Every finding on record at Marshfield Care Center for Rehab and Healthcare

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect food from possible contamination at all times when dented cans were stored with other food items in the dry food storage area; when food was properly store food and stored per manufacture guidelines; when food was not properly sealed; when food was not dated and labeled; when spoiled food was not removed and disposed of; when staff failed to follow proper handwashing during food service, and when staff failed to properly sanitize the thermometer between food items. The facility's census was 51.Review of the facility's policy titled, Food Safety Requirements, dated 06/30/25, showed food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. 1. Review of the facility's policy titled, Food Safety Requirements, dated 06/30/25, showed the -Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage;-Follow contract/vendor procedures when food arrives damages or concerns are noted. Remove these foods from use. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the following: -Depending on the circumstances, rusted and pitted or dented cans may present a serious potential hazard;-Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods, equipment, utensils, linens, or single-service or single-use articles. To preclude this, separate and segregated areas must be designated for storing unsalable goods. Observation on 05/03/26, at 2:55 P.M., of the dry food storage area showed the following:-One dented eight-pound can of pinto beans;-One dented six-pound can of chili sauce with meat;-Four dented six-pound cans of pizza sauce. Observation on 05/04/26, at 9:15 A.M., of the dry food storage area showed the following:-One dented eight-pound can of pinto beans;-One dented six-pound can of chili sauce with meat;-Four dented six-pound cans of pizza sauce. Observation on 05/05/26, at 9:25 A.M., of the dry food storage area showed the following:-One dented eight-pound can of pinto beans;-One dented six-pound can of chili sauce with meat;-Four dented six-pound cans of pizza sauce. During an interview on 05/06/26, at 10:45 A.M., [NAME] P said staff should not place dented cans on the shelf, Staff should be placed in the designated place for dented cans. Dented cans can be contaminated and make residents sick. During an interview on 05/06/26, at 10:19 A.M., Dietary Aide (DA) Q said dented cans are not to be used because they can make residents sick. During an interview on 05/06/26, at 10:45 A.M., the Dietary Manager (DM) said the following: -Dented cans were to be stored in the designated area and not used for meals;-Dented cans could contain pieces of tin, causing residents to choke and make residents sick. During an interview on 05/07/26, at 10:30 A.M., the Administrator said he/she expected staff to store dented cans in the designated area in the kitchen and for them not to be used for meals. 2. Review of the facility's policy titled, Food Safety Requirements, dated 06/30/25, showed the following: -Keep foods/beverages in clean dry area off the floor;-Foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Observation on the following dates and times of the dry food storage area showed the a fitty -pound bad of old-fashion oats sitting on the floor:-On 05/03/26, at 2:55 P.M.;-On 05/04/26, at 9:15 A.M. Observations of the top of the chest freezer/refrigerator showed the following: -On 05/03/26, at 2:30 P.M., one 13-pound box of ciabatta breadsticks made with garlic, two 10-pound boxes of bagels, and one 15-pound box of white bread with instructions on the box to keep frozen;-On 05/04/26, at 9:05 A.M., one 13-pound box of ciabatta breadsticks made with garlic, two 10-pound boxes of bagels, and one 15-pound box of white bread with instructions on the box to keep frozen;-On 05/05/26, at 9:21 A.M., one 13-pound box of ciabatta breadsticks made with garlic, two 10-pound boxes of bagels, and one 15-pound box of white bread with instructions on the box to keep frozen. During an interview on 05/06/26, at 10:45 A.M., [NAME] P said food items should not be stored on the floor. During an interview on 05/06/26, at 10:19 A.M., Dietary Aide (DA) Q said food items should be stored off the floor. During an interview on 05/06/26, at 10:45 A.M., the DM said food items should be stored based on the manufacturer's recommendation. Food items were to be stored off the floor. During an interview on 05/07/26, at 10:30 A.M., the Administrator said he/she expected staff to follow the manufacturers' directions on storing food. 3. Review of the facility's policy titled, Food Safety Requirements, dated 06/30/25, showed the following: -Food safety practice elements included storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms and employee hygienic practices. Observations at the following dates and times of the food storage area showed one fifty-pound bag of old-fashion oats open to air:-On 05/03/26, at 2:55 P.M.;-On 05/04/26, at 9:15 A.M. Observation on 05/04/26, at 9:07 A.M., of the side-by-side refrigerator and freezer in the storage room showed one five-pound cardboard container of orange sherbert. The lid of the container was torn and did not seal tightly. During an interview on 05/06/26, at 10:45 A.M., [NAME] P said all staff are responsible for sealing, dating, and labeling food prior to putting in refrigerator/freezer. During an interview on 05/06/26, at 10:45 A.M., the DM said all food items are to be sealed tightly when storing. During an interview on 05/07/26, at 10:30 A.M., the Administrator said he/she expected food to be sealed, labeled and dated prior to storing in the refrigerator/freezer. 4. Review of the facility policy titled, Date Marking for Food Safety, dated 06/30/25, showed the following: -The facility adheres to a date marking system to ensure the safety of the ready-to-eat, time/temperature control for safety food;-The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded;-The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. Observation on 05/03/26, at 2:46 P.M., on 05/04/26, at 9:07 A.M., and on 05/05/26, at 9:23 A.M., of the side-by-side refrigerator and freezer in the storage room showed the following:-One sausage, egg, and cheese croissant, undated;-Six, two-pound packages of roasted turkey breast, undated. The packages contained sharp, white frost (ice crystals) directly on the food surface. Observation on 05/03/26, at 3:09 P.M., on 05/04/26, at 9:18 A.M., and on 05/05/26, at 9:27 A.M. During an interview on 05/06/26, at 10:45 A.M., [NAME] P said all staff are responsible for sealing, dating, and labeling food prior to putting in refrigerator/freezer. Staff are to date items with the date they are removed from the freezer. Staff are not to serve food that appears freezer burnt to residents. During an interview on 05/06/26, at 10:19 A.M., DA Q said food items are to be labeled and dated prior to placing them in the refrigerator/freezer. Food items are good for three days after being prepared. Food items are to be dated when removed from the freezer to thaw. Food items appearing to be freezer burnt are not to be served. During an interview on 05/06/26, at 10:45 A.M., the DM said all staff were responsible for dating and labeling food items before storing them. During an interview on 05/07/26, at 10:30 A.M., the Administrator said he/she expected food to be sealed, labeled and dated prior to storing in the refrigerator/freezer. 5. Review of the FDA 2022 Food Code showed products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods, equipment, utensils, linens, or single-service or single-use articles. To preclude this, separate and segregated areas must be designated for storing unsalable goods. Review of the facility policy titled, Date Marking for Food Safety, dated 06/30/25, showed the Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. Observations on 05/03/26, at 2:50 P.M., and on 05/04/26, at 9:12 A.M., of the refrigerator labeled veg fridge, showed the following:-One two-pound package of smoked ham sitting on top of one zucchini that was wilted, split open, and leaking liquid;-One clear plastic bag containing celery sticks, dated 04/10. The celery was brown in color and wilted;-One clear plastic bag containing three heads of iceberg lettuce that were wilting and turning brown. Observation on 05/05/26, at 9:24 A.M., of the refrigerator labeled veg fridge, showed the following:-One clear plastic bag containing celery sticks, dated 04/10. The celery was brown in color and wilted;-One clear plastic bag containing three heads of iceberg lettuce that was wilting and turning brown. The bag was not dated. During an interview on 05/06/26, at 10:45 A.M., [NAME] P said all staff were responsible for discarding food that is past the use by date. During an interview on 05/06/26, at 10:19 A.M., DA Q said all staff are responsible for pulling out food that is past the use by date. During an interview on 05/06/26, at 10:45 A.M., the DM said all staff are responsible for discarding food that is past the use by date. During an interview on 05/07/26, at 10:30 A.M., the Administrator said he/she expected staff to discard food after the use by date. 6. Review of the FDA 2022 Food Code showed the following: -Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink;-Even though bare hands should never contact exposed, ready-to-eat food, thorough handwashing is important in keeping gloves or other utensils from becoming vehicles for transferring microbes to the food;-Soiled gloves can directly contaminate food if stored with ready-to-eat food or may indirectly contaminate food if stored with articles that will be used in contact with food. Review of the facility's policy titled, Food Safety Requirements, dated 06/30/25, staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Staff shall wash hands according to facility procedures. Review of the facility's policy titled, Handwashing Guidelines for Dietary Employees, not dated, showed the following:-Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparations, ware washing, or in a service sink used for the disposal of mop water or similar waste;-Dietary employees shall keep their hands and exposed portions of their arms clean;-Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: every time an employee enters the kitchen including at the beginning of the shift, after returning from break, and after using the toilet; after hands have touched anything unsanitary including garbage, soiled utensils/equipment, dirty dishes, etc.; after hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.); while preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready to eat food; before donning gloves for working with food; and after engaging in any activity that may contaminate the hands. Observation on 05/05/26, at 12:23 P.M., of lunch serve out showed the following:-The DM stood in the serve out area and retrieved a plate, walked into the kitchen, and donned gloves without washing his/her hands;-The DM retrieved a loaf of bread. The DM then went to the refrigerator and retrieved a bag of sliced cheese and container of butter; -The DM retrieved a skillet and spatula;-Without washing hands and changing gloves, the DM opened the loaf of bread and using his/her hands retrieved two pieces of bread and placed them on a plate;-Without washing hands and changing gloves, the DM opened the container of butter and using his/her hands picked up the bread and applied butter to each piece and placed in the skillet;-Without washing hands and changing gloves, the DM opened the bag of sliced cheese and using his/her hands retrieved two pieces of cheese and placed them on the bread;-The DM adjusted the temperature on the stove;-The DM doffed his/her gloves and washed his/her hands;-The DM left the kitchen, retrieved a plate from the serve out area and walked into the kitchen. The DM did not wash his/her hands; -The DM retrieved a jar of peanut butter, container of jelly, and used a spatula to turn the grilled cheese over;-Without washing hands and changing gloves, the DM used his/her hand to retrieve two pieces of bread out of the bag and placed them on a plate;-Without washing hands and changing gloves, the DM retrieved a knife, opened the container of peanut butter, using his/her hands spread peanut butter on one piece of bread with the knife;--Without washing hands and changing gloves, the DM opened the container of jelly, using his/her hands spread jelly on one piece of bread with the knife;-The DM doffed his/her gloves and did not wash his/her hands;-The DM took the peanut butter and jelly sandwich out of the kitchen to the serve out area, returned to the kitchen, and did not wash his/her hands;-The DM using his/her hands closed the loaf of bread, closed the peanut butter and sealed the bag of cheese;-The DM left the kitchen and retrieved a plate from the serve out area, returned to the kitchen, and did not wash his/her hands;-The DM retrieved the grilled cheese out of the skillet, placed it on a plate and took the sandwich to the serve out area. During an interview on 05/06/26, at 10:45 A.M., the [NAME] P said were to wash their hands when entering the kitchen, when serving trays, and between using utensils and having direct food contact. During an interview on 05/06/26, at 10:19 A.M., DA Q said staff were to wash hands every time they entered the kitchen, when having direct food contact, when preparing food, and when serving food. During an interview on 05/06/26, at 10:45 A.M., the DM said staff were to wash their hands when entering the kitchen, taking out trash, touching cooked or raw food, before serving food, and when doffing/donning gloves. During an interview on 05/07/26, at 10:30 A.M., the Administrator said he/she expected staff to use proper hand hygiene while preparing and serving food. 7. Review of the facility's policy titled, Record of Food Temperatures, dated 06/30/25 showed food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy. During an observation and interview on 05/05/26, at 12:13 P.M., of [NAME] P checking temperatures of food items showed the following:-Cook P took the thermometer, used a paper towel to wipe the probe of the thermometer, then pushed the probe through aluminum foil and into the ravioli to check the food temperature;-Cook P wiped the probe of the thermometer using a paper towel, then inserted the probe into a salad to check the food temperature;-Cook P wiped the probe of the thermometer using a paper towel, then inserted the probe into a breadstick to check the food temperature;-Cook P wiped the probe of the thermometer using a paper towel, then pushed the probe through plastic wrap and into the carrots to check the food temperature;-Cook P wiped the probe of the thermometer using a paper towel, then pushed the probe through plastic wrap and into the pureed carrots to check the food temperature;- [NAME] P wiped the probe of the thermometer using a paper towel, then pushed the probe through plastic wrap and into pureed bread to check the food temperature;- [NAME] P wiped the probe of the thermometer using a paper towel, then pushed the probe through plastic wrap and into the corn to check the food temperature;-Cook P said he/she should be using alcohol wipes to clean the probe of the thermometer between each food item but there were none available in the kitchen. During an interview on 05/06/26, at 10:45 A.M., [NAME] P said the probe of the thermometer should be cleaned with alcohol between each food item when checking the food temperature. During an interview on 05/06/26, at 10:45 A.M., the DM said the following: -The cook was responsible for cleaning the probe of the thermometer with alcohol between food items when performing the food temperature checks;-The kitchen was out of alcohol wipes;-He/she was responsible for ordering supplies for the kitchen. During an interview on 05/07/26, at 10:30 A.M., the Administrator said the following: -He/she expected staff to use alcohol wipes to clean the probe of the thermometer while checking food temperatures;-The DM was responsible for ordering supplies for the kitchen.

Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 51.Review of the facility's policy titled, Mandatory Training and Education Requirements, revised 09/2024, showed the following: -Purpose to ensure that all employees are adequately trained and educated to provide high-quality care while maintaining a safe environment for residents, visitors, and staff. This policy outlines the mandatory training and education requirements for employees, focusing on compliance with federal, state, and local regulations;-Job-specific training: Dietary staff: safe food handling, special dietary needs. Review of the facility document titled, Tide Group. Job Title: Dietary Manager, revised 09/2024, showed the following:-The primary purpose of the dietary supervisor is planning, organizing, developing and directing the overall operation of the dietary department in accordance with federal, state, and local standards;-Qualifications - Certificates, licenses and registrations: Must be a certified dietary manager or willing to become certified within four months of employment;-Must maintain ServSafe certification. 1. Review of the Dietary Manger (DM) personnel file showed the facility did not provide documentation of certification, training, or experience that met the requirements for a Director of Food and Nutrition Services in a long-term care setting. During an interview on 05/03/26, at 3:43 P.M., the Dietary Manager (DM) said the following: -She had been a dietary aide and cook for six years;-She started the DM position in December 2025;-She was not a Certified Dietary Manager and had not enrolled in a training/certificate course;-She was not a Certified Food Services Manager and did not have an associate's degree or higher in food service management or hospitality. During an interview on 05/07/26, at 10:30 A.M., the Administrator said he/she knew the DM was not a Certified Dietary Manager.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment when kitchen staff failed to clean the bottom of one freezer and one refrigerator in a timely fashion. The facility's census was 51.Review of the Food and Drug Administration (FDA) 2022 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 contactsurfaces so that pathogenic microorganisms will not be allowed to accumulate andinsects and rodents will not be attracted;-The presence of food debris or dirt on nonfood contact surfaces may provide a suitableenvironment for the growth of microorganisms which employees may inadvertentlytransfer to food. If these areas are not kept clean, they may also provide harborage forinsects, rodents, and other pests 1. Review of the kitchen cleaning log titled, Daily Cleaning Schedule, undated, showed the following:-The most current, partially completed daily cleaning schedule dated by staff showed a date of 04/11/26;-Staff completed cleaning tasks on Sunday, Monday, and Saturday of that week. Observations at the following dates and times of the side-by-side refrigerator and freezer in the storage room showed a pink substance frozen to the bottom of the freezer:-On 05/03/26, at 2:46 P.M.;-On 05/04/26, at 9:07 A.M.;-On 05/05/26, at 9:23 A.M. Observation on the following times and dates of the refrigerator labeled veg fridge showed a brown liquid substance covering the bottom of the refrigerator:-On 05/03/26, at 2:50 P.M.;-On 05/04/26, at 9:12 A.M. During an interview on 05/06/26, at 10:45 A.M., the [NAME] P said the following:-The Dietary Manager provides a cleaning schedule that showed what task each staff member was responsible for;-The staff were responsible for completing the task listed on the daily cleaning schedule. During an interview on 05/06/26, at 10:19 A.M., Dietary Aide (DA) Q said the DM provided a cleaning schedule for the kitchen. The schedule did not show what staff were responsible for certain areas of the kitchen. During an interview on 05/06/26, at 10:45 A.M., the DM said the following:-Kitchen staff were responsible for cleaning the kitchen;-Staff were provided a cleaning schedule with assigned task;-Staff have not been cleaning the kitchen according to the cleaning schedule. During an interview on 05/07/26, at 10:30 A.M., the Administrator said he/she expected kitchen staff to follow a cleaning schedule and complete all daily cleaning task.

Based on interview and record review, the facility failed to establish and maintain a complete infection control program when staff failed to have processes in place to ensure all resident and staff members were screened for tuberculosis (TB - a serious illness that mainly affects the lungs and can be spread when a person with the illness coughs, sneezes or sings) when staff failed to complete the two step test on three residents (Resident #5, #54, and #60) and three staff members (Registered Nurse (RN), A, Certified Nurse Aide (CNA) A, and CNA B). The facility census was 51. 1. Review of the facility policy titled Administration and Interpretation of Tuberculin Skin Tests, reviewed April 2025, showed the following:-The facility plans for the identification of tuberculosis infection or disease, and referrals for treatment in accordance with the facility's overall infection prevention and control program;-The facility administers and interprets tuberculin skin test in accordance with current Center for Disease Control and Prevention (CDC) guidelines;-Skin testing of residents will be in accordance with physician orders;-Residents and staff are tested for latent tuberculosis infection and screened for tuberculosis disease if infected with tuberculosis. Review of the State of Missouri Code of Regulations 19 CSR 20-20.100 showed the following:-Long-term care residents are required to have the initial test of a Mantoux PPD (purified protein derivative - skin test that is used to test for TB) two-step tuberculin test within one month prior to or one week after admission;-If the initial test is negative, zero to nine millimeters (mm), the second test, which can be given after admission, should be given one to three weeks later;-All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. 2.Review of Resident #60 face sheet showed the following:-admission date of 04/29/26;-Diagnoses included chronic obstructive pulmonary disease (COPD - a progressive lung disease) and acute respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). Review of the resident's current physician orders, reviewed on 05/06/26, showed an order, dated 04/29/26, to administer PPD (purified protein derivative) skin test that screens for tuberculosis) per facility policy. Review of the resident's Treatment Administration Record (TAR), dated 04/30/26 to 05/07/26, showed staff did not document treatments related to tuberculosis screening or tuberculosis testing. Review of the resident's Medication Administration Record (MAR), dated 04/30/26 to 05/07/26, showed no medication administrations related to tuberculosis screening or tuberculosis testing. Review of the resident's admission care plan, dated 05/05/26, showed no entries related to baseline tuberculosis screening or tuberculosis testing. Review of the resident's current immunizations record, reviewed on 05/06/26, showed no entries related to tuberculosis screening or tuberculosis testing. 3. Review of Resident #5 face sheet showed:-admission date of 03/11/26;-Diagnoses include chronic pulmonary edema (excess fluid buildup in the lung's air sacs). Review of the resident's current physician orders, reviewed 05/06/26, showed an order, dated 03/11/26, to administer PPD per facility policy. Review of the resident's TAR, dated 03/11/26 to 05/06/26, showed no treatments related to tuberculosis screening or tuberculosis testing. Review of the resident's MAR, dated 03/11/26 to 05/06/26, showed no medication administrations related to tuberculosis screening or tuberculosis testing. Review of the resident's admission care plan, dated 03/16/26, showed no entries related to baseline tuberculosis screening or tuberculosis testing. Review of the resident's current immunizations record, reviewed on 05/06/26, showed no entries related to tuberculosis screening or tuberculosis testing. 4. Review of resident #54 face sheet showed:-admission date of 09/22/25;-Diagnoses included COPD. Review of the resident's current physician orders, reviewed on 05/06/26, showed an order, dated 09/22/25, to administer PPD skin test per facility policy. Review of the resident's current care plan, revised 10/24/25, showed no entries related to baseline tuberculosis screening or tuberculosis testing. Review of the resident's current immunizations record, reviewed on 05/06/26, showed the following:-An entry for a step one TB skin test completed on 11/14/25;-Staff did not document completion of the second step. Review of the resident's TAR, darted 09/22/25 to 05/07/26, showed no treatments related to tuberculosis screening or tuberculosis testing. Review of the resident's MAR, dated 09/22/25 to 05/07/26, showed no medication administrations related to tuberculosis screening or tuberculosis testing. 5. During an interview on 05/06/26, at 12:45 A.M., Registered Nurse (RN) A said: -New residents receive a two-step TB test at admission and annually thereafter;-TB test for residents were completed by the charge nurse;-TB tests were tracked by the Director of Nursing (DON);-TB tests were an important part of a facilities infection prevention program. During an interview on 05/06/26, at 10:30 A.M., the Assistant Director of Nursing (ADON) said the following:-New residents are to receive a two-step TB test and repeat annually;-The admission nurse was responsible for ensuring residents receive two step TB test; -She had been working on updating orders, so residents receive their TB test. During interviews on 05/06/26, at 10:00 A.M. and 12:50 P.M., the MDS Coordinator said the following:-All residents receive two-step TB test on admission and annually to prevent introducing tuberculous into the facility;-The DON and ADON were responsible for tracking TB tests; During an interview on 05/06/26, at 10:40 A.M., the DON said the following:-She was aware that TB tests were not being completed on some residents and was working on a plan to ensure TB tests were completed as necessary;-She expected staff to follow facility policy and ensure residents received initial and annual TB tests. During interviews on 05/07/26, at 12:40 P.M. and 1:00 P.M., the administrator said the following:-Newly admitted residents receive a first step TB skin test that is read in 48 to72 hours and a second step test 14 to 21 days after;-She expected staff to follow facility policies related to TB skin tests for all residents and employees. 6. Review of the facility policy titled Employee Health and Infection Prevention, revised September 2024, showed the following:-All new employees must undergo comprehensive health screening, including tuberculosis testing;-Annual TB re-testing (as applicable). Review of the facilities policy titled Employee Tuberculosis Consent, undated, showed the following:-The purpose of the two-step tuberculosis test was to detect latent or active tuberculosis infections in compliance with CDC requirements for health care workers;-The two-step test consisted or two separate skin tests;-Initial test is placed and read withing 48 to 72 hours;-Second step test is placed 1 to 3 weeks later and read within 48 to 72 hours. Review of the State of Missouri Code of Regulations 19 CSR 20-20.100 showed the following:-All new long term care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD two-step tuberculin test within one month prior to starting employment in the facility;-If the initial test is zero to nine millimeters, the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years; -It is the responsibility of each facility to maintain a documentation of each employee's and volunteer's tuberculin status;-Employees and volunteers with an initial zero to nine millimeters Mantoux PPD two-step test shall be one-step tuberculin tested annually and the results recorded in a permanent record. 7. Review of Certified Nurse Aide (CNA) C's personnel record showed a hired date of 07/01/25. Review of CNA C's immunization record, dated 05/16/25, showed the following:-Step 1 TB skin test administered on 05/16/25;-Staff did not document results of the TB skin test;-Staff did not document a second step skin test administered. 8. Review of CNA B's personnel record showed a hired date of 08/08/25. Review of CNA B's immunization record, dated 08/07/25, showed the following:-Step 1 TB skin test administered on 08/07/25;-Staff did not document results of the TB skin test;-Staff did not document a second step skin test administered. 9. Review of RN A's personnel record showed a hired date of 09/18/25. Review of RN A's immunization record, dated 09/18/25, showed:-Step 1 TB skin test administered on 09/18/25;-Staff did not document results of the TB skin test;-Staff did not document a second step skin test administered. 10. During an interview on 05/06/26, at 12:45 A.M., RN A said: -New employees receive a two-step TB test and annually thereafter;-TB test for employees were completed by the charge nurse;-TB tests were tracked by the DON;-TB tests were an important part of a facilities infection prevention program. During interviews on 05/06/26, at 10:00 A.M. and 12:50 P.M., the MDS Coordinator said the following:-All employees receive two-step TB test on admission and annually to prevent introducing tuberculous into the facility;-The DON and ADON were responsible for tracking TB tests. During an interview on 05/06/26, at 10:40 A.M., the DON said she expected staff to follow facility policy and ensure residents and employees received initial and annual TB test. During interviews on 05/07/26, at 12:40 P.M. and 1:00 P.M., the Administrator said the following:-New employees were to receive a first and second step TB tests when hired and annually;-She expected staff to follow facility policies related to TB skin tests for all employees.

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 between 122 to 131.9 degrees Fahrenheit (F) in six residents rooms (Resident #17, Resident #27, Resident #34, Resident #35, Resident #43, and Resident #60) and a common bath/shower room to measure The facility census was 51.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 titled Safe Water Temperatures, revised 06/15/25, showed the following:-It is the policy of the facility to maintain appropriate water temperatures in resident care areas;-Direct care staff will monitor residents during prolonged exposure to warm or hot water for any signs or symptoms of burns, and will respond appropriately;-Staff will report abnormal findings, such as complaints of water too cold or too hot, burns or redness, or any problems with water temperature (example water is painful to touch or causes redness) to the supervisor and/or maintenance staff;-Water temperatures will be set to a temperature of no more than 120 degrees F, or the state's allowable maximum water temperature;-Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed.1. Review of Resident #17's face sheet (a brief resident profile sheet) showed the following:-admission date of 10/25/22; -Diagnoses included generalized anxiety disorder, cognitive communication deficit (difficulties with communication due to a lack of memory and problem-solving abilities) and need for assistance with personal care. Review of the resident's care plan, updated 12/24/25, showed the resident had cognitive loss/dementia (a group of thinking and social symptoms that interferes with daily functioning) as evidenced by Alzheimer's disease (progressive, irreversible brain disorder that destroys memory and thinking skills)Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/20/26, showed the following:-Moderately impaired cognitive skills;-Required set up assistance with oral and personal hygiene. Observation on 05/03/26, at 4:14 P.M., showed the sink hot water temperature in the resident's room measured at 122 degrees F. Observation on 05/04/26, at 12:36 P.M., showed the sink hot water temperature in the resident's room measured at 123.6 degrees F with the Maintenance Director's thermometer. 2. Review of Resident #27's face sheet showed the following:-admission date of 08/21/25; -Diagnoses included muscle weakness, unspecified abnormalities of gait (manner of walking) and mobility and cognitive communication deficit. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitive skills intact;-Supervision required with toileting and showering/bathing;-Set up or clean up assistance with personal hygiene. Review of the resident's care plan, dated 08/22/25, showed the resident had impaired vision and required the aide of his/her glasses. Observation on 05/04/26, at 12:16 P.M., showed the sink hot water temperature in the resident's room measured at 130.4 degrees F. Observation on 05/04/26, at 12:40 P.M., showed the sink hot water temperature in the resident's room measured at 131.9 degrees F with the Maintenance Director's thermometer. 3. Review of Resident #34's face sheet showed the following:-admission date of 12/04/25;-Diagnoses included muscle weakness and unsteadiness on feet. Review of the resident's care plan, revised 02/12/26, showed the resident had cognitive loss/dementia. Review of the resident's quarterly MDS assessment, dated 04/24/26, showed the following:-Moderately impaired cognitive skills;-Required set up or clean up assistance with oral hygiene;-Required supervision with personal hygiene. Observation on 05/03/26, at 4:14 P.M., showed the sink hot water temperature in the resident's room measured at 122 degrees F. 4. Review of Resident #35's face sheet showed the following:-admission date of 10/01/25;-Diagnoses included weakness. Review of the resident's care plan, revised 12/26/25, showed the resident at risk for falls related to unsteady balance. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitive skills intact;-Supervision required with personal hygiene;-Set up or clean up assistance required with oral hygiene. Observation on 05/04/26, at 1:00 P.M., showed the sink hot water temperature in the resident's room measured at 131.1 degrees F. During an interview on 05/04/26, at 1:17 P.M., the resident said he/she was aware the water temperature was very hot. 5. Review of Resident #43's face sheet showed the following:-admission date of 09/08/25;-Diagnoses included chronic pain syndrome. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitive skills intact;-Set up or clean up assistance required with oral hygiene, toileting and personal hygiene. Review of the resident's care plan, dated 04/27/26, showed the resident had a diagnosis of diabetes mellitus. Observation on 05/05/26, at 3:15 P.M., showed the sink hot water temperature in the resident's room measured at 130.6 degrees F. During an interview on 05/05/26, at 3:20 P.M., the resident said he/she wondered about the hot water since seems to be too hot. He/she would turn on the cold water to balance the temperature. 6. Review of Resident #60's face sheet showed the following:-admission date of 04/29/26;-Diagnoses included prediabetes, history of falling and hypertension (high blood pressure). Review of the resident's care plan, dated 05/05/26, showed the resident had cognitive loss/dementia. Observation on 05/04/26, at 1:00 P.M., showed the sink hot water temperature in the resident's room measured at 127.7 degrees F. During an interview on 05/04/26, at 1:10 P.M., the resident said he/she knew the water got very hot. 7. Observation on 05/04/26, at 12:25 P.M. and 12:40 P.M. showed the main bathroom/shower room on the 200 hall had a hot water temperature in the sink that measured 125.9 degrees F. Observation and interview on 05/04/26, at approximately 12:45 P.M., showed the following: -The Maintenance Supervisor said there was a hot water heater for each hall; -The water heater for the B hall in the mechanical room was set at 140 F. He said he checked this water heater last week and adjusted it up due to the temperature being too low;-The water heater for the C hall was set at 131 degrees F. 8. During an interview on 05/04/26, at 12:31 P.M., the Maintenance Supervisor said the following:-He/she was responsible to check the water temperatures once a week and documented on a log;-He/she did not want water temperatures over 120 degrees F. During an interview on 05/07/26, at 11:44 A.M., the Director of Nursing (DON) said staff should make sure hot water was not too hot. The hot water temperatures should be kept less than 120 degrees F and anything over 120 degrees F could cause burns, especially to the elderly who have thin skin. During an interview on 05/05/26, at 4:13 P.M., the Administrator said the Maintenance Supervisor checked the water temperatures monthly and as needed and should document on the log. The hot water temperatures should be kept at 120 degrees F and below. The Maintenance Supervisor should adjust the hot water heater within normal range if the water temperatures are above 120 degrees F and recheck the hot water temperatures.

