Every finding on record at Lakeview Health Care & Rehabilitation Center

Based on interviews and record review, facility staff failed to ensure residents were given the right to make choices about aspects of their lives in the facility, when staff did not give one resident (Resident #1) the choice to refuse his/her medication. The facility census was 56.1. Review of the facility's Resident Rights policy, dated 02/2001, showed employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/16/26, showed staff assessed the resident as cognitively intact, rejects care daily, and received antipsychotic medication. Review of the resident's care plan, dated 06/19/26, showed staff documented resident at risk for adverse reactions to his/her health and safety due to use of psychotropic medications for behavior management, hallucinations, and paranoid schizophrenia. Review of the resident's Physician Order Summary, undated, showed an order for staff to administer a 50 milligram/milliliter injection of Haloperidol Decanoate (used to treat schizophrenia and acute psychosis) Intramuscular Solution intramuscularly one time a day every 28 day(s). Review of the resident's progress note, dated 07/22/26, showed staff documented the Director of Nursing (DON), a Certified Nursing Assistant (CNA) and a nurse went to the residents' room to administer the resident's Haldol injection. Staff documented the resident refused the injection and staff explained to the resident that he/she had a court order to receive the medication. Staff documented the DON attempted to administer the medication to the resident and the resident began to hit the DON and knocked the needle out of DON's hand. Review of the facility investigation, dated 07/29/26, showed the DON documented he/she went to Resident #1's room to administer the resident's Haldol injection. Review showed the DON greeted the resident and explained and educated the resident about the injection and court order. The resident became combative and aggressive. He/she explained it had to be done and positioned himself/herself to ensure safe administration of the medication. The DON documented he/she positioned himself/herself with his/her back towards the resident to stabilize the resident's right leg. He/She documented he/she attempted the injection, and the resident pushed him/her multiple times in the back and scratched his/her arms up. During an interview on 07/29/26 at 9:26 A.M., the DON said the resident was due for his/her Haldol injection. The DON initially said the resident received the injection but then said the resident refused to take the medication. The DON said he/she straddled his/her legs across the resident's leg, with his/her back towards the resident, and braced his/her legs against the resident's leg to prevent movement. The DON said the resident was hitting his/her back during the attempted medication administration and then the resident knocked the syringe out of his/her hand. The DON said if a resident refused to take medication, he/she would expect staff to call the physician, but since there was a court order to administer the medication, there was no other route, other than sending the resident to the emergency room, so he/she attempted to force the resident to take his/her medication. The DON said sending the resident to the emergency room would be a waste of a trip. The DON said he/she did not contact the physician because he/she believed he/she had a legal obligation to administer the medication and he/she did not need to follow facility policy and procedure. The DON said he/she did let the guardian know the resident had refused his/her medication and he/she was going to attempt to give it to him/her. During an interview on 07/29/26 at 12:30 P.M., Licensed Practical Nurse (LPN) A said the resident had the right to refuse medication. He/She said if a resident refuses medications, staff are directed to notify the nurse and contact the physician. He/She said the resident had a history of refusing and he/she did contact the doctor for guidance in the past. The LPN said he/she did not notify the physician related to the resident's refusal to take his/her Haldol injection. During an interview on 07/29/26 at 12:50 P.M., the administrator said the resident had a right to refuse medication. He/She said if a resident refused to take his/her medication, staff are educated to reapproach and educate the resident on the importance of taking his/her medication. The administrator said he/she expected the resident's guardian and/or family and physician to be notified if a resident refused to take his/her medication. He/She said even though the resident had the right to refuse medication, he/she said it was a gray area because the resident had a court order to take the medication. During an interview at 07/29/26 at 12:51 P.M., the Assistant Director of Nursing (ADON) said the resident refused to have staff administer his/her medication and was screaming the hospital needed to give him/her the injection. He/She said staff did not administer the medication to the resident because the resident knocked the syringe out of the DON's hand. He/She said the resident had the right to refuse medication. He/She said due to the court order for the facility to administer the medication, he/she did not know how to handle the situation with the resident refusing the medication. 3118060

Based on observation, interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from restraint when the Director of Nursing (DON) used his/her body to restrain and prevent the freedom of movement for the resident to administer the resident's injectable medication. The facility census was 56. 1. Review of the facility's Use of Restraints policy, dated 2001, showed restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to treat the medical symptom; protect the resident's safety; and help the resident attain the highest level of his/her physical or psychological well-being. Review of the facility investigation, dated 07/29/26, showed the DON documented he/she went to Resident #1's room to administer the resident's Haldol injection. Review showed the DON greeted the resident and explained and educated the resident about the injection and court order. The resident became combative and aggressive. He/She explained it had to be done, positioned himself/herself to ensure safe administration of the medication. The DON documented he/she positioned himself/herself with his/her back towards the resident to stabilize the resident's right leg. He/She documented he/she attempted the injection, and the resident pushed him/her multiple times in the back and scratched his/her arms up. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/16/26, showed staff assessed the resident as cognitively intact and received an antipsychotic medication. Review of the resident's care plan, dated 06/19/26, showed the resident had a court order to administer psychotropic medication monthly by the least restrictive means necessary. Review showed staff documented the resident was at risk for adverse reactions to his/her health and safety due to the use of psychotropic medications related to behavior management, hallucinations, and paranoid schizophrenia. Review of the resident's Physician Order Summary, undated, showed an order for staff to administer a 50 milligram/milliliter injection of Haloperidol Decanoate (used to treat schizophrenia and acute psychosis) Intramuscular Solution intramuscularly one time a day every 28 day(s). Review of the resident's Medication Administration Record (MAR), dated July 2026, showed it did not contain documentation the resident received his/her Haldol injection. The MAR showed staff documented the resident refused his/her medication often. Review of the resident's progress note, dated 07/22/2026, showed staff documented the DON, a Certified Nursing Assistant (CNA) and a nurse went to the residents' room to administer his/her Haldol injection. Staff documented the resident refused the medication and staff explained to the resident that he/she had a court order for the medication. Staff documented the DON attempted to give the medication to the resident and the resident began to hit the DON and knocked the needle out of DON's hand. Staff documented the resident continued to curse and yell at staff. During an interview on 07/29/26 at 9:26 A.M., the DON said the resident was due for his/her Haldol injection. The DON initially said the resident received the injection but then said the resident refused to take the medication. The DON said he/she straddled his/her legs across the resident's leg, with his/her back towards the resident, and braced his/her legs against the resident's leg to prevent movement. The DON said the resident was hitting his/her back during the attempted medication administration and then the resident knocked the syringe out of his/her hand. The DON said if a resident refused to take medication, he/she would expect staff to call the physician, but since there was a court order to administer the medication, there was no other route, other than sending the resident to the emergency room, so he/she attempted to force the resident to take his/her medication. The DON said sending the resident to the emergency room would be a waste of a trip. The DON said he/she did not contact the physician because he/she believed he/she had a legal obligation to administer the medication and he/she did not need to follow facility policy and procedure. During an interview on 07/29/26 at 10:55 A.M., the Nurse Practitioner (NP) said the resident had a history of refusing care, including his/her Haldol. The NP said if the resident refused he/she would have asked staff to speak with legal guardian about the refusal. The NP said he/she would consider straddling a resident's leg, bracing their legs against the resident's leg to hold the leg in place to administer a shot, to be a restraint and not appropriate. During an interview on 07/29/26 at 12:30 P.M., Licensed Practical Nurse (LPN) A said if a resident refuses medications, staff are directed to notify the nurse and contact physician. He/She said the resident had a history of refusing and he/she did contact the doctor for guidance in the past. The LPN said staff are not allowed to force a resident to take medication. He/she said if staff were to straddle a resident's legs in a manner to hold them and prevent movement to administer medications then he/she would consider that restraining a resident, which was abuse. During an interview on 07/29/26 at 12:50 P.M., the administrator said if a resident refused to take his/her medication, staff are educated to reapproach and educate the resident on the importance of taking his/her medication. He/She said straddling the resident's leg and bracing his/her legs against the resident's leg to prevent movement, was a gray area when being considered a restraint, since there was a court order for the facility to administer the resident's medication. During an interview at 07/29/26 at 12:51 P.M., the Assistant Director of Nursing (ADON) said he/she was in the room during the incident between the resident and the DON. The ADON said the DON had his/her legs straddled over the resident's leg and braced his/her legs against the resident's leg. He/She said the resident was hitting the DON. He/She said the resident refused to have staff administer his/her medication and was screaming the hospital needed to give him/her the injection. He/She said staff did not administer the medication to the resident because the resident knocked the syringe out of the DON's hand. He/She said staff did not offer to send the resident to the hospital to receive the injection prior to the incident. The ADON said the facility had a court order to administer the resident's medication and he/she had never dealt with a court order before. The ADON said he/she did not feel like the DON was restraining the resident but stabilizing his/her leg. The ADON said he/she did understand how the resident being combative and hitting the DON while he/she held the syringe, could be considered dangerous. 3118060

Based on interviews, and record review facility staff failed to report an allegation of sexual abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the required two hour timeframe. The facility's census was 52.Review of the facilities Abuse, Neglect, Exploitation and misappropriation prevention program, revised April 2021, showed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not limited to other residents. Staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident and property and investigate and report any allegations within timeframes required by federal requirements.Review of Resident #1's quarterly minimum data set (MDS), a federally mandated assessment tool, dated 2/12/26, showed staff assessed the resident as cognitively intact with diagnoses of Schizoaffective disorder, bipolar type (a chronic mental health condition combining schizophrenia symptoms (hallucinations, delusions) with manic and sometimes depressive episodes), Major Depressive disorder, generalized anxiety disorder and bipolar disorder (chronic mental health condition characterized by extreme, often debilitating, mood shifts between high-energy manic or hypomanic episodes and low-energy depressive episodes).Review of the facility's investigation, dated 3/30/26, showed staff documented Certified Nursing Assistant (CNA) A reported on 03/29/26, immediately to Licensed Practical Nurse B he/she saw Resident #1 touched Resident #2's privates in the main dining room. CNA A separated the resident's immediately and LPN B spoke to Resident #1 who said Resident #2 forced him/her to touch his/her privates. LPN B spoke to Resident #2 who denied all allegations. The Administrator and Business office manager documented Resident #1 reported he/she assisted Resident #2 in playing with his/her privates but was forced to assist. Review showed the investigation did not contain documentation facility staff contacted DHSS within the two hours required timeframe after the resident representative reported the allegations. Review of the DHSS database did not contain a report facility reported allegations of sexual abuse for over 24 hours after resident #1 made the allegation.During an interview on 3/31/26 at 11:00 A.M., the administrator said he/she would have reported the allegation in two hours if it was not consensual, but he/she said it was never reported to him/her the resident said he/she was forced to do the sexual acts until 3/30/26. The administrator said the residents have a past sexual history and the residents were upset because they got caught.During an interview on 3/31/26 at 11:23 A.M., LPN B said CNA A reported to her he/she found Resident #1 with his/her hands down Resident #2's pantsHe/She said he/she called the administrator on 3/29/26 at 10:12 A.M. and explained in detail the allegations because he/she did say he/she was forced into the sexual act. He/She said the Administrator said the residents have a sexual history, so it was okay. Incident #2968263

Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for residents when staff failed to attempt to minimize foul odors in the hallway and facility entrance, failed to repair wall damage and failed to repair wheelchairs. The facility census was 46.1. Review of the facility's Homelike Environment policy, dated February 2021, showed:-The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting to include: a clean sanitary and orderly environment, clean bed linens that are in good condition and pleasant, neutral scents;-The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting, to include, institutional odors. 2. Observation on 01/05/26 at 9:45 A.M., showed the entranceway to the facility with a foul strong odor.Observation on 01/05/26 at 1:35 P.M., showed the entranceway to the facility with a strong foul odor.Observation on 01/06/26 at 8:02 A.M., showed the entranceway to the facility with a foul strong odor.Observation on 01/06/26 at 3:25 P.M., showed the entranceway to the facility with a strong foul odor. Observation on 01/07/26 at 08:02 A.M., showed the entranceway to the facility with a strong foul odor. 3. Observation on 01/05/26 at 11:32 A.M., showed the 400 hallway with a strong foul odor.Observation on 01/06/26 at 8:25 A.M., showed the 400 hallway with a strong foul odor. Observation on 01/06/26 at 1:54 P.M., showed the 400 hallway with a strong foul odor.Observation on 01/07/26 at 8:17 A.M., showed the 400 hallway with a strong foul odor. Observation on 01/07/26 at 1:01 P.M., showed the 400 hallway with a strong foul odor. 4. Observation on 01/05/26 at 11:17 A.M., showed resident occupied room [ROOM NUMBER] with a strong foul odor.Observation on 01/05/26 at 1:59 P.M., showed resident occupied room [ROOM NUMBER] with a strong foul odor. The wall behind the bed was gouged and chipped paint. Observation on 01/06/26 at 2:12 P.M., showed resident occupied room [ROOM NUMBER]'s wall behind the bed gouged with chipped paint.Observation on 01/08/26 at 9:12 A.M., showed resident occupied room [ROOM NUMBER]'s wall behind the bed gouged with chipped paint. 5. Observation on 01/05/26 at 1:38 P.M., showed Resident #21's room with a strong foul odor. During an interview on 01/07/26 at 1:32 P.M., the resident said he/she knows the facility has an odor. He/She said it is there every day, sometimes it is worse than others and some areas are worse than others. He/She said he/she believes it's just part of the facility and it never goes away. 6. Observation on 01/05/26 at 11:53 A.M., and 01/06/26 at 10:15 A.M., showed Resident #9 in a wheelchair in the dining room. The right armrest to the wheelchair hung to the side of the chair secured by a piece of black tape at the back edge. The left armrest was torn and cracked.7. Observation on 01/05/26 at 12:34 P.M., showed Resident #3 in a wheelchair in the dining room. The foot cushion frayed and exposed the inner foam. Observation on 01/05/26 at 2:02 P.M., showed the resident sat in a wheelchair. The foot cushion frayed and exposed the inner foam. Observation on 01/06/26 at 11:07 A.M., showed the resident sat in a wheelchair. The foot cushion frayed and exposed the inner foam.Observation on 01/07/26 at 8:18 A.M., showed the resident sat in a wheelchair at the nurse's station. The foot cushion frayed and exposed the inner foam. 8. During an interview on 01/07/26 at 3:25 P.M., Certified Nurse Aide (CNA) A said he/she had not noticed the odors in the building, but he/she is not surprised. He/She said if he/she notices a wheelchair is broken, he/she would tell maintenance so they can get it fixed. During an interview on 01/08/26 at 11:15 A.M., the maintenance director said if something needs repaired, staff are directed to document it in the maintenance request log located at the nurse's station. The maintenance director said staff had not notified him/her or documented in the repair needs in the maintenance log about repairs needed to Resident #3 and Resident #9's wheelchairs. He/She said he/she did not know about the wall repairs needed in room [ROOM NUMBER]. During an interview on 01/08/26 at 1:29 P.M., the administrator said he/she expects staff to complete maintenance work orders when they notice something is broken, which would include wheelchairs. He/She said maintenance staff are responsible to address work orders. The Administrator said he/she knows the facility has odors and there are a few residents who are heavy wetters and unfortunately their rooms are by the front door. He/She said some of the residents have their families wash their clothes and linens. The families do not always come in to take the items to be washed and refuse for staff to wash the items.

