Every finding on record at Lawrence County Manor

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegations of possible physical abuse by staff involving one resident (Resident #1). Management and DHSS were not made aware of the allegation until the following day. The facility census was 66. Review of the facility policy titled Abuse, undated, showed the following:-The facility will ensure each resident is free from abuse, neglect, misappropriation of resident property, and exploitation;-Every staff member must immediately report any observed or suspected abuse of a resident by another staff member, resident, family member, or visitor;-The Director of Nursing (DON) will ensure all alleged violations are reported immediately, but not later than 2 hours after the allegation is made if the allegations involve abuse or result in serious bodily injury;-The DON will report to the Administrator of the facility and to other officials, including DHSS, not later than 24 hours if the allegations do not involve abuse and result in serious bodily injury.1.Review of Resident #1''s face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 09/14/22;-Diagnoses included hemiplegia (paralysis affecting one side of the body) of the left side, diabetes mellitus, and high blood pressure.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/25/25, showed the following:-Severe cognitive impairment;-No behaviors indicated; -Resident used a wheelchair and dependent on staff for all activities of daily living (ADLs- essential, routine self-care tasks such as, bathing, dressing, toileting, and mobility).Review of the resident's care plan, dated 11/27/25, showed the following:-Resident is dependent on all ADLs;-Resident can be resistive to care at times;-Staff should give clear explanations of all care activities prior to as they occur.During an interview on 01/30/26, at 12:05 P.M. Certified Nurse Aide (CNA) D said the following:-He/she would report any abuse to the charge nurse immediately;-An allegation should be reported to the state within two hours;-On 01/27/26, at approximately 8:00 P.M., CNA B answered a call light in the resident's room;-After leaving the resident's room, CNA B was seen running down the hall with blood on his/her face;-He/she asked the nurse what had happened and was told the resident hit CNA B in the face;-He/she and another CNA went to finish changing the resident;-The resident was not aggressive while he/she provided care;-The resident said he/she did not want that expletive in his/her room anymore;-It was out of character for the resident to hit someone;-The resident said CNA B punched him/her in the stomach and leg;-He/she reported the allegation to the charge nurse (Licensed Practical Nurse (LPN) A); -The charge nurse asked the resident some questions and reported CNA B would not be in the resident's room again.Review of the resident's progress note dated 01/27/26, at 8:30 P.M., showed LPN A documented the resident had the call light on when a staff member went to check on the resident. The resident stated he/she needed to be changed. This writer was passing medication when CNA B reported he/she (the CNA) had a bloody nose and lip. The LPN notified the DON and physician. (The LPN did not document the resident's allegation of possible abuse.)Review of the facility investigation report, dated 01/28/26, showed the following: -The alleged incident occurred 01/27/26 at approximately 8:30 P.M. in the resident's room;-Administration was made aware of the allegation on 01/28/26 at approximately 11:30 A.M.; -Administrator and DON completed a self-report on 01/28/26 at approximately 12:30 P.M.Review of the resident's progress note dated 01/28/26, at 2:28 P.M., showed the Administrator interviewed the resident on 01/28/26, at 12:15 P.M. The resident said CNA B hit him/her in the ribs. The resident then said, quit hurting me or I will poke your eyes out. The resident said CNA B hit him/her a second time on the lower right leg. The resident stated he/she grabbed CNA B's fingers and said, I will get a fork and poke your eyes out.Review of the DHSS records showed the facility self-reported the allegation of abuse to DHSS on 01/28/26 at 12:46 P.M. (16 hours after incident was initially reported to the charge nurse).During an interview on 01/30/26, at 1:00 P.M., LPN A said the following:-He/she would report abuse allegations to the DON immediately;-The state should be notified within two hours;-CNA B came to him/her with a bloody nose and reported the resident punched him/her in the face;-The resident told him/her that CNA B punched him/her in the right leg and that's why he/she hit CNA B in the nose;-The LPN texted the DON and the physician that CNA B hit the resident and had a bloody nose because the resident hit him/her back;-He/she never received a response to the text to the DON or physician;-He/she was unsure of what to do about the incident due to not receiving a response to the text.During an interview on 01/30/26, at 12:00 P.M., LPN C said the following:-He/she would immediately report an allegation to the supervisor;-Abuse should be reported to the state within two hours.During an interview on 02/02/26, at 9:30 A.M., Certified Medication Technician (CMT) E said the following:-He/she would report any abuse to the charge nurse immediately;-The state should be notified of an allegation of abuse within two hours.During an interview on 02/02/26, at 10:30 A.M., LPN F said the following:-He/she would report to the supervisor immediately;-State should be notified of an allegation of abuse in two hours.During an interview on 02/02/26, at 10:45 A.M., CMT G said the following:-He/she would notify the charge nurse of any allegations of right away;-The state should be notified within two hours of an allegation of abuse.During an interview on 02/02/26, at 11:15 A.M., the DON said the following:-The resident reported an employee hit him/her in the ribs during a care plan meeting on 01/28/26;-He/she received a text from staff on the night of 01/27/26, but did not get the text message until after the care conference on 01/28/26; -He/she will educate staff to call and not text her with information;-Staff should report abuse to the DON, Administrator, and state.During an interview on 02/02/26, at 11:30 A.M., the Administrator said the following:-Staff should report abuse immediately to administration;-Abuse should be reported to the state within two hours.Complaint #2729044

Based on interview and record review, the facility failed to timely investigate an allegation of abuse and ensure protection of all residents during the investigation when after receiving an allegation of possible staff physical abuse involving one resident (Resident #1) the staff did not begin an investigation until the next day and allowed the staff member to continue to work with residents independently. The facility had a census of 66. Review of the facility policy titled Abuse, undated, showed the following:-The facility will ensure each resident is free from abuse, neglect, misappropriation of resident property, and exploitation;-The facility will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;-The facility will ensure that all alleged violations are thoroughly investigated; -The Director of Nursing (DON) will immediately initiate an abuse incident report and begin investigation of alleged abuse;-The DON will prevent further potential abuse while the investigation is in progress;-Report the results of all investigations to DHSS within five working days of the incident;-The DON or Administrator will reassign or suspend the involved employee at their discretion to protect the residents during the abuse investigation.1.Review of Resident #1''s face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 09/14/22;-Diagnoses included hemiplegia (paralysis affecting one side of the body) of the left side, diabetes mellitus, and high blood pressure.Review of the resident's care plan, dated 11/27/25, showed the following:-Resident is dependent on all activities of daily care (ADLs- essential, routine self-care tasks such as, bathing, dressing, toileting, and mobility);-Resident can be resistive to care at times;-Staff should give clear explanations of all care activities prior to as they occur.Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/25/25, showed the following:-Severe cognitive impairment;-No behaviors indicated; -Resident used a wheelchair and dependent on staff for all ADLs.During an interview on 01/30/26, at 12:05 P.M. Certified Nurse Aide (CNA D) said the following:-On 01/27/26, at approximately 8:00 P.M., CNA B answered a call light in the resident's room;-After leaving the resident's room, CNA B was seen running down the hall with blood on his/her face;-He/she asked the nurse what had happened and was told the resident hit CNA B in the face;-He/she and another CNA went to finish changing the resident;-The resident said he/she did not want that expletive in his/her room anymore; -The resident said CNA B punched him/her in the stomach and leg;-He/she reported the allegation to the charge nurse (Licensed Practical Nurse (LPN) A); -The charge nurse asked the resident some questions and reported CNA B would not be in the resident's room again;-CNA B continued to work the rest of the shift on another hall.Review of the resident's progress note dated 01/27/26, at 8:30 P.M., showed LPN A documented the resident had the call light on when a staff member went to check on the resident. The resident stated he/she needs to be changed. This writer was passing medication when CNA B reported he/she had a bloody nose and lip. DON and physician notified. (The LPN did not document the resident's allegation, beginning an investigation, or steps taken to protect all residents.)During an interview on 01/30/26, at 1:00 P.M., LPN A said the following:-CNA B came to him/her with a bloody nose and reported the resident punched him/her in the face;-The resident told him/her that CNA B punched him/her in the right leg and that's why he/she hit CNA B in the nose;-He/she texted the DON and the physician that CNA B hit the resident and had a bloody nose because the resident hit him/her back;-He/she never received a response to the text to the DON or physician;-CNA B continued to work the rest of the shift but did not work with Resident # 1;-Staff accused of abuse should not have access to a resident after the allegation;-He/she was unsure of what to do about the incident due to not receiving a response to the text.Review of the facility investigation report dated 01/28/26, showed the following: -The alleged incident occurred 01/27/26 at approximately 8:30 P.M. in the resident's room;-Administration was made aware of the allegation on 01/28/26 at approximately 11:30 A.M.;-The Administrator interviewed the resident while the DON and Social Services Director (SSD) performed resident interviews to determine if any other resident had altercations with staff;-LPN C performed a full body assessment on the resident with no bruising or open areas noted to the areas where resident indicated the staff had harmed him.-Staff did not document steps taken to protect all residents immediately after the allegation was made.Review of the resident's progress note dated 01/28/26, at 2:28 P.M., showed the Administrator interviewed the resident on 01/28/26, at 12:15 P.M. The resident said CNA B hit him/her in the ribs. The resident then said, quit hurting me or I will poke your eyes out. The resident said CNA B hit him/her a second time on the lower right leg. The resident stated he/she grabbed CNA B's fingers and said, I will get a fork and poke your eyes out.During an interview on 02/02/26, at 11:15 A.M., the DON said the following:-The resident reported an employee hit him/her in the ribs during a care plan meeting on 01/28/26;-He/she received a text from staff on the night of 01/27/26, but did not get the text message until after the care conference on 01/28/26;-He/she will educate staff to call and not text her with information; -An employee accused of abuse should be suspended immediately pending an investigation.During an interview on 02/02/26, at 11:30 A.M., the Administrator said the following:-CNA B should have been suspended as soon as the allegation was made;-CNA B should not have worked with residents after the abuse allegation was made;-Staff should document everything related to the abuse allegation in a progress note.Complaint #2729044

Based on record review and interview, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, and accounting of all drugs when eight cards of narcotics for eight residents (Resident #3, #4, #5, #6, #7, #8, #9 and #10) were found in the former Director of Nursing's (DON's) office desk. The facility census was 64.Review of a facility policy entitled Medications, Narcotics, undated, showed the following:-Narcotics will always be stored under a double lock system;-Each narcotic that the pharmacy dispenses to the facility is accompanied by a narcotic record;-Narcotics will be counted at the beginning and end of each shift by the nurse or CMT ending their shift and the nurse or CMT beginning the shift;-Discontinued narcotics must be pulled from the medication cart and placed in a locked box in the medication room with their narcotic sheets attachedReview of a facility policy entitled Medication Storage and Handling, undated, showed the following:-Medications will only be accessible to authorized staff, and in a locked area when not under the direct observation of authorized staff;-Each unit's medication room will remain locked at all times;-The medication cart will always be locked unless it is in direct view of the unit nurse. No medications should be left unattended in resident rooms, on medication carts, at nurse stations;-Medications will be monitored by the unit nurse, charge nurse, and consultant pharmacist to assure that there are no expired, contaminated, or unusable. 1. Review of the facility investigation, dated [DATE], showed the following was found in the office of the former DON's unlocked desk drawer: -Twenty tablets of oxycodone (a narcotic pain reliever) 10 milligram (mg) for Resident #3 with an original order date [DATE];-Thirty tablets of hydrocodone-acetaminophen (a narcotic pain reliever) 5-325 mg for Resident #4 with an original order date [DATE];-Nine tablets of hydrocodone-acetaminophen 10-325 mg for Resident #5 with an original order date of [DATE];-Thirty tablets of hydrocodone-acetaminophen 5-325 mg for Resident #6 with an original order date of [DATE];-Thirty tablets of hydrocodone-acetaminophen 5-325 mg for Resident #7 with an original order date [DATE];-Thirty tablets of hydrocodone-acetaminophen 5-325 mg for Resident #8 with an original order date of [DATE];-Thirty tablets of oxycodone-acetaminophen 10-325 mg for Resident #9 with an original order date [DATE];-Forty-two tablets of Tramadol (a narcotic pain reliever) 50 mg for Resident #10 with an original fill date [DATE].During an interview on [DATE], at 9:35 A.M., Licensed Practical Nurse (LPN) A said the following:-When medications were running low or the there was a change in the dose, the med tech or the nurse will re-order them;-When medications arrived, the nurse signed for them;-When narcotics arrived, the nurse signed for them and added them to the narcotic count;-Staff were to count the narcotics every shift;-To dispose of a narcotic that is no longer needed staff must have two nurses witness;-Narcotics are supposed to be stored behind two locks;-Narcotics are not supposed to be stored in the office, or in the DON's desk;-He/she did not know why narcotics were found in the office.During an interview on [DATE], at 9:43 A.M., Certified Medication Technician (CMT) B said the following:-CMTs pass the scheduled and as needed narcotics;-When he/she got low on a medication they would reorder them from the pharmacy;-When medications arrived, the nurse signed for them and added them to the count;-When a medication was no longer needed, he/she turned them into the nurse;-He/she completed a count of all narcotics before and after their shift;-Narcotics were stored in the narcotic box on the medication cart,;-Narcotics were always kept behind two locks,-Narcotics were not to be stored anywhere else.During an interview [DATE], at 4:10 P.M., the investigation police officer confirmed the narcotic medications for eight residents was found in a drawer in the former DON's office. The officer said all the found medications were taken by police for an investigation. During interviews on [DATE], at 11:00 A.M. and 1:00 P.M, the interim DON said the following:-Narcotic medications were found in the former DON's office on [DATE],-He/she did not know why the medication was kept in the office,-Narcotics were to be stored in a locked room behind two locks,-Narcotics were not to be stored in any staff members office.During an interview on [DATE], at 1:00 P.M., the Administrator said the following:-On [DATE], management searched the former DON's office and found narcotic medication in his/her desk;-Narcotics were not to be stored in any office. During an interview on [DATE], starting at 1:09 P.M., the Interim DON said narcotic medications should be stored in a locked medication cart, and in a separately locked section for narcotic medications. Complaint 2627589

Based on interview and record review, the facility failed to ensure all residents were free from misappropriation of property when staff used one resident's (Resident #1) credit card without resident permission and when staff took money from one resident (Resident #2). The facility census was 64.Record review of the facility's policy titled Abuse, undated, defined exploitation as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. The same facility policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.1. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), completed 08/18/25, showed diagnoses included non-Alzheimer's dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), schizophrenia (a serious mental health condition that affects how people think, feel and behave), depression, and moderately impaired cognition.During an interview 10/30/25, at 2:13 P.M., the resident said the following: -His/her billfold disappeared a few weeks ago. Then credit card charges he/she did not make showed up on a bank statement;-The credit card was always kept in the billfold. The billfold was always kept in the resident's pocket, or in the lock box in the facility business office;-He/she would never give his/her billfold, money, or credit cards to anyone other than his/her family members;-He/she never asked any family to buy anything for him/her at the facility;-He/she had never asked staff to buy anything for him/her;-Prior to the missing billfold and investigation, the resident said he/she didn't know there was a vending machine in the building.During an interview on 10/29/25, at 10:40 A.M., the bookkeeper said suspicious charges were found on the resident's credit card while he/she was assisting the resident with Medicaid information. After requesting bank records for the residents account, the bookkeeper could determine a series of charges made at the facility's vending machine. The charges, all from the vending machine, were on the resident's credit card and dated 08/27/25 through 09/25/25. Total amount charged to the card was approximately $54.00.Review of the resident's bank records showed 20 charges to the credit card, from the dates of 08/27/25 through 09/24/25. Individual charges were for $2.65 or $2.80 and totaled $55.40. All charges were verified to be from the facility vending machine. During an interview on 10/29/25, at 10:45 A.M., the Administrator said he was able to confirm the former Director of Nursing (DON) had been working at the facility every day a charge was made on the vending machine. Then the Administrator said the facility put up a camera by the vending machine on 09/24/25. On 09/25/25, the camera recorded the former DON using the resident's credit card to make a purchase at the facility vending machine. After watching the video, the Administrator called the police. The police spoke with the former DON and found the resident's credit card in his/her bag. The police then arrested the former DON and took him/her to jail. During an interview on 10/31/25, at 1:09 P.M., the Administrator and the current DON said the former DON had committed misappropriation by using the resident's credit card for her gain and without knowledge of the resident.2. Record review of Resident #2's quarterly MDS, completed 09/05/25, showed diagnoses included psychosis (including auditory hallucinations) and cognitively intact.Review on 10/29/25, of the facility investigation (related to unauthorized use of Resident #1's credit card by the former DON) showed concerns from the resident about missing cash. The investigation showed the resident said approximately $16,000.00 was missing. It was cash he/she had given to the former DON for safe keeping. During an interview on 10/30/25, at 12:05 P.M., the resident said the following: -He/she had about $16,000.00 in cash missing. The cash was from three different checks he/she received as a payout of life insurance for his/her family member. The resident said he/she spoke with only the former DON about different options to cash the checks since the resident did not have any kind of bank account. According to the resident, the former DON had arranged for the Information Technology (IT) Person to take the resident to the bank to cash the checks. The resident said the IT Person took him/her to a bank where the IT Person had an account. The checks had to be put on hold, and they did not come back to the facility with any money the day of the bank visit. The bank visit occurred towards the end of August;-The IT Person came to the facility with $5,000.00 in cash. The resident took $500.00 for himself/herself, then asked the IT-person to give the remainder of this cash ($4,500.00) to the former DON. The resident believed the IT Person did give the cash to the former DON, because he/she confirmed it. The former DON had told the resident he/she had a safe in his/her office and would keep the cash for him/her so that the facility and the State of Missouri (Medicaid) would not take the money from the resident.Review of a facility investigation (unknown start date) showed facility staff heard from the IT Person that he/she had taken the resident to the bank to cash the cashier's checks. According to the investigation, the IT-person was given $1,500.00 for taking the resident to the bank. During an interview on 10/30/25, at 1:00 P.M., the IT Person said the following: -He/she had a contract with the facility and had been working in the building for approximately 2 1/2 years. He/she did not have interactions with the residents, but was introduced at the end of July 2025, to the resident by the former DON. The IT Person said the former DON pressured him to help cash the resident's checks, to which he/she later agreed. Then the IT Person told the resident he/she had to sign over the cashier's checks to him (the IT Person) so the checks could be deposited into the IT Person's account. Since the bank put a hold on the three checks, he/she drove the resident back to the facility without any cash. The date of this trip to the bank was approximately 08/01/25.;-He/she sked the resident for $1,000.00 to cash each check ($3,000.00 total). However, the resident said this was too much, and they agreed on $500 each check ($1,500.00 total). As each of the three checks cleared his bank, the IT Person simply kept back $500.00 of the funds. Then he/she would make a trip to the facility to give the remaining amount to the resident;-The first check cleared on approximately 08/06/25, the IT Person came to the facility, tried to give the resident cash (approximately $4,500.00), the resident took $500, then directed the IT Person to give the remaining amount ($4,000.00 in cash) to the former DON, which the IT Person did;-When the second check cleared, the IT Person brought the cash and the resident kept $1,000.00 for himself/herself and the IT-person brought the remaining amount ($3,500.00) to the former DON;-For the third check, the resident did not want to keep any of the money, so the IT Person gave the former DON $4,500.00 cash in a bank envelope. This last transaction occurred approximately 08/20/25.-He/she did not see the former DON put any money in a safe and never saw a safe in the former DON's office. He/she believed that the former DON would keep the money safe for the resident.During an on 10/31/25, at 1:09 P.M., the Administrator and the current DON said the following:-There had been rumors at the facility about the IT Person cashing checks for the resident. The Administrator decided to ask the IT Person on 09/29/25 about it. The IT Person stated he/she did keep $1,500.00 of the resident's money; -There had never been a safe in the former DON's office. No money was found in the office after the former DON was arrested;-The Administrator said he could not determine which person gave money to the former DON, or how many times cash was given to him/her;-The facility did not have record of how much total the cashier's checks were. They only had information from the resident and the IT Person;-The Administrator said $1,500.00 was an egregious amount for the resident to give the IT Person for taking him/her to the bank. He would not consider this to be a case of misappropriation since the money was returned. Complaints 2627589, 2629430

