ambulate with assistance due to decline in cognition.-There was no Root Cause Analysis (RCA- a systematic problem-solving method used to identify the fundamental causes of a problem to prevent its recurrence) completed for the fall.Review of the resident's Incident Audit Report dated 10/9/25 showed:-The report was created on 10/9/25.-The resident had an unwitnessed fall on 9/28/25.-Staff had entered the resident's room and found the resident lying on his/her left side on a floor mat.-The resident was resting with his/her eyes closed.-The resident said he/she was unsure of how he/she ended up on the floor.-The immediate action taken was that the resident was assisted to bed.-The contributing factors of the fall included:--Confusion.--Incontinence.--Recent Illness.-There was no RCA completed for the fall.2. Review of Resident #3's admission Record showed he/she was admitted to the facility with a diagnosis of Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of memory control, judgement, and impulses), Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.Review of the resident's care plan dated 7/3/25 showed:-The resident was at high risk for falls related to gait/balance problems.-The resident wore a personal alarm which was worn to alert the resident to try not to stand on his/her own due to poor safety awareness.-The resident preferred to use a wheelchair for locomotion due to a history of numerous falls at a previous facility.-The following interventions were in place:--Answer call light promptly.--Anticipate and meet the resident's needs.--Assist the resident with all transfers.--Decrease obstacles in room.--Eliminate potential hazards.--Ensure night light was working.--Keep corridors clutter free,--Keep corridors/room well lit.--Keep personal items within reach.--Maximize time out of bed to increase tolerance.--Non-skid socks.--Remind the resident to use call light for assistance.--Review medications with physician.-All of the interventions in the resident's care plan were placed in the care plan on 12/26/22.- The care plan was not updated to show the resident had falls on 10/3/25 and 10/4/25 with new interventions as of 10/13/25.Review of the resident's Quarterly MDS dated [DATE] showed:-The resident severely cognitively impaired.-The resident had falls since the prior assessment.-The resident had two falls with injury since the prior assessment.Review of the resident's Incident Audit Report dated 10/9/25 showed:-The report was created on 10/9/25.-The resident had an unwitnessed fall on 10/3/25.-The nurse had been called to the resident's room.-The resident was found lying beside his/her bed on the floor.-The resident had said that he/she was trying to get out of bed when he/she fell.-The immediate action taken was to notify the resident's hospice company.-A predisposing environmental factor was that the resident had a fall alarm.-The predisposing physiological factors of the fall included:--Confusion.--Incontinence.-There was no RCA completed for the fall.Review of the resident's Incident Audit Report dated 10/9/25 showed:-The report was created on 10/9/25.-The resident had an un-witnessed fall on 10/4/25.-The nurse had been called into the resident's room.-The NA found the resident lying on the floor beside his/her bed.-The resident said that he/she was trying to get into bed and fell out of his/her wheelchair.-The resident had a small bruise on the right side of his/her forehead.-No other injuries were noted.-The immediate action taken was to notify the resident's hospice company and initiate neurological checks (a series of questions and tests used to evaluate the health and function of the brain, spinal cord, and nerves).-The predisposing physiological factors of the fall included:--Confusion.--Incontinence.-There was no RCA completed for the fall.3. During an interview on 10/14/25 at 9:43 A.M. Licensed Practical Nurse (LPN) A said:-The nurses were responsible for the initial fall documentation.-He/She was unsure of who was responsible for fall investigations.-He/She was unsure if there was a time frame in which the fall investigations needed to be completed.-He/She guessed that fall investigations needed to be completed within 72 hours of the fall.-He/She was unsure of who was responsible for completing care plans.-Care plans needed to be updated after every fall.-He/She was unsure of the current fall interventions that were in place for Resident #3 and Resident #19.During an interview on 10/14/25 at 10:57 A.M. LPN B said:-Nurses were responsible for completing the fall investigations.-The fall investigations needed to be completed as close to the time as the fall as possible.-The fall investigations for Resident #19 and Resident #3 should have been completed before 10/9/25.-The MDS Coordinator updated the care plans.-He/She was unsure if the MDS Coordinator would know to update a resident's care plan after fall if the fall investigation had not been completed.-He/She was unsure if care plans needed to be updated after each fall.-He/She was unsure if Resident #3's and Resident #19's care plans needed to be updated at that point in time.During an interview on 10/14/25 at 11:35 A.M. the DON said:-He/She had changed the way the staff were to complete fall investigations when he/she started working at the facility.-The nurses had to complete a five-to-six-page form and turn it into him/her after each resident fall.-There was also a form in the Electronic Medical Record (EMR) system that the nurses could fill out as well.-The nurses were responsible for completing the fall investigations.-He/She would be the person responsible for ensuring that all fall investigations were complete and thorough.-He/She had not been on top of that recently.-The MDS Coordinator and charge nurses could update care plans.-Care plans should be updated after every fall.-The MDS Coordinator and himself/herself was responsible for ensuring care plans were updated after each fall.-He/She was unsure if there was a time frame in place for when fall investigations and care plan updates needed to be completed after a resident fall.-He/She would have expected Resident #3's and Resident #19's fall investigations to have been completed prior to 10/9/25.-He/She was unsure why the fall investigations had not been completed.-He/She would have expected Resident #3's and Resident #19's care plans to have been updated by that point in time.During an interview on 10/14/25 at 12:19 P.M. the MDS Coordinator said:-Resident #3's and Resident #19's fall investigations were created and completed on 10/9/25.-He/She had completed Resident #3's and Resident #19's fall investigations.-He/She had been working with the floor nurses related to fall investigations.-Resident #3's and Resident #19's fall investigations should have been completed immediately after the fall.-Resident #3's and Resident #19's fall investigations were completed late.-He/She thought he/she had updated Resident #3's and Resident #19's care plans after they fell.-He/She was unsure if the floor nurses had the ability to update care plans, but he/she would not expect them to update the care plans because it was his/her responsibility to complete them.-Resident #3's and Resident #19's care plans should have been updated by that point in time.-He/She was unsure of what specific interventions were put into place after Resident #19's fall.-The interventions that were put into place after Resident #3's fall included:--Ensuring the resident's fall alarm was working.--Placing fall mats beside the resident's bed.

Based on observation, interview, and record review, the facility failed to ensure appropriate care for one sampled resident (Resident #10) with a Gastrostomy (G-Tube- an opening into the stomach from the abdominal wall, made surgically for the introduction of food) out of 18 sampled residents. The facility census was 75 residents.Review of the facility's undated policy titled Tube Feeding Protocol showed:-The head of bed (HOB) would be elevated at least 30 degrees.-If at any time during the tube feedings the resident's HOB was lower than the 30 degrees, staff were to stop the tube feeding until the HOB was re-elevated to at least 30 degrees.1. Review of Resident #10's admission Record showed the resident admitted to the facility with the following diagnoses:-Cerebral Palsy (a group of conditions that affect movement and posture caused by damage that occurs to the developing brain, most often before birth).-Gastrostomy Status.Review of the resident's care plan dated 7/24/25 showed:-The resident was fully dependent on staff for repositioning and turning in bed.-The resident required tube feeding and his/her HOB needed to be elevated at 45 degrees continuously, as tolerated, due to the resident sliding down in bed.Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 9/12/25 showed:-The resident was severely cognitively impaired.-The resident had a G-Tube.-The resident received 51% or more of his/her proportion of total calories through tube feeding.Review of the resident's Order Summary Report dated October 2025 showed an order for Jevity (a high protein, fiber-fortified liquid formula used to provide complete, balanced nutrition for people who require tube feeding or supplemental nutrition) 1.5 calorie via G-Tube at 30 milliliters (ml)/hour for 22 hours a day.Observation on 10/7/25 at 10:39 A.M. showed:-The resident's tube feeding was currently running.-The resident's HOB was at 30 degrees.-The resident had slid down in bed and was lying at an approximate 20-degree angle.Observation on 10/8/25 at 9:03 A.M. showed:-The resident's tube feeding was currently running.-The resident's HOB was at 30 degrees.-The resident had slid down in bed and was lying at an approximate 20-degree angle.Observation on 10/8/25 at 3:08 P.M. of the resident showed:-The resident was slumped over in the bed towards his/her right side and was sitting at a less than 30-degree angle.-Licensed Practical Nurse (LPN) C had come into the resident's room to give him/her some medication through his/her G-Tube.-LPN C had startled the resident awake and the resident sat back up in bed at a 30-degree angle.During an interview on 10/8/25 at 3:20 P.M. LPN C said:-The resident's HOB needed to be at 30 degrees at all times.-The resident had some ability to move around in bed and the staff would need to monitor the resident frequently due to the resident sliding down in bed.Observation on 10/9/25 at 11:30 A.M. showed the resident's HOB was less than 30 degrees.Observation on 10/10/25 at 9:00 A.M. showed the resident was lying flat in bed.Observation on 10/10/25 at 12:45 P.M. showed the resident was lying flat in bed.During an interview on 10/14/25 at 9:45 A.M. LPN A said:-He/She was unsure of the specific angle that a resident needed to be positioned at when tube feeding was running.-A resident should never lie flat in the bed when tube feeding was running.-When a resident with tube feeding was not positioned correctly it put the resident at risk of aspiration (unintentional inhalation of foreign materials, such as food, liquids, or gas, into the respiratory tract).-If he/she were to walk into a resident's room with tube feeding running and the resident was not positioned correctly, then he/she would reposition the resident and assess the resident for aspiration.During an interview on 10/14/25 at 10:01 A.M. LPN B said:-A resident's HOB needed to be raised to 30 degrees when tube feeding was running.-A resident should never lie flat in bed with tube feeding running.-It was important to keep a resident's HOB elevated when tube feeding was running to decrease the resident's risk of aspiration.-If nursing staff were to walk into a resident's room with tube feeding running and the resident was not positioned correctly, then staff should reposition the resident.During an interview on 10/14/25 at 11:45 A.M. the Director of Nursing (DON) said:-A resident's HOB needed to be elevated to at least a 30-degree angle when tube feeding was running.-If a resident with tube feeding running was not positioned correctly it would put them at an increased risk for aspiration.-He/She would have expected the nursing staff to have checked on the resident more frequently to make sure that the resident was positioned correctly throughout the week.