Based on observation, interview and record review, facility staff failed to ensure three residents (Resident #3, #42, and #45), who were unable to carry out activities of daily living (ADLs), received the necessary care and services to maintain personal hygiene out of eight sampled residents. The facility census was 46. 1. Review of the facility's ADL policy, dated April 2025, showed appropriate care and services are provided for residents who are unable to carry out ADL's, independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with bathing, dressing grooming and oral care) and toileting. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/18/25, showed staff assessed the resident as:-Cognitively impaired;-Did not have behaviors or reject care;-Dependent on staff for personal hygiene;-Diagnoses of dementia and diabetes.Review of the resident's care plan, dated 10/10/25, showed staff documented the resident is totally dependent on staff for personal hygiene.Review of the resident's shower sheets for December 2025 and January 3, 2026, showed staff did not document the resident refused a shave or nail care on 12/03/25, 12/10/25, 12/13/25, 12/17/25, 12/24/25, 12/27/25, 12/31/25 or 01/03/26. Observation on 01/05/26 at 12:24 P.M., showed the resident in the dining room with long facial hair and long jagged fingernails. His/Her hands were visibly soiled with buildup under his/her fingernails. He/She used his/her hands to eat his/her noon meal. Observation on 01/05/26 at 1:59 P.M., showed the resident in bed with visibly soiled hands, long jagged fingernails and long facial hair.Observation on 01/06/26 at 11:07 A.M., showed the resident in his/her wheelchair with long jagged fingernails and long facial hair.Observation on 01/07/26 at 8:18 A.M., showed the resident in his/her wheelchair at the nurse station. He/She had long jagged fingernails. Observation on 01/07/26 at 1:02 P.M., showed the resident in the dining room with long jagged fingernails. 4. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired and required some assistance with personal hygiene. Review of the resident's care plan, dated 02/06/26, showed staff documented the resident required assistance with showers and personal hygiene. Check nail length, trim and clean nails on bath days and as needed. Observation on 01/08/2026 at 10:51 A.M. showed the resident's feet with long and curled toenails. During an interview on 01/08/26 at 10:51 A.M., the resident said staff had not offered to trim his/her toenails during showers or since he/she was admitted . The resident said he/she is unable to trim his/her own toenails. The resident said he/she would allow staff to trim his/her nails if they offered and he/she could not recall if he/she had ever asked. 5. Review of Resident #45's, Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively impaired;-Did not reject care;-Dependent on staff for toileting, dressing and personal hygiene;-Required substantial to maximum assistance of staff for toilet transfers;-Frequently incontinent of urine and occasionally incontinent of bowel;-Diagnoses of Schizophrenia and diabetes.Review of the resident's care plan, dated 11/05/25, showed staff assessed the with -Poor toileting habits and required maximum assistance of one staff for toilet hygiene. Staff documented to provide structured activities to include toileting, assess and anticipate his/her toilet needs. Ensure toilet routine is enforced to encourage appropriate emptying of bowel and bladder. Perform frequent checks and assist with toileting as needed. Totally dependent on staff for personal hygiene. Check nail length and trim and clean nails on bath day and as needed (prn).Observation on 01/06/26 at 8:32 A.M., showed the resident in the dining room. He/She had long fingernails and long facial hair. Observation on 01/07/26 at 8:33 A.M., showed the resident ambulated the halls and wore black pants with a visible white debris build-up on the front. He/She had long fingernails.Observation on 01/07/26 at 9:48 A.M., showed the resident ambulated the halls and wore black pants with a visible white debris build up on the front. He/She had long fingernails. An unknown staff member had the resident sit in a chair by the vending machines and did not offer to change his/her pants or clip his/her nails.Observation on 01/07/26 at 1:10 P.M., showed the resident wore the same black pants to the dining room with the while build up on the front. The resident had long fingernails and had a strong smell of urine.During an interview on 01/07/26 at 3:25 P.M., CNA A said the resident's clothing is stained. The CNA said he/she has not had time to shave or provide nail care to the resident. 6. During an interview on 01/07/26 at 3:25 P.M., CNA A said it is routinely hard to get everything done with only two CNA's. Things like nail care, showers, and shaving are the things that are harder to get to, due to naps, toileting, and meal assistance. Dependent residents are the ones he/she tries to get to first, but there are a lot of residents that are more demanding of the aides' time which takes away from the care of others. He/She feels there is not enough teamwork to get everything done. During an interview on 01/08/26 at 9:07 A.M., the Director of Nursing (DON) said residents should be shaved and provided nail care including trims during showers. This can be done by the CNA's and/or the licensed nurses. He/She said he/she feels this is only getting done about 50 percent of the time depending on the staff that is working. During an interview on 01/08/26 at 1:29 P.M., the administrator said the facility has a resident shower schedule. Shaves and nail care should be a part of the shower process and/or as needed. CNA's and nurses are responsible to ensure resident care needs are being met but the DON is responsible to ensure the aides and nurses are completing the assigned tasks.

Based on observation, interview and record review, facility staff failed to reheat pureed food items in accordance with standardized recipes and failed to maintain the internal temperature of pureed food items placed on the steam table to prevent the growth of food-borne pathogens and potential for food-borne illness. The facility census was 46.1. Review of the facility's Cooking and Cooling policy, dated 2020, showed: -Foods will be cooked thoroughly, reaching the appropriate internal temperature specific to each item;-Length of cooking time and internal temperatures vary according to the type of food and temperatures must be reached and held for a specified amount of time;-A properly calibrated thermometer should be inserted into the thickest part of the food, and at least two readings should be taken in different places to ensure the proper temperature has been reached. Review of the facility's Pureed Food Preparation policy, dated 2020, showed the policy did not provide guidance to reheat pureed food items in accordance with the standardized recipes to prevent the growth of food-borne pathogens and potential for food-borne illness. 2. Review of the facility's diet spreadsheet for 01/07/26, showed the menu directed staff to provide the residents on pureed diets with pureed rosemary boneless chicken, pureed cauliflower au gratin, and pureed mushroom rice at the lunch meal. Review of the facility's standardized recipes for the pureed rosemary boneless chicken, pureed cauliflower au gratin and pureed mushroom rice, showed the recipes directed staff to reheat the pureed food items internal temperature to 165 F after blending the food items and to maintain an internal holding temperature of 135 F or 140 F (Based on current local state regulations). 3. Observation on 01/07/26 from 11:15 A.M., showed the dietary manager (DM) added four portions of rosemary boneless chicken, broth, and food thickener into the food processor and blended until smooth. Observation showed the DM scooped the pureed rosemary boneless chicken into a metal pan and, without checking the internal temperature of the pureed food, placed the pan in the steamtable and walked away. Observation on 01/07/26 at 11:35 A.M., showed the DM placed prepared portions of the cauliflower au gratin into the food processor and blended until smooth. Observation showed the DM scooped the pureed cauliflower au gratin into a metal pan, and without checking the internal temperature of the pureed food, placed the pan in the steamtable and walked away. Observation on 01/07/26 at 11:40 A.M., showed the DM placed portions of mushroom rice into the food processor and blended until smooth. Observation showed the DM scooped the pureed mushroom rice into a metal pan, and without checking the internal temperature of the pureed food, placed the pan in the steamtable and walked away. Observation on 01/07/26 at 11:50 A.M., showed the lid of the large metal pan containing the smaller metal pans of pureed food items, not fully closed and with approximately a two-inch gap between the metal pan and lid. Observation on 01/07/26 at 11:55 A.M., showed the following internal temperatures of the pureed food items placed on the steam table: -Pureed rosemary boneless chicken at 130 F;-Pureed cauliflower au gratin at 124 F;-Pureed mushroom rice at 120 F. Observation on 01/07/26 at 12:16 P.M., showed the DM continued to not check the internal temperature of the pureed food items after blending the food items and after he/she placed the items on the steam table. Observation showed the DM dished out the pureed rosemary boneless chicken, pureed cauliflower au gratin, and pureed mushroom rice onto four separate plates. Observation showed the four plates that contained the pureed food items were placed on the meal cart and wheeled out of the kitchen to serve to the residents. Observation showed the internal temperature of the pureed rosemary boneless chicken at 135 F, the pureed cauliflower au gratin at 125 F, and the pureed mushroom rice at 125 F. During an interview on 01/07/26 at 2:10 P.M., the DM said he/she should have checked the internal temperature of the pureed food items immediately after blending to determine if the food items needed to be reheated to 165 F. He/She said he/she should have checked the pureed food items internal temperatures again before the items were placed on the steam table. The DM said he/she is expected to check the internal temperature of all food items placed on the steam table prior to serving the food items to residents to ensure they are holding at 140 F. The DM said he/she was feeling overwhelmed and forgot to check the internal temperatures of the pureed food items after blending the items in the food processer and before serving the pureed food items from the steam table. During an interview on 01/07/26 at 2:41 P.M., Resident #35 said he/she has a pureed diet and sometimes the food is not hot, but lukewarm. The resident said he/she does not like to eat his/her food if it is not hot and said he/she will not eat the meal if it is not hot. During an interview on 01/07/26 at 3:31 P.M., the administrator said he/she is not sure what internal temperature pureed food items should be reheated to after blending in the food processor. The administrator said he/she would expect staff to check the internal temperature of the pureed food items prior to placing them on the steam table and said he/she would expect staff to check the internal temperatures of the pureed food items while on the steam table prior to serving the food to residents.

Based on observation, and interview, facility staff failed to provide complaint investigation results in a prominent and publicly available space for investigations completed January 30, 25 to December 8, 25. The facility staff also failed to post the location to for the reports. The facility census was 46.1. Review of the facility's Survey Binder located at the nurse's station did not contain complaint investigation results or documentation for investigations completed for 01/30/25, 03/11/25, 3/31/25, 05/01/25, 05/06/25, 06/12/25, 07/01/25, 07/04/25, 08/12/25, 09/16/25, 10/2/25, 12/01/25, and 12/08/25.2. Observation on 01/05/26 at 10:15 A.M., showed the survey binder on the nurse's station. The binder did not contain investigation results or documentation for investigations completed since 01/15/25. The facility did not post the location to for the reports. 3. Observation on 01/06/26 at 8:02 A.M., showed a survey binder sat on the nurse's station. The binder did not contain investigation results or documentation for investigations completed since 01/15/25. The facility did not post the location to for the reports. 4. Observation on 01/07/26 at 11:30 A.M., showed a survey binder sat on the nurse's station. The binder did not contain investigation results or documentation for investigations completed since 01/15/25. The facility did not post the location to for the reports. 5. Observation on 01/08/25 at 07:00 A.M., showed a survey binder sat on the nurse's station. The binder did not contain investigation results or documentation for investigations completed since 01/15/25. The facility did not post the location to for the reports. During an interview on 01/08/26 at 1:29 P.M., the administrator said he/she was responsible to ensure the survey binder was kept available and up to date for the residents and public to view. He/She said he/she had not updated it for a while and had the information available in his/her office. He/She did not have a reason why the binder was not updated with the complaint investigation results or why a sign to alert the public of the report availability was not posted.