Based on observation, interview, and record review, the facility failed to ensure all residents' environments were free of accident hazards when the facility failed to implement a process to ensure resident accessible hot water temperatures in all resident access areas were maintained at a safe temperature resulting in the hot water in 12 residents rooms (Resident #2, #12, #24, #25, #6, #68, #36, #34, #15, #44, #55, and #38) and a common bath/shower room to measure between 125.6 to 138 degrees Fahrenheit (F). The facility census was 70.The Administrator was notified on 08/08/25, at 1:55 P.M., of an Immediate Jeopardy (IJ) which began on 08/05/25. The IJ was removed on 08/09/25 as confirmed by surveyor on-site verification. Review of the American Burn Association website, updated 2002, showed the following:-Hot water caused third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white of blackened, charred skin) at the following temperatures and time parameters:-In 1 second at 156 degrees F;-In 2 seconds at 149 degrees F;-In 5 seconds at 140 degrees F;-In 15 seconds at 133 degrees F;-In 1 minute at 127 degrees F;-Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Review of the facility's policy, Water Temperatures, Safety of, dated December 2009, showed the following: -Tap water in the facility shall be kept within a temperature range to prevent scalding of residents;-Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperature of no more than (blank) degrees F, or the maximum allowable temperature per state regulation;-Maintenance staff are responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log;-Maintenance staff should conduct periodic tap water temperature checks and record the water temperatures in a safety log;-If at any time water temperatures feel excessive to the touch, staff will report this finding to the immediate supervisor;-Direct-care staff shall be informed of risk factors for scalding/burns that are more common in the elderly such as decreased skin thickness; decreased skin sensitivity; peripheral neuropathy (the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged. This condition often causes weakness, numbness and pain, usually in the hands and feet.); reduced reaction time; decreased cognition; decreased mobility; and decreased communication. 1. Review showed the facility did not provide hot water temperature logs. 2. Review of Resident #2's (resided on 200 hall) face sheet (a brief resident profile sheet) showed the following:-admission date of 12/03/24;-Diagnoses included neurocognitive disorder with Lewy bodies (a progressive brain disorder that affects thinking, movement, behavior, and sleep), dementia (a group of thinking and social symptoms that interferes with daily functioning), psychosis not due to a substance or known physiological condition, type II diabetes (body doesn't produce enough insulin), and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS – a federally mandated assessment tool completed by facility staff), dated 06/12/25, showed the following:-Severally impaired cognition;-Minimal upper and lower extremity impairments;-Used a walker to assist with ambulation. Review of the resident's care plan, updated 08/04/25, showed the resident had impaired cognitive function or impaired thought processes. Observation on 08/08/25, at 9:20 A.M., showed the sink hot water temperature in the resident's room measured at 130 degrees F. During an interview on 08/08/25, at 9:24 A.M., Certified Nurse Aide (CNA) G said the resident was able to ambulate to the bathroom on his/her own and was encouraged to wash his/her hands after using the restroom. During an interview on 08/08/25, at 9:25 A.M., CNA H said the resident was able to ambulate to the bathroom on his/her own and use the sink. During an interview on 08/08/25, at 9:28 A.M., the Activities Director said the resident used a walker and can get to the bathroom and sink on his/her own. During an interview on 08/08/25, at 9:30 A.M., Licensed Practical Nurse (LPN) F said the following:-The resident can ambulate in his/her room independently;-The resident has dementia and is confused most of the time;-The resident had not had any injury from the hot water, but the water was hot down the resident's hall. 3. Review of Resident #12's (resided on 200 hall) face sheet showed the following:-admission date of 03/18/24;-Diagnoses included chronic kidney disease (progressive damage and loss of function in the kidneys). Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident used a wheelchair to assist with mobility. Observation on 08/08/25, at 9:25 A.M., showed the sink hot water temperature in the resident's room measured at 138 degrees F. 4. Review of Resident # 24's (resided on 200 hall) face sheet showed the following:-admission date of 10/05/20;-Diagnoses included dementia, type II diabetes, and peripheral venous insufficiency (veins in the legs have trouble sending blood back to the heart). Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was severely cognitively impaired;-The resident used a wheelchair to assist with mobility. Observation on 08/08/25, at 9:20 A.M., showed the sink hot water temperature in the resident's room measured at 130 degrees F. 5. Review of Resident #25's (resided on 300 hall) face sheet showed the following:-admission date of 08/25/23;-Diagnoses include dementia, Alzheimer disease (a progressive disease that destroys memory and other important mental functions), and type II diabetes. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was severely cognitively impaired;-The resident used a walker to assist with mobility. Observation on 08/05/25, at 10:00 A.M., showed the sink hot water temperature in the resident's room measured at 136 degrees F. 6. Review of Resident #63's (resided on 200 hall) face sheet showed the following:-admission date of 02/27/25;-Diagnoses included dementia and Alzheimer disease. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was severely cognitively impaired;-The resident used a wheelchair to assist with mobility. Observation on 08/08/25, at 9:35 A.M., showed the sink hot water temperature in the resident's room measured at 136 degrees F. 7. Review of Resident #6's (resided on 200 hall) face sheet showed the following:-admission date of 10/31/22;-Diagnoses included peripheral vascular disease (narrowed blood vessels), epilepsy (seizure), hypertension (high blood pressure), other speech and language deficits following cerebral infarction (stroke), abnormalities of gait (manner to walk) and mobility, other lack of coordination, paranoid schizophrenia (a mental health disorder causing a feeling of distrust, suspicion, and fear of someone without good reason), and aphasia (a language disorder that affects a person's ability to communicate). Review of the resident's significant change MDS, dated [DATE], showed the following:-Severely impaired cognitive skills for daily decision making;-Resident used a wheelchair. Observation on 08/05/24, at 1:51 P.M., showed the hot water temperature in the sink of the resident's room measured 133.1 degrees F. Observation on 08/08/24, at 10:50 A.M., showed the water temperature in the sink of the resident's room measured 132 degrees F. 8. Review of Resident #68's (resided on 200 hall) face sheet showed the following:-re-admission date of 09/12/24;-Diagnoses included stroke, high blood pressure, type II diabetes mellitus without complications, and chronic pain. Review of the resident's annual MDS, dated [DATE], showed the following:-Moderately impaired cognitive status;-Resident used a wheelchair. Observation on 08/05/24, at 1:51 P.M., showed the hot water temperature in the sink of the resident's room measured 133.1 degrees F. Observation on 08/08/24, at 10:50 A.M., showed the hot water temperature in the sink of the resident's room measured 132 degrees F. 9. Review of Resident #36's (resided on 200 hall) face sheet showed the following:-admission date of 02/03/25;-Diagnoses included anxiety disorder, high blood pressure, gout (painful arthritis in the joints), and chronic pain. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Resident used a wheelchair. Observation on 08/05/24, at 2:02 P.M., showed the hot water temperature in the sink of the resident's room measured 133.3 degrees F. 10. Review of Resident #34's (resided on 200 hall) face sheet showed the following:-re-admission date of 03/31/21;-Diagnoses included Alzheimer's disease, senile degeneration of brain (a decline in memory, reasoning, and the ability to perform everyday activities), schizoaffective disorder (a mental health condition that involves seeing things or hearing voices that others do not observe), bipolar type (episodes of mood swings ranging from low to high), major depressive disorder (mental health disorder causing depressed mood or loss of interest in activities), unspecified dementia (loss of memory), cognitive communication deficit (difficulties with communication due to a lack of memory and problem solving abilities) , other abnormalities of gait (manner of walking) and mobility, and other lack of coordination (poor muscle coordination that causes unusual movements). Review of the resident's quarterly MDS, dated [DATE], showed cognitive pattern not assessed due to resident rarely/never understood. Observation on 08/05/24, at 2:02 P.M., showed the hot water temperature in the sink of the resident's room measured 133.3 degrees F. 11. Review of Resident #15's (resided on 300 hall) face sheet showed the following:-admission date of 05/11/23;-Diagnoses included dementia, anxiety disorder, major depressive disorder, type two diabetes mellitus, and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Required a wheelchair for ambulation. Observation on 08/08/25, at 12:15 P.M., showed the resident's hot water temperature measured at 127.9 degrees F. 12. Review of resident #44's (resided on 300 hall) face sheet showed the following:-admission date of 08/15/23;-Diagnoses included dementia, unspecified psychosis (delusions or hallucinations), multiple sclerosis (disease in which the immune system eats away at the protective covering of the nerves), legal blindness, anxiety disorder, and major depressive disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Does not require assistive devices. Observation on 08/08/25, at 12:15 P.M., showed the resident's hot water temperature measured at 127.9 degrees F. 13. Review of Resident #55's (resided on 300 hall) face sheet showed the following:-admission date of 06/19/25;-Diagnoses included Alzheimer's disease early unspecified psychosis, and anxiety disorder. Review of the resident's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Independent with walking. Observation on 08/08/25, at 12:15 P.M., showed the resident's hot water temperature measured at 125.6 degrees F. 14. Review of Resident #38's (resided on 300 hall) face sheet showed the following:-admission date of 12/04/17;-Diagnoses included vascular dementia, hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) affecting left non-dominant side, aphasia, high blood pressure, and major depressive disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Totally dependent on staff for all ADLs except eating. Observation on 08/08/25, at 12:15 P.M., showed the resident's water temperature at 126.8 degrees F. 15. Observation on 08/08/25, at 10:00 A.M., showed main bathroom/shower room on 200 hall, located just past room [ROOM NUMBER] and across from rooms [ROOM NUMBERS], with door unlocked and accessible to all residents had a hot water temperature in the sink that measured 138 degrees F. The water temperature in the shower measured 127 degrees F. 16. Observation on 08/08/25, at 9:45 A.M., showed the water heater on the 200 hall, which was behind a locked door, with a temperature set at 140 degree F. 17. During an interview on 08/08/25, at 9:40 A.M., the Maintenance Supervisor said the following:-He/she had been the maintenance supervisor for four months and had not tested any hot water temperatures in any resident rooms or the public restrooms;-He/she was under the impression that another department was doing that;-He/she just found out yesterday that the other department was not doing any hot water temperature testing;-The last water temperature logs were from 2023;-The water heater on the 200 hall was turned up to 140 degrees F. During an interview on 08/08/25, at 10:35 A.M., CNA I said the following:-He/she has been the shower aide for about three months;-The door to the main bathroom/shower room was always unlocked during the day shift and night shift;-Many residents use the bathroom and sink in the main shower room throughout the day as it is easier for the residents to use because of the larger size;-He/she didn't know who checked the water temperatures. During an interview on 08/08/25, at 11:05 A.M., the Housekeeping Supervisor said the following:-He/she did not check any resident hot water temperatures currently;-He/she checked resident water temperatures about ten years ago. He/she would test every resident room monthly and do random spot checks weekly. He/she also checked all the main bathroom/shower rooms on each hall weekly because a lot of residents use those bathrooms and wash their hands in those bathrooms;-Water temperatures should be between 105 to 115 degrees F;-Elderly skin is thin and frail and burns easier than an average adult;-Maintenance should be checking the water temperatures weekly. During an interview on 08/08/25, at 9:24 A.M., CNA G said the following:-He/she didn't know what temperature the hot water should be set at;-He/she didn't know who checked the hot water temperature or how often it was to be checked. During an interview on 08/08/25, at 9:25 A.M., CNA H said the following:-He/she didn't know what temperature the hot water should be set at;-He/she didn't know who checked the hot water temperature or how often it was to be checked. During an interview on 08/08/25, at 9:30 A.M., LPN F said he/she was not sure who monitored the water or how often. During an interview on 08/08/25, at 2:45 P.M., the Director of Nursing (DON) said the following:-He/she didn't have anything to do with testing of the hot water;-He/she didn't know who was to be monitoring the water temperatures;-He/she expected staff to notify him/her if the water was too hot;-He/she was not sure what the water temperature should be;-Anything over 120 degrees F was too hot;-A resident with dementia should not have a water temperature above 120 degrees. During an interview on 08/08/25, at 3:44 P.M., the Medical Director said the following:-He/she expected staff to be monitoring the hot water temperature;-He/she expected the thermostat on the hot water heater to be set per regulation;-He/she expected staff to notify maintenance or administration if the water temperature feels too hot;-He/she expected staff to follow the regulations. During an interview on 08/08/25, at 11:35 A.M., the Administrator said that water temperature checks were not being done and logged per protocol. The Maintenance Supervisor was under the assumption the Housekeeping Supervisor was doing the checks. The hot water temperatures be kept between 105 to 120 degrees F. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level.

Based on observation, interview, and record review, the facility failed to store, prepare and distribute and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility staff failed to ensure all food items were properly labeled and sealed, failed to ensure expired foods were discarded, and failed to ensure the dishwasher washed and rinsed the dishes at the recommended temperatures. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 70 residents.1. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location, and where it is not exposed to splash, dust, or other contamination. Review of the facility policy titled, Date Marking and Food Storage Policy and Procedure. revised 09/19/24, showed the following: -All food stored for more than 24 hours will be properly identified and marked according to the following guidelines;-Unopened cases of dry food items will be dated with the date the case was received into the facility and will be stored in such a manner to ensure the first in-first out (FIFO) method of rotation;-Once a case is opened, the individual food items from the case are dated with the date the items were received into the facility and placed in/on the proper storage unit utilizing the FIFO method of rotation;-Expiration dates on commercially prepared, dry storage food items will be followed;-Unopened cases of refrigerated food items will be dated with the date the item was received into the facility and will be stored in such a manner to ensure FIFO;-Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in the proper storage, ensuring FIFO;-Once opened, all ready to eat, potentially hazardous food will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date;-Unopened cases of frozen food items will be dated with the date the item was received into the facility and will be stored in such a manner to ensure FIFO;-Frozen food packages removed from the case will be dated with the date the item was received into the facility and placed in the proper storage, ensuring FIFO;-Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date;-Discard food items when the food item has been refrigerated for seven days, the food items is leftover for more than three days, or the food items is older than the expiration date. Observation on 08/04/25, at 9:38 A.M., in the kitchen showed the following:-A 57-ounce carton of mashed potatoes unsealed and open to air;-Inside the walk-in cooler was an opened bag of mozzarella cheese in an unsealed plastic bag open to air; tomato soup in a covered pitcher dated 07/30/25; minestrone soup in a covered pitcher dated 07/30/25; and angel food cake in sealed bag dated 07/28/25;-Inside the walk-in freezer was a bag of unlabeled, unsealed and open to air chicken fingers; an unsealed and open to air, unlabeled bag containing a pizza with visible ice crystals; and an unsealed and open to air, unlabeled bag of hamburger patties. Observation on 08/06/25, at 10:06 A.M., in the kitchen showed the following:-Inside the walk-in cooler was an opened bag of mozzarella cheese in an unsealed plastic bag open to air and minestrone soup in a covered pitcher dated 07/30/25;-Inside the walk-in freezer was an unsealed and open to air, unlabeled bag containing a pizza with visible ice crystals, and a box container unsealed and opened to air big blue bag of chocolate chips. During an interview on 08/07/25, at 2:00 P.M, Dietary Aide (DA) M said the following:-Staff should wrap or seal opened food and label with date opened, item name, and employee number;-Staff can refrigerate some leftovers and some open food for five days. Some food items must be discarded the same day. During an interview on 08/07/25, at 2:10 P.M., Dietary [NAME] (DC) N said the following:-Staff should ensure opened food in a sealed container with the date opened and date use by;-Refrigerated food can be stored for three to five days, but most should be thrown out after three days;-Any food item with ice crystals should be discarded.During an interview on 08/08/25, at 10:53 A.M., DC L said the following:-Staff should seal and label opened foods with date opened and use by, and initials;-Staff should discard leftovers and warmed foods after three days.During an interview on 08/7/25, at 2:21 P.M., the Dietary Manager (DM) said the following:-Staff should date, seal, and label opened food;-Leftovers can be stored for five days, but he/she preferred not storing over three days;-Soups can be refrigerated for five days after opening;-Staff should discard food with ice crystals.During an interview on 08/14/25, at 10:21 A.M., the Registered Dietitian said the following:-Staff should seal, label and date opened food items;-Staff should keep opened refrigerated foods for three days. During an interview on 08/07/25, at 5:44 P.M., the Administrator said the following:-Staff should label, date, and seal opened food;-Refrigerated food should be kept for three days and discarded after. 2. Review of the facility policy titled, Dishwashing Machine, revised 09/24/24, showed the following: -The food services staff shall maintain the operation of the dish machine according to established procedure and manufacture guidelines posted or contained in this policy to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food;-All dishwashing machines should be operated according to manufacturer recommendations. Tableware, utensils, and pots and pans should be cleaned and sanitized in either a high temperature dishwashing machine that uses hot water, or a chemical-sanitizing dishwashing machine that uses a chemical sanitizing solution;-Monitor that the machine is maintaining operating guidelines for wash, rinse, and final rinse temperatures to reach 150 degrees Fahrenheit (F) for wash and 180 degrees F for rinse, and log after each meal service. Review of the manufacturer's recommendations of the CMA-180 high temperature commercial dishwasher temperature should reach 155 to 160 degrees F for the wash cycle and 180 to 195 degrees F for the rinse cycle. Observations of the kitchen and review of the temperature record for the dishwasher on 08/07/25, at 1:50 P.M., showed the following:-The manufacturer minimum temperature levels for the wash at 155 degrees F and rinse 180 degrees F were visible on the side of the dishwashing unit;-The wash cycle showed a temperature of 130 degrees F and the rinse cycle showed a temperature of 175 degrees during the first observation;-The wash cycle showed a temperature of 134 degrees F and the rinse cycle showed a temperature of 172 degrees during the second observation;-The wash cycle showed a temperature of 130 degrees F and the rinse cycle showed a temperature of 168 degrees during the third observation;-The temperature record for the wash cycle from 08/01/25 to 08/06/25, showed the highest temperature documented at 152 degrees F. During an interview on 08/07/25, at 1:50 P.M., DA R said the following:-The dishwasher manufacturer recommendations were for the temperature of the wash cycle to be a minimum of 150 degrees F and the rinse cycle to be a minimum of 180 degrees F;-Staff should log temperatures after every meal service;-He/she drained the dishwasher if the temperature was not reaching minimum levels;-If the temperature was still not reaching minimum levels, he/she would notify the DM. During an interview on 08/07/25, at 2:00 P.M, DA M said the following:-The dishwasher wash cycle temperature should be a minimum of 150 degrees F and rinse at a minimum of 180 degrees F;-Staff should log dishwasher temperatures after each meal service;-He/she would notify the maintenance supervisor if the dishwasher temperatures were not reaching minimum degrees. During an interview on 08/07/25, at 2:10 P.M., DC N said the following:-The dishwasher wash cycle temperature should be a minimum of 150 degrees F and rinse at a minimum of 180 degrees F;-Staff should log dishwasher temperatures after each meal service;-He/she would notify maintenance if the dishwasher temperatures were not reaching minimum degrees.During an interview on 08/08/25, at 10:53 A.M., DC L said the dishwasher wash cycle temperature should be a minimum of 150 degrees F and rinse at a minimum of 180 degrees F. During an interview on 08/07/25, at 2:21 P.M., the DM said the following:-The dishwasher wash cycle temperature should be a minimum of 150 degrees F and rinse at a minimum of 180 degrees F;-If the temperatures were not reaching minimum levels, staff would wash, rinse, and sanitize dishes by hand;-She notified the technician with any concerns.During an interview on 08/14/25, at 10:21 A.M., the RD said staff should follow the manufacturer recommendations for minimum temperatures for the dishwasher and if not meeting the minimum, wash and sanitize by hand or have a process to run bleach through until repaired. During an interview on 08/07/25, at 5:44 P.M., the Administrator said the following:-The dishwasher wash cycle temperature should be a minimum of 155 degrees F and rinse at a minimum of 180 degrees F;-Staff should log dishwasher temperatures after each meal service;-Staff should notify maintenance if not reaching minimum levels.

Based on interview and record review, the facility failed to implement their abuse and neglect prevention policies, when they failed to complete an employee disqualification list (EDL - a list of individual prohibited from working in a long-term care facility in Missouri due to a finding of abuse or neglect) check and a check of the Nurse Aide (NA) Registry (a list checking for a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them from working in a certified facility) for four staff members (Housekeeper (HK) S, Certified Nurse Aide (CNA) T, Dietary Aide (DA) U, and Dietary [NAME] (DC) N) of ten sampled records. The facility census was 70.Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised April 2021, showed the facility will conduct employee background checks and not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property; or a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. 1. Review of HK S's personnel record showed the following:-Hire date of 06/18/25;-Facility staff did not document completion of an EDL check or check of the NA registry. 2. Review of Certified Nurse Aide (CAN) T's personnel record showed the following:-Hire date of 06/11/25;-Facility staff did not document completion of an EDL check or check of the NA registry. 3. Review of DA U's personnel record showed the following:-Hire date of 03/27/24;-Facility staff did not document completion of an EDL check or check of the NA registry. 4. Review of DC N's personnel record showed the following:-Hire date of 07/03/24;-Facility staff did not document completion of an EDL check or check of the NA registry. During an interview on 08/13/25, at 12:40 P.M., the Administrator said the following:-The Business Office Manager completed EDL and NA registry checks on all staff prior to hire;-Periodic EDLs should be completed quarterly on all staff.