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to ensure complete, timely, and accurate skin assessments were completed for three residents (Resident # 1, Resident #27 and Resident #39) with wounds. The facility census was 51. Review of the facility's policy titled 'Skin Assessment,' revised 06/10/25, showed a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse (RN) upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Review of the facility's standing orders, dated 05/23/18, showed the following: -Moisture-Associated Skin Damage (MASD -inflammation and erosion of the skin caused by prolonged exposure to moisture, such as urine, stool, sweat, or wound drainage) without suspicion of yeast; -For buttocks cleanse with soap and water or Pure and Clean and dr thoroughly. House barrier cream two times a day and as needed with toileting. May keep at bedside; -For skin folds cleanse with soap and water or Pure and Clean and dry thoroughly. Place dry pillowcase between fold, to be changed twice a day and as needed. 1.Review of the Resident #1's face sheet (document that gives the resident's information at a quick glance) showed the following: -admission date of 03/30/23; -Diagnoses included difficulty in walking and cognitive communication deficit. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 01/08/26, showed the following: -Moderately impaired cognitive skills -Dependent with toileting hygiene; -MASD. Review of the resident's current care plan showed the following: -The resident is at risk for skin breakdown and odor due to bowel and bladder incontinence; -Staff to conduct a systemic skin assessment weekly. Review of the resident's weekly skin assessment dated [DATE], at 12:23 P.M. showed the following: -General appearance of skin was dry, warm and reddened; -Skin issues on left gluteal fold (the horizontal skin crease separating the lower buttock from the upper posterior thigh) with open area 3.0 centimeters long by 3.0 cm wide by 0.0 in depth; -Treatment remains in place for MASD open area. Review of the resident's progress notes, dated 03/05/26 through 03/12/26, showed staff did not document regarding the resident's open area or MASD. Review of the resident's shower sheet, dated 03/12/26, showed staff documented an area across the chest that had a rash and/or abnormal coloring and an area in the coccyx (small triangular bone at the base of the spinal column) area that indicated the area was open. Review of the resident's progress notes, dated 03/12/26 through 03/16/26, showed staff did not document regarding the resident's rash and/or abnormal coloring, open area, or MASD. Review of the resident's shower sheet, dated 03/16/26, showed staff documented an area in the lower abdomen that had scratches and an area in the coccyx area that indicated the area was open. Review of the resident's infection note dated 03/17/26, at 2:53 P.M., showed a nurse documented he/she notified the nurse practitioner of a boil under the resident's chin that was spreading to the resident's left side of his/her face. Review of the resident's infection note dated 03/18/26, at 4:59 P.M., showed a nurse documented the physician saw the resident. The physician ordered a medication change for the boil on his/her face and thigh. Review of the resident's physician visit dated 03/19/26, at 8:51 A.M., showed the following: -The resident had chronic debility and decrease in activity. The resident had urine incontinence and rash on his/her groin/perineal area. Resident advised to call for assistance for incontinent product changes; -Assessment and plan regarding moist peri wound skin probably due to his/her incontinence. The resident's brief change protocol according to the nursing staff is every two hours. The physician encouraged the resident to request assistance as needed. Nursing staff to monitor the resident closely and call with changes or concerns. Review of the resident's progress note dated 03/19/26, at 5:16 P.M., showed a nurse documented the resident continued on an antibiotic for a boil located on his/er face/neck area. (Staff did not document a boil on the resident's thigh) Review of the resident's infection note dated 03/21/26, at 10:03 A.M., showed a nurse documented the resident continued on medication for his/her boil to his/her face/neck area and upper thigh. Review of the resident's infection note dated 03/22/26, at 12:17 P.M. showed a nurse documented the resident continued on medication for his/her boil to his/her face/neck area and upper thigh. Review of the resident's shower sheet, dated 03/23/26, showed staff documented boil on the resident's body and two other areas marked as abnormal coloring. Review of the resident's progress note dated 03/24/26, at 1:16 A.M., showed a nurse documented the resident continued antibiotic for a boil under his/her chin. The affected area was no longer swollen and had redness to the head of the boil area and dry flaky skin surrounded the boil. Review of the resident's shower sheet, dated 03/27/26, showed staff documented boil on the resident's body noted with a question mark and abnormal coloring. Review of the resident's shower sheet, dated 03/30/26, showed staff documented boil marked on the resident's body with a comment of the nurse treating it. Review of the resident's weekly skin assessment dated [DATE], at 3:40 P.M., showed the following: -General appearance of the skin was dry and warm; -Skin issues of left gluteal fold monitored for MASD; -No new skin issues noted. (Approximately three weeks since last weekly skin assessment. Staff did not document regarding an open area or boil on the resident's body.) Review of the resident's physician's progress note dated 04/01/26, at 7:11 P.M., showed the following: -Reason for visit was skin infection; -Cellulitis of jaw and moist peri wound skin; -The resident treated recently for a perineal skin infection using an antibiotic; -Left gluteal area infection examined and improved erythema (redness) and the size noted; -Moist peri wound skin infection improved. Review of the resident's quarterly assessment dated [DATE], at 12:23 P.M., showed the following: -The skin was intact and dry skin; -Left gluteal fold MASD. Review of the resident's shower sheet, dated 04/06/26, showed staff documented an area on the chest, lower abdomen, and upper leg area that had abnormal coloring. Review of the resident's weekly skin assessment dated [DATE], at 2:15 P.M. showed the following: -General appearance was skin: warm, intact and moist; -Skin issued included groin MASD, left gluteal fold MASD, and right gluteal fold MASD; -MASD has expanded; -The resident had MASD to his/her groin and bilateral gluteal folds. Staff educated to check the resident frequently to ensure area is staying clean and dry. Staff educated to apply barrier cream to area with each brief change. (Staff did not document regarding the resident's boil on his/her chin or thigh or open areas.) Review of the resident's annual MDS, dated [DATE], showed the following: -Severely impaired cognitive skills; -MASD. Review of the resident's progress note dated 04/09/26, at 5:00 A.M., showed a nurse documented he/she notified the physician of the resident's change of condition and order to send to emergency room for evaluation. Review of the resident's progress note dated 04/14/26, at 5:34 P.M., showed a nurse documented the resident returned to the facility. Review of the resident's readmission assessment dated [DATE], at 5:52 P.M., showed skin assessment showed dry skin and groin MASD. Review of the resident's skilled evaluation progress note dated 04/15/26, at 2:09 A.M., showed staff documented the resident's skin was warm and dry with skin color within normal limits. Review of the resident's skilled evaluation progress note dated 04/20/26, at 1:10 A.M., showed staff documented the resident's skin was warm and dry with skin color within normal limits. Review of the resident's shower sheet, dated 04/20/26, showed staff documented the coccyx area had abnormal coloring and two open areas on the back of the resident's upper legs. Review of the resident's skilled evaluation progress note dated 04/21/26, at 2:21 A.M., showed staff documented the resident's skin color within normal limit and skin was fragile. Staff applied barrier cream to the resident's coccyx with each brief change. Review of the resident's skilled evaluation progress note dated 04/22/26,at 12:46 A.M., showed staff documented the resident's skin warm and dry and skin color within normal limits. Review of the resident's shower sheet, dated 04/27/26, showed staff documented three areas on the upper chest that had abnormal coloring and an open area on the front side (groin area) of the resident. Review of the resident's skilled evaluation progress note dated 04/28/26, at 11:12 P.M., showed staff documented the resident's skin color within normal limits. The resident's skin was fragile. Staff apply cream to the resident's peri area. The resident had excoriation (abrasion of the skin's surface) under his/her bilateral breasts, staff apply powder. (Staff did not document regarding an open area that was marked on the shower sheet dated 04/27/26.) Review of the resident's skilled evaluation progress note dated 04/28/26, at 1:15 A.M., showed staff documented the resident's skin color within normal limits. The resident's skin was fragile. The resident has some excoriation to his/her underside of his/her bilateral breasts and staff applied nystatin power. The resident had cream to treat his/her buttock and inner thighs. Review of the resident's weekly skin assessment dated [DATE], at 8:57 P.M., showed the following: -General appearance marked warm, intact and moist; -Abdomen lower left quadrant had scabbed over scratches; -Right lilac crest (rear) scabbed over scratches; -Groin had redness/MASD; -Left gluteal fold had redness/MASD; -Right gluteal fold had redness/MASD; -No new skin issues new marked no; -The resident's skin was warm, intact, and moist in between groin; -Treatment orders in place for barrier cream to his/her groin and gluteal folds; -Staff educated to continue rounding on the resident every two hours and applying cream with each brief change. (Staff did not document regarding an open area noted on shower sheet dated 04/27/26) Review of the resident's shower sheet, dated 05/01/26, showed staff documented three areas across the resident's chest and lower abdomen that had abnormal coloring and an open area on the back of the resident's upper legs. Observation on 05/05/26, at 1:41 P.M., showed the following: -Resident was in his/her bed and turned to his/her right side; -Resident had red excoriated open areas to the left and right inner thighs; -Certified Nurse Aide (CNA) H cleansed the area and applied barrier cream. During an interview on 05/05/26, at 1:45 P.M., CNA H said the following: -The resident had red open areas to his/her inner thighs; -He/she cleansed the area and applied barrier cream during perineal care; -He/she was not aware of the nurses are treating the area, but the CNAs are encouraging the resident to lay down and leave the area open to air; -The resident often refused to lay down to be changed. During an interview on 05/06/26, at 7:20 A.M., Licensed Practical Nurse (LPN) D said the following: -He/she did not know of any current issues with the resident's skin; -Every once in a while, the resident had excoriation under his/her chest area and staff used nystatin powder in the past; -The resident had areas on his/her under side of his/her thighs, which appeared to be the brief rubbing him/her; -Sometimes the areas require a cream to heal. During an interview on 05/06/26, at 9:30 A.M., CNA E said the following: -The resident's skin is off in between his/her legs; -The areas were healed up but reopened; -He/she had not been on the hall in a while but a week ago it was healed up; -He/she informed the charge nurse who put cream in a cup and aides applied it on the resident's skin; -He/she saw it on Monday (05/04/26) and in between the resident's inner thighs was an open area, a quarter size in the lower buttock area and inner thigh, no other open areas. During an interview on 05/06/26, at 9:49 A.M., CNA H said the following: -The resident had a spot on the back of his/her left side up by the buttock cheek; -The resident was incontinent, and CNA H thought it was moisture and where the brief sits on the resident. The area was open and bleeding a little yesterday when he/she cleaned it off. While the spot is not open, there are a few areas where it is bleeding a little; -The actual area itself is the size of a dime; -The area looks better than it did a week ago, staff have applied cream to the area. A week ago, the area was more reddened. During an interview on 05/06/26, at 10:07 A.M., Registered Nurse (RN) I said the following: -He/she had not seen the resident's skin in a while; -The resident tends to get rubbing or burns from his/her brief; -The resident has large folds, and staff always has to monitor the resident's skin; -Staff did not report any new open areas or areas of bleeding yesterday; -He/she saw weekly skin assessments for 04/28/26 and 04/07/26. Staff should have completed weekly skin assessments in between those dates; -He/she did not find a progress note of any skin concerns in the resident's progress notes from yesterday (05/05/26). During an interview on 05/06/26, at 10:31 A.M., RN A said he/she was not aware of the resident's skin concerns yesterday (05/05/26). The last time he/she saw the resident's skin was good. During observation and interview on 05/06/26, at 10:40 A.M., showed the following: -The Assistant Director of Nursing (ADON) assisted resident in turning to his/her side; -Visible red open areas to the resident's left and right thighs were visible; -Staff cleansed the area and applied barrier cream; -The ADON said the area was MASD with open areas that have a pink wound bed. During interviews on 05/06/26, at 11:40 A.M. and 1:10 P.M., the ADONs said the following: -The resident is very incontinent and likes to sit in his/her wheelchair a lot during the day; -The 03/04/26 assessment of the resident's left gluteal fold was not pressure but moisture from his/her brief; -Staff did not complete weekly skin assessments between 03/04/26 and 03/31/26; -She did not see the resident's 05/01/26 shower sheet of the open area; -She did not see anything open on 04/27/26; -The resident had consistent MASD. During an interview on 05/06/26, at 1:04 P.M., Shower Aide/CNA J said on 05/01/26, the resident had an open area inside of his/her thigh area. The area was a couple inches. It was open but looked like scabbed over now. The resident has redness under his/her breasts. 2. Review of Resident #27's face sheet showed the following: -admission date of 08/21/25; -Diagnoses included muscle weakness and cognitive communication deficit. Review of the resident's quarterly MDS assessment, dated 01/15/26, showed the following: -Cognitive skills intact; -Supervision required with toileting and showering/bathing; -Set up or clean up assistance with personal hygiene. Review of the resident's weekly skin assessment dated [DATE], at 12:12 P.M., showed the following: -General appearance of skin was dry, warm and intact; -Left antecubital (triangular space or region located on the inner or front side of the elbow)-skin tear/scabbed; -Skin tear to left upper arm 1.5 centimeters (cm) long by 0.5 cm wide by 0.0 cm in depth. Review of the resident's nurses' notes, dated 03/05/26 to 04/13/26, showed staff did not document regarding the resident's skin tears. Review of the resident's medical record, dated 03/05/26 to 04/13/26, showed staff did not complete a weekly skin assessment. Review of the resident's quarterly assessment dated [DATE], at 12:34 P.M., showed skin intact and dry. Review of the resident's progress note dated 04/15/26, at 11:07 A.M., showed the following: -Staff documented the resident found on the floor leaning on his/her roommate's bed; -The resident complained of right leg pain; -The resident's right arm had several large skin tears; -Staff notified the resident's provider and received order to transfer the resident to the emergency room. Review of the resident's readmission assessment dated [DATE], at 4:08 P.M., showed the following: -Skin intact with surgical wound, skin tear and bruise; -Right antecubital bruising and skin tear; -Right iliac crest (front) surgical incision 5 cm long by 0.1 cm wide by 0 cm; -Right trochanter (hip) surgical incision 6 cm long by 0.1 cm wide by 0 cm; -Right hand (back) bruising; -Right shoulder (front) bruising; -Right shoulder (front) skin tear. Review of the resident's progress note dated 04/19/26, at 1:32 P.M., showed staff documented the resident was on skilled services for his/her right hip fracture/repair. The resident had a right hip dressing which was dry, intact, and changed today by the wound nurse. Review of the resident's skilled evaluation dated 04/21/26, at 2:57 A.M. showed the following: -Resident's skin color within normal limits; -Resident's skin was fragile with normal skin turgor (elasticity); -Resident had a surgical wound to his/her right hip and wound with dressing intact to the resident's right arm. Review of the resident's skilled evaluation dated 04/22/26, at 1:38 A.M., showed the following: -Resident skin color within normal limits; -The resident's skin was fragile with normal skin turgor; -The resident has a surgical incision/wound to his/her right hip and to his/her right upper extremity from a fall. Review of the resident's skilled evaluation dated 04/28/26, at 1:16 A.M., showed the following: -Resident skin color within normal limits; -Resident's skin was fragile with normal skin turgor; -The resident had a surgical wound to his/her right hip with dressing in place. Review of the resident's progress note dated 04/30/26, at 11:06 P.M., showed the following: -A nurse documented the resident's three incisions to his/her right hip were steri stripped after 20 staples were removed with minimal difficulty; -The resident experienced burning blisters from the adhesive around the border gauze that were open and weeping. Review of the resident's care plan, revised 05/03/26, showed the following: -The resident had a surgical wound to his/her right hip; -Staff to monitor for signs or symptoms of infection and report to physician; -Monitor for worsening of condition and report to the charge nurse and physician. Review of the resident's record, dated 04/30/26 to 05/07/26, showed staff did not document the resident's blisters that were open and weeping or the resident's right arm. Observation on 05/05/26, at 10:15 P.M., showed the following: -RN A washed his/her hands and donned gloves; -RNA A removed the dressing from the resident's right hip; -The resident had two open areas approximately .5 inches to the right hip; -RN A changed his/her gloves then cleansed the wound and applied triple antibiotic ointment to the wound; -No closed blisters observed. During an interview on 05/06/26, at 10:07 A.M., RN I said the resident had tape burns and staff put cream on them. During an interview on 05/06/26, at 10:31 A.M., RN A said he/she removed the resident's staples last Thursday (04/30/26). The resident had border gauze in place, and he/she removed it. During interviews on 05/06/26, at 1:43 P.M., and on 05/07/26, at 11:25 A.M., the ADON said he/she was told of the resident's blisters around his/her incisions. She was not aware of the resident's blisters on Monday (05/04/26) During an interview on 05/07/26, at 1:16 P.M., the MDS/Care Plan Coordinator said she did not know of the resident's blisters until yesterday (05/06/26). She would have revised the resident's care plan if she was aware. During an interview on 05/07/26, at 10:22 A.M., LPN K said he/she rounded with the physician last Monday (04/27/26) and the top blister had popped. 3. Review of Resident #39's face sheet showed the following: -admission date of 03/03/25; -Diagnoses included polyneuropathy (condition where multiple peripheral nerves throughout body malfunction causing widespread weakness, numbness and burning pain). Review of the resident's quarterly MDS assessment, dated 12/12/25, showed the following: -Cognitive skills intact; -MASD. Review of the resident's weekly skin assessment dated [DATE], at 1:17 P.M., showed a nurse documented the following: -General appearance of skin dry, warm, and reddened; -Sacrum (triangular shaped bone located at the base of the lumbar spine) had MASD. Review of the resident's shower sheet, dated 3/11/26, showed staff documented an area in the coccyx area that had abnormal coloring. Review of the resident's quarterly assessment dated [DATE], at 1:05 P.M., showed a nurse documented on skin assessment, no condition of skin marked. Review of the resident's annual MDS, dated [DATE], showed the following:-Moderately impaired cognitive skills; -Substantial/maximal assistance required with mobility; -MASD. Review of the resident's care plan, revised on 03/24/26, showed the following: -The resident was at risk for impaired skin integrity related to immobility and refusal to get out of bed; -Staff to apply barrier cream as ordered; -Staff to assist with repositioning to prevent skin breakdown; -Complete weekly skin assessment per schedule; -The resident is at risk for skin breakdown and odor due to bowel and bladder incontinence. Review of the resident's shower sheet, dated 03/25/26, showed staff documented an area on the upper arm that had abnormal coloring, the feet area had hardened skin, and the coccyx area noted as nurse treating it. Review of the resident's shower sheets showed the following: On 04/01/26, staff documented an area in the coccyx area had abnormal coloring; -On 04/08/26, staff documented an area in the coccyx area had abnormal coloring; -On 04/15/26, staff documented an area in the coccyx area had abnormal coloring; -On 04/22/26, staff documented an area in the coccyx area had abnormal coloring; -On 04/25/26, showed staff documented the resident's family member was going to complete the resident's shower; On 04/29/26, staff documented an area in the coccyx area that had abnormal coloring. Review of the resident's medical record, dated 03/14/26 to 05/04/26, showed staff did not document in the progress notes of any skin concerns or weekly skin assessments. Review of the Wound Clinic Nurse Practitioner (NP) visit dated 05/05/26, at 7:03 P.M. showed the following: -Reason for visit was first evaluation of existing wound; -Consulted for wound to coccyx. The facility had been placing barrier cream with no other treatments; -Assessment: Wound 1; -Location: Coccyx; -Incontinence Associated Dermatitis (IAD); -Stage/Severity: Partial Thickness; -Size: 3 cm long by 9.5 cm wide by 0.1 cm in depth. Calculated area is 28.5 square cm; -Wound base: 100% epithelial (the thin tissue forming the outer layer of a body's surface); -Exudate (drainage): Light amount of Serous (clear, thin watery fluid); -Peri wound (tissue and skin surrounding a wound): Erythema (redness); -Irritant contact dermatitis due to fecal, urinary or dual incontinence; -Assessment/plan: The resident has a pressure injury. Rounded with the support nurse on initial visit today. Nurse states staff have applied barrier cream, nothing specific. The nurse noted that it has improved, and redness has gotten lighter. During interviews on 05/06/26, at 1:43 P.M., and on 05/07/26, at 11:25 A.M., the ADON said the following: -Resident was care planned for refusing showers quite often; -She reviewed the resident's 04/22/26 and 04/29/26 shower sheets and was aware staff put barrier cream on the resident for redness; -The resident's only weekly skin assessments were completed on 01/20/26 and 03/13/26; -The resident was placed on the list for the wound company who comes to the facility once per week; -She was not aware of the resident having skin issues for months per the wound clinic NP note; -She did not see the resident's 05/01/26 shower sheet; -She saw the resident's skin on Monday (4/27/26) and it was MASD on his/her buttocks in the center with redness on both sides; -The resident has a standing order for moisture cream to the area. Observation on 05/07/26, at 10:08 A.M. showed staff resident was turned to his/her side and his/her coccyx area appeared red. During an interview on 05/07/26, at 11:44 A.M., the Director of Nursing (DON) said last week the resident's buttocks were red and had MASD. During an interview on 05/07/26, at 12:26 P.M., the Nurse Practitioner (NP) from the wound care clinic said the following: -The resident's skin area was from incontinence based on looking at his/her skin; -Staff said the area had been red since admission and they had not done anything except barrier cream. During an interview on 05/07/26, at 1:16 P.M., the MDS/Care Plan Coordinator said the first time she heard of the resident's MASD was a week ago. 4. During an interview on 05/06/26, at 6:57 A.M., CNA G said the following: -Staff monitor residents' skin when assisting with dressing, and toileting; -Aides should report to the nurse of any open areas, shearing, or rashes; -The nurses complete the weekly skin assessments. During an interview on 05/06/26, at 9:30 A.M., CNA E said the following: -Staff monitor residents' skin with incontinent care and should report any skin concerns to the charge nurse immediately; -Charge nurses complete the weekly skin assessments; -The shower aide assesses the resident's skin and completes a shower sheet that has the front and back of a picture of a body, marks areas of concerns, and turns into the charge nurse who signs it. During an interview on 05/06/26, at 9:49 A.M., CNA H said the following: -Staff monitor skin when changing resident's clothes, providing incontinent care, and reports to the charge nurse or wound nurse of any skin concerns; -Aides should report any new skin concerns to the charge nurse. During an interview on 05/06/26, at 1:04 P.M., Shower Aide/CNA J said as a shower aide, he/she assessed the resident's skin during the shower and documented on a shower sheet. He/she circled areas of concern and turned it in to the nurse at the end of the day. During an interview on 05/06/26, at 7:20 A.M., LPN D said the following: -Staff should report to the nurse any skin issues and the nurse assesses the resident; -Nurses should document any skin issues in the progress notes; -Nurses should notify the provider of any skin issues and enter a treatment order if applicable; -The day charge nurse completed the weekly skin assessments; -Staff pass in the shift report if any resident required a barrier cream treatment and it flags on the computer; -Nurses should complete weekly skin assessments; -It was important to complete weekly skin assessment to not have increased skin breakdown or infections. During an interview on 05/06/26, at 10:07 A.M., RN I said the following: -The nurse on duty was responsible for completing weekly skin assessments; -There was a list of assigned weekly skin assessments per shift; -Nurses should observe the resident head to foot, ears, under folds, and the peri area; -Nurses should document the weekly skin assessment in the electronic medical record; -Nurses should notify the physician of any new skin concerns to obtain a treatment order; -Nurses should view the resident's previous weekly skin assessment to see if any new areas. During an interview on 05/06/26, at 10:31 A.M., RN A said the following: -He/she completed the wound care when he/she was the support nurse; -The shower bath aide completed the skin sheet and included any abnormality in the skin and turned into the charge nurse; -Aides should inform the nurse of any new open areas, bruises or rashes; -The charge nurse or support nurse completed the weekly skin assessments; -Nurses complete the weekly skin assessment and should document any abnormalities; -Nurses should look at the previous skin assessment to see if there are any changes; -Management staff monitor to see if the weekly skin assessments are completed. During an interview on 05/07/26, at 1:16 P.M., the MDS/Care Plan Coordinator said the following: -She expected nurses to complete skin assessments weekly; -Staff discussed any skin issues in the morning meetings and she updated the care plan. During interviews on 05/06/26, at 11:40 A.M. and 1:10 P.M., the ADON said the following: -The nurse was responsible for completing weekly skin assessments which are assigned by rooms and shifts; -The support nurse completed the weekly skin assessment and if not able, the charge nurse should complete it; -Weekly skin assessments are important to monitor any new wounds, rashes and/or skin tears and to put a treatment in place; -The aides should report to the charge nurse of any new skin concerns; -He/she audits the completed weekly skin assessments on Fridays. He/she did not know why the weekly skin assessments were not getting completed. It seemed to be the same nurses; -The shower aide gives the shower sheet to the charge nurse and then it comes to him/her; -The charge nurse or the treatment nurse should review the shower sheet, sign it to acknowledge it, and assess any skin concerns as needed; -The shower aide should get him/her of any new skin concerns. During interviews on 05/06/26, at 11:45 A.M., and on 05/07/26, at 9:01 A.M. and 11:44 A.M., the DON said the following: -The charge nurse completed the weekly skin assessment; -The ADON reviewed the completed skin assessments on Friday and was resp

Based on interview and record review, the facility failed to complete a discharge assessment and electronically transmit encoded data Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessments from the facility to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days for two residents (Resident #28 and Resident #52) out of a sample of 19 residents selected for review. The facility had a census of 51 residents. Record review of the facility policy, titled 'Assessment Frequency/Timeliness', revised 06/30/25, showed the purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI manual. 1. Review of Resident #'28's face sheet (admission data) showed the following information:-admitted to the facility on [DATE];-The resident discharged on 02/23/26. Review on 05/06/26 of the resident's MDS assessments, showed staff did not complete or submit the resident's discharge MDS assessment data into the facility system, and did not electronically transmit the encoded MDS information within 14 days from the facility to the QIES ASAP System. During an interview on 05/06/26 at 11:19 A.M., the MDS/Care Plan Coordinator said the following:-She did not complete or submit the resident's discharge MDS assessment;-The resident discharged on 02/23/26. 2. Review of Resident #52's face sheet showed the following information:-admitted to the facility on [DATE];-The resident discharged on 02/23/26. Review on 05/06/26 of the resident's MDS assessments showed staff did not complete or submit the resident's discharge MDS assessment data into the facility system, and did not electronically transmit the encoded MDS information within 14 days from the facility to the QIES ASAP System. During an interview on 05/06/26 at 11:19 A.M., the MDS/Care Plan Coordinator said the following:-She did not complete or submit the resident's discharge MDS assessment;-The resident discharged on 02/23/26. 3. During an interview on 05/06/26, at 11:19 A.M., the MDS/Care Plan Coordinator said the following:-She was responsible for completing the MDS assessments; -She was responsible for ensuring the MDS assessments are completed timely;-She believed the MDS assessment should be submitted within seven days after completion; -The interdisciplinary team meets every morning and discusses new admissions and discharges. 4. During an interview on 05/07/26, at 11:44 A.M., the Director of Nursing (DON) said the following: -The MDS/Care Plan Coordinator gives her a calendar of MDS assessments which are due; -The MDS/Care Plan Coordinator completes the discharge MDS assessments and should submit within 24 hours. During an interview on 05/07/26, at 12:32 P.M., the Administrator said she expected the MDS assessments to be completed and submitted timely.

Based on observation, interview and record review, the facility failed to ensure all residents were treated with dignity and respect, when staff did not allow one resident (Resident #26) to eat in the dining room with other residents, talk with other residents, and smoke with other residents after the resident displayed behaviors. The facility census was 51. Review of the facility's policy titled, Resident Rights, dated 06/10/25, showed the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Review of the facility's policy titled, Patient bill of rights as provided by the LTC (Long term care) Ombudsman Program, dated 04/22/24, showed you shall be treated with consideration, respect, and full recognition of your dignity and individuality, including privacy in treatment and in care for your personal needs. 1. Review of Resident #26 face sheet (a brief summary of the resident's medical and admission history) showed the following: -admission date of 01/28/26;-Diagnoses included depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 02/21/26, showed the following: -The resident was cognitively intact;-The resident exhibited the following behavior one to three days during look back period; -Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) were exhibited. Review of the facility's follow-up investigation report, dated 05/01/26, included the following:-On 4/29/26, at 8:10 P.M., Certified Medical Technician (CMT) L reported to the charge nurse that he/she walked into the dining room and witnessed the resident acting inappropriately with another resident. CMT L immediately separated the residents; -The resident was very remorseful and said he/she understood his/her actions were inappropriate;-The resident had been friendly with other residents who were cognitively aware of the situation, such as hand holding and eating lunch with and conversing; -The resident was alert and oriented; -Staff updated the resident's care plan to reflect the inappropriateness with some residents; -The resident had a diagnosis of depression; -Staff immediately placed the resident on one-to-one care and on 15-minute checks to ensure the safety of other residents; -Alternate placement for the resident had been confirmed and staff scheduled transportation to the facility for 05/07/26;- The Director of Nursing (DON), Administrator, and charge nurses are ensuring that the one-to-one and 15-minute checks are being documented and that the resident is not left alone around any residents of the opposite sex until his/her discharge to another facility. Review of the resident's care plan, last reviewed 05/03/26, showed the following: -The resident had socially inappropriate/disruptive behavior symptoms as evidence by his/her frustration with and/or yelling at staff because he/she was upset;-The resident had an incident where he/she acted inappropriately towards another resident; -The resident was accepted to another facility due to his/her inappropriateness;-Remove the resident from other residents' rooms and unsafe situations as needed; -Divert the resident's behavior by the use of activities; -When he/she becomes inappropriate move him/her to a quiet, calm environment; -Remove the resident from group activities when behavior was present as needed; -Missing smoking times angered the resident and the rules around smoking cause him/her to become angry and irritable. -If disruptive behaviors occur during the smoke break, that specific smoking time can immediately end to de-escalate the situation; -Staff to assist to/from smoking designation area as needed; -When the resident becomes socially inappropriate/disruptive, provide comfort measures for basic needs; -Assess whether the resident's behavior endangers the resident or other residents; -Staff to intervene if necessary and divert the resident's behavior by the use of activities if able. Observations on 05/03/26, showed the following: -At 4:43 P.M., the resident sat in a recliner in the day room. The resident said, Nobody helps me, I wait for hours: -At 6:54 P.M., the resident sat in a recliner in the day room eating a sandwich. During an interview on 05/04/26, at 12:56 P.M., Resident #27 said the following:-Resident #27 and Resident #26 used to visit every day;-Staff did not allow him/her to visit with Resident #26 because Resident #26 was on restrictions;-Resident #26 had not acted inappropriate with him/her. During an interview on 05/04/26, at 3:15 P.M., Resident #26 said the following: -He/she had an incident involving a resident and was placed on restrictions;-The resident smoked and staff told the resident that he/she was not allowed to smoke with the other residents who smoke even though staff supervised those resident when they smoked; -The resident had to smoke alone, after the other smokers finished;-The resident had to sit in the day room during the day to be watched by staff;-Staff told the resident he/she was not allowed to participate in activities;-Staff told the resident that he/she was not allowed to visit with his/her friends at the facility. Observation on 05/06/26, at 5:05 A.M., showed the following:-The residents at in his/her wheelchair propelling self around the day room;-Nursing Assistant (NA) M told the resident that he/she was getting to close to the other resident;-While walking through the day room, the DON told the resident that he/she was on 15-minute checks and had to stay away from residents of the opposite sex. During an interview on 05/06/26, at 6:05 A.M., Certified Nurse Aide (CNA) N said the following: -Staff checked on the resident every 15-minutes due to an incident that involved another resident;-Resident #26 and Resident #27 were friends and used to visit in the dining room daily;-Resident #26 and Resident #27 were no longer allowed to visit with each other. During an interview on 05/06/26, at 7:02 A.M., CNA G said the following:-Staff checked on the resident every 15-minute check and he/she was not sure if staff allowed the resident to visit with other residents;-Staff did not allow the resident to smoke with the other smokers and had to smoke alone;-When staff did not allow a resident to visit with other residents and restricted him/her to a specific area, that would be isolation, which violated the resident's rights. Observation on 05/05/26, at 7:56 A.M., showed the resident sitting in a recliner in the day room eating breakfast. During an interview on 05/05/06, at 9:19 A.M., Nurse Aide (NA) M said the following: -The resident was a danger to other residents based on his/her past behaviors; -Staff checked on the resident every 15-minutes;-The resident had to stay in the day room so staff could watch him/her;-The resident had to smoke alone as he/she was not allowed to be around other residents;-The resident was on restrictions to keep other residents safe, and it did not violate his/her rights. During an interview on 05/06/26, at 1:49 P.M., CNA H said the resident was not allowed to eat in the dining room or smoke with the other residents. During an interview on 05/06/26, at 9:30 A.M., CNA E said the following: -The resident was on 15-minute checks. and staff always had the resident in eyesight; -The resident cannot smoke with other residents which has something to do with another resident who goes out to smoke; -The resident was not able to go out to smoke with other residents even if a staff member is present. During an interview on 05/07/26, at 10:12 A.M., Certified Medication Tech (CMT) O said the following:-The resident was not to be in the vicinity of residents of the opposite sex;-The resident was not allowed to smoke with other residents;-The resident was to eat meals in the day room by himself;-Keeping a resident from talking to other residents and not letting the resident visit with alert and oriented residents in a common area would go against resident's rights and could be considered isolation. During an interview on 05/06/26, at 7:20 A.M., Licensed Practical Nurse (LPN) D said the following: -Staff check the resident every 15-minutes on the night shift and make sure he/she was in bed; -Staff encouraged the resident to keep distance from other residents; -The resident can visit with other residents as long as there was adequate space and reasonable boundaries. During an interview on 05/07/26, at 10:45 A.M., the MDS Coordinator said staff were taking the resident to smoke separately because other residents were calling him/her names During an interview on 05/07/26, at 11:44 A.M., the DON said the following: -The resident could not sit or eat lunch with any residents of the opposite sex unsupervised; -The resident was on a separate smoke break due to one resident who had post-traumatic stress disorder; -The resident was allowed to go to activities and anything supervised by staff. Complaint #2999226

Based on observation, record review, and interview, the facility failed to provide pharmaceutical services in a manner to ensure the proper storage, destruction, and accountability of medications when the facility did not have a process in place for timely destruction of the unused medications to ensure a clean and orderly medication room when a sample of medications for 22 residents' (Resident #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and #26) medications were located in the medication room waiting to be destroyed. The facility census was 48. Review of the facility provided policy titled Destruction of Unused Drugs, dated 06/10/25, showed the following:-All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations;-Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements;-Unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed;-The actual destruction of drugs conducted by the facility must be witness by the consultant pharmacist and one of the following individuals: an agent of the State Board of Pharmacy, facility administrator, or the Director of Nursing (DON) services;-A non-controlled medication destruction record must be maintained for all non-controlled drugs destroyed and such record must be verified by the consultant pharmacist;-The facility utilizes a waste disposal service or reverse distributor to destroy dangerous drugs and controlled substances. 1. Observation on 11/06/25, at 12:00 P.M., of the medication room located behind the nurses' station showed the following:-While standing in front of the sink, the counter was full to the right side of the sink, approximately five feet of counter space, of the medications that included medication cards, bottles, bags, and individual doses. The countertop was full and touching the underside of the cupboard above; -There was a white bucket full of additional medications above the medication refrigerator located in the corner of the room;-A sample of medication cards included:-One bottle of cyclobenzaprine (muscle relaxant for relief of muscle spasms) 10 milligram (mg - unit of measurement), dispensed on 06/16/25 and one card of tizanidine 4 mg (muscle relaxant for management of muscle spasticity), with 8 tabs remaining, dispensed on 06/23/25 for Resident #5;-One card of potassium chloride micro (supplement that treats low potassium) 20 milliequivalent (meq) extended release (ER), 10 tabs remaining, dispensed on 07/13/25, for Resident #6;-One card of spironolactone 25 mg (generic prescription that helps manage fluid buildup), 11 tabs remaining, dispensed on 08/01/25, for Resident #7;-One card of citalopram 20 mg (prescription used to treat depressive disorder), 4 tabs remaining, dispensed on 08/01/25, for Resident #8;-One card of loxapine 5 mg (used to treat symptoms of schizophrenia), 1 capsule remaining, dispensed on 08/02/25 and one card of lamotrigine 150 mg (used to manage mood disorders), 26 tabs remaining, dispensed on 08/04/25 for Resident #9;-One card of metoprolol 25 mg (used to treat high blood pressure), 42 tabs remaining, dispensed on 08/07/25, for Resident #10;-One card of gabapentin 300 mg (used to treat nerve pain), 57 caps remaining, dispensed on 08/28/25, for Resident #11;-One card of gabapentin 100 mg capsules, 18 capsules remaining, dispensed on 08/28/25, for Resident #12;-One card of doxycycline hyclate 100 mg (antibiotic used to treat bacterial infections), 4 tabs remaining, dispensed on 08/31/25, for Resident #13;-One card of doxycycline 50 mg, 3 doses of 2, dispensed on 09/14/25, for Resident #14;-One card of venlafaxine 75 mg ER (used to improve mood and reduce anxiety), 10 tabs remaining, dispensed on 09/14/25, for Resident #15;-One bottle of megestrol acetate suspension 40 mg/ml (used as an appetite stimulant to treat significant and unexplained weight loss), one full bottle dispensed on 09/20/25, for Resident #16;-One card of amoxicillin clavulanate potassium 875 mg /125 mg (generic of Augmentin, combination antibiotic to treat bacterial infections), 16 tabs remaining, dispensed on 09/21/25, for Resident #17;-One card of topiramate 50 mg (used to treat seizures and prevent migraine headaches), 10 tabs remaining, dispensed on 09/23/25, for Resident #18;-One card of ciprofloxacine 500 mg, 2 tabs remaining, dispensed on 09/24/25 and one card of metronidazole 500 mg (antibiotic medication used to treat a wide variety of infections), 4 tabs remaining, dispensed on 09/24/25, for Resident #19;-Bydureon BCise 2 mg injection (used to improve blood sugar control), 2 syringes remaining, dispensed on 10/01/25, for Resident #20;-One card of Cephalexin 500 mg (used to treat bacterial infections), 20 tabs remaining, dispensed on 10/03/25, for Resident #21;-Ipratropium/Albuterol solution (used to relax muscles in the airways to make breathing easier), 5 packages of 5 vials, dispensed on 10/15/25, for Resident #21;-One card of trazadone 150 mg (used to treat depressive disorder, anxiety, and as a sleep aid), 30 tabs remaining, dispensed on 10/16/25, for Resident #22;-One card of Cefdinir 300 mg (used to treat bacterial infections), 2 tabs remaining, dispensed on 10/17/25, for Resident #23;-One card of venlafaxine 150 mg ER, 30 tabs remaining, dispensed on 10/17/25, for Resident #24;-One vial of insulin lispro injection 100 /ml (helps control high blood sugar in people with diabetes), dispensed on 10/18/25, for Resident #25;-Amlodipine 5 mg (used to treat high blood pressure), 2 tabs in individual packets remaining, dispensed on 10/26/25 and meloxicam 15 mg (used to relieve pain and swelling), 1 tab in individual packet remaining, dispensed on 10/26/2, for Resident #26.During an interview on 11/06/25, at 1:15 P.M., Certified Medication Tech (CMT) E said that the medication room included extra over-the-counter medications, refrigerated medications, and supplies. The room also had non-narcotic medications that were no longer in use. The room was a mess at the time. The nursing managers needed to destroy expired medications.During an interview on 11/06/25, at 12:00 P.M., Licensed Practical Nurse (LPN) A said the medication room was currently a mess pending medications to be destroyed. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) generally take care of the medications that no longer have active orders.During an interview on 11/06/25, at 2:00 P.M., the MDS Coordinator said the medication room has lots of unused medications and the room was a disaster. It has been that way for at least a couple of months.During an interview on 11/06/25, at 1:30 P.M., the ADON said that two people, including at least one nurse, can destroy non-narcotics. The medication room was a mess. The counter was full of medications that needed to be destroyed. There was an RN that worked for a few months in the past and had the room in order. It has been several months since it was clean and orderly.During an interview on 11/06/25, at 12:30 P.M., DON said the medication room was a mess at the time. She said there was a ton of medications, that are non-narcotics, that needed to be destroyed. It would take days to complete this and get that room cleaned up. It has been a major problem. She has not had the time to take care of that process and paperwork. The narcotics remain locked in the medications carts until they were destroyed.During an interview on 11/06/25, at 3:10 P.M., the Interim Administrator said the medication room should be kept clean and organized and all medications not in use should be destroyed timely.Complaint 2660953