Based on interviews and record review, facility staff failed to report an allegation of physical abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the two-hour timeframe. The facility's census was 43. 1. Review of the facility's Abuse Investigation and Reporting policy, Revised July 2014, showed an alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of an unknown source and misappropriation of resident property) will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Findings of abuse investigations will also be reported.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/21/25, showed staff assessed the resident as follows:-Moderate cognitive impairment;-No impairment to upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities:-Independent with bed mobility, and transfers;-Required partial assistance with upper body dressing, and substantial assistance with lower body dressing;-Diagnoses to include Anxiety Disorder, Bipolar Disease, and Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).Review of facility's investigation report, dated 06/05/25, showed staff documented the resident reported he/she was abused by five to six individuals who were rough with him/her while they assisted to dress his/her about three to four days prior. Staff documented they assessed the resident for physical and psychological harm, investigated, in-serviced staff on abuse and neglect, and notified the resident's physician and representative. The report did not contain documentation facility staff reported the allegation to DHSS within the two-hour timeframe after the resident reported the allegation of abuse. During an interview on 07/01/25 at 10:42 A.M., the Director of Nursing (DON) said he/she completed an investigation on 06/05/25 for the resident's allegation of abuse. He/She said all allegations of abuse should be reported to DHSS within two hours, but he/she did not report to DHSS because the internal investigation did not reveal that the resident was abused.During an interview on 07/01/25 at 1:15 P.M., the assistant Director of Nursing (ADON) said all allegations of abuse should be reported to DHSS within two hours, but the resident's story kept changing, and after the investigation was completed, the administrator and corporate nurse advised staff the allegation did not need to be reported to DHSS.During an interview on 07/01/25 at 1:39 P.M., the corporate nurse said the investigation did not reveal the resident was abused, or the allegation met the requirement to be reported to DHSS.Complaint #1734617

Based on interview and record review, facility staff failed to transcribe one resident (Resident #2) out of two sampled residents medication Omeprazole (used for heartburn) order from the hospital. The facility census was 43.1. Review of the facility's Administering Medications policy, dated 2001, showed staff are directed as follows:-Medications are administered in a safe and timely manner, and as prescribed;-The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication;-If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment, dated 05/29/25, showed staff assessed the resident as cognitively intact, and diagnoses to include heart failure, high blood pressure, and gastroesophageal reflux disease ((GERD) a chronic form of acid reflux that causes heartburn).Review of the resident's hospital discharge orders, dated 05/22/25, showed an order for omeprazole 40 mg capsule, take one capsule by mouth daily.Review of the resident's Physician's Order Sheet (POS), dated 05/23/25 through 07/01/25, showed an order for Omeprazole 40 mg capsule, give 40 capsules by mouth one time a day for GERD. Staff did not accurately transcribe the Omeprazole order from the hospital discharge orders. Review of the resident's Medication Administration Record (MAR), dated July 2025, showed staff were directed to administer 40 Omeprazole capsules by mouth daily for GERD.During an interview on 07/01/25 at 2:59 P.M., RN A said he/she said staff should have realized prior that the Omeprazole order needed to be clarified.During an interview on 07/01/25 at 1:15 P.M., the Assistant Director of Nursing (ADON) said he/she was responsible to ensure the resident's hospital discharge orders were transcribed accurately. He/She said when a resident is admitted , he/she and the DON are responsible to review the medication list, and enter the medications on the POS. He/She said the DON does not double check the orders entered by him/her and he/she does not normally verify the orders entered by the DON. He/She said errors in transcription of the physician's orders create a risk for staff to administer an incorrect dosage of the medication.During an interview on 07/01/25 at 3:28 P.M, the DON said staff are expected to always follow physician's orders. He/She said medications should be administered as prescribed, or staff should contact the physician to clarify orders as needed. He/She said if a nurse or Certified Medication Technician (CMT) observes an order that seems to have been transcribed inaccurately, he/she would expect him/her to bring it to either him/her or the ADON first to check, and then the physician for clarification.173461

Based on interview and record review, facility staff failed to review and revise the comprehensive care plan for two residents (Resident #1 and #2) out of three sampled residents care plans who sustained falls. The facility census was 42. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 03/2022, showed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's Falls policy, undated, showed falls can often be an indicator of an impending decline. Each fall must be followed up with and updated in the plan of care with new interventions. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/24/25, showed staff assessed the resident as severely cognitively impaired and one non-injury fall since admission. Review of the facility's Registered Nurse (RN) Investigation Report, dated 03/23/25, showed staff documented the found sitting on the bathroom floor. The resident said he/she lowered himself/herself to the floor due to weakness. Review of the resident's care plan, dated 02/21/25, showed staff did not document a new intervention after the fall on 03/23/25. During an interview on 05/01/25 at 2:43 P.M., the MDS Coordinator said if a resident lowered himself/herself on to the floor, it would be considered a fall, since it was a change in plane. He/She said the Interdisciplinary Team (IDT) implemented the use of a call light, after the resident's fall on 03/23/25, but he/she did not realize the intervention was already in place effective 11/20/24. During an interview on 05/01/25 at 2:53 P.M., the Director of Nursing (DON) said if a resident was lowered to the floor, it would be considered a fall. He/She said he/she did not know a new intervention was not added to the resident's care plan after the fall on 03/23/25. He/She said he/she was responsible to ensure the interventions were added in the care plan, but he/she said he/she overlooked verifying the information was added. 3. Review of Resident #2's annual MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired and did not contain documentation of a fall since admission. Review of the facility's RN Investigation Report,, dated 03/24/25, showed staff documented the resident slid off the edge of the bed onto his/her buttocks. Review of the resident's care plan, dated 09/26/24, showed staff did not document a new intervention after the resident fell on [DATE]. During an interview on 05/01/25 at 2:43 P.M., the MDS Coordinator said he/she did not have any documentation of a fall for the resident, so he/she did not know a new intervention should be implemented. During an interview on 05/01/25 at 2:53 P.M., the DON said he/she did not know new a intervention was not added to the resident's care plan. He/She said he/she was responsible to ensure the interventions were added in the care plan, but he/she said he/she overlooked verifying the information was added. 4. During an interview on 05/01/25 at 2:43 P.M., the MDS Coordinator said the IDT team discuss new interventions after each fall. He/She said he/she was responsible to update the resident care plan with new interventions after each fall. He/She said he/she took notes during the IDT meeting and kept it in a notebook, which he/she referred back to in order to ensure interventions were added to the resident's care plan. During an interview on 05/01/25 at 2:53 P.M., the DON said he/she worked with the administrator and the MDS Coordinator to determine new interventions after each fall. He/She said the new interventions would be documented in the resident's care plan. He/She said he/she was responsible to ensure the interventions were added in the care plan, but he/she said he/she overlooked verifying the information was added. MO00253473

Based on observation, interview and record review, facility staff failed to follow infection control practices and implement outbreak testing when two residents (Resident #1 and Resident #2) became symptomatic for Coronavirus Disease (COVID-19) . The facility census was 48. 1. Review of the facilty's COVID-19 - Testing Residents policy, undated, showed facility staff were directed to test residents with sign or symptoms of COVID-19 as soon as possible, regardless of vaccination status. Staff are directed residents and staff are tested for the SARS-CoV-2 virus to detect the presence of current infections (viral testing) and to help prevent the transmission of COVID-19 in the facility. Facility staff to conduct out break testing is initiated when a single new case of COVID-19 occurs among resident or staff to determine if others have been exposed, and a single new case of SARS-CoV-2 infection in any staff or resident should be evaluated to determine if others in the facility could have been exposed. 2. Review of Resident #1's change in status, Minimum data set (MDS), a federally mandated assessment tool, dated 9/27/24, showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of current Covid-19 infection, seizure disorder and depression. During an interview on 12/10/24 at 11:56 A.M., the resident said he/she had body aches, throwing up, diarrhea, mucous with blood and he/she cannot get comfortable, he/she said symptoms started last week and he/she has told multiple staff and no one has offered to test her for Covid-19. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of current Covid-19 infection, coronary artery disease, heart failure, diabetes, stroke, depression and COPD. During an interview on 12/10/24 at 12:00 P.M., the resident said he/she has not felt well for a few days and his/her roommate, Resident #1, has been sick too. Resident #2 said he/she has a runny nose, sore throat, cough and body aches. Resident #2 said he/she has had symptoms for two to three days and he/she wondered why no staff had tested him/her because he/she knew some residents in the building had covid. 4. During an interview on 12/10/24 at 10:30 A.M., the Director of Nursing (DON) said the facility has four known positives and have not started out break testing. The DON said he/she is being advised by corporate office to not test any other residents because it had to be reported to state. He/She said there are multiple residents that are symptomatic that he/she believes should be tested . During an interview on 12/10/24 at 11:15 A.M., He/She said if a resident has symptoms they can be tested but asymptomatic residents are not tested . During an interview on 12/10/24 at 11:16 A.M., the infection preventionist said he/she has not been instructed that someone with symptoms can not be tested , staff should question residents if they feel okay and tests them if not, but asymptomatic residents are not tested per the policy. During an interview on 12/10/24 at 11:33 A.M., the DON said eleven residents have symptoms headaches, body aches, cough and fatigue, none of them have been tested because they were advised not to test the residents by their corporate office. During an interview on 12/10/24 at 11:46 A.M., Registered Nurse B said he/she rounded with the physician today and got standing orders for residents who have symptoms to be tested . RN B said he/she does not know if the facility administration have denied testing but the physician ordered it and he/she will follow physician orders. MO00246246

AT Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility census was 35. 1. Review of the facility's Staffing, Sufficient and Competent Nursing Policy, undated, showed the facility provides sufficient numbers of nursing staff with appropriate skills and competency necessary to provide nursing and related care and services 24 hours a day, including a registered nurse for at least 8 consecutive hours daily, seven days a week. 2. Review of the facility's RN staff schedule, dated June 2024, showed the facility did not have an RN in the building on: -06/28/24; -06/29/24; -06/30/24. 3. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN in the building on: -07/04/24; -07/05/24; -07/06/24; -07/07/24; -07/08/24; -07/09/24; -07/10/24; -07/22/24; -07/27/24; -07/28/24. 4. Review of the facility's RN staff schedule, dated August 2024, showed the facility did not have an RN in the building on: -08/03/24; -08/04/24; -08/24/24; -08/25/24. 5. During an interview on 09/12/24 at 1:33 P.M., the Director of Nursing (DON) said there was no one else available to cover the shifts he/she was not available. He/She said it is a risk not having a RN in case of an emergency and no RN would be available. During an interview on 09/12/24 at 2:14 P.M., the administrator said he/she was not aware there were days with no RN coverage. He/She said he/she expects there to be RN coverage daily. He/She said the risk of not having RN coverage daily is not meeting the requirements.

Reviewed-sk/at Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 35. 1. Review of the facility provided policies, showed the records did not contain a policy related to the qualifications for Director of Food and Nutrition Services. During an interview on 09/10/24 at 9:08 A.M., the dietary supervisor (DS) said he/she started in the dietary supervisor position about three months prior. The DS said he/she had taken food handler courses in the past but had never taken any type of food service manager courses. The DS said he/she thought he/she was signed up for an on-line food service manager course but the assistant administrator had the paperwork. The DS said he/she had not started the food service manager course because the kitchen was short staffed and he/she had to work in the kitchen. During an interview on 09/12/24 at 3:35 P.M., the administrator said he/she was responsible for ensuring the dietary manager had proper training and qualifications. The administrator said he/she thought the dietary manager could complete training after hired to the position. The administrator said he/she did not realize the dietary manager had to have dietary manager qualifications when hired.

