Every finding on record at Neighborhoods Rehabilitation and Skilled Nursing B

Based on observation, interview and record review, facility staff failed to update the care plan with interventions for three residents (Resident #1, Resident #2 and Resident #3) out of three sampled residents who experienced falls. Facility census was 86.1. Review of the facility's policy, Comprehensive Care Plans, dated 2025, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objective and timeframes to meet a residents medical, nurses, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 2. Review of Resident #1's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/02/26, showed staff assessed the resident as moderately cognitively impaired and did not have any falls since admission/entry or reentry or the prior assessment.Review of the resident's progress notes, dated 07/26/26, showed staff documented the resident found on the floor on his/her bottom in front of his/her wheelchair and said he/she slipped from the chair.Review of the resident's care plan, revised 07/17/26, showed the resident at risk for safety concerns related to mobility, medication use, and cognition. Review showed it did not contain documentation of new interventions after the falls on 07/26/26. 3. Review of Resident #2's comprehensive MDS, dated [DATE], showed staff assessed the resident as cognitively intact and had one noninjury fall since admission/entry or reentry or the prior assessment.Review of the resident's care plan, revised 06/22/26, showed staff documented the resident at risk for safety concerns related to behaviors, medication use, mobility and incontinence. Review showed it did not contain documentation of new interventions after the falls on 07/02/26.Review of the resident's progress notes, dated 07/2/2026, showed staff documented staff found the resident on the floor and he/she did not know how he got on the floor. 4. Review of Resident #3's comprehensive MDS, revised 07/06/26, showed staff assessed the resident as cognitively intact and had one noninjury fall since admission/entry or reentry or the prior assessment.Review of the residents care plan, dated 07/08/26, showed the resident was at risk for safety concerns related to behaviors, medication use, mobility, and incontinence. Review showed it did not contain documentation of a new intervention after the resident fell on [DATE].Review of the resident's progress notes, dated 07/11/2026, showed staff document the resident was found on his/her bottom on the fall matt. Staff documented the resident said he/she was getting out of bed because the room was hot when he/she fell. 5. During an interview on 08/03/26 at 12:42 P.M., Licensed Practical Nurse (LPN) A said if a resident experienced a fall, the MDS Coordinator should add a new intervention to the care plan for each fall.During an interview on 08/03/26 at 2:02 P.M., the administrator said the MDS Coordinator was responsible for updating the care plan with new interventions after each fall. She said the teams meet every morning to discuss a fall and what new interventions to add to the care plan. The administrator said it was not completed because the MDS Coordinator did not complete the interventions.During an interview on 08/03/26 at 2:03 P.M., the Director of Nursing (DON) said he/she did see the fall listed on the resident's care plans, but did not realize a new intervention was not added to the care plans. During an interview on 08/03/26 at 2:03 P.M., the DON said the MDS Coordinator was the person who would update the care plan with the new fall interventions discussed during morning meeting. She said she did audit the resident's care plans after a resident had a fall.During an interview 0n 08/17/28 at 3:59 P.M., the MDS Coordinator said staff look at the fall reports every morning and falls are discussed and what new interventions are to be put in place. He/She said he/she cannot recall if he/she was told about the resident's falls. He/She said staff may not have communicated or the falls for each of the resident fell through the cracks. 3121610

Based on interview and record review, facility staff failed to provide an appropriate emergency discharge notice to one resident (Resident #1) when staff discharged the resident to the hospital and refused to allow him/her to return to the facility. The facility census was 93.1. Review of the facilities policies did not contain a policy for emergency discharge.2. Review of Resident #1's face sheet, dated 5/29/26, showed the resident admitted to the facility on [DATE] and staff discharged him/her to the local hospital on 5/20/26.Review of the resident's progress notes, dated 5/20/26 at 11:48 A.M., showed staff documented the resident discharged back to the hospital for uncontrolled pain.Review of the resident's medical records did not contain documentation of an emergency discharge issued to the resident.During an interview on 5/29/26 at 8:47 A.M., the Director of Nursing (DON) said the facility was not informed of the full acuity of care and it was felt they could not meet the residents' needs. He/She said it is not clinically safe for the resident to be at the facility.During an interview on 5/29/26 at 8:48 A.M., the Administrator said when the resident was assessed his/her acuity of care was much higher than anticipated. He/She said the resident was sent to the hospital and the social worker at the hospital was informed the resident would not be permitted back because of the level of care the resident needed. He/She said he/she did not issue a written discharge. Complaint #3021427

Based on observation, interview, and record review, facility staff failed to label eye drops and nasal sprays in accordance with professional standards and failed to destroy expired medications for three medication carts and one medication room. The facility census was 88.1. Review of the facility's Medication Storage policy, dated 2025, showed the policy did not contain direction or guidance for labeling or destruction of eye drops or nasal sprays. Review of the facility's Administration of Eye Drops policy, dated 2001, showed the policy directed staff to label new bottles with date opened and follow facility policy or manufacturer's instructions for when to discard and replace the bottle.Review of the facility's Administration of Nasal Spray Administration policy, dated 2025, showed the policy did not contain direction or guidance for labeling or destruction of nasal sprays.2. Observation on 01/20/26 at 9:52 A.M., showed the medication cart on the [NAME] and [NAME] unit contained one opened and undated bottle of Atropine eye drops (used to dilate pupils and treat lazy eye) and six opened and undated bottles of artificial tears (used to treat dry eye, irritation and eye discomfort).During an interview on 01/20/26 at 9:52 A.M., Certified Medication Technician (CMT) E said he/she does not date the bottles when he/she opens them and he/she uses the expiration date on the bottl. The CMT said it is his/her responsibility to ensure medications are not expired prior to administering them. 3. Observation on 01/20/26 at 10:02 A.M., showed the Flat Branch medication cart sat below a cork board on the wall. Observation showed a sign posted on the cork board which read, all vials and miscellaneous items should be dated and discarded after 28 days of opening to include eye drops and any vials that the facility opens. Observation showed the medication cart contained:-One opened and undated bottle of artificial tears;-One opened bottle of artificial tears dated 11/28/25;-One opened and undated bottle of Lantoprost (lowers eye pressure in glaucoma);-Two opened and undated bottles of flucotisone (treats allergies and reduce swelling) nasal spray.During an interview on 01/20/26 at 10:02 A.M., CMT F said eye drops and nasal sprays are good for 30 days. The CMT said he/she knows the drops and sprays need a label but he/she just forgot and did not think about it. The CMT said giving an undated medication could mean the medication is expired and no longer any good. The CMT said it is their responsibility to ensure medication is labeled and dated. 4. Observation on 01/20/26 at 10:15 A.M., showed the medication cart on the [NAME] Station unit contained:-One opened and undated bottle of Olopatadine (used to treat itchy, red and swollen eyes) eye drops;-One opened and undated bottle of azelastine (treats itching, redness and irritation) eye drops;-One opened bottle of artificial tears dated 11/15/25;-One opened bottle of artificial teas dated 07/10/25;-One opened bottle of artificial tears dated 11/28/25;-Three opened and undated bottles of normal saline nasal spray;-One opened and undated bottle of deep sea normal saline nasal spray.During an interview on 01/20/25 at 10:20 A.M., CMT G said eye drops and nasal sprays are only good for 30 day and he/she is responsible to ensure they are dated and not expired but he/she just did not pay attention.5. Observation on 01/20/26 at 10:22 A.M., the refrigerator on the [NAME] Station unit contained:-One opened and undated vial of Lantus insulin;-One opened and undated vial of Aspartate insulin;-One opened and undated bottle of Humalog insulin. Observation showed the manufacturers expiration date on the vial listed as 12/09/25.During an interview on 01/20/26 at 10:30 A.M., Licensed Practical Nurse (LPN) A said insulin is good for 30 days once opened and it is his/her responsibility to ensure the vials are not expired and dated when opened. The LPN said he/she did not know the insulins were not dated and giving expired medication could mean the resident's dose is not effective.6. During an interview on 01/23/26 at 3:50 P.M., the Director of Nursing (DON) said he/she is fairly new to the building but it is his/her responsibility to make daily rounds and he/she checks the cart for expired medications. The DON said if a medication is unopened, the expiration would be based on the manufacturer's date and if it is opened, the medication would be expired after 28 days. The DON said the CMT's are responsible to date the vials/bottles when opened and routinely checked for outdated items and discard them. The DON said giving medication beyond the use by date could make the medication ineffective. The DON said he/she did not know there were expired and/or undated medications on the medication carts. During an interview on 01/23/26 at 4:32 P.M., the administrator said CMT's on each unit are responsible to ensure the carts are reviewed every Wednesday for undated and expired medications. The administrator said he/she is not sure the weekly check is being completed on all the units and he/she does not see the audits. The administrator said a Performance Improvement Plan (PIP) was created and continued, but unfortunately they have had many changes in staff. The administrator said medications should not be used if it has been opened more than 28 days.