Based on observation, interview, and record review the facility failed to ensure a medication error rate under five percent (%) for one sampled resident (Resident #69) out of 18 sampled residents. Two medication errors were detected out of 31 observed opportunities resulting in an error rate of 6.45%. This deficient practice had the ability to affect all residents. The facility census was 75 residents.Review of the facility's undated policy titled Crushing Medication Policy showed:-Medications that were not to be crushed may be opened and sprinkled into pudding or applesauce if clinically appropriate.-If medications were not able to be crushed or opened up, staff were to place them whole into a medication cup along with the crushed medication, then mixed together with pudding or applesauce.Review of How to Take Your Depakote (a medication used as a mood stabilizer or anti-convulsant (used to control seizures) which can come in a various oral formulations, including delayed-release tablets, extended-release (ER) tablets, and sprinkle capsules) Product dated in 2025 created by Depakote.com showed:-Depakote products were to be taken exactly as the doctor prescribed.-Depakote tablets or Depakote ER Tablets should be swallowed whole and should not be crushed or chewed.1. Review of Resident #69's admission Record showed he/she admitted to the facility with the following diagnoses:-Epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures, which are caused by abnormal, excessive electrical activity in the brain), Intractable (resistant to conventional anti-epileptic drug (AED) treatment), With Status Epilepticus (a prolonged or recurrent seizure that lasts for more than five minutes or consists of multiple seizures without regaining consciousness between them).-Generalized Idiopathic Epilepsy (GIE- a group of epilepsy syndromes characterized by seizures that affect the entire brain).Review of the resident's Order Summary Report dated October 2025 showed:-An order for Depakote Oral Tablet Delayed Release 125 milligrams (mg), give one tablet by mouth two times a day for seizures, give the 125 mg with 500 mg tablet to equal 625 mg dose.-An order for Depakote Oral Tablet Delayed Release 500 mg, give one tablet by mouth two times a day for seizures, give 500 mg with 125 mg tablet to equal 625 mg dose.Observation on 10/9/25 at 9:40 A.M. of the resident's medication administration pass completed by Licensed Practical Nurse (LPN) A showed:-LPN A grabbed the resident's medication packets.-LPN A popped all of the resident's medications into a medication cup.-LPN A then placed all of the medications into a plastic bag and crushed all of the medications, to include the 125 mg and 500 mg doses of Depakote Delayed Release Tablets.-LPN A then emptied the contents back into the medication cup and mixed the crushed medications in pudding.-LPN A then assisted the resident in taking the medication.During an interview on 10/9/25 at 9:50 A.M. LPN A said he/she would not have done anything differently during the resident's medication administration.During an interview on 10/14/25 at 9:40 A.M. LPN A said:-Depakote tablets could not be crushed.-Depakote tablets could not be crushed because it could affect how the resident would receive the dose.-Not crushing Depakote tablets was a standard of practice and the facility did not need to have an order to not crush the resident's Depakote.-The resident did not get crushed medications.-He/She did not remember crushing the resident's medication on 10/9/25.During an interview on 10/14/25 at 10:04 A.M. LPN B said:-Depakote tablets could not be crushed.-There were different forms of Depakote and for resident's who could not take whole medications, the facility could order sprinkle form.-Not crushing Depakote tablets was a standard of practice and the facility did not need to have an order to not crush the resident's Depakote.-Depakote tablets could not be crushed because it affected how the resident received the dose.-The resident did not normally get crushed medications.-He/She was unsure why LPN A crushed the resident's medications.During an interview on 10/14/25 at 11:55 A.M. the Director of Nursing (DON) said:-Depakote tablets could not be crushed.-Depakote tablets could not be crushed because it could affect how the resident would receive the dose.-The resident's medication order should state that the medication should not be crushed.-He/She was unsure if the resident normally received crushed medication.-LPN A should not have crushed the resident's Depakote tablets.

Based on observation, interview, and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week in the fourth quarter of the fiscal year for July 2023, August 2023, September 2023, in the first quarter of the fiscal year for October 2023, November 2023, December 2023 and in the second quarter of fiscal year for January 2024, February 2024, March 2024. The facility further failed to ensure the Director of Nursing (DON) was not serving as the charge nurse when the facility census was greater than 60 residents. This deficiency had the potential to affect all residents. The facility census was 69 residents. A facility RN staffing policy and procedure was requested and not received prior to exit. Review of the facility's Facility Assessment updated 8/2024 showed: -Purpose to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. -The resident population characteristics include: --Bowel and bladder incontinence; bedfast all or most of the time; chair fast all or most of the time; pressure ulcers (localized injury to the skin and/or underlying tissue over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); hospice ( a comprehensive, holistic program of care and support for terminally ill patients and their families); tube feedings (a medical device used to provide nutrition to patients who cannot obtain nutrition); Injections; dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration on intellectual capacity and function, and impairment of control of memory, judgement and impulse) and psychiatric/mood disorders. 1. Review of the Center for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report from the Community Assessment for Public Health Emergency Response (CASPER) report 1705D for fiscal year quarter four 2023 (July 1st thru September 30th), fiscal year quarter one 2023 (October 1st thru December 1st) and fiscal year quarter two 2024 (January 1st thru March 1st) showed: -Four or more days within the quarters with no RN hours for the following dates: --Seven days in July 2023: 7/1/23- Saturday; 7/2/23- Sunday; 7/8/23- Saturday; 7/15/23- Saturday; 7/16/23- Sunday; 7/18/23- Tuesday; 7/23/23- Sunday; 7/29/23- Saturday. --Five days in August 2023: 8/5/23- Saturday; 8/6/23- Sunday; 8/20/23- Sunday; 8/26/23- Saturday; 8/27/23- Sunday. --Seven days in October 2023: 10/4/23- Saturday; 10/8/23- Sunday; 10/16/23- Monday; 10/21/23- Saturday; 10/22/23- Sunday; 10/26/23- Thursday; 10/28/23- Saturday; 10/29/23- Sunday. --Eight days in November 2023: 11/4/23- Saturday; 11/5/23- Sunday; 11/12/23- Sunday; 11/16/23- Thursday; 11/17/23- Friday; 11/18/23- Saturday; 11/19/23- Sunday; 11/26/23- Sunday. --Nine days in December 2023: 12/2/23- Saturday; 12/3/23- Sunday; 12/10/23- Sunday; 12/16/23- Saturday; 12/17/23- Sunday; 12/24/23- Sunday; 12/26/23- Tuesday; 12/30/23- Saturday; 12/31/23- Sunday. --Six days in January 2024: 1/5/24- Friday; 1/6/24- Sunday; 1/7/24- Saturday; 1/20/24- Saturday; 1/27/24- Saturday; 1/28/24- Sunday. --Five days in February 2024: 2/3/24- Saturday; 2/4/24- Sunday; 2/14/24- Wednesday; 2/24/24- Saturday; 2/25/24- Sunday. --Twelve days in March 2024: 3/2/24- Saturday; 3/4/24- Monday; 3/8/24- Wednesday; 3/9/24- Friday; 3/10/24- Saturday; 3/16/24- Sunday; 3/17/24- Saturday; 3/18/24- Sunday; 3/23/24- Saturday; 3/24/24- Sunday; 3/31/24- Saturday; 3/30/24- Sunday. 2. Review of the facility staffing daily staffing schedule showed: -On 8/20/24 the DON was scheduled to work the floor as the charge nurse. The facility census was 69 residents. -On 8/22/24 the DON was scheduled to work the floor as the charge nurse. The facility census was 69 residents. Observations during the survey from 8/18/24 - 8/22/24 showed: -On 8/20/24 between 8:00 A.M. - 2:00 P.M., the DON was the charge nurse. -On 8/22/24 between 8:00 A.M. - 12:00 P.M., the DON was the charge nurse. During an interview on 8/22/24 at 10:09 A.M., the Administrator said: -He/She was aware that not all days were covered with an RN for eight hours. -He/She was still trying to hire more RN's. During an interview on 8/22/24 at 10:25 A.M., the DON said: -He/She was the only RN currently for the facility. -He/She would expect there to be an RN in the facility for eight hours daily. -He/She picks up hours working on the floors as the charge nurse since he/she is the only RN. -The facility as an RN that works as needed (PRN), but he/she does not pick up very many hours.