Reviewed AT Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for one resident (Resident# 21), and failed to update care plans at least quarterly in conjunction with the required Minimum Data Set (MDS), a federally mandated assessment tool to be completed by staff, to provide current interventions to meet individual needs for four (Resident #15, #17, #20, and #30) out of 12 sampled residents. The facility's census was 35. 1. Review of the facility's Care Plans-Baseline Policy, dated March 2022, showed the baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). Review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated March 2022, showed staff were directed as follows: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The comprehensive person-centered care plan is developed within seven days of the completion of the required MDS assessment (Admissions, Annual or Significant Change in status), and no more than 21 days after admission; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including any specialized services to be provided. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change; -The IDT reviews and updates the care plan: i). When the resident has been readmitted to the facility from a hospital stay; ii). At least quarterly, in conjunction with the required quarterly MDS assessment. 2. Review of Resident #21's admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted on [DATE]; -Cognitively intact; -Diagnoses of peripheral vascular disease ((PVD) narrowing of blood vessels), diabetes mellitus, hyperlipidemia (high levels of fat in the blood); -Received Insulin injections seven days of the seven day look back period (period of time used to complete assessment); -Care area triggers activiites of daily living (ADL) care, nutrition, urinary incontinence, psychosocial, mood, and pressure ulcers. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Re-entered the facility from an acute hospital stay on 07/02/24; -Diagnoses of PVD, hyperlipidemia; -Did not receive injections of any type during the seven day look back period. Review of the resident's medical records showed it did not contain documentation of a comprehensive person-centered care plan for the resident in conjunction with the required admission MDS, to provide directions for the resident's nutritional status, ADL care, urinary incontinence, psychosocial, mood, skin and diabetes. Staff did not document the care plan was updated quarterly. During an interview on 09/09/24 at 1:18 P.M., the resident said he/she returned to the facility from a hospital stay about two months ago and was concerned that facility staff did not resume monitoring his/her blood sugar levels, or the need for insulin medication as an intervention to treat his/her diabetes. 3. Review of Resident #15's annual MDS, dated [DATE], showed staff assessed the resident as: -Cognition not assessed; -Used two bed rails daily; -Lower extremity impairment on both sides Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use bed rails; -Lower extremity impairment on both sides. Review of the resident's care plan, dated 10/02/23, showed the plan did not contain direction for the use of side rails. Staff did not document the care plan was updated quarterly. Observation on 09/10/24 at 3:28 P.M., showed the resident in bed with quarter rails in the upright position on both sides. The resident held on to the left rail and repositioned him/herself in bed. Observation on 09/11/24 at 9:53 A.M., showed the resident in bed on his/her left side and held on to the left rail, quarter rails in the upright position on both sides. During an interview on 09/09/24 at 2:26 P.M., the resident said he/she uses the bed rails sometimes when in bed. 4. Review of Resident #17's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Mild cognitive impairment; -Upper extremity impairment on both sides. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition, not assessed; -Upper extremity impairment on both sides. Review of the resident's care plan, dated 11/06/23, showed the plan did not contain direction to prevent further contractures or care for the resident's hand contractures. Staff did not document the care plan was updated quarterly. Observation on 09/09/24 at 11:09 A.M., showed the resident in bed on his/her right side, both hands/fingers contracted with nothing in his/her palms. Observation on 09/10/24 at 12:23 P.M., showed the resident in his/her wheelchair at the dining table, both hands/fingers contracted with nothing in his/her palms. 5. Review of Resident #20's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Diagnoses of Seizure, Depression, and Schizophrenia; -Did not display any behavioral symptoms during the seven day look back period. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition not assessed; -Diagnoses of Seizure, Depression, and Schizophrenia; -Displayed other behavioral symptoms not directed towards others (hitting, scratching self, pacing, rummaging, verbal symptoms, etc.) one to three days of the seven day look back period. Review of the resident's care plan, dated 10/26/23, showed staff did not update the care plan to address the residents behavioral symptoms. Staff did not document the care plan was updated quarterly. 6. Review of Resident #30's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition, not assessed; -Upper extremity impairment on one side. Review of the resident's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Upper extremity impairment on both sides. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Upper extremity (shoulder, elbow, wrist, hand) impairment on both sides. Review of the resident's care plan, dated 11/01/23, showed the plan did not contain direction for the care of the resident's right upper extremity contracture. Staff did not document the care plan was updated quarterly. 7. During an interview on 09/12/24 at 1:10 P.M., the Director of Nursing (DON) said residents' care plans should be person-centered, and give a full picture of the specific resident's well-being. The DON said care plans should be updated at least quarterly, and should include interventions for bed rails, psychotropic medications, contractures, and any other identified care area of concern. The DON said the nurses will be responsible to add updates to resident's care plans with changes as they occur, the Care Plan Coordinator (CPC) will be responsible to complete the care plans, and the DON will ensure they are done routinely. During an interview on 09/12/24 at 2:04 P.M., the CPC said he/she started working at the facility about two weeks prior. The CPC said he/she is responsible to complete resident's care plans at least quarterly, as needed with changes, and in correlation with the MDS. He/She said the residents' care plans should be personalized with interventions to address any care area of concern, such as specific diagnoses, bed rails, contractures, psychotropic meds, behavioral symptoms, and capture the entire well-being of the resident. During an interview on 09/12/24 at 2:16 P.M., the Administrator said all staff from therapy, nursing, dietary, activities, and social service are responsible to update residents' care plan in real time with changes. The administrator said the CPC is responsible to complete the care plans, they should be updated at least quarterly with the MDS, should be person-centered, and include interventions for bed rails, contractures, psychotropic meds, behavioral symptoms, etc. 39644

Reviewed AT Based on observation, interview, and record review, facility staff failed to ensure residents' environment remained free of accident hazards when staff failed to ensure resident rooms were free of smoking materials for three unsupervised residents who smoke (Resident #16, #27 and #31) out of five sampled residents. The facility census was 35. 1. Review of the facility's Resident Smoking Policy, undated, showed independent smokers will be issued lockers with a lock and a key. Smoking materials may not be kept in resident rooms. 2. Review of Resident #16's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/14/24, showed staff assessed the resident as cognitively intact. Observation on 09/09/24 at 2:30 P.M., showed the resident had a half carton of cigarettes on the floor by the residents bed. Observation showed an oxygen concentrator in the residents room next to his/her bed. Observation on 09/10/24 at 10:15 A.M., showed the resident had a half carton of cigarettes on the floor by the residents bed. Observation on 09/10/24 at 2:50 P.M., during the Life Safety Code tour showed the resident wore a nasal cannula with oxygen being delivered at four liters per minute from an oxygen concentrator. Observation showed a carton of cigarettes set on the floor next to the resident's bed and an open pack of cigarettes set on the resident's walker, which was next to the bed. Observation showed the resident also kept a lighter in his/her walker. During an interview on 09/10/24 at 2:51 P.M., the resident said he/she was an independent smoker. The resident said he/she kept cigarettes and a lighter in his/her room. Observation on 09/12/24 at 1:00 P.M., showed the resident walked down the hallway with his/her walker, with a pack of cigarettes in basket of the walker. The resident entered their room. 3. Review of Resident #27's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Observation on 09/09/24 at 11:05 A.M., showed the resident with one pack of cigarettes on his/her bedside table in room. During an interview on 9/09/24 at 11:05 A.M., resident said he/she is an independant smoker and is able to go out to smoke anytime he/she wants to. He/She said that he/she keeps open pack of cigerattes with him/her to go outside anytime. Observation on 09/10/24 at 11:25 A.M., showed the resident with one pack of cigarettes on his/her bedside table in room. Observation on 09/11/24 at 10:38 A.M., showed the Resident had one pack of cigarettes on his/her bedside table in room. 4. Review of Resident #31's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Observation on 09/09/24 at 11:50 A.M., showed the resident with two packs of cigarettes on his/her bedside table in his/her room. Observation on 09/10/24 at 2:53 P.M., showed the resident with an open pack of cigarettes and two lighters on his/her bedside table next to bed. Observation on 09/10/24 at 3:30 P.M., showed the resident with one pack of cigarettes on his/her bedside table in his/her room. Observation on 09/11/24 at 10:35 A.M., showed the resident with two packs of cigarettes and a pink disposable electronic cigarette on his/her bedside table in room. 5. During an interview on 09/12/24 at 2:00 P.M., Certified Nurse Aid (CNA) F said smoking materials are kept in the medication room for supervised smokers and unsupervised smokers material keep smoking materials in their room. CNA F said he/she does not know what the facility policy says about smoking materials. The CNA said there are lockers but has never seen residents put their cigarettes or lighters in them lockers. During an interview on 09/12/24 at 2:02 P.M., Registered Nurse (RN) D said unsupervised residents keep their cigarettes and lighter in a locked locker. He/She said if he/she sees a resident with smoking materials in their room, he/she takes another staff member into residents' room, takes the smoking materials, and takes them to the Director of Nursing (DON) to discuss further. He/She said if resident has oxygen and has smoking materials it is a risk for expulsion or a chance that another resident can come in the room and take them. During an interview on 09/12/24 at 3:45 P.M., the Director of Nursing (DON) said residents who have oxygen should not have have a lighter or cigarettes on them, because this is a fire hazard and an explosion could happen. The DON said residents should keep their cigaretts and lighters in a locker, to which they have a key for. The DON said all staff are responsible to make sure these items, to include vapes are not in a residents room. During an interview on 09/10/24 at 4:00 P.M., the administrator said independent smokers were required to keep cigarettes and lighters in lockers located in the little dining room. The administrator said several residents kept cigarettes and lighters in their possession during the day. The administrator said if a resident is using oxygen they should not have cigarettes or lighters in their room. 45564 50422

AT Based on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5% out of 42 opportunities observed, 21 errors occurred, resulting in a 50% error rate, which effected four residents (Resident #13, #14, #20, and #27) out of 11 sampled residents. The facility census was 35. 1. Review of the Facility's Administering Medication policy, revised April 2019, showed medications are administered in accordance with prescriber orders and the individual administering the medication checks the label three (3) times to verify the right dose before giving the medication. 2. Review of Resident #14's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/12/24, showed staff documented the resident diagnosis of gastroesophageal reflux disease ((GERD) acid indigestion). Review of the resident's physician's order sheets (POS), dated September 2024, showed an order for Calcium Carbonate (Calcium supplement or to relieve acid indigestion) 500 milligrams (mg) by mouth three times daily. Observation on 09/10/24 at 12:15 P.M., showed Certified Medication Technician (CMT) C administered calcium carbonate 750 mg to the resident. During an interview on 09/11/24 at 3:32 P.M., CMT C said he/she would consider giving 750mg of calcium carbonate instead of 500 mg as a medication error. He/She said he/she was wondering why it was a different amount. He/She said staff are expected to use and give the ordered dose of calcium carbonate. He/She said there is not anything required for him/her to do differently when he/she has a medication error. During an interview on 09/11/24 at 3:50 P.M., Registered Nurse (RN) D said if a medication is given that is not the ordered dose it is a medication error, even if calcium carbonate. He/She said it should not be given and he/she thinks the wrong dose is in the medication cart because they have had changes in administrative staff and who is ordering stock medications. He/She said there have been issues since it has been passed around to different people and it was better when one person was responsible for ordering them. During an interview on 09/12/24 at 1:10 P.M., the Director of Nursing (DON) said he/she would consider it a medication error if the wrong dose of medication was given. He/She said he/she was not aware staff were giving the wrong dose of calcium bicarbonate. He/She said he/she believes the reason the wrong dose was in the medication cart was because recently a staff member had to run to a local store to pick one up and grabbed the wrong dose. He/She said that is not normal practice. During an interview on 09/12/24 at 2:17 P.M., the administrator said he/she expects his/her staff to give medications according to the physician orders. He/She said if medications are not given per the physicians orders he/she would consider that a medication error and staff should notify the charge nurse, physician, and/or DON. 3. Review of the Facility's Administering Medication policy, revised April 2019, showed: -Medications are administered in accordance with prescriber orders, including any required time frame; -Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders); -The individual administering the medication checks the label three times to verify the right time before giving the medication. Review of the Facility's Medication Pass times, provided at entrance, showed morning (A.M.) medication pass from 6:00 A.M.-9:00 A.M. and noon medication pass is from 11:00 A.M.-1:00 P.M. 4. Review of Resident #13's POS, dated September 2024, showed staff is directed to administer medications between 8:00 A.M.- 9:00 A.M.: -Benztropine Mesylate (for treatment of Parkinson's disease) 2 mg; -Calcitriol (to treat chronic kidney disease) 0.25 Microgram (mcg); -Clozapine (treatment of psychiatric disorders) 50 mg; -Fluvoxamine Maleate (treats depression) 50 mg; -Folic Acid (treatment of anemia) 1 mg; -Gabapentin (neuropathy) 300 mg; -Gemfibrozil (treatment of high cholesterol) 600 mg; -Haloperidol (antipsychiatric medication) 5 mg; -Hydralazine (treat high blood pressure) 25 mg; -Metoprolol tartrate (treat high blood pressure) 25 mg; -Sodium bicarbonate (Antacid) 650 mg; -Tamsulosin HCL (to treat enlarge prostate) 0.4 mg; -Lorazepam (treat anxiety) 1 mg. Observation on 09/11/24 at 10:49 A.M., showed CMT C administered Benztropine Mesylate, Calcitriol, Clozapine, Fluvoxamine Maleate, Folic Acid, Gabapentin, Gemfibrozil, Haloperidol, Hydralazine, Metoprolol Tartrate, Sodium Bicarbonate, Tamsulosin HCL, and Lorazepam. The CMT administered the medication one hour and forty-nine minutes after the scheduled administration time. 5. Review of Resident #27's POS, dated September 2024, showed staff is directed to administer the following medications between 08:00 A.M.- 09:00 A.M.: -Cyanocobalamin (Vitamin B12 deficiency) 1000 mcg; -Eliquis (blood thinner) 5 mg; -Metformin HCL ER (treatment for high blood sugar) 500 mg; -Tamsulosin HCL 0.4 mg; -Venlafaxine HCL ER (treatment of depression) 75 mg; -Pregabalin (treatment of nerve pain) 150 mg; -Oxycodone HCL (pain relief) 5 mg. Observation on 09/11/24 at 11:00 A.M., showed CMT C administered Cyanocobalamin, Eliquis, Metformin HCL ER, Tamsulosin HCL, Venlafaxine HCL ER, Pregabalin, and Oxycodone HCL. The CMT administered the medication two hours after the scheduled administration time. During an interview on 09/11/24 at 3:32 P.M., CMT C said his/her morning medication pass was late. He/She said it is not uncommon for him/her to run late on his/her morning medication pass. He/She said it is hard to do both the skilled nursing facility (SNF) and residential care facility (RCF) residents all on his/her own in the required time frames. He/She said he/she has around 45 residents to get done within the time frame and do blood pressure checks. He/She said he/she thinks it is a staffing issue and it would be better if he/she had another CMT to help pass the medications. He/She said he/she has from 7:00 A.M.-10 A.M. to finish the morning medication pass and sometimes goes over the time. He/She said medication passes for the morning are from 7:00 A.M.-10:00 A.M., Noon pass from 12:00 P.M.- 2:00 P.M., evening 3:00 P.M.- 6:00 P.M He/She said when medications are late there is not anything he/she has been instructed to do different. He/She said their system documents that it is late for him/her. He/She said he/she has never been instructed to notify the physician, charge nurse, or DON when medications are late. During an interview on 09/11/24 at 3:50 P.M., RN D said late medication are a medication error. He/She said if medication are given late staff should be notifying the physician that they are late. He/She said the physician ordered them a certain way and there could be special reasons they are at a scheduled time. He/She said medications that are twice daily or three times daily should be looked at so that medications are not given too close together. He/She said medications given too close together could cause side effects or over dose. During an interview on 09/12/24 at 1:10 P.M., the DON said he/she would consider medications given at the wrong time or late as a medication errors. He/She said morning medication pass is from 6 A.M. to 9 A.M. and staff get an hour leeway to pass medications. During an interview on 09/12/24 at 2:17 P.M., the administrator said staff should administer medications according to the physician orders and the time frame given by the physician. He/She said the concern for being given outside the parameters would be that medication are given multiple times daily may be given too close together. He/She would expect staff to notify the physician if medications are late. 6. Review of the Novolog manufacturers prescribing information insert, dated 02/2023, showed before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to enusre proper dosing follow the below: -Turn the selector to select two units; -Hold the pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards, press the push button all the way in, the dose selector returns to zero; -A drop of insulin should appear at the needle tip. 7. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff documented the resident diagnosis of Diabetes Mellitus and received insulin injections seven days of the seven days in the look back period. Review of the resident's POS, dated September 2024, showed an order for NovoLOG FlexPen (rapid-acting insulin) inject per sliding scale for a blood sugar of greater than 325 inject six units subcutaneous (under the skin). Observation on 09/11/24 at 11:20 A.M., showed RN D took the lid off the Novolog flexpen, applied the needle, and dialed in six units of insulin. The RN did not to prime the insulin pen before he/she administered the insulin into the resident's abdomen. During an interview on 09/11/24 at 3:50 P.M., RN D said when using the insulin pen, staff should check the medication administration rights, take the lid off the pen, attach the needle, and dial in the dose. He/She said pens need to be primed the first time they are opened and then do not need to be primed after. He/She said staff are given new employee education regarding insulin administration but no further education after. Why did During an interview on 09/12/24 at 2:19 P.M., the administrator said he/she expects staff to verify the physicians orders, clean the pen, attach the needle, prime the pen, and then dial in the dose before administration. He/She said it is important to prime the pen to ensure the resident gets the correct dose of insulin. During an interview on 09/12/24 at 3:08 P.M., the DON said when staff administer insulin via pen to a resident, he/she expects staff to first wipe the rubber seal on the pen, attach the needle, prime the pen with two units of insulin, dial the pen to the ordered dose, and administer the insulin to an appropriate site. The DON said if staff did not prime the pen prior to dialing the ordered dose, he/she may not administer the full dose of the insulin medication to the resident, which would result in a medication error.