Based on observation, interview and record review, the facility staff to ensure waste containers in food preparation areas remained covered when not in use. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed maintain the internal temperature of hot foods held in the steamtable at a minimum of 140 degrees Fahrenheit (dF) to prevent the growth of food-borne pathogen. Facility staff also failed to ensure staff involved in food preparation and service wore effective hair restraints to prevent physical contamination of food and food contact surfaces. These failures had the potential to affect all residents. The facility census was 88.Based on observation, interview and record review, the facility staff to ensure waste containers in food preparation areas remained covered when not in use. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed maintain the internal temperature of hot foods held in the steamtable at a minimum of 140 degrees Fahrenheit (dF) to prevent the growth of food-borne pathogen. Facility staff also failed to ensure staff involved in food preparation and service wore effective hair restraints to prevent physical contamination of food and food contact surfaces. These failures have the potential to affect all residents. The facility census was 88. 1. Review of the facility's policy titled Disposal of Garbage and Refuse, dated 2025, showed the policy directed staff to dispose of garbage in refuse containers with plastic liners and lids and to cover the refuse containers when not in use. Observations on 01/20/26 at 12:00 P.M. and 01/23/26 at 8:20 A.M., showed the waste container, contained paper and food waste, in the Flat [NAME] kitchen uncovered and not in use by staff. Observation showed the area did not contain a cover for the waste container. During an interview on 01/23/26 at 8:20 A.M., Dietary Aide (DA) U said he/she did not have a cover for the waste container in the Flat Branch kitchen. The DA said he/she did not work that unit very often, so he/she did not know if the container ever had a cover. Observations on 01/20/26 at 12:10 P.M. and on 01/23/26 at 8:00 A.M., showed the waste container, which contained paper and food waste, in the [NAME] and [NAME] kitchen uncovered and not in use by staff. Observation showed the area did not contain a cover for the waste container. During an interview on 01/23/26 at 8:00 A.M., DA V said he/she did not have a cover for the waste container in the [NAME] and [NAME] kitchen. The DA said there use to be a cover for it, but there had not been one for a while and he/she did not know what happened to the cover. Observations on 01/20/26 at 12:23 P.M. and on 01/23/26 at 8:55 A.M., showed the waste container, which contained paper and food waste, in the Boonslick kitchen uncovered and not in use by staff. Observation showed the area did not contain a cover for the waste container. During an interview on 01/23/26 at 8:55 A.M., DA W said he/she did not have a cover for the waste container for the Boonslick kitchen. The DA said he/she could not remember if the waste container ever had a cover, but he/she knew if had not had one in at least two months. Observations on 01/20/26 at 12:31 and on 01/23/26 at 8:45 A.M., showed the waste container, which contained paper and food waste, in the Smithton Village kitchen uncovered and not in use by staff. Observation showed the area did not contain a cover for the waste container. During an interview on 01/23/26 at 8:45 A.M., DA X said he/she did not have a cover for the waste container in the Smithton Village kitchen and he/she did not know if it ever had a cover. Observations on 01/20/26 at 12:45 A.M. and on 01/23/26 at 8:35 A.M., showed the waste container, which contained paper and food waste, in the [NAME] Station kitchen uncovered and not in use by staff. Observation showed the area did not contain a cover for the waste container. During an interview on 01/23/26 at 9:05 A.M., the Dietary Manager (DM) said kitchen waste containers should be covered when not in actual use and staff are trained on this requirement. The DM said there were a couple of the waste container lids that broke and he/she requested maintenance to order replacements, but he/she did not know that status of that order and he/she did not know that all of the waste containers in the unit kitchens did not have covers. During an interview on 01/23/26 at 3:00 P.M., the administrator said kitchen waste containers should have lids and be covered when not in use. The administrator said he/she knew a couple of the lids broke and when they ordered the replacements, they were the wrong lids. The administrator said he/she did not know that the waste containers in all the unit kitchens did not have lids. 2. Review of the facility's policy titled Dietary Employee Personnel Hygiene, dated 2025, showed the policy directed staff to wash their hands prior to beginning work, before they put on gloves, after they remove gloves, and after they engage in other activities that contaminate the hands. Review showed the policy did not provide direction to the staff on the procedure to use when they wash their hands. Observation on 01/20/26 at 12:23 P.M., showed DA W cut a raw onion with gloved hands and then removed his/her gloves. Observation showed when the DA washed his/her hands, he/she placed soap on his/her hands and then rubbed his/her hands together under running water. Observation showed the DA then served prepared foods to residents at the lunch meal. Observations on 01/23/26 at 8:06 A.M., showed DA U entered the kitchen and, without performing hand hygiene, obtained raw eggs from the walk-in refrigerator. Observation showed the DA then lifted the lid of the waste container with his/her bare hand to dispose of trash, put on a hair net and, without performing hand hygiene, transported a cart of prepared food to the Flat Branch kitchen. Observation showed when the DA washed his/her hands upon entry to the Flat Branch kitchen, he/she placed soap on his/her hands and then rubbed his/her hands together under running water, turned the faucet off with a paper towel and then used the same paper towel to dry his/her hands. Observation showed the DA then placed the prepared food items into the steamtable for service to residents at the breakfast meal. Observation on 01/23/26 at 8:20 A.M., showed DA U removed soiled gloves from his/her hands, exited the kitchen to dispose of the soiled gloves and then returned to the kitchen. Observation showed when the DA washed his/her hands, he/she placed soap on his/her hands and then rubbed his/her hands together under running water, turned the faucet off with a paper towel and then used the same paper towel to dry his/her hands. During an interview on 01/23/26 at 8:20 A.M., DA U said staff trained him/her on proper hand hygiene procedures upon hire and staff should preform hand hygiene when they enter the kitchen, before and after glove use, before they handle food, and after they touch anything dirty. The DA said staff should scrub their hands with soap in the water for 30 to 45 seconds, dry their hands with a paper towel and then turn the faucet off with a different paper towel. The DA said staff should not use the same paper towel they used to turn off the faucet to dry their hands because the faucet is dirty and it would just make their hands dirty again. The DA said he/she did not realize that he/she dried his/her hands with the same paper towel he/she used to turn off the faucet. During an interview on 01/23/26 at 9:05 A.M., the DM said staff should perform hand hygiene when they enter the kitchen, before and after glove use, before they handle or serve food, and after they touch anything dirty. The DM said when staff wash their hands, they should scrub their hands with soap out of the running water for 20 to 30 seconds, dry their hands with a paper towel and then use a different paper towel to turn the faucet off. The DM said staff should not use the same paper towel they used to turn off the faucet to dry their hands because the faucet is dirty and it would just make their hands dirty again. The DM said staff are trained on proper hand hygiene procedures upon hire and during in-services as needed. During an interview on 01/23/26 at 3:00 P.M., the administrator said staff should perform hand hygiene when they enter the kitchen, before and after glove use and after they touch anything dirty. The administrator said when staff wash their hands, they should scrub their hands with soap out of the running water for 20 to 30 seconds, dry their hands with a paper towel and then use a different paper towel to turn the faucet off so they do not recontaminate their hands. The administrator said staff are trained on how to properly wash their hands. 3. Review of the facility's policy titled Record of Food Temperatures, dated 2025, showed: -It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled;-Hot foods will be held at 135 dF;-If the food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food;-Potentially hazardous food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 dF for at least 15 seconds before holding for hot service;-No food will be served that does not meet the food code standard temperatures;-Food will not be cooked or reheated using the steam table because it does not bring food to the proper temperature within acceptable timeframes. Observation on 01/20/26 at 12:31 P.M., showed DA U served food to residents from the steam table in the Smithton Village kitchen. Observation showed open spaces around the pans of food on the steam table which allowed heat to escape from the steam table. Observation at this time showed the internal temperature of the spaghetti noodles measured 124 dF and the vegetables measured 130 dF. During an interview on 01/20/26 at 12:33 P.M., DA U said hot food held in the steam table should maintain a temperature of 145 dF or higher. The DA said he/she checked the internal temperature of the hot foods when he/she placed them on the steam table and all foods were at least 145 dF. The DA said he/she did not know the temperature of the foods were less than 145 dF and he/she did not realize the open spaces around the pans of food would not keep the food hot enough. Observation on 01/20/26 at 12:45 P.M., showed DA N served food to residents from the steam table in the [NAME] Station kitchen. Observation showed open spaces around the pans of food in the steam table which allowed heat to escape from the steam table. Observation at this time showed the internal temperature of the spaghetti noodles measured 120 dF, the spaghetti sauce measured 130 dF and the vegetables measured 118 dF. Review of the food temperature log located in the [NAME] Station kitchen, showed staff documented the internal temperature of the spaghetti noodles measured 107 dF, the spaghetti sauce measured 168 dF and the vegetables measured 135 dF. During an interview on 01/20/26 at 12:47 P.M., DA N said the internal temperature of hot food held in the steam table should be 140 dF. The DA said he/she checked the internal temperature of the hot foods when he/she placed them on the steam table and documented the temperatures on the food temperature log. The DA said, at that time, the temperature of the spaghetti noodles measured 107 dF so he/she covered them to let them heat up on the steam table. The DA said when he/she rechecked the internal temperature of the noodles they measured 138 dF, but he/she did not document that temperature because he/she had already written down the 107 dF temperature. The DA said when he/she checked the temperature of the vegetables when he/she placed them on the steam table, the internal temperature measured 135 dF and he/she figured they would warm up on the steam table before service. The DA said while he/she knew the internal temperature of hot foods should be 140 dF, he/she served the food items in the steam table anyway because that was as close as they were going to get to the right temperature without him/her running late to serve them. Observation on 01/23/26 at 8:15 A.M., showed