Based on record review and interview, the facility failed to promote and facilitate each resident's right of self-determination when staff failed to provide timely bathing for four residents (Resident #1, #2, #3, and #4) out of a sample of seven residents. The facility census was 48. Review of the facility's policy titled, Activities of Daily Living (ADLs), dated 05/16/25, showed the following:-The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable;-Care and services will be provided for the ADLs including bathing, dressing, grooming and oral care;-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;-The facility will maintain individual objective of the care plan and periodic review and evaluation.Review of the facility's policy titled, Resident Showers, dated 05/16/25, showed the following:-It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues in accordance with current standards of practice;-Each resident will be provided showers in accordance with the resident's preference, care plan, and safety needs, as well as the facility's scheduled bathing protocol;-Partial baths may be given between regular showers schedules in accordance with facility policy;-The certified nurse aide (CNA) will assess the skin for changes while performing bathing and inform the nurse of any changes;-Assist the resident to the shower room and bring all necessary supplies;-Help the resident with the shower;-Help the resident back to their room and return personal hygiene products to their designated spot.1.Review of Resident #1's face sheet showed the following:-admission date of 10/25/22;-Diagnoses included nondisplaced fracture of left socket of the hipbone (break in the cup-shaped part of the pelvis where the top of the thigh bone fits to form the hip joint), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and anxiety disorder.Review of the resident's care plan, last updated 07/02/25, showed the following:-Resident had an activities of daily living (ADL - dressing, showers, etc.) functional problem as evidence by the need for staff assistance with ADL's due to diagnosis of chronic obstructive pulmonary disorder (COPD - a term for lung and airway diseases that restrict breathing) and Alzheimer's dementia;-Staff should provide one shower per week;-Resident may request an alternative type of bathing (bed bath, dry method of hair care, sponge bath);-Staff should assist with showers and skin assessments as needed;-Staff should clean and trim nails as needed.Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/17/25, showed the following:-Moderate cognitive impairment;-Required substantial to maximal assistance for toileting hygiene, personal hygiene, showering, and dressing.Review of the resident's October 2025 and November 2025 Skin Monitoring: Comprehensive CNA Shower Review forms, showed the following:-On 10/09/25, staff documented the resident received a shower and shave, had no new skin issues, and had swelling in his/her feet;-On 10/25/25, staff documented the resident received a shower, no new skin issues, and toenails needed cut (16 days after the prior documented shower);-On 10/27/25, staff documented the resident received a shower;-Staff did not document any additional showers for October 2025 or November 2025.During an interview on 11/06/25, at 9:00 A.M., the resident said that he/she preferred at least one shower per week and was unsure when his/her last shower was provided.2. Review of Resident #2's face sheet showed the following:-admission date of 04/06/23;-Diagnoses included chronic peripheral venous insufficiency (condition where veins, most often in the legs, have trouble efficiently sending blood back to the heart), high blood pressure, depressive disorder, and chronic pain.Review of the resident's care plan, last updated 07/02/25, showed the following:-Resident had ADL functional problems as evidenced by need for staff assistance with ADL's due to diagnosis of radiculopathy (condition where a nerve root in the spinal column becomes compressed or irritated) and dementia;-Staff should provide supervision and touching assistance with showers;-Resident will be provided with one shower per week;-Upon resident request he/she may be offered an alternative type of bathing (bed bath, dry method of hair care, sponge bath);-Staff should assist with showers and skin assessments as needed.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Required partial to moderate assistance with shower transfer, showering, lower body dressing;-Required supervision or touch assistance with personal hygiene and upper body dressing;-Required set up or clean up assistance with personal hygiene and toileting hygiene. Review of the resident's October 2025 and November 2025 Skin Monitoring: Comprehensive CNA Shower Review forms, showed the following:-On 10/02/25, staff documented resident received a shower;-On 10/09/25, staff documented resident received a shower and had no new skin issues (seven days after the prior documented shower);-On 10/14/25, staff documented resident received a shower and had redness to private area and powder was applied;-On 10/16/25, staff documented resident received a shower and had an open sore on the left great toe;-On 11/06/25, staff documented resident received a shower (21 days after the last documented shower);-Staff did not document any additional showers for October 2025 or November 2025. During an interview on 11/06/25, at 9:45 A.M., the resident said that he/she would like to receive at least one shower per week, however, he/she would prefer two showers per week. He/she said the last shower provided was at least one week and two days ago. He/she felt dirty without a routine shower and said that after a shower if felt so good to be clean.3. Review of Resident #3's face sheet showed the following:-admission date of 09/08/25;-Diagnoses included COPD, chronic pain syndrome (persistent pain that lasts for at least 6 months), depression, and anxiety.Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Required partial to moderate assistance with showering and personal hygiene;-Required supervision or touching assistance with oral hygiene and dressing.Review of the resident's care plan, last updated 10/10/25, showed the following:-Resident was at risk for impaired skin integrity;-Staff should complete weekly skin assessment as scheduled;-Resident had ADL function problems as evidenced by need for staff assistance with ADLs due to diagnosis of below the knee amputation (surgical removal of the lower leg below the knee joint);-Staff should assist with his/her shower and skin assessment twice weekly and as needed;-Staff should clean and trim his/her nails weekly and as needed;-Staff will provide one shower per week;-Upon resident request he/she may be offered an alternative type of bathing (bed bath, dry method of hair care, sponge bath);-Staff should assist with showers.Review of the resident's October 2025 and November 2025 Skin Monitoring: Comprehensive CNA Shower Review forms, showed the following:-On 10/30/25, staff documented resident received a shower;-On 11/06/25, staff documented resident received a shower, his/her toenails did not need cut, his/her right foot area was very dry and lotion applied;-Staff did not document any additional showers for October 2025 or November 2025.During an interview on 11/06/25, at 10:15 A.M., the resident said that showers were a disappointment. He/she was scheduled to have a shower this day, but it had been over one week since his/her last shower and was about three weeks for the previous shower. He/she would prefer to have at least one shower per week but two showers per week would be even better. He/she felt dirty and gross when not receiving a shower. He/she went from a shower every day at home to barely one shower per week and that did not make him/her feel good.4. Review of Resident #4's face sheet showed the following:-admission date of 10/23/25;-Diagnoses included acute and chronic respiratory failure with hypoxia (note enough oxygen in the blood), atrial fibrillation (an irregular and often very rapid heart rate that can lead to blood clots in the heart), and iron deficiency anemia (condition where the body does not have enough iron to produce healthy red blood cells).Review of the resident's medical records showed no baseline or comprehensive care plan initiated or completed.Review showed no information in the nursing notes related to showers.Review of the resident preference evaluation, dated 10/27/25, showed the following:-It was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath;-Resident preferred a shower.Review of the resident's October 2025 and November 2025 Skin Monitoring: Comprehensive CNA Shower Review forms, showed the following:-On 11/02/25, staff documented resident received a shower and had rash in the private area;-On 11/06/25, staff documented that resident received a shower;-Staff did not document any additional showers for October 2025 or November 2025.During an interview on 11/06/25, at 10:45 A.M., the resident said that he/she had been at the facility for twenty days. He/she had been discharged from physical therapy today and would be going home tomorrow. He/she said that after admission to the facility he/she went eleven days before being offered a shower and that was the only shower he/she had been provided. He/she generally took a shower several times per week at home. When he/she asked the staff about a shower, the staff said they did not know where he/she was on the shower schedule. The resident was upset about not receiving a shower and felt he/she might stink.During an interview on 11/06/25, at 2:20 P.M., Nurse Aide (NA) C and NA D said they do the best they can to get to resident showers, but some days they were not getting done. It really depended on the day. Most of the time if they were not able to get to the shower one day they would try to get to the shower the next day.During an interview on 11/06/25, at 1:45 P.M., Certified Nurse Aide (CAN) B said there was a shower schedule at the nursing station each day. Showers were assigned by hall and by shift. Residents should receive two showers per week and if a resident asked for an extra staff should try to get that done. When the facility was short staffed, it was difficult to get showers completed with all the other tasks needing to be done for residents each day.During an interview on 11/06/25, at 1:10 P.M., Certified Medication Tech (CMT) E said there was a shower schedule that was located at the nursing desk each day. When he/she worked on the floor as an aide, he/she would try to get the resident in the shower that morning it was scheduled. During an interview on 11/06/25, at 12:00 P.M., Licensed Practical Nurse (LPN) A said there was a shower list every day that was posted by the Director of Nursing (DON). The aides were to complete the scheduled showers. However, there was often only two to three aides and there was not enough aides to do any extra work, so showers did not get done every day.During an interview on 11/06/25, at 2:00 P.M., the MDS Coordinator said residents should receive at least one shower per week, but staff should try to give the residents two showers per week. Also, showers should be given according to the resident's preference which is reviewed on admission and with care plan meetings. The residents that receive therapy services sometimes receive a shower with therapy assistance so they are able to care for themself at home. During an interview on 11/06/25, at 1:25 P.M., the Assistant Director of Nursing (ADON) said the shower schedule was done by the DON each day. The aides were to initial on the shower sheet when the shower was done and put it in the DON's mailbox each day. The staff should complete a shower sheet and skin check with each resident's shower. She was not aware of showers not being completed until she was looking for shower sheets this day. She did not find as many as she would expect or like to see.During an interview on 11/06/25, at 12:30 P.M., the DON said she made the shower scheduled for staff every day. There was not one aide assigned to showers. When the new corporation took over, they took away an assigned shower person. The aides working on the floor have to do the baths. The bath schedule was on the desk with the staff schedules. A lot of improvements need to be made related to showers. There have been a lot of staff call in and left only three aides on the floor with 48 residents. Staff were to complete a shower sheet with skin check for each bath, then give to the charge nurse, the charge nurse should sign off and evaluate the resident for any areas of concern noted. Then the sheet went into a scan pile to get scanned in eventually.During an interview on 11/06/25, at 3:10 P.M., the Interim Administrator said residents should be provided with showers twice per week, as resident requested, or as care planned per resident preference. He/she did not like to see that residents went weeks without showers. There was not a dedicated shower aide. All the floor aides should be providing showers according to the schedule.Complaint 2660953

Based on interview and record review, the facility failed to protect residents from misappropriation of property when the facility did not provide sufficient pharmaceutical services to prevent diversion of medication resulting in one staff member obtaining narcotic medications for 14 residents (Resident #21, #10, #17, #22, #14, #1, #3, #2, #6, #11, #18, #8, #12, and #20) and keeping the medication instead of stocking them in the medication cart. The census was 51.Review of the facility policy Controlled Substance Administration and Accountability, dated 06/10/25, showed the following:-It is the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances;-The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure;-The pharmacy maintains the supply of controlled substances in automated dispensing systems;-For patient care areas which do not utilize automated dispensing systems, daily orders for stock narcotics are filled out by the charge nurse according to the following procedure:-The amount on hand is checked against the amount used daily from the documentation records; -The designated order form is completed and sent to the appropriate pharmacy making sure it contains the unit of ordering the medication, the signature of person making the request, the date, the medications and quantities required;-Controlled substances are delivered to and signed for by a licensed nurse;-The person who delivers the medications returns the signed delivery form to the pharmacy for record keeping;-The medications delivered are immediately recorded on the appropriate drug disposition record and stored in the controlled drug storage area by the nurse accepting delivery;-Controlled Drug Record Forms are signed and the pharmacy record receipt copy removed and returned to the pharmacy by the person who delivered the drug;-The original and remaining copies remain in the care area to account for each dose administered;-When the sheet has been completed or the medication discontinued:-The original is placed in the patient chart;-The pharmacy copy is returned to the pharmacy for their disposition record (DEA-required record keeping, etc.);-The nursing copy of the Controlled Drug Record remains in the clinical area for a 30-dayperiod after which it is returned to the Pharmacy;-Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it is discovered;-For those areas with automated dispensing systems, an icon appears on the screen to alert users to the presence of a discrepancy;-Resolution can be achieved by review of dispensing and administration records and consulting with all staff with access;-Additional reports may be available from the pharmacy;-Any discrepancies which cannot be resolved must be reported immediately as follows:-Notify the director of nursing (DON), charge nurse, or designee and the pharmacy;-Complete a report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted;-The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy and possibly the State Licensure Board for Nursing Home Administrators;-Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies.1. During an interview on 12/16/25, at 1:15 P.M., the Administrator and Corporate Registered Nurse (RN) Liaison said the following:-During audits for other citations, they noted an increase in discontinued medications. During their review they noted that there were multiple prescriptions for oxycodone (controlled substance used to treat severe pain) 10 milligram (mg) that had been entered into electronic medical record (EMR) and then discontinued within a short period of time;-The medications were never provided to the residents. The medications were written by Assistant Director of Nursing (ADON) and noted as ordered by a physician that did not currently work for the facility. The medications were all for oxycodone 10 mg with a quantity of 90 tablets each for about 15 residents;-None of the residents were taking this medication;-The narcotics were not received by the nursing staff from the pharmacy; -The ADON had picked them up at the pharmacy;-The local pharmacy was generally used for emergency medications or items that were not available through the on-site dispensing;'-Most of the orders were made using the previous provider's name and prescriber number, Physician #2. The current provider, Physician #1, signed one of the orders;-The residents were all current residents at the facility;-No residents were without medications;-No medication was missing from the building. The oxycodone pills never made it to the facility. 2. Review of Resident #21's Physician Order Sheet (POS) showed an order dated 09/22/25, at 10:39 A.M., created by the ADON, for oxycodone hydrochloride (HCL - salt form of oxycodone) tablet 10 mg, give 1 tab by mouth every 4 hours as needed for pain, with no discontinued dated. The order was entered as written by Physician #2.Review of the pharmacy Daily Filled Rx Delivery List, dated 12/13/25, showed oxycodone 10 mg, 90 tablets, dispensed for the resident. The delivery was signed as received by ADON.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/14/25, 90 oxycodone, $23.32;-On 11/29/25, 90 oxycodone, $23.32. 3. Review of Resident #10's POS showed an order dated 09/22/25, at 10:36 A.M., created by ADON, for oxycodone HCL tablet 10 mg, give 1 tab by mouth every 4 hours as needed for pain with a discontinue date of 10/21/25, 9:18 A.M. The discontinue order was entered by the ADON. The order was entered as written by Physician #2 and discontinue (DC) reason as DC by physician.Review of the pharmacy Daily Filled Rx Delivery List, dated 12/12/25, showed oxycodone, 90 tablets, dispensed for the resident. The deliver was signed received by ADON.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/14/25, 90 oxycodone, $18.38;-On 11/29/25, 90 oxycodone, $23.32. Review of the pharmacy billing statements, billing date 12/17/25, showed the following charges for the resident:-On 12/12/25, 90 oxycodone, $23.32. 4. Review of Resident #17's POS showed an order dated 10/18/25, at 8:47 A.M., created by ADON, for oxycodone HCL tablet 10 mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 10/18/25, at 8:49 A.M., by ADON. The order was entered as written by Physician #2 and DC reason as order changed.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/02/25, 90 oxycodone, $23.32.Review of the pharmacy billing statements, billing date 12/17/25, showed the following charges for the resident:-On 12/05/25, 90 oxycodone, $23.32.5. Review of Resident #22's POS showed an order dated 10/20/25, at 10:48 A.M., created by ADON, for oxycodone HCL tablet 10 mg, give 1 tab by mouth every 4 hours as needed for pain, with no discontinue order. The order was entered as written by Physician #2.Review of the pharmacy billing statements, billing date 10/31/25, showed the following charges for the resident:-On 10/20/25, 90 oxycodone, $18.38.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/03/25, 90 oxycodone, $23.32.6. Review of Resident #14's POS showed an order dated 10/25/25, at 11:35 A.M., created by ADON, for oxycodone HCL tablet 10 mg, give 1 tab by mouth every 4 hours as needed for pain, with no discontinue order. The order was entered as written by Physician #2.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/06/25,90 hydrocodone/APAP 10-325 mg, $16.62;-On 11/15/25, 90 hydrocodone/APAP 10-325 mg, $16.62;-On 11/29/25, 90 hydrocodone-APAP 10-325 mg, $16.62.7. Review of Resident #1's POS showed an order dated 10/21/25, at 4:04 P.M., created by ADON, for oxycodone HCL tablet 10 mg, give 1 tab by mouth every 4 hours as needed for pain with no discontinue orders. The order was entered as written by Physician #2.Review of the pharmacy billing statements, billing date 10/31/25, showed the following charges for the resident:-On 10/21/25, 90 oxycodone 10 mg, $18.38.8. Review of Resident #3's POS showed an order dated 10/25/25, at 11:37 A.M., created by ADON, for oxycodone HCL tablet 10 mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 11/13/25, at 12:40 P.M., by ADON. The order was entered as written by Physician #2 and no DC reason listed.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/06/25, 90 oxycodone 10mg, $18.38.9. Review of Resident #2's POS showed an order dated 11/05/25, at 12:09 P.M., created by ADON, for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 11/17/25, at 11:49 A.M., by ADON. The order was entered as written by Physician #2 and DC reason as order discontinued.Review of the pharmacy Daily Filled Rx Delivery List, dated 12/01/25, showed oxycodone, six tablets, dispensed for the resident. The delivery was signed as received by ADON. Review of the pharmacy Daily Filled Rx Delivery List, dated 12/01/25, showed oxycodone, 84 tablets, dispensed for the resident. The delivery was signed as received by ADON.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/05/25, 90 oxycodone 10 mg, $18.38;-On 11/18/25, 90 oxycodone 10 mg, $23.32.Review of the pharmacy billing statements, billing date 12/17/25, showed the following charges for the resident:-On 12/01/25, 90 oxycodone 10 mg, $23.32.10. Review of Resident #6's POS showed an order dated 11/08/25, at 12:23 P.M., created by ADON for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 11/10/25, at 8:20 A.M., by ADON. The order was entered as written by Physician #2 and DC reason as incorrect entry.Review of the resident's POS showed an order dated 11/21/25, at 12:09 P.M., created by ADON, for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 11/21/25, at 12:10 P.M., by ADON. The order was entered as written by Physician #2 and DC reason as error.Review of the resident's POS showed an order dated 12/13/25, at 12:30 P.M., created by ADON, for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 12/13/25, at 12:32 P.M., by ADON. The order was entered as verbal order by Physician #2 and DC reason as order entry error.Review of the pharmacy Daily Filled Rx Delivery List, dated 12/13/25, showed oxycodone 10 mg, 90 tablets dispensed for the resident. The form was signed as received by ADON. Review of a copy of a handwritten prescription, for the resident, dated 12/13/25, showed an order for oxycodone 10mg, 1 tablet by mouth every 4 hours as needed for pain, dispense 90 pills with no refills, with prescriber signature. Text with Physician #1 with question if the signature belonged to him/her. The physician responded no.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/08/25, 90 oxycodone 10 mg, $18.38;-On 11/21/25, 90 oxycodone 10 mg, $23.32.Review of the pharmacy billing statements, billing date 12/17/25, showed the following charges for the resident:-On 12/13/25, 90 oxycodone 10mg #90, charges $23.32. 11. Review of Resident #11's POS showed an order dated 11/12/25, at 10:58 A.M., created by ADON for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 11/12/25, at 11:00 A.M., by ADON. The order was entered as written by Physician #2 and DC reason as order entry error.Review of the resident's POS showed an order dated 11/25/25, at 8:01 A.M., created by ADON, for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 11/25/25, at 8:03 A.M., by ADON. The order was entered as written by Physician #2 and DC reason as error entry.Review of the pharmacy Daily Filled Rx Delivery List, dated 12/08/25, showed oxycodone 10 mg, 90 tablets dispensed for the resident. The medication was signed for by ADON.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/12/25, 90 oxycodone 10 mg, $18.38;-On 11/25/25, 90 oxycodone 10 mg, $23.32.Review of the pharmacy billing statements, billing date 12/17/25, showed the following charges for the resident;-On 12/08/25, 90 oxycodone 10 mg, $23.32.12. Review of Resident #18's POS showed an order dated 11/25/25, at 7:59 A.M., created by ADON, for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 11/25/25, at 8:01 A.M., by ADON. The order was entered as written by Physician #2 and DC reason as entry error.Review of the pharmacy Daily Filled Rx Delivery List, dated 12/08/25, showed oxycodone 10 mg, 90 tablets dispensed for the resident. The medication was signed for by ADON.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/04/25, 90 oxycodone 10 mg, $23.32;-On 11/25/25, 90 oxycodone 10 mg, $23.32.13. Review of Resident #8's POS showed an order dated 11/26/25, at 2:39 P.M., created by ADON, for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. Ther order was discontinued on 11/26/25, at 2:43 P.M., discontinued by ADON. The order was entered as written by Physician #2 and DC reason as entry error.Review of the pharmacy Daily Filled Rx Delivery List, dated 12/11/25, showed oxycodone 10mg, 90 tablets dispensed. The delivery was signed as received by by ADON.Review of the pharmacy billing statements, billing date 11/30/25, showed the following charges for the resident:-On 11/13/25, 90 oxycodone 10 mg, $18.38;-On 11/26/25, 90 oxycodone 10 mg, $23.32.Review of the pharmacy billing statements, billing date 12/17/25, showed the following charges for the resident:-On 12/11/25, 90 oxycodone 10 mg, $23.32.14. Review of Resident #12's POS showed an order dated 12/01/25, at 3:41 P.M., created by ADON, for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 12/01/25, at 3:44 P.M., by ADON. The order was entered as written by Physician #2 and DC reason as entry error.Review of the pharmacy Daily Filled Rx Delivery List, dated 12/01/25, showed oxycodone, six tablets, dispensed for the resident. The delivery was signed as received by ADON. Review of the pharmacy Daily Filled Rx Delivery List, dated 12/01/25, showed oxycodone, 84 tablets, dispensed for the resident. The delivery was signed as received by ADON.15. Review of Resident #20's POS showed an order dated 12/06/25, at 12:15 P.M., created by ADON, for oxycodone HCL tablet 10mg, give 1 tab by mouth every 4 hours as needed for pain. The order was discontinued on 12/06/25, at 12:17 P.M., by ADON. The order was entered as verbal order by Physician #2 and DC reason as order entry error.Review of the pharmacy Daily Filled Rx Delivery List, dated 12/06/25, showed oxycodone 10 mg, 90 tablets dispensed, for the resident. The medication was signed for by ADON.Review of the pharmacy billing statements, billing date 12/17/25, showed the following charges for the resident:-On 12/06/25, 90 oxycodone 10 mg, $23.32.16. Review of the Pharmacist statement, dated 12/17/25, showed the following:-To help in the investigation of ADON, we questioned her on several occasion and here are her responses:-When we questioned on whether we should deliver the medications instead of having her pick them up, she stated that there was an investigation on diversion of controlled substances at the facility and that she was the ADON. She was in charge of controlled substances to limit access to others at the facility and the pharmacy were to deliver to her;-When the pharmacy asked her to fax the orders, she said the fax was down and she would bring the prescription by, or the pharmacy could pick it up when they delivered the medications. She said to text her when we got to the facility and she would meet us at the door;-This started in October 2025 and continued into December 2025.17. During an interview on 12/18/25, at 8:15 A.M., the Administrator said the pharmacist said that the ADON would sometimes bring in an original prescription and other times fax the prescriptions. The items on the invoices that were not oxycodone 10 mg were in the building. An audit was done of the destroyed medications and all resident medications on hand. One resident had an open order for oxycodone 10 mg with no oxycodone in the cart. One prescription was signed by Physician #1 and when asked to verify his signature, he denied that was his signature. During an interview on 12/18/25, at 10:20 A.M., Certified Medication Tech (CMT) B said he/she did not administer oxycodone. He/she counted the narcotic of the medication cart at the beginning and end of every shift. If the count was ever not correct, the two staff would first check charts and see if something was not signed out. Then they would contact the DON and Administrator. Any new or refilled medications were usually delivered during the night shift. They are added to the card count and listed what card was added. If a card is discontinued, staff generally just move it out of rotation and mark as discontinued. Staff continue counting in the cart until removed for destruction. If a medication was not available staff have a full Ekit (emergency drug kit). During an interview on 12/18/25, at 10:30 A.M., Registered Nurse (RN) A said the nurses complete narcotic counts at the beginning and end of each shift for their medication cart and the Bureau of Narcotics and Dangerous Drugs (BNDD) kit (a supply of emergency-controlled substances maintained on-site, a practice specifically regulated by the Missouri Bureau of Narcotics and Dangerous Drugs.) Most new or refills medications are received during the night shift. Occasionally something is sent to the local pharmacy for refill if urgent. Staff count before and after each shift. If the count is not correct, staff re-count, then look to see if something was not signed out, and then notify the DON. Generally, all physician orders were received from Physician #1. Occasionally an outside specialist provider would order a pain pill, but staff still have to get Physician #1's approval. He digitally signs all narcotic orders. The nurse had never received a hard paper copy prescription from the physician. On Monday, 12/15/25, a hospice nurse asked the nurse if Resident #8 had anything other than Tylenol. The resident had reported pain to the hospice nurse. RN A said that the resident had something for pain when initially came from the hospital, so he/she looked at all the orders including discontinued orders. The nurse found an order dated 11/26/25 for oxycodone 10 mg but noted it was discontinued the same day it was created. RN A was not aware of this type of pain medication order for the resident. He/she then noted the physician's name was one he/she did not recognize, and this raised a red flag. He/she then searched for that physician's name and nine additional resident names came up with orders from that physician. Not all were narcotics but there were many for oxycodone 10 mg. RN A said he/she notified Corporate RN Liaison of the concern. The Corporate RN had the RN run an order audit task that was available in the electronic medical software system. When narcotics were received at the facility the receiving nurse added the disposition record to the narcotic count book. The BNDD arrived as sealed packages and only DON handled this medication. RN A said when he/she first started at the facility the ADON was in control of the BNDD kit. There were times that he/she would overhear the ADON telling other staff that an order was discontinued and would immediately pull the narcotic card from the cart, this was much quicker than the normal process. RN A said he/she told Previous Administrator that something felt off with ADON and BNDD and recommended she not have control of BNDD. Previous Administrator did remove ADON from BNDD control and DON took over. During an interview on 12/18/25, at 11:30 A.M., Physician #1 said that the Administrator showed him a hand signed prescription that he said was not his signature. Generally, he signed narcotics by digital signature. He said that he started as the physician at the facility in August 2025. He asked the ADON why she was not using the computer system for ordering, and she stated there were in the process of changing to another pharmacy, so she had only paper prescriptions for me to sign while in the process of transitioning. Physician #1 said that the way he practiced was to have the facility fax the refill request to the pharmacy and the pharmacy can fax to his office and the Medical Assistant audits if too early before even sending to him for approval. Then he reviews as well and digitally signs for narcotic prescriptions. #2687697, #2694929

Based on interview and record review, the facility failed to ensure that all residents received treatment and care in accordance with professional standards of practice when the facility staff failed to notify family and physician of fall with possible injury in a timely fashion, when staff failed to complete and document initial assessment and ongoing fall monitoring, including neurological checks (evaluates the nervous system), for one resident (Resident #2), who suffered a fall resulting in a fracture, out of 7 sampled residents. The facility census was 42.Review showed the facility did not provide a policy and procedure related to falls, fall documentation, and/or fall notifications. 1. Review of the Resident #2's face sheet (brief look at resident information) showed the following information:-admission date of 10/25/22;-Diagnoses included Alzheimer's disease, muscle weakness, high blood pressure, and respiratory failure.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 07/24/25, showed the following information:-Intact cognition;-No impairment of extremities;-Required the use of a walker and supervision from staff for toileting and mobility.Review of the resident's care plan, revised 09/11/25, showed the following:-At risk for falling related to unsteady balance;-Encourage the resident to request assistance with transfers, provide assistance with his/her walker, and ensure that he/she has properly fitted shoes;-Fall on 09/09/25. Please make sure the resident's bathroom is clean and the floor is dry. The physician requested scan for possible fracture to hip and the resident was sent to the Emergency Department (ED) per request.Review of the resident's progress note dated 09/10/25, at 3:15 A.M., showed Licensed Practical Nurse (LPN) A documented the following:-Staff alerted LPN A to the resident's room after hearing help from down the hall. The resident was observed to be laying on his/her left side, resting upon his/her left hip;-The resident's walker was seen several feet away from him/her;-The resident said he/she was trying to go to the bathroom and his/her walker got away from him/her and he/she just fell over;-The resident complained of pain and discomfort to the left hip. The resident was assessed after rolling onto his/her back. The resident remained guarded but was able to lift his/her left leg when instructed to pull it in toward him/her;-No abduction (movement from midline) was seen;-Staff placed a gait belt on the resident and assisted him/her to his/her feet. The resident remained guarded to the left leg and was fearful to put pressure onto the left foot;-The resident was able to hold onto his/her walker with staff holding him/her with the gait belt;-Two staff ambulated the resident back into his/her bed and LPN provided an as needed pain mediation;-Staff notified the physician.(Staff did not document notification of the resident's next of kin regarding the fall with possible injury. The nurse did not document a full assessment including base-line neuro-checks after the fall.)Review of the resident's progress note dated 09/10/25, at 6:32 P.M., showed LPN D noted the following:-The resident was transferred to the hospital via Emergency Medical Services (EMS) around 6:15 P.M.;-The resident had a fall around 3:00 A.M. and injured his/her left hip;-Immediate X-ray was ordered and performed on this shift. The results came back as showing a possible acute fracture to the left superior pubic root ( the left upper portion of the pubic bone);-Staff notified provider and Assistant Director of Nursing (ADON) of the results;-The resident was transferred to the hospital for further testing and to prevent further injury;-Staff notified the resident's next of kin.Review of the resident's progress notes showed staff did not document monitoring of the resident between the fall and being sent to the ED. Review of the resident's hospital progress note, dated 09/13/25, showed the following information:-The resident admitted to the hospital after a ground level fall resulting in left hip pain and inability to bear weight;-On admission, imaging revealed a diagnosis of closed fracture of multiple left pubic rami (a break in one of the bones that make up the front part of the pelvis) and sacral fracture (a break in the sacrum, a triangular shaped bone at the bottom of the spine that forms the back of the pelvis). During an interview on 10/14/25, at 12:38 P.M., Nursing Assistant (NA) B said the following:-The resident fell in the floor on 09/10/25, at approximately 3:00 A.M.;-He/she was present for the incident, and recalled the resident continuously stating he/she could not walk and was in pain;-When LPN A entered the room. He/she did not obtain any vital signs or neurological checks;-LPN A insisted the resident was fine, and instructed him/her and NA C to get the resident up off the floor;-NA B and NA C did as they were told and during the transfer it took the both of them with a gait belt and a walker to assist the resident back into bed. Previously the resident was independent with mobility;-The resident continuously pointed at his/her pelvic area and yelled out with pain;-The expected process for falls was to get the charge nurse and get a set of vital signs. The charge nurse would assess the resident for injury and call the physician and the resident's family. The charge nurse would also document and begin neurological checks and fall monitoring;-The following shift ended up sending the resident to the ED.During an interview on 10/14/25, at 12:45 P.M., NA C said the following:-The expected process for falls was to get the charge nurse and get a set of vital signs. The charge nurse would assess the resident for injury, call the physician and the resident's family, and document and begin neurological checks and fall monitoring;-The resident complained of a lot of pain in his/her pelvic region and LPN A said he/she was fine, to get him/her up off the floor.During an interview on 10/14/25, at 1:20 P.M., LPN D said the following:-The expected process for falls was to assess for injury. Once staff have determined if there is any injury, vital signs should be checked;-If there was not an injury, staff should assist the resident back to a seated position;-If the fall was unwitnessed, neurological checks should be initiated;-Incident reports within the risk management tab should be documented, 72-hour fall monitoring should be initiated, the physician should be notified, and the resident's family should be notified;-If there was a fall that resulted in injury on the night shift, the nurse on duty should immediacy make contact with the physician for advisement;-If the nurse on duty was unable to contact the physician and the fall resulted injury and complaints of pain with guarding of a limb, he/she would send the resident out to the ED for further evaluation;-He/she was the nurse on duty, the shift following the resident's fall. After receiving report that the resident had fallen overnight, he/she seen the resident and noted that the resident was no longer independent with cares and was complaining of pain;-He/she contacted the physician and got an immediate result (STAT) x-ray ordered;-The x-ray was obtained on his/her shift, and showed the resident had a probable fracture to his/her pelvis. Upon receiving those results, he/she contacted the physician again and had the resident sent to the ED.During an interview on 10/14/25, at 1:37 P.M., LPN A said the following information:-The expected process for falls was to go and assess the resident for injury, obtain vital signs, and have staff assist in getting the resident back to his/her feet;-If there was a noticeable injury, staff should notify the physician and let them know rather the resident just needs an Xray or should be sent to the ED;-Additionally, family and the Administrator should be notified;-An incident report should be documented, as well as initiation of neurological checks and 72-hour fall monitoring;-He/she would send a resident to the ED if their range of motion was different, if they had elevated pain, or if their mobility was not at baseline;-He/she was the nurse at the time of the fall. Staff called him/her to the resident's room and the resident was seen laying on the floor with his/her walker beside him/her;-The resident did complain of pain, but he/she was able to walk, so he/she offered her a pain pill;-He/she reported to the oncoming shift the events of the fall;-He/she obtained vital signs, but was not aware of where he/she put that documentation;-He/she did not contact the physician. He/she was not sure why not;-He/she did not contact the resident's family. He/she was not sure why not;-The resident was still able to ambulate with assistance, so he/she did not believe it to be an emergent issue and believed the residents behavior was more related to anxietyDuring an interview on 10/14/25, at 2:29 P.M., the Social Services Director (SSD) said falls should be documented appropriately in the resident's chart.During an interview on 10/14/25, at 2:48 P.M., the Director of Nursing (DON) said the following:-She expected nurses to go assess the resident for injury after a fall. The aides should obtain a set of vital signs;-During the nurse's assessment, he/she should assess rather an injury occurred or the resident hit their head. If an injury occurred or their head was hit; neurological assessments should be started;-Additionally, the nurse should fill out an incident report, and begin 72-hour monitoring;-The physician, family, and she should be notified of the fall;-She did not believe she was notified of this incident;-If the resident was guarding a body part and experiencing pain, orders for Xray and or to be sent to the hospital should have been obtained;-The physician should have been notified, as well as the family;-She printed off the incident report under risk management tab. The nurse had initiated and showed that showed no assessment were completed other than the progress note.During an interview on 10/14/25, at 3:19 P.M., the Administrator said the following:-She expected the physician to be notified of a fall, as well as herself and the family;-The nurses should document the fall, complete an incident report, and initiate 72-hour monitoring. If it was an injury fall, neurological checks should also be initiated.During an interview on 10/16/25, at 11:03 A.M., the Medical Director said the following:-He expected to be contacted for all falls. There is a rule that he needs to be contacted within two hours of any fall;-If the resident experienced an injury with a fall, he expected to be contacted immediately to give appropriate advisement. Complaint #2639380