Based on observation, interview, and record review, the facility failed to ensure all residents were appropriately screened prior to placement in a nursing home when the facility failed to obtain documentation of Preadmission Screenings and Resident Reviews (PASARR) for two residents (Resident #2 and #69). The facility census was 70.Review of the document the facility provided as their policy titled Missouri Department of Health & Senior Services Level One Form Training, dated 02/08/24, showed the following:-The PASARR process requires that all applicants to Medicaid-certified nursing facilities (regardless of whether their stay will be covered by private funds, Medicare, or Medicaid) be given a preliminary assessment to determine whether they might have a serious mental illness (SMI) or an intellectual disability (ID);-PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care;-All applicants to a Medicaid-certified nursing facility will be evaluated for a serious mental disorder and/or intellectual disability;-Nursing homes may not admit a resident suspected of having a SMI or ID diagnosis without the Level II screening being completed;-The Level II screening provides a comprehensive review of the resident's past and current behavioral health conditions, and the services needed to ensure their health and safety;-All clients entering/residing in a Medicaid certified bed must have a Level I form completed. 1. Review of Resident #2's face sheet (a brief resident profile sheet) showed the following:-admission date of 12/03/24;-Diagnoses included neurocognitive disorder with Lewy bodies (a progressive brain disorder that affects thinking, movement, behavior, and sleep), dementia (a group of thinking and social symptoms that interferes with daily functioning), psychosis not due to a substance or known physiological condition, and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS – a federally mandated assessment tool completed by facility staff), dated 06/12/25, showed severally impaired cognition. Review of the resident's care plan, updated on 08/04/25, showed the resident had impaired cognitive function or impaired thought processes. Review of the resident's electronic medical record (EMR) showed staff did not have documentation of a Level I or Level II PASARR completed. During an interview on 08/07/25, at 4:30 P.M., the Bookkeeper said the following:-Resident #2 was a private resident;-The facility did not do any PASARRs on private pay residents. 2. Review of Resident #69's face sheet showed the following-admission date of 07/31/24;-Diagnoses schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar disorder (mood swings ranging from depressive lows to manic highs), major depressive disorder, anxiety disorder, and unspecified dementia. Review of the resident's care plan, revised 05/12/25, showed the following:-Resident had a public administrator as his/her guardian;-Resident wandered due to dementia and had a history of destructive and inappropriate behaviors due to schizophrenia. Resident received care from a psychiatric physician;-Resident has impaired cognitive function and impaired though processes related to dementia and schizophrenia;-Resident has delirium related to dementia and delirium;-Resident used antipsychotic, antianxiety, and antidepressant medications. Review of the resident's quarterly MDS, dated [DATE], showed the resident was moderately cognitively impaired. Review of the resident's EMR showed staff did not have documentation of a Level I or Level II PASARR completed During an interview on 08/07/25, at 4:30 P.M., the Bookkeeper said the resident came to the facility from another facility that is not required to complete a Level I or Level II PASARR. The resident was a private pay resident. The facility does not do any PASARRs on private pay residents. During an interview on 08/07/25, at 4:30 P.M., the Bookkeeper said the following:-He/she had been doing PASARRs at the facility for the last 11 years;-He/she does all the PASARRs for the facility;-All Medicaid/Medicare residents should have a Level I PASARR and a Level II PASARR (if indicated) on file;-The facility does not do any PASARRs on private pay residents;-All the beds in the facility were dually certified as Medicare/Medicaid and private pay beds. During an interview on 08/13/25, at 11:15 A.M., the Administrator said the following:-The Bookkeeper completed all the PASARRs;-The Administrator expected that all residents have a Level I and Level II PASARR, if indicated, upon entering the facility.

Based on observation, interview, and record review, the facility failed to ensure the nutritional needs of all residents were met when staff failed to prepare pureed diets per approved recipes and failed to provide the approved serving size for pureed meals. The facility census was 70.Review of the facility policy titled, Puree Step by Step Guide, undated, showed the following:-Count items needed for puree as you are placing it into the food processor, and make two additional portions above your number of puree diets;-Gradually add hot liquid of choice with food to puree to a pudding like consistency (gravy/broth/hot milk-never use water);-Scrape sides of food processor and continue blending until there are no lumps/bumps in puree;-Use tongs to take blade out of food processor and use spatula to scrape product into serving pan;-Re-heat puree product in steam water bath on stove to 165 degrees Fahrenheit (F) or greater. 1. Review of the facility's recipe for pureed jambalaya showed the following:-Prepare according to the regular jambalaya recipe;-Blend until smooth and serve one cup portion or two #8 scoops (four ounce (oz) per serving. Review of the facility's recipe for pureed white rice with gravy showed the following:-Bring two cups and three tablespoons of water to a boil;-Add three fourths of a teaspoon of salt and six and three fourth ounces of rice to the boiling water, stir, cover tightly, and cook on low heat until rice is tender and all the water is absorbed (about 20 minutes);-Remove from heat and let stand, covered, for five to ten minutes and then add three fourths teaspoon of margarine;-Dissolve one and three fourth ounces of any chicken base in one cup and three tablespoons of hot water to make broth. Remove portions needed from regular prepared recipe of white rice and place in food processor. Add the broth and blend until smooth;-Prepare any gravy mix according to package instructions and serve one fourth a cup (four oz) over one half cup of rice.Review of the facility's menu spread sheet for 08/06/25 showed residents should have one cup of pureed jambalaya (eight ounces) and one-half (four ounces) cup of pureed white rice with gravy.Observation on 08/06/25, at 11:12 A.M., showed the following;-Dietary [NAME] (DC) L began to puree the lunch meal for six puree diets;-DC L used six oz scoops to place six servings of jambalaya with the rice mixture into the processor (the recipe called for 8 ounces of jambalaya per serving and one cup of rice per serving and or them to be pureed separately);-DC L used a total of seven tablespoons of powdered thickener while pureeing the jambalaya to puree to the correct consistency;-DC L said did not consult a recipe during the puree process.Observation on 08/06/25, at 11:56 A.M., showed the following:-DC L placed a three-ounce scoop in the pureed jambalaya mixed together with rice and gravy;-DC L used two three-ounce scoops equal to six ounces for serving one pureed portion of jambalaya mixed together with rice and gravy.During an interview on 08/08/25, at 10:53 A.M., DC L said the following: -He/she does not follow a recipe to prepare puree meals;-Staff have menus to tell them what scoops to use for serve out, but he/she did not use them and just goes by what the Dietary Manager (DM) tells him/her to use;-He used six-eight ounces scoops for meat and four-six ounces scoops for vegetables or whatever the DM tells him/her to use;-DM has trained there is a set number for meats and vegetables. During an interview on 08/07/25, at 2:21 P.M., the DM (DM) said the following: -Staff do not follow a recipe for preparing puree meals;-She trained staff to use a three oz green scoop for meats to puree lunch and dinner meals and two oz scoop for meats to puree for breakfast meals, four oz scoop to puree fruits and vegetables, and doubles to six oz to puree meals such as jambalaya;-Staff do not use menus to thicken puree meals. She trains them on consistency, and how to thin out if necessary. The staff all know how much to use;-Staff do not follow a menu to determine which scoops/amounts to serve residents;-She has trained staff to use four ounces for fruits and vegetables and three ounces for meat. If meat is combined with other ingredients like the jambalaya with rice, double the three ounces for total of six or eight;-She followed menus for serve out when she first came to the facility, but stopped after she had all staff trained.During an interview on 08/14/25, at 10:21 A.M., the Registered Dietician (RD) said staff should follow the menu for portion sizes for puree, get the correct amount, and puree it. Staff should also follow the menu for portions sizes for serve out.During an interview on 08/07/25, at 5:44 P.M. the Administrator said staff should follow a menu for preparing and serving pureed meals.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standard and the resident's choices when the facility failed to follow-up regarding a cardiology referral for one resident (Resident #40), who had a pacemaker, in a timely manner. This would place the resident at an increased risk for a cardiac incident due to lack of oversite on his/her pacemaker. The facility census was 70.Review of the facility provided policy titled, Verbal Orders, revised February 2014, showed the following:-Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order;-Verbal orders will always be based on verbal exchange with the prescribing practitioner or on approved written protocols;-Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record;-Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf;-A telephone order is a verbal order given over the telephone;-The individual receiving the verbal order must write in on the physician's order sheet as v.o. (verbal order) or t.o. (telephone order);-The individual receiving the verbal order will read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed, record the ordering practitioner's last name and his or her credentials (MD, NP, PA, etc.), and record the date and time of the order;-The practitioner will review and countersign verbal orders during his or her next visit;-If a treatment, test, or another intervention is included in a written protocol that has been reviewed and approved by the medical director, then a verbal order may be written for a situation that is covered by the protocol;-Otherwise, a verbal order will not be written that is not based on a conversation with the practitioner;-Anyone writing an unauthorized verbal order will be subject to disciplinary action.Review of the facility provided policy titled, Telephone Orders, revised February 2014, showed the following:-Verbal telephone orders may be accepted from each resident's attending physician;-Verbal telephone orders may only be received by licensed personnel;-Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record;-The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information;-Telephone orders must be countersigned by the physician during his or her next visit.1. Review of Resident #40's face sheet (gives basic profile information) showed the following:-admission date of 03/03/25;-Diagnoses included chronic systolic (congestive) heart failure (CHF), paroxysmal atrial fibrillation (irregular and rapid heart rate), and presence of cardiac pacemaker.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 06/10/25, showed the following:-Cognitively intact;-Resident used walker and wheelchair;-Primary medical conditions show debility and cardiorespiratory conditions, including heart failure.Review of the resident's progress note dated 03/31/25, at 1:29 P.M., showed Licensed Practical Nurse (LPN) O noted the resident complained of skin being taut around pacemaker site. Resident complained of needing follow-up with cardiologist for pacemaker checkup. Skin around pacemaker site is clean, dry, and intact with no redness, discoloration, edema (swelling), or drainage noted or reported.Review of the resident's physician order summary report showed an order dated 03/31/25 for a cardiologist referral.Review of the resident's medical record showed staff did not document regarding the cardiologist referral or if an appointment was scheduled. Review of the resident's care plan, revised on 08/11/25, showed the following:-An activities of daily living self-care performance deficit because of weakness from CHF;-Has a pacemaker related to atrial fibrillation;-Will remain free of signs and symptoms of altered cardiac output;-Monitor, document, and report as needed any signs and symptoms of altered cardiac output or pacemaker malfunction such as dizziness, syncope, difficulty breathing, pulse rate lower than programmed rate, or lower than baseline blood pressure.During an interview on 08/04/25, at 1:13 P.M., the resident said he/she had been at the facility since March of 2025. He/she had a history of heart problems, went to the hospital, and now was at the facility. He/she told the Medical Records staff member that made appointments for residents that he/she would like to see his/her heart doctor. He/she also told LPN F that he/she would like to see his/her heart doctor. He/she has had a difficult time getting his/her appointments scheduled and to his/her appointments since he/she has been in the facility. During interviews on 08/08/25, at 10:12 A.M. and 10:19 A.M., LPN F said the following:-He/she did not recall the resident mentioning to him/her that he/she needed to see a cardiologist;-The resident has not been able to find his/her pacemaker box;-If the resident would have mentioned needing to see a cardiologist, the facility Medical Director would have written a referral;-He/She was not aware of the Medical Director providing an order for a cardiology referral for the resident;-He/she checked the nursing notes and found the 03/31/25 referral note for the cardiologist and said an agency nurse put the cardiologist referral order into the resident's electronic record;-The issue with the referral appointment not being scheduled was because no one knew the referral was there;-The agency nurse should have made a copy of the referral order and placed it in the box at the nurses' station for the Medical Records staff member to pick up;-Resident medical appointments are made by the Medical Records staff member;-If Medical Records staff is too busy or not available to make an appointment, then the facility charge nurse, or the facilities Medical Director office staff makes the appointments;-When any nurse puts in or takes an order, including a referral for an appointment, they need to put it on the nursing treatment administration record (TAR) or medication administration record (MAR) otherwise, it just sits there, and no one knows about it;-Agency nurses are not educated on the process that needs to be followed when physician orders are received.During an interview on 08/08/25, at 11:10 A.M., the Medical Records staff member said the following:-The resident never told him/her that he/she needed to see a cardiologist and he/she has not seen an order from the Medical Director to schedule a cardiology appointment;-He/She was not aware of the nurse's progress note or the physician's cardiology referral for the resident;-The nurse should have put the order in the box at the nurse's station for him/her, but he/she must not have put it in there;-He/She has made appointments for residents for a year or longer;-When the facility gets an admission staff should let him/her know if a resident needs an appointment;-He/She does not always know if a resident needs an appointment because the process does not always get passed on to him/her;-If the Medical Director is in the facility and orders an appointment, he/she puts it in his/her mailbox basket;-When an appointment is made, he/she puts it on the calendar and in his/her appointment book;-If the nurses take an appointment order by phone, they should print off the order and put it in his/her basket at the nurses' station;-He/She empties the basket at the nurses' station every morning and sorts it out.During an interview on 08/08/25, at 2:25 P.M., Housekeeper D said the following:-The resident has a pacemaker and when he/she was admitted to the facility he/she did not have any paperwork or the machine for his/her pacemaker;-He/She has looked everywhere for the resident's pacemaker paperwork and equipment, but he/she has not found it;-Today, the facility called to schedule the resident an appointment with a cardiologist.During interviews on 08/08/25, at 3:20 P.M., and on 08/13/25, at 11:00 A.M., the Director of Nursing (DON) said the following:-The first week in the facility the resident needed an appointment for a cardiologist;-He/she knew the resident had a pacemaker, so he/she investigated to find out what needed to be done with it;-An agency nurse messaged the facility Medical Director about the resident's request to see a cardiologist;-They facility did not have the resident's doctor's information or know who put the pacemaker in;-He/she called 20 to 30 cardiologists and could not get anyone to take the resident on because they did not put the pacemaker in;-The resident had a machine he/she was supposed to keep and use for the pacemaker, but the resident had not had it since he/she was admitted to the facility in March of 2025;-Today, an appointment was made with a cardiologist for September of 2025;-The agency nurse passed along in report that a cardiology referral was provided by the Medical Director, so the Medical Records staff should have made the appointment;-The agency nurse should have put a note in the Medical Records staff members box regarding the cardiology referral so he/she would have known to schedule the appointment.-His/Her expectation was for a resident to see an outside physician if they feel they need to.During an interview on 08/08/25, at 3:50 P.M., the Medical Director said the following:-He/She was unsure if an appointment has been made for the resident to see a cardiologist;-If the resident had a pacemaker, they would want to keep his/her pulse rate above 60;-If no pacemaker box was available for the resident, then the resident should be set up with a cardiologist appointment;-The resident did not have any information regarding the pacemaker when he/she was admitted ;-If he/she ordered a cardiologist referral in March of 2025, he/she would expect the facility to have the appointment scheduled before now.During an interview on 08/13/25, at 12:00 P.M., the Administrator said the following:-Medical records staff member was very organized, so someone probably did not do their job and give him/her the message that a cardiology appointment needed to be scheduled;-His/Her expectation is for a resident to see an outside physician if they feel they need to;-All appointments go the Medical Records staff member to be scheduled;-If the Medical Director provides a referral order or if residents come back to the facility with paperwork, staff are expected to put the order or referral on the Medical Records staff member's desk;-If staff was aware that a resident wanted to be seen by a physician outside the facility, he/she would expect the staff to help get it scheduled to the best of their ability.

Based on observation, interview, and record review, the facility failed to ensure correct installation and maintenance of bed rails when the bed rail of one resident (Resident #11) was loose and improperly secured. The facility census was 70.Review of the facility policy titled, Bed Rail Policy, dated 2017, showed the following:-It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use;-A duo-faceted approach will be used to achieve sustainable quality outcomes, including regular bed maintenance and individual bed rail evaluations;-In response to the requirement of providing for a safe, clean, comfortable, and homelike environment, the facility's regular maintenance program will include regular inspection of all bed systems (e.g. rails, frames, and mattresses, and operational components) to ensure they are clean, comfortable, and safe;-The facility will also ensure individual resident bed rail evaluations are performed on a regular basis;-Individual bed rail evaluations will include data collection analysis and determination of potential alternatives to bed rail use;-When bed rail(s) are deemed necessary and appropriate, the facility will provide education to resident or resident's representative pertaining to the risk and benefits of bed rail use;-The facility's priority is to ensure safe and appropriate bed rail use;-No matter the purpose of use, bed rails, although prescribed to improve functional independence with bed mobility and transfers, can increase resident safety risk;-Precautions include following manufacturer equipment alerts and recommendations for installing and maintaining bed rails;-The interdisciplinary team will use data collected from regular bed inspections and individual bed rail evaluations to bolster care planning and positive resident outcomes;-The facility will conduct regular bed inspections, utilizing an interdisciplinary, team-based approach (e.g. nursing and maintenance) to risk identification and prevention;-The Director or Nursing (DON) and Maintenance Director (or qualified designees) cooperatively will be responsible for completion of bed inspections on a regular basis;-All employees will be trained on the bed rail policy;-Education will be provided to any resident or his/her representative pertaining to risks and benefits of bed rail(s) use;-Before admission, prospective residents will be screened to help determine if care needs may necessitate specialized beds or accessories (e.g. side rails);-Upon admission, readmission, or change of condition, residents will be screened to determine their level of independence with bed mobility, bed comfort level, if the bed meets manufacturers recommendations and specifications pertaining to resident height and weight;-Upon admission, readmission, or change of condition, residents will be screened to assess the need for special equipment or accessories (e.g. side rails);-Assess the resident to identify appropriate alternative prior to installing bed rails;-Assess the resident for risk of entrapment from bed rails prior to installation;-Facility will have indicated documentation that the side rail is the least restrictive alternative for the least amount of time;-The facility will document the ongoing need for the use of a bed rail;-Review the risk and benefits with resident and resident representative;-Obtain informed consent;-Obtain physician order for medical symptom assessed for need for bed rail use;-Resident care plan will include use of bed rails as assessed;-When installing or maintaining bed rails, the maintenance department staff will follow the manufacturer's recommendations and specifications, or provide another bed or appropriate alternative in accordance with individual bed inspections;-The maintenance department will conduct regular (*facility to designate frequency) inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment;-The interdisciplinary team will identify resident-specific bed adaptions and pertinent safety risks on the resident care plan. 1. Review of Resident #11s face sheet (gives basic profile information) showed the following:-admission date of 05/19/25;-Diagnoses included fracture of unspecified part of neck of left femur (thigh bone), unspecified symptoms and signs involving cognitive functions and awareness, anxiety (worry and fear about everyday situations), and depressed mood. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 05/26/25, showed the following:-Cognitively intact;-Dependent on staff for going from sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed to chair transfer, and with wheelchair use;-Substantial/maximum assistance required for rolling left to right;-Resident used walker and wheelchair;-History of falling in the past month prior to admission. Review of the resident's progress note, dated 06/04/25, showed the following: -Care conference held this date. The resident and family attended, along with the facility administration, Social Services Director (SSD), and MDS Coordinator;-Quarter bed rails requested by the family;-Family further requested quarter rails for bed mobility as resident had them on his/her bed at home;-The team explained the risks to using rails and family understood and accepted the risks;-Resident continued dependent on staff for all cares.Review of the resident's Side Rail Assessment, dated 06/05/25, showed the following:-Bed rails used for increased bed mobility;-Quarter rails used at home for bed mobility;-Quarter rails for increase in independence in bed mobility;-Used rails to enhance bed mobility;-Past history of rail use;-Side rails were indicated and serve as an enabler to promote independence;-Resident, family, and Durable Power Of Attorney informed of the risks and benefits of side rails;-Based on the summary findings, bilateral assist bar was indicated;-Signed on by family, the MDS Coordinator, and physician. Review of the resident's August 2025 Physician Order Sheet (POS) showed an order, dated 06/05/25, for bilateral 1/2 side rails for increased independence with bed mobility, repositioning, and safety. Review of the resident's care plan, initiated and revised on 06/12/25, showed the following:-Side Rails: Two half rails up as per physician order for safety during care provision, to assist with bed mobility;-Observe for injury or entrapment related to side rail use;-Resident used rails on his/her bed at home prior to admission to the facility;-My family was aware of the risks. Review of the facility weekly bed rail audits showed the following:-Week of 06/16/25, resident had 1/3 bed rails bilateral;-Week of 06/25/25, the resident had 1/3 bed rails bilateral;-Week of 07/01/25, the resident had 1/4 bed rails bilateral;-Staff did not document a weekly audit report from 07/02/25 through 07/13/25;-Week of 07/14/25, the resident had 1/4 bed rails bilateral;-Staff did not document a weekly audit report from 07/15/25 through 07/22/25;-Week of 07/23/25, the resident had 1/4 bed rails bilateral. Observation and interview on 08/04/2025, at 12:56 P.M., showed 1/4 bed rails to each upper side of the resident's bed in place and in the upright position. The resident wiggled the right upper bed rail with his/her right hand and said the bed rail was loose. During an interview and observation on 08/05/2025, at 11:44 A.M., the resident said the following:-The right bed rail was loose;-He/she was having difficulties using the bed rail to get up out of bed and to turn in bed;-He/she was lying in bed and wiggled the bed rail;-The resident said it was hard for him/her to use the rail;-When lightly touched the right bed rail wiggled and it appeared very loose and unstable;-The resident was observed struggling to use the rail to pull himself/herself up on the side of the bed;-He/she did not feel like the loose bed rail was safe;-The loose bed rail makes it difficult for him/her to turn in bed and pull himself/herself up in bed;-He/she told a couple of staff members including the maintenance man that the rail was loose, but no one had fixed it;-The resident would like to have the loose bed rail fixed. During an interview on 08/08/25, at 10:09 A.M., Licensed Practical Nurse (LPN) F said the following:-He/She had not noticed the resident's bed rail being loose;-The resident sets him/herself up when he/she wants to get out of bed;-If he/she noticed a side rail was loose, he/she would report it to maintenance;-Quarterly inspections/audits are completed by the nursing staff or the MDS Coordinator;-The Restorative Aide does weekly bed rail checks to make sure bed rails are still appropriate for the resident because residents move beds a lot;-The maintenance department does measurement checks on the bed rails. During an interview on 08/08/25, at 10:39 A.M., Certified Nurse Aide (CNA) I said the following:-He/She had not noticed the resident's bed rail being loose;-The resident never told him/her the side rail was loose;-If he/she was aware of a loose side rail, he/she would report it to a nurse or find someone in maintenance and let them know. During an interview on 08/08/25, at 11:53 A.M., the Maintenance Assistant said the following:-He/She was not aware of the resident's or any other resident's bed rails being loose;-The Maintenance Assistant thought the resident's loose bed rail could have been caused by a bolt being threaded wrong;-He/She had done some bed rail checks;-He/She was not sure who checks them to see if they are loose;-He/She had never checked any bed rails to see if they were loose;-When new beds arrive at the facility or he/she was told a resident needed bed rails, he/she put them on. During an interview on 08/08/25, at 11:56 A.M., CNA G said the following:-He/She works with the resident, but he/she did not notice the side rail was loose;-The resident had never told him/her the side rail was loose;-He/She believed maintenance or housekeeping completed bed rail checks;-He/She did not know how often bed rails are checked;-If he/she noticed that a side rail was loose, he/she would tell someone in maintenance.During an interview on 08/12/25, at 3:10 P.M., the Restorative Aide (RA) said the following:-On 02/28/24, he/she was asked to complete the weekly bed rail audits because it was a state thing;-He/she goes room to room weekly as his/her schedule allows to document who has bed rails;-He/she records the room number and if it is bed A or B, the resident's name, bed type such as vinyl, metal, hospice, etc., and the rail size that he/she observes on the bed;-The weekly bed rail audit documentation is turned into the DON and the MDS Coordinator when it is completed for the week;-He/She did not always have time to complete the weekly bed rail audits because he/she was pulled to the floor to work;-When he/she does not have time to complete the weekly bed rail audits they do not get completed. During an interview on 08/12/25, at 11:35 A.M., Housekeeper P said the following:-The last he/she recalled (unsure of date) completing the resident's bedrail paperwork, the resident's bed rails were fine;-He/She was not aware the resident's bedrail was loose;-The last maintenance person prior to the Maintenance Supervisor now did not want to do the bed rail measurements, so he/she was given that job;-He/She was expected to measure the rails quarterly;-He/She had paperwork to fill out for each bed when he/she completed the measurements;-He/She turned his/her measurement documents into the Housekeeping Supervisor, and the Housekeeping Supervisor turned the paperwork into the DON;-He/she wiggled the bed rails to see if they are loose when he/she completes the quarterly measurements;-Maintenance was responsible for tightening the bed rails;-If he/she were to find a loose bed rail he/she would fill out a work order and documents it;-He/She gave work orders to the Housekeeping Supervisor, or he/she put them in a box for maintenance. During an interview on 08/12/25, at 1:06 P.M., the Maintenance Supervisor said the following: -He/she was not aware of the resident's bed rail being loose until the resident stopped him/her in the hall last Friday, 08/08/25, and told him/her that the bed rail was loose, and it needed to be looked at;-His/her role with bed rails is that if he/she was handed a work order saying a bed rail needed to be checked and measured, he/she would do that;-Normally Housekeeper P did the bed rail measurements.During an interview on 08/08/25, at 9:40 A.M., the Housekeeping Supervisor and the DON said the following:-Maintenance was not involved with bed rail checks;-Housekeeper P does side rail measurements every three months;-The DON has the RA do a bed rail audit every week;-Bed rail assessments were done quarterly and involved nurses checking to make sure resident consent forms were signed and that bed rails were still appropriate for the resident;-They would both expect staff to tell maintenance if repairs need to be made to bed rails;-The DON said the facility/staff does not do any testing of the bed rails to see if they are loose;-Housekeeper P would make sure the bed rail goes up and down and he/she would know if the bed rail were loose;-Housekeeping makes sure the assessments and measurements were done;-The maintenance department puts the bed rails on, removes them, and makes any repairs. During an interview on 08/13/25, at 11:00 A.M., the DON said the following:-If the RA did not have time to complete the weekly bed rail audits, they do not get done, but there is no facility policy saying they have to be completed weekly, he/she just likes them completed weekly for his/her own record since residents are moved to different rooms often;-The weekly bed rail audit consists of the RA or the nurses documenting which residents have side rails and if they are half or quarter rails etc.;-The nurses complete the quarterly bed rail assessments in the resident's electronic health record;-The nursing staff completes the bed rail assessments in the electronic health record quarterly, but that does not include checking for loose bed rails. During an interview on 08/13/25, at 12:00 P.M., the Administrator said the following:-His expectation is for staff to complete side rail audit checks and assessments at least quarterly, but the staff is doing them monthly instead;-The RA, DON, nursing, housekeeping, and maintenance departments are involved in bed rail checks and maintenance;-He/She was not sure that staff had a time frame to check for loose bed rails. There is nothing scheduled for that;-Loose bed rails were taken care of as needed;-The expectation would be for staff, residents, and family to tell someone if a bed rail was loose;-The majority of the bed rails in the facility are half rails and residents like them because they need them to help them position in the bed.