DA U check the internal temperatures of the hot food items held in Flat Branch steam table to be served to residents at the breakfast meal. Observation showed the internal temperature of the sausage on the steamtable measured 119 dF, the ground sausage measured 130 dF, and the peppered white gravy measured 125 dF. Observation showed the DA left the food items uncovered on the steam table. During an interview on 01/23/26 at 8:16 A.M., DA U said the internal temperature of hot foods held in the steam table should be at least 140 dF. The DA said he/she still had some time before service so he/she was just going to let the food heat up on the steam table. Observation on 01/23/26 at 8:26 A.M., showed DA U rechecked the internal temperatures of the hot foods held in the steam table. Observation showed the internal temperature of the sausage on the steamtable measured 120 dF, the ground sausage measured 130 dF, and the peppered white gravy measured 125 dF. Observation showed the DA prepared to serve the food items from the steamtable to the residents. During an interview on 01/23/26 at 8:26 A.M., the DA said if the temperature of hot food on the steam table is not at least 140 dF, they should be removed and reheated but he/she did not have time to reheat them because they were waiting for him/her to serve. During an interview on 01/23/26 at 9:05 A.M., the DM said the internal temperature of hot food held in a steam table should be at least 140 dF. The DM said staff are trained on appropriate food temperatures and to check the temperature of the food before they serve it. The DM said staff should not use the steam table to raise the temperature of hot foods to the required temperatures and if the hot food is not at least 140 dF, staff should remove it from the service line and reheat it to an internal temperature of at least 165 dF. The DM said staff are also trained on these requirements and if food is not maintained at the appropriate temperatures there is risk for the growth of bacteria that could cause food-borne illness to the residents. During an interview on 01/23/26 at 3:00 P.M., the administrator said the internal temperature of hot food held in the steam table should be at least 140 dF and staff are trained on proper food temperatures. The administrator said staff are also trained to check the internal temperature of the food before it is served to residents and if it is not at the appropriate temperature, they should remove it to have it reheated and not leave it to reheat on the steam table. 4. Review of the facility's policy titled Dietary Employee Personal Hygiene, dated 2025, showed the policy directed all dietary staff to wear hair restraints, such as a hairnet, hat and/or beard restraint, to prevent hair from contacting food. Observation on 01/23/26 at 8:05 A.M., showed [NAME] Y, who had facial hair, prepared food items in the main kitchen for service to residents at the breakfast meal without the use of a facial hair restraint. Observations on 01/23/26 from 8:06 A.M. to 8:26 A.M., showed DA U had head and facial hair. Observation showed, without the use of head or facial hair restraints, the DA pushed a cart of prepared food into the main kitchen and obtained raw eggs from the walk-in refrigerator. Observation showed the DA then put a hair net on his/her head and, without the use of a facial hair restraint, transported the cart of prepared food to the Flat Branch kitchen, placed the prepared food items into the steamtable and served the food to the residents at the breakfast meal. Observation 01/23/26 at 8:40 A.M., showed DA X, who had facial hair, served food to residents at the breakfast meal in the Smithton Village kitchen. During an interview on 01/23/26 at 9:00 A.M., the DM said all dietary staff are trained to wear hair restraints, including facial hair restraints, and he/she did not know staff did not wear hair restraints as required. During an interview on 01/23/26 at 3:00 P.M., the administrator said anyone who is around the food should wear a hair restraint, including facial hair restraints if they have facial hair, and staff are trained on this requirement.

Based on observation, interview and record review, the facility staff failed to provide Enhanced Barrier Precautions (EBP) during wound care for two (Residents #5 and #15) of five residents who had a wound and one (Resident #5) of two residents who had a catheter. The facility staff failed to provide appropriate hand hygiene between glove changes during the provision of care for one (Residents #5) of six residents. The facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for tuberculosis (TB)) was completed in accordance with their policy and on file for eight employees (Housekeeper J, Certified Medication Technician (CMT) K, Certified Nurse Aide (CNA) L, Housekeeper M, Dietary Aide (DA) N, Licensed Practical Nurse (LPN) O, Social Service Designee (SSD), and the Assistant Business Office Manager (ABOM) out of ten sampled employees. The facility census was 88.1. Review of facility's Enhanced Barrier Precautions policy, dated 2025, showed:-All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions;-All staff receive training on high risk activities and common organisms that require EBP;-An order for EBP will be obtained for resident with wounds, indwelling medical devices (i.e. central lines, urinary catheters, feeding tubes, and hemodialysis catheters) even if the resident is not known to be infected or colonized with a multi-drug resistant organism;- Gowns and gloves are immediately available near or outside of the resident's room;-High contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, assisting with toileting, device care, wound care (any skin opening requiring a dressing).-EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the would or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility's Hand Hygiene policy, dated 2025, showed:-All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;-Hand hygiene will be performed before applying and after removing personal protective equipment (PPE) (including gloves), after handling items potentially contaminated with blood, body fluids, secretions or excretions, when, during resident care, moving from a contaminated body site to a clean body site and before and after handing clean or soiled dressings or linens, etc. 2. Review of Resident #5's, Significant Change of Status (SCS) Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/27/25, showed staff assessed the resident as:-Severe cognitive impairment;-Dependent on staff for toilet hygiene and upper and lower body dressing;-Use of indwelling catheter (tube used to drain the bladder);-Presence of one Stage 3 Pressure ulcer (full thickness loss of skin in which fat is visible in the ulcer) and one Deep Tissue Pressure Injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister). Review of the resident's care plan, dated 12/21/25, showed:-Used an indwelling catheter;-At risk for skin breakdown;-The care plan did not contain direction or guidance for EBP or presence of a sacral wound.Observation on 01/23/26 at 5:09 A.M., showed the resident's door contained a sign directed staff to wear a gown and gloves for hygiene, assisting with toileting, catheter care and wound care. CNA H and LPN I entered the resident's room and applied gloves. The CNA cleansed the resident's buttocks and inner folds, removed his/her gloves and applied new gloves. The CNA did not perform hand hygiene before applying clean gloves. The CNA cleansed the resident's inner thighs, catheter site and catheter tubing. CNA H removed his/her gloves and applied new gloves. CNA H did not perform hand hygiene before applying clean gloves. LPN I removed the soiled bed-pad, cleansed the resident's buttocks and inner folds and removed his/her gloves and applied new gloves. LPN I did not perform hand hygiene before applying clean gloves. The staff rolled the resident to his/her left side, a large dressing was removed from a wound on the resident's tailbone area. The LPN cleansed the wound, removed his/her gloves and applied clean gloves. LPN I did not perform hand hygiene before applying clean gloves. The LPN applied a clean dressing and secured with tape. The LPN and the CNA did not wear a gown during wound care or catheter care. During an interview on 01/23/26 at 5:36 A.M., CNA H said he/she was taught about EBP but did not think about it with this resident. He/She was nervous and did not pay attention to the signage that is posted on the door. The aide said he/she knew he/she did not wash his/her hands prior to applying new gloves like he/she should have because he/she was nervous. The aide said if you don't perform hand hygiene, you can spread germs. During an interview on 01/23/26 at 5:42 A.M., LPN I said he/she did hand hygiene as he/she was taught. He/She said he/she did not know what EBP was and he/she did not believe this resident required the EBP during care. The LPN said the signage on the door was outdated and could be removed. 3. Review of Resident #15's admission MDS dated [DATE], showed staff assessed the resident as cognitive with diagnoses of orthopedic condition, wound infection, surgical joint repair, surgical wound care.Review of the resident's Physician Order Set (POS), dated 01/26, showed the following order: -Wound care left upper arm: Cleanse area and apply soaked gauze, cover with dressing pad and secure with kerlix and ACE wraps. Change daily. one time a day for wound care.Observation on 01/22/26 at 09:25 A.M., showed the resident's door did not contain EBP signage or gowns available on the PPE cart.Observation on 01/02/26 at 09:50 A.M., showed LPN A applied a kerlix wrap to the resident's left upper arm wound, removed his/her gown, then wrapped the arm with an ACE bandage. While he/she removed the gown, LPN A said he/she was not going to be in contact with other residents, so he/she did not need it. During an interview on 01/02/26 at 10:00 A.M., the resident said he/she has never seen staff wear gowns during wound care prior to today. During an interview on 01/22/26 at 03:10 P.M., LPN A said EBP is implemented when the resident has an infection or catheter, but it depends on why they have a catheter. He/She said Resident #15 had a PICC line (peripherally inserted central catheter used to deliver intravenous antibiotics) until recently, but PICC lines do not require EBP. LPN A said masks and gloves are helpful but not required. LPN A said he/she receives annual online training for EBP. He/She said there are currently no residents on the unit who needs EBP. He/She said it is the responsibility of the Director of Nursing (DON), Assistant Director of Nursing (ADON) and nursing supervisors to ensure adherence to EBP.4. During an interview on 01/23/26 at 01:55 P.M., the Infection Preventionist said EBP is implemented for residents with wounds, catheters, and intravenous lines. He/She said all staff are aware of who is on EBP protocol and have completed training on EBP and hand hygiene. The IP said signs and PPE carts are distributed by housekeeping after notification by the IP, DON or Admissions. He/She said signs cue staff for proper PPE usage. During an interview on 01/22/26 at 2:11 P.M., Registered Nurse (RN) B said EBP is implemented when a resident has a known pathogen, such as influenza. He/She said it includes air-borne, droplet, contact and bloodborne transmission modes. RN B said if he/she observed staff not complying with EBP, he/she would stop the process, ensure supplies were available and educate the person in the moment. RN B said he/she would not promote the removal of a gown during wound care. He/She said proper hand hygiene includes washing hands before and after providing care, and in between glove changes.During an interview on 01/23/26 at 04:00 P.M., the DON said staff receive online EBP training and are observed by the IP. The DON said EBP PPE includes gloves, gowns, and mask, and a face shield if spray is expected. He/She said the DON and IP ensure signs are posted and PPE carts are available. He/She said hand hygiene is to be performed upon entry, when providing care and when hands become soiled. During an interview on 01/23/26 at 04:20 P.M., the Administrator said facility staff are expected to follow EBP and hand hygiene policies and protocols. The Administrator said the expectations are covered in staff training. He/She said it is the responsibility of the charge nurses and IP to ensure adherence to the policies and ensure supplies are available. 