Based on observation, interview, and record review, the facility failed to maintain a procedure to document a resident's choices regarding advanced directives (a written instruction, such as a living will, or power of attorney, recognized under state law, relating to the provision of heath care when the individual is incapacitated), when the facility failed to clearly document code status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) in one resident's (Resident #1) chart out of 7 sampled residents resulting in staff being unable to locate the resident's code status in an emergency. The facility census was 42.Review of the facility policy tiled Communication of Code Status, revised on [DATE], showed the following information:-The facility will follow policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive;-When an order is written pertaining to a resident's presence or absence of an advance directive, the directions will be clearly documented in designated sections of the medical record;-The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record;-The designated sections of the medical record may include face sheet, physician orders, care plan, and advanced directives;-In the absence of an advance directive or further direction from the physician, the default direction will be full code (resident wishes to receive cardiopulmonary resuscitation (CPR) if their heart or breathing stops);-The Social Services Director (SSD) will maintain a list of residents who have an advance directive on file;-The resident's code status will be reviewed at least quarterly and documented in the medical record. 1. Review of the Resident #1's face sheet, showed the following information:-admission date of [DATE];-No code status listed;-Diagnoses included pleural effusion (an abnormal accumulation of fluid in the pleural space, the thin membrane that lines the lungs and chest wall), high blood pressure, diabetes, and pneumonia (an infection of the lungs that causes inflammation of the air sacs).Review of the resident's admission baseline care plan, dated [DATE], showed the resident was a full code and required cardiopulmonary resuscitation (CPR- refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) if his/her heart or breathing stopped.Review of the resident's POS, dated [DATE] through [DATE], showed the resident did not have an order regarding code status entered.Review of the resident's progress note dated [DATE], at 5:25 A.M., showed Licensed Practical Nurse (LPN) A noted the following:-LPN A was called into the resident's room when staff members reported that the resident was holding his/her hand and said help. After saying help, the resident went limp and unresponsive, without breathes;-LPN A found the resident to be unresponsive and without pulse. LPN A was unable to identify code status, so he/she began CPR;-Emergency Medical Services (EMS) arrived at 5:35 A.M. and LPN A continued to participate in CPR with EMS until they left with the resident at 6:03 A.M.;-Staff notified the resident's next of kin and physician.Review of the resident's care plan, dated [DATE], showed the resident's code status was added with the additional information:-Full code;-Place a copy of code status in the front of his/her chart. Ensure that family and physician has signed the status.During an interview on [DATE], at 12:38 P.M., Nursing Assistant (NA) B said the following:-Resident code statuses should be found in the resident's chart, on their door, and in the code status book that is located at the nurses' station;-He/she went into the resident's room to check on him/her and noticed the resident was unresponsive. At that time NA C went and got LPN A;-Three minutes later, LPN A entered the room and told NA B that he/she did not know what to do that he/she could not find the resident's code status;-NA B suggested they begin CPR. LPN A left the resident's room again to return approximately three minutes later and instructed that NA B, NA C, and him/herself would be starting CPR;-The Social Services Director (SSD) generally updates the resident's code status in all the locations. However, he/she does not believe there is someone hired in that position at this time, so it hasn't been getting done.During an interview on [DATE], at 12:45 P.M., NA C said the residents' code statuses should be found in the resident's chart, on their doors, and in the code status book that is located at the nurse's station. All the information should match.During observation and interview on [DATE], at 1:20 P.M., LPN D said the following:-Code status should be found in the resident's chart, including the care plan, face sheet, and physician orders;-Code status should also be found in the code status book that can be found in the nurses' station, and on the resident's name tag outside of their room. If the name tag is blue, that means full code (CPR). If the name tag is white, that means no code (no CPR);-The nurse admitting the resident is who is responsible for putting the orders into the resident's chart. All the information should match;-He/she had heard there was a delay in a code being started for the resident, due to the status not being found;-LPN D showed the surveyor the book/binder titled Code Status Book. The resident's information was not seen in the book.During an interview on [DATE], at 1:37 P.M., LPN A said the following information:-In the early morning hours, approximately 5:00 A.M., on [DATE], an aide came and got him/her and told him/her that the resident was unresponsive. At that time, he/she went and entered the resident's room. He/she cannot remember if the resident was unresponsive at that time or not;-He/she left the resident's room and went to the nurses' station to locate the resident's code status. He/she looked in the resident's physician orders, face sheet, and the code status book, and was unable to retrieve the resident's code status;-After approximately 5 minutes of looking for the resident's code status and calling EMS, he/she re-entered the resident's room and instructed staff to join him/her in performing CPR;-Approximately 10 minutes later, around 5:30 A.M., EMS showed up and continued performing CPR until they took the resident to the hospital;-Code status should be easily accessible and found on the resident's face sheet, in the physician orders, care plan, and in the code status book.During an interview on [DATE], at 2:29 P.M., the SSD said the following:-She had been employed with the facility for only a couple weeks and was currently working on doing audits on all resident's code status as there is some discrepancies due to the facility not having someone in his/her position for some time;-She was responsible for auditing the residents' charts, code status book, and care plans for code status;-All information should match;-Additionally, any resident's code status should also be scanned into the miscellaneous section in the resident's chart.During an interview on [DATE], at 2:48 P.M., the Director of Nursing (DON) said the following:-Code statuses can be found on each resident's face sheet, name tag on the door, and code status book;-She believed code statuses should also be found in the care plan, but has not reviewed those to be sure;-She believed it's the SSD's responsibility to update code status;-She expected those to be accurate across the board and accessible to staff.During an interview on [DATE], at 3:19 P.M., the Administrator said the following:-Code statuses can be found in each resident's face sheet, and care plan. Additionally, there is a code status book that is behind the nurses' station that should have that information;-The SSD is newly employed and working on getting all residents' code statuses updated;-She expected all information to be accurate across the board and accessible to staff. During an interview on [DATE], at 11:12 A.M., The Medical Director said the following:-He expected all residents to have an updated code status;-Those code statuses should be found on the resident's face sheet, as well as the care plan;-All information should match and be able to be found in a quick manner for efficiency.2639380

Based on observation, record review, and interview, the facility failed to provide pharmacy services to meet the needs of each resident when the facility failed to have ordered medications available for staff administration and failed to notify the physician of the unavailable medications resulting in three residents (Resident #1, #2, and #3) not receiving medications as ordered. The facility census was 49.Review of the facility's policy titled Medication Administration, revised 05/07/25, showed medications are administered as ordered by the physician and in accordance with professional standards of practice.1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information:-admission date of 09/05/25;-Diagnoses included multiple sclerosis (a chronic, autoimmune disease that affects the central nervous system), cardiac pacemaker (a small, implantable medical device that helps regulate the heart's rhythm by sending electrical impulses to the heart muscle), hypothyroidism (the thyroid gland doesn't make and release enough hormone into the bloodstream), and restless legs syndrome (a neurological disorder characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations like tingling or crawling).Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 09/08/25, showed the resident had no cognitive impairment.Review of the resident's care plan, reviewed on 09/08/25, showed staff to administer medications as ordered.Review of the resident's current physician orders showed the following information:-An order, dated 09/06/25, for pantoprazole sodium (used for ulcer prevention) oral tablet delayed release 40 milligram (mg). Start date of 09/06/25 at 7:30 A.M.;-An order, dated 09/06/25, for venlafaxine HCI (an antidepressant) ER oral tablet extended release 24-hour 75 mg. Start date of 09/06/25 at 7:30 A.M.;-An order, dated 09/06/25, for mirabegron (an antispasmodic) ER oral tablet extended release 24-hour 50 mg. Start date 09/06/25 at 8:00 A.M.;-An order, dated 09/06/25, for ropinirole HCI (an anti-parkinson medication) 2 mg, at bedtime.Start date of 09/06/25 at 8:00 P.M.Review of the resident's September 2025 Medication Administration Record (MAR) showed the following information:-On 09/06/25, at 7:30 A.M., staff documented the doses of pantoprazole and venlafaxine as Not Administered: Drug not available;-On 09/06/25, at 8:00 A.M., staff documented the dose of mirabegron as Not Administered: Drug not available;-On 09/06/25, at 8:00 P.M., staff documented the dose of ropinirole as Not Administered: Drug not available;-On 09/07/25, at 7:30 A.M., staff documented the dose of pantoprazole and venlafaxine as Not Administered: Drug not available;-On 09/07/25, at 8:00 P.M., staff documented the dose of ropinirole as Not Administered: Drug not available.Review of the resident's September 2025 Progress Notes showed staff did not document physician notification of the missed doses of pantoprazole, venlafaxine, mirabegron and ropinirole.During an interview on 09/10/25, at 2:30 P.M., the resident said he/she had not refused any medications. He/she admitted to the facility on [DATE], at 9:00 P.M. Because he/she did not receive his/her medications for a couple of days, it will take his/her body weeks to get back to feeling normal. His/her body was used to the prescribed medications and that he/she had been on those medications for a while, and they were working well for him/her. If he/she would have known prior to coming to the facility that they would not have her medication, he/she would have gone to another facility.During an interview on 09/10/25, at 11:45 A.M., Licensed Practical Nurse (LPN) A said the residents came in late in the day and on a weekend, so their medications would not have been available until Monday.During an interview on 09/10/25, at 2:45 P.M., LPN D said he/she and the Director of Nursing (DON) notified the physician of the resident's admission and told the physician that they did not have the medications. The physician was not happy they accepted the resident knowing that we did not have the medications. The physician gave no other orders.During an interview on 09/10/25, at 12:00 P.M., the Assistant Director of Nursing (ADON) said he/she did not realize the resident did not receive their medications.During an interview on 09/10/25, at 3:30 P.M., the Director of Nursing (DON) said the resident admitted to the facility with an order for ropinirole 1 mg every morning and ropinirole 2 mg every night. The facility does not keep that medication in the e-kit so they had to wait for the pharmacy to bring the medication. He/she called the physician and reviewed the medication list for the resident. The physician was upset that the facility accepted the resident knowing that they could not get their medications. No other orders were received during the phone conversation.During an interview on 09/10/25, at 5:10 P.M., the Medical Director said he did not know about the resident not receiving their medications until 09/09/25. Staff did not notify him. 2. Review of Resident #2's face sheet showed the following information:-admission date of 09/05/25;-Diagnoses included pulmonary embolism (blood clot in the lungs), hypertension (high blood pressure), history of bariatric surgery, presence of left artificial knee joint, moderate protein-calorie malnutrition, major depressive disorder, restless legs syndrome, congestive heart failure (CHF - a long-term condition that happens when the heart can't pump blood well enough to give your body a normal supply ), chronic embolism and thrombosis of left calf muscular vein (blood clot in the leg).Review of the resident's admission MDS, dated [DATE], showed the resident had no cognitive impairment.Review of the resident's care plan, reviewed on 09/08/25, showed staff to administer medications as ordered.Review of the resident's current physician orders showed the following information:-An order, dated 09/06/25, for amlodipine besylate (used to treat high blood pressure) oral tablet 5 mg. Start date of 09/06/25 at 7:00 A.M.;-An order, dated 09/06/25, for biotin (supplement) oral tablet, one tablet daily for immunodeficiency. Start date of 09/06/25 at 7:00 A.M.;-An order, dated 09/06/25, for duloxetine HCI (used to treat depression) oral capsule delayed release sprinkle 60 mg. Start date of 09/06/25 at 7:00 A.M.;-An order, dated 09/06/25, for fluconazole (antifungal medication) oral tablet 150 mg, daily for skin infection. Start date of 09/06/25 at 7:00 A.M.;-An order, dated 09/06/25, for folic acid (supplement) tablet 1 mg, daily for immunodeficiency. Start date of 09/06/25 at 7:00 A.M.;-An order dated 09/06/25, for losartan potassium (used to treat high blood pressure) oral tablet 25 mg. Start date of 09/06/25 at 7:00 A.M.;-An order, dated 09/06/25, for metoprolol succinate (used to treat high blood pressure) oral capsule ER 24-hour sprinkle 25 mg. Start date of 09/06/25 at 07:00 A.M.;-An order, dated 09/06/25, for potassium chloride (supplement) ER tablet extended release 20 milliequivalents (meq), daily for congestive heart failure. Start date of 09/06/25 at 7:00 A.M.;-An order, dated 09/06/25, for spironolactone (potassium-sparing diuretic (water pill)) oral tablet 12.5 mg, daily for swelling. Start date of 09/06/25 at 7:00 A.M.;-An order, dated 09/06/25, for gabapentin (used to treat nerve pain) capsule 300 mg, daily for polyneuropathy (generalized nerve pain). Start date of 09/06/25 at 8:00 P.M.Review of the resident's September 2025 Medication Administration Record (MAR) showed the following information:-On 09/06/25, at 7:00 A.M., staff documented the dose of amlodipine, biotin, duloxetine, fluconazole, folic acid, losartan potassium, metoprolol, potassium chloride, and spironolactone as Not Administered: Drug not available;-On 09/07/25, at 7:00 A.M., staff documented the dose of biotin and metoprolol succinate as Not Administered: Drug not available;-On 09/07/25, at 8:00 P.M., staff documented the dose of gabapentin as Not Administered: Drug not available;-On 09/08/25, at 7:00 A.M., staff documented the dose of biotin and metoprolol succinate as Not Administered: Drug not available.Review of the resident's September 2025 Progress Notes showed staff did not document physician notification of the missed doses of amlodipine besylate, biotin, duloxetine, fluconazole, folic acid, losartan potassium, metoprolol succinate, spironolactone, and gabapentin.During an interview on 09/10/25, at 10:30 A.M., the resident said he/she had not refused any medications. The resident said that he/she admitted to the facility on [DATE], at 9:00 P.M., due to a fall at home that resulted in a broken knee and blood clots that developed in his/her lungs and leg.During an interview on 09/10/25, at 11:45 A.M., LPN A said the resident came in late in the day and on a weekend, so their medications would not have been available until Monday.During an interview on 09/10/25, at 2:45 P.M., LPN D said he/she and the DON notified the physician of the resident's admission and told the physician that they did not have the medications. The physician was not happy they accepted the resident knowing that we did not have the medications. The physician gave no other orders.During an interview on 09/10/25, at 12:00 P.M., the ADON said he/she did not realize the resident did not receive their medications.During an interview on 09/10/25, at 3:30 P.M., the DON said he/she called the physician and reviewed the medication list for the resident. The physician was upset the facility accepted the resident knowing that they could not get their medications. No other orders were received during the phone conversation.During an interview on 09/10/25, at 5:10 P.M., the Medical Director said he did not know about the resident not receiving their medications until 09/09/25, when the resident informed him/her during their exam. Staff did not notify him.3. Review of Resident #3's face sheet showed the following information:-admission date of 09/22/23;-Diagnoses included chronic obstructive pulmonary disease (COPD - a group of lung diseases making it difficult to breathe), type 2 diabetes (unable to control blood sugar), and left lower leg amputation.Review of the resident's admission MDS, dated [DATE], showed minimal cognitive impairment.Review of the resident's care plan, reviewed on 08/13/25, showed staff to administer medications as ordered.Review of the resident's current physician orders showed an order, dated 09/06/25, for pregabalin (used to treat nerve pain) oral Capsule 200 mg, twice daily for pain. Start date of 07/23/25 at 9:00 P.M.Review of the resident's September 2025 MAR showed the following information:-On 09/03/25, at 9:00 A.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/03/25, at 9:00 P.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/04/25, at 9:00 A.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/04/25, at 9:00 P.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/05/25, at 9:00 P.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/06/25, at 9:00 A.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/06/25, at 9:00 P.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/07/25, at 9:00 A.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/07/25, at 9:00 P.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/08/25, at 09:00 A.M., staff documented the dose of pregabalin as Not Administered: Drug not available;-On 09/08/25, at 09:00 P.M., staff documented the dose of pregabalin as Not Administered: Drug not available.Review of the resident's September 2025 Progress Notes showed staff did not document physician notification of the missed doses of pregabalin.During an interview on 09/10/25, at 10:50 A.M., the resident said he/she had not refused any medications. He/she had been on pregabalin for years for phantom pain related to his/her amputated leg. His/her surgeon told him/her that he/she would likely need to be on the medication for life after his/her amputation. He/she did not receive his/her scheduled dose of pregabalin for several days the beginning of September. Staff kept telling him/her they were waiting on the physician to reorder the medication. During an interview on 09/10/25, at 11:45 A.M., LPN A said pregabalin is in the e-kit (emergency medication kit used when medications have not been received). He/she was not sure why the resident did not receive his/her medication. During an interview on 09/10/25, at 2:10 P.M., Certified Medication Technician (CMT) B said the resident was on a high dose of pregabalin, 200 mg. The facility only has pregabalin 25 mg in the e-kit. One dose would completely wipe out the e-kit. The facility did not have the resident's pregabalin because they changed physicians, and the physician didn't sign the prescription in time and the facility ran out of the resident's medication. CMT B said that he/she told the Assistant Director of Nursing (ADON) who keeps up with the narcotics. The ADON told him/her that he/she called the physician and got a new order sent into pharmacy, but they had to wait for the medication to be delivered by pharmacy and that sometimes takes a few days.During an interview on 09/10/25, at 2:15 P.M., CMT C said they do not keep every medication in the e-kit, but they do have pregabalin in 75 mg and 25 mg tablets. The resident should have gotten his/her medication because it was in the e-kit.During an interview on 09/10/25, at 12:00 P.M., the ADON said he/she failed to notify the physician that the resident needed a new prescription signed when the new Medical Director took over services. When he/she realized that the resident didn't get his/her pregabalin renewed. The ADON called the physician immediately and the physician took care of it the same day. The ADON is not sure why the resident did not receive his/her medication after that as plenty of pregabalin is kept in the e-kit. During an interview on 09/10/25, at 05:10 P.M., the Medical Director said the resident was on pregabalin. When he took over services, two weeks ago, nursing staff failed to include the resident as one of the residents that needed a new prescription signed due to being a narcotic. He/she was notified on 09/06/25 and ordered the medication immediately. He/she was also informed that the medication was in the e-kit and staff would be able to administer the medication immediately. He/she was not aware that the resident did not receive his/her medication on 09/03/25, 09/04/25, 09/05/25 (night dose only), 09/06/25, 09/07/25, and 09/08/25.4. During an interview on 09/10/25, at 2:10 P.M., CMT B said that there was nothing that he/she can do if he/she does not have the medication to give. Some medications can be pulled from the e-kit. It usually takes 24 to 48 hours to get all the medications in from pharmacy for a new admit. He/she does not call the doctor personally if he/she does not have the medication available. He/she is not allowed to call the physician. He/she would notify the nurse if the medication was not available.During an interview on 09/10/25, at 02:15 P.M., CMT C said that if he/she doesn't have a medication available to give, he/she notifies the nurseDuring an interview on 09/10/25, at 11:45 A.M., Licensed Practical Nurse (LPN) A said new resident orders are faxed to the pharmacy, and they are delivered the next night, usually around midnight. Staff can get medications out of the e-kit if they are in there. If it is a medication that is not in the e-kit, staff would need to call the physician and get a different order. Pregabalin is in the e-kit. He/she was not sure why Resident # 3 did not receive his/her medication. Residents # 1 and # 2 came in late in the day and on a weekend, so their medications would not have been available until Monday.During an interview on 09/10/25, at 2:45 P.M., LPN D said the physician is the new Medical Director and wants to be called with every new admission. The physician wants the nurse to go over the orders and medications with him/her over the telephone. After reviewing the orders with the physician, the nurse will enter the orders into the electronic medical record (EHR) and then fax the medication list to the pharmacy. Staff can pull medications from the e-kit, it they are in the e-kit. Otherwise, staff must wait for the pharmacy to deliver the medications. The pharmacy is in Kansas City. They deliver medications every night. He/she notifies the physician if the facility does not have a medication. During an interview on 09/10/25, at 12:00 P.M., the ADON said that when they get a new admit, they call the physician and review the medications and orders. The physician must approve all orders. The nurse then enters the orders into the electronic medical record (EHR) and fax the medication orders to the pharmacy. If it is a narcotic, staff must have a signed prescription. The physician takes care of narcotics. If the medication is not in the e-kit, nursing staff will notify the physician that the medication is not available. If they don't have the medication, it usually takes 24 to 48 hours before they can get the medication. During an interview on 09/10/25, at 03:30 P.M., the DON said that when they get a new admit, the nurse will enter the orders from the hospital discharge. The nurse will call the physician and review the medications. The nurse then enters the orders into the EHR and fax the medication list to pharmacy. If the medication is a narcotic, such as pregabalin, the pharmacy requires a signed prescription. The physician will take care of that. The CMT or nurse can pull medications from the e-kit. It the medication is not in the e-kit, staff notify the physician that the medication is not available, and he will either write an order to hold the medication or write an order to get the medication from the local pharmacy.During an interview on 09/10/25, at 5:10 P.M., the Medical Director said there are some processes that need to be addressed and changed. The facility is having difficulty with the pharmacy they are currently contracted with. The facility is having difficulty receiving resident medications timely. He/she expected staff to notify him/her when a new resident arrived at the facility, and he/she would go over the medications and orders with the nursing staff. The Medical Director expected staff to follow his/her orders. If the staff has any problems with medications, he/she expected staff to call him/her, and they would discuss other optionsDuring an interview on 09/10/25, at 04:30 P.M., the Administrator said the facility knows they have a problem getting medications for new admits. The Administrator said their pharmacy is located in Kansas City, and it takes days sometimes to get medications delivered. The facility has a contract with the current pharmacy that ends in November. The facility is hoping to use another pharmacy because this one is just not working out. The Administrator said that he/she expected staff to notify the physician any time they don't have the medication that the physician has ordered. It is up to the physician whether he/she wants to hold the medication or write an order to the local pharmacy. He/she expected staff to follow the policy. He/she was not sure what the policy states regarding medication that is not available.Complaint #2610008