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionell, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility also failed to have a system for tracking and monitoring infections in the facility for the previous 12 months and to ensure residents were tested upon admission and/or screened annually for tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for two sampled residents (Resident #6 and #73) out of 17 sampled residents. The facility census was 69 residents. 1. Observation on 8/20/24 between 10:11 A.M. and 1:34 P.M. during the initial facility Life Safety Code (LSC) basement inspection with the Maintenance Supervisor (MS) showed the following: -The facility was fully sprinklered and had its incoming water supply in the fire sprinkler riser room (A dedicated space for fire protection equipment). -There was a kitchen with a three-sink area, a dish-washing machine, and a hand-washing sink. -There was a laundry area with clothes washers. Observation on 8/21/24 between 9:03 A.M. and 11:04 A.M. during the facility LSC walk-through inspection of the first floor with the MS showed there were gender specific public restrooms located on the west wall along with a Beauty Shop with a sink. Observation on 8/21/24 between 11:04 A.M. and 1:27 P.M. during the facility LSC walk-through inspection of the second floor with the MS showed the following: -There were at least 17 resident rooms with private or shared bathrooms and sinks. -There were two Shower Rooms. -There was a Janitor's Closet with a mop hopper and a Medication Room with a sink. Observation on 8/21/24 between 1:27 P.M. and 2:47 P.M. during the facility LSC walk-through inspection of the third floor with the MS showed the following: -There were at least 17 resident rooms with private or shared bathrooms and sinks. -There were two Shower Rooms. -There was a Janitor's Closet with a mop hopper and a Medication Room with a sink. Review of the facility's maintenance folder entitled Legionella, last reviewed 8/1/23 and provided by the MS, showed the following: -There was no facility-specific risk management plan assessment that considered all elements of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens, though the first page of their assessment stated to refer to it. -There was no facility-specific infection prevention and control program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There was a schematic, diagram, or flowchart of the facility's water system, but no written explanation of the water flow throughout the facility. -There were no indications of possible stagnation locations throughout the facility on the flowchart, with assessments of each location's individual potential risk level. -There were no facility-specific testing protocols and acceptable ranges for control measures with a method of monitoring them at this facility, with interventions or action plans for when control limits were not met. -There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. During an interview on 8/22/24 at 12:05 P.M. the MS said that he/she learned about the Legionella program requirements from the previous MS. During an interview on 8/22/24 at 12:19 P.M. the Administrator said the following: -The MS was responsible for implementing the Legionella program. -The MS had been educated on it through their corporate office. -He/She was aware of some of the basic requirements. 32720 2. Review of the facility Infection Control Surveillance policy dated 2018 showed: -Separate infection tracking for those that occurred within the facility (facility-acquired) from those that were admitted to the facility with an infection. -A systematic observation on the occurrence and distribution of facility-acquired infections for the purpose of prevention and control. -To help make a judgement on what infection control practices needed to be stressed. -Review data to determine clusters and trends. -Include antibiotic stewardship program. Review on 8/22/24 at 8:20 A.M. of the facility Infection Control book for tracking and trending showed: -The book did not include 12 months of tracking and trending. The first month available for review was February 2024. -The available logs did not include if the infections were facility-acquired or present upon admission to the facility. -The available logs did not include if the infections were resolved and when. -The available logs did not include the type of infectious organisms present. -The available logs did not include the utilization of an antibiotic stewardship program. During an interview on 8/22/24 at 9:22 A.M., the Director of Nursing (DON) said: -He/She took over the Infection Control book in 2/24. -The person previously responsible left in 3/23. He/She was not aware he/she was supposed to be responsible for the program until 2/24. -He/She had not taken the Infection Preventionist course yet. He/She was not aware what information should be included in the tracking/trending logs other than what was on the monthly Infection/Antibiotic log. 3. A policy for resident TB testing and screening was requested but not received at the time of exit. Review of Resident #73's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's electronic medical record showed: -No documentation a two step TB skin test was completed upon admission to the facility. -A TB signs and symptoms assessment was completed on 7/17/24. 4. Review of Resident #6's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's electronic medical record showed his/her last TB assessment for yearly signs and symptoms assessment was completed on 1/17/23. No other assessments were located or provided by the facility. 5. During an interview on 8/22/24 at 10:26 A.M., the DON said: -TB tests for residents should be completed by the admitting charge nurse upon admission to the facility. A second step should be administered two weeks later. -Resident #73 should have had a two step TB skin test completed by now. -Residents should be screened annually for signs and symptoms of TB and documented in their medical record. -He/She did not know why there was not a more recent TB assessment for Resident #6.

Based on interview and record review, the facility failed to develop and implement an antibiotic stewardship protocol/program and a system to monitor appropriate antibiotic use for residents. The facility census was 69 residents. Review of the facility's Antibiotic Stewardship policy dated 2018 showed: -The purpose of the policy included: --To apply the best practice into a system to monitor antibiotic use. --To implement protocols to ensure residents who require an antibiotic are prescribed the appropriate antibiotic. --To monitor the use of antibiotics. --To reduce the risk of adverse events, including development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. -Apply the revised McGreer criteria for assessing for the suspected infections for Upper Respiratory Infections (URI), Urinary Tract Infections (UTI), or other infections. -Document the antibiotic prescribed is for the correct indication, dose, and duration to appropriately treat the resident. -Implement Antibiotic Use Protocol: Antibiotic Prescribing Practices: --Document indication, dose, and duration of the antibiotic. --Review the laboratory results to determine if the antibiotic is indicated or needs to be adjusted. --Monitor antibiotic use. 1. Review of the facility Infection Control tracking log on 8/22/24 at 8:29 A.M. showed: -The tracking log did not include 12 months worth of infection tracking or antibiotic use logs. The only months available were 2/24, 3/24, 4/24, 5/24, 6/24, 7/24, and 8/24. -The monthly logs included a page for each floor titled Infection/Antibiotic Log. Staff were to document the following on the Infection/Antibiotic Log: --The date, room number, resident name, infection type, antibiotic name, order, labs (yes or no), and organism. -The log did not include any lab results or logs indicating signs or symptoms of infections for antibiotic use. No infectious organisms were identified. -An antibiotic stewardship guide that included protocols for three common infections, UTIs, respiratory tract infections, and skin and soft tissue infections. The guide included criteria to be met as an indication to initiate antibiotic use for those infection types. During an interview on 8/22/24 at 9:22 A.M., the Director of Nursing said: -He/She had been in charge of the Infection Control tracking log and antibiotic stewardship program since 2/24. -If an antibiotic was prescribed, he/she entered it on the log along with the resident room number, and type of infection such as wound, UTI, or pneumonia. -If there was a lab or an X-ray, the results were added in the tracking book. -He/She could not locate lab results or X-ray results in the tracking book. -The tracking book did not include signs or symptoms of infections being treated with antibiotics.