5. Review of the facility's Employee Tuberculosis Testing policy, dated 2025, showed: -All new staff shall receive two Mantoux TB skin tests given two weeks apart (two-step testing);-All initial and follow-up TB tests shall be administered and interpreted (48-72 hours for skin tests) by a trained healthcare provider on our staff or any licensed physician;-Compliance with initial and subsequent TB screening/testing is required for continued employment with the facility. Review of the Centers for Disease Control, Baseline Tuberculosis Screening and Testing for Health Care Personnel, dated 12/19/23, showed if the Mantoux tuberculin skin test (TST) is used for baseline testing or health care personnel, use the two-step testing. 6. Review of Housekeeper J's employee file showed: -Hire date of: 07/01/25;-First step PPD administered on 07/01/25 and read on 07/03/25;-The file did not contain documentation a second PPD was administered one to three weeks after the first PPD skin test is read. 7. Review of CMT K's employee file showed: -Hire date of: 05/06/25;-First step PPD administered on 05/07/25 and read on 05/10/25;-The file did not contain documentation a second PPD was administered one to three weeks after the first PPD skin test is read. 8. Review of CNA L's employee file showed: -Hire date of: 03/18/25;-First step PPD administered on 03/18/25 and read on 03/29/25;-the file did not contain documentation a second PPD was administered one to three weeks after the first PPD skin test was read. 9. Review of Houskeeper M's employee file showed: -Hire date of: 05/20/25;-First step PPD administered on 05/20/25 and read on 05/23/25;-The file did not contain documentation a second PPD was administered one to three weeks after the first PPD skin test was read. 10. Review of DA N's employee file showed: -Hire date of: 12/16/25;-First step PPD administered on 01/14/26 and read on 01/16/26;-The file did not contain documentation a second PPD was administered one to three weeks after the first PPD skin test was read. 11. Review of LPN O's employee file showed: -Hire date of 12/16/25;-First step PPD administered on 12/10/25 and read on 12/13/25;-The file did not contain documentation a second PPD was administered one to three weeks after the first PPD skin test was read. 12. Review of the SSD's employee file showed: -Hire date of 09/30/25;-First step PPD administered on 09/16/25 and read on 09/19/25;-The file did not contain documentation a second PPD was administered one to three weeks after the first PPD skin test was read. 13. Review of the ABOM's employee file showed: -Hire date of 12/30/25;-First step PPD administered on 12/17/25 and read on 12/19/25;-The file did not contain documentation a second PPD was administered one to three weeks after the first PPD skin test was read. 14. During an interview on 01/23/26 at 1:00 P.M., the Assistant Business Office Manager said he/she handles human resources tasks but does not do anything with the employee TB testing. He/She has only been in the role for eight days and still learning. He/She believes the nurse who works the Flat Branch hallway is responsible for the administration and tracking of the employee TB test.During an interview on 01/23/26 at 1:31 P.M., LPN P said he/she normally works Flat Branch hallway and is responsible to administer the staffs new hire TB test. The tested employee is responsible to return for the test to be read within three days of administration. He/She does not know who ensures the second step is given timely or tracks when it is due.During an interview on 01/23/26 at 3:50 P.M., the DON said the Flat Branch nurse is responsible to initiate and read the PPD skin test on employees. He/She is aware the facility is out of compliance.

Based on interview, and record review, the facility staff failed to obtain written consent from the resident or his/her designee, guardian and conservator, or conservator to manage the personal funds of the resident in the facility resident trust account for four residents (Residents #31, #68, #121 and #122) out of nine sampled residents. Facility staff also failed to maintain a system that assured full, complete, and separate accounting of each resident's personal funds to preclude the commingling of resident funds with facility funds for one resident (Resident #124) out of two sampled residents and ensure timely refunds for five residents (Residents #121, #122, #123, #124, #125) out of six sampled discharged residents. The facility census was 88. 1. Review of the facility's policy titled, Resident Personal Fund, revised 01/05/25, showed: -If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility;-The facility will deposit any resident's personal funds in excess of $50 in an interest-bearing account (or accounts) separate from any of the facility's operating accounts, and will credit all interest earned on resident funds to that account;-The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf;-The system will preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident;-Upon the discharge, eviction, or death of a resident with personal funds deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with state law. Review of the facility's admission agreement, revised June 2020, showed direction that in order for the facility to manage the resident's personal funds, the resident/designee must provide authorization of such in writing. 2. Review of Resident #31's admission agreement, dated 07/02/19, showed the resident's guardian documented he/she did not authorize the facility to place the resident's personal funds in the possession of the facility. Review of the resident's Resident Trust Transaction History, dated 01/01/25 through 01/23/26, showed $80 of the resident's funds placed in the facility resident trust account to open his/her individual account on 07/30/25. Review showed additional deposits and a withdrawals on the account for the dates of 09/30/25 through 12/31/25 which left the resident with a balance of $231.62 on 12/31/25. Review of the facility's Resident Trust-Current Account Balance Report, dated 01/23/26, showed the resident with a current balance of $231.62. During an interview on 01/23/26 at 1:40 P.M., the Business Office Manager (BOM) said he/she did not have written authorization to manage the resident's personal funds in the facility's resident trust account. The BOM said the resident's guardian just started sending money to the facility for the resident to use for haircuts and gift purchases and he/she did not have any documentation from the resident's guardian authorizing the facility to manage the resident's personal funds and he/she did not know he/she needed to have it in writing. 3. Review of Resident #68's admission agreement, dated 04/29/24, showed the resident documented he/she did not authorize the facility to place the resident's personal funds in the possession of the facility. Review of the resident's Resident Trust Transaction History, dated Review showed an additional deposit to the account on 12/31/25 which left the resident with a balance of $300.01 on 12/31/25. Review of the facility's Resident Trust-Current Account Balance Report, dated 01/23/26, showed the resident with a current balance of $300.01. During an interview on 01/23/26 at 1:40 P.M., the BOM said he/she did not have written authorization to manage the resident's personal funds in the facility's resident trust account and he/she did not know he/she needed to have it in writing. 4. Review of Resident #121's admission agreement, dated 03/09/22, showed the resident documented he/she did not authorize the facility to place his/her personal funds in the possession of the facility. Review of the resident's Resident Trust Transaction History, dated 01/23/26, showed $221 of the resident's funds placed in the facility resident trust account to open his/her individual account on 06/27/25. Review of the facility's Resident Trust-Current Account Balance Report, dated 01/23/26, showed the resident with a current balance of $221. During an interview on 01/23/26 at 1:40 P.M., the BOM said he/she did not have written authorization to manage the resident's personal funds in the facility's resident trust account and he/she did not know he/she needed to have it in writing. 5. Review of Resident #122's admission agreement, dated 05/17/22, showed the resident's responsible party documented he/she did not authorize the facility to place the resident's personal funds in the possession of the facility. Review of the resident's Resident Trust Transaction History, dated 01/23/26, showed $150 of the resident's funds placed in the facility resident trust account to open his/her individual account on 11/10/22. Review of the facility's Resident Trust-Current Account Balance Report, dated 01/23/26, showed the resident with a current balance of $150. During an interview on 01/23/26 at 1:40 P.M., the BOM said the facility received three of the resident's social security checks in November 2022 and they deposited the resident's personal spending allowance from those social security checks in the facility's resident trust account. The BOM said he/she did not have written authorization to manage the resident's personal funds in the facility's resident trust account and he/she did not know he/she needed to have it in writing. During an interview on 01/23/26 at 1:55 P.M., the administrator said the BOM is responsible for the resident funds and he/she assumed the BOM had been trained on the requirements for the management of resident funds. The administrator said there should be written authorization to manage the personal funds of residents and the written authorization should be received before the holding the funds. The administrator said he/she did not know the BOM managed funds for residents without written authorization. 6. Review of the facility's accounts receivable aging report, dated 01/21/26, showed Resident #124 with a current private pay credit balance of $2,576. Review also showed the resident with a discharge date of 11/11/25. Review of the resident's medical records showed the resident discharged from the facility on 11/11/25. During an interview on 01/23/26 at 11:42 A.M., the BOM said he/she is responsible for the accounting of the facility's operating account and he/she tries to review the accounts receivable aging report twice a month. The BOM said if a resident discharges from the facility, any personal funds that remain should be refunded within 30 days. The BOM said the resident discharged from the facility on 11/11/25 and they were holding the resident's funds until they received payment owed from his/her insurance. The BOM said he/she did not have written authorization to hold the resident's private pay credit balance in the facility's operating account to cover non-payment by third parties and he/she did not know he/she needed written authorization because that is what they had always done. During an interview on 01/23/26 at 1:55 P.M., the administrator said the BOM is responsible for the resident funds and assumed the BOM had been trained on the requirements for the management of resident funds. The administrator said the BOM is to review the facility's accounts receivable monthly and if a resident has a credit balance the BOM should send a refund request to the corporate office. The administrator said the personal funds of residents cannot be held by the facility for non-payment by third parties without written authorization from the resident or his/her responsible party and he/she did not know about the resident's credit balance in the facility's operating account. 