Based on interview and record review, the facility failed to provide care per professional standards related to pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for all residents when staff failed to provide wound care per physician orders, failed to update wound care orders, failed to complete full and timely assessments and monitoring of all wounds, and failed to care plan related to wounds for one resident (Resident #1) resulting in deterioration of two wounds and infection of one wound. The facility census was 46. Review of the facility policy titled, Wound Care Policy for Long-Term Care, undated, showed the following: -Purpose to ensure standardized, evidence-based would care practices that promote healing, prevent infections, and enhance quality of life for residents in long-term care settings; -This policy applied to all licensed nurses, wound care specialists, and relevant care staff providing wound care services to residents; -Conduct initial wound assessment within 24 hours of identification or admission; -Document wound location, size (length x width x depth), stage (for pressure injuries), exudate (drainage), wound bed, and perineal (peri- area between the anus and genitals) wound condition; -Reassess wounds at least weekly or per physician's orders; -Develop an individualized wound care plan addressing etiology, treatment goals, and prevention strategies; -Update care plan based on wound progress, resident response, or change in condition; -Select dressings based on wound type, exudate level, presence of infection, and goals of care; -Follow manufacturer instructions for use; -Record assessment findings, treatments, resident response, and any complications; -Maintain accurate and timely wound care records; -Wound care practices will be reviewed quarterly by the facility's wound care team. 1. Review of Resident #1's face sheet (brief resident profile) showed the following: -admission date of 11/22/23; -Diagnoses include long term effects of a stroke, type II diabetes mellitus with other circulatory complications (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), cellulitis of right toe (skin infection), chronic pain, and hemiplegia and hemiparesis following stroke (muscle weakness or partial paralysis on one side of the body). Review of the resident's care plan, revised 10/01/24, showed the following: -Resident at risk for pressure ulcer injury as evidenced by need of staff to assist with mobility, history of stroke with left side weakness, incontinence of urine, and admitted with a pressure ulcer; -Staff to assist resident with turning/repositioning every two hours and as needed and assist with keeping resident clean and dry as possible; -Staff to conduct a systemic skin assessment weekly; -Staff to provide treatments per physician orders and assess and document pressure ulcer size, depth, and color weekly; -Staff to monitor for effectiveness of current treatment and notify physician if no improvement noted;. -External wound care provider referral as ordered and follow any recommendations; -Staff to use moisture barrier to perineal area as needed and report any signs or symptoms of skin breakdown to charge nurse. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool administered by staff), dated 02/26/25, showed the following: -Moderate cognitive impairment; -Partial to moderate assistance required with mobility and substantial to maximal assistance required with transfers; -At risk for pressure ulcers with no unhealed pressure ulcers, ulcers, wounds, or other skin problems. Review of the resident's current Physician Order Sheet (POS) showed an order, dated 02/28/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate (highly absorbent wound dressing from brown seaweed) to wound bed, cover with ABD (highly absorbent dressing) pad, and wrap with Kerlix (a brand of gauze bandage rolls) daily one time a day for wound care. Review of the resident's March 2025 Treatment Administration Record (TAR) showed the following: -An order, dated 03/01/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate to wound bed, cover with ABD pad, and wrap with Kerlix change daily one time a day for wound care; -Staff did not document administering the treatment on 03/01/25 and 03/03/25. Review of the resident's record showed staff did not document regarding the missed treatments on 03/01/25 and 03/03/25. Review of the resident's Skin Observation Tool, dated 03/04/25, showed the following: -Right heel pressure sore measured 5 centimeters (cm) length, 4 cm width, and 0.25 cm depth. The wound was a stage three pressure wound (full-thickness loss of skin in which subcutaneous fat may be visible in the ulcer). Pressure sore to right heel had no exudate (drainage) and wound bed was pink; -Right gluteal fold pressure sore measured 0.75 cm length and 0.75 cm width with no depth noted. The wound was a stage two pressure wound (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer). Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actually skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's March 2025 TAR showed staff did not complete the ordered treatment to the resident's right heel on 03/05/25, 03/06/25, 03/07/25, 03/08/25, and 03/10/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 03/05/25, 03/06/25, 03/07/25, 03/08/25, and 03/10/25. Review of the resident's March 2025 TAR showed the following: -An order, dated 03/05/25, to apply wound cleanser and dressing to right gluteal pressure wound in the morning; -Staff did not document administering the treatment on 03/05/25, 03/06/25, 03/07/25, 03/08/25, and 03/10/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 03/05/25, 03/06/25, 03/07/25, 03/08/25, and 03/10/25. Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actually skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's progress note, dated 03/10/25, from the wound care provider showed the following: -Wound to right heel had improved this week. Wound measured smaller with less drainage and good granulation tissue (fleshy, pinkish red tissue that forms during the wound healing process). Continue with same treatment of collagen (structural protein found in skin), calcium alginate, ABD pad, and change daily; -Wound image measurements of area of 4.7 square cm with perimeter of 9.8 cm, length 3.8 cm, width 1.9 cm, with no depth noted; -Granulation red or pink and bumpy 75%; -No slough (non-viable tissue); -Epithelial (final layer of skin during wound healing) 25%. (The wound care provider did not document regarding the wound on the right gluteal fold wound.) Review of the resident's March 2025 TAR showed staff did not complete the ordered treatment to the resident's right heel on 03/11/25, 03/12/25, 03/13/25, 03/14/25, 03/15/25, 03/16/25, and 03/17/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 03/11/25, 03/12/25, 03/13/25, 03/14/25, 03/15/25, 03/16/25 and 03/17/25. Review of the resident's March 2025 TAR staff did not document administering the treatment to the resident's gluteal fold wound on 03/11/25, 03/12/25, 03/13/25, 03/14/25, 03/15/25, 03/16/25, and 03/17/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 03/11/25, 03/12/25, 03/13/25, 03/14/25, 03/15/25, 03/16/25 and 03/17/25. Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actually skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's progress note, dated 03/17/25, from the wound care provider, showed the following: - Wound to right heel had deteriorated this week. Wound measured larger with increased drainage and small amount of nonviable tissue noted. Good granulation tissue noted. Continue with same treatment of collagen, calcium alginate, ABD pad, and change daily; -Wound image measurements were area of 6.6 square cm with perimeter of 12.6 cm, length 1.9 cm, width 4.8 cm and max depth 0.3 cm; -Granulation 75%; -Slough 25%. (The wound care provider did not document regarding the wound on the right gluteal fold.) Review of the resident's March 2025 TAR showed staff did not document completing the ordered treatment to the right heel on 03/19/25, 03/20/25, 03/21/25, 03/22/25, and 03/23/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 03/19/25, 03/20/25, 03/21/25, 03/22/25, and 03/23/25. Review of the resident's March 2025 TAR showed staff did not document completing the order treatment to the right gluteal pressure wound on 03/19/25, 03/20/25, 03/21/25, and 03/22/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 03/19/25, 03/20/25, 03/21/25, and 03/22/25. Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actually skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's progress note, dated 03/24/25, from the wound care provider, showed the following: -Wound to right heel had improved measuring smaller with less drainage and good granulation tissue; -Wound image measurements were area 5.5 square cm, with perimeter 11.6 cm, length 4.6 cm, width 1.7 cm, and max depth 0.2 cm; -Granulation 80%; -Slough 20%. (The wound care provider did not document regarding the wound on the right gluteal fold.) Review of the resident's March 2025 TAR showed staff did not document completing the ordered wound care for the right heel on 03/25/25, 03/26/25, 03/27/25, 03/28/25, 03/29/25, and 03/31/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 03/25/25, 03/26/25, 03/27/25, 03/28/25, 03/29/25, and 03/31/25. Review of the resident's March 2025 TAR showed staff did not document completing the ordered wound care for the right gluteal pressure wound on 03/25/25, 03/26/25, 03/27/25, 03/29/25, and 03/31/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 03/25/25, 03/26/25, 03/27/25, 03/29/25, and 03/31/25. Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actually skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's progress note, dated 03/31/25, from the wound care provider, showed the following: -Wound to right heel had improved measuring smaller with less drainage and good granulation tissue; -Wound image measurements of area 4.5 square cm with perimeter 9.6 cm, length 4.0 cm, width 1.8 cm, and max depth 0.2 cm; -Granulation 50%; -Epithelial 50%; (The wound care provider did not document regarding the wound on the right gluteal fold.) Review of the resident's April 2025 TAR showed the following: -An order, dated 03/01/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate to wound bed, cover with ABD pad, and wrap with Kerlix change daily one time a day for wound care; -Staff did not document administering the treatment on 04/03/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 04/03/25. Review of the resident's April of 2025 TAR showed the following: -An order, dated 03/05/25, to apply wound cleanser and dressing to right gluteal pressure wound in the morning; -Staff did not document administering the treatment on 04/03/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 04/03/25. Review of the resident's progress note, dated 04/07/25, from the wound care provider showed the following: -Wound to right heel had deteriorated measuring larger with increased drainage and nonviable tissue noted. Nonviable tissue required debridement and resident tolerated procedure well. Change treatment to Santyl nickel (an enzyme that removes dead tissue from wounds) thick in wound bed, calcium alginate, ABD pad, Kerlix, and change daily. Will reassess next week; -Wound image measurements of area 5.7 square cm with perimeter 11.3 cm, length 3.8 cm, width 2.3 cm, max depth 0.1 cm; -Granulation 40%; -Epithelial 50%; -Eschar 10% (dead tissue). (The wound care provider did not document regarding the wound on the right gluteal fold). Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actually skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's April 2025 TAR showed staff did not enter the new order from the wound care provider to change the treatment to Santyl nickel thick in wound bed, calcium alginate, ABD pad, Kerlix, and change daily. Review of the resident's April 2025 TAR showed the following: -An order, dated 03/01/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate to wound bed, cover with ABD pad, wrap with Kerlix change daily one time a day for wound care; -Staff did not document administering the treatment on 04/08/25 and 04/09/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 04/08/25 and 04/09/25. Review of the resident's April of 2025 TAR showed staff did not document completing the ordered wound tratement to the right gluteal fold wound on 04/08/25 and 04/09/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 04/08/25 and 04/09/25. Review of the resident's Skin Observation Tool, dated 04/10/25, showed the following: -Right heel pressure sore measured 5 cm length, 4 cm width, and 0.25 cm depth. The wound was a stage three (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure sore. The pressure sore to right heel was pink; -Right gluteal fold pressure sore 0.75 cm length, 0.75 cm width, with no depth noted. Wound was a stage two pressure sore. Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actual skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's April 2025 TAR showed the following: -An order, dated of 03/01/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate to wound bed, cover with ABD pad, wrap with Kerlix change daily one time a day for wound care; -Staff did not document administering the treatment on 04/13/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 04/13/25. Review of the resident's April 2025 TAR showed staff did not document completion of the order treatment to the resident's gluteal fold on 04/13/25 Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 04/13/25. Review of the resident's progress note, dated 04/14/25, from the wound care provider, showed the following: -Wound to right heel had improved measuring smaller, with less drainage and good epithelial tissue. Will change treatment to calcium alginate, ABD pad, Kerlix, and change daily; -Wound image measurements of area 2.8 square cm with perimeter 7.2 cm, length 2.7 cm, width 1.2 cm, and max depth 0.2 cm; -Granulation 40%; -Epithelial 60%. (The wound care provider did not document regarding the wound on the resident right gluteal fold.) Review of the resident's April 2025 TAR showed the following: -An order, dated of 03/01/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate to wound bed, cover with ABD pad, wrap with Kerlix change daily one time a day for wound care; -Staff did not document administering the treatment on 04/19/25 and 04/20/25, Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 04/19/25 and 04/20/25. Review of the resident's April 2025 TAR showed staff did not document administering the treatment to the gluteal fold on 04/19/25 and 04/20/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 04/19/25 and 04/20/25. Review of the resident's progress note, dated 04/21/25, from the wound care provider, showed the following: -Wound to right heel deteriorated in measurements with moderate drainage and nurse reported an odor. Non-viable tissue noted. Due to not being able to debride, will recommend Santyl ointment nickel thick to the wound bed daily x 1 week and calcium alginate; -Wound image measurements of area 12.60 square cm with length 3 cm, width 4.2 cm, and max depth 0.2 cm; -Granulation 20%; -Slough 75% -Eschar (dead or devitalized tissue that is hard or soft in texture) 5%; (The wound care provider did not document regarding the wound on the resident's right gluteal fold.) Review of the resident's April 2025 TAR showed staff did not enter the new order from the wound care provider to change the treatment to Santyl nickel and calcium alginate for one week. Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actual skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's April 2025 TAR showed the following: -An order, dated of 03/01/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate to wound bed, cover with ABD pad, and wrap with Kerlix change daily one time a day for wound care; -Staff did not document administering the treatment on 04/23/25 and 04/26/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 04/23/25 and 04/26/25. Review of the resident's April of 2025 TAR showed staff did not complete the treatment to the resident's right gluteal pressure on 04/23/35 and 04/26/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 04/23/25 and 04/26/25. Review of the resident's progress note, dated 04/28/25, from the wound care provider, showed the following: -Wound to right heel had deteriorated, measuring larger, with increased drainage and non-viable tissue noted. Strong foul odor noted. Incorrect dressing on and unsure when it was last changed. Tissue culture acquired and sent to lab. Non-viable tissue required debridement. Resident tolerated procedure well. Ensured nursing staff had correct dressing orders. Will continue same treatment of Santyl nickel thick in wound bed, calcium alginate, ABD pad, Kerlix, and change daily. Will reassess next week; -Wound image measurements of area 8.7 square cm with perimeter 12.2 cm, length 4.4 cm, width 2.4 cm, and no depth noted; -Granulation 10%; -Slough 60% -Eschar 30%; (The wound care provider did not document regarding the wound on the right gluteal fold.) Review of the resident's April 2025 TAR showed staff did not enter the new order from the wound care provider to change the treatment to Santyl nickel and calcium alginate for one week. Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actual skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's current POS showed an order, dated 04/26/25, for external wound care provider to evaluate and treat for wound on buttocks (gluteal fold). Review of the resident's April 2025 TAR showed the following: -An order, dated of 03/01/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate to wound bed, cover with ABD pad, wrap with Kerlix change daily one time a day for wound care; -Staff did not document administering the treatment on 04/27/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 04/27/25. Review of the resident's April 2025 TAR showed the following: -An order, dated 03/05/25, to apply wound cleanser and dressing to right gluteal pressure wound in the morning; -Staff did not document administering the treatment on 04/27/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 04/27/25. Review of the resident's current POS showed an order, dated 04/28/25, for right heel wound culture. Review of the resident's April of 2025 TAR showed staff did not document administering the treatment to the resident's gluteal fold on 04/30/35. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's gluteal fold on 04/30/25. Review of the resident's April 2025 TAR showed the following: -An order, dated of 03/01/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate to wound bed, cover with ABD pad, wrap with Kerlix change daily one time a day for wound care; -Staff did not document administering the treatment on 04/30/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 04/30/25. Review of the resident's progress note, dated 05/05/25, from the wound care provider, showed the following: -Resident not feeling well; -New wound to right buttock; -Started doxycycline (antibiotic) for leg wound infection; -No culture of buttock had been done; -Resident complained of pain in buttock; -Upon rolling resident large amount of foul, purulent (pus discharge) drainage; -Dressing removed to open wound to abscess, copious amount of drainage expulsed, and wound bed deep; -Recommend for resident to be sent out for evaluation due to deteriorating status, needs cultures, x-ray with possible CT scan or MRI. Review of the resident's hospital progress notes, dated 05/07/25, showed the following: -Resident admitted on [DATE] from long term care for worsening chronic wounds to right buttock and right heel; -Evidence of tunneling (type of wound that extends deeper in the tissue than its surface) abscess noted to buttock with purulent drainage; -Surgery team consulted, taken to operating room for incision and drainage on 05/06/25; -Intravenous antibiotics with Cefepime and vancomycin ( a common combination of broad-spectrum antibiotics used to treat suspected bacterial infections, particularly in hospitalized patients); -Wound care following for heel wound, plans to follow up in clinic at time of discharge; -Wound cultures obtained in emergency. Review of the resident's current care plan, last revised 10/01/24, showed staff did not update the resident's care plan to reflect the actual skin breakdown and treatments for heel and gluteal fold wounds. Review of the resident's May 2025 TAR showed the following: -An order, dated 03/01/25, to cleanse right heel with wound cleanser, skin prep peri wound, apply alginate to wound bed, cover with ABD pad, wrap with Kerlix change daily one time a day for wound care; -Staff did not document administering the treatment on 05/10/25. Review of the resident's record showed staff did not document regarding the missed treatments to the wound on the resident's heel on 05/10/25. Review of the resident's progress note dated 05/12/25, from the wound care provider, showed the following: -Resident lying comfortably in bed upon entering room; -Rounded with floor nurse. Resident sleeping during visit. Recently had incision and drainage performed from an abscess noted last week to sacrum (a triangular bone in the lower back) resident was placed on oral Bactrim for treatment by hospital; -Right heel had also improved this week. Will continue same treatment with same changing frequency; -Will continue wet to dry on sacrum and reassess next week; -Right heel wound image measurements of area 4.9 square cm with perimeter 8.9 cm, length 2.0 cm, width 2.5 cm, no depth noted, granulation 10%, and epithelial 90%; -Sacrum wound image measurements of area 10.6 square cm with perimeter 13.3 cm, length 3.0 cm, width 5.2 cm, and no depth noted. During an interview on 05/16/25, at 10:34 A.M., Nurse Assistant (NA) D said staff should report any skin changes to the charge nurse. He/she was aware of the resident's abscess a day or two before he/she was sent out and encouraged the resident to switch from the bed to chair. During an interview on 05/16/25, at 10:48 A.M., Certified Nurse Assistant (CNA) C said staff should report any skin changes to the charge nurse. He/she noticed the resident had a small spot on his/her right buttock and was aware the wound nurse was providing treatment. During an interview on 05/16/25, at 11:03 A.M., Licensed Practical Nurse (LPN) B said the following: -He/she was hired as the wound care nurse; -Staff should document providing wound care in the TAR per physician orders and should document if unable to provide wound care with the correct code. If not documented, staff did not provide the treatment; -The TAR should not have blanks for wound care; -The resident had a wound to the right heel and a small pressure ulcer on the right buttock toward the end of March 2025; -The resident had an order to treat the right buttock with daily cream and gauze; -Nurses provide the same care as the the wound provider including taking pictures with a camera that measures the wounds; -Nurses should complete skin assessments weekly for every resident, including measurements; -The wound care provider should be providing care for all wounds on a resident under their care. During an interview on 05/16/25, at 12:40 P.M., Family Nurse Practitioner (FNP) E said the following: -He/she provided weekly wound care for the resident, including the right heel wound; -He/she did not know about the wound to the right buttock until 05/05/25, when the nurse said the resident was not feeling well. He/she was shown the wound to the right buttock, which looked like an abrasion with a little scab and was draining from the middle and from the side. He/she lanced it and notice purulent drainage with a foul smell, unsure how deep, but did not occur overnight; -There have been multiple issues with the facility staff not changing dressings, and he/she knows this was the case when the wound was not getting better. The resident's right heel worsened due to facility staff not changing dressings; -The wound dressings don't have dates on them at times or have the incorrect dressings; -He/she does not have access to the residents' physician orders and depends on staff to advise of orders. During an interview on 05/16/25, at 2:22 P.M., the MDS Coordinator said the following: -The wound care provider treated all resident wounds over stage II; -The wound care provider treated all wounds of a resident while under their care except for surgical wounds; -Staff should document providing wound care per physician order in the TAR and should document if unable to provide the wound care as well; -The week before the resident was sent out the shower aide called her into the shower room to look at the buttock. The area was hard, not opened with a couple little spots like a pressure ulcer or maybe deep tissue wound; -She was unaware the resident had a right gluteal/buttock wound in March of 2025; -He/she did not know if wound care was completed per physician order for the resident; -She did not know if the external wound care provider was treating the resident's right gluteal wound. During an interview on 05/16/25, at 3:04 P.M., the Assistant Director of Nursing (ADON) said the following: -Nurses were responsible for wound care for residents; -Nurses should complete weekly skin assessments on all residents, including wound measurements; -The wound care provider treated resident wounds every Monday at the facility; -The wound care provider should be notified of any new wounds; -The wound care provider treated all wounds of residents under their care except surgical; -Staff should document wound treatments in the TAR and/or reason not provided; -She was not aware of the resident's wound to the right buttock until the day he/she was sent to the hospital for the abscess; -Staff should change wound dressings per physician order. During an interview on 05/16/25, at 3:41 P.M., the Administrator said the following: -Staff should complete a skin assessment upon admission of a resident, and she is unsure of how frequently after admission; -Staff should document all wound care treatments on the TAR and/or if unable to provide the treatment; -Staff should follow physician orders for wound care treatments and notify the external wound care provider of any new orders or wounds. MO00254120

Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control program when staff failed to perform hand hygiene and failed to follow Enhanced Barrier Precautions (EBP - infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) while providing wound care for three residents (Residents #1, #2, and #3). The facility also failed to ensure staff were trained on EBP and EBP supplies and signage were available. The facility census was 46. Review of the facility policy titled Hand Hygiene, dated 04/28/22, showed the following: -The facility will provide guidelines to employees on proper handwashing and hand hygiene techniques that will aid in the prevention of the transmission of infections; -Hand hygiene should be performed before/after providing care; -Hand hygiene should be performed before/after performing aseptic task; -Hand hygiene should be performed when in contact with blood, body fluids, or contaminated surfaces; -Hand hygiene should be performed before/after applying/removing gloves and personal protective equipment; -Hand hygiene should be performed after handling soiled lines/items potentially contaminated with blood, body fluids, or secretions; -Employees will perform handwashing with soap and water when hands are visibly soiled; -Employees may use an alcohol-based hand rub when hands are not visibly soiled. Review of the facility policy titled Infection Control Policy, undated, showed the following: -The purpose of the policy was to prevent and control the spread of infections within the facility, ensuring a safe environment for residents, staff, and visitors by implementing evidence-based practices; -All staff are responsible for complying with infection control procedures and reporting infections or breaches; -All staff must follow standard precautions at all times. This includes hand hygiene before and after resident contact or contact with potentially infectious material and the use of personal protective equipment such as gloves, gowns, masks, or eye protection as appropriate; -When standard precautions are not sufficient use transmission-based precautions, which includes contact precautions for infections such as Methicillin-resistant Staphylococcus aureus (MRSA-a type of staph bacteria that is resistant to many antibiotics) or (C. difficile- inflammation of the colon caused by bacteria); -Signage will be placed to alert staff and visitors to required transmission-based precautions; -With resident care practices follow appropriate wound, catheter, and respiratory protocols; -Maintain proper environmental hygiene in resident rooms and common areas. Review of the facility policy titled Wound Care policy for Long-Term Care, undated, showed the following: -The purpose of the policy was to ensure standardized, evidence-based wound care practices that promoted healing, prevented infection, and enhanced the quality of life for residents in long-term care settings; -Use aseptic technique when applying or changing dressings; -For infection control follow standard and transmission-based precautions; -Perform hand hygiene before and after dressing changes; -Dispose of waste according to infection control protocols. Review of the Centers for Disease Control and Prevention (CDC)'s Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/24, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO; -Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care; -Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization; -Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care (use of central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care (any skin opening requiring a dressing). -When implementing contact precautions or EBP, it was critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use; -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves); -For EBP signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves; -Make PPE, including gowns and gloves, available immediately outside of the resident room Review of the facility policy titled Barrier Precautions Policy for Long-Term Care, undated, showed the following: -The purpose of the policy was to reduce the risk of transmission of infectious agents, especially MDROs, among residents and healthcare personnel in long-term care settings through the consistent application of evidence-based barrier precautions; -The facility shall implement standard transmission-based barrier precautions, guided by the latest CDC and World Health Organization recommendations, for the prevention and control of infectious diseases in residents; -With standard precautions, perform hand hygiene before and after resident contact, after contact with potentially infectious material, and before donning and after removing gloves; -Use gloves when touching blood, body fluids, mucus membranes, non-intact skin, and contaminated surfaces; -Use gowns, masks, and eye protection based on anticipated exposure; -Clean and disinfect equipment and surfaces routinely and between uses; -For transmission-based precautions, contact precautions include wearing a gown and gloves before entering the room, dedicated resident-care equipment, and prioritized room placement; -Individualized risk assessments should guide the use of precautions to balance infection control with resident quality of life. Residents with cognitive impairments or those requiring frequent hands-on care may need enhanced precautions and staff training; -Staff education and compliance include initial staff education and annual training on infection control and use of personal protective equipment, competency assessments on donning and doffing, ongoing compliance audits with feedback. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admission date of 11/22/23; -Diagnoses include long term effects of a stroke, type II diabetes mellitus with other circulatory complications (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), cellulitis of right toe (skin infection), depression, chronic pain, hemiplegia and hemiparesis following stroke (muscle weakness or partial paralysis on one side of the body), aphasia following stroke (language disorder caused by damage to the brain. Review of the resident's care plan, last revised on 10/01/24, showed the following: -Resident had bowel and bladder incontinence and will remain clean and dry daily with staff assistance; -Staff will provide incontinence care after each incontinent episode, apply moisture barrier to skin, and use incontinence briefs as needed; -Staff will provide routine toileting upon rising, before and after meals, at bedtime, and as needed. -Resident at risk for pressure ulcer injury as evidenced by need of staff to assist with mobility, history of stroke with left side weakness, incontinence of urine and admitted with a pressure ulcer; -Use moisture barrier to perineal area as needed and report any signs or symptoms of skin breakdown to charge nurse. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool administered by staff), dated 02/26/25, showed the following: -Moderate cognitive impairment; -Partial to moderate assistance required with mobility and substantial to maximal assistance required with transfers; -Always incontinent of bladder and bowel; -At risk for pressure ulcers with no unhealed pressure ulcers, ulcers, wounds, or other skin problems. Observations on 05/15/25, at 11:13 A.M., showed the following: -A cart was located outside the resident's room with gowns and gloves in it. There was no enhanced-barrier precautions sign posted outside the resident's door. -Licensed Practical Nurse (LPN) A gathered all dressing change supplies and wound care treatments from the treatment cart in the hall. LPN A entered the resident's room and placed the hall treatment cart tablet, wound care cleanser, and supplies on the resident's bedside table. (The LPN did not place a barrier to prevent the supplies from possible contamination from the beside table.); -The MDS Coordinator entered the room to assist LPN A during the wound care; -LPN A and the MDS Coordinator applied gloves and a gown without completing hand hygiene. LPN A said they were wearing gowns and gloves due to the resident having MRSA (methicillin-resistant staphylococcus aureus infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) in the buttock wound and finishing antibiotics; -LPN A and the MDS Coordinator assisted the resident with rolling to his/her left side. The resident's incontinence brief was noted to be wet with urine and soiled with feces from a large bowel movement; -The MDS Coordinator continued to assist the resident with staying on his/her side and LPN A removed the soiled incontinence pad and placed it in the resident's trash can;. -LPN A used wipes available in the resident's room to clean the urine and feces from his/her buttocks and peri area; -The right buttock dressing was in place and contained a moderate amount of tan drainage; -A large amount of feces was noted at the bottom edge of the buttock dressing; -LPN A continued to use multiple wipes to clean the urine and feces from the resident's buttocks and peri area; -LPN A removed the buttock dressing and placed it in the resident's trash can; -He/she removed his/her gloves and placed them in the trash and applied new gloves without performing hand hygiene; -LPN A grabbed the wound cleanser bottle from the resident's bedside table that he/she brought into the room from the treatment cart in the hall and placed the bottle on the resident's bed (The LPN did not place a barrier to prevent the supplies from possible contamination from the bed.); -The right buttock wound had packing in place that was dried on the wound tissue. LPN A sprayed the packing with the wound cleanser; -Upon placing the wound cleanser bottle back on the bed, the wound cleanser bottle fell onto the floor in the resident's room; -LPN A picked the wound cleanser bottle up off the floor and placed it back on the bed without cleansing the bottle or completing hand hygiene or changing gloves. LPN A bumped the bedside table that had sealed dressing supplies on it and one sealed dressing fell on the floor. He/she picked the sealed dressing up off the floor and placed it on the resident's bed for use. LPN A did not clean the sealed package, complete hand hygiene, or change his/her gloves after picking the dressing up off the floor; -LPN A sprayed the buttock wound packing with the wound cleanser a second time, removed the packing, and threw it in the trash can. LPN A changed his/her gloves and did not complete hand hygiene; -LPN A used the bottle of wound cleanser to moisten gauze and he/she repacked the wound; -The MDS Coordinator and LPN A changed their gloves and applied new gloves without completing hand hygiene; -LPN A applied an alginate dressing over the buttock wound packing along with an ABD pad (a large pad used for wound care) and secured the ABD pad with tape; -The MDS Coordinator and LPN A changed the resident's sheets and applied a new incontinence pad; -Without completing hand hygiene, or changing his/her gloves, LPN A removed the resident's outer layer right heel dressing; -LPN A changed his/her gloves, and sprayed the smaller right heel dressing with wound cleanser to loosen the dressing from the skin and remove it; -LPN A A changed his/her gloves without completing hand hygiene. He/she cleansed the right heel wound with gauze soaked in wound cleanser, dried the area, and applied a new dry dressing secured with an ABD pad and kerlix (a type of gauze bandage roll used in wound care); -The roll of tape that LPN A took into the room from the hall treatment cart fell in the floor. He/she picked it up off the floor and placed it on the resident's bed (no barrier); -LPN A applied new gloves without completing hand hygiene. The nurse sprayed wound cleanser on the left ankle wound to help loosen it prior to removing it and placing it in the trash; -He/she did not apply new gloves or complete hand hygiene. LPN A cleansed the resident's left ankle wound with wound cleanser, applied gauze to the area that was soaked with wound cleanser, covered it with a dry dressing, applied an ABD pad to the area, and secured it with Kerlix. -Without removing his/her gloves and gown or performing hand hygiene, LPN A gathered up all the package and unused wound care supplies and bottle of wound cleanser and placed them on the resident's bedside table (no barrier); -LPN A picked up the unused wound care supplies and bottle of wound care spray from the bedside table and carried them out of the room and placed them on top of the hall treatment cart; -The nurse used alcohol wipes located on the treatment cart to wipe off the hall treatment cart tablet, and wound cleanser bottle that has been in the resident's room; -He/she placed the unused dressing supplies back in the treatment cart located in the hallway. During an interview on 05/16/25, at 10:34 A.M., Nurse Aide (NA) D said the following: -He/she used gloves and a gown while providing care to the resident because the resident had MRSA and was on isolation; -Staff were supposed to be wearing a mask, goggles, gloves, and a gown while caring for the resident. During an interview on 05/16/25, at 10:48 A.M., Certified Nurse Aid (CNA) C said the following: -The resident had a wound on the right side of his/her buttocks; -Staff tried to do his/her wound care during the morning shift; -The resident is on isolation. He/she thought the isolation was due to a diagnosis of MRSA; -He/she wore a gown, gloves, and mask while providing care to the resident. During an interview on 05/16/25, at 11:03 A.M., LPN B said the following: -The resident had a wound on his/her right heel; -LPN B thought the resident's right heel had MRSA in it and felt like the MRSA traveled to his/her buttock wound; -He/she wears gloves at all times while changing the resident's dressings; -Staff were to wear gloves and a mask while providing care to the resident. During an interview on 05/16/25, at 1:36 P.M., LPN A said the following: -LPN A thought the resident's buttock wound was positive for MRSA; -He/she thought the resident received an IV antibiotic for MRSA. During an interview on 05/16/25, at 2:21 P.M., the MDS Coordinator said the following: -The resident developed a pressure ulcer on his/her buttocks approximately the week before his/her hospitalization; -The resident had MRSA in his/her buttock wound, but he/she is not sure if the resident's other wounds have MRSA; -He/she did not observe any hand washing by LPN A while they were in the the resident's room cleaning the resident up after an incontinent bowel movement or before, during, or after the multiple dressing changes. During an interview on 05/16/25, at 3:00 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she was aware of the resident's buttock wound/abscess; -The ADON is not sure if resident had a diagnosis of MRSA. 2. Review of Resident #2's face sheet (brief information sheet about the resident) showed the following: -admission date of 04/18/25; -Diagnoses included diffuse large B-cell lymphoma (a cancer that starts in the lymphatic system), unspecified protein-calorie malnutrition (a condition that occurs when the body does not receive or absorb enough nutrients to maintain health), acute (sudden) kidney failure, critical illness myopathy (a serious complication of critical illness that causes widespread muscle weakness), and thrombocytopenia (low platelet level). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent with toileting hygiene, lower body dressing, and chair/bed to chair transfer; -Substantial to maximal assistance with showering/bathing, and rolling left to right; -Always incontinent of urine and stool; -Moisture associated skin damage; -Pressure ulcer care; -Surgical wound care; -Application of nonsurgical dressings; -Skin and ulcer treatment application of ointments/medications. Review of the resident's care plan, updated 04/20/25, showed the following: -Required assistance with activities of daily living related to immobility; -Required substantial assistance with bed mobility; -Dependent for toileting and transfers; -Max assist for showers and hygiene; -Change dressings per physician's order. Observations on 05/15/25, at 12:37 P.M., showed the following: -No enhanced-barrier precautions sign posted outside the resident's door and no personal protective equipment cart outside the resident's room; -LPN A gathered the wound care supplies from the treatment cart in the hallway. LPN A utilized hand sanitizer and applied gloves; -There was no dressing over the coccyx (tailbone) wound; -Certified Nurse Aide (CNA) F reported that the dressing came off while staff was changing the resident's soiled brief just prior to the LPN entering the room to complete the dressing change. He/she reported that the dressing had green and bloody drainage on it; -LPN A cleansed the wound with wound cleanser and changed his/her gloves. He/she did not perform hand hygiene. LPN A packed the tunneling area of the wound and then filled in the rest of the wound bed with packing. An ABD pad was placed over the wet to dry packing and it was taped in place; -LPN A removed his/her gloves and cleansed his/her hands with hand sanitizer; -When the nurse moved away from the resident's bed, he/she bumped the small refrigerator/freezer that a small cup which contained gauze soaked with wound cleanser was sitting on and the cup with the soaked gauze fell onto the floor. LPN A picked the cup up off the floor and put it back on the refrigerator/freezer; -LPN A put gloves on without performing hand hygiene; -With the new gloves on, the nurse grabbed the resident's bed control device and lowered the head of the resident's bed; -LPN A removed the resident's feeding tube dressing without difficulty; -Per the resident's request, LPN A soaked the midline abdominal dressing with wound cleanser to assist with removal of the dressing; -After removing the dressing, LPN A removed his/her gloves and did not perform hand hygiene; -LPN A applied new gloves and cleansed the midline abdominal incision and the wound cleanser; -The resident touched the midline abdominal incision and the feeding tube area, so LPN A recleaned both areas with Vashe wound cleanser; -LPN A removed his/her gloves and used hand sanitizer; -The nurse applied a dry dressing to the feeding tube site; -LPN A removed his/her gloves and put on a new pair of gloves without performing hand hygiene; -He/she soaked gauze in the wound cleanser and packed the midline abdominal wound with it. He/she applied an ABD pad over the wet gauze. During an interview on 05/16/25, at 10:48 A.M., Certified Nurse Aid (CNA) C said he/she was aware that the resident had a dressing on their buttock. He/she wore gloves while providing care to the resident, but he/she did not wear a gown. 3. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following: -admission date of 05/01/25; -Diagnoses included MRSA infection, acute congestive heart failure, anxiety, and hypertension (high blood pressure). Observations on 05/15/25, at 10:48 A.M., showed the following: -No enhanced-barrier precautions sign posted outside the resident's door and no personal protective equipment cart outside the resident's room; -LPN A prepared wound care supplies at the treatment cart in the hallway for the resident; -He/she sprayed wound cleanser on gauze and put into a clean cup; -The nurse entered the resident room with prepared supplies and a bottle of wound cleanser from the treatment cart; -He/she placed all supplies on the resident's bedside table (no barrier); -The nurse applied gloves in room without performing hand hygiene; -The nurse removed the non-saturated dressing and put it in the resident's trashcan. He/she removed gloves and disposed of them in the trash can; -LPN A applied new gloves without performing hand hygiene. LPN A wiped the resident's left buttock wound with wound cleanser on the prepared gauze and patted it dry with dry gauze. He/she applied ointment to the bilateral buttock redness and scabbed area on the resident's left buttock. LPN A applied a boarder gauze dressing and secured it to the skin with tape. He/she removed his/her gloves and disposed of them in the trash can; -LPN A did not perform handy hygiene prior to leaving the resident's room; -He/she took the wound cleanser bottle from the resident's bedside table and placed it back on the treatment cart in the hallway without cleaning it. 4. During an interview on 05/16/25, at 10:34 A.M., Nurse Aide (NA) D said the following: -He/she was not familiar with what EBP were; -He/she washes his/her hands before and after resident care and wears gloves while providing resident care. During an interview on 05/16/25, at 10:48 A.M., Certified Nurse Aid (CNA) C said the following: -He/she was not aware of what EBP meant; -He/she used hand sanitizer and applied gloves prior to providing incontinence care; -He/she washed his/her hands upon leaving the resident's room. During an interview on 05/16/25, at 11:03 A.M., LPN B said the following: -He/she was the wound care nurse; -During dressing changes, he/she washed his/her hands, put on gloves, took off the dressing, washed his/her hands again, and put new gloves on to apply a new dressing; -After the dressing was changed, he/she took his/her gloves off and washed his/her hands; -While at the treatment cart, he/she used hand sanitizer prior to handling dressing change supplies; -With multiple wounds, LPN B washed his/her hands before moving to the next wound for a dressing change; -If a resident has a bowel movement while changing a dressing, he/she would change the soiled incontinence pad first, then complete hand hygiene and change his/her gloves; -Wound supplies were kept in a supply room and on the treatment cart in the hall; -Wound treatment supplies were used for all residents; -If wound supplies were taken into a room of a resident with MRSA, the supplies should be left in the room or thrown away; -The hand sanitizer was shared between staff, so it should be left outside the resident's room; -The facility had one bottle of wound cleanser that was used for all residents, so it should not be taken into a resident's room; -Staff know residents are on isolation precautions by the supply cart that is located outside a resident's room; -He/she always used gloves and hand hygiene with wound care procedures; -LPN B has not received any EBP training in the facility. He/she did not know what EBP meant; -The facility did not have any EBP signs that he/she was aware of; -Nursing staff communicate during shift change if a resident is MRSA positive; -If wound care supplies are dropped on the floor, they should be put in the trash and new supplies obtained; -If the wound cleanser bottle is dropped on the floor, he/she would get a new bottle or clean the bottle that was dropped on the floor with alcohol wipes; -He/she prevented contamination of wound care supplies by only taking the supplies that are needed into the resident's room. During an interview on 05/16/25, at 1:36 P.M., LPN A said the following: -His/her normal job was charge nurse, but he/she provided wound care infrequently; -Gloves should be applied after completing hand hygiene; -If he/she had to touch or move a resident, he/she will put gloves on; -He/she would change his/her gloves after changing a dirty dressing; -LPN A would change his/her gloves after cleaning a resident up or changing them; -He/she would put on new gloves to change a dressing after cleaning a resident up; -Hand hygiene should be done before and after each procedure; -Hand sanitizer should be used in between glove changes; -Hand washing with soap and water should be completed before and after each procedure; -Wound care supplies come from a supply room and are stocked on treatment cart in the hall; -He/she used the same bottle of wound care cleanser for all residents with wounds; -All wound care supplies were shared between residents. No resident has their own wound supplies; -If he/she takes extra wound care supplies into a resident's room and they are not used, he/she takes the unused supplies out of the room and places them back in the treatment cart in the hallway; -If a wound care supply was opened in a resident room, but not used, he/she would leave the item in the room to use for the next dressing change or throw it away; -Extra wound care supplies should not be taken into a resident's room who is diagnosed with MRSA; -If extra supplies were taken into the room, they should stay in the room and not be put back on the treatment supply cart; -Wound care supplies that are dropped on the floor should be tossed in the trash; -LPN A was not familiar with EBP and he/she did not know what it meant; -He/she had not received any in-services at the facility regarding EBP; -If he/she was caring for a resident with MRSA, he/she would wear a gown, gloves, and mask; -The facility should have a sign posted outside resident rooms for things like MRSA. During an interview on 05/16/25, at 2:21 P.M., the MDS Coordinator said the following: -He/she did not know what EBP meant; -Staff had not received any in-services on EBP; -He/she was not sure how staff would know if a resident had EBP in place; -The MDS Coordinator believed there should be an EBP sign outside the resident's room; -Staff should wash their hand when entering and exiting a resident's room; -Staff should wash their hands in between caring for residents; -If a resident has MRSA, staff should not take supplies into the room and bring them back out; -Supplies that are dropped on the floor should be tossed in the trash. During an interview on 05/16/25, at 3:00 P.M., the Assistant Director of Nursing (ADON) said the following: -When changing wound dressings, staff were expected to wash their hands and wear gloves; -Staff were expected to wash their hands in between residents, before starting any care with a resident, and after taking their gloves off; -Staff were expected to wash their hands after cleaning a resident up following a bowel movement; -Staff were expected to wash their hands after they take their personal protective equipment/gown off; -A resident that was diagnosed with MRSA should have their own wound care dressing supplies and wound care cleanser bottle in their room; -Staff should not take wound care supplies in the room of a resident diagnosed with MRSA and bring the supplies back out of the room; -It was not acceptable to drop wound supplies on the floor and then use them; -It was not acceptable to lay wound care supplies on a resident's bed and then use the supplies on a resident in another room; -The facility should have more residents on EBP than they do; -Residents with EBP should have a cart outside their room stocked with gowns and gloves. They should also have a sign posted outside their room that identifies them as being on EBP; -When a resident had multiple wounds, staff should clean and dress the dirtiest wounds first and the cleanest wounds last; -If supplies were dropped on the floor they should be discarded or thrown away, not used on residents; -It was not appropriate for staff to take wound care supplies into a resident's room who has been diagnosed with MRSA and bring the supplies back out of the room. During an interview on 05/16/25, at 3:40 P.M., the Administrator said the following: -EBP should be used for any resident that has a wound; -Staff were expected to wear a gown and gloves with direct resident care; -Every resident with a wound should have their own wound care supplies in their room; -He/she was unsure if residents on EBP should have a sign placed outside their room alerting staff and visitors; however, he/she did not know how staff would know about the EBP otherwise; -Staff would know if a resident were on isolation by the isolation prevention cart being present outside the residents room; -He/she expected staff to wear a gown and gloves while caring for residents with MRSA and wounds; -He/she expected staff to use hand hygiene when they enter a resident's room or change their gloves; -He/she expected staff to wash their hands prior to leaving a resident's room; -In between glove changes, he/she expected staff to wash their hands or use hand sanitizer; -He/she expected staff to throw away wound care supplies that were dropped on the floor, and get new supplies; -If a wound care cleanser bottle was taken into a resident's room that was diagnosed with MRSA, the bottle should stay in the room, rather than remove it from the room and sanitize it; -He/she expected residents on isolation to have their own equipment and supplies and not share them with other residents. MO00254120