Based on interview and record review, the facility failed to ensure each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence possible when staff failed to provide restorative nursing services three times weekly per the restorative therapy program for one resident (Resident #52). The facility census was 70.Review of the facility policy titled, Restorative Nursing Services, revised July 2017, showed the following:-Residents will receive restorative nursing care as needed to help promote optimal safety and independence;-Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational, or speech therapies);-Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care;-Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care;-The resident or representative will be included in determining goals and the plan of care;-Restorative goals may include but are limited to supporting and assisting the resident in adjusting or adapting to changing abilities; developing and maintaining or strengthening his/her physiological and psychological resources; maintaining his/her dignity, independence, and self-esteem; and participating in the development and implementation of his/her plan of care. 1. Review of Resident #52's face sheet (a brief resident profile) showed the following:-admission date of 04/28/25;-Diagnoses included congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), morbid obesity, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's Prospective Payment System (PPS) Part A Discharge (Medicare discharge) Minimum Data Set (MDS-a federally mandated assessment tool administered by staff) dated 06/10/25, showed the following:-Cognitively intact;-Required partial/moderate staff assistance with most activities of daily living (ADLs), including transfers, bed mobility, and walking 10 feet. Review of the resident's care plan, revised on 05/07/25, showed the following:-Resident had an ADL self-care performance deficit related to weakness;-Resident will improve current level of function in ADLs through the review date. Resident's goal is to rehab to home;-Physical therapy and/or occupational therapy evaluation and treatment as per physician orders. Review of the resident's restorative nursing program, effective date 06/06/25, showed the following: -Frequency three times weekly for 90 days;-Active range of motion (AROM - the extent to which a joint can be moved by a person's own muscle contractions, without any external assistance) of left and right upper extremities;-Resident to perform bilateral upper extremity therapy exercises with green resistance band all planes, times 10 to 15 repetitions, times one to two sets, with rest breaks as needed;-Resident to perform bilateral upper extremities therapy exercises with arm bike, time 10 minutes, as resident tolerates;-Resident to perform five sit to stands at grab bar, with rest breaks as needed, with moderate assistance;-Resident to perform functional ambulation with moderate assistance transfer, minimal assistance with rolling walker times 100 feet, with rest breaks as needed. Review of the resident's June 2026 nursing notes showed the resident received restorative therapy on 06/08/25, 06/12/25, 06/17/25, 06/21/25, 06/26/25, and 06/30/25. Staff did not document any resident refusals of therapy. (The resident did not receive restorative therapy three times weekly per the restorative nursing program.) Review of the resident's July 2026 nursing notes showed the resident received restorative therapy on 07/04/25, 07/14/25, 07/18/25, 07/19/25, 07/23/24, and 07/24/25. The resident declined therapy on 07/05/25. (The resident did not receive restorative therapy three times weekly per the restorative nursing program.)During an interview on 08/05/25, at 9:38 A.M., the resident said he/she was placed on restorative therapy a couple of months ago, but only receives the therapy on average one time per week and needs more. He/she wanted to ambulate again and return home. During an interview on 08/07/25, at 3:32 P.M., Restorative Aide (RA) K said the following:-He/she had been the RA for two years;-Residents typically come to restorative therapy for maintenance following completion of physical or occupational therapy, if the Director of Nursing (DON) recommends due to falls, or upon recommendation of the physician;-He/she always documents restorative therapy sessions or if the resident is unable/declines, in progress notes in the electronic record;-All residents are planned for restorative therapy three times per week;-The resident does not decline restorative therapy sessions;-He/she was not able to complete restorative therapy three times weekly with each resident, because he/she is often pulled to work the floor due to staffing issues. During an interview on 08/07/25, at 5:00 P.M., the DON said the following:-Residents are placed on restorative therapy through therapy recommendations, resident requests, or if the risk team recommends based on a resident's decline with ADLs;-The facility has a standing physician order for restorative therapy;-Residents are typically planned for restorative therapy three times per week;-The RA is the first to get pulled to work the floor when staff call in on the shift, and is unable to meet the needs the way he/she prefers for restorative therapy;-The RA documents each restorative therapy session or if a resident is unable or chooses not to participate in the electronic record;-The resident does not decline to participate in restorative therapy. During an interview on 08/07/25, at 5:44 P.M. the Administrator said the following:-Residents were placed on restorative therapy when Medicare-A stopped paying for skilled therapy for maintenance or if referred by the risk team due to a decline;-The facility has a standing physician order for restorative therapy;-Resident frequency of restorative therapy varies, but typically is three times per week;-The resident is supposed to receive restorative therapy three times per week;-Residents are not receiving 100% of planned restorative therapy sessions due to short staffing and the RA being pulled to work the floor.

Based on interview and record review, the facility failed to ensure each resident was treated with respect and dignity at all times when the facility staff made harsh and upsetting comments to one resident (Resident #1) in front of other residents; when staff threatened two resident's (Resident #1 and #3) smoking rights if they shared cigarettes with one resident (Resident #1); and when staff talked with one resident (Resident #4) regarding being friends with one resident (Resident #1). A sample of six residents was reviewed in a facility with a census of 65. Review of the facility's policy titled Dignity, revised February 2021, showed the following information: -Residents are treated with dignity and respect at all times; -Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person, or entity associated with the facility; -Staff are to speak respectfully to residents at all times; -Staff are to protect confidential clinical information. Verbal staff to staff communication should be conducted outside the hearing range of residents and the public; -Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care; -Demeaning practices and standards of care that compromise dignity are prohibited. 1. Review of the Resident #1's face sheet (brief look at resident information) showed the following information: -admission date of 08/06/24; -Diagnoses included diabetes, liver cell carcinoma(cancer), high blood pressure, and chronic pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 02/19/25, showed the following information: -Cognitively intact; -No feelings of depression; -Not isolating socially. Review of the resident's care plan, revised 08/19/24, showed the following: -Provide a comfortable and safe environment; -Assist and encourage the resident to develop appropriate methods of coping and interacting rather than being accusatory; -Attempts to manipulate staff. During an interview on 05/01/25, at 10:30 A.M., the resident said the following: -He/she wanted to discharge from the facility due to the Director of Nursing (DON) making unwanted comments; -He/she has been self-isolating to his/her room, because the DON has told him/her if any other behaviors occur, he/she will be issued a 30 day notice; -He/she has never been verbally or physically aggressive with staff. The DON says he/she has behaviors because he/she requests timely pain management and/or has borrowed cigarettes from other residents; -He/she is afraid the facility is going to cause him/her to be homeless again; -The DON has gone into other resident rooms and talked badly about him/her; -He/she feels humiliated and hurt. Observation on 05/01/25, at 11:20 A.M., of a recording of the DON in her office showed the following: -Resident #2 and Resident #3 was in the DON's office. The DON was discussing Resident #1's behaviors and questioning mental illness. Resident #1 then entered the DON's office; -Resident #1 questioned the DON and other resident's as to why they were talking about him/her; -The DON said You have a history of lying a lot; -Resident #1 began pleading his/her case as to why he/she was borrowing cigarettes from the two residents in the room; -The DON said, You are doing something wrong. Take accountability for your actions. Take accountability for the sneakiness. The sneakiness is what I cannot stand; -Resident #1 began pleading his/her case again insisting the resident was given cigarettes, not stealing them; -The DON said, What's really screwed up is all the cigarettes you've taking from Resident #3. You want to discharge to another facility, but another facility won't take you because of these behaviors. You are just harming yourself by smoking; -Resident #1 said he/she was not a routine smoker. He/she was just craving some peace after his/her cancer diagnoses; -The DON said, Take some accountability and stop blaming everything on your cancer. Why are we wasting our time on taking you to your cancer appointments, if you are going to kill yourself by smoking; -The meeting ended with the DON asking Resident #2 if he/she had learned his/her lesson to not lend cigarettes out. During an interview on 05/01/25, at 1:29 P.M., Resident # 2 said the following: -Resident # 1 asks for cigarettes a lot, so the facility staff get onto him/her. -There was a recent meeting, and the DON did get onto Resident #1 during that time; -Facility staff are getting irritated with Resident #1; -The DON told him/her if he/she did not stop giving Resident #1 cigarettes, she would take away the Resident #2's smoking privileges. During an interview on 05/01/25, at 1:40 P.M., Resident # 4 said the following: -Resident #1 admitted to the facility with a past and is treated differently because of it; -Resident # 1 has been called into the DON's office several times; -The DON came into his/her room and told him/her to be careful with being friends with Resident #1 as he/she is manipulative and could take advantage of him/her easily. During an interview on 05/01/25, at 1:56 A.M., Resident # 3 said the following: -The DON has threatened to take away his/her smoking privileges due to him/her loaning out cigarettes; -He/she does not understand what the problem is, it's his/her property and money. During an interview on 05/01/25, at 2:25 P.M., Certified Mediation Technician (CMT) A said he/she would report if a resident was talked down to and/or humiliated by staff. Staff should not threaten to take away a resident's rights. During an interview on 05/01/25, at 2:32 P.M., Licensed Practical Nurse (LPN) B said if he/she heard a resident not being treated with dignity and respect, he/she would report it. During an interview on 05/01/25, at 2:40 P.M., the Social Services Director (SSD) said if he/she became aware of a resident not being treated with dignity and respect, he/she would report it to the Administrator, State Agency Office, and remove the resident from the situation. During an interview on 05/02/25, at 10:09 A.M., the Medical Records Nurse said residents should be treated with dignity and respect. If she became aware of a resident being talked down to or humiliated, she would report it. During an interview on 05/02/25, at 10:37 A.M., LPN C said it would not be appropriate to talk to any resident in a manner that degraded and or humiliated them. During an interview on 05/02/25, at 10:59 A.M., the Nurse Practitioner said all residents should be treated with dignity and respect regardless of diagnoses and/or past. During an interview on 05/02/25, at 11:30 A.M., the DON said the following; -The resident often threatens to report her to the State Agency Office; -The resident is very accusatory; -She talked with the resident recently about being sneaky when obtaining cigarettes to smoke; -She told the resident to stop stealing cigarettes from his/her peers; -The resident has his/her behaviors charted and that is why another facility won't accept him/her. Behaviors include manipulation and threatening; -She did approach Resident #4 regarding the resident, because she didn't want Resident #4 manipulated into giving Resident #1 money. She did not encourage Resident #4 to not associate with Resident #1; -The resident might not like what she has to say, because she is firm with him/her; -She should have not said the things she said to the resident. She was trying to educate the resident on his/her behaviors but did not intend to sound malicious. During an interview on 05/02/25, at 1:01 P.M., the Administrator said the following: -All residents should be treated with dignity and respect; -The DON made him aware of the statements she had made to the resident today; -The resident has behaviors and they are looking into additional placement for him/her. MO00251691