7. Review of the facility's Resident Trust-Current Account Balance Report, dated 01/23/26, showed Resident #121 with a current balance of $221. Review of the resident's medical records showed the resident discharged from the facility on 08/07/25. During an interview on 01/23/26 at 11:25 A.M., the BOM said the resident passed away on 08/07/25 and they had not been able to contact the resident's durable power of attorney (DPOA) to refund the money because the DPOA had been out of the country since the resident's passing. The BOM said he/she did not contact anyone else about the resident's personal funds and he/she sent the resident's funds to the state unclaimed property on 12/24/25, so he/she should not have a balance in the resident funds trust account. The BOM said he/she did not have any documentation to the show the resident's funds were sent to the state unclaimed property and if a resident's funds are withdrawn from their account, their resident funds trust account should show the withdrawal. The BOM said he/she could not explain why the resident's account did not show his/her funds withdrawn from his/her account. During an interview on 01/23/26 at 1:55 P.M., the administrator said he/she could not provide documentation to show the resident's personal funds were withdrawn from his/her resident funds trust account. The administrator said if a resident's funds are withdrawn from their account, the acceptable accounting practice would be for the withdrawal to be accounted for in their resident funds trust account. 8. Review of the facility's Resident Trust-Current Account Balance Report, dated 01/23/26, showed Resident #122 with a current balance of $150. Review of the resident's medical records showed the resident discharged from the facility on 11/02/22. During an interview on 01/23/26 at 11:38 A.M., the BOM said the resident passed away on 11/02/22. The BOM said the resident's funds were sent to the state unclaimed property in 2023, so he/she should not have a balance in the resident funds trust account. The BOM said he/she did not have any documentation to the show the resident's funds were sent to the state unclaimed property and if a resident's funds are withdrawn from their account, their resident funds trust account should show the withdrawal. The BOM said he/she could not explain why the resident's account did not show his/her funds withdrawn from his/her account. During an interview on 01/23/26 at 1:55 P.M., the administrator said he/she could not provide documentation to show the resident's personal funds were withdrawn from his/her resident funds trust account. The administrator said if a resident's funds are withdrawn from their account, the acceptable accounting practice would be for the withdrawal to be accounted for in their resident funds trust account. 9. Review of the facility's Resident Trust-Current Account Balance Report, dated 01/23/26, showed Resident #123 with a current balance of $3,192.91. Review of the resident's medical records showed the resident discharged from the facility on 11/17/25. During an interview on 01/23/26 at 11:34 A.M., the BOM said the resident passed away on 11/17/25. The BOM said he/she had not refunded the resident's money because the resident still owed the facility his/her Medicaid surplus amount of $2520.68 for November 2025. The BOM said they did not receive the resident's social security checks until after the resident passed away and he/she did not know what he/she was supposed to do with the money, because they did not have written authorization to pay his/her outstanding balance with the funds since the resident always paid his/her bill in person. The BOM said he/she had not contacted anyone about what to do with the resident's personal funds to date. During an interview on 01/23/26 at1:55 P.M., the administrator said personal funds of residents should be refunded within 30 days of a resident's discharge to the facility and they should not hold a resident's personal funds without written authorization from the resident or their responsible party. 10. Review of the facility's Resident Trust-Current Account Balance Report, dated 01/23/26, showed Resident #125 with a current balance of $172.86. Review of the resident's medical records showed the resident discharged from the facility on 09/29/20. During an interview on 01/23/26 at 11:29 A.M., the BOM said the resident discharged from the facility on 09/29/20. The BOM said the resident's personal funds in the resident funds trust account had not been refunded because the resident still owed the facility money and they had turned his/her billing account over to a collection agency, so they were waiting to see what the collection agency would be able to collect. The BOM said he/she did not have written authorization from the resident or their responsible party to hold the resident's personal funds in the resident funds trust account for future facility payment. During an interview on 01/23/26 at1:55 P.M., the administrator said personal funds of residents should be refunded within 30 days of a resident's discharge to the facility and they should not hold a resident's personal funds without written authorization from the resident or their responsible party.

Based on observation, interview and record review, facility staff failed to develop and implement a person-centered care plan to included behavioral interventions and activity preferences for three of three sampled residents (Resident #2, #5 and #9) who resided on a secured memory care unit. The facility census was 88. 1. Review of the facility's Dementia Care policy, dated 2025, showed individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. Review of the facility's Activity policy, dated 2026, showed it is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Special considerations will be made for developing meaningful activities for residents with dementia. Review of the facility's Comprehensive Care Plans policy, dated 2025, showed the comprehensive care plan will describe, at a minimum, the following: services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. 2. Review of Resident #2's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/07/25, showed staff assessed the resident as:-Cognitively impaired;-Did not have behaviors or reject care;-Felt it was somewhat important to listen to music, go outside when the weather was nice and attend religious activities;-Felt it was important to have books or magazines and/or participate in favorite activities;-Felt it was very important to attend group activities;-Diagnosis of Dementia.Review of the resident's nurses' notes, dated 11/01/25 through 01/22/26, showed staff documented the resident had behaviors of confusion, required verbal cues, restless at times, agitation and anxiety.Review of resident's care plan, dated 11/03/25, showed the care plan did not address the resident's need for a secured memory care unit, activity preferences, or behavioral interventions for when the resident had anxiety. Observation on 01/20/26 at 11:00 A.M., showed the resident lived on the secured memory care unit. Observation showed the resident became restless in the television room and attempted to self-transfer from his/her wheelchair to a regular chair and, when unsuccessful, he/she became agitated evidenced by a change in his/her verbal tone and he/she struck the armrest of the wheelchair. Observation showed an unknown staff member unlocked the resident's wheelchair and the resident then self-propelled around the sitting area. 3. Review of Resident #5's SCSA MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Did not have behaviors or reject care;-Felt it was important to have activities with music, groups of people, participate in favorite activities and religious activities;-Diagnosis of Dementia.Review of the resident's nurses' notes, dated 10/01/25 through 01/22/26, showed staff documented the resident had agitation during an assessment and did not contain documentation of other behaviors. Review of the resident's care plan, dated 12/21/25, showed the care plan did not address the secured memory care unit, activity preferences, or behavioral interventions. Observation on 01/20/25 at 2:24 P.M., showed the resident in bed on the secured memory care unit with his/her eyes closed. Observation on 01/21/25 at 8:46 A.M., showed the resident in bed on the memory care unit with his/her eyes closed. 4. Review of Resident #9's admission MDS, dated [DATE], showed staff assessed the resident as:-Cognitively impaired;-Did not have behaviors or reject care;-Felt it was somewhat important to have music and religious act;-Felt it was important to have books or magazines and/or participate in favorite activities but cannot do or no choice to do;-Diagnosis of dementia.Review of the resident's nurses' notes dated,11/01/25 through 01/22/26, showed the resident wandered at night, spit food, yelled out, had chronic confusion and disorganized thinking, required cues, refused care, hallucinated, and behaviors increased when without hearing aids.Review of the resident's care plan, dated 11/04/25, showed the care plan did not contain direction for wandering, spitting food, required cueing, hallucinations or use of hearing aids to ease behavioral episodes. Observation on 01/20/25 at 11:42 A.M., showed the resident in his/her wheelchair at the lunch table and he/she would occasionally speak to him/herself.Observation on 01/21/25 at 8:51 A.M., showed the resident in bed with his/her eyes closed. 5. During an interview on 01/23/25 at 10:23 A.M., CNA T said Residents #2, #5, and #9 all reside on the secured memory care unit. He/She said he/she does not know what their behaviors are and staff inform him/her during shift report of any resident behaviors. The CNA said behaviors should be care planned so staff know how to assist the residents when they have behaviors. The CNA said the activities staff comes to the unit and provides activities, but they are not always there. During an interview on 01/23/26 at 11:06 A.M., SSD U said activity assessments are used to develop the care plan and incorporate the residents likes and dislikes. Staff are encouraged to use the information to help residents with behavior management and cognition. He/She is new to the role but is working closely with the Activity Director (AD) to update the care plans. During an interview on 01/23/26 at 11:20 A.M., the AD said he/she has been in the role for three weeks. He/She has been trying to put new things in place and has been working to get some dementia related materials to incorporate into his/her program for those that reside on the memory care unit. The AD said she is not currently updating the care plans because she is still learning. During an interview on 01/23/26 at 3:34 P.M., the MDS nurse said he/she tries to incorporate behaviors into the care plans. He/She said knowing the residents likes and dislikes can help manage difficult behaviors. Behaviors should be care planned with specific interventions. He/She said all team members have access to the care plans and can update it appropriately. He/She said if the MDS coordinator is not informed of important information regarding the resident in between assessments, he/she does not know about it.During an interview on 01/23/26 at 3:50 P.M., the Director of Nursing (DON) said residents with dementia should have a care plan that includes dementia. The care plan should include things that comfort them, specific behaviors and interventions, things that redirect them, activity needs and why they live on a secured unit. The DON said he/she has only been in the role a couple of months and is still trying to get processes together.During an interview on 01/23/26 at 4:32 P.M., the administrator said the Interdisciplinary Team (IDT) is responsible to ensure that care plans are up to date. Dementia care residents that reside on the secured unit should have an indication why they live there in their care plans as well as activity preferences and resident specific behaviors and interventions.