Based on interview and record review, the facility failed to designate one or more individuals with the required primary professional training as the Infection Preventionist (IP) for the facility's Infection Prevention Control Program. The facility census was 69 residents. The facility did not provide a policy regarding required primary professional training for the IP. 1. During an interview on 8/22/24 at 9:22 A.M., the Director of Nursing (DON) said: -He/She was going to be the facility IP. -He/She had not taken any of the certification classes for the IP role at this time. During an interview on 8/22/24 at 9:38 A.M., the Administrator said: -He/She had the IP certificate and dedicated two to three hours per week for Infection Control duties. -His/Her degree was in Social Work. He/She did not have a degree in any of the approved primary professional medical trainings. -The previous IP left the faciity on [DATE]. The current DON was going to be the primary IP but he/she had not taken the IP classes at this time.

Based on observation, interview and record review, the facility failed to ensure a policy and a physician's order that addressed the settings for a low air loss mattress (LAL - a mattress with an air pump designed to distribute the patient's body weight over a broad surface area to prevent and treat pressure wounds) for one sampled resident (Resident #25) with an unstageable (not stageable due to coverage with dead tissue) pressure ulcer, failed to complete weekly wound/skin assessments to include detailed descriptions of the wounds, measurements, and accurate staging of the pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) and failed to update the resident's care plan to reflect the current stage of the resident's pressure ulcer, out of 17 sampled residents. The facility census was 69 residents. Review of the facility Pressure Ulcer Treatment Policy and Procedure, dated 2007 showed: -Reduce or eliminate causative factors including pressure. -The policy identified treatment recommendations for different stages of wounds but did not discuss or identify recommendations for unstageable wounds. Review of the facility Ulcer Documentation policy dated 2021 showed: -Document the stage of the ulcer. -An ulcer with intact eschar (dead tissue that is hard or soft, usually black, brown, or tan in color, and may appear scab-like, and is usually firmly adherent to the base of the wound) should be noted as unstageable due to eschar formation. A low air loss mattress policy was requested and not received. 1. Review of Resident #25's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning), dated 3/18/24 showed: -He/She was severely cognitively impaired. -He/She no pressure ulcers and no other skin conditions. Review of the residents Hospice (end of life care) Visit Note, dated 5/20/24 showed: -He/She had a lateral right upper buttock Stage 2 (partial thickness skin loss presenting as a shallow open sore with a red or pink wound bed, may also present as a fluid filled blister) pressure ulcer. -The documentation did not include a detailed description of the wound, the wound bed, or any measurements. Review of the residents Hospice Visit Note, dated 5/22/24 showed he/she had a lateral right upper buttock Stage 2 pressure ulcer that measured 0.8 centimeters (cm) X 0.75 cm X 0.0 deep. Review of the resident's Licensed Nurse Weekly Skin assessment dated [DATE] showed: -He/She had an open ulcer on his/her right buttock. -The documentation did not include a detailed description of the wound, including type of ulcer and stage of ulcer, the wound bed, or any measurements. Review of the resident's Licensed Nurse Weekly Skin assessment dated [DATE] showed: -He/She had an open ulcer on his/her right buttock. -The documentation did not include a detailed description of the wound, including type of ulcer and stage of ulcer, the wound bed, or any measurements. Review of the residents Hospice Visit Notes, dated 5/26/24, 5/30/24, 6/3/24, 6/5/24, 6/10/24 showed: -He/She had a lateral right upper buttock Stage 2 pressure ulcer. -The documentation did not include a detailed description of the wound, the wound bed, or any measurements. Review of the resident's Physician's Visit, dated 6/11/24 showed no mention of the resident's skin/open ulcers. Review of the facility Weekly Wound Tracking form dated 6/12/24 showed: -The resident had a right hip stage 4 (full thickness issue loss with exposed bone, tendon or muscle) pressure ulcer that measured 1.5 cm X 1.5 cm with no depth (Note: a Stage 4 pressure ulcer would have measurable depth), no drainage and had granulation tissue (granular pink or red moist vascular connective tissue formed on the surface of a healing wound). -The type of wound was incorrectly identified as a stasis ulcer. -The documentation did not include a detailed description of the wound, or the wound bed. -The documentation did not indicate if the right hip wound was a new wound, or when the wound was acquired. -The documentation did not include any information on the resident's previously documented lateral upper buttock stage 2 pressure ulcer. -No documentation a wound/skin assessment was completed between 5/30/24 through 6/12/24. Review of the resident's quarterly MDS, dated [DATE] showed: -He/She was severely cognitively impaired. -He/She had one Stage II pressure ulcer. -His/Her skin and pressure ulcer treatments included a pressure reducing device for his/her bed. -He/She was receiving hospice services. Review of the facility's Weekly Wound Tracking form dated 6/26/24 showed: -The resident had a right hip unstageable wound that measured 1.5 cm X 1.5 cm, no drainage and had granulation tissue (granular pink or red moist vascular connective tissue formed on the surface of a healing wound) -The type of wound was incorrectly identified as a stasis ulcer. -The wound description said only pink surrounding pale center. -The documentation did not include a detailed description of the wound, or the wound bed. -The documentation did not include any information on the resident's previously documented lateral upper buttock stage 2 pressure ulcer. -No documentation a wound/skin assessment was completed between 6/12/24 through 6/26/24. Review of the resident's care plan dated 6/26/24 showed: -The resident had potential for pressure ulcer development. -Goals that he/she would have no skin breakdown and that would have intact skin, free of redness, blisters or discoloration. -No mention of the resident's unstageable pressure ulcer. -No mention of the resident's LAL mattress settings. The LAL mattress was an intervention but there was no instruction regarding the settings or to monitor the settings. Review of the facility's Weekly Wound Tracking form dated 7/10/24 showed: -Measurements of 1.0 cm X 2.1 cm and depth of 0.5 cm and treatment completed by hospice in the notes section of the form. -The documentation did not include a detailed description of the wound, including type of ulcer and stage of ulcer, the wound bed and location of the wound. -No documentation a wound/skin assessment was completed between 6/26/24 through 7/10/24. Review of the resident's weight record showed he/she weighed 182.7 pounds on 7/11/24. Review of the resident's electronic medical record (EMR) showed the following physician's order, dated 7/20/24: -Hospice services dated 2/17/24. -Cleanse right hip with wound cleanser, apply pixie dust (a powdered antibiotic applied directly to a wound), pack with calcium alginate with silver (a highly absorbent wound dressing with antimicrobial properties to prevent and treat wound infection), cover with calcium alginate with silver and adhesive dressing, change daily and as needed. -There was no physician's order for a LAL mattress. -No treatment orders for the resident's right buttock pressure ulcer. Review of the residents Hospice Visit Note, dated 7/22/24 showed: -His/her Stage 2 pressure ulcer on his/her lateral right upper buttock was restaged to Stage 3 (full thickness tissue loss, fat may be visible, slough may be present but does not obscure the depth of tissue loss). -Measurements were 2.0 cm X 2.5 cm and had a depth of 0.9 cm. -The documentation did not include a detailed description of the wound, or the wound bed. -The documentation did not include any information on the resident's previously documented right hip pressure ulcer. -No documentation a wound/skin assessment was completed between 7/10/24 through 7/22/24. Review of the facility's Weekly Wound Tracking form dated 7/24/24 showed: -The resident had a right hip unstageable wound that measured 2.0 cm X 2.0 cm and a depth of 0.5 cm no depth. -The wound had odor, moderate drainage and a dark center. -The type of wound was incorrectly identified as a stasis ulcer. -The documentation did not include any information on the resident's previously documented right buttock pressure ulcer. Review of the facility's Weekly Wound Tracking form, dated 7/31/24 showed: -The resident had a right hip unstageable wound that measured 2.2 cm X 2.0 cm and a depth of 0.6 cm. -The wound had moderate drainage and an open red center. -The type of wound was incorrectly identified as a stasis ulcer. -The documentation did not include any information on the resident's previously documented right buttock pressure ulcer. Review of the Licensed Nurse Weekly Skin Assessment, dated 8/13/24 showed: -A circle on the resident's right hip and pressure sore written with a line connecting to the circled area. -The box to indicate there were open ulcers and a comment section with treatment ordered. -The documentation did not include a detailed description of the wound, the wound bed, the stage of the pressure ulcer or measurements. -The documentation did not include any information on the resident's previously documented right buttock pressure ulcer. -No documentation a wound/skin assessment was completed between 7/31/24 through 8/13/24. Review of the facility's Weekly Wound Tracking form, dated 8/14/24 showed: -The resident had a right buttock wound (no stage identified) that measured 2.0 cm X 2.5 cm and had a depth of 0.5 cm. -There was moderate drainage, no odor, and the wound had granulation tissue (the pink-red moist tissue that fills an open wound, when it starts to heal). Observation on 8/19/24 at 9:49 A.M. showed the resident was up in his/her Broda chair (A specialized medical device comfort cushioned chair that can tilt for positioning and reduces heat and moisture and relieves pressure). Observation on 8/21/24 at 9:38 A.M. showed: -The resident was lying in bed on his/her back. -His/Her LAL mattress was set at 350 pounds. Review of the resident's Physician's Orders Sheet (POS) Active Orders as of 8/21/24 showed: -No order for the resident's LAL mattress or settings for the LAL mattress. -Cleanse right hip with wound cleanser, apply pixie dust (a powdered antibiotic applied directly to a wound), pack with calcium alginate with silver (a highly absorbent wound dressing with antimicrobial properties to prevent and treat wound infection), cover with calcium alginate with silver and adhesive dressing, change daily and as needed. --NOTE: The treatment order had not been updated regarding packing the pressure ulcer after the resident's pressure ulcer became unstageable. Observation and interview on 8/21/24 at 10:02 A.M. showed: -The resident was lying in bed on his/her LAL mattress. -The setting on the LAL mattress was 350 pounds. -He/She had an unstageable pressure ulcer on his/her right buttock that was approximately nickel sized and was greater than 90% covered with with slough. -The wound nurse applied Pixie dust, then calcium alginate to the surface of the resident's unstageable pressure ulcer. --NOTE: The order was for the nurse to apply