Based on observation, interview, and record review, the facility failed to implement and maintain an effective pain management for all residents when staff failed to accurately and consistently document pain levels and steps taken to address pain, failed to document timely physician notification of pain, and restricted a resident's access to certain medications without a physician order for one resident (Resident #1) out of six sampled residents. The facility census was 65. Review of the facility's policy titled Pain Care, undated, showed the following information: -The effectiveness of the facility's pain care program will be examined monthly; -Pain assessments should include the location, description, frequency, level, what alleviates or exacerbates the pain, history and effectiveness of pain medications, and the residents desires about future pain care; -For residents with daily or chronic pain, maximum relief is achieved with around the clock medications and as needed (PRN) medications for breakthrough pain; -New interventions must be implemented when old interventions are ineffective. 1. Review of the Resident#'s face sheet (brief look at resident information) showed the following information: -admission date of 08/06/24; -Diagnoses included diabetes, liver cell carcinoma(cancer), high blood pressure, and chronic pain. Review of the resident's care plan, revised 08/19/24, showed the following: -Staff to administer analgesic (non-opioid drugs used to alleviate pain) medications as ordered by the physician. Staff to monitor/document side effects and effectiveness every shift; -Staff to ask physician to review medication if side effects occur; -Staff to monitor/document/report as needed medication adverse reactions to analgesic therapy. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 02/19/25, showed the following information: -Cognitively intact; -No behavioral symptoms; -Administered a scheduled pain mediation regimen; -Received as needed pain mediation, as well as non-medication interventions for pain. Review of the resident's February 2025 Medication Administration Record (MAR) and Physician Order Sheet (POS) showed the following: -An order, dated 09/09/24, for Tylenol (analgesic medication used to relieve pain) Extra Strength 500 milligram (mg), give one tablet by mouth four times a day; -An order, dated 09/27/25, for ibuprofen (nonsteroidal anti-inflammatory drug used to relieve pain) 600 milligrams (mg), give one tablet by mouth every eight hours for pain; -An order dated 02/06/25, for Butrans Transdermal Patch (an opioid partial agonist medication used to treat chronic pain) 10 micrograms per hour (mcg/hr), apply one patch one time a day every seven days for pain. The order was discontinued 02/08/25; - An order, dated 02/09/25, for Butrans Transdermal Patch 10 mcg/hr, apply one patch one time a day every seven days for pain. The order was discontinued 02/27/25. Review of the resident's progress note dated 02/23/25, at 6:15 P.M., showed staff noted the resident was complaining of pain in the right upper quadrant (RUQ) and the right lower quadrant (RLQ) of the abdomen. Pain was controlled when heat was applied. The resident said the pain was sharp and did not last for long. (Staff did not document physician notification of the resident's complaint of pain.) Review of the resident's progress note dated 02/25/25, at 3:37 P.M., showed staff noted the resident was complaining of left quadrant abdominal pain and it was believed to be caused by an old hernia and/or weight loss injection. The nurse documented he/she would continue to monitor. (Staff did not document physician notification of the resident's complaint of pain.) Review of the resident's progress note dated 02/27/25, at 1:26 P.M., showed staff noted the resident was complaining of left mid-back pain, causing pain with breathing. The resident also complained of blood when wiping after toileting. Staff notified the physician and an order for a pelvic ultrasound was received. Review of the resident's progress note dated 02/27/25, at 3:52 P.M., showed staff noted the resident complained of having migraine headaches for the last couple of weeks. The resident described the pain at an eight out of 10 with light and sound sensitivity that encompasses the entire head. The time frame when headaches started coincided with starting the Butrans Patch. The medication can have adverse reactions that include headache disorder. The resident said to the nurse that he/she would rather have the other pain instead of the headaches. Staff notified the physician and received order to discontinue the Butrans patch. Review of the resident's progress notes, dated 02/28/25 through 03/18/25, showed staff did not document related to the resident pain. Review of the resident's March 2025 MAR and POS showed the order for ibuprofen 600 mg tablet was discontinued on 03/03/25. The resident continued to have an order for Tylenol for pain treatment. Review of the resident's MAR, dated 03/08/25, showed staff noted the resident's pain was rated at a four out of 10 on day shift. Review of the resident's medical record, dated 03/08/25, showed staff did not document steps taken to address the resident pain level of four out of ten on day shift or how/if the resident's pain was relieved. Review of the resident's care plan, revised 03/11/25, showed staff added the resident had a history of misusing pain medications and self-medicating while he/she was in the community. The physician was treating his/her pain with non-opioids because of his/her history. Review of the resident's MAR, dated 03/17/25, showed staff noted the resident's pain was rated at a seven out of 10 on day shift. Review of the resident's medical record, dated 03/17/25, showed staff did not document steps taken to address the resident pain level of seven out of ten on day shift or how/if the resident's pain was relieved. Review of the resident's progress note dated 03/19/25, at 11:53 P.M., showed the resident came to the nurses' station and requested to go to the emergency department (ED) for left flank pain, presenting with throbbing, stabbing and tenderness. Staff noted no signs and symptoms of distress. The resident was calm and collected during the nurses' assessment. Review of the resident's MAR, dated 03/19/25, showed a pain scale of 0/10 on both day and night shifts. (The assessments did not reflect the pain noted in the progress notes.) Review of the resident's progress note dated 03/20/25, at 9:00 A.M., showed the resident returned from the ED and was said to have lesions on the liver. Staff notified the physician of the resident's return. Review of the resident's progress notes, dated 03/22/25, showed the following: -At 10:10 A.M., staff noted the resident was expressing concerns that he/she had cancer due to the pain he/she was experiencing. -At 11:00 A.M., staff noted the resident reported to the nurse he/she was feeling bad with severe right side abdominal pain. The resident was crying and said that his/her pain was a 10 out of 10 and wanted to go to the ED. Staff notified the physician and the resident was sent to the ED. -At 11:25 A.M., staff noted the nurse on duty called the ED and instructed them that the resident was not allowed to have any narcotics per doctors orders. Review of the resident's March 2025 POS showed staff did not transcribe an order to indicate the resident had a physician order to not administer narcotics. Review of the resident's ED History and Physical, dated 03/22/25, showed the following; -The resident was found to have a possible metastatic disease (also known as stage IIII cancer that occurs when cancer cells from the original tumor spread to other body parts) due to multiple masses on his/her liver; -The nurse at the facility where the resident resided called the ED department and said that the resident could not have any narcotic pain medications and could not return to the facility if that was prescribed at the hospital. The reasoning for this needs to be explored as the resident has metastatic cancer and will need pain management. The resident does not know the reasoning why the facility treats him/her this way other than in his/her distant past he/she was homeless and had substance abuse issues, but that has not been the case for the last six years; -Contact with the facility was made regarding diagnoses of cancer. The resident was on a Butrans patch which was discontinued several days ago. The Director of Nursing (DON) told the ED that the resident can not get narcotic pain management at the facility and they would be unable to accept the resident back at the facility if that were the case. No specific reasoning given; -ED provider does not believe discharging the resident back to the facility is appropriate as they refuse to provide an appropriate pain management regimen. Review of the resident's MAR, dated 03/23/25, showed a pain scale of six out of ten on day shift and no assessment of pain on the night shift. (The resident was not in the facility on this date.) Review of the resident's MAR, dated 03/24/25, showed a pain scale of six out of ten on day shift and no assessment of pain on the night shift. (The resident was not in the facility on this date.) Review of the resident's ED After Visit Summary, dated 03/25/25, showed the following: -Resident was to discharge back to the facility with an order for Percocet (opioid controlled substance medication used to treat pain) 5-325 mg, take one tablet by mouth every four hours as needed for pain. -Hand written note on the After Visit summary showed staff noted they conferred with the Primary Care Physician (PCP) on 3/25/25, at 5:00 P.M. Review of the resident's March 2025 MAR and POS showed the following: -The hospital order for Percocet was not transcribed to the POS. -An new order, dated 03/25/25, for Fentanyl Patch 25 mg, apply new patch every three days. Review of the resident's progress note dated 03/25/25, 5:16 P.M., showed staff did not indicate the resident had returned from the hospital and said that the physician had reviewed orders from the resident's hospitalization and wanted to return to the previous orders. Review of the resident's MAR, dated 03/25/25, showed the resident had pain rated a six out of 10 on the day shift and a seven out of 10 on the night shift. Review of the resident's medical record, dated 03/25/25, showed staff did not document steps taken to address the resident pain level of six out of 10 on day shift and seven out of 10 on night shift or how/if the resident's pain was relieved. Review of the resident's MAR. dated 03/26/25, showed the resident had pain rated a seven out of 10 on the day shift and a six out of 10 on the night shift. Review of the resident's medical record, dated 03/26/25, showed staff did not document steps taken to address the resident's pain level of seven out of 10 on day shift and six out of 10 on night shift or how/if the resident's pain was relieved. Review of the resident's progress note dated 03/27/25 showed the resident took off his/her Fentanyl patch that was placed in the hospital due to increased irritation of the skin. Physician notified and new orders for MS Contin (opioid agonist controlled substance indicated for management of severe pain)15 mg two times a day (BID) received. Review of the resident's March 2025 MAR showed the following: -An order, dated 03/27/25, for Fentanyl Patch 25 mg, apply new patch every three days. The order was discontinued on 03/27/25 before it had been administered in the facility; -An order, dated 03/27/25, for MS Contin (opioid agonist controlled substance indicated for management of severe pain) 15 mg, give one tablet by mouth twice a day for pain. Staff administered medication at 5:00 P.M. on 03/27/25. The order was discontinued on 03/28/25; -An order, dated 03/28/25, for MS Contin 30 mg, give one tablet by mouth every 12 hours for pain. Review of the resident's MAR, dated 03/27/25, showed a pain scale of five out of 10 on the day shift and a 0/10 on the night shift. Review of the resident's medical record, dated 03/27/25, showed staff did not document steps taken to address the resident pain level of five out of 10 on day shift or or how/if the resident's pain was relieved. Review of the resident's progress note, dated 03/28/25, showed the DON said that the resident was screaming at her due to uncontrolled pain. The DON insisted that the resident wanted different types of medication based off his/her history with log term drug use to give the resident his/her desired effect. Continuing to educate the resident on non-pharmacological options for pain control. Review of the resident's progress note, dated 03/30/25, showed the resident was complaining of itching all over, nausea, generalized pain that was uncontrolled with administration of MS Contin 30 mg. The resident had recently been diagnosed with liver cancer and is very concerned with his/her condition. Staff notified physician and the resident was sent to ED. Review of the resident's care plan, revised 03/31/25, showed staff added the following: -Assist and encourage the resident to develop more appropriate methods of coping and interacting rather than being accusatory and indicating that his/her pain is not being appropriately treated; -The resident has a history of misusing controlled medication while in the community. The resident continues to demand instant release opioids rather than use extended-release medications. If the resident does not feel he/she has received his/her medication timely, he/she will request to go to the ED. Review of the resident's MAR, dated 03/31/25, showed the resident's pain rated at a six out of 10 on the day shift. Review of the resident's medical record, dated 03/31/25, showed staff did not document steps taken to address the resident pain level of six out of 10 on the day shift or how/if the resident's pain was relieved. Review of the resident's progress note dated 04/01/25, at 9:48 A.M., showed staff did not indicate the resident returned from the ED. Staff noted the resident was seeking more pain medication with complaints of headache and abdominal pain. The resident was notified he/she could not have any more pain medication. The resident was aware of this and knew the parameters of his/her pain medication orders. (Staff did not document of physician notification of the resident's complaints of additional pain.) Review of the resident's MAR, dated 04/01/25, showed a pain scale of 6/10 on the day shift and a 3/10 on the night shift. Review of the resident's medical record, dated 04/01/25, showed staff did not document steps taken to address the resident pain level of six out of 10 on day shift and three out of 10 on night shift or how/if the resident's pain was relieved. Review of the resident's April 2025 POS showed an order, dated 03/28/25, for MS Contin 30 mg, give one tablet by mouth every 12 hours for pain was increased on 04/01/25 to MS Contin 30 mg give one tablet by mouth three times daily for pain. Review of the resident's MAR, dated 04/02/25, the resident's pain rated at a five out of 10 on the day shift. Review of the resident's medical record, dated 04/02/25, showed staff did not document steps taken to address the resident pain level of five out of 10 on the day shift or how/if the resident's pain was relieved. Review of the resident's MAR, dated 04/03/25, showed the resident's pain rated as a six out of 10 on the night shift. Review of the resident's medical record, dated 04/03/25, showed staff did not document steps taken to address the resident pain level of six out of 10 on the day shift or how/if the resident's pain was relieved. Review of the resident's MAR, dated 04/04/25. showed the resident's pain rated as a three out of 10 on the night shift. Review of the resident's medical record, dated 04/04/25, showed staff did not document steps taken to address the resident pain level of three out of 10 on the night shift or how/if the resident's pain was relieved. Review of the resident's MAR, 04/06/25, showed the resident's pain rated as a three out o f 10 on the day shift and a two out of 10 on the night shift. Review of the resident's medical record, dated 04/06/25, showed staff did not document steps taken to address the resident pain level of three out of 10 on the day shift and a two out of 10 on the night shift or or how/if the resident's pain was relieved. Review of the resident's progress notes, dated 04/07/25, showed the following: -At 12:00 P.M., staff noted the resident came to the nurses' station numerous times and told the staff he/she was hurting due to his/her cancer diagnoses and needed something to be done. The staff member reported to the resident that he/she had seen the physician on Friday with no changes. The resident said he/she wanted to go to the hospital for pain management then as the medication was ineffective and his/her pain level was nine out of 10. The resident did not show any signs and symptoms of pain. He/she was up in the wheelchair and propelling self through the facility, eating meals, and attending smoke breaks. -At 3:18 P.M., the resident said he/she wanted to go to the ED and told staff that he/she can go whenever he/she wants as the physician has already told him/her that. DON and the Administrator spoke with the resident regarding the request to go to the ED. The physician was notified and gave the order to send the resident to the ED. Review of the resident's progress note dated 04/08/25, at 11:18 P.M., showed the resident returned from the hospital with new orders for Percocet 7.5/325 mg tablet every six hours for pain. Staff notified the physician and was awaiting confirmation. Review of the resident's ED's after visit summary, dated 04/08/25, showed a new order for Percocet 7.5/325 mg tablet by mouth every six hours as needed. Review of the resident's April 2025 POS showed an order, dated 04/10/25, for Percocet 5-325 mg by mouth every six hours as needed for pain. Observation and interview on 05/01/25, at 10:30 A.M., showed the resident said the following: -The resident wanted to discharge from the facility due to staff refusing to treat his/her pain; -The DON says he/she has behaviors because he/she requests timely and effective pain management. The DON would only allow him/her to have Tylenol until his/her most recent hospitalization where he/she was diagnosed with stage III cancer; -He/she has had to go to the ED so much for unrelieved pain that the DON now makes him/her sign an Against Medical Advice (AMA) Form if he/she wished to go to the ED for pain; -The resident provided the AMA form for the surveyor to view. During an interview on 05/01/25, at 2:25 P.M., Certified Mediation Technician (CMT) A said the following: -If a resident complained of pain, he/she would let the nurse know, assess the pain, and administer pain medication if it was available. After the administration of pain medication, effectiveness should be documented; -No resident's are denied pain medication, even if they have a history of substance abuse; -The facility has tried a few different things for the resident, but he/she would have interactions so those medications would get discontinued; -The resident complained of pain frequently. During an interview on 05/01/25, at 2:32 P.M., Licensed Practical Nurse (LPN) B said the following: -If a resident was complaining of increased pain and the current pain regimen was not controlling the pain, he/she would contact the physician; -The facility staff attempted to use all non-pharmacological means to treat the resident's pain prior to the use of narcotics related to his/her history of substance abuse. During an interview on 05/01/25, at 2:40 P.M., the Social Services Director (SSD) said the following: -The resident came in with the goal of sobriety, so non-narcotic medication was offered, but when he/she got a terminal diagnosis that changed everything; -She was not sure if the sobriety goal is documented anywhere; -She was aware of the resident's past substance abuse due to getting the resident from a halfway house. During an interview on 05/02/25, at 10:09 A.M., the Medical Records Nurse said the following: -If a resident complained of increased pain, she would report it to the charge nurse who would assess the pain and contact the physician; -The resident has a history of past substance abuse, so the facility attempted non-pharmacological attempts to relieve pain; -This should be documented in the POS and care plan. During an interview on 05/02/25, at 10:37 A.M., LPN C said the following; -If a resident is exhibiting increased pain, staff should assess the pain and try non-pharmacological attempts prior to administering pain medication. If those attempts do not work, administer pain medication, and notify the doctor; -The physician said he/she did not want the resident to have any narcotics. The resident could go to the ED if his/her pain was unrelieved; -The resident now has seemed to experience some relief with the new pain medications on board. During an interview on 05/02/25, at 10:59 A.M., the on-call Nurse Practitioner (NP) said effective pain medication should not be withheld from any resident regardless of their history. The resident is in a controlled environment, so there is not a concern of the resident becoming re-addicted to narcotics. She is not sure how or where the physician would have documented that the resident is not allowed to have narcotics. They expected to be contacted for uncontrolled pain and/or an ineffective regimen. During an interview on 05/02/25, at 11:30 A.M., the DON said the following; -If a resident was exhibiting pain, she expected the staff to assess the pain. Staff should also monitor if the resident is complaining of pain and is sleeping or not showing signs and symptoms of pain; -If the resident continued to complain of increased pain, they can go to the ED if the physician won't order anything additional; -Pain medication wasn't withheld from the resident, other avenues were explored due to his/her history; -The resident had a lot of behaviors and the physician determined what was appropriate for the resident and narcotics were chosen not to be allowed; -Just because a medication is not a narcotic does not mean it doesn't work for the resident's pain; -The resident will complain of pain but will appear drowsy and or laughing. -The resident would present as drowsy and fatigued since starting medication. She does not believe that this could be related to a diagnoses of stage IIII cancer. -Since the resident has had new medications on board, the resident has had much fewer complaints of pain. During an interview on 05/02/25, at 1:01 P.M., the Administrator said the following: -If a resident is complaining of increased pain, he expected staff to assess the pain and communicate with the physician; -The resident came to the facility with a history of substance abuse, so it was a goal for him/her to be sober; -The physician was on board with the resident remaining sober; -The resident went to the ED several times for pain not being relieved, but if they were to give him/her narcotics he/she would be addicted again; -Since the resident has had medication changes, he/she has not complained of pain as frequently. MO00251691

Based on interview and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff failed to follow proper technique during a mechanical lift transfer of one resident (Resident #1). The facility census was 68. The Director of Nursing (DON) was notified by facility staff on 04/24/24 of the noncompliance that occurred on 04/24/24. The DON and Administrator made an online self-report to the Department of Health and Senior Services, began an investigation, and began in-servicing with all nursing staff regarding transfers on 04/24/24. The facility implemented monitoring of the resident involved and all residents who required a two person assistance transfer assistance with a Hoyer lift (mechanical lift normally used to transfer non-weight bearing residents) to ensure transfers were completed safely and as required with two staff. The noncompliance was corrected on 04/25/24. Review of the facility policy titled, Safe Lifting and Movement of Residents, with a revision date of July 2017, showed the following: -In order to protect the safety and well-being of staff and residents, and promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Two staff members must be present when operating a mechanical lifting device. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]: -Diagnoses included joint pain and Alzheimer (brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 03/25/24, showed the following: -Cognition severely impaired; -Dependent on staff for transfers, mobility, dressing, toileting, and bathing; -No falls with injury since admission. Review of the resident's Care Plan, dated 04/02/24, showed the following: -Required maximum staff assistance with activities of daily living; -Impaired visual function; -Impaired cognition and thought process due to dementia; -Limited physical ability due to Alzheimer, weakness, and contractures; -High risk for falls related to confusion. Review of of the resident's Progress Notes showed the following: -On 04/24/24, at 6:15 A.M., a certified nurse aide (CNA) reported possible injury to resident during transfer. The resident's right lower extremity (RLE) was caught or hit during the transfer and the resident began complaining of increased pain. The nurse's assessment of RLE showed a protruding area mid shin, tender to the touch. Staff administered pain medication immediately. Staff transferred the resident back to bed, stabilized leg, and ordered X-ray. -On 04/24/24, at 7:58 A.M., nurse arrived to work and report showed that during a transfer out of bed this morning resident either hit the foot of the bed or the Hoyer lift with right calf. The resident was crying in pain and pain medication had been administered per orders. Resident's leg had a hematoma and slight indent was noted to the shin area; -On 04/24/24, at 2:25 P.M., the physician reviewed the X-ray results and did not believe the resident was a candidate for surgery. The physician ordered a long leg splint that goes from above the knee to below the ankle, ace wrapped to immobilize the leg. Review of the resident's X-ray report, dated 04/24/24, showed an acute midshaft tibial (long bone in lower leg) fracture and osteopenia (a decrease in bone mineral density). Review of the resident's Care Plan, dated 04/24/24, showed the following update: -On 04/24/24, resident transferred by staff in Hoyer lift and right leg became entangled. Resident had large hematoma (bruising) immediately noted to right mid-calf. An X-ray showed mid-shaft fracture to right mid-calf. Staff to ensure that there are two staff for Hoyer lift transfers, sling is in proper position and right size, placement of my limbs during transfers, and make sure no obstacles in the path of the lift and resident. -Resident to wear a long leg splint above knee and below ankle. Resident is non-weight bearing and staying in bed until splint is applied. During an interview on 05/09/24, at 3:15 P.M., Nurse Aide (NA) A said the following: -He/she had training on use of a Hoyer lift when transferring a resident from bed to a chair and from chair to bed; -There should always be two staff when using the Hoyer lift; -The resident required total assistance from staff with transferring and mobility; -The resident required the use of a Hoyer mechanical lift for all transfers; -The resident was very fragile; -The resident complained of pain frequently; -On 04/24/24, he/she and CNA B were getting the resident up and dressed for the day; -CNA B controlled the mechanical lift while the resident was in the lift and he/she was supposed to guide the resident's legs and feet to ensure safety; -The mechanical lift sling had been placed on the resident and the resident was hooked up to the lift while lying in bed; -NA A stepped away from the resident in the lift to look for the resident's slipper; -CNA B did not notice he/she had walked away -NA A walked approximately six feet away from the resident when the resident yelled out in pain, -CNA B lifted the resident in the air using the mechanical lift while NA A was six feet away from the resident and he/she thinks the residents leg hit something while being lift; -NA A said he/she should not have stepped away from the resident during a transfer; -There should always be two staff when using a mechanical lift, one runs the lift and the other ensures the legs and feet are safe. During an interview on 05/09/24, at 3:40 P.M., Registered Nurse (RN) C said the following: -Hoyer lift transfers always require two staff members; -One staff guided while the other staff is driving the Hoyer lift; -The staff should never step away from the resident during the transfer; -If the staff have to walk away then the resident should be put back down until both staff can safely transfer the resident. During an interview on 05/09/24, at 3:45 P.M., Licensed Practical Nurse (LPN) D said the following: -When transferring a resident with a Hoyer lift there should always be two staff present; -The resident required the use of a Hoyer lift with all transfers; -The resident would [NAME] his/her legs straight out and become stiff; -The resident was very tiny and brittle. During an interview on 05/09/24, at 4:48 P.M., the DON said when transferring a resident using a Hoyer lift there should always be two staff. One staff should control the mechanical lift and the other staff member should guide the residents legs and feet. The staff should never walk away from the resident until the transfer is completed. During an interview on 05/09/24, at 4:51 P.M., the Administrator said there should always be two staff when transferring a resident using a Hoyer lift. One staff should control the mechanical lift and the other staff member control the resident so the residents legs and feet don't swing. The staff should never step away from the resident until the transfer is completed. If the staff have to step away the staff need to communicate with each other and the staff should stop the transfer until it is safe to transfer the resident. MO00235175

Based on interview and record review, the facility failed to ensure all allegations of abuse were immediately reported to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff witnessed one resident (Resident #1) touch another resident (Resident #2) in a sexual manner and the nurse failed to report the allegation to management or the SSA. The facility census was 62. Review of the facility's policy titled Abuse Reporting, revised 03/15/18, showed the following: -It is the policy of the facility that all personnel promptly report any incident or suspected incident of resident abuse; -The facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends or other individuals; -Any alleged violations involving mistreatment, neglect, or abuse must be reported to the Administrator and/or Director of Nursing (DON) as soon as suspicion has been formed; -If a suspicion of abuse has been formed at least one law enforcement agency as well as the State Survey Agency (SSA) must be notified immediately and no later than two hours after forming the suspicion; -All allegations of mistreatment, neglect or abuse, injuries of unknown source, and misappropriation of resident property are immediately reported to the Administrator and other officials in accordance with state law. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]: -Diagnoses included, depression, personally disorder, heart failure, cognitive social or emotional deficit and a nontramatical chronic subdural hemorrhage (a bleeding in the area between the brain and the skull-head trauma). Review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 09/30/23, showed the residents cognition was moderately impaired. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]: -Diagnoses included traumatic brain injury, anxiety, schizoaffective disorder (a mental health condition with a combination of symptoms of schizophrenia and mood disorder), bipolar (psychiatric illness characterized by both manic and depressive episodes or manic ones ), depression, asthma, and arthritis in the right ankle and foot. Review of the resident's admission MDS, dated [DATE], showed the resident's cognition was intact. Review of the resident's nursing note dated 10/06/23, at 10:22 P.M., listed as a behavior entry, showed the following: -The resident was argumentative with other residents during the smoke time around dinner; -At the last smoke break of the evening, CNA B witnessed Resident #1 jiggling Resident #2's breast; -Resident #2 was visibly upset; -Staff removed Resident #1 from the situation and told the resident this behavior was unacceptable. (Staff did not document reporting the allegation of abuse to the Administrator or DHSS.) Review of the resident's nursing note dated 10/09/23, at 12:05 P.M., listed as an incident note, showed the following: -DON and Administrator interviewed Resident #1 about the allegations; -The resident said he/she was just trying to give Resident #2 a hug and grazed him/her; -The physician was notified and an order for medroxyprogesterone (a hormone treatment) 5 milligrams (mg) one time daily was received; -Staff implemented 15-minute checks. -Staff assessed the resident. 3. Review of the facility's incident report, dated 10/09/23, showed the following: -Date of incident was 10/06/23 with P.M. noted for time -Location of the incident was the residents smoke area hall; -Certified Nurse Aide (CNA B) reported Resident #1 touched Resident #2's breast. 4. Review of DHSS records showed the allegation was reported by a staff member on 10/09/2023, at approximately 2:34 P.M. (three days after a staff became aware of the allegation of abuse). 5. During an interview on 10/10/23, at 3:15 P.M., CNA B said the following: -On 10/06/23, at the last smoke break, residents were in the hall waiting by the door going to the smoke area. At approximately 8:00 P.M., he/she witnessed Resident #1 touching Resident #2 inappropriately and he/she approached the residents immediately and separated the residents; -He/she then took all the residents out to smoke and after the smoke break he/she reported the abuse to Licensed Practical Nurse (LPN) A. 6. During an interview on 10/10/23, at 3:47 P.M., LPN A said the following: -All abuse and neglect should be reported immediately; -All abuse has to be reported to SSA within two hours; -CNA B reported an allegation of sexual abuse between Resident #1 and Resident #2 on 10/06/23; -LPN A failed to report the allegation of sexual abuse to the DON and/or the Administrator; -He/she should have reported the allegations of sexual abuse involving Resident #1 and Resident #2 immediately to the DON and the Administrator. 7. During an interview on 10/10/23, at 12:40 P.M., the DON said the following: -On 10/09/23, she was monitoring weekend charting and when reviewing charts she saw an incident note dated 10/06/23 that stated Resident #1 had jiggled' Resident #2's breast and the two residents were separated; -She called LPN A and LPN A said he/she failed to report the situation; -DON started an investigation and reported the alleged abuse to the SSA on 10/09/23. 8. During an interview on 10/10/23, at 5:00 P.M.,the Administrator and the DON said the following: -All reports of abuse must be immediately reported to the charge nurse, DON, and the Administrator; -LPN A should have reported all allegations of abuse to the DON and the Administrator; -All reports of abuse should be reported to the SSA within two hours of the alleged incident. MO000225626