AT Based on interview and record review, facility staff failed to ensure the two-step purified protein derivative ((PPD) skin test for Tuberculosis (TB)) was completed in accordance with their policy and on file for four employees (Director of Nursing (DON)), Licensed Practical Nurse (LPN) A, Dietary B, and Minimum Data Set (MDS) coordinator) out of ten employee files reviewed. The facility census was 35. 1. Review of the Facility's Employee Screening for TB, revised March 2021, showed: -All employees are screened for latent tuberculosis (LTBI) and active TB disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment. Review of the Center for Disease Control and Prevention's, Clinical Testing Guidance for TB: TB Skin Tests, Dated May 14, 2024, showed: -Two-Step testing; -If the first skin test is negative, a second TB skin test should be done 1to 3 weeks later; -If the second TB skin test result is positive, it is probably a boosted reaction; -Interpreting test results; -The skin test reaction should be read between 48-72 hours after administration by a health care worker trained to read TB skin results. 2. Review of DON's employee file showed: -Hire date of 09/16/23; -First step PPD administered on 09/26/23 and read on 09/29/23; -Second step PPD administered on 10/03/23; -Staff did not wait seven-21 days after the first dose to administer the second step PPD. 3. Review of LPN A's employee file showed: -Hire date of 08/18/23; -First step PPD administered on 08/15/23 and read on 08/18/23; -Second step PPD administered on 08/23/23; -Staff did not wait seven-21 days after the first dose to administer the second step PPD. 4. Review of Dietary B's employee file showed: -Hire date of 11/17/23; -First step PPD administered on 10/20/23 and read on 10/23/23; -Second step PPD administered on 10/27/23; -Staff did not wait seven-21 days after the first dose to administer the second step PPD. 5. Review of MDS coordinator's employee file showed: -Hire date of 08/26/24; -The file did not contain documentation staff administered the two step PPD. During an interview on 09/10/24 at 10:46 A.M., the Business Office Manager (BOM) said he/she and the department heads had covid when the MDS coordinator was hired, and his/her Two step TB was never started. 6. During an interview on 09/11/24 at 10:01 A.M., the Director of nursing said he/she is responsible for ensuring two step TB's are completed. He/She said he/she starts the first step prior to hire. He/She said TB's a read 48-72 hours after administration and the second step is give one to three weeks after the first step. He/She said he/she has been in the DON position for a year and he/she is unsure why some TB's were not completed in the appropriate time frames. During an interview on 09/12/24 at 2:17 P.M., the administrator said two step TB's are initiated before hire. He/She said he/she expects TB's to be read 48-72 hours after administration and the second step to be completed one to three weeks after the first step. He/She said the DON is responsible for ensuring TB's are completed in the appropriate times frames. He/She was not aware that there was a staff member who did not have the two step TB completed or that there were TB's that were not completed in the appropriate time frames.

Reviewed AT Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends for three residents (Resident #2, #27, and #39) out of 12 sampled residents. The facility's census was 35. 1. Review of the facility's policy titled, Activity Programs, dated 06/2018, showed the activities program is provided to support the well-being of residents and to encourage both independence and community interaction. Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. 2. Review of the facility's Activity Calendar, dated July, 2024, showed: -Saturday, 07/06/24- Cards/Word Searches; -Sunday, 07/07/24- National Macaroni Day/Christmas Pajama Day; -Saturday, 07/13/24- Christmas Movie Marathon; -Sunday, 07/14/24- Puzzles/Crosswords; -Saturday, 07/20/24- Axe throwing/Cards; -Sunday, 07/21/24- Junk Food and Binge Watch TV Day; -Saturday, 07/27/24- Coloring Sheets; -Sunday, 07/28/24- Puzzles. 3. Review of the facility's Activity Calendar, dated August, 2024, showed: -Saturday, 08/03/24- Watermelon day; -Sunday, 08/04/24- National friendship day and Sister day; -Saturday, 08/10/24- Lazy day; -Sunday, 08/11/24- Chalk; -Saturday, 08/17/24- Coloring/Reading; -Sunday, 08/18/24- Pajama day; -Saturday, 08/24/24- Color sheets; -Sunday, 08/25/24- Axe throwing; -Saturday, 08/31/24- Eat outside day. During an interview on 09/09/24 at 11:05 A.M., Resident #27 said there are no activities on the weekends. He/She said he/she wishes there was activities on the weekends he/she could go to. He/She said even if a tv with football playing in the dining room since it is football season. During an interview on 09/09/24 at 11:37 A.M., Resident #2 said they do not have any scheduled activities on the weekends. The resident said if they had activities on the weekends, he/she would participate, but for now, he/she just waits until Mondays when they have something going on. During an interview on 09/09/24 at 1:03 P.M., Resident #39 said on the weekends, activities are scaled back. The resident said if staff offered some activities on the weekends, he/she would definitely go and participate. During an interview on 09/10/24 at 3:17 P.M., Resident #2 said there is nothing to do on the weekends. The resident said when the Activities Director (AD) says goodbye to the residents on a Friday, they don't see the AD again until Monday. He/She said it would be nice if the facility could hire someone to do stuff on the weekends with the residents, since the AD cannot be at the facility all the time. During an interview on 09/12/24 at 11:37 A.M., the AD said he/she puts out books and puzzles for the weekends. He/She said he/she is not physically in the facility on the weekends to do activities. He/She said there are no staff led activities on the weekends. He/She said he/she was not aware that there needed to be staff led activities on the weekends. During an interview on 09/12/24 at 1:30 P.M., the Director of Nursing (DON) said there are card or board games on the weekends for the residents to play. He/She said there are no staff led activities on the weekends. He/She said he/she was aware that there are supposed to be activities on the weekends. He/She said he/she does not know why they are not being done on the weekend. During an interview on 09/12/24 at 2:14 P.M., the administrator said on the weekends the residents have coloring sheets and puzzles. He/She said the aides can help with activities if they have time on the weekends. He/She said there are no scheduled activities on the calendar for the weekends. 50422

AT Based on observation, interview, and record review, facility staff failed to complete the required nurse staffing information to include the facility census. The facility census was 35. 1. Review of the facility's Posting Direct Care Daily Staffing Numbers policy, dated 08/2022, showed the information recorded on form shall include the resident census at the beginning of the shift for which the information is posted. Records of staffing information for each shift are kept for a minimum of eighteen months. 2. Review of facility's daily staffing sheets, dated August 2024, showed the sheets did not contain facility census on: -08/11/24; -08/12/24; -08/13/24; -08/14/24; -08/19/24; -08/24/24; -08/24/24; -08/25/24; -08/26/24; -08/27/24; -08/28/24. 3. Review of facility's daily staffing sheets, dated September 2024, showed the sheets did not contain facility census on the following dates: -09/01/24; -09/03/24; -09/04/24; -09/05/24. 4. Review of facility's daily staffing sheets, dated August 2024, showed facility staff did not provide a daily staffing sheet for the following dates: -08/05/24; -08/07/24; -08/08/24; -08/09/24; -08/10/24; -08/15/24; -08/16/24; -08/20/24; -08/21/24; -08/22/24; -08/23/24; -08/30/24. 5. Review of facility's daily staffing sheets, dated September 2024, showed facilty staff did not provide a daily staffing sheet for the following dates: -09/02/24; -09/06/24; -09/07/24. During an interview on 09/12/24 at 1:36 P.M., the Director of Nursing (DON) said he/she expects the daily staffing sheet to be posted daily. He/She said the night shift nurse is responsible for filling it out and posting it. He/She said the sheet should include how many staff, hours worked, and resident census. He/She said he/she is responsible for ensuring the daily staffing sheet is completed. He/She said the night nurse must have had a busy night and the facility census and daily sheets were missed being done. During an interview on 09/12/24 at 2:19 P.M., the administrator said he/she expects the staffing daily sheet to be posted every day. He/She said the night shift nurse is responsible for filling the sheet out daily. He/She expects all the information on the sheet to be filled out, including the facility census. He/She it is the DON's who ensures the daily staffing sheet is completed daily. He/She said there shouldn't be a reason that there were no daily sheets done.