pixie dust, then pack the wound with calcium alginate with silver, then cover the wound with calcium alginate with silver and adhesive dressing. -While completing the resident's pressure ulcer treatment, the facility Wound Nurse said the resident had a pressure ulcer on his/her right buttock that was unstageable because it was covered with eschar; he/she did not monitor the settings on the resident's LAL mattress. During an interview on 8/22/24 at 9:37 A.M. Licensed Practical Nurse (LPN) A said: -He/She did not look at the settings on the resident's LAL mattress. -He/She did not know what the setting should be; it would be good to know that so that a happy medium could be found between what was comfortable for the resident and the resident's weight. -The resident's LAL mattress should not be set at 350 pounds; the resident did not weigh 350 pounds. -There was nothing in place for the settings on the resident's LAL mattress, nothing that identified what the setting should be and nothing regarding monitoring the setting. -The resident's LAL mattress was not on his/her physician's orders in the resident's electronic medical record (EMR) orders. -He/She did not know why the resident's LAL setting should not be on the resident's physician's orders or at least on the resident's care plan; there was no physician's order for the resident's LAL mattress; he/she did not know if the resident's care plan addressed his/her LAL mattress. -If there had been a LAL mattress physician's order in his/her EMR, it could have included the settings and to monitor the settings; had there been such a physician's order, then monitoring the settings for the resident's LAL mattress settings could have been on the resident's Treatment Administration Record (TAR). Review of the resident's TAR on 8/22/24 showed there was no documentation regarding the resident's LAL mattress settings. During an interview on 8/22/24 at 10:11 A.M. the MDS/Care Plan Coordinator said: -He/She was aware the resident had an unstageable pressure ulcer. -He/She hoped he/she would have updated the resident's care plan to show his/her pressure ulcer was unstageable; he/she could not recall if he/she had updated the resident's care plan to include the current stage of the resident's pressure ulcer. -If the current stage of the resident's pressure ulcer was not in the resident's care plan, then his/her care plan should have been updated to show his/her pressure ulcer was unstageable. During an interview on 8/22/24 at 10:40 A.M. the Director of Nursing (DON) said: -The resident had an unstageable pressure ulcer. -There should have been a physician's order for the resident's LAL mattress -He/she did not recall that LAL mattresses with pressure ulcers were set to a resident's weight. -The resident's care plan should have included the current stage of the resident's pressure ulcer. -Care plans should be individualized and he/she audited care plans quarterly. During an interview on 8/22/24 at 11:42 A.M. the DON said all pressure ulcer documentation should have included the type of wound, the stage and location of the wound and a full description of the wound bed, drainage, odor, and measurements of the wound. Telephone messages were left with the resident's physician on 9/3/24 at 2:10 P.M.:36 A.M. and on 9/4/24 at 8:36 A.M. and at 11:50 A.M. As of 4:00 P.M. no return call had been received.

Based on observation, interview and record review, the facility failed to utilize a tube feeding policy that instructed licensed nursing staff regarding the current professional standard for verifying correct placement of gastrostomy (G-tube - surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube; also known as feeding tube) tubes failed to ensure and document measurement of the resident's feeding tube to ensure correct placement and to ensure the resident's physician's order was correct and that the resident's tube feeding infused in accordance with the physician's order for one sampled resident (Resident #1) out of 17 sampled residents. The facility census was 69 residents. Review of https://www.ncbi.nlm.nih.gov/books/NBK593216/ the National Institutes of Health, National Library of Medicine, Enteral (also known as tube feeding) Tube Management, dated 2021 showed: -The placement of an enteral tube is immediately verified after insertion by an X-ray; after X-ray verification, the tube should be marked to indicate the point on the tube where the feeding tube penetrates the abdominal wall; the mark or number on the tube at the entry point should be documented in the resident's medical record. -At the start of every shift, nurses evaluate if the incremental marking or external tube length has changed. If a change is observed, bedside tests such as visualization or pH testing of tube aspirate can help determine if the tube has become dislocated. If in doubt, a radiograph should be obtained to determine tube location. -Older methods of checking tube placement included observing aspirated (using a syringe, a tube with a nozzle and piston or bulb for sucking in and ejecting liquid) contents or the administration of air with a syringe while auscultating listening with a stethoscope (a medical instrument for listening to sounds in the body) - however, research has determined these methods are unreliable and should no longer be used to verify placement. Review of the facility Procedure for Tube Care policy, section on Verification of Tube Placement, undated showed: -Check for tube graduation marks if present (Note: there was no instruction to note the mark at the point the tube entered and document that mark in the resident's medical record). -Aspirate and monitor gastric residuals (the volume of fluid remaining in the stomach at a point in time during tube feeding) with a syringe. -Inject air into the tube with a syringe and listening for air bubbles in the stomach with a stethoscope. Review of the facility Continuous Enteral Tube Feeding, undated showed: -No instruction regarding what the physician's orders should include, i.e. the amount of tube feeding to infuse, the time period for the tube feeding infusion/the number of hours for the tube feeding to infuse/run stop times for the tube feeding. -Check placement of feeding tube by injection air into the tube and listening with a stethoscope over the stomach. Review of the facility Tube Feeding Protocol, dated 2022 showed: -Verify the physician's order for tube feedings. -Verification of tube placement shall be done by aspirate of a small amount of gastric contents. -Note: the policy did not instruct staff to verify correct placement by measuring and documenting the length of the feeding tube. 1. Review of Resident #1's electronic medical record (EMR) showed the following order, dated 2/29/24: -Jevity (tube feeding formula) 1.5 calories, 30 milliliters (ml) per hours every night shift for supplement. -The physician's order did not specify an amount of tube feeding to be infused or what time period for the resident's tube feeding to infuse, i.e. how many hours for the resident's tube feeding to infuse or what time to start and end the resident's tube feeding. Review of the resident's care plan, dated 7/10/24 showed the resident's care plan did not include the method and frequency for checking for correct placement of the resident's gastrostomy tube and the rate and duration or daily amount of tube feeding the resident was to receive. Review of the resident's Registered Dietitian's (RD) note, dated 8/14/24 showed: -He/She visited the resident in his/her room and his/her tube feeding was on 30 ml/hr. -The resident's weight was stable and he/she was tolerating his/her tube feeding without problems. -The RD would continue to monitor the resident. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning), dated 8/15/24 showed: -He/She was severely cognitively impaired. -He/She had a feeding tube and received greater than 51% of his/her calories via tube feeding and more that 501 cc fluids via his/her feeding tube daily. -He/She had a diagnosis of cerebral palsy (a brain disorder that happens when areas of the brain that control movement and posture do not develop correctly or get damaged; it may cause difficulty eating due to problems with chewing, swallowing, and sucking). Observation on 8/19/24 at 9:37 A.M. showed: -The resident was lying in bed. -His/Her tube feeding was connected and running at 30 ml/hour (hr.). Observation on 8/20/24 at 9:46 A.M. showed: -The resident was lying in bed. -His/Her tube feeding was connected and not infusing (the pump was not running). Observation and interview on 8/20/24 at 11:08 A.M. showed: -The resident was lying in bed. -His/Her tube feeding was connected and not infusing; there was no change in the amount of tube feeding in the tube feeding bag. -Without assessing placement of the resident's feeding tube, the Director of Nursing (DON) disconnected the resident's tube feeding tubing (the tubing that delivers the tube feeding formula from the pump to the G-tube) from his/her G-tube, attached a syringe to the end of the resident's G-tube and poured approximately 30 ml of water into the resident's G-tube, followed by approximately 40 ml of water. -The DON said that when he/she checks G-tube placement he/she used a stethoscope, injected about 30 cubic centimeters (cc) of air into the tube with a syringe and listened over the G-tube insertion area for a bubbly sound; another method that could be used was to attach a syringe with plunger (the piston that expels contents in the syringe/pulls contents into the syringe) to the G-tube, pull back on the plunger and check for check for gastric (stomach/intestine) contents. -The DON said he/she had missed checking the resident's G-tube placement because he/she had left his/her stethoscope in his/her office; checking the placement of the G-tube was the most important part of G-tube care. Observation on 8/21/24 at 1:14 P.M. showed: -The resident was lying in bed. -His/Her tube feeding was connected and running at 30 ml/hour (hr.). During an interview on 8/22/24 at 10:40 A.M. Licensed Practical Nurse (LPN) A said: -The resident's tube feeding was 30 ml continuously around the clock. -When asked, he/she checked the physician's order in the resident's electronic medical record (EMR) and said the order was not correct, the physician's order was supposed to be for his/her tube feeding to be at 30 ml continuously around the clock. -The physician's order for the resident's tube feeding must have been entered incorrectly into the resident's EMR. -He/She would find the hard copy of the resident's tube feeding physician's order and ensure that the resident's tube feeding order matches what the physician had ordered. During an interview on 8/22/24 at 8:02 A.M. the MDS Care Plan Coordinator said: -He/She worked shifts in the facility both nights and days on both floors. -He/She would aspirate to check the residents feeding tube placement. -Aspiration was the only method he/she knew of to check for correct feeding tube placement. -He/She would not have put the method of checking the resident's feeding tube placement in the resident's care plan. During an interview on 8/22/24 at 10:40 A.M. the DON said: -He/She had not known that the professional standard for checking placement of feeding tubes was to look at and document the length of the tube. -He/She had always checked G-tube placement by listening and/or aspirating. -He/She had just been made aware of an issue with the resident's tube feeding order and the order was in the process of being corrected; the physician's order for tube feeding should have previously been noted to be incorrect; licensed nurses check physician's orders monthly and resident physician's review and verify orders monthly.