Based on interview and record review, the facility staff failed to maintain $4,000.00 cash for one resident (Resident #1) when staff had possession of the cash and could not locate the cash and provide it to the resident upon request. The facility census was 44.Review of the (undated) facility policy titled, Abuse and Neglect, showed the following:-Residents have the right to be free from verbal, sexual, physical, and mental abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, and involuntary seclusion.-Misappropriation of property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent;-Any staff member or person affiliated with this facility, including facility consultants and/or attending physician, who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report the mistreatment or offense to the Administrator;-All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, should be reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and the designated state agency. All alleged violations must be reported immediately;-After the facility submits an immediate report of an alleged violation, the facility must conduct a thorough investigation; prevent any other incidents from occurring during the course of the investigation and report the results of the investigation to the state agency within five working days or as designated by state law. The facility may report the results of the investigation by completing the remainder of the reporting form and resubmitting to the state agency. 1.Review of the facility investigation summary, undated, showed the following:-In December 2024 or January 2025, the administrator found $4,000.00 cash belonging to the resident in the business office manager's (BOM) office. She made a log and placed the money in the facility safe per the regional BOM until the money could be taken to the bank;-The resident's family member came to the facility in the same time frame of December 2024 or January 2025 and requested money. The administrator is unsure if any money was given to the family member and the log placed with the money is missing;-Just before the BOM discontinued employment in April 2025, the BOM and administrator opened the safe and did not see the money and thought the money was given to the family member, but the log was not in the safe;-On 05/16/25, the resident requested money from the $4,000.00 that he/she had given the BOM. The resident denied giving any money to his/her family member;-On 05/21/25, after speaking with family, a friend, and looking into bank records, the money was not located and was considered missing. The state agency and law enforcement were contacted. Review of the police report, dated 05/22/25, showed no arrests were made, and the case was closed unless new evidence was found. Review of the facility record showed a copy of a check made out to the resident, dated 06/18/25, for $4,000.00. 2. Review of Resident #1's face sheet (a brief resident profile) showed the following:-The resident admitted to the facility on [DATE];-Diagnoses included heart failure, rhabdomyolysis (a breakdown of muscle tissue that released a damaging protein into the blood), hearing loss, type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), cognitive communication deficit (difficulty communicating), Bell's palsy (sudden weakness of muscles on one half of the face) kidney failure, and respiratory failure. Review of the resident's care plan, revised on 04/16/25, showed the following:-Resident has activities of daily living (ADL) functional problems as evidenced by the need for staff assistance with ADL's related to rhabdomyolysis;-Resident has communication problems as evidenced by impaired hearing. Resident does not wear hearing aids. Face the resident when speaking. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 05/14/25, showed the resident was cognitively intact. During an interview on 07/09/25, at 10:28 A.M., the resident said the following:-The facility lost $4,000.00 of his/her money. It just disappeared;-The facility replaced the $4,000.00 about two weeks ago;-The facility made him/her aware the money was missing about a month ago when he/she tried to get a partial withdrawal;-The facility staff talked him/her into keeping $5,000.00 originally in the business office for safe keeping;-The last time he/she withdrew any money was in January for $1,000.00, leaving $4,000.00. During an interview on 07/09/25, at 1:57 P.M., Certified Nurse Assistant (CNA) A said the following:-He/she would immediately notify the charge nurse or administrator if a resident reported missing money;-Staff should never take a resident's money, and he/she considers this to be abuse. During an interview on 7/09/25, at 1:57 P.M., CNA B said the following: -He/she heard in the hall that approximately two months ago, the resident had money missing from the facility, but he/she did not know any other details;-He/she would tell the nurse and social worker upon becoming aware a resident had missing money. He/she would look for the missing money.-He/she said it would be considered misappropriation and financial abuse if staff took or stole money from a resident. During an interview on 07/09/25, at 2:04 P.M., Registered Nurse (RN) C said the following:-He/she would immediately notify management and maybe the police if a resident reported missing money;-Staff should never take money from a resident, and he/she considers this abuse. During an interview on 7/09/25, at 2:09 P.M., Licensed Practical Nurse (LPN) D said the following: -He/she is not aware of any residents missing money;-If a resident reported money missing, he/she would contact the Director of Nursing (DON), and then complete an investigation to find the money;-At the request of the DON, he/she would contact the police department to file a report;-He/she considers stealing money from a resident abuse and misappropriation of property. During an interview on 07/09/25, at 2:38 P.M., the Business Office Manager (BOM) said the following:-Staff should report any allegation of a resident missing money immediately, and then an investigation should be completed;-The facility has two hours to notify the state agency of a resident missing money;-Staff should never take a resident's money, and she considers this to be misappropriation of property and abuse;-He/she was the acting administrator at the time the money was placed in the safe in the administrator's office sometime in December 2024 or January 2025;-She had discovered the resident's $4,000.00 in the previous BOM's office in a lock box that was not locked at the time;-She took the money and called corporate and was advised to place the money in the safe in her office along with a log containing pertinent information;-Both her and the previous BOM had access to the safe, but she is unsure if anyone else knew the money was in the safe;-The key to the safe was in the administrator's bathroom in an unlocked box;-The code to the safe was written on a sticky note taped to the drawer in the administrator's office;-Staff had access to the bathroom and the drawer as the office was not locked while the administrator was in the building;-The previous BOM left the second week of April 2025. About a week before she left, they both looked in the safe and the resident's money was not in there. They assumed the resident had given the money to his/her family member because it had been discussed previously;-The resident asked for money on 05/16/25;-There was no money and no log in the safe or in the BOM's lock box;-After exhausting all avenues to find the money, it was determined on 05/21/25, the money was missing, and the state agency and law enforcement was contacted;-She would never take a resident's money and did not take this resident's money. During an interview on 07/14/25, at 9:15 A.M., the previous BOM said the following:-She was the BOM for four years until 04/09/25;-She oversaw the resident funds, which was located in a lock box in her office;-She and the administrator had access to the lock box;-The resident's money was not included in the resident funds. During an interview on 07/09/25, at 3:10 P.M., the administrator and the Assistant Director of Nursing (ADON) said the following:-Staff should report allegations of misappropriation to the appropriate department head immediately, and the state agency within two hours;-Staff should never take a resident's money and it is considered abuse and misappropriation of property;-An investigation should be completed for any allegation of misappropriation of property, including staff and residents in the room or surrounding area;-The facility replaced the resident's $4,000.00;-The key to the safe was in the administrator's bathroom in an open lock box with several other keys and was not easily identifiable;-Staff used the administrator's bathroom;-The code was written on a sticky note inside the administrator's desk;-The safe required the key and the code to open.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards that protected food from possible contamination at all times when staff failed to ensure condiments kept in the serve-out refrigerator were not expired and when staff failed to ensure non-food contact surfaces were clean and maintained in good repair. The facility census was 48. Review showed the facility did not have a policy regarding cleaning the kitchen and/or serving station. Review of the facility's Daily Deep Cleaning Scheduled showed the following: -Tuesday: The PM [NAME] was to clean the steam table top to bottom, behind and front glass, and de-lime the steam table; -Saturday: The PM [NAME] was to clean and de-lime steam table, clean floor underneath steam table, and behind steam table from top to bottom. 1. Observation on [DATE], at 10:35 A.M., showed the following: -The chrome surfaces surrounding the water wells of the steam table contained debris and dried food particles; -The chrome surface surrounding the plate warmer contained debris and dried liquid substance; -The lower shelf of the steam table had several spots of dried liquid substance; -The trash can lid was splattered with a dried substance; -A tub of butter was on the back counter, resting on top of the lid was a spatula covered with butter. Observation on [DATE], at 11:00 A.M., showed the following: -The chrome surfaces surrounding the water wells of the steam table contained debris and dried food particles; -The chrome surface surrounding the plate warmer contained debris and dried liquid substance; -The lower shelf of the steam table had several spots of dried liquid substance; -The trash can lid was splattered with a dried substance. Observation on [DATE], at 11:20 A.M., showed the following: -The chrome surfaces surrounding the water wells of the steam table contained debris and dried food particles; -The lower shelf of the steam table had several spots of dried liquid substance; -The chrome surface surrounding the plate warmer contained debris and dried liquid substance; -The trash can lid was splattered with a dried substance. Observation on [DATE], at 1:15 P.M., showed the following: -The chrome surfaces surrounding the water wells of the steam table remained covered with debris and dried food particles; -The lower shelf of the steam table had several spots of dried liquid substance. Observation on [DATE], at 2:39 P.M., showed the toaster on the back counter was covered in crumbs. The inside of the toaster contained crumbs and a dried substance was on the chrome edging surrounding the bread slots. Observation on [DATE], at 3:50 P.M., showed the following: -The chrome surfaces surrounding the water wells of the steam table remained covered with debris and dried food particles; -The inside of the toaster contained a layer of crumbs and a dried substance remained on the chrome edging surrounding the bread slots. During an interview on [DATE], at 11:07 A.M., [NAME] A said he/she and the dietary aide (DA) are responsible for cleaning the dining room tables, steam table, and serving area after breakfast and lunch. Usually the aide works on the dining room while the cook cleans up the kitchen and the service area. The A.M. cook and DA are responsible for washing all dishes and cookware after breakfast. The P.M. cook and DA help put away leftover food and help with the dishwashing after lunch, and are responsible for cleaning the dining room tables, steam table, and serving area after dinner. [NAME] A said it was difficult to get everything done between breakfast and lunch since there were only two kitchen staff working the shift. During an interview on [DATE], at 2:35 P.M., [NAME] C said the cooks and DAs are responsible for cleaning the dining tables, steam table, plate warmer, microwave, toaster, and serving area countertops after each meal. During an interview on [DATE], at 2:49 P.M., the Dietary Manager (DM) said the cook and dietary aide are expected to do the cooking, prep work, and clean-up for each meal served on their shift. Staff should clean the steam table, plate warmer, microwave, toaster, and all countertops of the serving area after each meal. During an interview on [DATE], at 3:55 P.M., the Administrator and the Director of Nursing (DON) said the DM was responsible for scheduling the staff and ensuring the meal preparation, service, and cleanup were completed appropriately. The staff should clean the kitchen and service area as needed and after each meal. The heavy cleaning should be done at the end of the day, to include the floors. Staff should ensure the cleanliness of all surfaces prior to each meal, and they should clean the steam table, plate warmer, countertops, microwave, and toaster after each meal. 2. Observation on [DATE], at 2:47 P.M., of the refrigerator in the dining room serve out station showed the following condiments in squeeze bottles: -Mustard hand labeled with use by ,d+[DATE]; -Mayonnaise: hand labeled use by ,d+[DATE]; -Oil based salad dressing hand labeled use by ,d+[DATE]; -Barbecue sauce hand labeled use by ,d+[DATE]; -Mayonnaise hand labeled use by ,d+[DATE]. During an interview on [DATE], at 2:49 P.M., the DM said some of the kitchen staff are new and are not in the habit yet of checking the use by dates on condiments and other food items. They transfer condiments from the large containers in the kitchen refrigerator into the small hand-held bottles. Staff should label the bottles to be used within seven days and discard the contents after that date. During an interview on [DATE], at 3:55 P.M., the Administrator and the Director of Nursing (DON) said staff should label food items when they are received, when they are opened, and labeled with a use by date as applicable. Food items and condiments should be discarded after the use by date. MO00248704

Based on interview and record review, the facility failed to document a timely and thorough investigation of verbal abuse when staff did not begin an immediate investigation into an allegation of staff cursing at one resident (Resident #1) and failed to document interviews with multiple staff as part of the investigation. A sample of ten residents was reviewed. The facility had a census of 48. Review of the facility's Abuse and Neglect Policy, revised September 2024, showed the following: -It is the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; -Within five business days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation and indicate any corrective actions taken if the allegation was verified. It is important that the facility provides as much information as possible, to the best of its knowledge at the time of submission of the report; -Abuse is the act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury to a resident. This includes verbal or mental/psychological abuse; -Mental/psychological abuse, within the definition of abuse, means to inappropriately treat or exploit a resident, not resulting in physical harm, including, but not limited to , humiliation, harassment, threats of punishment, deprivation or intimidation; -Verbal abuse is the use of oral, written, or gestured language that includes disparaging derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability; -The home's administration will conduct and investigate allegations of crimes, abuse, neglect, or misappropriation of property, and will provide notification and release of information to the proper authorities, in accordance with federal and state regulations. 1. Review of Resident #1's face sheet (gives basic profile information) showed the following: -Re-admitted [DATE]; -Diagnoses included age-related physical debility, mild cognitive impairment of uncertain or unknown cause, and generalized anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/02/24, showed the following information: -Moderately impaired cognition; -Utilized a wheelchair for mobility; -Required assistance for toileting, dressing, personal hygiene, and mobility. Review of the resident's care plan, last reviewed 11/02/24, showed the following: -Communication problems as evidenced by impaired hearing; -Cognitive loss; -Staff should introduce themselves during interactions and establish an environment of mutual trust and respect. Review of the facility's investigation documentation showed the following: -Nurse Aide (NA) A's handwritten statement, dated 01/11/25, showed he/she witnessed NA B walk into the resident's room and say to him/her, (called the resident by his/her first name), stop being a fucking brat, and stop calling your fucking family when you don't get your way. -On the statement, NA A noted he/she notified the charge nurse on 01/10/25, between 10:15 A.M. and 10:20 P.M.; -Questionnaires were filled out showing interviews with seven residents, dated 01/11/25 (unsigned), regarding their feelings of safety in the facility and whether or not anyone had ever hurt them there. (Investigative staff did not document any additional staff interviews.) Review of the resident's nurses' notes showed staff did not document information pertaining to the allegation made by NA A or notifications made to the administration, physician, or resident's family. During an interview on 01/17/25, at 11:53 A.M., Certified Medication Technician (CMT) E said staff should report any allegation of abuse immediately to the charge nurse, DON, or the Administrator so they could start an investigation. During an interview on 01/17/25, at 2:10 P.M., Graduate Practical Nurse (GPN) F said cursing at a resident would be considered verbal abuse. All allegations of abuse should be reported immediately to the charge nurse or DON to investigate. During an interview on 01/17/25, at 2:55 P.M., Licensed Practical Nurse (LPN) I said staff should report any allegation of abuse immediately to their supervisor and remove the resident from the situation. Administration is responsible for investigating allegations of abuse. During an interview on 01/17/25, at 3:00 P.M., Certified Nurse Aide (CNA) G said cursing would be considered a type of abuse and should be reported immediately to the charge nurse or DON. The CNA said he/she wasn't sure who conducted an investigation. During an interview on 01/17/25, at 3:08 P.M., CNA J said the Administrator or DON investigates allegations of abuse. During an interview on 01/17/25, at 3:15 P.M., GNP H said cursing at a resident is verbal abuse. All allegations of abuse should be investigated. During an interview on 01/17/25, at 3:55 P.M., with the Administrator and the DON, the following was said: -On the morning of 01/11/25, LPN D had come to the facility to drop off a family member for work. At that time, NA A told LPN D about the allegation and said he/she had told the on-duty charge nurse, RN C, at the time of the incident around 10:15 P.M. to 10:20 P.M.; -LPN D called the Administrator and the Director of Nursing (DON) to confirm they were aware of the abuse allegation. The Administrator said he/she had not seen the notification text sent to him/her by RN C at 1:08 A.M. that morning. He/she directed LPN D to begin an investigation; -LPN D interviewed a sample of residents regarding possible abuse and gave them the documentation regarding those interviews. LPN D told them NA A was the only witness to the alleged incident. There were no other staff witness statements obtained; -The Administrator and the DON said RN C should have verified contact with either of them to ensure a timely report to the State and an investigation started immediately; -They said the investigation should include witness statements and interviews with the named resident and any others that may have been under the care of the same alleged staff member. MO00247859 51882

Based on interview and record review, the facility failed to ensure all allegations of abuse and neglect were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required two-hour time frame when staff failed to immediately report an allegation of employee to resident verbal abuse of involving one resident (Resident #1). The facility census was 48. Review of the facility's Abuse and Neglect Policy, revised September 2024, showed the following: -It is the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; -If there is any allegation of abuse, then the facility must report immediately to the administrator and State Survey Agency, no later than two hours; -Abuse is any act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury to a resident. This includes verbal or mental/psychological abuse; -Mental/psychological abuse within the definition of abuse means to inappropriately treat or exploit a resident, not resulting in physical harm, including, but not limited to , humiliation, harassment, threats of punishment, deprivation or intimidation; -Verbal abuse is the use of oral, written, or gestured language that includes disparaging derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. 1. Review of Resident #1's face sheet (gives basic profile information) showed the following: -Re-admitted [DATE]; -Diagnoses included age-related physical debility, mild cognitive impairment of uncertain or unknown cause, and generalized anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/02/24, showed the following information: -Moderately impaired cognition; -Utilized a wheelchair for mobility; -Required assistance for toileting, dressing, personal hygiene, and mobility. Review of the resident's care plan, last reviewed 11/02/24, showed the following: -Communication problems as evidenced by impaired hearing; -Cognitive loss; -Staff should introduce themselves during interactions and establish an environment of mutual trust and respect. Review of the facility's investigation documentation showed the following: -Nurse Aide (NA) A's handwritten statement, dated 01/11/25, showed he/she witnessed NA B walk into the resident's room and say to him/her, (called the resident by his/her first name), stop being a fucking brat, and stop calling your fucking family when you don't get your way. -NA A noted he/she notified the charge nurse of the allegation between 10:15 P.M., and 10:20 P.M.; -Staff did not find documentation of the allegation by the charge nurse Registered Nurse (RN C) on duty on 01/10/25, at 10:15 P.M. - 10:20 P.M.; -Staff did not document interviews with staff other than NA B; -Staff did not write a summary statement or document notification to the State Agency (DHSS). Review of the resident's nurses' notes showed staff did not document information pertaining to the allegation made by NA A or notifications made to the Administration, physician, or resident's family. Review of DHSS records showed an online report was made of the allegation by Licensed Practical Nurse ([NAME] D) on 01/11/25, at 6:27 A.M. (the day after the alleged event). During a phone interview on 01/21/25, at 3:01 P.M., NA B said it was wrong to curse at or in front of any resident. During an interview on 01/17/25, at 3:00 P.M., Certified Nurse Aide (CNA) G said cursing would be considered a type of abuse and should be reported immediately to the charge nurse or Director of Nursing (DON). The facility has two hours to report abuse allegations to the State. During an interview on 01/17/25, at 3:08 P.M., CNA J said he/she would report allegations of abuse to the charge nurse. All allegations of abuse should be called in to the State within two hours of the incident. During an interview on 01/17/25, at 11:53 A.M., Certified Medication Technician (CMT) E said staff should report any allegation of abuse immediately to the charge nurse, DON, or the Administrator. The facility must report all abuse allegations to the State within two hours. During an interview on 01/17/25, at 2:10 P.M., Graduate Practical Nurse (GPN) F said cursing at a resident would be considered verbal abuse. All allegations of abuse should be reported immediately to the charge nurse or DON to investigate and must be reported to the State within two hours. During an interview on 01/17/25, at 3:15 P.M., GNP H said cursing at a resident is verbal abuse. If staff witnesses verbal abuse by another staff to a resident, they should immediately report it to the DON or charge nurse. All allegations of abuse should be reported to the State within two hours. During an interview on 01/17/25, at 2:55 P.M., LPN I said staff should report any allegation of abuse immediately to their supervisor. The facility must report all abuse allegations to the State within two hours. During an interview on 01/17/25, at 3:55 P.M., with the Administrator and the DON, the following was said: -On the morning of 01/11/25, LPN D had come to the facility to drop off a family member for work. At that time, NA A told LPN D about the allegation and said he/she had told the on-duty charge nurse, RN C, at the time of the incident around 10:15 P.M. to 10:20 P.M.; -LPN D called the Administrator and the DON to confirm they were aware of the abuse allegation. The Administrator said he/she had not seen the notification text sent to him/her by RN C at 1:08 A.M. that morning and told LPN D to do an investigation. The Administrator said LPN D had NA B write a statement and LPN D conducted and documented the resident interviews; -The Administrator and the DON said RN C should have verified contact with either of them to ensure a timely report to the State and an investigation started. -They said the reported incident would be verbal abuse and should be reported to the State within two hours and an investigation started immediately. MO00247859 51882

Based on observation, interview and record review, the facility failed to implement the facility's policy regarding allegations of abuse when staff did not investigate all allegations of abuse committed by one resident (Resident #6) with a documented history of increased sexual behaviors and impulse control who staff witnessed standing over, with hands near the privates, of one dependent resident (Resident #1) who lay in bed with covers and undergarments pulled down staring at his/her exposed body despite multiple attempts to redirect. Staff also witnessed the resident make sexual remarks to another dependent resident (Resident #14) then later crawl into bed with the resident without his/her consent. Staff also failed to investigate in a timely manner, an allegation of a verbal threat by staff to harm one resident (Resident #8). Staff also did not immediately report allegations of abuse to the State Licensing Agency as required. Twelve residents, with two additional residents were chosen for review. The facility census was 51. 1. Record review of the facility's Abuse/Neglect policy, dated 6/13/2014, titledPolicy and Procedure Abuse Neglect included the following information: -Policy: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. It is the policy of the facility to ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate adjudicate alleged resident abuse and neglect; -Definitions: Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion, and the facility's responsibilities to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property, that if left unchecked, lead to abuse; -Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the individual, family members or legal guardians, friends, or other individuals; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish; -Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault; -Training: It is the responsibility of the administrator and Director of Nursing Services to ensure the training of employees, through orientation and on-going in-services on issues related to abuse prohibition practices which include: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; how staff should report their knowledge related to allegations without fear of reprisal; and what constitutes abuse; -Identification: It is the responsibility of the administrator and Nursing Services to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation; -Investigation: The administrator and/or the Director of Nursing Services are responsible for initiation of the investigation immediately upon notification of alleged event or findings. The facility will document investigation findings, including witness statements, corrective actions, and conclusions in administrative file. Facility will be responsible to notify the resident, resident's legal representative or interested family member of any investigational findings and facility outcomes as allowable within privacy standards; -Protection: The administrator and Director of Nursing Services are responsible for taking immediate action and ensuring the resident is protected from harm during the investigation of the alleged incident New employees are in-serviced on resident's rights and resident abuse and neglect at orientation and all employees participate in biannual resident's rights and resident abuse and neglect in-services to assure they are aware of the importance of these policies; -Reporting: It is the responsibility of every employee of this facility to report alleged violations that include an employee witnessing or having knowledge of any abuse situation occurring in the facility, that employee is to immediately notify the supervisor who will notify the administrator and/or Director of Nursing Services; any allegation of abuse (rather it is substantiated or not) reported by the resident, staff, or responsible party; -Alleged incidents include occurrences between staff/resident, resident/resident, family, visitor, volunteer, and responsible party/resident; -Once facility administration becomes aware of any of these alleged violations, the facility must report immediately to the designated state agency. CMS indicates that the termimmediately means as soon as possible, but no more than 24-hours after the alleged incident is discovered. It is irrelevant whether the facility investigated the incident and determined the allegations were unfounded; all alleged violations must be reported immediately; -After the facility submits an immediate report of an alleged violation, the facility must conduct a thorough investigation; prevent any other incidents from occurring during the course of investigation and report the results of the investigation to the state agency within 5 working days or as designated by state law. The facility may report the results of an investigation by completing the remainder of the reporting form and resubmitting it to the state agency; -The administrator and Director of Nursing Services shall analyze the occurrences to determine what changes are needed, if any, to facility practices to prevent further occurrences. 2. Record review of Resident #6's face sheet showed an original admission date of [DATE] and a readmission date of [DATE], from a psychiatric hospital. [DIAGNOSES REDACTED]. -[MEDICAL CONDITION] with delusions due to known physiological condition; -Dementia with behavior disturbance; -[MEDICAL CONDITION]. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 08/17/15, showed the following information: -Cognition severely impaired; -Inattention and disorganized thinking comes and goes; -Feeling down or depressed; -Feeling bad about self - or feeling of letting self and family down; -Hallucinations; -Other behavior symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds); -Behavior symptoms did not put others at significant risk or physical injury; -Behavior symptoms did not intrude on the privacy or activity of others; -Behavior symptoms did not significantly disrupt care or living environment; -Required limited assistance with bed mobility; -Required extensive assistance for transfers, walking, dressing and toileting; -Not steady, but able to stand and transfer self, without human assistance; -Used a walker or wheelchair for mobility; -[MEDICAL CONDITION]; -Anxiety; -Depression; -Received antidepressant and antianxiety medications seven days a week. Record review of the resident's care plan, dated 08/17/15, showed the following information: -At risk for inappropriate sexual activity; -Help resident identify sexual needs as resident struggles with expressing desire; -Until the resident determines what role sexual material will play in his/her life, it is difficult to establish safe and appropriate boundaries; -Social Service Director (SSD) to help the resident work through this with family, so please ask them where resident is on his/her journey in this new territory; -Obtain necessary psychological/medical/spiritual consults as needed; -Offer to help resident explore his/her sexuality with appropriate boundaries; -Help the resident log onto the facility computer and monitor him/her every 30 minutes to make sure he/she is not viewing pornographic material as the facility computer is not an appropriate avenue for this activity; -Help resident understand his/her sexuality is nothing to be ashamed of or embarrassed by. Reassure resident his/her feelings are normal and help him/her channel those feelings appropriately. Record review of the SSD progress notes, dated 08/24/15, showed the following information: -Resident apologized for his/her behavior and said curiosity got the better of me; -Resident told the SSD, he/she did not wish to partake in this kind of behavior and he/she would be stopping; -Staff called SSD over the weekend and informed her that the resident spent the majority of the day looking at pornography on the facility computer; -Spoke with the resident and a family member about pornography history and how exploring sexuality was alright, but using the facility equipment to do it was not alright. Record review of the resident's September 2015 nurses' notes showed the following information: -On 09/26/15, at 2:45 P.M., a nurse documented two certified nurse aides (CNA) reported the resident was standing close to his/her roommate's (Resident #1) bed. Staff redirected the resident back to his/her side of the room. Ten minutes later, staff again found the resident standing by his/her roommate's bed with the roommate's blankets/sheets at the foot of the bed. The roommate's personal undergarments were also pulled down the residents legs. Staff againintercepted and redirected the resident to his/her own side of the room; -On 09/26/15, at 2:50 P.M., a nurse documented staff reported, a third time, the resident stood close to the roommate's bed and they redirected the resident to his/her own side of the room. The nurse notified the SSD who instructed the nurse to notify the Director of Nurses (DON); -On 09/26/15, at 3:30 P.M., a nurse documented the DON called the facility and the nurse reported the incidents and of staff relocating the roommate (Resident #1) to another room. The nurse informed the DON of the SSD's suggestion of a psychiatric evaluation at an acute care setting (hospital). The DON will address this on Monday per SSD suggestion; -On 09/26/15, at 4:00 P.M., a nurse documented the resident apologized to two CNAs, at separate times, for his/her actions earlier. He/she said he/she only wanted his/her roommate to go somewhere with him/her. -On 09/27/15, at 8:50 P.M., a nurse documented staff redirected the resident off the C hall, where his/her former roommate (Resident #1) now resided. Shortly after staff redirected him/her, the resident propelled himself/herself to the C hall and attempted to open a door. Staff redirected the resident away from the room again and wheeled him/her to his/her room. A few minutes later, staff found the resident again half way down the C hall in the doorway of Resident #1's room. Resident #1 shouted,Help! Staff redirected the resident out of the room. The resident said, he/she wasjust trying to be friends, but it was no use. The resident told the nurse, Resident #1 was always alone and he/she wanted to keep Resident #1 company; it used to be his/her (Resident #6's) room and he/she had been in and out of there many times. Staff instructed the resident not to go in other residents' rooms and redirected him/her back to his/her room. The resident said he/she would not go in there again. -On 09/29/15, at 2:30 P.M., a nurse documented staff transported the resident to an adult psychiatric hospital for evaluation. The resident's family was at the facility and spoke with the SSD. Record review of a form titled Acute Visit, completed by the resident's physician on 09/29/15, showed yesterday (09/28/15), the physician received a report of Resident #6 fondling another resident (Resident #1). Resident #6 denied this allegation and said he/she was helping Resident #1 with his/her blankets which were wrapped around him/her. Record review of an Intake Assessment form for the Behavioral Health System (facility for the evaluation and treatment of [REDACTED].M. (three days after the incident), showed the following information: -The facility staff phoned the behavioral treatment center requesting admission for the resident's identified problems of [MEDICAL CONDITION] and sexual maladaptive behavior (SMB - behaviors that fall outside of the acceptable social limits); -Facility staff reported to the treatment center the resident's display of threatening and [MEDICAL CONDITION], seen in three different incidents while at the facility; -Resident reported to be displaying increased sexual behavior - masturbation and pornography. Resident's roommate (Resident #1) was found disrobed on 09/26/15. Staff found the resident several times on his/her roommate's side of the room and required redirection to stay on his/her own side of room. Resident has been pulling roommate's bedding and undergarments down; -Resident is free from severe cognitive impairment. Record review of the resident's psychiatry progress note from the hospital, dated 10/05/15, showed the physician documented the resident appeared to be, most of the time, oriented to person, place and time. Most of the time, the resident seems to have some good recollection, but does not remember exactly what happened about his/her inappropriate sexual acting out behavior that led to this hospitalization . He/she had minimal insight regarding his/her sexual acting out behavior, but was not actively verbalizing what happened on that particular issue. Record review of the resident's psychiatry progress note from the hospital, dated 10/07/15, showed the physician documented the resident would not say why he/she thought he/she was admitted into a psychiatric hospital. When the resident's sexual inappropriate behavior was mentioned to the resident, he/she neither denied or agreed to it. In addition to this, it was mentioned that the resident was agitated almost to the point of being combative in placement. At this point, the resident has no particular insight regarding his/her difficulties or elected not to verbalize them but recognized the reason why he/she is here. So far the resident has not exhibited any inappropriate sexual acting out behavior that had been observed from him/her while in placement. Continue [MEDICATION NAME] (female hormone), [MEDICATION NAME] (antidepressant prescribed and documented by the physician to treat the resident's anxiety and inappropriate sexual acting out behavior), and [MEDICATION NAME] (antipsychotic medication). Record review of the Behavioral Health System Aftercare/Discharge Summary showed the following information: -Staff admitted the resident to the hospital on [DATE], with a [DIAGNOSES REDACTED]. On 10/13/15, the resident discharged and returned to the facility with a discharge [DIAGNOSES REDACTED]. Problems addressed and status of treatment goals at discharge included disturbed thought process. Discharge medications included [MEDICATION NAME] for treatment of [REDACTED]. Record review of the resident's History and Physical assessment, completed by the resident's primary physician and dated 10/15/15, showed the resident reported decreased sexual urges. Record review of forms titled Acute Visit, physician assessments signed and dated by the resident's physician, showed the following information: -10/27/15: Aberrant (departure from the normal) sexual behavior-improved; -11/06/15: Reports no sexual urges; -11/10/15: Has had some sexual ideation's return. Record review of the resident's significant change MDS, dated [DATE], showed the following information: -Cognition severely impaired; -[MEDICAL CONDITION] with hallucinations; -Felt bad about self or felt he/she let self and family down; -No behaviors; -Required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene; -Not steady, but able to stand and transfer self, without human assistance; -Used a walker or wheelchair for mobility; -[DIAGNOSES REDACTED]. -Psychological therapy for at least 15 minutes one day within the last seven days. Record review of the resident's care plan, dated 11/10/15, showed the following information: -Recently returned from Behavioral Health System; -Significant change in condition with improvement in activities of daily living (ADL) and behaviors; -Continued to have cognitive loss/dementia; -Administer medications as ordered; -Encourage to participate in activities; -Provide cues and supervision. Anticipate needs and check on resident hourly and as needed (PRN). Provide consistent daily routine; -Structure daily programs around the physical aspects of the resident's life; cognitive, exercise, ADL's, eating, etc. Encourage and assist to group activities if needed; -Divert resident's behavior by the use of activities; -Support appropriate moods/behaviors; -Occupy resident with meaningful distractions: music, companion, crafts, etc.; -Assess and document effectiveness of antianxiety and antidepressant medications; -Monitor and document the resident's abnormal behavior and response to medication every shift; -Report any change in condition to the physician; -Help resident identify sexual needs as resident struggles with expressing desire he/she does not want to engage or look at any kind of pornographic material but is unable to stop; -Until the resident determines what role sexual material will play in his/her life, it is difficult to establish safe and appropriate boundaries; -SSD to help the resident work through this with resident's family so please ask them where Resident is on his/her journey in this new territory; -Obtain necessary psych/medical/spiritual consults as needed; -Monitor resident for inappropriate behaviors and report to the charge nurse immediately; -Offer to help resident explore his/her sexuality with appropriate boundaries; -Help the resident log onto the facility computer and monitor him/her every 30 minutes to make sure he/she is not viewing pornographic material as the facility computer is not an appropriate avenue for this activity; -Help resident understand his/her sexuality is nothing to be ashamed of or embarrassed by. Reassure resident his/her feelings are normal and help him/her channel those feelings appropriately. Record review of the physicians Interval Examination Form, dated 11/17/15, showed the physician documented the resident has had some sexual temptation, but was not acting on it. Record review of the physician's progress note, dated 12/01/15, showed the physician documented the resident's hypersexuality (extremely frequent or suddenly increased sexual urges or sexual activity) showed some deterioration based on speech content. Record review of the December 2015 nurses' notes showed the nurses documented the following information: -On 12/08/15, at 10:30 P.M., staff found the resident naked in his/her room sitting on the side of bed; -On 12/10/15, at 12:30 A.M., staff directed the resident to bed when they discovered him/her walking in the hallway. A few minutes later, staff discovered the resident in roommate's (Resident #14) bed laying with the roommate. Staff directed the resident back to his/her own bed; -On 12/10/15, at 3:00 P.M., staff reported the resident inappropriately touching them; -On 12/11/15, at 7:40 P.M., staff heard Resident #6 making inappropriate sexual comments to his/her roommate (Resident #14). Staff notified the DON, moved the roommate to another room and placed Resident #6 on 15 minute checks until further notice; -On 12/11/15, at 7:50 P.M., the nurse notified the physician; -On 12/11/15, at 11:30 P.M., the resident was anxious, wandered occasionally and looked into other residents' rooms. Staff easily redirected him/her, but only for short periods of time. Staff continued safety checks on the resident every 15 minutes; -On 12/14/15, at 11:35 A.M., the nurse notified physician of the resident's increase in behaviors; -On 12/15/15, at 12:10 A.M., staff monitored the resident every 15 minutes; -On 12/16/15, at 12:45 A.M., staff checked on the resident frequently. Record review of the facility's form titled,15 Min. Checks showed the following information: -On 12/11/15, from 6:00 P.M. to 6:30 P.M., staff signed the form (at 15 minute intervals) indicating they visibly checked the resident every 15 minutes. From 6:45 P.M. to 11:15 P.M., staff drew a line with an arrow indicating they visibly checked the resident every 15 minutes (for four hours and 30 minutes). Staff resumed signing the sheet indicating they visibly checked on the resident from 11:30 P.M. to 5:45 A.M.; -On 12/12/15, from 6:00 A.M. to 5:45 A.M. (the following morning), staff signed the monitoring sheet (at 15 min intervals) indicating they visibly checked on the resident every 15 minutes; -On 12/13/15, from 6:00 A.M. to 6:45 A.M. (45 minutes), staff did not sign the monitoring sheet to indicate they visibly checked on the resident every 15 minutes. From 7:00 A.M. to 5:45 P.M., staff signed the form indicating they visibly checked the resident every 15 minutes. From 6:00 P.M. to 10:00 P.M. staff drew a line with an arrow indicating they visibly checked the resident every 15 minutes (for four hours) then discontinued the 15 minute monitoring checks. Record review of a Psychological Services session, dated 12/14/15, showed the psychologist provided the resident supportive talk therapy to address adjustment and discussed disease and how it affected impulses. Observation and interview on 12/14/15, at 2:30 P.M., showed the resident gone from his/her room. The Director of Nurses (DON) said the resident had some roommate issues. Problems centered around the resident taking too much time in the bathroom. The DON said the resident was veryimpulsive and/or manic (excited, emotional, intense). The resident spent some time in a psychiatric hospital three months ago. The physician readjusted the resident's antipsychotic medications, but the issues are getting worse. Observation and interview on 12/14/15, at 5:00 P.M., showed CNA I entered the room and assisted the resident with toileting and dressing. CNA I said he/she noticed the resident required more assistance with ADLs in the past couple of weeks.Some days are better than others. The resident could take him/herself to the bathroom, but staff checks and takes him/her on days when he/she needs more assistance. The CNA said at one time, the resident was sexually inappropriate. Observations on 12/15/15 showed the following information: -From 9:15 A.M. to 10:30 A.M., the door to the resident's room closed. The room remained darkened and the resident lay in bed with his/her eyes closed. No staff was observed checking in on the resident during this time. -At 11:35 A.M., the resident sat in his/her wheelchair wandering the hallways unattended. During an interview on 12/15/15, at 11:40 A.M., CNA B said staff checks on the resident at least every 30 minutes. The resident did not have any behaviors he/she was aware of. During an interview on 12/17/15, at 2:30 P.M., Licensed Practical Nurse (LPN) G said the following: -He/she and LPN H worked the night (09/26/15) staff found the resident standing over his/her roommate (Resident #1). Resident #1 was yelling. Staff believed the resident was inappropriate with Resident #1. -Registered Nurse (RN) G remained at the facility after his/her shift ended to assist LPN H and help problem solve. -LPN H notified the DON of the incident; RN G did not know what the DON said. RN H also notified the SSD. Neither nurse notified the administrator; they assumed the DON called the administrator. The RN did not know how the administrator became aware of the incident. -Staff moved Resident #1 to another hall. -Both he/she and LPN H thought the DON or the administrator would come to the facility and start an investigation but they never did. -Resident #6 was very impulsive. The nurses instructed staff to keep an eye on the two residents and keep them separated. -Resident #1 was upset and would yell out. After the incident, he/she refused to eat or take his/her medications, but the RN did not know if this was a direct result of the incident. Now, Resident #1 is doing great; but every now and then he/she may have day he/she is more resistive to cares. -Since Resident #6 returned to the facility (10/13/15), following a stay in the Behavioral Health System, the resident has had two other roommates. The RN could not remember any specific incidents between Resident #6 and Resident #14, but he/she did remember Resident #14 would point at Resident #6 and say he/she is crazy. Resident #15 was Resident #6's roommate prior to Resident #14. Resident #15 complained Resident #6 took his/her stuff. -The facility had not provided staff with any recent in-services on managing residents with behavior issues. -RN G said the resident knows what he/she is doing but just cannot help it. During an interview on 12/17/15, at 3:08 P.M., CNA B said he/she witnessed the incident on 09/26/15 between Resident #6 and his/her roommate (Resident #1). The door to the residents' room was open and he/she saw Resident #6 standing over Resident #1. Resident #1's undergarments were down to his/her knees and he/she was curled up in a ball saying,No! Resident #6 just stood there, staring at Resident #1. The CNA assisted Resident #6 into his/her wheelchair and wheeled him/her out of the room. The CNA reported the incident to the nurse. The nurse instructed us (the staff) to keep an eye on Resident #6 and conducted 15 minute checks on the resident. Staff moved Resident #1 into another room the same day the incident occurred. The CNA was not aware of Resident's #6's recent history of viewing pornography on a facility computer. Resident #1 acted fine, after the incident, just quiet. He/she was not aware of any other incidents between Resident #6 and other residents. The facility had not conducted any recent in-services with staff pertaining to this subject matter. During an interview on 12/17/15, at 3:17 P.M., CNA C said the following: -He/she received in report, information about the incident between Resident #6 and Resident #1. Staff told him/her Resident #6 was standing over Resident #1's bed; Resident #1's brief was pulled down around his/her ankles. Staff moved Resident #1 to the C-hall. -The nurse instructed staff to keep an eye on Resident #6 when he/she was around other residents and to listen and watch for inappropriate behavior. The nurse also instructed staff to check on Resident #1 to ensure he/she was okay and that Resident #6 was not near him/her. -The CNA heard from other staff, Resident #6 wheeled himself/herself to the C-hall, looking for Resident #1. He/she poked his/her head in other residents' rooms, but did not make it to Resident #1's room. When staff redirected Resident #6 off of the C-hall, he/she became snippy. -After the 09/26/15 incident between Resident #6 and Resident #1, Resident #1 became really grouchy and did not want to get out of bed, to eat or do anything. He/she did not want to be bothered. -For about a week prior to his/her hospitalization (09/29/15), Resident #6 acted strange; he/she was usually well mannered, but at that time, the resident acted agitated and jittery. -After Resident #6 returned to the facility, following a stay in the Behavioral Health System, the CNA heard in report that Resident #6 was standing over Resident #14's bed; the CNA did not know the specifics of that incident. Staff moved Resident #14 to another room and moved Resident #6 to a private room. -If staff witnessed any inappropriate actions, they notify the charge nurse. Staff performed 15 minute checks of Resident #6 for a couple of days. -The facility had not conducted any recent in-services with staff pertaining to this subject matter. During an interview on 12/17/15, at 3:35 P.M., CNA D said he/she was not aware of the 09/26/15 incident between Resident #6 and Resident #1. He/she just knew they were now in separate rooms. Staff is conducting 15 minute checks on Resident #6. We are watching for behaviors due to an incident that occurred (recently). The CNA did not know the specifics of the recent incident. He/she did not know of any incidents between Resident #6 and another resident. The facility had not conducted any recent in-services on what to do for residents with inappropriate behaviors. Staff was not currently monitoring Resident #6. During an interview on 12/17/15, at 3:50 P.M., Certified Medication Technician (CMT) E said the following information: -Staff told him/her, in report, about the 09/26/15 incident between Resident #6 and Resident #1. Staff said around bedtime, they found Resident #6 standing/ hovering over Resident #1. Resident #1 was agitated. -The nurse instructed staff to observe Resident #6's behaviors and report any inappropriate behaviors between Resident #6 and Resident #1. -Resident #1 was very agitated for a while. For two weeks, following the incident, Resident #1 would not get up out of bed or take his/her medications.This was a change for him/her. Resident #1 is much better now. -The CMT did not know of any incident between Resident #6 and Resident #14. The CMT thought the reason Resident #6 no longer roomed with Resident #14 was because one resident wanted the TV on while the other resident wanted the TV off. -The facility had not conducted any recent in-services on reporting inappropriate behavior. -Staff documents residents' behaviors in the Medication Administration Record (MAR). A lot of the time, the behaviors we are observing for, are related to a certain medication. The MDS coordinator writes the target behaviors on the MAR and the CMTs document if they observed those behaviors every shift. If a resident is exhibiting a behavior not listed, staff asks the charge nurse to add the new behavior. Record review of Resident #6's December 2015 MAR Section I: Target Behavioral Symptoms showed the following: -[MEDICAL CONDITION] During an interview on 12/17/15, at 6:30 P.M., the administrator and the DON said the following: -The administrator said Resident #6 continued to pester Resident #1, causing Resident #1 to be agitated. That is why staff moved Resident #1 out of Resident #6's room. There is no justification for further action if a resident is just pestering another resident; -They did not know if Resident #1 would allow someone to touch him/her physically; -Resident #6 walked around in his/her room a lot; -Resident #6 stoops when he/she stands; -Administrator was notified of the room change for Resident #1; -The administrator believed he documented speaking with staff about the incident between Resident #6 and Resident #1, but need to look into it; -After the incident with Resident #6 and room change, Resident #1 was just Resident #1; -Not aware of Resident #6 lying in bed with Resident #14; -When Resident #1 is wet or soiled, he/she will pull his/her incontinent brief down; -Resident #1 is low functioning and yells out at times when he/she does not like something. This was an ongoing issue; -Resident #1 did not adjust to change well and has a history of not eating or staying in his/her room whenever moved to a new room; -The administrator said Resident #6's pornography viewing was the only thing