Based on interview and record review, the facility failed to document a timely investigation of an allegation of sexual abuse and failed to immediately take steps to protect all residents when Certified Nurse Aide (CNA) B alleged one resident (Resident #1) was observed to touch another resident (Resident #2) in a sexual manner. The facility census was 62. Review of the facility policy titled Abuse Investigating, revised 03/15/18, showed the following: -It is the policy of the facility that reports of abuse will be promptly and thoroughly investigated; -The administrator will provide to the person in charge of the investigation a copy of the Resident Abuse Report Form and any supporting documents relative to the investigation: -The representative's investigation shall consist of a review of the completed Resident Abuse Report Form and an interview with the person(s) reporting the incident. Review of the facility's Abuse Policy included a copy of a form, including the steps taken to protect residents, which showed the following: -Describe all steps taken immediately to ensure residents are protected; -Immediate assessment of the alleged victim and provision of medical treatment as necessary; -Evaluation of whether the alleged victim feels safe and if he/she does not feel safe, taking immediate steps to protect the resident, such as a room relocation and/or increased supervision; -Immediate notification to the alleged perpetrator's (if a resident) and/or the alleged victim's physician and the resident representative when there is injury, a significant change in condition or status, and/or a need to alter treatment significantly; -If the alleged perpetrator is facility staff, removal of the alleged perpetrator's access to the alleged victim and other residents and assurance that ongoing safety and protection is provided for the alleged victim and other residents; -If the alleged perpetrator is a resident or visitor, removal of the alleged perpetrator's access to the alleged victim and, as appropriate, other residents and assurance that ongoing safety and protection is provided for the alleged victim and other residents; -Other measures the facility is taking to prevent further potential abuse, neglect, exploitation, and misappropriation of resident property. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]: -Diagnoses included depression, personality disorder, heart failure, cognitive social or emotional deficit, and a nontramatical chronic subdural hemorrhage (a bleeding in the area between the brain and the skull-head trauma). Review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 09/30/23, showed the resident's cognition was moderately impaired. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]: -Diagnoses included traumatic brain injury, anxiety, schizoaffective disorder (a mental health condition with a combination of symptoms of schizophrenia and mood disorder), bipolar (psychiatric illness characterized by both manic and depressive episodes or manic ones ), depression, asthma, and arthritis in the right ankle and foot. Record review of the resident's admission MDS, dated [DATE], showed the resident's cognition was intact. Review of the resident's nursing note dated 10/06/23, at 10:22 P.M., listed as a behavior entry, showed the following: -The resident was argumentative with other residents during the smoke time around dinner; -At the last smoke break of the evening CNA B witnessed Resident #1 jiggling Resident #2's breast; -Resident #2 was visibly upset; -Staff removed Resident #1 from the situation and told the resident this behavior was unacceptable. (Staff did not document the start of an investigation or what additional steps were taken to protect all residents.) Review of the resident's nursing note dated 10/09/23, at 12:05 P.M., listed as an incident note, showed the following: -DON and Administrator interviewed Resident #1 about the allegations; -The resident said he/she was just trying to give Resident #2 a hug and grazed him/her; -The physician was notified and an order for medroxyprogesterone (a hormone) 5 mg one time daily was received; -Staff implemented 15 minute checks put in place (3 days after the allegation occurred); -Staff assessed the resident. 3 Review of the facility's incident report, dated 10/09/23, showed the following: -Date of incident was 10/06/23 with P.M. noted as time; -Location of the incident was the residents' smoke area hall; -CNA B reported Resident #1 touched Resident #2's breast. (Staff did not document an immediate investigation or immediate steps taken to protect all residents.) 4. During an interview on 10/10/23 at 1:55 P.M., Resident #2 said the following: -While he/she sat in a chair in the hall waiting to go outside to smoke, Resident #1 wheeled his/her wheelchair up next to him/her and grabbed his/her right breast; -CNA B witnessed the incident and separated the residents; -Nobody came and talked to him/her that day or throughout the weekend; -The nurse did not assess the resident that day or anytime throughout the weekend; -The staff did not keep Resident #1 away from him/her. They all (residents) continued to wait in the hall waiting to go smoke and Resident #1 was in the same area in the smoking area. During an interview on 10/10/23, at 3:15 P.M., CNA B said the following: -On 10/6/23, at the last smoke break residents were in the hall waiting by the door going to the smoke area. At approximately 8:00 P.M., he/she witnessed Resident #1 touching Resident #2 inappropriate and he/she approached the residents immediately and separated the residents; -He/she then took all the residents out to smoke and after the smoke break he/she reported the abuse to Licensed Practical Nurse (LPN) A; -CNA B was not sure what had been done about this situation; -There was not any official monitoring of either resident; -There were no 15-minute checks of either resident until 10/09/23. During an interview on 10/10/23, at 3:47 P.M., LPN A said the following: -All abuse and neglect should investigated immediately; -The nurse should assess the residents involved in any reports of resident-to-resident abuse; -Residents involved in a resident-to-resident altercation should be monitored by initiating 15-minute checks; -CNA B reported an allegation of sexual abuse between Resident #1 and Resident #2 on 10/06/23; -LPN A did not go and assess either resident after the report was made; -LPN A did not initiated any monitoring of either resident; -No investigations was initiated after the report of resident-to-resident sexual abuse; -LPN A said he/she should have assessed both residents after the report of sexual abuse was reported to him/her; -An investigation should have been started and statements from staff should have been taken. During an interview on 10/10/23 at 12:40 P.M., the Director of Nursing (DON) said the following: -On 10/09/23, she was monitoring weekend charting and when reviewing charts she saw an incident note dated 10/06/23 that stated Resident #1 had jiggled' Resident #2's breast and the two residents were separated; -She called LPN A and LPN A said he/she failed to report the situation; -Staff initiated 15-minute checks on 10/09/23; -The residents should be kept separated and monitored for safety; -She started an investigation on 10/09/23. During an interview on 10/10/23, at 5:00 P.M., the Administrator and the DON said the following: -All reports of abuse must be investigated immediately; -During the investigation the accused resident should be placed on 15-minutes monitoring and the victim of the alleged abuse should be protected; -All investigations should be completed and sent to the SSA within five days. MO000226226

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to clean the hand washing sink, sink in the food preparation area, floor under the three vat sink, the area between the wall and the stove, fryer, and warming cart, the vent above the ice machine, and failed to repair the walls behind the dishwasher and in the beverage room and tiles and wall under the three vat sink to ensure they were washable surfaces; staff failed wear hair nets appropriately to prevent contamination of food; staff failed to regularly test and have knowledge of the correct temperatures of the dishwashing machines; and the drain from the ice machine had no air gap between it and the drain. The facility census was 60. 1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the facility policy titled Job Description for Certified Dietary Managers (CDMs), undated, showed the following: -Prepare cleaning schedules and maintain equipment to ensure food safety; -Ensure proper sanitation and safety practices of staff. Review showed the facility did not provide a policy related to cleanliness of the kitchen. Observations on 09/17/23, at 4:15 P.M., on 09/18/23, at 3:24 P.M., and on 09/19/23, at 8:54 A.M., showed the following: -The handwashing sink had a grayish colored film in the bowl and around the edges; -The sink in the food preparation are had a brownish film in both bowls and around the edges; -The vent above the ice machine, it's latch that held it shut, and the top approximate two feet of an approximate three foot chain had a thick layer of what appeared to be dust on it; -The floor that was approximately fourteen feet in length between the wall and stove, fryer, and warming cart had a buildup of dirt, food debris and paper on it. The pipes and fittings that ran into the back of the stove and fryer in this same area had a thick layer of what appeared to be dust; -The floor under the three vat sink had a buildup of food debris and had five tiles that were partially missing; -The covering on the wall and cobase under the three vat sink was coming away from the wall; -The wall behind and to the right of the dish washer and the wall behind the juice and coffee machines and to the right of them was peeling. During an interview on 09/20/23, at 10:19 A.M., Dietary Aide (DA) A said the following: -The kitchen had cleaning schedules that showed to sweep, mop, clean, no food on floors or counters, all trash picked up, wipe off carts and food warmers, clean the microwave, and wipe the sinks off and make sure they are dry; -When he/she completed a task, he/she put his/her initials next to that task; -The DA's and dishwasher were responsible for cleaning the hand washing sink and the sink in the food preparation area and the dishwasher was responsible for sweeping and mopping under the three vat sink and behind the stove; -The maintenance man was responsible for cleaning the vent above the ice machine; -There should not be a buildup of dust on the vent, latch or chain above the ice machine because it could fall into the residents' ice or drinks; -There should not be a buildup of dust, food debris or paper behind the stove, fryer and warming cart or under the three vat sink because it was unsanitary; -The wall behind the dishwasher was not a cleanable surface because it was peeling. He/she had not told anyone about the wall, but should report this to the DM; -All kitchen staff should keep the kitchen clean; -The Dietary Manager (DM) was responsible for ensuring staff cleaned the kitchen. During an interview on 09/20/23, at 10:41 A.M., DA B said the following: -The cleaning schedule for the dishwasher was on a clipboard in the dish washing area and for the dietary aides on the microwave; -DAs cleaned the sink in the food preparation area and the dishwasher cleaned the hand washing sink and swept and mopped under the three vat sink and behind the stove and fryer. Kitchen staff should clean the sinks and there should not be food, paper or dust behind the stove area or under the three vat sink because it could contaminate the food and attract pests; -All kitchen staff should clean the vent above the ice machine. There should not be dust on the vent, latch or chain because it could fall in the ice machine and contaminate the ice in the residents' drinks; -The DM was responsible to ensure kitchen staff completed the cleaning tasks. During an interview on 09/20/23, at 10:54 A.M., Cook D said the following: -Every station should have a cleaning schedule posted. He/she did not have one posted now; -The DA and dishwasher were responsible for cleaning the hand washing sink and sink in the food preparation area; -The cook was responsible for sweeping and mopping under the three vat sink and behind the stove, fryer, and warming cart; -All kitchen staff could clean the vent above the ice machine, but the task was not on a specific cleaning schedule; -There should not be food and broken tiles under the three vat sink or food, dust and paper behind the stove, fryer and warming cart because it could attract pests and contaminate food; -There should not be a buildup of dust on the vent above the ice machine because it could contaminate the ice, cups, coffee pots and tea pots in the room; -The DM and cooks were responsible for ensuring staff completed the cleaning tasks. During an interview on 09/20/23, at 3:05 P.M., the DM said the following: -The kitchen had cleaning schedules, but had not been using them and had slacked off on cleaning; -All kitchen staff were responsible for cleaning the hand washing sink, the DAs were responsible for cleaning the sink in the food preparation area, maintenance was responsible for cleaning the vent above the ice machine, and all kitchen staff were responsible for cleaning the floor behind the stove, fryer and warming cart; -The floor under the three vat sink was not cleanable due to the missing/broken tiles; -He/she told the Administrator about the missing/broken tiles under the three vat sink and the Administrator did a walk-through with the Maintenance Director to show him/her the tiles; -The walls in the dish washing room and the beverage room were not cleanable. He/she told the Administrator about the walls; -It was important for kitchen staff to keep the kitchen clean for sanitation and prevention of pests; -He/she was responsible for ensuring kitchen staff completed the cleaning assignments. During an interview on 09/22/23, at 8:37 A.M., the Maintenance Director said the following: -He/she and the maintenance assistant cleaned the vent over the ice machine and kitchen staff cleaned it too; -The vent, latch and chain should not have a buildup of dust due to sanitary reasons; -He/she and the DM were responsible for monitoring the vent for cleanliness and ensuring the vent was kept clean. During an interview on 09/22/23, at 2:47 P.M., the Administrator said the DM was responsible for ensuring the cleanliness of the kitchen. 2. Review of the FDA 2013 Food Code showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility policy titled Job Description for Certified Dietary Managers (CDMs), undated, showed the following: - Protect food in all phases of preparation, holding, service, cooking, and transportation, using Hazard Analysis and Critical Control Points (HACCP) Guidelines. Review of the facility's policy titled Personnel, undated, showed the following: -Dietary employees will use effective hair restraints to prevent the contamination of food or food contact surfaces. Observation on 09/17/23, at 4:15 P.M., showed a DA, preparing residents' drinks. The DA wore a hair net covering the top and back of his/her head, but did not cover his/her bangs. Observations on 09/19/23, at 8:54 A.M. and 11:10 A.M., showed DA A wore a hairnet over the top of his/her head and left the back of his/her hair hanging out of the hairnet. He/she prepped salads for residents. During an interview on 09/20/23, at 10:19 A.M., DA A said the following: -Staff should wear hairnets covering all of their hair; -If he/she saw a kitchen staff not wearing a hairnet appropriately, he/she told the staff member to fix it; -Staff should not wear hairnets with their bangs or back of their hair hanging out because they could get hair in the residents' food. During an interview on 09/20/23, at 10:36 A.M., DA B said the following: -Staff should wear hairnets covering all of their hair; -Staff should not wear hairnets with their bangs or back of their hair hanging out because they could get hair in the residents' food; -The DM was responsible for ensuring kitchen staff wore hairnets appropriately. During an interview on 09/20/23, at 10:54 A.M., Cook D said the following: -Staff should wear hairnets covering all of their hair; -Staff should not wear hairnets with their bangs or back of their hair hanging out because they could get hair in the residents' food; -If he/she saw a kitchen staff member wearing their hairnet wrong, he/she corrected them; -The cooks were responsible for ensuring kitchen staff wore hairnets appropriately. During an interview on 09/20/23, at 3:05 P.M., the DM said he/she expected kitchen staff to wear hairnets appropriately and he/she was responsible for ensuring kitchen staff did. During an interview on 09/22/23, at 2:47 P.M., the Administrator said the DM was responsible for ensuring the kitchen staff wore hairnets appropriately. 3. Review of the 2013 Missouri Food Code showed a warewashing machine shall be equipped with a temperature measuring device that indicates the temperature of the water in each wash and rinse tank and as the water enters the hot water sanitizing final rinse manifold or in the chemical sanitizing solution tank. Review showed the facility did not provide a policy related to dishwasher temperature logs. Review of the facility's Temperature Record for Dishwasher, dated August 2023, showed the following: -Wash temperature 150 degrees Fahrenheit (F) and rinse 180 degrees F; -A spot to log wash and rinse temperatures and staff initials for breakfast, lunch and supper; -Staff did not record temperatures in the log for breakfast on 08/01/23, 08/03/23 through 08/16/23, 08/18/23 through 08/21/23, and 08/23/23 through 08/31/23; -Staff did not record temperatures in the log for lunch for the entire month of August; -Staff did not record temperatures in the log for supper on 08/03/23 through 08/04/23, 08/07/23, 08/09/23 through 08/10/23, 08/12/23 through 08/13/23, 08/15/23 through 08/18/23, 08/20/23 through 08/29/23 and 08/31/23; -Staff recorded rinse temperatures of 179 degrees F on 08/01/23, 177 degrees F on 08/05/23, and 172 degrees F on 08/30/23. Review of the facility's Temperature Record for Dishwasher, dated 09/2023, showed the following: -Staff did not record temperatures in the log for breakfast, lunch, and supper on 09/01/23 through 09/18/23, lunch and supper on 09/19/23 and 09/21/23 and supper on 09/20/23. During an observation and interview on 09/19/23, at approximately 10:00 A.M., DA C said the following: -The dishwasher temperature should be over 155 degrees F for the wash and he/she did not know what it should be for the rinse; -He/she believed this should be documented each shift, but he/she did not do this; -He/she ran the dishwasher and wash was 160 degrees F and rinse was 164 degrees F and then ran it again and the wash was 155 degrees F and rinse was 181 degrees F. During an interview on 09/20/23, at 10:19 A.M., DA A said the following: -The dishwasher used heated water to sanitize the dishes. The wash should be 180 degrees F and the rinse should be 180 to 185 degrees F; -Dishwashers documented that on a log on the wall. They wrote down the temperature and initialed the log and completed this each shift; -The dishwashers were responsible for completing the log and the DM was responsible for ensuring they completed the logs. During an interview on 09/20/23, at 10:41 A.M., DA B said the following: -The dishwasher used chemicals to sanitize and the dishwasher had test strips to check the levels; -He/she did not know if the water temperature had to be a certain degree F; -He/she had not tested the dishwasher before and did not know if the dishwasher had to complete a log; -He/she believed the DM tested the dishwasher and did not know how often. During an interview on 09/20/23, at 11:17 A.M., DA C said the following: -The dishwasher water temperature for the wash should be 160 degrees F and the rinse should be 180 degrees F; -The dishwasher documented the temperatures but he/she did not know how often; -The cooks and the DM were responsible for ensuring dishwashers completed the dishwasher logs. During an interview on 09/20/23, at 3:05 P.M., the DM said the following: -The dishwasher used heat sanitation. The wash should be 150 degrees F and the rinse should be 180 degrees F; -Dishwashers should document this each meal; -Every DA that washed dishes should know the temperatures and where to document them; -He/she was responsible for ensuring DAs that washed dishes knew the proper temperatures for wash and rinse and completed the dishwasher log. During an interview on 09/22/23, at 2:47 P.M., the Administrator said the DM was responsible for ensuring the kitchen staff completed the dishwasher logs. 4. Review of the 2013 Missouri Food Code showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch (1). Review showed the facility did not provide a policy related to the air gap. Observations on 09/17/23, at 4:15 P.M. and on 09/19/23, at 8:54 A.M., showed the drain from the ice machine was even with the drain in the floor and did not have an air gap. During interviews on 09/20/23, at 3:05 P.M., and on 09/22/23, at 8:37 P.M., the Maintenance Director said the following: -There should be an air gap between the drain on the ice machine and the drain in the floor; -The air gap should be two inches. During an interview on 09/20/23, at 3:05 P.M., the DM said the following: -There should be an air gap between the drain from the ice machine and the drain in the floor to prevent back flow. He/she did not know how much the air gap should be; -The Maintenance Director was responsible for ensuring there was an air gap.

Based on interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for four residents (Resident #16, #25, #29, and #31). The facility census was 60. Review of the facility's policy titled, Advance Directives, revised [DATE], showed the following: -Advance directives will be respected in accordance with state law and facility policy; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 1. Review of Resident #'16's face sheet (admission data) showed the following: -admitted [DATE]; -Code status of Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) Review of the resident's current Physician's Order Sheet (POS), dated [DATE], showed the resident's code status as a DNR. Review of the list of residents on the crash cart located at the nurses' station showed code the resident's code status as a DNR Review of the resident's care plan, revised [DATE], showed the resident's code status as full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep alive). During an interview on [DATE], at 12:15 P.M., the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff)/Care Plan Coordinator said the resident's code status showed as full code on the care plan. 2. Review of Resident #'25's face sheet showed the following: -admitted [DATE]; -Code status of DNR. Review of the Outside the Hospital DNR form showed the following: -The resident signed the form on [DATE]; -The resident's physician signed the form on [DATE]. Review of the resident's current POS showed the resident's code status as a DNR. Review of the list of residents on the crash cart located at the nurses station showed the resident's code status as a DNR Review of the resident's care plan, dated [DATE], showed a the resident's code status as full code. During an interview on [DATE], at 12:15 P.M., the MDS/Care Plan Coordinator said the resident's code status showed as full code on the care plan. 3. Review of Resident #'29's face sheet showed the following: -admitted [DATE]; -Code status of DNR. Review of the resident's DNR form showed the following: -The resident's representative signed the form on [DATE]; -The resident's physician signed the form on [DATE]. Review of the resident's current POS showed the resident's code status of code status as a DNR. Review of list of residents on the crash cart located at the nurses station showed the resident's code status as DNR Review of the resident's care plan, dated [DATE], showed the resident's code status as full code. During an interview on [DATE], at 12:15 P.M., the MDS/Care Plan Coordinator said the resident's code status showed as full code on the care plan. 4. Review of Resident #'31's face sheet showed the following: -admitted [DATE]; -Staff did not document the resident's code status on the face sheet. Review of the resident's care plan, dated [DATE], showed the resident's code status as full code. Review of the resident's current POS, dated [DATE], showed the resident's code status, dated [DATE], as a DNR. Review of the crash cart located at the nurses station showed the resident's code status as DNR. During an interview on [DATE], at 12:15 P.M., the MDS/Care Plan Coordinator said the resident's code status showed as full code on the care plan. 5. During an interview on [DATE], at 11:30 A.M., Certified Nurse Aide (CNA) H said the following: -He/she finds the code status in the care plan book at the nurses' desk in the unit; -Full code means perform CPR; -DNR means to not perform CPR. 6. During an interview on [DATE], at 1:14 P.M., Certified Medication Technician (CMT) I said the following: -He/she would get the nurse if a resident was found unresponsive; -Staff should check the resident's code status on the crash cart in the binder; -DNR means do not perform CPR; -CPR means to resuscitate. 7. During an interview on [DATE], at 1:35 P.M., Licensed Practical Nurse (LPN) J said the following: -Staff find a resident's code status in the book located on the crash cart; -Staff find a resident's code status in the care plan; -Full code means perform CPR; -DNR means No CPR -Code status should match throughout the residents' medical record. 8. During an interview on [DATE], at 12:15 P.M., the Care Plan Coordinator said the following: -She is responsible for updates to the residents' care plans; -She reads the 24 hour report everyday; -Staff should inform her of any updates needed to the residents' care plans; -Nurse aides find the care plans in the computer system; -Staff find a resident's code status on the crash cart, care plan, face sheet, and the physician order; -The code status should match throughout the resident's medical record; -She checked the code status to make sure resident's code status matched throughout the medical record. 9. During an interview on [DATE], at 2:33 P.M., the Director of Nursing said the following: -Staff discuss changes for care plans in the weekly risk meetings; -The care plan coordinator updates the care plans; -Code status should be in the book on the crash cart which staff should look at first; -Code status can be found in the computer system on the care plan; -Code status should match throughout the resident's medical record. 10. During an interview on [DATE], at 2:57 P.M., the Administrator said a resident's code status should be consistent throughout the resident's medical record.