Based on interview and record review, the facility failed to provide Trauma Informed Care (TIC - an approach to delivering care incorporating knowledge about trauma into care plans, policies, and practices to avoid re-traumatization) assessment and care planning for two sampled residents (Resident #18 and Resident #53) out of 17 sampled residents. Residents #18 and #53 were diagnosed with Post Traumatic Stress Disorder (PTSD - an anxiety disorder that can develop after a person experiences or witnesses a traumatic event. Symptoms of PTSD can include outbursts, disturbed sleep, distressing memories and thoughts about the event, and emotions such as fear, anger, guilt, and shame, which can be severe enough to interfere with one or more aspects of daily life). The facility census was 69 residents. Review of the facility's Trauma Informed Care policy, dated 2022 showed: -Provide self-assessment and trauma questionnaire by Social Services designee or the admitting staff before admitting to the facility. The self-assessment is updated every three years. -Screening for trauma exposure and related symptoms for newly admitted resident using the Brief Trauma Questionnaire for screening. -Address the assessment and findings into the care plan to prevent triggers. -Establish a trauma-informed committee to address the program. -All staff, including direct care staff, is trained/has ongoing training in trauma informed care. Staff trained in trauma informed care should: --Understand trauma and the principles of TIC. --Know the impact of trauma on a resident's life. --Know strategies to mitigate the impact of trauma. --Understand re-traumatization and its impact. -Procedures include: --Incorporate the Brief Trauma Questionnaire into the admission package. --Interview the resident/family about trauma-related events or experiences. --Report to the Care Team for developing a focused individual plan for the resident. --Inform staff of care approaches. --The assessment and Plan of Care for trauma will be in the medical records. -Attached to the TIC policy were the following: --Brief Trauma Questionnaire in which the resident was to be asked 10 questions related to past trauma. --PTSD Checklist - Civilian Version related to signs and symptoms of PTSD. --Evaluation for Psychological Well-Being - History of Trauma Care Plan needs. 1. Review of Resident #18's Admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included PTSD. Review of the resident's Pre-Admission Screening and Resident Review (PASRR), Level II (a person-centered evaluation completed for anyone identified by the PASRR Level I screening as having or suspected of having a serious mental illness (SMI), intellectual disability (ID), developmental disability (DD) or related condition (RC). It confirms whether the individual has a SMI or ID/DD/RC; assesses the individual's need for Medicaid certified nursing facility services; and assesses whether the individual requires specialized services.), dated [DATE] showed the resident: -Was diagnosed with PTSD. -Had other psychiatric diagnoses. -Had PTSD as a result of extensive sexual abuse in his/her past. -Had psychiatric symptoms and history including: anxiety; isolating self from others, keeping his/her head down in public; wringing his/her hands and pacing; withdrawn and depressed, suspiciousness and paranoia; had a history of extensive sexual abuse in his/her younger years and substance abuse starting at age 18; long term psychiatric history of alcohol and drug abuse, mental health issues and homelessness. -Felt his/her long struggle with depression and suicidal ideation was a result of extensive past sexual abuse. -Liked plants and flowers, drawing and coloring. -Communicated he/she was abused his/her whole life and was afraid of people. People say they are your friends, but they are not. He/She felt safe in his/her room. -Did not meet the criteria for dementia to the extent he/she would not benefit from specialized services. -Had needs which could be met in a Nursing Facility (NF). -Had needs for a behavioral support plan, medication management, and structured environment providing a schedule. -Needed a crisis intervention plan that provided emotional support, education, safety planning, and case management to handle an immediate crisis that identified clear steps to support the individual during a crisis. The plan should specify who to contact for assistance, how staff should work together with the individual during a crisis, and when the physician or emergency services should be contacted. -The following supports and services were to be provided by the NF: Behavioral Support Plan, structured environment, crisis intervention services, discharge planning, medication therapy, Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) program, and personal support network. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated [DATE] showed the resident: -Was cognitively intact. -Did not have inattention, disorganized thinking, or altered level of consciousness. -Felt down and depressed and bad about himself/herself more than half of days. -Was always socially isolated. -Had psychiatric and mood disorders including PTSD. Review of the resident's Mood Care Plan, initiated [DATE] showed the resident: -Had Major Depression (MD - a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Personality Disorder (a class of mental disorders characterized by maladaptive behavior patterns which are developed early and are associated with significant distress). -PTSD. -The plan did not have interventions specific to the resident's TIC needs. There was no information related to: --Contributing factors to the resident's past trauma. --Triggers associated with his/her past trauma. --Steps staff should take to mitigate triggers. --How the resident typically responded when triggered by past trauma. --How staff could assist the resident if he/she was triggered or had emotional distress related to past trauma. -The plan showed behavioral health consults as needed, but did not specify if the services would include addressing the resident's PTSD needs. Review of the resident's comprehensive Care Plan, updated [DATE], showed there was no PTSD care plan and no interventions in any other individual care plan specifically related to the resident's TIC/PTSD needs. Review of the resident's Psychotherapy Progress Note, dated [DATE] showed: -Therapy was focused on his/her diagnoses of major depressive disorder and anxiety disorder. His/Her PTSD was not mentioned. -The resident wanted to restore his/her relationship with multiple family members and explore his/her use of art to help manage emotions and as a communication tool with his/her family. During an interview on [DATE] at 1:06 P.M. the resident said: -He/She was diagnosed with PTSD related to past sexual abuse during his/her childhood and sexual abused while in jail. -One of his/her family members had overdosed on medications he/she was getting and died as a result. He/She always blamed himself/herself because he/she knew of the addiction problem and couldn't help the family member. -He/She was still emotionally bothered by his/her past trauma, but couldn't identify any particular event that might trigger his/her PTSD. -Nobody at the facility had ever asked him/her about his PTSD or past trauma. -Drawing helped him/her manage his/her anxiety. Review of the resident's medical record on [DATE] showed there was no documentation of the following: -Brief Trauma Questionnaire. -PTSD Checklist - Civilian Version. -Psychological Well-Being - History of Trauma Care Plan evaluation. During an interview on [DATE] at 11:26 A.M. Certified Medication Technician (CMT) A said: -He/She often worked on the resident's floor. -He/She was not aware the resident was diagnosed with PTSD. -He/She didn't know how the resident reacted when triggered and didn't know how staff were supposed to respond when the resident was triggered. -He/She didn't know what the resident's triggers were or what staff were supposed to do to try to prevent the resident from being triggered. -He/She was not educated on trauma informed care. During an interview on [DATE] at 12:06 P.M. the Social Services Director (SSD) said: -The resident received psychiatric treatment and psychological counseling services at the facility. He/She was last seen for counseling on [DATE] and [DATE]. -According to the resident, he/she had a diagnosis of PTSD caused by childhood trauma. He/She didn't know the nature of the resident's trauma and figured the resident would tell him/her about it if he/she wanted to do so. -He/She didn't know what the resident's triggers were. -Since the resident had been at the facility staff hadn't reported the resident being triggered. He/She was not aware of any serious depression or reactions of fearfulness. -The resident once saw a movie with kids in it and said he/she missed his/her family. Family members didn't want to have anything to do with him/her. -It helped the resident's anxiety to sit and talk. The resident watched TV or went to his/her room to calm himself/herself. -The resident had a Level II PASRR, but he/she didn't