Based on observation, interview and record review, facility staff failed to review and revise the comprehensive care plan for three of three sampled residents (Resident #2, #6, and #9) who had falls and failed to update the care plan for one resident (Resident #5) of two sampled residents with pressure ulcers (wound created from pressure). The facility census was 88.Review of the Comprehensive Care Plan policy, dated 2025, showed the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 1. Review of Resident #2's Significant Change of Status (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/07/25, showed staff assessed the resident as:-Cognitively impaired:-Needed some help with functional cognition;-Had impaired range of motion in one upper and one lower extremity;-Dependent on staff for sit to stand transfers;-Had not fallen since prior assessment;-Diagnosis of stroke.Review of the resident's nurses' notes, dated 01/15/26, showed staff documented the resident fell out of bed at 7:15 P.M., and fell from his/her wheelchair at 10:00 P.M. Review of the resident's care plan, dated 11/29/25, showed the care plan did not contain documentation of a review for the resident's two falls on 01/15/26. 2. Review of Resident #6's Annual MDS dated , 12/01/25, showed staff assessed the resident as:-Cognitively intact;-Diagnoses of progressive neurological disorder and Parkinson's disease;-Had not fallen since admission;-Required substantial maximal assistance with toileting, dressing, hygiene, and mobility.Observation on 01/21/2/25 at 01:55 P.M. showed the resident wore a neck brace and had a forehead laceration. Observation on 01/22/25 at 10:20 A.M., showed Registered Nurse (RN) B cleansed a laceration on the resident's forehead, while the resident wore a neck brace. During an interview on 01/21/25 at 1:55 P.M., the resident said he/she fell and hit his/her head on the bedside table and broke his/her neck on 12/17/25.Review of the resident's care plan, dated 11/25/25, showed the care plan did not contain documentation of a review for the resident's fall or direction for the forehead laceration or neck brace. 3. Review of Resident #9's admission MDS, dated [DATE], showed staff assessed the resident as:-Cognitively impaired;-Had impaired range of motion to one upper extremity;-Dependent on staff for sit to stand transfers;-Had a history of falls prior to admission;-Diagnosis of dementia.Review of the resident's nurse notes', dated 10/28/25 through 01/22/26, showed staff documented the resident fell on [DATE] and 01/19/26. Review of the resident's care plan, dated 11/04/25, showed the care plan did not contain documentation of a review for the resident's falls on 01/17/26 or 01/19/26. 4. Review of Resident #5's SCSA MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Had a Stage III pressure wound (full-thickness wound with exposed fat);-Had a deep tissue pressure injury (localized damage to soft tissue);-Had a surgical wound;-Received hospice services;-Diagnoses of dementia and anemia.Review of the resident's care plan, dated 12/21/25, showed:-Stage III wound to the right heel;-Surgical wound to the right thigh;-The care plan did not contain documentation of the pressure ulcers located on the resident's left upper arm or tailbone. Observation on 01/23/26 at 5:02 A.M., showed the resident in bed with a stage II pressure (partial thickness loss of skin, shallow) wound to his/her left upper arm and a stage IV pressure (full thickness skin damage exposing bone) wound to his/her tailbone. Observation showed the resident did not have a wound to the right heel or right thigh. 5. During an interview on 01/23/26 at 3:34 P.M., the MDS nurse said staff must tell him/her if changes are needed to the residents' care plans. He/She said a care plan should be updated with a resident change in condition, falls, treatments, acute illnesses and specialized equipment. He/She said it is his/her responsibility to ensure the care plans are accurate, but they can be updated by the nurses or interdisciplinary team (IDT). If a resident falls, documentation is reviewed, and the care plan should be reviewed and updated. He/She is not sure why the care plans were not updated after Residents #2, #6 and #9 had falls, probably overlooked. During an interview on 01/23/26 at 3:50 P.M., the Director of Nursing (DON) said care plans should reasons for treatments, equipment needs, wounds, and falls. The care plan should be updated if there are any changes and as soon as possible. The charge nurse and MDS nurse can update the care plans. The care plans should be reviewed after each fall and updated as needed.