Based on observation, interview, and record review, facility staff failed to provide necessary treatment and services, consistent with professional standards of practice to prevent the development of pressure injuries and promote healing when staff failed to complete weekly wound assessments for one resident (Resident #1) of three sampled residents and failed to notify the physician when the resident's pressure injury worsened. The facility census was 45. 1. Review of the National Pressure Injury Advisory Panel's, Staging Definitions, dated 2016, showed Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Review of the facility's policy titled Wound and Skin Protocols, undated, showed: -It will be the responsibility of the Director of Nursing (DON) to ensure the wound care protocols are instituted and followed for all resident's needing wound treatment and have orders for protocol; -The DON will be responsible for reviewing weekly wound report and monitoring progress/decline of any wound and assuring compliance; -A complete wound assessment documentation will be done weekly on all pressure injuries until healed. A complete wound assessment and documentation will be done weekly on all pressure injuries until healed, the criteria to be included: -Site/location; -Stage; -Size: length, width, and depth measured in centimeters (cm); -Appearance of the wound bed; -Undermining/tunneling: if present measure the depth of the area in cm and describe in relation to the face of a clock what position it is in; -Surrounding skin: describe the condition of the surrounding skin; -Drainage/exudate: describe the amount, color, consistency, and odor. 2. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/28/24 showed staff assessed the resident as: -admitted to the facility on [DATE]; -Did not resist care; -Required maximum assistance of staff for bathing, and dressing; -Dependent on staff for toileting, and hygiene; -Incontinent of bowel and bladder; -At risk for pressure injuries; -Did not have a pressure injury; -Diagnosis of Parkinson's disease (a disorder that effects your nervous system), Coronary Artery Disease, Diabetes (a condition that effects your heart), and Dementia (inability to remember, think or make decisions); -Did not contain a cognition level assessment. Review of the resident's care plan, dated 03/21/24, showed staff assessed the resident with cognitive loss due to dementia. Review showed the resident required moderate to extensive assistance for toileting, bathing, dressing, and hygiene. Review of the resident's Physician's Order Sheet (POS), dated May 2024 showed physician orders to follow facility wound care protocol. Reviewed showed it did not contain an order for a treatment to the resident's coccyx wound. Review of the resident's Treatment Administration Record (TAR), dated May 2024 showed staff are directed to clean and cover the small open area on the resident's coccyx daily and as needed until healed. Review of the resident's weekly skin assessment, dated 05/29/24, showed staff documented the resident with an open area to his/her coccyx. The weekly skin assessment did not contain a complete wound assessment. Review of the resident's weekly skin assessments, dated June 2024, showed staff documented: -06/05/24 open area to coccyx; -06/12/24 open area, but did not contain where; -06/19/24 wound to coccyx; -06/26/24 two open wounds to coccyx. Review of the resident's weekly skin assessment for June 2024 did not contain a complete wound assessment. Review of the resident's hospital wound consult note, dated 06/13/24, showed hospital staff assessed the resident wound as follows: -Right lower coccyx stage 3 pressure injury 2 centimeters (cm) x 1 cm x 0.3 cm with 90 percent slough (moist, stringy tissue over the wound); -Unstageable (full thickness tissue loss covered with slough) coccyx pressure injury 3 cm x 2 cm, wound bed soft dry eschar, no drainage; -Resident not able to reposition himself/herself; -Order for pressure relieving cushion in the wheelchair, air mattress for the bed, and Mepilex dressing to coccyx area. Review of the resident TAR, dated 06/01/2024 to 06/14/2024, showed the TAR did not contain treatment orders for the residents coccyx wound. Review of the resident's POS, dated June 14, 2023, showed the resident physician order directed staff to check air pressure mattress and pressure reducing cushion twice a day, to soak gauze in Vashe (solution used to treat wounds) for seven to nine minutes, clean the coccyx wound bed with Vashe soaked gauze and pat dry, apply a nickel size thick layer of Triad (a cream used to treat wounds), cover wound with mepilex (dressing used to cover wounds) and change ever Monday, Wednesday, Friday, and as needed. Review of the resident's TAR, dated June 14, 2024, showed staff were directed to soak gauze in Vashe for seven to nine minutes, clean the coccyx wound bed with Vashe soaked gauze and pat dry, apply nickel size thick layer of Triad, cover wound with mepilex, and change every Monday, Wednesday, Friday and as needed. Review showed air Mattress and pressure reducing wheelchair cushion check twice a day. Observation on 07/01/24 at 1:20 P.M., showed an open wound approximately the size of a quarter on the resident's coccyx and an open wound approximately the size of a quarter on the resident's left inner gluteal area. Observation showed the wound on the left inner gluteal area had slough (yellow or white matter in the wound bed) in the wound bed. During an interview on 07/01/24 at 9:30 A.M., Registered Nurse (RN) A said the resident had a small reddened-purple area on his/her coccyx and staff were attempting to have the resident seen by the facility wound care consultant. RN A said the resident had eye surgery on 06/13/24 before the wound care consultant could see the resident. RN A said the hospital had the wound care team consult while having eye surgery and the wound was debrided. RN A said the wound care consultants come to the facility on ce a week. RN A said all wound documentation for the facility is completed by the wound consultant. During an interview on 07/01/24 at 1:45 P.M., RN A said he/she attempted to contact the resident's physician to advise him/her of the wound decline but has not had any response and he/she did not document the attempts. RN A said he/she does not know why measurements were not documented for the resident's wounds. RN A said without proper measurements and wound descriptions staff will not know if the wound has improved or declined. RN A said if something is not documented then it was not done. During an interview on 07/01/24 at 1:45 P.M., Licensed Practical Nurse (LPN) B said if staff do not document something that means it was not done. LPN B said he/she did not know why the resident's skin assessments did not contain measurements or descriptions of the wounds. LPN B said measurements and description of the wound is important so staff can tell if a wound is declining. LPN B said he/she did not contact the physician. During an interview on 07/01/24 at 3:05 P.M., the administrator said the charge nurse is responsible for completing the weekly skin assessments and the DON oversees them. The administrator said he/she was not aware the staff were not completing weekly measurements on wounds per the facility protocol. The administrator said the charge nurse is responsible for calling a resident's physician to obtain new orders or treatments. The administrator said the charge nurse is responsible to document the new orders and transcribe them to the POS, MAR, and TAR. The administrator said if something is not documented then it is not done, and staff must document what they complete. The administrator said measurements, and correct orders are important to ensure a resident gets the proper wound care. During an interview on 07/17/24 at 2:00 P.M., physician C said he/she was aware the resident had a wound on his/her buttock, but he/she has not seen the wound and does not know if the wound would be avoidable or not. He/She said he/she is not sure if the wound consultant had seen the wound or not as the resident is currently in the hospital. The resident's physician said he/she was notified of the resident having a would a couple of weeks ago but does not know the exact date. The resident's physician said he/she made monthly rounds the first part of June 2024 and did not make notation of a wound then, so he/she believes he/she was notified after that. He/She said he/she would expect staff to contact him/her within a couple of days of finding the wound to get treatment orders if a new wound, or if a wound got worse. He/She said he/she would change the treatment orders if a wound was deteriorating with the current orders. He/She said he/she expects staff to assess any wounds when they do treatments and document the wound measurements, the etiology, any drainage, and color of the drainage. He/She said he/she expects staff to assess wounds at least weekly and if not assessed over a period of time the resident could get more wounds or deterioration of the wound. MO00237546