see any Level II recommendations. During an interview on [DATE] at 9:34 A.M. Licensed Practical Nurse (LPN) A said: -A resident diagnosed with PTSD should have a PTSD care plan which showed the resident's triggers. -He/She hadn't seen any behaviors or reactions indicating the resident had been affected by PTSD. During an interview on [DATE] at 8:08 A.M. the MDS Coordinator said: -He/She was responsible for the MDS and care plans done upon admission and quarterly. -If a resident was diagnosed with PTSD, it was part of their Behavior Care Plan (BCP). Behaviors related to diagnoses were documented in the BCP. -If the resident was actively showing signs of PTSD they would have a PTSD care plan. They wouldn't have one just because they had the diagnosis. The plan should show the resident's triggers and behaviors. -He/She assumed the Social Worker would do a TIC assessment. -He/She wasn't familiar with trauma informed care. During an interview on [DATE] the Director of Nursing (DON) said: -The facility hadn't been doing the TIC assessment. It should be part of the admission packet and done quarterly or as needed. -The MDS Coordinator was responsible for updating care plans which should be individualized. -He/She was responsible for auditing the care plans quarterly. -If a resident was diagnosed with PTSD they had been documenting that in the Behavior Care Plan. The care plan should show the resident's triggers and how staff can help mitigate triggers. 46890 2. Review of resident #53's Admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included PTSD. Review of the resident ' s Behavioral Care Plan, revised on [DATE] showed the resident: -Had anxiety. -Depression. -PTSD. -Personality Disorder. -The plan did not have interventions specific to the resident's TIC needs. There was no information related to: --Contributing factors to the resident's past trauma. --Triggers associated with his/her past trauma. --Steps staff should take to mitigate triggers. Review if the resident's quarterly MDS, dated [DATE] showed the resident: -Was cognitively intact. -Had psychiatric and mood disorders including PTSD. Review of the resident Electronic Medical Record [DATE] showed there was no documentation of the following: -Brief Trauma Questionnaire. -PTSD Checklist - Civilian Version. -Psychological Well-Being - History of Trauma Care Plan evaluation

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #7) was free from physical abuse. On 2/25/23, Resident #9 struck Resident #7 in the face, resulting in him/her sustaining a broken nose and facial bruising out of seven sampled residents. The facility census was 82 residents. On 3/14/23, the Administrator was notified of the past noncompliance which occurred on 2/25/23. The facility administration was notified on the same day of the incident and the investigation was started. Facility staff were educated on abuse and neglect policy, resident intervention and behaviors before the start of the next shift. The deficiency was corrected on 3/4/23. Record review of the facility's Abuse and Neglect policy, dated 2016, showed: -Abuse was the willful infliction of injury, with resulting physical harm, pain or mental anguish. -The use of physical force that might result in bodily injury, physical pain, or impairment. -It would include hitting, slapping, pinching or kicking. -The following signs and symptoms were examples of possible indicators of abuse. --Bruises, black eyes, welts, lacerations, rope marks, imprint injuries. --Open wounds, cuts, or punctures. 1. Record review of Resident #7's Admission Record showed an admission on 2/20/23 with the following diagnosis: -Mental disorder (a wide range of conditions that affect mood, thinking, and behavior). -Prediabetes (a serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes). Record review of Resident #7's Admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 3/3/23, showed a Brief Interview for Mental Status (BIMS, an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) score of 15, indicating cognitively intact. Record review of Resident #7's undated Care Plan showed: -The resident was in a possible altercation on 2/25/23 with another resident in their room. -The resident was seen flipping off another resident which may have caused the other resident to hit him/her causing a small laceration on the resident's forehead as well as a bloody nose. Record review of Resident #9's Admission Record showed an admission on 7/28/2022 with the following diagnosis: -Adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life). -Personal history of other mental and behavioral disorders. Record review of Resident #9's Preadmission Screening and Resident Review (PASRR, DA-124C, a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source; this includes dually certified beds both Medicare and Medicaid), dated 8/10/22, showed: -Moderate withdrawn, depressed, suspicious and/or paranoid behaviors. -Minimal verbal and physical aggression. -Maximum abnormal thought process. -Will stay in a room with a roommate who also was at the homeless shelter. -Thinks staff are not trying to take care of resident's needs. -When staff tried to explain to him/her they were doing their best, resident said they were not. -He/she would interrupt and speak for 10 to 15 minutes on why the staff were not taking care of the resident. -Did not allow staff to complete tasks he/she was requesting. Record review of Resident #9's Quarterly MDS, dated [DATE], showed a BIMS score of 15. Record review of Resident #9's undated Care Plan showed: -The resident has a behavior problem or potential for behavior problem related to becomes agitated when he/she does get his/her way, verbally demanding. -On 11/8/22 the resident became angry with his/her roommate and hit the roommate in the back with a drinking cup. -He/she can be rude to others at times. -On 2/25/23 he/she had a physical altercation with roommate. -Roommate has a small laceration on forehead and a bloody nose. Record review of the facility Accident or Incident Report, dated 2/25/23 at 10:05 P.M., showed: -When Resident #9 wheeled self into the room, Resident #7 made an inappropriate gesture with both hands and made an inappropriate verbal remark. -Resident #9 took offense and stood up and hit Resident #7 in his/her left eye causing a small laceration (approximately 1 centimeter) to his/her left eyebrow. Record review of Resident #9's Nurse Note, dated 2/26/23 at 1:00 A.M., showed at approximately 10:05 P.M. the resident got into a verbal and physical altercation with another resident resulting in the other resident sustaining injuries. Record review of the Resident #7's Nurse Notes, dated 2/26/23, showed the resident was involved in an altercation with Resident #9. Record review of the Resident #7's X-ray Patient Report, dated 2/28/23, showed a acute nondepressed fracture involving the vomer (the small thin bone that forms part of the septum between the nostrils) was noted. Record review the facility's Follow-up Investigation Report, dated 3/1/23, showed: -Resident #9 reported So, I physically assaulted someone. I guess, because I'm stupid. I guess. -Resident #9 wanted to move and planned to leave the facility like he/she has stated in the past. -Resident #7 was bringing clothing to be marked when staff noticed the resident's nose bleeding after the event on 2/25/23. -Conclusion: Resident to resident abuse with no major injuries that resulted in hospitalization or police activity. -Both residents refused to give a statement as to what occurred. -Resident #7 was observed with a laceration to his/her forehead and a bleeding nose. Record review of Resident #7's Physician's Orders, dated 3/7/23, showed a physician order for the Ear Nose and Throat specialist to evaluate his/her vomer fracture (broken nose). During an observation and interview on 3/8/23 at 12:57 P.M., Resident #7 said: -The other resident did break his/her nose. -Complained of pain from the broken nose. -Observed the resident to have bruising under his/her left eye from the altercation. During an interview on 3/27/23 at 12:04 P.M., the Director of Nursing (DON) said: -There were no witnesses to the altercation. -There was a small laceration to Resident #7's forehead. -He/she was unaware of the fracture to the nose or the referral to specialist for the fracture. During an interview on 3/27/23 at 12:15 P.M., the Administrator said: -There was not a witness to the incident. -The only injury he/she was aware of was the laceration to Resident #7's forehead. -He/she was told the x-ray showed an old fracture to the nose. -Resident #7 refused to discuss what happened. -Resident #9 was the one who reported Resident #7 flipped him off. During an interview on 3/27/23 at 12:28 P.M., the Medical Director said: -He/she remembered discussing the resident to resident altercation. -He/she reviewed the x-ray results which indicated a fracture and a referral was made to the Ear, Nose and Throat (ENT) Specialist. -He/she expected the staff to handle behaviors and altercations according to the facility policy. MO00214578