Based on observation, interview, and record review, facility staff failed to provide services to meet professional standards when staff failed to document and obtain orders for catheter use and indication, catheter size and bulb size for catheters on two of two sampled residents (Resident #8 and #111) and failed to document and obtain orders for dialysis to include days of week, location of clinic, and indication for two of two residents (Resident #2 and #5) who received dialysis. The facility census was 88.1. Review of the facility's Catheter Care policy, undated, showed the policy did not contain direction or guidance for contents of a physician order for catheters. 2. Review of Resident #2's Significant Change of Status (SCS) Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/07/25, showed staff assessed the resident as: -Cognitively impaired;-Indwelling catheter;-Diagnosis of Dementia. Review of the residents Physician Order Sheet (POS), dated 01/22/26, showed: -Catheter care every shift, cleansing from proximal to distal for infection prevention;-Empty drainage bag every shift;-Change drainage bag every Sunday on nightshift;-The POS did not contain an order for the size of the catheter, the bulb size of the catheter or the indication for the catheter. Review of the resident's care plan, dated 11/03/25, showed the care plan did not contain direction or guidance for catheter indication, size or bulb size. Observation on 01/20/25 at 11:40 A.M., showed the resident in his/her wheelchair and a catheter drainage bag hung from the bottom of the wheelchair. Observation on 01/21/25 at 8:24 A.M., showed the resident in his/her wheelchair and a catheter drainage bag hung from the bottom of the wheelchair. During an interview on 01/23/26 at 10:50 A.M., Licensed Practical Nurse (LPN) Q said residents who have an indwelling catheter should have an order, which includes why the resident has the catheter and the size and care of the catheter, and it is the responsibility of the nurse who obtained the order to put it into the chart. LPN Q said he/she is not sure why Resident #2 did not have an order for use of a catheter, size or balloon size. LPN Q said the resident has a catheter because he/she has dementia. During an interview on 01/23/26 at 3:50 P.M., the Director of Nursing (DON) said the resident has a catheter for an approved diagnosis of dementia with psychosis. 3. Review of Resident #5's SCS MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired;-On hospice services;-Indwelling catheter;-Presence of one stage III pressure injury (full thickness skin loss exposing the fat layer);-Dependent on staff for bed mobility;-Diagnosis of dementia; Review of the resident's POS, dated 01/22/26, showed the following orders: -Catheter care every shift, cleansing from proximal to distal for infection prevention;-Empty drainage bag every shift;-Change drainage bag every Sunday on nightshift;-The POS did not contain an order for the size of the catheter, or the bulb size of the catheter or the indication for the catheter. Review of the resident's care plan, dated 12/21/25, showed the care plan did not contain direction of guidance for size of catheter or bulb size. Observation on 01/20/25 at 11:28 A.M., showed the resident in bed with a catheter drainage bag hooked to the side of the bed. Observation on 01/23/25 at 5:02 A.M., showed the resident in bed with a catheter drainage bag hooked to the side of the bed. During an interview on 01/23/26 at 10:50 A.M., LPN Q said residents who have an indwelling catheter should have an order, which includes why the resident has the catheter and the size and care of the catheter, and it is the responsibility of the nurse who obtained the order to put it into the chart. LPN Q said he/she is not sure why Resident #5 did not have an order for use of a catheter, size or balloon size. LPN Q said the resident is on hospice and is allowed to have a catheter. During an interview on 01/23/26 at 3:50 P.M., the DON said the resident has a catheter for hospice and pressure wound to the bottom. 4. During an interview on 01/23/26 at 3:50 P.M., the DON said the nurses are responsible to obtain an order for urinary catheters. The order should include a reason for use, size and bulb size. The DON said he/she did not know Residents #2 and #5 did not have appropriate orders. 5. Review of the facility's Hemodialysis policy, dated 2025, showed the facility will ensure that the physician's orders for dialysis include: -The type of access for dialysis;-The dialysis schedule;-The nephrologist name and phone number;-The dialysis facility name and phone number. 6. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact;-On dialysis;-Diagnosis of End Stage Renal Disease (ESRD). Review of the resident's POS, dated 1/22/26 showed orders for the following: -Check dialysis port before and after dialysis twice a day every Monday, Wednesday and Friday;-Take vital signs (VS) pre and post dialysis twice a day every Monday, Wednesday and Friday;-Weigh pre dialysis and post dialysis every dayshift on Tuesday, Thursday, Saturday and Sunday;-Check dialysis port before and after dialysis twice a day every Monday, Wednesday and Friday;-The POS did not contain orders for dialysis to include days of week, location of clinic, and indication for dialysis. During an interview on 01/22/26 at 2:15 P.M., LPN R said he/she was not sure which clinic Resident #8 goes to and could not find it in the medical record. He/She said if there would be an emergency, he/she would have to dig through the chart or ask someone more familiar with the resident to know who to contact. He/She said he/she is informed of what days the resident goes to dialysis in a daily report from the off-going shift. He/She said it would be a good idea to have that information more readily available and does not know who is responsible to ensure the chart contains that information. 7. Review of Resident #111's medical record, showed the resident admitted to the facility on [DATE] and did not have a completed MDS assessment. Review of the resident's baseline care plan, dated 01/14/26, showed the resident received dialysis every Monday, Wednesday and Friday. Review of the resident's POS, dated 01/22/26, showed the following orders: -Dialysis assessment on dialysis days in the afternoon every Monday, Wednesday and Friday;-Dialysis clinic chair time of 6:30 A.M.;-No lab draws or blood pressure on arm with fistula;-Left fistula, if dressing is in place, change as needed when soiled;-Monitor left arm fistula site every shift, assess bruit (sound associated with blood flow) or thrill (vibration felt on the skin associated with blood flow), every shift-The physician orders did not contain orders for indication of dialysis, location of clinic, or name and phone number of nephrologist. During an interview on 01/22/26 at 2:30 P.M., LPN S said dialysis orders are obtained by the admitting nurse when the resident arrives from the hospital and the orders should include days of the week and shunt care, if any. He/She said he/she did not know if the resident had such orders. He/She said the resident goes to dialysis three days a week and knows that because the resident told them. 8. During an interview on 01/23/26 at 3:50 P.M., the DON said residents who undergo dialysis should have appropriate orders that include reason, days of week and location of services and the nurses are responsible to obtain such orders during admission or with a new order. The DON said he/she did not know Residents #8 and #111 did not have appropriate orders.

Based on interview, and record review, facility staff failed to meet professional standards of practice when facility staff failed to transcribe physician's orders for one resident (Resident #3) and failed to complete weekly skin assessments for three residents (Resident #2, #3, and #5) out of five sampled residents. The facility census was 86. 1. Review of the facilities Physician Orders policy, undated, showed staff are directed as follows:-All physicians orders should be carried out as ordered upon the signed order of a person lawfully authorized to prescribe;-Each order should be noted and processed according to the standards of practice;-The order will be input into the electronic medical record system and then will populate into the proper areas for administration. 2. Review of Resident #3's Significant Chage Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/30/25, showed staff assessed the resident with severe cognitive impairment. Review of the resident's care plan, revised 11/03/25, showed staff assessed the resident as:-Cognitive deficit;-Required assistance for all Activities of Daily Living (ADL's), transfers, and mobility;-At risk for skin breakdown.Review of the resident's Physician's Order Sheet (POS), dated 11/18/25, did not contain documentation for Hydrocolloid sheet apply once weekly and as needed: if saturated, soiled, or dislodged to left medial upper back. Review of the resident's wound consultant orders, dated 11/13/25, showed an order for Hydrocolloid sheet apply once weekly and as needed: if saturated, soiled, or dislodged for 23 days to left medial upper back.Review of the resident's wound consultant orders, dated 11/06/26, showed an order for Hydrocolloid (a substance used for wound care that forms a gel when they absorb moisture) sheet apply once weekly and as needed: if saturated, soiled, or dislodged for 30 days to left medial upper back. Review of the resident's nurse's notes, dated 11/04/25, showed staff documented a new stage two pressure ulcer to the resident's thoracic spine.Review of the residents Treatment Administration Record (TAR), dated 11/01/25 through 11/18/25, did not contain documentation of Hydrocolloid sheet apply once weekly and as needed: if saturated, soiled, or dislodged to left medial upper back. Review of the resident's weekly skin assessments, dated October 2025, did not contain documentation a weekly skin assessment was completed on 10/1/25 and 10/29/25.During an interview on 11/18/25 at 1:35 P.M., Registered Nurse (RN) A said the purpose of physician's orders is to ensure a resident gets the proper care they need. RN A said if a physician's order for wound care is not followed it could result in the wound getting worse, infection, or new wound development. RN A said the charge nurse is responsible to transcribe and enter any new orders to the resident's POS. RN A said the wound consultant physician comes to the facility and makes rounds with the facility wound nurse. RN A said the wound consultant physician's documentation is automatically uploaded to the resident's chart under miscellaneous. RN A said it is the charge nurse's responsibility to look at that consult note and enter any new wound care orders as the physician prescribes them on to the resident's POS. RN A said he/she does not know why the resident's wound care orders were not entered as he/she only works two days a week and does not work the day they are there. RN A said if something is not documented it did not get done . During an interview on 11/18/25 at 2:30 P.M., the facility wound care nurse said he/she has many roles at the facility including the wound nurse, He/She makes rounds with the wound consultant physician every Thursday and assist him/her to change each resident's dressing at that time of service. The wound care nurse said he/she does not enter any new orders into the resident's chart, that the wound care consultant's documentation is automatically uploaded to the resident's chart under the miscellaneous tab. The wound care nurse said it is the charge nurse's responsibility to pull that document up and enter any new orders into the resident's POS. The wound care nurse said it is his/her responsibility to go behind the charge nurse to ensure those orders are entered correctly. The wound care nurse said he/she did not follow up with the resident's new orders like he/she should have and was not aware the resident's new orders were not entered. The wound care nurse said he/she should have followed up, but he/she is very busy with all his/her roles and didn't. The wound care nurse said the consequences of not entering those orders or following them could result in the wound getting infecting, getting larger in size, getting deeper, and overall decline of the wound. 