Based on interview and record review, the facility failed to document a full discharge summary with information regarding discharge for one resident (Resident #59). The facility census was 60. Review of the facility's policy titled, Discharge Procedure, revised 04/26/00, showed the following: -To assist family and resident to continue care if returning home; -To advise other departments promptly of dismissal; -To facilitate proper closing of records and collection of personal belongings; -Upon notification of dismissal, the records will be completed as quickly as possible assuring an organized dismissal. 1. Review of Resident #59's face sheet (admission data) showed the following information: -Re-admitted [DATE]; -Diagnoses included unspecified dementia, obesity, and anxiety disorder. Review of the resident's progress note dated 06/28/23, at 2:14 P.M., showed the Social Service Director (SSD) documented the resident to discharge on 06/30/23. The resident will stay with his/her family member. Nursing staff notified and an order to discharge with medications and an order for home health. The physician to send the prescription to the pharmacy for medications. Review of the resident's electronic and paper medical records showed staff did not document information pertaining to the resident's discharge. Staff did not document in the medical record when, how, where, or why the resident discharged from the facility. Staff did not document a post-discharge plan of care or review of medication. Staff did not document a recapitulation of the resident's stay. During an interview on 09/21/23, at 1:52 P.M., Licensed Practical Nurse (LPN) E said the following: -The nurses should notify the physician and review the medications with the resident and/or responsible party; -The nurses should give the medications and instructions to the resident/responsible party upon discharge if the medications are sent; -Nurses should have the resident and/or responsible party sign if narcotics are sent with the discharge. During an interview on 09/22/23, at 1:33 P.M., LPN F said the following: -The charge nurse should document in the resident's progress notes of a resident's discharge; -The charge nurse should document where the resident was discharged to, medications sent, belongings medications sent, and home health services. During an interview on 09/21/23, at 2:00 P.M., the SSD said the following: -She completes the discharge plan and summary for residents; -She discusses with the resident of discharge plans to home, home health services, or wishes to remain in the facility; -She gives home health brochures to the resident and/or responsible party to review and they notify her of the home health choice. The responsible party or resident sometimes contact the home health company; -Nursing staff should document a discharge summary in the resident's progress note; -She and nursing staff should develop a resident's discharge plan as a team; -She did not know of the of recapitulation of stay note when a resident discharged from the facility; -She did not document the resident's discharge plan or summary; -The resident discharged to home with his/her family; -She did not document a note on the resident's discharge date . During an interview on 09/21/23, at 2:33 P.M., the Director of Nursing (DON) said the following: -The charge nurse should document a discharge summary; -Nurses should send a medication list with the resident and instructions if the medications are sent; -Nurses should document a note in the resident's progress notes of the discharge. During an interview on 09/22/23, at 2:57 P.M., the Administrator said facility staff should complete a discharge summary of a resident's discharge.

Based on record review and interview, the facility staff failed to ensure two cognitively impaired residents (Resident #1 and Resident #2) in the special care unit (SCU - a locked hall that provides care for residents with dementia) were free from abuse when one staff member (Certified Nurse Aide (CNA) A) assisted the residents in a rough manner and was verbally abusive to them. The facility census was 46. Record review of the facility's Abuse Reporting Policy, revised 7/22/19, showed the following: -The facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals; -Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or metal anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing; -Verbal abuse is defined as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability -Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment and withholding needed treatments or services. This includes any negative physical contact, even when it does not result in injury. 1. Record review of Resident #1's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/19/21, showed the following: -Severe cognitive impairment; -Extensive assistance with one-person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of the resident's care plan, dated 7/26/21, showed the following: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Severe cognitive impairment; -Behaviors will be managed in a manner to decrease anxiety; -Due to a persistent decline in multiple health issues the resident has been admitted to services of hospice, with the objective that all care will be directed with comfort as the main goal. Record review of the facility's grievance log dated 8/23/21, at 10:30 A.M., showed the following statement hand written by the Office/Activities Assistant B: -While working with the residents in the SCU, he/she heard the resident hollering for someone to help him/her over and over. He/she went to the resident to see what he/she needed. The resident was asking for help to the restroom; -He/she told CNA A that the resident needed help. CNA A said that he/she called for help and no one came to help. He/she offered to help CNA A with the resident; -When they got to the resident's room, CNA A grabbed the resident's legs and threw the resident on the bed and did not tell the resident what he/she was going to do; -CNA A roughly began to take the resident's pants off; -When they started to roll the resident over to get the wet pad and clothing off him/her, CNA A was pushing on the resident's back; -When he/she went to roll the resident the other way, CNA A grabbed the resident's left arm and yanked on it instead of helping him/her roll to his/her right side; -They proceeded to put the resident's pants on. CNA A grabbed the resident's left arm and yanked the resident up to the sitting position. CNA A then yanked the resident's shirt off over his/her head, pulling the resident's hair. At that point, the resident began to cry again; -When they were done dressing the resident, CNA A left the room and he/she cleaned everything up and combed the resident's hair; -He/she sat with the resident for a few more minutes until he/she was calmed down. During interviews on 9/3/21, at 12:55 P.M., and on 9/7/21, at 2:43 P.M., the Office/Activities Assistant B said the following: -The incident with CNA A involving the resident happened on 8/23/21, at 10:30 A.M. CNA A was rough and too quick with the resident. The resident had tears in his/her eyes and didn't want to let go of the Office/Activities Assistant B's hand. He/she feels CNA A physically abused the resident; -He/she was so upset that day of the incident that he/she reported it to the Business Office Manager immediately after it happened; -CNA A grabbed the resident's legs and threw them. By this he/she meant that CNA A did this very quickly without offering back or body support and without verbalizing to the resident what he/she was doing. It emotionally upset the resident and the resident gave a whining cry like he/she was hurt; -CNA A abruptly pulled the resident's pants down past his/her hip; -When CNA A pushed the resident over the old pad toward the Office/Activities Assistant B, CNA A did not give the resident any support. He/she pushed firmly on the back of the resident's right hip like the resident was a rag doll; -When CNA A yanked the resident's left arm, he/she meant CNA A pulled it quickly and firmly away from the resident's body to the right side; -CNA A pulled the resident quickly and firmly again by the left arm to a sitting position without explaining what CNA A was doing, or without supporting the resident's back or body; -He/she said when the CNA yanked the resident's shirt off and pulled the resident's hair, CNA A did this quickly and with a lot of force that made the resident cry out, Oh God loudly, and then more active tears came from the resident's eyes. Record review of the resident's progress notes showed staff did not document regarding the Office/Activities Assistant B's allegation of abuse again CNA A. Staff did not document an assessment of the resident. Record review of the facility's grievance log dated 9/2/21, at 7:30 A.M., showed the following statement hand written by Nurse Aide (NA) C: -The aides went to go change the resident and CNA A asked if NA C would pull the resident's pants up. CNA A then roughly pulled the resident up out of the chair. As NA C, pulled the resident's brief and pants up the resident said, Ouch, you are hurting me, and CNA A told the resident, No, I am not, shut up. As the aides were walking out the resident said, I'm sorry. CNA A then told the resident, No, you are not. I hate this job. You guys make me hate you guys. During interviews on 9/7/21, at 9:40 A.M., and on 9/7/21, at 3:05 P.M., NA C said the following: -He/she felt that CNA A verbally and physically abused the resident; -He/she reported this incident to the Director of Nursing (DON) and the charge nurse as soon as possible; -When CNA A roughly pulled the resident up, CNA A did it quickly and abruptly. Record review of the the resident's progress notes showed the following: -On 9/3/21, at 11:19 A.M., the DON documented a late entry incident note for 9/2/21, at 11:30 A.M. The DON noted a report by another staff of incident that occurred earlier this morning with new staff member who was unaware of reporting policy. Education given that reporting needs to be done immediately, and will follow up teaching in in-service. See Social Services for further details. Assessed resident and found no apparent injury physically, when asked unable to verbalize what occurred; -On 9/2/21, at 12:30 P.M., physician and family were notified at the time of the event; -On 9/3/21, at 11:56 A.M., a late entry incident note for 9/2/21, showed the reported staff member involved in reported incident was immediately removed from resident care area and instructed to clock out. Said staff member not allowed to work until results of investigation of reported incident. 2. Record review of Resident #2's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Extensive assistance with one-person physical assist with bed mobility, transfers, dressing, and toilet use; -Limited assistance with one-person physical assist for locomotion on and off the unit. Record review of the resident's care plan, with review start date of 6/7/21, showed the following: - Requires extensive assistance with activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting); -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Severe cognitive impairment; -Behaviors will be managed to decrease the resident's stress and anxiety. Record review of the facility's grievance log dated 9/2/21, at 7:30 A.M., showed the following statement hand written by Nurse Aide (NA) C: -The aides proceeded to the resident's room. The resident did not want to get up. He/she held onto his/her blanket. CNA A then ripped the blanket from the resident, grabbed him/her up to roll him/her when the resident said, You are hurting me, please stop. CNA A told the resident to shut up. CNA A said, I'm not [OBSCENITY] ing hurting you. The aides got the resident's pants and brief on and finished up. CNA A then told the resident he/she hated him/her. During interviews on 9/7/21, at 9:40 A.M. and 3:05 P.M., NA C said the following: -He/she felt that CNA A verbally and physically abused the resident; -He/she reported this incident to the charge nurse and DON as soon as possible; -When CNA A ripped the blanket from the resident, CNA A forcefully and quickly grabbed the blanket out of the resident's hands and threw it forcefully across the floor; -CNA A grabbed the resident's arm and leg and forcefully rolled the resident the other way. Record review of the the resident's progress notes showed the following: -On 9/3/21, at 11:06 A.M., a late entry incident note for 9/2/21 at 11:30 A.M., staff noted a report by another staff of incident that occurred earlier this morning with new staff member who was unaware of reporting policy. Education given on reporting that this needs to be done immediately, and will follow up teaching in in-service. See Social Services for further details. Assessed resident and found no apparent injury physically, when asked unable to verbalize what occurred; - On 9/3/21, at 11:51 A.M., a late entry incident note for 9/2/21, showed a reported staff member involved in reported incident was immediately removed from resident care area and instructed to clock out. Said staff member was not allowed to work until results of investigation of reported incident; -On 9/3/21, at 3:12 P.M., a late entry Social Services note for 9/2/21, showed there was an incident involving resident and employee. DHSS was notified and investigation was started. 3. During an interview on 9/3/21, at 10:10 A.M., CNA E said staff should report abuse immediately to supervisor. 4. During an interview on 9/3/21, at 10:54 A.M., the Social Services Director (SSD) said on occasion a couple residents have mentioned CNA A is too rough when he/she is moving and rolling residents and that CNA A jokes in verbally inappropriate ways, saying to residents, Oh hush, when rolling residents. Not all residents know that is a joke. The SSD thinks CNA A has both physically and verbally abused Resident #1 and Resident #2. 5. During an interview on 9/3/21, at 11:45 A.M., Registered Nurse (RN) G said if he/she saw abuse he/she would separate the resident, make sure the resident is okay, and report it to the supervisor immediately. 6. During an interview on 9/3/21, at 1:34 P.M., the Administrator said the Business Office Manager reported the incident between CNA A and Resident #1 to him/her on 8/23/21, immediately after the Business Office Manager heard about it. The Administrator said she talked with the DON about it immediately. After the incident between CNA A and Residents #1 and #2 on 9/2/21 occurred, the Administrator thinks the DON had the Office/Activities Assistant B write up a statement about the incident that he/she had witnessed on 8/23/21. 7. During an interview on 9/7/21, at 4:05 P.M., the Administrator and the DON said the following: -Abuse is never tolerated. If seen, staff should report it to their supervisor or above; -The DON said on 8/23/21, he/she assessed the incident involving CNA A and Resident #1, and he/she felt it was not abuse; -The Administrator said that the Office/Activities Assistant B who reported the 8/23/21 incident tends to exaggerate what goes on at the facility with others and herself. The Administrator said they felt she was just exaggerating about the incident between CNA A and Resident #1; -The DON said he/she did not document that he/she assessed the resident or the incident on 8/23/21; -After the 8/23/21 incident, the DON said CNA A was moved out of the SCU to the regular floor where there was more staff who could monitor CNA A, and another aide was put back in the SCU permanently; -The Administrator and DON said they did not feel it was necessary to have other staff monitor CNA A with resident cares because first, there are more staff on the main halls to watch CNA A and the staff and the residents on the main halls are more verbally inclined to say something or report abuse; and second, because the staff may have ganged up on CNA A if they had told the staff to not leave CNA A alone with the residents; -The Administrator and DON said it is hard to work the SCU too, and Resident #1 can be aggressive, so they wanted to give CNA A a break from the SCU in hopes that that would mitigate the problem. They tried to keep CNA A out of the SCU after 8/23/21, provided the schedule would allow for it; -The Administrator and DON expect staff to treat residents with dignity and respect. 8. During an interview on 9/9/21, at 9:15 A.M., the Business Office Manager said the following: -Physical, verbal, and financial are all forms of abuse; -H/she has no recollection that the Office/Activities Assistant B reported to him/her the alleged abuse by CNA A to Resident #1 on 8/23/21; -The Business Office Manager said the Office/Activities Assistant B talks a lot while he/she is trying to work, so sometimes the Business Office Manager is only half listening to the Office/Activities Assistant B's statements. MO 372