Based on record review, observations and interviews the facility failed to protect residents and maintain an environment free from harassment of one resident (Resident #6) with a documented history of increased sexual behaviors and impulse control who staff witnessed standing over, with hands near the privates, of one dependent resident (Resident #1) who lay in bed with covers and undergarments pulled down staring at his/her exposed body despite multiple attempts to redirect. Staff also witnessed the resident make sexual remarks to another dependent resident (Resident #14) then later crawled into bed with the resident without his/her consent. The facility failed to identify, adjust and implement different interventions in an attempt to prevent further falls for one resident (Resident #8) with a known history of falling. The facility census was 51. 1. Record review of the facility's Abuse Neglect policy, dated 6/13/2014, and titled, Policy and Procedure Abuse Neglect included the following: -Purpose: To establish guidelines that identifies and report resident abuse and neglect; -Policy: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. It is the policy of the facility, to ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate adjudicate alleged resident abuse and neglect; -Definitions: Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion, and the facility's responsibilities to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property, that if left unchecked, lead to abuse; -Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the individual, family members or legal guardians, friends, or other individuals; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or deprivation by an individual, including a caretaker, or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish; -Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault; -Training: It is the responsibility of the administrator and Director of Nursing Services to ensure the training of employees, through orientation and on-going in-services on issues related to abuse prohibition practices which include: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; How staff should report their knowledge related to allegations without fear of reprisal; and what constitutes abuse; -Identification: It is the responsibility of the administrator and Nursing Services to; identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation; -Investigation: The administrator and/or the Director of Nursing Services are responsible for initiation of the investigation immediately upon notification of alleged event or findings. Facility will document investigation findings, including witness statement, corrective actions, and conclusions in administrative file. Facility will be responsible to notify the resident, resident's legal representative or interested family member of any investigational findings and facility outcomes as allowable within privacy standards; -Protection: The administrator and Director of Nursing Services are responsible for taking immediate action and ensuring the resident is protected from harm during the investigation of the alleged incident. New employees are in-serviced on resident's rights and resident abuse and neglect at orientation and all employees participate in biannual resident's rights and resident abuse and neglect in-services to assure they are aware of the importance of these policies; -Reporting: It is the responsibility of every employee of this facility to report alleged violations that include an employee witnesses or has knowledge of any abuse situation occurring in the facility, that employee is to immediately notify the Supervisor who will notify the administrator and/or Director of Nursing Services; and any allegation of abuse (rather it is substantiated or not) reported by the resident, staff, or responsible party; -Alleged incidents include occurrences between staff/resident, resident/resident, family, visitor, volunteer, and responsible party/resident; -After the facility submits an immediate report of an alleged violation, the facility must conduct a thorough investigation; prevent any other incidents from occurring during the course of investigation and report the results of the investigation to the state agency within 5 working days or as designated by state law. The facility may report the results of an investigation by completing the remainder of the reporting form and resubmitting it to the state agency; -The administrator and Director of Nursing Services shall analyze the occurrences to determine what changes are needed, if any, to facility practices to prevent further occurrences. 2. Record review of Resident #6's face sheet showed an original admission date of [DATE] and a readmission date of [DATE], from a psychiatric hospital. [DIAGNOSES REDACTED]. -Psychotic disorder with delusions due to known physiological condition; -Dementia with behavior disturbance; -Parkinson's disease. Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff), dated 08/17/15, showed the following information: -Cognition severely impaired; -Inattention and disorganized thinking comes and goes; -Feeling down or depressed; -Feeling bad about self - or feeling of letting self and family down; -Hallucinations; -Other behavior symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds); -Behavior symptoms did not put others at significant risk or physical injury; -Behavior symptoms did not intrude on the privacy or activity of others; -Behavior symptoms did not significantly disrupt care or living environment; -Extensive assistance needed for transfers, ambulation in room, dressing and toileting; -Not steady, but able to stand and transfer self, without human assistance; -Uses a walker or wheelchair for mobility; -Parkinson's; -Anxiety; -Depression; -Receives antidepressant and antianxiety seven days a week. Record Review of the resident's care plan, dated 08/17/15, showed the following information: -At risk for inappropriate sexual activity; -Help resident identify sexual needs as resident struggles with expressing desire he/she does not want to engage or look at any kind of pornographic material, but is unable to stop; -Until the resident determines what role sexual material will play in his/her life, it is difficult to establish safe and appropriate boundaries; -Social Service Director (SSD) to help the resident work through this with resident's family so please ask them where resident is on his/her journey in this new territory; -Obtain necessary psych/medical/spiritual consults as needed; -Offer to help resident explore his/her sexuality with appropriate boundaries. -Help the resident log onto the facility computer and monitor him/her every 30 minutes to make sure he/she is not viewing pornographic material as the facility computer is not an appropriate avenue for this activity; -Help resident understand his/her sexuality is nothing to be ashamed of or embarrassed by. Reassure resident his/her feelings are normal and help him/her channel those feelings appropriately. Record review of the resident's SSD progress notes, dated 08/24/15, showed the following information: -Resident apologized for his/her behavior and said curiosity got the better of me.; -Resident said to SSD, he/she did not wish to partake in this kind of behavior and they would be stopping. Record review of the September 2015 nurses' notes showed the following information: -On 09/26/15, at 2:45 P.M., a nurse documented two certified nurse aides (CNA) reported the resident standing over close to the roommate's (Resident #1's) bed. Staff redirected the resident back to his/her side of the room, then 10 minutes later, again found the resident standing by the roommates bed with the roommates blankets/sheets to the foot of the bed. The roommate's personal undergarments also pulled down the residents legs. Staff again intercepted and redirected the resident to his/her own side of the room; -At 2:50 P.M., staff reported a third time the resident standing close to the roommates bed and redirected the resident to his/her own side of the room. Social Services notified of resident's behavior and was directed to notify the Director of Nurses (DON); -At 3:30 P.M., a nurse documented the DON called the facility and the nurse reported the incidents and of relocating the roommate to another room. The DON was informed of the SSD suggestion of a psychiatric evaluation at an acute care setting. The DON to address initiation Monday per SSD suggestion; -At 4:00 P.M., a nurse documented the resident apologized to two CNAs at separate times for his/her actions earlier saying he/she only wanted his/her roommate to go somewhere with him/her. -On 09/27/15, at 8:50 P.M., a nurse documented staff redirected the resident off the C hall where his/her former roommate now resided. Resident soon propelled him/herself back to the C hall and grabbed at a door handle to open the door. Staff redirected the resident away from the room again and took him/her off the hall to his/her room. A few minutes later, staff found the resident again half way down the C hall in the doorway of Resident#1's room. Resident #1 shouted, Help! Staff redirected the resident out of the room. The resident said, Just trying to be friends. No use. He/she is always alone and wanted to keep him/her company. That used to be my room and I've been in and out of there many times. Staff informed the resident not to go in other residents' rooms and redirected back to his/her room. The resident said, Oh I won't go in there again after that. -On 09/29/15, at 2:30 P.M., a nurse documented staff transported the resident to an adult psychiatric hospital for evaluation. Record review of a form titled Acute Visit, completed by the resident's physician on 09/29/15, showed the following information: -Yesterday (09/28/15), the physician received a report of Resident #6 fondling another resident. Resident #6 denied this stating he/she was helping with the resident's blankets which were wrapped around him/her. Record review of an Intake Assessment form for the Behavioral Health System (facility for the evaluation and treatment of [REDACTED].M. (three days after the incident), showed the following information: -The facility staff phoned the behavioral treatment center requesting admission for the resident's identified problems of psychosis and sexual maladaptive behavior (SMB); -Facility staff reported to the treatment center the resident's display of threatening and hypersexual behaviors, seen in three different incidents while at the facility. -Resident reported to be displaying increased sexual behavior - masturbation and pornography. Resident's roommate was found disrobed on 09/26/15. Resident found several times on roommate's side of the room and required redirection to stay on his/her own side of room. Resident has been pulling roommate's bedding and undergarments down; -Resident is free from severe cognitive impairment. Record review of the psychiatry Progress Note, dated 10/05/15, showed the physician documented the resident appeared to be, most of the time, oriented times three (person, place and time). In some cases, at times when he/she could also have some lapses of memory, but most of the time seems to have some good recollection, although he/she does not remember exactly what happened about his/her inappropriate sexual acting out behavior that led to this hospitalization . He/she has minimal insight as far as his/her sexual acting out behavior is concerned, but is not actively verbalizing what happened on that particular issue. Record review of the psychiatry Progress Note, dated 10/07/15, showed the physician documented the resident normally does not verbalize the reason why he/she ended up here because of his/her inappropriate sexual acting out behavior in placement. When this was mentioned to the resident, he/she neither denied or agreed to it. In addition to this, it was mentioned that he/she was agitated almost to the point of being combative in placement. At this point, the resident has no particular insight regarding his/her difficulties or elected not to verbalize them but recognized the reason why he/she is here. So far the resident has not exhibited any inappropriate sexual acting out behavior that had been observed from him/her while in placement. Continue Provera (female hormone), Paxil (antidepressant prescribed and documented by the physician to treat the resident's anxiety and inappropriate sexual acting out behavior), and Zyprexa (antipsychotic medication). Record review of the Behavioral Health System Aftercare/Discharge Summary showed the resident admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 10/13/15, the resident discharged and returned to the facility with a discharge [DIAGNOSES REDACTED]. Problems addressed and status of treatment goals at discharge included disturbed thought process. Discharge medications included Zyprexa for treatment of [REDACTED]. Record review of of the physician's History and Physical assessment dated [DATE], showed the physician documented the resident reports decreased sexual urges. Record review of forms titled, Acute Visit, physician assessments signed and dated by the resident's physician, showed the following information: -On 10/27/15: Aberrant sexual behavior - improved; -On 11/06/15: Reports no sexual urges; -On 11/10/15: Has had some sexual ideation's return. Record review of the resident's significant change MDS, dated [DATE], showed the following information: -Cognition severely impaired; -Psychosis with hallucinations; -Feeling bad about self - or feeling of letting self and family down; -No behaviors; -Extensive assistance needed for bed mobility, transfers, dressing, toileting and personal hygiene; -Not steady, but able to stand and transfer self, without human assistance; -Uses a walker or wheelchair for mobility; -Dementia; -Parkinson's; -Psychotic disorder (other than schizophrenia); -Psychological therapy for at least 15 minutes one day within the last seven days. Record review of the resident's care plan, dated 11/10/15, showed the following information: -Recently returned from Behavioral Health System; -Significant change in condition with improvement in activities of daily living (ADLs) and behaviors; -Continues to have cognitive loss/dementia; -Administer medications as ordered; -Provide cues and supervision. Anticipate needs and check on resident hourly and as needed (PRN). Provide consistent daily routine; -Structure daily programs around the physical aspects of the resident's life; cognitive, exercise, ADLs, eating, etc.; -Divert resident's behavior by the use of activities; -Support appropriate moods/behaviors; -Occupy resident with meaningful distractions: music, companion, crafts, etc.; -Assess and document effectiveness of antianxiety and antidepressant medications; -Monitor and document the resident's abnormal behavior and response to medication every shift; -Report any change in condition to the physician; -Help resident identify sexual needs as resident struggles with expressing desire he/she does not want to engage or look at any kind of pornographic material but is unable to stop; -Until the resident determines what role sexual material will play in his/her life, it is difficult to establish safe and appropriate boundaries; -SSD to help the resident work through this with resident's family so please ask them where resident is on his/her journey in this new territory; -Obtain necessary psych/medical/spiritual consults as needed; -Monitor resident for inappropriate behaviors and report to the charge nurse immediately; -Offer to help resident explore his/her sexuality with appropriate boundaries; -Help the resident log onto the facility computer and monitor him/her every 30 minutes to make sure he/she is not viewing pornographic material as the facility computer is not an appropriate avenue for this activity; -Help resident understand his/her sexuality is nothing to be ashamed of or embarrassed by. Reassure resident his/her feelings are normal and help him/her channel those feelings appropriately. Record review of the physician's Interval Examination Form, dated 11/17/15, showed the physician documented the resident has had some sexual temptation, but was not acting on it. Record review of the physician's progress note, dated 12/01/15, showed the physician documented the resident's hypersexuality showing some deterioration based on speech content. Record review of the resident's December 2015 nurses' notes showed the nurses documented the following information: -On 12/08/15, at 10:30 P.M., resident found naked in room on the side of bed; -On 12/10/15, at 12:30 A.M., resident directed to bed when discovered walking the hallway. A few minutes later, staff discovered the resident in roommate's (Resident #14) bed laying with roommate. Staff directed the resident back to his/her own bed; -On 12/10/15, at 3:00 P.M., staff report the resident inappropriately touching them; -On 12/11/15, at 7:40 P.M., resident observed making inappropriate sexual comments to his/her roommate. Notified the DON and moved the roommate to another room. Resident placed on 15 minute checks until further notice; -On 12/11/15, at 7:50 P.M., physician notified; -On 12/11/15, at 11:30 P.M., resident anxious and wanders occasionally. Easily redirected, but for short periods of time. Resident looking in other residents' rooms. Staff to continue safety checks every 15 minutes; -On 12/14/15, at 11:35 A.M., physician notified of the resident's increase in behaviors; -12/15/15, at 12:10 A.M., resident monitored every 15 minutes; -12/16/15, at 12:45 A.M., resident checked frequently. Record review of the facility's form titled 15 Min. Checks showed the following information: -On 12/11/15, from 6:00 P.M. to 6:30 P.M., staff signed the form indicating they visibly checked the resident every 15 minutes. From 6:45 P.M. to 11:15 P.M., staff drew a line with an arrow indicating they visibly checked the resident every 15 minutes (for four hours and 30 minutes). Staff resumed signing the sheet indicating they visibly checked on the resident from 11:30 P.M. to 5:45 A.M.; -On 12/12/15, from 6:00 A.M. to 5:45 A.M. (the following morning), staff signed the monitoring sheet indicating they visibly checked on the resident every 15 minutes; -On 12/13/15, from 6:00 A.M. to 6:45 A.M. (45 minutes) staff did not sign the monitoring sheet to indicate they visibly checked on the resident every 15 minutes. From 7:00 A.M. to 5:45 P.M., staff signed the form indicating they visibly checked the resident every 15 minutes. From 6:00 P.M. to 10:00 P.M. staff drew a line with an arrow indicating they visibly checked the resident every 15 minutes (for four hours) then discontinued the 15 minute monitoring checks. Record review of a Psychological Services session, dated 12/14/15, showed the psychologist documented the resident was provided with supportive talk therapy to address adjustment. Discussed disease and how it effects impulses. Observation and interview on 12/14/15, at 2:30 P.M., showed the resident gone from his/her room. The Director of Nurses (DON) said the resident has had some roommate issues. Problems center around the resident taking too much time in the bathroom. The DON said the resident is very impulsive and/or manic. He/she spent some time in a psychiatric hospital three months ago. The physician readjusted the resident's antipsychotic medications, but the issues are getting worse. Observation on 12/14/15, at 2:45 P.M., showed the resident in a wheelchair wandering in the dining room near the kitchen serve out windows. The resident's voice was barely audible and incoherent. Observation and interview on 12/14/15, at 5:00 P.M., showed CNA I entered the room and assisted the resident with toileting and dressing. CNA I said he/she noticed the resident required more assistance with ADLs in the past couple of weeks. Some days are better than others. The resident can take him/herself to the bathroom, but staff check and take him/her on days when he/she needs more assistance. The CNA said the resident was sexually inappropriate at one time. Observation on 12/15/15, from 9:15 A.M. to 10:30 A.M., showed the door to the resident's room closed. The room remained darkened and the resident in bed with eyes closed. No staff observed checking in on the resident during this time. Observation on 12/15/15/, at 11:35 A.M., showed the resident in his/her wheelchair wandering the hallways unattended. During an interview on 12/15/15, at 11:40 A.M., CNA B said staff check on the resident at least every 30 minutes. The CNA said the resident did not have any behaviors he/she was aware of. During an interview on 12/17/15, at 2:30 P.M., Registered Nurse (RN) G said he/she and RN H worked the night when staff found the resident standing over his/her roommate (Resident #1). RN G said staff believed the resident was inappropriate with Resident #1 and Resident #1 was yelling. RN G said he/she hung around after his/her shift because he/she knew the residents needed to be separated and he/she stayed on to assist and help problem solve. RN H notified the DON and staff moved Resident #1 to another hall as instructed by the SSD. RN G said both he/she and RN H believed the DON or the administrator would come do an investigation, but they never did. RN H told RN G the next day that nothing was done. Resident #6 was very impulsive. Staff were instructed to keep an eye on the two residents and keep them separate. Resident #1 refused to eat or take his/her medications after the incident. Since Resident #6 returned to the facility following a stay in the Behavioral Health System, the resident had incidents with two other residents. Staff were not provided any recent inservices on managing residents with behavior issues. Approximately two months ago, a CNA voiced concern about providing care for Resident #6. RN G said the resident knows what he/she is doing but just cannot help it. During an interview on 12/17/15, at 3:15 P.M., CNA B said he/she witnessed the incident with the resident and his/her roommate on 09/26/15. The CNA said the door to the resident's room was open and he/she saw Resident #6 standing over Resident #1. Resident #1's undergarments were down to his/her knees, he/she was curled up in a ball and was saying, No! CNA B said he/she redirected Resident #6 away from Resident #1 and was instructed to keep an eye on him/her with 15 minute documentation and notify the nurse if anything observed. CNA B said he/she was not aware of any incidents between Resident #6 and other residents since he/she returned from the psychiatric hospital. Staff have not had any recent inservices on anything pertaining to this subject matter. During an interview on 12/17/15, at 3:17 P.M., CNA C said he/she received in report, information about the incident between Resident #6 and Resident #1. The nurse instructed staff to make sure Resident #6 did not touch or speak to Resident #1 and to keep Resident #6 out of Resident #1's room. CNA C said Resident #6 became snippy when redirected away from Resident #1's hall. After the 09/26/15 incident between Resident #6 and Resident #1, CNA C said Resident #1 refused to eat, shower, or do anything. After Resident #6 returned to the facility following a stay in the Behavioral Health System, he/she received information in report about Resident #6 standing over Resident #14's bed. Staff moved Resident #14 to another room and moved Resident #6 to a private room. If staff witnessed any inappropriate actions, they were instructed to notify the charge nurse. Staff instructed to document 15 minute checks of Resident #6 for two days. Staff have not had any recent inservices on anything pertaining to this subject matter. During an interview on 12/17/15, at 3:35 P.M., CNA D said he/she was not aware of the 09/26/15 incident between Resident #6 and Resident #1. CNA D said he/she just knew they were now in separate rooms and instructed to check resident behaviors every 15 minutes. The CNA said he/she was not aware of the recent incident with Resident #6 and Resident #14. CNA D said staff have not had any recent inservices on what to do for residents with inappropriate behaviors and staff are not currently monitoring Resident #6. During an interview on 12/17/15, at 3:30 P.M., Certified Medication Technician (CMT) E said he/she received information in report pertaining to the 09/26/15 incident between Resident #6 and Resident #1. Following the incident, Resident #1 would not eat or take his/her medications for two weeks. This was a change for him/her. The CMT said he/she was not aware of any incident between Resident #6 and Resident #14. Staff have not had any recent inservices on reporting inappropriate behavior. Behavior charting is documented in the Medication Administration Record (MAR). The MDS coordinator completes target behaviors and the CMTs document on them every day every shift. If a behavior is not listed, staff ask the charge nurse to add the new behavior. Record review of Resident #6's December 2015 MAR Section I: Target Behavioral Symptoms showed the following: -Insomnia. During an interview on 12/17/15, at 6:30 P.M., the administrator and the DON said the following: -Resident #1 moved out of Resident #6's room because Resident #6 continued to pester him/her; -No justification for further action if just pestering; -They did not know if Resident #1 would allow someone to touch him/her physically; -Not aware of Resident #6 lying in bed with Resident #14; -When Resident #1 is wet or soiled, will pull his/her incontinent brief down; -Resident #1 is low functioning and yells out at times when he/she does not like something. This was an ongoing issue; -Resident #1 does not adjust to change well and has a history of not eating or staying in his/her room whenever moved to a new room; -The administrator said Resident #6's pornography viewing was the only thing sexually I was aware of; -When Resident #6 returned from the psychiatric hospital, staff placed him/her with Resident #15 as both residents were very active; -Resident #15 moved to another room because the spouse complained about Resident #6; -Resident #14 moved in with Resident #6 because staff thought they would make better roommates; -Notified last Friday that Resident #6 made inappropriate remarks to Resident #14. Staff heard Resident #6 say Should I molest him/her now? The CNAs told the charge nurse and the residents were separated to different rooms. Resident #6 put on 15 minute checks. During an interview on 12/18/15, at 12:10 P.M., the MDS/Care Plan Coordinator (MDS/CPC) said the following: -Care Plans are updated annually, whenever there is a change in condition, and as needed; -Nurses do not change the care plans often. Just the DON, ADON and MDS/CPC; -Receive information for care plan updates from copies of daily reports, nurses notes, staff, and doctors' orders; -Resident #6's rummaging behaviors go back and forth; -Sexual inappropriateness is a new behavior for Resident #6; -SSD input used for the resident's pornography interventions; -Not aware of any incidents of sexual inappropriateness from Resident #6 following incident with Resident #1 on 09/26/15; -Included general monitoring carefully in the resident's care plan in order to keep the resident's dignity. Staff obtain the details of sexual inappropriateness when they receive report at shift change; -Resident receives Klonopin for anxiety, Parkinson's and [DIAGNOSES REDACTED]; -Resident receives Abilify for psychosis and hallucinations. Should have a behavior monitoring sheet for this medication in the MAR; -Behavior monitoring sheets are kept for any resident on a psychoactive medication. During an interview on 12/18/15, at 12:42 P.M., the medical director said the following; -Staff notified him of two to three incidents involving Resident #6 with other residents; -Staff walked in on Resident #6 standing over Resident #1; Resident #6's hands were near Resident #1's genitalia, but the physician was not sure if staff observed Resident #6 fondling Resident #1. Resident #1 was mad and told Resident #6 to get away from him/her; -Staff moved Resident #1 to another room and transferred Resident #6 to a Psychiatric hospital after the incident; -Resident #1 was much more withdrawn for a couple weeks after the 09/26/15 incident and the physician suspected it was a direct response to the incident; -When the physician tried to examine Resident #1's abdominal area the resident became very guarded of his/her genitalia and would say no, no. There is some question as to if Resident #6 touched Resident #1; -When Resident #6 returned to the facility, staff placed him/her in a room with another resident (Resident #15). Staff did not place the resident into a private room due to a financial conflict about qualifications for the private room; -After hospitalization , Resident #6's behaviors improved, but then he/she became very rigid (stiff, inflexible) as a result of the Zyprexa (an antipsychotic medication) and Abilify (an antipsychotic medication) used for impulse suppression of sexual urges; -Added Proscar (a medication commonly used to treat an enlarged prostate in men) to decrease the resident's libido; -There is some question as to a [DIAGNOSES REDACTED]. There are times Resident #6 is quiet, then he/she escalates to fidgeting, taking things apart, rummaging through others' things and difficulty controlling sexual impulses; -Resident #6's ability to control his/her sexual impulses has been a continuous problem; one he/she has had since he/she was a teenager; Resident #6's [DIAGNOSES REDACTED] (a type of dementia that causes a progressive decline in mental abilities) also affects his/her impulse control; -Family told the SSD about Resident #6's history while he/she was in the Behavioral Health System. The resident moved to this area approximately five years ago, because he/she started viewing Internet pornography, on a family member's computer, while living in their home. He/she also had some questionable actions when he/she was younger; -Staff have recently notified the physician about Resident #14 complaining that Resident #6 was messing with him/her in a sexual nature