Based on interview and record review, the facility failed to protect two sampled residents (Resident #3 and #4) from physical abuse when Resident #4 hit Resident #3, then Resident #3 hit Resident #4 back and Resident #4 fell and acquired a cut and skin tear, out of six sampled residents. The facility census was 76 residents. Record review of the facility's policy, Abuse and Neglect, dated 2016 showed: -Abuse was the willful infliction of injury, with resulting physical harm, pain or mental anguish. -The use of physical force that might result in bodily injury, physical pain, or impairment. -It would include hitting, slapping, pinching or kicking. -The following signs and symptoms were examples of possible indicators of abuse. --Bruises, black eyes, welts, lacerations, rope marks, imprint injuries. --Open wounds, cuts, or punctures. 1. Record review of Resident #4's face sheet showed he/she was admitted to the facility with the following diagnoses: -Cirrhosis of Liver (chronic liver damage usually resulting from Hepatitis or alcohol abuse). -Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar). -Depression. -Epilepsy (a disorder in which nerve cell activity in the brain was disturbed, causing seizures - a sudden, uncontrolled electrical disturbance in the brain). -Chronic Viral Hepatitis (an infection that causes liver inflammation and damage). -Transient Ischemic Attack (a brief stroke lie attack that may resolve within minutes to hours). -Cerebral Infarction (a disrupted blood flow to the brain). -Hereditary and Idiopathic Neuropathy (a condition which causes numbness, tingling and muscle weakness). -Visual Loss (unable to see normally). -Osteoarthritis(a degenerative joint disease). Record review of Resident #4's Preadmission Screening and Resident Review (PASRR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment) dated 12/23/21 showed: -Physician signed the form on 12/23/21. -The form was not filled out completely. Record review of Resident #4's Quarterly Minimum Data Set (a federally mandated assessment tool completed by the facility staff for care planning) dated 12/16/22 showed the resident: -Had a Brief Interview for Mental Status (BIMS) score of four, which indicated he/she was severely cognitively impaired. -Had behaviors directed towards himself/herself during the look back period. -Had wandering behaviors during look back period. Record review of Resident #4's Care Plan dated 12/21/22 showed: -The problem identified: --He/she was in an actual physical altercation, the resident hit his/her roommate, then the roommate hit him/her back dated 1/19/23. -The desired outcome: --Resident #4 would be on a secured unit, dated 9/9/22. -Interventions dated 9/9/22 included: --Resident #4 and his/her roommate were separated by staff with a 1 to 1 conversation that appeared to de-escalate the situation. --Staff were to explain or reinforce why his/her behavior was not appropriate and unacceptable to the resident. --Staff was to have a 1 to 1 conversation with the resident dated 9/9/22. --If reasonable staff were to discuss the resident's behavior. --Staff were to intervene as necessary to protect the rights and safety of others. --Staff were to monitor for signs and symptoms of increasing agitation and report. --Staff were to remove the resident from an upsetting situation. --Staff were to visually check on Resident #4 every two hours. --Staff were to monitor/document/report to physician any signs or symptoms of complications; altered level of consciousness or disorientation. --Staff were to obtain and monitor lab or diagnostic work as ordered by the physician. --Staff were to report lab results and follow up as indicated. --Staff were to report any changes in level of consciousness and changes in behavior. Record review of Resident #3's face sheet showed he/she was admitted with the following diagnoses: -Schizoaffective Disorder (a mental health condition which would include delusion hallucination depressed episode and manic periods of high energy). -Psychosis (a mental health disorder characterized by a disconnection from reality). -Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -Mood Affective Disorder (a mental health disorder that affects a person's emotional state). Record review of Resident #3's PASRR dated 2/6/02 showed: -He/she had been diagnosed with Paranoid Schizophrenia (a severe mental health condition that can involve delusions and paranoia (the irrational and persistent feeling that people are 'out to get you'). -The form showed you must follow the guide on the back page. -There was no back page. -There was no physician's signature. Record review of Resident #3's Care Plan dated 12/27/22 showed: -The problem identified: --Resident #3 had an actual physical altercation where he/she hit his/her roommate, dated 1/15/23. -The desired outcome: --He/she would not harm self or others. -Interventions included: --Staff were to direct others away from him/her when agitated, dated 11/5/19. --Staff were to make frequent room checks, dated 11/5/19. --Staff were to document hallucinations or delusions, dated 12/27/22. --Staff were to redirect the resident to his/her room when agitated. --Resident was separated from his/her roommate and put on 15 minute room checks dated 1/15/23. Record review of Resident #3's Quarterly MDS dated [DATE] showed: -His/her BIMS score was 13 which indicated he/she was cognitively intact. -He/she had hallucinations and delusions (heard or saw things that were not there). -He/she had behavioral symptoms not directed at others during the look back period. Record review of Resident #4's Nurses' Notes dated 1/15/23 showed: -The Nurse was summonsed to Resident #4's room. -The resident was laying on his/her left side in the doorway. -He/she had a skin tear to his/her left elbow and an abrasion to the left side of his/her head. -His/her vital signs were taken (within normal limits). -No misalignment was noted. -The Nurse and a Certified Nursing Assistant (CNA) assisted the resident to his/her feet. -His/her Guardian was notified by telephone of the fall. Record review of the facility's Initial Report dated 1/16/23 showed: -The incident happened on 1/15/23 at 3:20 P.M. -Resident #4 was the victim in the same room as Resident #3. -Resident #3 was the Alleged Perpetrator. -A peer saw Resident #3 hit Resident #4 and then Resident #4 fell down. -Licensed Practical Nurse (LPN) B heard a noise and went into the hall, and saw Resident #4 on the ground. -Resident #4 had obtained an abrasion on his/her left forehead and a skin tear to his/her left outer elbow. -First aid was provided to Resident #4's elbow and forehead. -The residents were separated. -The residents were put on 15 minute checks for 24 hours. -Resident #3 was in a room by himself/herself. -Resident #4 was moved to a different room. -LPN B counseled Resident #3 on proper steps to take when agitated with a peer and coping skills. Record review of the facility's Investigation Report dated 1/18/23 showed: -Resident #3 admitted to the DON that he/she did hit Resident #4 causing the other resident to fall. -Resident #3 said he/she hit Resident #4 because Resident #4 hit Resident #3 in his/her blind eye. -Resident #3 had no injuries or complaints. -Resident #4 was noted to have an abrasion to his/her left forehead and a skin tear to his/her left elbow. -Resident #4 was unable to express or describe what had happened due to cognitive deficits. -Resident #3 said, Resident #4 hit him/her in his/her blind eye so he/she hit Resident #4 like this (took a fist and punched toward his/her own forehead) and Resident #4 fell down. Record review of the written statement by LPN B as part of the investigation dated 1/18/23 showed: -He/she was summoned to the room where Resident #4 was lying on his/her left side in the doorway. -A peer said he/she had seen Resident #3 hit Resident #4 causing the fall. -LPN B asked Resident #4 what happened and he/she shrugged his/her shoulders. -LPN B asked Resident #3 what happened and he/she said he/she had not hit Resident #4. -No staff had witnessed the incident. During an interview on 1/19/23 at 9:15 A.M. the Administrator said: -The incident between Resident #3 and Resident #4 happened. -The incident between Resident #3 and Resident #4 was abuse. -Resident #4 hit Resident #3 in the eye. -Resident #3 then hit Resident #4 on the left side of his/her head and then Resident #4 fell down. -Resident #4 was not able to say why he/she hit Resident #3. -He/she was not aware of any prior behaviors from Resident #4. -The incident was not witnessed. -He/she thought Resident #3 and Resident #4 had been agitated from being on isolation. During an interview on 1/19/23 at 3:10 P.M. Resident #3 said: -He/she was hit by his/her roommate (Resident #4) and so he/she hit him/her back. -He/she hit his/her roommate (Resident #4) just one time. During an interview on 1/23/23 at 9:30 A.M. LPN B said: -He/she was working on 1/15/23 and was notified a resident was on the floor. -He/she went into the isolation room with Resident #3 and found Resident #4 was laying on the floor. -Resident #4 had an abrasion on the left side of his/her head and a skin tear on his/her left elbow. MO00212695