Based on observation, interview and record review, and in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for 2019 Novel Coronavirus Disease (COVID-19), the facility failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to separate positive Covid-19 residents from residents who had tested negative for Covid-19 or had only been exposed to Covid-19. This put 11 residents (Resident #3, #4, #9, #12, #17, #19, #21, #22, #28, #30, #33) at an increased risk of contracting Covid-19 due to prolonged exposure. Additionally, facility staff failed to encourage residents to remain in isolation rooms, or ensure residents followed CDC recommendations before leaving their rooms, failed to conduct proper COVID19 screenings, failed to utilize National Institute for Occupational Safety and Health (NIOSH) approved facemasks, failed to utilize and properly dispose of required personal protective equipment (PPE) in isolation and quarantine rooms, failed to perform hand hygiene after removing PPE used in isolation rooms, and to ensure doors to isolation rooms were closed for seven residents (Resident #6, #7, #24, #25, #27, #35, and #36). Furthermore, facility staff failed to place isolation supplies, signs to alert staff of isolation rooms, and/or signage that instructed healthcare personnel (HCP) of PPE requirements for 39 residents (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35 ,#36, #37, #38, #39, #41). The facility census was 54. The Administrator was notified on 11/5/20 of an Immediate Jeopardy (IJ) which began on 10/15/20. The IJ was removed on 11/5/20, as confirmed by surveyor onsite verification. Review of the CDC's Coronavirus Disease 2019 (COVID-19) Responding to Coronavirus (COVID-19) in Nursing Homes, Resident Cohorting, updated 4/30/20, showed: -Determine the location of the COVID-19 care unit and create a staffing plan before residents or healthcare personnel (HCP) with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit; -Facilities that have already identified cases of COVID-19 among residents but have not developed a COVID-19 care unit, should work to create one unless the proportion of residents with COVID-19 makes this impossible (e.g., the majority of residents in the facility are already infected); -Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms; -Ensure that HCP have been trained on infection prevention measures, including the use of and steps to properly put on and remove recommended PPE; -Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing -Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents; -If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit; -Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other resident unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit); -Exposed resident may be permitted to room share with other exposed residents if space is not available for them to remain in a single room; -HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. Review of the CDC's Preparing for COVID-19 in Nursing Homes, updated 6/25/20, showed core practices should include: -Make tissues and trash cans available in common areas and resident rooms for respiratory hygiene and cough etiquette and source control; -Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room; -Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19; -Have a plan for how residents in the facility who develop COVID-19 will be handled. Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission and should not be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and gown when caring for these residents. Cloth face coverings are not considered PPE and should only be worn by HCP for source control, not when PPE is indicated; -Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). Review of the CDC's Strategies for Optimizing the Supply of N95 Respirators Conventional Capacity Strategies (should be incorporated into everyday practices), updated 6/28/20, showed cohorting is the practice of grouping together patients who are infected with the same organism to confine their care to one area and prevent contact with other patients. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology, and mode of transmission of the infectious agent. When single patient rooms are not available, patients with confirmed COVID-19 may be placed in the same room. Review of The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance, updated 7/15/20, recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 (COVID-19) infection showed: -Place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed, and the patient should have a dedicated bathroom; -As a measure to limit HCP exposure and conserve personal protective equipment (PPE), facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift; -It might not be possible to distinguish patients who have COVID-19 from patients with other respiratory viruses. As such, patients with different respiratory pathogens might be cohorted (the practice of grouping together patients who are infected with the same organism to confine their care to one area and prevent contact with other patients) on the same unit. However, only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with COVID-19 should ideally not be housed in the same room as a patient with an undiagnosed respiratory infection or a respiratory infection caused by a different pathogen; -HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions (minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered) and use a NIOSH-approved N95 (particulate filtering facepiece respirator that filters at least 95 percent of airborne particles but is not resistant to oil) or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. -HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process; -Employers should select appropriate PPE and provide it to HCP in accordance with Occupational Safety and Health Administration (OSHA) PPE standards. HCP must receive training on and demonstrate an understanding of when to use PPE, what PPE is necessary, how to properly don (put on), use, and doff (take off) PPE in a manner to prevent self-contamination, how to properly dispose of or disinfect and maintain PPE, the limitations of PPE; -Cloth face coverings are NOT PPE and should not be worn for the care of patients with suspected or confirmed COVID-19 or other situations where use of a respirator or facemask is recommended. Review of the CDC's Coronavirus Disease 2019 (COVID-19), Considerations for Wearing Masks, updated 8/7/20, showed; -The purpose of masks is to keep respiratory droplets from reaching others to aid with source control (use of cloth face coverings or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing). However, masks with one-way valves or vents allow air to be exhaled through a hole in the material, which can result in expelled respiratory droplets that can reach others. This type of mask does not prevent the person wearing the mask from transmitting COVID-19 to others. Therefore, CDC does not recommend using masks for source control if they have an exhalation valve or vent; -A face shield is used primarily for eye protection for the person wearing it. At this time, it is not known what level of protection a face shield provides to people nearly from the spray of respiratory droplets from the wearer. There is currently not enough evidence to support the effectiveness of face shields for source control. Therefore, CDC does not currently recommend use of face shields as a substitute for masks. Review of the CDC's Coronavirus Disease 2019 (COVID-19) Clinical Questions about COVID-19: Questions and Answers Infection Control section, updated 10/5/20, showed PPE used by infected HCP - HCP wearing a facemask (or respirator) and face shield that extends down below the chin might have had better source control than wearing only a facemask. Note that respirators with exhalation valves might not provide source control. Review of the facility's COVID-19 Surveillance Plan during outbreak Policy, undated, showed: -Those entering the facility will be asked to sanitize their hands, answer a series of questions, and have their temperature taken. If there are no red flags, they will be given a mask to wear; -Positives will be isolated in their rooms along with their roommate until COVID status is determined; -Guidelines from the CDC or DHSS (Department of Health and Senior Services) for the residents in the facility will be adopted and implemented immediately. Review of the facility's Pandemic Illness Policy, undated, showed: -The most important thing is to recognize an outbreak so we can minimize the spread to other individuals. With that in mind, an outbreak consists of two residents with similar symptoms in 24 hours; -Residents suspected of having one of these diseases should be isolated in their rooms until a definitive [DIAGNOSES REDACTED]. Staff should wear masks and gloves when caring for these residents, and a gown if providing hands on care or if coming in contact with the resident or items in his/her room; -Staff and housekeeping would need to be educated on proper PPE; -If the infection spreads, it may be necessary to place all infected residents on one wing. 1. During an interview on 10/8/20, with the Section for Long Term Care Regulation (SLCR) Division of Regulation & Licensure (DRL) Regulatory Compliance Manager, the Administrator said the facility had nine Covid-19 positive residents. He/She said the facility intended to cohort the positive residents in the facility's empty rooms on their Intermediate Care Facility (facility that provides nursing and support care on a non-continuous basis), if he/she could get approval. He/She went on to say that he/she would contact Licensure and Certification for the information he/she needed to accomplish this. During an interview on 10/13/20 with the SLCR DRL Regulatory Compliance Manager, the Administrator confirmed the facility had a total of 20 Covid-19 positive residents, and eight Covid-19 positive staff members. He/She said the facility had three separate units, but they had residents who wander. He/She said they were attempting to keep everyone isolated. 2. Observation on 10/15/20 at 10:15 A.M., showed Certified Nursing Assistant (CNA) A came to the front door wearing a cloth mask with two vents in the front and a face shield that came down past his/her eyes, but did not cover his/her mask. The director of nursing (DON) arrived wearing a cloth facemask with a vent, with an attached shield covering his/her eyes and escorted the surveyor to the Administrator's Office. The administrator wore a cloth facemask with a vent and a face shield. Neither CNA A nor the DON screened the surveyor for his/her temperature or for signs and symptoms of COVID-19. Observation showed screening supplies were not available at the entrance. Further observation showed multiple staff members wore cloth facemasks with vents and face shields. Additional observation, showed some of the masks were not covered by faceshields. Review of the facility's COVID-19 surveillance sheets showed on 10/12/20, CNA A had tested positive for COVID-19. Observation on 10/15/20 at 11:20 A.M., showed a thermometer and COVID screening questions on the counter at the nurse's station. During an interview on 10/15/20 at 11:20 A.M., CNA B said he/she entered the building through the front door and went to the nurse's station to be screened when he/she arrived at work. He/She then went to the supply room to get a mask if he/she did not bring a reusable mask to work. He/She went on to say the facility provides facemasks. Furthermore, he/she said staff used the disposable N95 if they forgot to bring their cloth mask with a vent to work. During an interview on 10/15/20 at 1:10 P.M., the Administrator said he/she would have expected staff to screen the surveyor. He/She went on to say if staff forgot a mask, he/she would hope they would call so someone could bring one out to them when they arrived, but if not, staff should stop at the screening station and get a mask. He/She was not aware staff was going to the nurse's station to be screened. During an interview on 10/16/20 at 9:37 A.M., the Administrator said the CDC only required staff to wear a surgical mask. He/She said the cloth masks with valves and a carbon filter were recommended for healthcare workers. 3. Review of the facility's COVID-19 surveillance sheets showed on 10/9/20, Resident #24 and Resident #25 both tested positive for COVID-19. Observation on 10/15/20 at 10:40 A.M., showed Resident #24 shared a room with Resident #25. There were no isolation towers (a plastic, three drawer container) containing PPE or signs outside the door to alert staff the residents were in isolation. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. Additionally, the door to the room was open. CNA A and CNA B entered Resident #24 and Resident #25's room. CNA A wore a cloth facemask with two vents and a face shield that came down past his/her eyes, but did not cover the mask. CNA A and CNA B provided perineal care and transferred Resident #24 with a mechanical lift without wearing gowns. Additional observation showed, Resident #24 and Resident #25 coughed several times. During an interview on 10/15/20 at 11:20 A.M., CNA B said the rooms with the isolation carts outside of the doors were the residents in isolation, due to testing positive for COVID-19. The charge nurse gave the staff a list of residents who had tested positive at the beginning of their shift. Furthermore, he/she said staff are to wear a mask, face shield, and gloves when they provide direct resident care, and are to wear a gown if residents are in isolation. During an interview on 10/15/20 at 12:25 P.M., the DON said staff were made aware which residents tested positive for COVID-19 through shift report. He/She said isolation rooms are identified with stop signs on most of the doors or isolation towers outside of the room. During an interview on 10/15/20 at 1:00 P.M., CNA B said he/she did not wear a gown when he/she provided care to the residents, because he/she did not know the residents tested positive for COVID-19. During an interview on 10/15/20 at 1:15 P.M., the Administrator said PPE supplies should be outside of isolation rooms. He/She said the easiest way to identify an isolation room of a COVID-19 positive resident, would be a stop sign on the door. Furthermore, he/she said staff should wear gowns when they provide direct care for residents who are positive for Covid-19. 4. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #6 and Resident #7 had been exposed to COVID-19. Observation on 10/15/20 at 11:00 A.M., showed Resident #6 shared a room with Resident #7. The door to the room was open. There were no isolation towers containing PPE or signs outside of the door. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. Additional observation showed, Resident #6 was in and out of his/her room multiple times, walked up and down the hallway, and spoke to staff, while he/she wore a blue medical mask and staff did not encourage the resident to remain in his/her room. Certified Medication Technician (CMT) C entered the room without a gown, checked Resident #7's blood sugar, and returned to the medication cart. During an interview on 10/20/20 at 9:25 AM., CMT C said the charge nurse told staff which residents were in isolation, and there were isolation carts and signs outside of the isolation rooms. He/She said staff should wear gowns, booties, faceshields, masks, and gloves into residents' rooms that have been placed on precautions. He/She said he/she did not wear a gown in the resident's room, because half of the hall tested positive for Covid-19. Furthermore, he/she went on to say he/she was aware the residents had been exposed to Covid-19 and he/she should have put on a gown before he/she entered the room. 5. Review of the facility's Covid-19 surveillance sheets showed on 10/9/20, Resident #2 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #2 tested positive for COVID-19, and Resident #3 had only been exposed to COVID-19. Observation on 10/15/20 at 11:30 A.M., showed Resident #2 shared a room with Resident #3. Outside of the door in the hallway was an isolation tower and a small trash can without a lid. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 6. Review of the facility's COVID-19 surveillance sheets showed, on 10/9/20, Resident #5 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #5 tested positive for COVID-19, and Resident #4 had only been exposed to COVID-19. Observation on 10/15/20 at 11:30 A.M., showed Resident #4 shared a room with Resident #5. Outside of the door in the hallway was an isolation tower and a stop sign on the door. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 7. Review of the facility's COVID-19 surveillance sheets showed on 10/9/20, Resident #8 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #8 tested positive for COVID-19, and Resident #9 had only been exposed to COVID-19. He/She went on to say Resident #9 now had symptoms, so he/she expected the resident to test positive this week. Observation on 10/15/20 at 11:30 A.M., showed Resident #8 shared a room with Resident #9. There were no isolation towers containing PPE or signs outside of the door. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 8. Review of the facility's COVID-19 surveillance sheets showed on 10/6/20, Resident #13 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #13 tested positive for COVID-19 and Resident #12 had only been exposed to COVID-19. Observation on 10/15/20 at 11:30 A.M., showed Resident #12 shared a room with Resident #13. Outside of the door in the hallway was an isolation tower and a small trash can with no lid. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 9. Review of the facility's COVID-19 surveillance sheets showed on 10/1/20, Resident #10 and Resident #11 both tested positive for COVID-19. Observation on 10/15/20 at 11:50 A.M., showed Resident #10 shared a room with Resident #11. Outside of the door in the hallway was an isolation tower, a stop sign on the door, and a small trash can with the flip-lid, held open by trash. Further observation, showed staff were given no direction in regard to the type of PPE to apply before entering the room. Additional observation, showed Resident #10 held the door open, while he/she wore a blue medical mask, hooked on his/her ears, but pulled below his/her chin. Resident #10 stopped the surveyor to ask about his/her smoke break. At that time, an announcement came over the intercom for group #2's smoke break. Resident #10 called for Resident #11, and they both put their blue, medical masks on and left the room without washing their hands, and walked past the nurse's station to the outside door. 10. Review of the facility's COVID-19 surveillance sheets showed on 10/7/20, Resident #14 tested positive for COVID-19 and on 10/9/20, Resident #15 tested positive for COVID-19. Observation on 10/15/20 at 10:40 A.M. showed Resident #14 sat in a wheelchair in the doorway of his/her room, without a mask on. Further observation showed, CNA A and CNA B walked past the resident, and did not encourage the resident to stay in his/her room, or apply a mask. Observation on 10/15/20 at 11:50 A.M., showed Resident #14 shared a room with Resident #15. There were no isolation towers containing PPE or signs outside of the door. Observation showed, staff were given no direction in regard to the type of PPE to apply before they entered the room. Additional observation showed, Resident #14 continued to sit in his/her wheelchair in the doorway of his/her room, without a mask on. 11. Review of the facility's COVID-19 surveillance sheets showed on 10/7/20, Resident #16 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #16 tested positive for COVID-19 and Resident #17 had only been exposed to COVID-19. Observation on 10/15/20 at 11:50 A.M., showed Resident #16 shared a room with Resident #17. Outside the door, in the hallway, was an isolation tower and a stop sign on the door. Further observation, showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 12. Review of the facility's COVID-19 surveillance sheets showed on 10/9/20, Resident #18 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #18 tested positive for COVID-19 and resident #19 had only been exposed to COVID-19. He/She went on to say, Resident #19 now had symptoms, so he/she expected the resident to test positive this week. Observation on 10/15/20 at 11:50 A.M., showed Resident #18 shared a room with Resident #19. There were no isolation towers containing PPE or signs outside of the door to alert staff the residents might be in isolation. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 13. Review of the facility's COVID-19 surveillance sheets showed on 10/2/20, Resident #20 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #20 tested positive for COVID-19, and Resident #21 had only been exposed to COVID-19. Observation on 10/15/20 at 11:50 A.M., showed Resident #20 shared a room with Resident #21. Outside of the door in the hallway was an isolation tower. Further observation, showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 14. Review of the facility's COVID-19 surveillance sheets showed on 10/9/20, Resident #23 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #23 tested positive for COVID-19 and Resident #22 had only been exposed to COVID-19. Observation on 10/15/20 at 11:50 A.M., showed Resident #22 shared a room with Resident #23. There were no isolation towers containing PPE or signs outside of the door to alert staff the residents were in isolation. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 15. Review of the facility's COVID-19 surveillance sheets showed on 10/7/20, Resident #26 and Resident #27 both tested positive for COVID-19. Observation on 10/15/20 at 11:50 A.M., showed Resident #26 shared a room with Resident #27. There were no isolation towers containing PPE, or signs outside of the door to alert staff the residents were on isolation. Further observation showed staff were given no direction in regard to the type of PPE to apply before entering the room. Additional observation showed the door to the room was open, a pedestal fan was on, and Resident #27 lay in his/her bed. 16. Review of the facility's COVID-19 surveillance sheets showed on 10/9/20, Resident #29 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #29 tested positive for COVID-19, and Resident #28 had only been exposed to COVID-19. Observation on 10/15/20 at 11:50 A.M., showed Resident #28 shared a room with Resident #29. Outside of the door in the hallway was an isolation tower. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 17. Review of the facility's COVID-19 surveillance sheets showed on 10/7/20, Resident #31 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #31 tested positive for COVID-19, and Resident #30 had only been exposed to COVID-19. Observation on 10/15/20 at 11:50 A.M., showed Resident #30 shared a room with Resident #31. There were no isolation towers containing PPE or signs outside of the door to alert staff the residents were on isolation. There was a small trash can, with a flip lid, held open by trash. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 18. Review of the facility's COVID-19 surveillance sheets showed on 10/6/20, Resident #32 tested positive for COVID-19. Observation on 10/15/20 at 12:05 P.M., showed Resident #32 in his/her room. Outside of the door, in the hallway, was an isolation tower and a small trash can with a flip lid, held open by trash, and a stop sign on the door. Further observation, showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 19. Review of the facility's COVID-19 surveillance sheets showed on 10/9/20, Resident #34 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #34 tested positive for COVID-19, and Resident #33 had only been exposed to COVID-19. Observation on 10/15/20 at 12:05 P.M., showed Resident #33 shared a room with Resident #34. Outside of the door, in the hallway, was an isolation tower. Further observation, showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 20. Review of the facility's COVID-19 surveillance sheets showed on 10/9/20, Resident #35 and Resident #36 tested positive for COVID-19. Observation on 10/15/20 at 12:05 P.M., showed Resident #35 shared a room with resident #36. Outside of the door, in the hallway, was an isolation tower. Further observation, showed staff were given no direction in regard to the type of PPE to apply before they entered the room. Additional observation, showed the door to the room was open and both residents were up in chairs. CMT C prepared medication for Resident #35, entered the room without a gown or gloves, and gave the resident his/her crushed medication in a spoon. CMT C then returned to the cart and prepared medications for Resident #36. CMT C reentered the room without a gown or gloves on, handed Resident #36 his/her medications in a cup, and then returned to the medication cart. During an interview on 10/20/20 at 9:25 AM., CMT C said the charge nurse told staff which residents were in isolation, and there were isolation carts and signs outside of the isolation rooms. He/She said staff should wear gowns, booties, faceshields, masks, and gloves into isolation rooms. Furthermore, he/she said he/she did not wear a gown in the room, because half of the hall was positive for COVID-19. Additionally, he/she went on to say he/she was aware the residents were positive for COVID-19 and he/she should have put on a gown before entering the room. 21. Review of the facility's COVID-19 surveillance sheets showed on 10/9/20, Resident #37 and Resident #38 tested positive for COVID-19. Observation on 10/15/20 at 12:10 P.M., showed Resident #37 shared a room with Resident #38. There were no isolation towers or signs outside the door to alert staff the residents were in isolation. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. 22. Review of the facility's COVID-19 surveillance sheets showed on 10/9/20, Resident #39 tested positive for COVID-19. During an interview on 10/15/20 at 10:30 A.M., the DON said Resident #39 tested positive for COVID-19 and Resident #40 tested negative for COVID-19. Observation on 10/15/20 at 12:15 P.M., showed Resident #39 in his/her room. There were no isolation towers or signs outside the door to alert staff the resident was in isolation. Further observation showed staff were given no direction in regard to the type of PPE to apply before they entered the room. CNA D came out of the resident's room, stood in the doorway and removed his/her gown and gloves. He/She called for another staff member to bring him/her a trash can while he/she held the used gown and gloves in his/her hand. CNA D then placed the gown and gloves on the floor inside of the door, walked across the hall to get another gown and gloves out of an isolation cart, put the gown and gloves on and went back in the same room, without performing hand hygiene. He/She then returned to the door, grabbed the outside knob of the door to shut it, but did not, removed the gown and gloves and laid them on the floor with the first gown and g (TRUNCATED)