Based on record review and interview the facility failed to thoroughly assess and monitor one resident (Resident #1) who was receiving anticoagulant medication for signs and symptoms of active bleeding. The facility failed to notify the resident's physician in a timely manner when the resident began to show signs and symptoms of active bleeding and failed to develop and implement a policy and procedure for residents' receiving anticoagulant therapy. These deficient practices resulted in Resident #1 requiring emergency transfer to the emergency room and subsequent admission to the intensive care unit for the treatment of [REDACTED].#1's central venous catheter (a catheter that is placed into a large vein in the neck, chest, or groin to administer medication or fluids or obtain blood tests). The facility had a census of 43. 1. Record review of Mosby's Manual of Diagnostic and Laboratory Tests, 1998; Mosby's Nursing Drug Reference, 22nd edition, 2009; and Mosby's Diagnostic and Laboratory Test References, 7th edition, 2005, showed the following information: -[MEDICATION NAME] is an anticoagulant (blood-thinning) medication used to help minimize the risk of blood clot formation in individuals with, or at risk for, blood clots;-[MEDICATION NAME] inhibits the clotting ability of the blood and can lead to prolonged bleeding time and/or hemorrhage if the blood is allowed to become too thin;-[MEDICATION NAME] ([MEDICATION NAME] sodium) therapy can be monitored by following the patient's [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) (a lab test used to determine the clotting tendency of blood); -The degree of anticoagulation can be monitored through the performance of a PT/INR test on the individual's blood; -The dosage of anticoagulant medication is adjusted based on the results of the PT/INR test to keep the blood-clotting time within therapeutic range; -A therapeutic PT range is usually 1.5 to 2.0 times the normal value of 11.0 to 12.5 seconds; -A therapeutic INR value is usually considered to be within the range of 2.0 to 3.5 depending on the clinical situation;-The preferred INR range for the prevention of [MEDICAL CONDITION] (blood clots) is 1.5 to 2.0;-The preferred INR range for the treatment of [REDACTED]. -[MEDICATION NAME] is slow acting, but the action may persist for 7 to 14 days after discontinuation of the drug; -The action of the drug can be reversed in 12 to 24 hours by slow administration of Vitamin K; -The administration of plasma will even more rapidly reverse the [MEDICATION NAME] effect. 2. Record review of Resident #1's summary of hospitalization showed the following information: -The resident admitted to the hospital on [DATE], with a primary [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. -Hospital discharge instructions included for the resident to have a follow-up blood draw for an INR within five days due to [MEDICATION NAME] therapy. The discharge instructions also included the directive for the resident to take precautions to prevent injury because [MEDICATION NAME] therapy increased the risk of bleeding. -Medications included [MEDICATION NAME] one daily after lunch. The order did not include the dosage of the [MEDICATION NAME]. Record review of the nurses' notes showed staff admitted the resident to the facility on [DATE]. Record review of an email communication to the physician, dated 7/8/14, showed the facility staff notified the physician of the resident's admission to the facility with orders for [MEDICATION NAME] and that the hospital physician would follow the resident. Record review of the physician's orders [REDACTED]. Record review of the physician telephone orders dated 7/8/14, showed orders that included a complete blood count (CBC, a blood test used to evaluate overall health and detect a wide range of disorders). Record review of the resident's initial care plan, dated 7/8/14, showed the following information: -The staff did not address the resident's anticoagulation therapy. -The care plan did not direct the staff to monitor the resident for signs and symptoms of bleeding or provide interventions for the staff to implement related to the anticoagulant therapy. Record review of the resident's PT/INR laboratory report, dated 7/9/14, showed the resident had a PT of 21.2 and an INR of 2.0. Staff wrote on the report they called the results to the hospital physician at 1:20 P.M., and faxed the results to the resident's facility physician who was the facility's medical director. Record review of the nurses' notes, dated 7/9/14, showed staff called the results of the INR to the hospital physician and the resident's facility physician. Staff received new orders from the facility physician. Record review of the physician's orders [REDACTED]. The order did not include when to recheck the PT/INR. Record review of the nurses' notes from 7/10/14 through 7/15/14 showed the following information: -On 7/10/14, at 1:00 A.M., the resident continued on [MEDICATION NAME] 7.5 mg daily. The resident's PT was 21.2 and INR was 2.0. The staff monitored the resident for excessive bruising/bleeding. -On 7/11/14, at 1:30 A.M., the resident continued on [MEDICATION NAME] 7.5 mg daily. Staff awaited orders from the physician on when to draw the next PT/INR. The staff monitored the resident for excessive bruising/bleeding. -On 7/14/14, at 1:00 A.M., the resident continued on [MEDICATION NAME] 7.5 mg daily. The staff monitored the resident for excessive bruising/bleeding. -On 7/15/14, at 1:30 A.M., the resident continued on [MEDICATION NAME] 7.5 mg daily and the staff monitored him/her for excessive bruising/bleeding. -The nurses' notes did include any information about excessive bruising/bleeding exhibited by the resident. Record review of the resident's CBC lab report, dated 7/14/14, showed the following information: -The lab results, reported on 7/15/14, showed the following information: -Red blood cells (carries oxygen throughout the body) 2.71 (normal is 3.90-5.20); -Hemoglobin (permits the red blood cells to carry oxygen) 8.2 (normal is 11.5-16.0); -Hematocrit (number of red blood cells) 27.6 (normal is 34.5-46.5); -MCV (average volume of red blood cells) 101.7 (normal is 80-100). -The physician wrote an order (undated) on the form to repeat the test in one week. Record review of a physician visit report, dated 7/15/14, showed the following information: -The physician reviewed the resident's medications and the results of the CBC and complete metabolic profile (CMP). -The report did not contain information regarding [MEDICATION NAME] orders or orders for the next PT/INR. -The resident was to continue current medications and treatment. -New orders included to obtain a CBC in one week and a Vitamin D level in six months. During an interview on 7/23/14, at 3:10 P.M., certified medication technician (CMT) M said the resident had recurrent nose bleeds. He/she knew the resident had nose bleeds three mornings in a row (Monday 7/14/14, Tuesday 7/15/14, and Wednesday 7/16/14). When he/she saw it, it was minute drainage like the resident had scratched the inside of his/her nose. CMT M said the days may be mixed up but he/she knew the resident had a nose bleed on Monday (7/14/14) and he/she reported it to the charge nurse. CMT M said the charge nurse was either LPN A or LPN C. He/she did not remember what the nurse said or did. The resident was late to breakfast because they had to clean him/her up. CMT M did not know of any other nose bleeds on the day shift that Monday (7/14/14). Record review of the 24 hour nursing shift reports dated 7/8/14 evening shift through 7/15/14 evening shift showed no documentation related to the resident having nose bleeds. During an interview on 7/23/14, at 2:45 P.M., certified nurse aide (CNA) O said on Tuesday (7/15/14) the resident had a little bit of blood on his/her hands that was dry. He/she saw two droplets of blood in the bed and reddish brown colored blood in the sink. CNA O told the nurse who he/she thought was LPN A. The nurse said to get vital signs and clean up the resident. The resident did not have any further nose bleeds that day. He/she did not see the resident have a nose bleed while in the dining room. During an interview on 7/22/14, at 10:50 A.M., licensed practical nurse (LPN) A said on Tuesday (7/15/14) the resident had a small nose bleed at breakfast which stopped. The resident kept picking at his/her nose. The blood was bright red. The physician came in that afternoon for rounds. LPN A did not remember if he/she passed on in report that the resident had a nose bleed so did not know if the physician had been informed. LPN A did not know why he/she did not document the nose bleed but said he/she should have. The resident said he/she has had nose bleeds all his/her life. LPN A said at that time he/she did not really think the bleeding was because of the [MEDICATION NAME] with it being just a little bit. During an interview on 7/22/14, at 1:40 P.M., LPN B said he/she was the evening charge nurse on 7/15/14. LPN B said did not believe he/she received information in shift change report that the resident had a nose bleed that day. The resident was doing fine. That evening the resident had a Kleenex with a little spot of dark red blood on it. LPN B did not know of any other bleeding. LPN B said he/she honestly did not know if the resident was on [MEDICATION NAME]. If he/she did not give the [MEDICATION NAME] would probably not know if the resident was on [MEDICATION NAME] unless he/she specifically looked for it. LPN B believed the physician was there when he/she came on shift but did not talk to him about anything. During an interview on 7/22/14, at 12:00 P.M., LPN I said usually works the night shift. The resident had blood on a couple of his/her fingers and wiped it on his/her face the night of 7/15/14. LPN I reported it to the day shift charge nurse the resident had blood on his/her fingers and face and probably needed to address the resident's depression. He/she never saw any active bleeding. At that point he/she did not think about the [MEDICATION NAME] because it wasn't that much blood. Record review of the 7/15/14 nursing shift report sheet showed the day and evening shift staff did not note the resident had a nose bleed on 7/15/14. The night shift noted the resident picked at his/her nose till it bled. Record review of the nurses' notes, dated 7/16/14, showed the following information: -At 2:00 A.M., the night nurse documented he/she noted dried blood on the resident's fingers and face (this was the first documentation of any bleeding). The nurse encouraged the resident not to pick his/her nose due to being on a blood thinner. -At 2:30 A.M., the night nurse documented the resident said he/she had bloody noses for years that would come and go and it makes her cough at times. -The night nurse did not document any notification of the resident's physician of the resident having nose bleeds and receiving [MEDICATION NAME]. Record review of a nurse's note, dated 7/16/14, at 9:10 A.M. showed the nurse documented the resident had epistaxis (a nose bleed). The speech therapist reported to staff the resident saw flashes of light. Staff made an appointment with the eye doctor. Record review of an email communication to the physician, dated 7/16/14, at 9:26 A.M., showed the resident had two nose bleeds in the last 12 hours and was on [MEDICATION NAME]. The resident was also seeing flashes of light and had an appointment for the eye doctor that day at 1:00 P.M. The physician responded at 10:51 A.M., with an order for [REDACTED]. Record review of a nurse's note, dated 7/16/14, (no time documented) showed the resident had a couple of small nose bleeds that evening. The nurse did not document any information to show he/she informed the physician about the resident's nose bleeds during the evening. The nurse documented the lab was at the facility at 6:30 P.M., to draw a stat PT/INR. Record review of the PT/INR laboratory report, dated 7/16/14, showed the lab collected the specimen at 6:35 P.M. The resident's PT was 87.3 and INR was 11.2. This represented a critically high INR. At 9:36 P.M., the hospital lab called staff at the lab that drew the blood to report the "potentially critical/toxic INR". Record review of a nurse's note, dated 7/16/14, showed at 9:45 P.M., the nurse called the results of the critical PT/INR to the physician and received a new order. The nurse did not document any information to show he/she informed the physician about the resident's nose bleeds during the evening. Record review of the physician's orders [REDACTED]. Record review of the nurses' notes, dated 7/17/14, showed the following information: -At 2:00 A.M., the nurse documented the resident was having nose bleeds. The resident told the nurse he/she has had them all his/her life. The nurse instructed the resident not to blow or pick at his/her nose due to being on a blood thinner and he/she would bleed a lot more than usual. The nurse noted bloody Kleenexes on the floor, in the bed, and on the dresser. The nurse instructed the resident to throw the bloody Kleenexes in the trash. The resident had dried blood on his/her hands, clothes, and face. The resident refused to let staff wash it off. The resident's PT was 87.3 and INR was 11.2. The 2:00 P.M. to 10:00 P.M. nurse had notified the physician of the lab results and received an order to place the resident's [MEDICATION NAME] on hold for three days and then repeat the PT/INR. The nurse documented he/she monitored the resident frequently for excessive bleeding but observed no active bleeding. The nurse did not document that he/she notified the doctor of the resident's nose bleeds that had occurred on the evening of 7/16/14 or of the bloody Kleenexes found on the early morning of 7/17/14. Record review of a nurse's note, dated 7/17/14, at 6:30 A.M., showed the CNA called the nurse to the room. The nurse observed dried blood on the resident's face, lips, clothing, hands, and bed linens. A blood clot was noted on the floor. The resident had several wadded up Kleenex with bright red blood on the bedside table. The resident's blood pressure was 160/80, pulse 81, respiration 24, temperature 99.6 and oxygen saturation 90% (a measure of oxygen in the blood, normal levels are 90-100%). The resident was very pale and shaking. The resident requested to go to the hospital. The nurse notified the physician and obtained orders to send the resident to the emergency room . Record review of the facility's patient transfer form, dated 7/17/14, showed the physician ordered an emergency transfer via ambulance to the emergency room due to excessive bleeding. The nursing assessment showed the resident's color was very pale, the resident had increased bleeding out the nose, and had a critically high INR of 11.2. Record review of the hospital history and physical, dated 7/17/14, showed the following information: -Admission on 7/17/14; -Reason for admission included hemorrhagic shock and over anticoagulation; -The resident received blood products and Vitamin K in the emergency room and reduced the PT/INR from the initial marked elevation of 13.79 to 4.62. -When the resident presented to the emergency room his/her hemoglobin was 7.0 and hematocrit 21.5 and he/she received one unit of blood. During an interview on 7/22/14, at 10:50 A.M., LPN A said nose bleeds were something he/she would watch for if a resident was on [MEDICATION NAME]. LPN A said it was not standard protocol to let a resident leave the facility if they were waiting on stat labs to be done. He/she would have canceled the eye appointment. Lab usually came "pretty quick" when they ordered stat labs. LPN A said anytime the staff receives a critical lab level they call the physician. He/she would have asked the physician to send the resident to the emergency room with the critical INR result. LPN A said when he/she came to work Thursday morning (7/17/14) the night shift nurse showed him/her the PT/INR results. LPN A said he/she said to the night nurse, the physician "didn't order Vitamin K? " The night shift nurse said the physician just wanted the [MEDICATION NAME] held for three days. During nursing report the morning of 7/17/14, the CNA came to get him/her. The resident had black, crusty, dried blood on his/her hands, forehead, end of nose, and lips. The resident's shirt was covered in brown colored blood and there was blood on the sheet and on the floor. There was a clot on the floor that was approximately five inches long and Kleenex on the bedside table with red blood on them. The night shift nurse said the resident had not been like that. The resident was very pale, shaking, and you could see blood forming in his/her nose. He/she called the physician who said to send the resident to the emergency room . LPN A said when the facility admits a resident on [MEDICATION NAME] the hospital discharge orders usually say to check a PT/INR in a week. The admitting nurse does the initial care plan. [MEDICATION NAME] therapy should be included on the initial care plan. Interventions should include monitoring for excessive bleeding and/or bruising and monitoring laboratory values. He/she did not inform the CNAs of what to watch for with residents taking [MEDICATION NAME]. During an interview on 7/22/14, at 12:00 P.M., LPN I said he/she usually works the night shift. He/she was not aware of any nose bleeds the resident had before 7/16/14. He/she would hope it would be documented and passed on in report if the resident did. When he/she came to work the night of 7/16/14, the evening shift nurse was calling the lab to get the results of the PT/INR. The nurse told the lab he/she sent it as stat then called the physician immediately. LPN I said he/she thought they were going to have to monitor the resident closely. The evening nurse told him/her the order and he/she thought, "Is that all?" LPN I said the doctors don't like to be questioned and thought he/she would be assessing the resident very close and if anything came up he/she would call the physician. He/she and the evening shift nurse did not discuss administration of Vitamin K. He/she never saw any red bleeding. He/she thought maybe it was a little more because of the Kleenex. The CNA said they caught the resident trying to blow his/her nose. The resident said he/she had nose bleeds all his/her life. There was not that much bleeding. There was a drop or two on two Kleenex tissues. He/she thought if it kept up he/she would call the physician. He/she checked on the resident about 5:15 A.M. and the resident was sleeping. When he/she gave report to the day shift nurse the aides came to get the nurse. The bright red bloody Kleenex were not there the last time he/she checked on the resident. LPN I said when residents are admitted the staff know they are on [MEDICATION NAME] from the medication list received from the hospital. LPN I told the staff to let him/her know if they see any signs of bleeding. The admitting nurse would be responsible for placing [MEDICATION NAME] therapy on the initial care plan. He/she did not think they put [MEDICATION NAME] on the initial care plans before but thought it was a good idea. If a resident showed signs of bleeding and were on [MEDICATION NAME] he/she would call the physician. During an interview on 7/23/14, at 1:50 P.M., LPN I said he/she completed a head to toe assessment on the resident every night because he/she was on Medicare A. During interviews on 7/18/14, at 2:30 P.M., on 7/22/14, at 2:45 P.M., and on 07/23/14, at 7:50 A.M., LPN C said when the facility admits a resident on [MEDICATION NAME] they check a PT/INR and monitor them for bleeding. If they have any signs and symptoms of abnormal bleeding they notify the physician. LPN C was not aware of the resident having any nose bleeds before 7/16/14. He/she called the physician on 7/16/14 due to being told the resident had been crying and had a nose bleed overnight. He/she sent an email communication to the physician. When the staff received orders for a stat lab (PT/INR) for the resident they called the lab. The lab said they would send a tech as soon as possible. He/she told the certified medication technician (CMT) to hold the resident's [MEDICATION NAME] until they got the results of the INR. The resident did not have any other signs of abnormal bleeding and went to the eye doctor on 7/16/14. He/she thought with the eye doctor being close to the facility and it usually took the lab a long time to get there it was okay to send the resident out. The resident was doing fine and vital signs were normal. The resident had always been pale in color but showed no significant change in color. He/she never saw gushing blood but when the resident wiped his/her nose there was bright red blood. LPN C said if he/she had a resident with a critical PT/INR he/she would call the physician. He/she would expect the physician to order more than holding the medication but he/she was not the doctor. LPN C said it would depend on the situation, but he/she would ask if the physician wanted to do anything else because of the high INR. When asked how the nurses know if a resident is on [MEDICATION NAME] LPN C said he/she makes it his/her business to know and tries to look at the medications the residents take. If the resident is new, he/she would pass it on in report, but that was not always the case at the facility. LPN C said that is important information to pass on in report. During interviews on 7/18/14, at 3:00 P.M. and at 4:45 P.M., and on 7/22/14 at 2:30 P.M., LPN D said when a resident takes [MEDICATION NAME] he/she monitors them for excessive bleeding and bruising. If the resident shows any signs and symptoms he/she would call the physician to see if the physician wanted to check a PT/INR. If a lab is ordered stat they call the lab to order it. The evening before Resident #1 went to the hospital (7/16/14), he/she had a small amount of bleeding. In shift report he/she was told the resident had exhibited some nose bleeds. LPN D said when he/she came on shift 7/16/14, the resident was gone to the eye doctor. The lab came earlier that day (7/16/14) but the resident was at the eye doctor. LPN D said he/she would have had the resident wait until the stat lab was done before going to the eye doctor. When the resident returned he/she called the lab and told them he/she had a stat PT/INR. He/she thought it was around 2:30 P.M. to 3:00 P.M. He/she asked the lab how long it would be and they said they had other stat labs they were doing but would be there as soon as possible. That was around 3:00 P.M. The resident was himself/herself and had a couple of small nose bleeds that evening. It was dark with a little bright red blood but not much. The resident said he/she has had nose bleeds all his/her life. LPN D said he/she called the hospital that evening between 8:30 P.M. and 9:00 P.M. when he/she had not received the PT/INR results. The lab said they turned it in as a routine order. The LPN said he/she told them it was stat. Within a half hour the lab called back with the lab results and he/she called the results to the physician. The LPN said he/she told the physician the resident had a couple of small nose bleeds. The physician said to continue to hold the [MEDICATION NAME] and recheck a PT/INR in three days. LPN D said he/she was not aware of any bleeding the resident had before the night shift of 7/16/14. He/she did not ask the physician about administration of Vitamin K when he/she called the physician with the critically high INR. LPN D said usually the physician would just order the Vitamin K. LPN D said sometimes the physicians do not like to be questioned. During an interview on 7/22/14, at 9:15 A.M., CNA E said the resident pretty much did for himself/herself. The day before the resident went to the hospital (7/16/14) he/she had a nose bleed. CNA E said he/she reported it to the charge nurse LPN C who went to see the resident and the nose bleed had stopped. The nose bleed was bright red. It was not gushing but when the resident wiped his/her nose it would bleed. CNA E said he/she was not aware of what may have been making the resident bleed but assumed the resident was on [MEDICATION NAME] because he/she had a family member that took [MEDICATION NAME]. The charge nurse did not tell him/her anything particular to watch for related to bleeding. The nurses did not discuss with the CNAs if a resident took [MEDICATION NAME]. He/she did not notice any signs of bleeding before. If he/she needed to know anything about a resident they had a care plan book. When the facility admitted a new resident they got report from the nurse about the resident. During an interview on 7/22/14, at 3:35 P.M., CNA H said the day before the resident went to the hospital he/she gave the resident a shower. He/she knew the resident had been bleeding and had an eye appointment at 1:00 P.M. The resident had red blood coming from his/her nose. He/she talked to the charge nurse LPN C who said they were aware of the bleeding. During an interview on 7/22/14, at 9:35 A.M., CNA F said he/she saw the resident bleeding Thursday (7/17/14) morning. He/she answered the resident's call light and the resident had blood on his/her shirt and hands. He/she told the charge nurse. The resident had wadded up Kleenex tissues that were wet with blood, one on the floor, and some in the trash can. The resident had a nose bleed the day before but this was more. Staff did not tell them if a resident was on a blood thinner or to watch for bleeding. He/she did not know signs of bleeding to watch for. During interviews on 7/22/14, at 3:25 P.M. and 5:35 P.M., LPN G said he/she works as a charge nurse and other times he/she passes medication. He/she said did not know as much about the residents when he/she was the charge nurse. He/she would know if a resident was on [MEDICATION NAME] if he/she admitted the resident. It is not passed on in shift report if a resident is on [MEDICATION NAME]. LPN G said he/she took care of the resident on 7/10/14 and 7/11/14. He/she did not see any signs of bleeding. LPN G said if the staff receives critical INR results they call the physician. If a resident has a critical INR and the physician orders [REDACTED]. LPN G said if the resident has active signs of bleeding he/she would probably push the Vitamin K issue. During an interview on 7/22/14, at 4:50 P.M., the laboratory director of long term care operations for the laboratory service used by the facility said they received a call from the facility about noon on 7/16/14, for a stat PT/INR. They had staff in the area that got to the facility about 1:15 P.M. but the resident was gone to an appointment. The lab staff waited a while then came back to the lab. The facility called again between 3:00 P.M., and 3:15 P.M. They had no documentation that the lab was ordered stat. They have a place on the requisition form to mark whether it is routine or stat. They cannot say for sure whether it was told to them it was stat; however, they put it on the same day list. They drew the lab at 6:35 P.M., and had the blood to the lab at 8:15 P.M. The laboratory director believed the facility staff called the hospital. The hospital lab called the results to their lab at 9:37 P.M., and they called the facility at 9:39 P.M. During interviews on 7/18/14, at 6:10 P.M., and on 07/22/14, at 5:15 P.M., with the administrator and Director of Nursing (DON), the DON said the staff told her the resident had a little bit of a nose bleed and she told them to call the physician. The physician ordered the staff to check a PT/INR. The administrator said she would have probably sent the resident to the emergency room and would have asked the physician if he wanted anything else like Vitamin K. The administrator called the physician today (7/18/14) who said the nurse did tell him what the results were of the PT/INR test. The DON said she talked to the resident in therapy on Tuesday (7/15/14) or Wednesday (7/16/14) and the resident did not appear to be symptomatic. The administrator said anticoagulant therapy would be part of the care planning process. When asked if anticoagulant therapy should be included on the initial care plan she said she would like for that to happen. The DON said it was hard to get every medication on the initial care plan. They first had to call the hospital physician about Resident #1's [MEDICATION NAME], so she did not know if they would know right away whether the resident was going to be on [MEDICATION NAME]. The hospital orders did not include the dose of [MEDICATION NAME] and it took three phone calls to find out about the [MEDICATION NAME]. The hospital nurse said to call the PT/INR results to the hospital physician the next day. If the charge nurse saw any signs of bleeding they would look at the PT/INR and place a call to the physician which they did. If a resident had a nose bleed she would expect them to notify the physician which they did. The DON did not know of any nose bleeds before 7/16/14. The DON said maybe they got their days confused. The administrator said the staff called the eye doctor because the resident was seeing flashes of light. The doctor said it could be a retinal tear and to bring the resident immediately. The administrator said it was appropriate that the staff sent the resident to the eye doctor because they thought he/she had a retinal tear. The staff thought they could send the resident quickly because it was close by and at that time they did not know what the PT/INR was and her priority would have been the retinal tear. During an interview on 7/22/14, at 10:10 A.M., the resident's physician said the staff contact him if a resident has a high PT/INR. He knew of Resident #1's situation. When a resident is admitted to the facility on [MEDICATION NAME] he orders a PT/INR on admission and if it is in therapeutic range then he orders the test once a month. If he has to adjust the [MEDICATION NAME] he would order a PT/INR in two weeks just depending on the [MEDICATION NAME]. He expected the staff to notify him of any bleeding. The physician said the staff did not notify him of any increased bleeding after he ordered the stat PT/INR on 7/16/14. If the resident had increased bleeding he would have ordered Vitamin K to be administered and would have sent the resident to the hospital. If a resident was not having active bleeding he was not sure they needed Vitamin K. Staff told him the resident had nose bleeds but nothing dramatic. He did not remember the phone call when staff called the critical PT/INR results to him because he was asleep. He would have expected staff to ask him about ordering Vitamin K. He would have probably ordered Vitamin K with a critical INR. During an interview on 7/23/14, at 9:35 A.M., the administrator said she thought the staff knew the resident's lab results were critical but believed they may have thought the resident was not experiencing active bleeding so they were going to monitor the resident and let the physician know if there were any changes. During an interview on 7/23/14, at 1:30 P.M., LPN G said he/she did not know if the facility had a policy and procedure on [MEDICATION NAME] therapy. [MEDICATION NAME] was not something that got passed on in report on a daily basis. It got passed on in report if they were waiting on a lab result. During an interview on 7/23/14, at 2:05 P.M., LPN C said there was no official system to ensure all staff knew if a resident was on [MEDICATION NAME] but he/she would pass it on in report. During an interview on 7/23/14, at 2:30 P.M., CNA J said if a resident has a skin tear or bruising the nurse may tell them (the CNAs) the resident is on a blood thi

Based on record review, observation and interview the facility failed to assess, implement interventions, notify the physician, monitor and treat a new area of suspected deep tissue injury (DTI) to one resident's (Resident #6) right great toe, for 24 days, in a selected sample of ten residents. The facility's census was 41. According to the National Pressure Ulcer Advisory Panel (NPUAP), -Deep tissue injury is "a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment." (NPAUP, 2002). Deep tissue injury represents a dangerous lesion due to its potential for rapid deterioration; -Deep tissue injury may present as a serum blister or blood blister and be appropriately labeled as a Stage II (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) pressure ulcer, although the expected deterioration of this injury differentiates it from typical, minor Stage II pressure ulcers which will heal in days or a few weeks. Record review of the facility's wound and skin care policy and protocol, dated 02/01/09, showed the following information: -To prevent ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions; -To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown; -To promote healing of pressure ulcers in a cost efficient and timely manner; -Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers; -Findings from the weekly skin assessment should be documented by the licensed nurse on a weekly skin assessment form; -Nurse aides should complete a comprehensive Certified Nurse Aide (CNA) shower review on all residents when they are bathed or showered and given to the charge nurse; -CNAs should observe skin integrity during the daily provision of routine cares and report any impairments to the charge nurse for appropriate follow-up; -The charge nurse should review, sign and address any conditions noted; -After review by the charge nurse, the comprehensive CNA shower review should be given to the wound nurse, or designee, for appropriate follow-up; -The comprehensive CNA shower review should be reviewed by the director of nursing (DON) at least weekly; -Any skin impairments should be assessed and documented weekly by the wound nurse on the wound evaluation flow sheet; -Documentation should cover all pertinent characteristics if existing ulcers, including size, depth, color of the ulcer and surrounding tissues, and a description of any drainage, eschar (dead tissue), necrosis, odor, tunneling or undermining. 1. Record review of Resident #6's admission nursing assessment and nurses' note, dated 09/01/13, showed a nurse documented the resident had a 2 centimeters (cm) x 2.5 cm open area, with no drainage, to his/her right great toe. The nurse did not document a complete assessment to include Stage, color and type of tissue present in the wound bed and appearance of surrounding tissue and did not document physician notification of the open area. Record review of the September 2013 physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Heel protectors while in bed; -Weekly skin assessments; -No wound care orders for open area to the right great toe. Record review of the weekly skin assessment sheet, dated 09/03/13, showed staff did not document performing an assessment of the resident's skin. Record review of the skin monitoring: comprehensive CNA shower review form, dated 09/05/13, showed the following information: -A CNA observed a skin issue on the resident's right great toe but he/she did not describe the skin issue; -The charge nurse signed and dated the form indicating he/she reviewed it but did not document an assessment of the area on the resident's right great toe. During an interview conducted on 09/26/13, at 3:45 P.M., the administrator said she talked with CNA I, who completed the CNA shower review form on 09/05/13, about the skin issue on the resident's right great toe. CNA I said he/she saw a brown scab, not open, on the resident's toe. Record review of the 5-day Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, completed by facility staff, dated 09/08/13, showed the following information: -Cognitively intact as indicated by a total score of 14 on the brief interview for mental status (BIMS); -Required limited assistance for bed mobility; -Required extensive assistance for transfers, walking, dressing, toilet use, personal hygiene, toileting and bathing; -Occasionally incontinent of urine; -Always continent of bowel; -[DIAGNOSES REDACTED]. -Not at risk for developing pressure ulcers; -No pressure ulcers; -Pressure reliving devices for bed and chair; -Turning/repositioning program; -Application of ointments/medications other than to feet. Record review of the weekly skin assessment sheet, dated 09/09/13, showed staff did not observe or document any skin issues to the resident's right foot. Record review of the skin monitoring: comprehensive CNA shower review form, dated 09/09/13, showed the following information: -A CNA documented he/she observed skin issues to the resident's arms and stomach but none to his/her right foot; The charge nurse signed and dated the form indicating he/she reviewed it but did not document an assessment of the areas observed by the CNA. Record review of the 14-day MDS, a federally mandated comprehensive assessment tool, completed by facility staff, dated 09/15/13, showed the following changes from the 09/08/13 MDS: -Required limited assistance for bed mobility, transfers, walking, dressing, toilet use, personal hygiene and toileting; -Applications of nonsurgical dressings (with or without topical medications) other than to feet. Record review of the weekly skin assessment sheet, dated 09/16/13, showed staff did not observe or document any skin issues to the resident's right foot. Record review of the care plan, initiated 09/16/13, showed the following information: -Right-sided weakness due to a stroke; -Required assistance with transfers; -Used a walker for mobility for short distances and a wheelchair for longer distances; -Wound with wound care to the resident's leg otherwise skin in good condition; -Staff did not identify and implement interventions related to the wound on the resident's right great toe. Record review of the skin monitoring: comprehensive CNA shower review form, dated 09/17/13, showed the following information: -A CNA documented he/she observed skin issues to the resident's arms, chest, stomach and right lower leg but none to his/her right foot; -The charge nurse signed and dated the form indicating he/she reviewed it but did not document an assessment of the areas observed by the CNA. During an interview conducted on 09/26/13, at 3:45 P.M., the administrator said she talked with CNA I, who completed the CNA shower review form on 09/17/13, about the skin issue on the resident's right great toe. CNA I told the administrator the resident had a scab on his/her toe. He/she did not document the description because the charge nurse knew about the area, it had been there the whole time (since 09/01/13). Record review of the a nurse's note, dated 09/19/13, not timed, showed staff performed a wound assessment and wound care to the resident's right lower leg wound but did not document an assessment of his/her right great toe. Record review of the skin monitoring: comprehensive CNA shower review form, dated 09/21/13, showed the following information: -A CNA documented he/she observed skin issues to the resident's chest and buttocks but none to his/her right foot; -The charge nurse signed and dated the form indicating he/she reviewed it but did not document an assessment of the areas observed by the CNA. Record review of the weekly skin assessment sheet, dated 09/23/13, showed staff did not observe or document any skin issues to the resident's right foot. Record review of the weekly wound tracking sheets, completed by the assistant director of nursing (ADON), for September 2013, showed the nurse did not document any assessments of the deep tissue injury located on the resident's right great toe. During an observation and interview conducted on 09/25/13, at 11:20 A.M., showed the following: -Staff removed the compression hose from the resident's right foot and showed a 0.8 cm x 0.9 cm dark red unstageable pressure ulcer with a 0.2 cm x 0.6 cm fluid-filled blister, directly below the reddened area, on the tip of the great toe; -The ADON said the top of the wound felt hard and the bottom soft and fluid-filled. The area was a pressure ulcer with possible deep tissue injury. The ADON thought she reviewed the 09/01/13 admission skin assessment and did not see any new wounds. She was not aware of the pressure ulcer to the resident's right great toe until today (09/25/13). Record review of a nurses' note, dated 09/25/13, not timed, showed the following information: -Right great toe possible deep tissue injury present on admission (09/01/13); -Measured 0.8 cm x 0.9 cm; -Hard tissue at the top of the wound; -Soft tissue at the bottom of the wound with a small white area that may be fluid filled; -Notified the physician (24 days after staff initially found the wound) who instructed staff to apply [MEDICATION NAME] (an ointment that increases blood flow and helps fight bacteria) to the resident's right great toe every shift until healed and no shoe or compression stockings on his/her right foot/leg. Record review of the September 2013 POS showed on 09/25/13 the physician ordered the following: -Cleanse the resident's right great toe, pat dry and apply a thin layer of [MEDICATION NAME] every shift until resolved; -No shoe or compression stocking to the resident's right lower leg until further notice. During an interview conducted on 09/26/13, at 3:45 P.M., the administrator said the ADON performs wound assessments weekly. The assessment should include documentation of the wound size, color and drainage. Interviews conducted on 09/27/13 with Licensed Practical Nurse (LPN) A showed the following: -At 10:15 A.M. the LPN said an admission skin assessment should include all skin on the resident's entire body. The charge nurses complete the weekly skin assessments; each charge nurse completes about three a day. If staff identifies a new area, either on the admission skin assessment or weekly skin assessment, staff notifies the physician and wound nurse (ADON); -At 12:15 P.M., the LPN said he/she did sign the bath assessment on 09/05/13 but may have overlooked the circle the CNA wrote on the diagram indicating a skin issue on the resident's right foot. A staff member showed the LPN the dry brown scab on the resident's right great toe but he/she does not remember the date or who showed him/her. The resident wears compression hose on his/her right leg. When the LPN performs the dressing change to a wound on the resident's lower leg, he/she does not remove the compression hose. He/she did not know there was an issue regarding the scab. During an interview conducted on 09/27/13, at 12:25 P.M., CNA H said if staff observes any abnormal skin areas, they report the area to the charge nurse. CNA H was assisting CNA I when they found the area on the resident's right great toe. CNA I documented on the bath sheet what they found and gave it to the charge nurse. CNA H did not report the finding to any other nurses because he/she knew staff had already reported the area.