Based on observation, interview, and record review, the facility failed to identify pressure ulcers, failed to provide care to prevent the development of pressure ulcers for three residents (Resident #3, #9 and #12) out of 13 sampled residents and failed to accurately stage pressure ulcers. Staff did not follow physician orders [REDACTED]. The facility had a census of 50 residents. According to the U.S. Dept. of Health and Human Services Clinical Practice Guidelines, pressure ulcer staging is defined as follows: -Stage I - a persistent area of skin redness without a break in the skin, that is non-blanchable (redness of skin surface that persists when pressure is applied); -Stage II - partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister; -Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough (slough is dead skin tissue that may have a yellow or white appearance. It is important to remove this tissue to prevent infection and promote healing) may be present but does not obscure the depth of tissue loss. May include undermining or tunneling; -Stage IV - Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. Record review of the facility's skin report, showed the following definitions of pressure ulcers: -Any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are graded and staged to classify the degree of damage. -Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. -Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough my be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable Pressure Sores- are defined as full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. -DTI (deep tissue injury) - as defined by purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or sheer. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: DTI may be difficult to detect in individuals with dark skin tones. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Record review of the facility's "Skin Team" policy, revision dated 09/25/13, showed the following information: -All nursing staff will report immediately any skin issues to the skin nurse team leader, charge nurse and/or Registered Nurse (RN) supervisor to fill out a skin report sheet and implement protocol necessary. -Document staging, measurements and the treatment according to facility policy on the skin report sheet and in the nurses' notes at least weekly and for an additional three weeks following closure of the area. -To ensure all areas of skin breakdown are identified and addressed, the bath aide checks each resident at the time of their bath and completes a body assessment form. -The skin nurse will report weekly to the physician and family of progress or deterioration of skin conditions and those not responding positively to the ordered treatment will be reported to the physician. -The nurse requests an assessment or a change of treatment by the physician. Areas that persist in not healing may require the services of a wound care specialist. -Staff completes an updated Braden scale. -During a weekly skin review meeting, staff updates the resident's care plan to correlate with the resident's current skin care needs. -Staff provides a copy of any active skin report along with the Braden scale during the weekly care plan meeting. Record review of a facility form (undated) titled, "Guidelines for using Skin Report", showed instruction to report all skin areas of concern on the skin report sheet upon admission, readmission and on an as needed basis. Record review of the facility's "Pressure Ulcer" protocol, dated 09/27/13, showed the following information: -Submit skin report to the skin nurse; -Notify family/responsible party, physician, Director of Nursing (DON) and the administrator; -Initiate daily monitoring with appropriate dressings as well as routine measurements; -Offer toileting/changing and repositioning every two hours and prn (as needed); -Assess the resident daily and at least weekly in the skin book and in the nurse's notes. 1. Record review of Resident #3's significant change Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 09/25/14, showed the following information: -Short and long-term memory problem with impaired decision-making ability; -Extensive assistance of two staff members for bed mobility; -Total dependence on two staff members for transfers and toileting; -Non-ambulatory; -An indwelling supra-pubic catheter (a urinary catheter that is inserted directly into the bladder through an incision in the lower abdomen); -Always incontinent of bowel; -[DIAGNOSES REDACTED]. -At risk for development of pressure ulcer; -No current unhealed pressure ulcers at Stage I or higher; -No pressure ulcer present on prior assessment; -Staff documented the resident had Moisture Associated Skin Damage (MASD); -Staff documented the resident had a pressure-relieving device for his/her chair; -Staff documented the resident was on a turning and repositioning program; -Staff documented the application of a non-surgical dressing and ointment/medication to area other than to feet. Record review of the resident's Braden scale (an assessment instrument used to predict pressure ulcer risk), completed on 9/23/14, showed the resident to be at moderate risk of developing a pressure ulcer. Record review of the care plan, dated 10/01/14, showed the following information: -Required assistance of two staff members with a mechanical lift for transfers; -Turn/reposition every two hours; -Staff identified the resident as at risk for skin breakdown related to bowel incontinence and decreased mobility; -Head to toe skin assessment with showers and monitor skin with daily care and report any skin issues to charge nurse. During an interview on 12/07/14 at 7:50 P.M., Certified Nursing Assistant (CNA) C said the following: -He/she worked full-time on the night shift; -He/she transferred residents into wheelchairs starting at 4:30 A.M., which included Resident #3; -During the past two weeks, there had been two CNAs on the night shift to care for over 40 residents. During an interview on 12/07/14, at 9:05 P.M., CNA D said he/she worked the night shift. On more than one occasion, he/she worked without another CNA and cared for over 40 residents. Observation and interview on 12/08/14 showed the following: -At 9:45 A.M., the resident sat up in a wheelchair; -At 11:00 A.M., the resident's spouse wheeled the resident into the assisted dining room for lunch and said staff informed him/her the resident had been up out of bed since before breakfast; -At 11:14 A.M., the resident sat in the dining room eating lunch; -At 11:58 A.M., staff wheeled the resident from the assisted dining room to the TV area across from the nurses' station; -At 1:00 P.M., the resident sat in the TV area in his/her wheelchair and attempted to shift position and groaned showing facial grimacing; -At 1:50 P.M., a Certified Medication Technician (CMT) reported the resident just finished a shower; -At 2:08 P.M., after receiving a shower, the resident continued to sit in a wheelchair in the shower room; -At 2:40 P.M., the resident sat in the TV room across from the nurses' station in his/her wheelchair; -From at least 9:45 A.M. until 2:40 P.M., the resident sat in the wheelchair, except for the time he/she received a shower. Observations on 12/09/14 showed the following: -At 9:30 A.M., the resident sat in the TV area across from the nurses' station in a wheelchair; -At 9:35 A.M., staff wheeled the resident to the dining room for a music activity; -At 10:15 A.M., the resident remained in a wheelchair in the dining room for a music activity; -At 11:00 A.M., the resident sat in a wheelchair in the assisted dining room; -At 12:10 P.M., staff wheeled the resident to the TV area across from the nurses' station; -At 1:50 P.M., the resident remained in the TV area across from the nurses' station. During an interview on 12/09/14, at 2:00 P.M., CNA E said the resident had been in the wheelchair since before breakfast. CNA E said he/she was unable to transfer the resident because the resident required two staff assistance and a mechanical lift, and the other two CNAs were not available. During observation and interview on 12/09/14, at 2:15 P.M., CNA F and CNA G assisted the resident to bed and said the resident had been up in the wheelchair since before breakfast. CNA G said he/she needed more help to care for the residents. The CNAs discovered an open blister to the resident's coccyx with surrounding redness. CNA G said, "At least, it's not bleeding." The CNAs cleansed the area with peri-wash. The resident yelled out in pain when CNA G dried the area with a washcloth. Both CNAs said they were not aware the resident had an open pressure ulcer on the coccyx. The CNAs discovered another open pressure ulcer on the resident's left gluteal fold and redness to the scrotal and groin area. Both CNAs said they did not have the time to lay the resident down until then. The CNAs said they typically work the shift with three CNAs total for over 40 residents and they are usually not able to lay most residents down until the afternoon. The CNAs said if they had more help they would like to lay the dependent residents down after breakfast and lunch. But, there were too many residents who required the assistance of two staff for transfers. Therefore, not all of the residents were laid down. During observation and interview on 12/09/14, at 2:45 P.M., CNA F and CNA G notified the charge nurse the resident had two pressure ulcers. Licensed Practical Nurse (LPN) O said he/she was unaware of any pressure ulcers on the resident. RN P (an RN supervisor) said he/she was unaware of any pressure ulcers on the resident. The LPN measured the resident's pressure ulcers. The LPN said the coccyx pressure ulcer was a Stage II with the appearance of an open blister. It measured 1.5 centimeters (cm) x 0.4 cm with red tissue to the wound bed. An area of redness to the surrounding intact skin measured 3.0 cm x 2.6 cm. A second Stage II pressure ulcer located on the left gluteal fold measured 0.3 cm x 0.8 cm, with an area of redness to the surrounding intact skin measuring 5.0 cm x 3.4 cm wide. At 3:00 P.M., RN P said he/she expected the CNAs to lay the residents down after meals. RN P said staff should ensure those residents with skin issues were the last residents up for meals and the first residents in bed after meals. During an interview on 12/09/14, at 3:15 P.M., all three CNAs working the day shift, CNAs E, F and G, said the night shift CNAs typically get Resident #3 up before they leave at 6:00 A.M. The resident was already in his/her wheelchair at 5:45 A.M. that morning when they arrived at work. Observation and interview on 12/09/14, showed the resident sat up in the wheelchair from approximately 5:45 A.M. until 2:15 P.M. Observation on 12/10/14 showed the following: -At 9:50 A.M., the resident sat in the TV area across from the nurses' station with his/her eyes closed. -At 10:30 A.M., the resident remained in the TV area with his/her eyes closed. -At 10:40 A.M., CMT M wheeled the resident to his/her room to perform the resident's blood glucose finger stick test. The resident moaned in pain. CMT M asked the resident if his/her legs hurt and the resident replied, "Oh man, you can't imagine". -At 10:58 A.M., the resident sat in the dining room for lunch. During an interview on 12/10/14 at 11:06 A.M., LPN N, in charge of caring for the resident, said the resident's skin was not open. During an interview on 12/10/14, at 1:24 P.M., CNA I and CNA J said they had just assisted the resident into bed. CNA I and CNA J said the resident had been up in his/her wheelchair since 7:00 A.M. CNA I and CNA J said the day shift was now getting the resident up after they arrived due to the pressure ulcers. Observation and interview on 12/10/14, showed the resident sat in the wheelchair for approximately six hours. During an interview on 12/11/14, at 4:15 A.M., CNA H said the night shift usually had two CNAs caring for over 40 residents. CNA H said he/she started getting the residents out of bed at 4:30 A.M. CNA H said the night shift had a list of residents they are required to get out of bed before they leave in the morning. CNA H listed several of those residents, including Resident #3. CNA H said the night shift gets up approximately twelve residents between 4:30 A.M. and 6:00 A.M. Most of these residents are the harder ones to get up. The night shift CNAs assisted the residents who required two staff members or a mechanical lift for transfers. CNA H said the day shift does not have the time to get them up. Observation on 12/11/14 showed the following: -At 4:10 A.M., the resident lay in bed with his/her eyes closed with the lights on in the room and a full body lift pad under him/her; -At 4:37 A.M. the resident sat up in a wheelchair in his/her room; -At 4:40 A.M., staff wheeled the resident to the TV area across from the nurses' station; -At 5:15 A.M., the resident remained in the TV area in a wheelchair; -At 5:48 A.M., the resident continued to sit in the TV area in a wheelchair; -At 6:08 A.M., the resident sat in the TV area in a wheelchair; -At 6:15 A.M., a CMT took the resident to his/her room to do a blood glucose finger stick; -At 6:22 A.M., the resident sat in the assisted dining room alone; -At 9:17 A.M., staff returned the resident from the shower room and assisted the resident to bed at 9:20 A.M. During an interview on 12/11/14, at 11:40 A.M., Resident #3's spouse said the staff have left the resident in a wheelchair for many hours at a time and frequently do not lay him/her down after meals as they should. He/she said the facility is short staffed and there are not enough CNAs to assist all residents needing to lie down in bed. 2. Record review of Resident #9's annual MDS, dated [DATE], showed the following information: -Both short term and long-term memory problems and impaired decision-making ability; -Total dependence on two staff members for transfers and bed mobility; -Incontinent of bowel; -At risk for pressure ulcers; -Moisture associated skin damage present; -On a turning/repositioning program; -[DIAGNOSES REDACTED]. Record review of the care plan, dated 10/21/14, showed the following information: -Potential for skin breakdown due to obesity, incontinence and limited mobility; -Pressure relieving boots; -Incontinent care every two hours and as needed; -Turn and reposition every two hours while in bed; -A potential for pain from muscle spasm, peripheral [MEDICAL CONDITIONS], contractures and decreased mobility; -Position the resident for comfort and lay the resident down after meals and reposition the resident every two hours when up in a chair. Record review of the resident's Braden scale, completed on 10/21/14, showed the resident to be at very high risk of developing a pressure ulcer. Record review of the resident's bath assessment sheet, dated 12/05/14, showed staff documented the resident's "butt red and open". Staff did not document on the body graph the location of the open area. A charge nurse initialed the assessment sheet. Observations on 12/07/14 at 8:15 P.M., showed CNA C and CNA D wheeled the resident to his/her room. Staff transferred the resident into bed using a full body lift. The resident's incontinent brief was saturated and brown in color with a strong urine odor. The CNAs provided incontinence care. Observation of the resident's skin showed a gauze and tape dressing on the left gluteal fold area measuring approximately 2.0 cm x 4.0 cm and an open blister on the left buttock, measuring approximately 1.5 cm in size. Observations and interview on 12/11/14 showed the following: -At 4:15 A.M., CNA H said the night shift assisted the resident out of bed in the morning between 4:30 A.M. and 6:00 A.M. every day. -At 4:34 A.M., the resident sat in a wheelchair in the TV area across from the nurses' station. The resident continued to sit in the TV area at 5:11 A.M. -At 6:21 A.M., a CMT took the resident to his/her room to perform a blood glucose finger stick and then returned the resident to the TV area. -At 6:32 A.M., staff wheeled the resident to the assisted dining room. During observation and interview on 12/11/14 at 2:25 P.M., (four days after observation of the dressing and open blister pressure ulcer on 12/07/14), RN P said he/she was unaware of any open areas to the resident's skin. The nurse and CNA L assisted the resident to a side lying position in bed and the resident's buttocks showed a pressure ulcer to the left buttock which measured 0.75 cm x 0.50 cm with "yellow slough" to the wound bed. The surrounding area of redness measured 4.5 cm x 2.0 cm. Additionally, there was an open blister to the left gluteal fold area that measured 0.5 cm x 0.5 cm. The resident's socks caused a distinct indentation to his/her swollen lower legs. Staff removed the resident's socks and the nurse said the right heel was red, "mushy to touch" (indicating possible deep tissue injury) and measured 5.0 cm x 2.5 cm. Record review of the skin report, dated 12/11/14, at 3:00 P.M., showed RN P documented the resident had a stage II wound to the left buttock. The nurse did not document the type of wound. The nurse documented the margins of the wound were red with surrounding pink blanchable tissue. It measured 0.75 cm x 0.5 cm, with depth of less than 0.1 cm. The wound did not have any drainage, odor, or tunneling/undermining. The nurse described the wound base color as "yellow slough". The nurse documented the area was not present on admission. (A wound covered in slough would be considered an unstageable wound.) Record review of the skin report, dated 12/11/14, at 3:00 P.M., showed RN P documented the resident had an area on the right heel with a red wound base and red blanchable skin surrounding the area. The area measured 5 cm x 2.5 cm, with less than 0.1 cm depth. The nurse did not identify the type of ulcer. The nurse did not describe the area as "mushy to touch" which would indicate a possible deep tissue injury. During an interview on 12/11/14, at 3:20 P.M., the DON said she was unaware of any open areas on the resident's skin. The DON said the bath aides were responsible for the skin bath sheets for the resident's during their bath/shower. The bath aides gave the sheets to the charge nurse to review. The charge nurse should have completed a skin assessment and measured any open areas and reported to the physician, family member, DON and the administrator. The DON said she reviewed the skin bath sheets, ensured staff identified any problems and the charge nurse signed off on the form. The DON said she verbally notified the skin nurse. The DON said she did not remember a skin sheet for the resident and was unaware of any open areas on the resident's skin. During an interview on 12/12/14 at 10:55 A.M., CNA K said the resident had heel protectors in the past, but it was not an order. The CNA said the use of heel protectors on the resident were "at the CNAs discretion". The CNA searched the resident's room for the heel protectors, but was unable to find them. The CNA said staff must have gotten rid of them. Record review of the December 2014 physician order [REDACTED].M. and take off at 9:00 P.M. 3. Record review of Resident #12's annual MDS, dated [DATE], showed the following information: -The facility admitted the resident on 1/30/07; -Non-verbal: -Staff assessed the resident's mental status as both short and long-term memory problems with no recall ability and severely impaired decision-making ability; -Dependent upon assistance of two staff for transfers, bed mobility, and toileting; -Dependent upon assistance of one staff for locomotion and personal hygiene; -Always incontinent of bladder and bowel; -At risk for pressure ulcers; -On a turn/reposition program. Record review of the care plan reviewed by the facility staff on 8/22/14 showed, in part, the following information: -Dependent for care needs and activities of daily living (ADLs); -Dependent on two staff for turning and repositioning every two hours; -Incontinent, check for every two hours and as needed; -Potential for altered skin integrity, redness related to incontinence and impaired mobility; -Pericare after incontinent episodes and report any areas of concern promptly. -Lay down as much as possible. Record review of the bath assessment sheet, dated 11/28/14, showed staff documented the resident's "butt" as "red" but there were no open areas. Record review of the RN skin nurse's progress note, dated 12/07/14 at 11:10 A.M., showed an area "appears as skin tear" to the left gluteal fold (the prominent fold on the back of the upper thigh that marks the upper limit of the thigh from the lower limit of the buttock) measuring 2.0 cm x 2.0 cm. Staff cleansed the area with Hydrogel (a hydrated polymer, which contains 90% water in a gel base and helps regulate fluid exchange from the wound surface) and applied a "breathable" dressing. Staff notified the resident's spouse and physician. Record review of the bath assessment sheet, dated 12/09/14, showed staff documented the resident with an "open area" on his/her "bottom". The body graph showed an area circled on the buttocks and "open area" noted as well. During an interview on 12/09/14, at 10:15 A.M., RN C said in addition to being a RN supervisor, he/she was the facility skin nurse and completed all of the resident's skin treatments and dressing changes. Record review of the medical record showed staff failed to document a nursing progress note from 12/07/14 to 12/12/14. During observation and interview on 12/12/14, starting at 9:54 A.M., CNA A and CNA B transferred Resident #12 from the wheelchair onto a bath gurney on the bed with the full body mechanical lift. The resident had an open area to his/her left buttock, identified as a Stage II pressure ulcer which measured approximately 1.0 cm x 0.2 cm and superficial depth with a reddened wound bed and the peri-wound area was light pink and blanchable. CNA A said the resident received a bath three days earlier and he/she could not recall whether the area was present during the prior bath or not. During an interview on 12/12/14, at 10:33 A.M., CNA/bath aide B said he/she gave a list of the residents who received a bath, along with their bath assessment sheets to the charge nurse at the end of the day. Record review of the resident's skin report, dated 12/12/14 at 11:00 A.M., showed staff documented a Stage II "ulcer" to the left buttock. Record review of an ADON progress note, dated 12/12/14 at 11:07 A.M., showed an assessment completed "this morning and discovered" a "partial thickness opening" area to the resident's left buttock. She documented the area as a "Stage II" which measured 0.6 cm x 0.3 cm, "appears as an area of incontinence associated skin damage with pressure contribution", with a yellow wound bed and no drainage or odor present. The peri-wound area was warm, dry, blanchable and intact. Record review of the December 2014 treatment administration record (TAR) did not show any treatment or dressing provided by staff to the resident's buttock areas. 4. During interview on 12/11/14 at 3:20 P.M., the DON and Assistant Director of Nursing (ADON) said the following: -Staff should have completed a Braden scale assessment to identify those residents at risk. -Staff should have laid down the residents' identified as a risk first and should have ensured they were the last residents up and "at minimum were to be laid down after each meal". -Staff should give the charge nurse the bath sheets. -The charge nurse is responsible to have completed a skin report sheet which included the pressure ulcer circled and listed the measurements of the pressure ulcer. -Either the charge nurse or the nurse who identified the pressure ulcer should have notified the resident's family and physician as well as the DON and administrator. -The charge nurse signs off on all bath sheets. -The DON checked the residents' bath sheets to ensure the charge nurse signed them and whether there were any pressure ulcers. -Staff should have notified the skin nurse verbally whenever there is a pressure ulcer. -Pressure ulcer documentation every seven days should have included: the measurement of the length, width and depth, the appearance of the wound bed and peri-wound area, whether there is drainage and/or any discomfort. Staff should have ensured treatment orders were in place and preventative measures as well. -Staff provided a copy of the skin report and the wound report to the MDS coordinator. -The ADON said staff had not updated all of the resident care plans. MO 407

Based on interviews and record review, the facility staff failed to consistently assess, monitor and obtain treatment for [REDACTED]. Facility staff failed to assess the resident for pain and failed to provide additional pain medication between 8:00 A.M. and 8:00 P.M. The resident required evaluation and treatment at the hospital and was diagnosed with [REDACTED]. Three residents were selected for review in a facility with a census of 54. Review of Mosby's 2013 Nursing Drug Reference showed the following information: -[MEDICATION NAME]/[MEDICATION NAME] is a narcotic pain medication used for mild to moderate pain; -Duration of action for pain relief is four to six hours. 1. Record review of Resident #1's current care plan dated 12/19/12, reviewed on 2/27/13, showed the following information: -Resident had difficulty making self understood related to [MEDICAL CONDITION], ask simple questions requiring yes/no answers and staff must anticipate needs; -Two full side rails up when in bed for positioning and safety and staff to monitor frequently; -Monitor for acute illness. Record review of nursing notes showed licensed practical nurse (LPN) A documented on 2/8/13, at 8:49 A.M., that the hospice certified nurse aide (CNA) C gave the resident a bath and noted the resident's left knee joint had swelling and a very faint yellow color around it. The knee had the appearance of an old bruise and the resident had [DIAGNOSES REDACTED]. During a telephone interview on 2/27/13, at 10:30 A.M., hospice CNA C said on 2/8/13, at about 7:00 A.M. or 7:30 A.M., CNA C and another hospice aide gave the resident a shower and noticed the resident's knee while up in the shower chair. CNA C said the resident's knee was very swollen and he/she told the other hospice aide to get LPN A to look at the resident's knee. LPN A was with the Director of Nursing (DON) at the time and the DON instructed LPN A check the resident's knee. CNA C said LPN A said it looked like an old bruise and swelling from arthritis. CNA C said LPN A touched the resident's knee but did not move it. CNA C said LPN A told him/her to finish the resident's shower and return the resident to the SCU to eat breakfast. CNA C said he/she called hospice RN D and reported the injury. Hospice RN D said he/she would look into it further. CNA C reported they did not hit the resident's legs on the side rail or bump them on anything during the transfer or shower, the injury did not occur while they provided care. During an interview on 2/25/13, CNA E said on 2/8/13, at 3:00 P.M., he/she and CNA F assisted the resident to get up and noticed the resident's left knee was swollen, had a red mark on top of the knee, and a bruise with a bump on the knee. CNA E said the resident's knee was warm to touch. CNA F reported the symptoms to LPN A who did not check the resident at that time. At 7:00 P.M., CNA E and CNA F returned the resident to his/her bed and noticed more redness of the leg and CNA F reported it to LPN A. At 9:00 P.M. CNA E and CNA F did a bed check on the resident and observed more red marks on the resident's knee, including the side of the left knee and more redness to the left leg. CNA E said when lifting the resident's left knee the resident indicated it was very uncomfortable and hurt. Prior to leaving at 10:00 P.M., CNA E asked LPN B to please come check the resident's left leg. During an interview on 2/25/13, CNA F said on 2/8/13, he/she and CNA E went to get the resident up at 3:00 P.M. and found the resident's left knee swollen and yellow in color with a small quarter size bruise and two one-inch red lines on both sides of the bruise. When CNA F and CNA E placed their hands under the resident's knee the resident made a face and grimaced. CNA F said LPN A was notified and LPN A told CNA F to keep an eye on it. CNA F said LPN A said hospice had already notified him/her. CNA F said LPN A did not come look at the resident's knee. CNA F said he/she told LPN B at about 7:00 P.M. to 7:30 P.M. of the condition of Resident #1 left knee. At around 9:45 P.M. LPN B checked the resident's knee, told staff to place pillows under the resident's knee, and said it looked like something was broken. Record review of hospice nursing assessment dated [DATE], showed the following: -At 4:00 P.M., hospice registered nurse (RN) D documented that CNA F asked him/her to look at the resident's left knee. The knee was swollen with [MEDICAL CONDITION] and had a red area on the knee cap approximately two inches by one inch with no open areas. The resident moaned and grimaced when the left knee was touched. Hospice RN D reported the resident's symptoms to LPN A. LPN A told hospice RN D the knee had been assessed and would be monitored; -Facility staff are to call hospice with any changes in condition or needs; -Pain noted in left knee of resident when touched, unable to rate pain and behavior calm unless handling the resident's knee. Record review of nursing notes showed LPN B documented on 2/8/13 at 10:00 P.M., staff asked him/her to check the resident's left knee. LPN B found the resident's left knee very swollen with a dark purple area on top of the knee cap with some warmth noted to the resident's skin. The resident's left leg was externally rotated and shortened. At 10:00 P.M., LPN B called the resident's family to inform them of the swelling, pain and warmth to the resident's left knee. LPN B notified the resident's physician and obtained orders to send the resident to the hospital for evaluation and treatment. At 10:50 P.M., LPN B notified the DON of the resident's symptoms and that the resident was going to the hospital. During an interview on 3/1/13, at 4:55 A.M., LPN B said he/she worked the 6:00 P.M. to 6:00 A.M. shift on 2/8/13. LPN B said when getting report from LPN A, LPN A said he/she checked the resident in the shower room that morning and found the resident to have a yellow colored swollen knee and thought it was arthritis. LPN B said he/she did not go look at the knee at that time, it was not until later just prior to shift change when CNA E asked if the prior CNA had reported anything to him/her about the resident's left knee. LPN B said at that time, approximately 9:30 P.M. to 9:45 P.M., he/she checked the resident and found the resident's left knee very swollen, red and purple color from swelling on the knee cap and the left leg was short and rotated. LPN B said he/she called the resident's physician and family. The physician gave an order to send the resident to the hospital. Record review of the hospital history and physical dated 2/18/13, showed the resident was transferred to the hospital on [DATE], for evaluation of his/her left knee. X-ray results showed the resident had a left tibial plateau fracture (left knee fracture). Review of nursing notes showed on 2/8/13 between 8:49 A.M. and 10:00 P.M. (over 12 hours), nursing staff failed to reassess, monitor and document the status of the resident's left knee. Review of the February 2013, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -[MEDICATION NAME]/APAP 5/325 mg one at 8:00 A.M. and 8:00 P.M. received at scheduled time on 2/8/13; -[MEDICATION NAME] 500 mg two every six hours for pain and elevated temperature, not administered on 2/8/13; -[MEDICATION NAME]/APAP 5/325 mg one every four hours as needed for pain, administered once at 10:26 P.M. for left knee pain prior to transferring to the hospital; -Documentation showed the staff did not administer pain medication between 8:00 A.M. and 8:00 P.M.; -Further review of the February MAR indicated [REDACTED]. and 8:00 P.M. During a telephone interview on 3/1/13, at 12:20 P.M., LPN A said he/she was the charge nurse on 2/8/13, from 6:00 A.M., until 6:00 P.M. LPN A said the hospice aides were in to give the resident a bath that day and prior to starting the shower they asked LPN A to check the resident's left knee. LPN A described the left knee as being swollen and the knee appeared to have old bruising to the knee. LPN A said the knee did not normally look like that and the resident did have some pain with it. LPN A instructed staff to be careful with the knee and thought the swelling was probably arthritis and asked staff to let him/her know if there were any further changes. LPN A said he/she did not call the resident's physician, but did check the resident's chart for anything that might have caused the swelling like [MEDICAL CONDITION]. LPN A said around 4:00 P.M. or 5:00 P.M. the staff in the SCU called the nursing station and left a message for him/her to come to the unit, but were not specific as to why. LPN A said he/she did not go to the SCU unit because he/she had a new admission and had a resident fall. LPN A said there were no further comments or reports from any staff and said he/she left between 6:00 P.M. and 7:00 P.M. LPN A said he/she left it on report for the next shift and told LPN B of the condition of the resident's knee. An interview on 3/1/13, at 12:10 P.M. with the DON showed the following: -The DON did a verbal disciplinary action with LPN A related to not monitoring and assessing the resident timely; -No further training was done with LPN A; -The DON reports she asked LPN A why he/she did not check the resident and LPN A responded he/she just didn't and didn't remember why. Refer to Complaint Number MO 657