Based on interview, and record review, facility staff failed ensure resident safety and provide protective oversight to residents living in the home. The staff failed to properly store and secure narcotic medications from the reach of residents, which resulted in an intentional overdose by one resident (Resident #1), who required hospitalization . The facility census was 58 residents. 1. Review of Resident #1's medical record showed the resident was admitted to the facility on [DATE]. Review of the resident's medical record showed staff did not complete an initial comprehensive Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, for the resident as required. (The facility is already out of compliance in this area. Please see Statement of Deficiencies dated 5/13/16). Review of the resident's medical chart showed the resident had the following [DIAGNOSES REDACTED]. - Mood Disorder; - Dementia; - Personality change due to known psychological disorder; - Opioid ( a class of narcotic pain medication) abuse. Review of the resident's Plan Of Care (POC) showed facility staff did not plan interventions to address the resident's needs. Instead, the staff utilized the resident's previous care facility's POC which they last updated on 10/06/15. (The facility is currently out of compliance in this area. Please see the Statement of Deficiencies dated 5/13/16). The previous facility documented the resident had a [DIAGNOSES REDACTED]. - Behavior- The previous facility staff assessed the resident demanded scheduled medications prior to their schedule times. The resident's behavior escalated with impulsive and /or assaultive behaviors. (pulling fire alarms, wrapping things around neck, becoming physically aggressive). During an interview on 6/1/16 at 3:30 P.M., the administrator said the following: - Resident #1 was admitted to the facility on [DATE]. - Staff did not complete an initial MDS as required on Resident #1. - The facility used the previous facility's Plan Of Care from the time of admission until 5/20/2016. Observation on 6/1/16 at 11:00 A.M., showed the resident with moderate cognitive impairment, was self ambulatory, and followed or walked with the staff. Further observation on 6/1/16 at 11:00 A.M., showed the resident stood near the medication carts and the nursing station voicing the word medicines repeatedly. Review of nursing notes dated 5/18/2016 at 11:25 P.M., showed staff documented Resident #1's roommate called Certified Nursing Assistant (CNA) A and Licensed Practical Nurse (LPN) B to the resident's room on 5/18/16 at approximately 11:00 P.M. Staff documented the resident ingested 31 tablets which contained 5 milligrams (mg) Hydrocodone (an opioid narcotic used for pain management) and 325 mg Acetaminophen. (According to (Drugs.com 2016) an overdose of this medication can cause loss of breathing, resulting in death). Staff documented the resident stated he/she did not take the medication. LPN B documented in the nursing notes he/she placed the medication under a binder at the nurse's station for a period of 20 minutes. The staff called Law Enforcement, Emergency Medical Services (EMS), and next of kin following the incident. EMS transported the resident to a local hospital for emergency treatment and they transferred the resident to a specialty care hospital for further treatment. The resident was hospitalized for [REDACTED]. Review of the resident's emergency department records showed the resident's acetaminophen level obtained by blood sample on 5/18/16 measured 152.3 micrograms per milliliter (normal range is 10.0 - 30.0 mcg/ml), five times the normal range. Records also showed the resident required the medication Naloxone 0.2 mg. (a medication used for overdoses of opioid narcotic medication) which was administered twice at the hospital emergency department. Review of CNA A's written statement (undated) showed CNA A retrieved a card of pills from the resident while walking down the hall on 5/16/16 between 9:00 P.M. and 9:30 P.M. CNA A informed LPN B he/she found the resident with the card of medication and gave the card of medication to LPN B. As of 06/10/16 attempts to contact CNA A for an interview were unsuccessful. Review of LPN B's written statement, dated 5/19/16 at 2:00 P.M., showed LPN B documented the resident had taken a full card of Hydrocodone that was placed under a three ring binder at the nurses desk, unknown to LPN B. LPN B stated CNA A had retrieved the card from the resident previously at approximately 10:00 P.M. CNA A gave the gave of narcotic medication to LPN B who placed in back under the three ring binder at the nursing station, before he/she responded to a resident alteration down the 400 hall. LPN B returned to the nursing station 20 minutes later and discovered the card of narcotic medication to be missing and summoned CNA to assist in its location. The resident's roommate alerted staff to the resident in his/her room who had ingested the 31 tablets from the narcotic medication card. During an interview on 6/1/15 at 10:30 A.M., LPN B confirmed his/her written statement. LPN B said he/she was familiar with the resident and was aware the resident had a history of [REDACTED]. LPN B said he/she had observed the resident who was known to stand at the nursing station and demand medications in the past. LPN B said he/she initially did not know there was a medication card which contained 31 tablets of Hydrocodone/ Acetaminophen at the nursing station. LPN B said the medication may have been put there during or after shift change at 2:00 P.M., but denied placing the medication under a three-ring binder at the nursing station. LPN B said CNA A retrieved a card of Hydrocodone/ Acetaminophen pills from the resident while walking down the hall around 9:00- 9:30 P.M LPN B said CNA A found the resident with the card of medication and gave the card of medication to LPN B. LPN B said he/she did not lock up the medication, and placed the medication under a binder at the nurse's station for a period of 15-20 minutes while he/she responded to a resident to resident physical altercation on the 400 hall. LPN B said upon his/her return to secure the medication, the medication was missing, and Resident#1's roommate alerted the staff Resident#1's ingested all the tablets of Hydrocodone/ acetaminophen within the card. LPN B said they contacted emergency medical services (EMS) and the local police immediately. LPN B said the resident was awake and talking and EMS obtained vital signs which were in normal limits. LPN B said the resident's roommate discharged to another facility due to unrelated reasons, and confirmed CNA A was no longer employed at the facility. During an interview on 6/1/15 at 1:00 P.M., LPN C said the resident had a history of [REDACTED]. LPN C said he/she and Certified Medication Technician (CMT) D completed inventory count for day shift on 5/18/16, and placed one card of 31 tablets containing 5 mg Hydrocodone and 325 mg acetaminophen on the medication cart in front of LPN B to secure in the cart's lock box. LPN B, LPN C CMT D and the Director of Nursing (DON) were standing at/or near the cart at that time. During an interview on 6/1/15 at 1:30 P.M., CMT D said the resident often stood at the nursing station and medication carts wanting medicines. CMT D said he/she and LPN C completed inventory and LPN C placed one card of 31 tablets containing 5 mg Hydrocodone and 325 mg acetaminophen on the medication cart in front of LPN B to secure in the cart's lock box. LPN C, CMT D, and LPN B were standing at/or near the cart at that time. During an interview on 6/1/15 at 4:30 P.M., the administrator confirmed she conducted an investigation following the incident involving the resident's overdose. The administrator said staff did not complete a comprehensive assessment MDS for the resident who was admitted on [DATE]. The administrator said the staff were aware of the resident's medication seeking behaviors and utilized the resident's previous care facility's POC which they last updated 10/06/15. The administrator said they did not plan interventions for the resident until 5/20/16 following the resident's overdose. The administrator said they re-educated all licensed staff who administer medications on the topic of medication safety, medication storage and facility policy. MO 294

Based on interview and record review, facility staff failed to thoroughly investigate an allegation of verbal abuse in a timely manner, failed to remove the alleged perpetrator from working with residents at the time of the report to ensure resident safety, failed to report the incident to the Department of Health and Senior Services (DHSS) after they determined it was abuse as required and as directed in the facility policy, and allowed the alleged perpetrator to return to work directly with residents without providing monitoring, increased supervision, or re-education to ensure resident safety. The facility census was 33. 1. Review of the facility's Abuse Prevention Program, revised 2012, showed the policy directed staff as follows: -"Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability"; -If an incident occurs, or there is any reason to suspect that an incident might have occurred of abuse, neglect, mistreatment, or misappropriation of resident property, the administrator, or designee, will investigate; -While the investigation is being conducted, accused individuals or those suspected of being responsible for abuse, neglect, mistreatment, or misappropriation of resident property, and who are employees of the facility will be placed on suspension pending the results of the investigation; -If an alleged or suspected incident of abuse, neglect, mistreatment, or misappropriation of resident property occurs, the administrator, or designee, will report to the following: Missouri requires a call be made to the Elderly Abuse and Neglect Hotline. 1. Review of Resident #15's Minimum Data Set (MDS), a federally mandated instrument required to be completed by facility staff, dated 08/09/13, showed staff identified the resident understands and is understood. Additional review showed staff assessed the resident required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the care plan, updated 08/09/13, showed staff identified the resident requires extensive assistance with activities of daily living due to weakness and inability to transfer self. Review showed staff identified the resident as incontinent of bladder and bowel. Review of the care plan showed staff are directed to provide pericare after each episode of incontinence. Review of the facility's "Complaint/Grievance report", dated 08/01/13, showed the Director of Nursing (DON), documented Resident #14 reported to her an allegation of verbal abuse. Resident #14 reported Certified Nurse Aide (CNA) B yelled at Resident #15 to change his/her clothes after an incontinent accident. CNA B then asked Resident #14, "is he/she retarded?" (referring to Resident #15). The DON did not complete the remainder of the form including areas regarding findings of investigation, plan to resolve complaint/grievance, results of actions taken and reportable to state agency. During an interview on 08/28/13 at 2:15 P.M., Resident #14 said he/she reported to the DON that CNA B "was rude and hateful." The resident reported to the DON, CNA B told Resident #15 "you better be up and dressed." CNA B turned to Resident #14 and asked "Is something wrong with him/her? Is he/she retarded?" Review of the facility's "Disciplinary Action" form, dated 08/13/13, showed the facility suspended CNA B on 08/13/13 and 08/14/13 for "verbal abuse" and "rough care." Further review showed the DON documented Resident #15 reported CNA B was verbally abusive and rough with him/her after an incontinence episode on 07/31/13 and asked his/her spouse (Resident #14) if Resident #15 "was retarded." Additional review showed CNA B, the DON and the administrator signed the form. Review of the facility schedule, dated August 2013, showed CNA B was scheduled to work the following dates (after resident #14 and Resident #15 reported the allegation to the DON): -08/03/, 08/04, 08/08, 08/09, 08/11 and 08/12. Further review of the schedule showed CNA B was scheduled to work the following dates (returning from suspension): -08/19, 08/23, 08/25 and 08/26. During an interview on 08/28/13 at 1:10 P.M., the DON confirmed CNA B worked on the dates he/she was scheduled after the residents reported the verbal abuse allegation. During an interview on 08/28/13 at 1:10 P.M., the DON said she "did not know" why she did not investigate the allegation or suspend the employee in accordance with the facility policy. The DON said she did not report the incident to the Department of Health and Senior Services (DHSS) after she concluded it was verbal abuse because "they only report physical abuse." During an interview on 08/28/13 at 4:10 P.M., the administrator said the DON did not report the allegation to him/her until 08/13/13. The administrator said she would expect the facility staff to investigate and report allegations of abuse in accordance with the facility policy. The administrator said they should have reported the allegation of abuse to her immediately. During an interview on 08/29/13 at 9:55 A.M., the DON said they did not provide increased monitoring or supervision of CNA B when he/she returned to work on 08/19/13. During an interview by phone on 09/04/13 at 10:40 A.M., CNA B said the charge nurses and/or DON did not give him/her any special instructions when he/she returned to work after suspension. The CNA said when he/she returned "it was back to work as usual." NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility in-serviced staff regarding the Facility Abuse Prevention Program. All staff will be in-serviced on the facility abuse Prevention Program prior to returning to work. Review of Resident rights dealing with abuse will be discussed with residents at the monthly resident council meetings and quarterly care plan meetings. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the " D " level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, staff interview and medical record review, staff failed to implement interventions as directed in one resident's (Resident #1)plan of care to prevent falls. Staff failed to apply alarms on the resident's bed and wheelchair as directed and the resident suffered a fall from his/her wheelchair without staff aware of the resident's attempt to stand without assistance. The facility census was 42. 1. Review of Resident #1's 14 day Medicare Minimum Data Set (MDS), a federally mandated assessment tool dated 09/27/10, showed the staff assessed the resident as follows: -Short and long term memory loss; -Cognitive skills moderately impaired for daily decision making; -Required extensive assistance of two staff members for bed mobility; -Required total assistance of two staff members for transfers and toileting; -Incontinent of urine and frequently incontinent of fecal material; -Unsteady gait; -fell in the last 31-180 days. Review of the resident's care plan updated 09/27/10 showed staff planned the following interventions regarding falls and accidents: -Place a personal alarm on the resident while in bed and chair; -Place a mat beside the resident's bed. Review of the resident's fall risk assessment dated [DATE] showed staff assessed the resident as at high risk for falls. Review of the resident's nurse's notes dated 12/20/10 showed staff documented they found the resident on the floor in his/her room. Staff documented the resident stood from the wheelchair and fell while trying to brush his/her teeth. The resident received a small abrasion to his/her left elbow. Staff did not document if the chair alarm sounded to alert the staff the resident stood up. During an observation on 12/28/10 at 1:30 P.M., Certified Nurse Aide (CNA) A and Nurse Aide (NA) B assisted the resident into bed. The staff started to leave the room without applying a bed alarm or placing a mat beside the bed. During an interview at that time, the staff said they "thought the resident should have a mat beside the bed" and placed a mat only after the surveyor inquired about the interventions for the resident. The CNAs also said the resident should have a personal alarm while in bed and in his/her wheelchair, but were unable to locate the alarms. Staff left the room and did not locate or apply an alarm on the resident while in bed as directed by the resident's plan of care. During an interview on 12/28/10 at 2:15 P.M., the MDS coordinator said staff should place a mat beside the resident's bed and the resident "did have a personal alarm on his/her wheelchair, but he/she was unsure if staff continued to place it." During an interview on 12/28/10 at 2:30 P.M., CNA C said staff no longer placed the bed alarm on the resident, but they continued to place a chair alarm on the resident's wheelchair. CNA C did not locate the alarm nor place it after assisting the resident to sit in his/her chair. During an interview on 12/28/10 at 2:30 P.M., Licensed Practical Nurse (LPN) D said he/she did not know if staff were directed to place a personal alarm on the resident's wheelchair. LPN D said he/she transferred from the evening shift and staff always assisted the resident into bed before he/she began the shift. He/She looked at the resident's chair and said the resident did not have an alarm at that time. He/She did not consult the resident's plan of care for direction. During an interview on 12/28/10 at 2:55 P.M., LPN E said staff no longer placed an alarm on the resident's bed or wheelchair. He/She said they discontinued alarms when the resident goes without a fall for at least 90 days. He/She said resident did not have an alarm attached to his/her wheelchair when the resident had a fall on 12/20/10. During an interview on 12/28/10 at 3:00 P.M., the administrator and the director of nurses (DON) said the resident's current care plan directed staff to place a personal alarm on the resident while he/she sat in the wheelchair and while in bed and expect staff to do so. The administrator directed staff to place an alarm on the resident's wheelchair immediately. MO 319