3. Review of Resident #2's Significant Change MDS, dated [DATE], showed staff assessed the resident as having moderate cognitive impairment. Review of the resident's care plan, dated 08/06/25, showed staff assessed the resident as:-Cognitive deficit;-Required assistance for all ADL's, transfers, and mobility;-At risk for skin breakdown.Review of the resident's POS, dated 11/18/25, showed orders to complete a licensed weekly skin assessment every Tuesday day shift.Review of the resident's weekly skin assessments, dated October 2025, did not contain documentation a weekly skin assessment was completed 10/7/25, 10/21/25, and 10/28/25.Review of the resident's weekly skin assessments, dated September 2025, did not contain documentation staff completed a weekly skin assessment on 9/2/25, and 9/30/25.Review of the resident's weekly skin assessments, dated August 2025, did not contain documentation staff completed a weekly skin assessment on 8/12/25.4. Review of Resident #5's annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's care plan, revised 10/08/25, showed staff assessed the resident as follows: -Cognitive deficit;-Required assistance for all ADL's, transfers, and mobility;-At risk for skin breakdown.Review of the resident's POS, dated 11/18/25, showed an order to complete a licensed weekly skin assessment every Saturday night shift. Review of the resident's weekly skin assessments, dated November 2025, did not contain documentation staff completed a weekly skin assessment on 11/8/25.Review of the resident's weekly skin assessments, dated October 2025, did not contain documentation a weekly skin assessment was completed 10/18/25, and 10/25/25.Review of the resident's weekly skin assessments, dated September 2025, did not contain documentation a weekly skin assessment was completed 9/13/25.5. During an interview on 11/18/25 at 1:50 P.M., the Director of Nursing (DON) said today is his/her first day at the facility. The DON said he/she expects staff to follow physician's orders. The DON said the purpose of a physician's order is to direct resident care. The DON said if a physician's order is not followed it could potentially result in a resident's decline or safety. The DON said if wound care orders are not followed or weekly skin assessments are not completed it could lead to a decline in the wound, a potential for infection, sepsis, or not discovering a new wound. The DON said the charge nurse is responsible to transcribe any new orders to the resident's chart and to complete the weekly skin assessments. The DON said if something is not documented then staff don't know if it was done. The DON said he/she did not know the facility process for the wound consultant physician.During an interview on 11/18/25 at 1:58 P.M., the Regional Nurse said he/she has not been able to do his/her role as a regional nurse for months as he/she was placed an interim administrator at another facility. The Regional Nurse said he/she has only been coming back to the facility regularly two days a week for the past three weeks. The Regional Nurse said the facility wound nurse makes rounds with the wound consultant physician but does not enter the orders he/she prescribes. The Regional Nurse said the wound consultant's documentation is automatically uploaded to the miscellaneous tab on the resident's chart and it is the charge nurse's responsibility to pull up that document and enter any new wound care orders he/she prescribed. The Regional Nurse said he/she expects staff to follow physician's orders as this is what directs a resident's care. During an interview on 11/18/25 at 2:10 P.M., the Administrator said the purpose of a physician's order is to direct staff on how to administer care to the residents. The Administrator said he/she expect all staff to follow all physician's orders. The Administrator said the consequence of not following a physician's order would depend on what the order is, but in regard to wound care a wound could deteriorate, get infected, and new wounds may not be discovered when the develop. The Administrator said it is the charge nurse's responsibility to transcribe any new orders along with completing the weekly skin assessments for each resident. The Administrator said it is the DON's responsibility to oversee the nursing staff and ensure the complete their documentation. The Administrator said if something is not documented it is not done. The Administrator said when the wound consultant physician makes rounds the facility wound nurse goes with him/her. The Administrator said those wound documents are automatically uploaded to the resident's chart and it is the charge nurse's responsibility to transcribe any new orders to the resident's POS. The Administrator said it is the facility wound care nurse's responsibility to follow behind the charge nurse and ensure those orders are entered onto the resident's POS correctly. The Administrator said in general, she expects any nurse who gets a new order to ensure those orders are entered to the resident's chart correctly. Complaint #2646647 and 2660011

Based on interview and record review, facility staff failed to monitor one resident (Resident #1) at least every two-hours per facility policy and based on resident needs. Staff did not monitor the resident between the hours of 11:00 P.M. and 3:10 A.M. Resident #1 was found entrapped in the bedrail, face down in the mattress, unresponsive, and he/she passed away. The facility census was 89.The administrator was notified on [DATE] of Past Non-Compliance Immediate Jeopardy (IJ) which occurred on [DATE]. The Administrator immediately terminated Licensed Practical Nurse (LPN) C, suspended Certified Nursing Assistant (CNA) B pending the results of the investigation, conducted an investigation, and in-serviced all staff on rounding on [DATE]. Review of the facility's walking rounds shift report policy, undated, showed staff are directed that rounds will be made during each shift according to resident care needs and individual preferences following nursing standards of practice (typically at least every two hours dependent on situations occurring throughout the shift).Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as follows:-Moderately cognitively intact;-Required two staff for bed mobility and transfers; -Manual wheelchair use;-No paralysis on either side;-Staff did not assess bed rails and/or grab bars as used by resident.Review of the Physician's Order Sheets (POS), dated [DATE], showed a physician's order for enablers to both sides of the bed.Review of the resident's baseline care plan, dated [DATE], showed staff assessed the resident as follows:-Required mechanical lift for transfers;-Required assist of two staff for bed mobility, transfers, and toileting;-Had enablers/grab bars to both sides of the bed;-Exhibited behaviors to include hollering.Review of the resident's nurse's notes, dated [DATE] 3:15 A.M., showed LPN A documented CNA B came to LPN A for assistance with the resident. LPN A found the resident kneeling on the floor with his/her head against the bedrail and mattress. LPN A assessed the resident with no pulse, unresponsive Cardiopulmonary Resuscitation (CPR) initiated by LPN A. While he/she performed CPR, LPN A called emergency medical services (EMS) via personal cell phone to summon for assistance. EMS arrived and assisted with CPR.Review of Resident #1's nurses notes, dated [DATE] at 11:29 A.M., showed staff documented time of death called at 3:57 A.M. by the local emergency department and Information relayed to local funeral home.Review of the facility's investigation, undated, showed facility staff documented CNA B did not lay eyes on the resident from 11:00 P.M. on [DATE] to 3:10 A.M. on [DATE]. CNA B said he/she said went into the resident's room and observed the resident on his/her left side of his/her bed with his/her neck on the bed and bed rail. He/She said the resident was not moving. LPN A documented CNA B requested the nurse for assistance with the resident. LPN A found the resident knelt on the floor with his/her head rested against the bed rail and mattress. LPN A assessed the resident with no pulse, unresponsive and CPR initiated by LPN A. While LPN A performed CPR, LPN A called EMS via personal cell phone for assistance. EMS arrived and assisted with CPR.During an interview on [DATE] at 10:04 A.M., LPN A said CNA B came to get him/her because the resident was on the floor. When he/she entered the room the resident was on the left side of the bed, on his/her knees, with his/her head resting between the siderail and the mattress. He/She said he/she had to take the palm of his/her hand and forcefully remove the resident's head from between the rail and the mattress. He/She said the residents head was trapped and he/she was unsure if the resident suffocated, but the resident was face down. He/She called 911 on his/her personal phone on speaker and started chest compressions because the resident was unresponsive. He/She said all residents should be checked every two hours. During an interview on [DATE] at 12:24 P.M., LPN C said he/she last laid eyes on the resident around 10:30 P.M. when he/she started the resident's Cefazolin Sodium (first generation cephalosporin antibiotic) two gram Intravenous ((IV fluids, medications, or nutrients directly into the body's bloodstream through a vein using a small tube called a catheter). He/She said CNA B was responsible for rounds and should perform rounds every two hours. LPN C said he/she forgot to return to the resident and disconnect his/her IV from his/her Peripherally Inserted Central Catheter (PICC) line. He/She said CNA B and LPN A told him/her the resident was found with his/her head between the bed rails. LPN C said he/she should have removed the resident's antibiotic at 11:00 P.M., but that he/she forgot. During an interview on [DATE] at 1:51 P.M., CNA B said he/she is responsible for rounds every two hours, but he/she last laid eyes on the resident around 10:00 P.M. or 11:00 P.M. He/She thought the nurse would go back in the room to unhook the resident's IV medication, but he/she never did. CNA B said he/she walked into the resident's room around 3:10 A.M. and saw the IV pole hanging across the bed, the resident sitting with his/her knees on the ground, his/her left check on the mattress, and his/her right cheek on the bed rail, the resident was not moving. He/She said the resident's nurse LPN C was gone so he/she ran to the next unit and got LPN A who called 911, and initiated CPRDuring an interview at 2:44 P.M., the Director of Nursing (DON) said CNA B is responsible for rounds every two hours, but CNA B thought LPN C would lay eyes on the resident when he/she removed the resident's IV, and the nurse never removed the IV. He/She said both CNA B and LPN C should have checked on the resident sooner. He/She said the standard is to check residents every two hours or as needed. Complaint #2599782

Based on observation, interview and record review, facility staff failed to re-assess bedrail use after a significant change in condition per policy for one resident (Resident #1). Resident #1 was found entrapped in the bedrail, found face down in the mattress and unresponsive, resulting in his/her death. The facility census was 89. The administrator was notified on 09/03/2025 of an Immediate Jeopardy which began on 08/26/2025. The IJ was removed on 09/03/2025, as confirmed by surveyor onsite verification. 1. Review of the facility's Proper Use of Bed Rails policy, undated, showed staff are to ensure the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, or depth. Review showed responsibilities of ongoing monitoring and supervision are specified as follows:-Direct care staff will be responsible for care and treatment in accordance with the plan of care; -A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail;-The interdisciplinary team will make decisions regarding when the bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the bed rail;-The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails. Review of the facility's bed rail safety guidance form, undated, showed staff are directed as follows:-Zone one (entrapment within the rail) is measured within the rail and recommendation are less than 4 and 3/4 inches;-Zone two (entrapment under the rail, between the rail supports or next to a single rail support) is measured under bed rail and between rail supports recommendation less than 4 and 3/4 inches;-Zone three (entrapment between the rail and the mattress) is measures between rail and mattress recommendation less than 4 and 3/4 inches;-Zone four (entrapment under the rail, at the end of rail) is measured under rail at ends of the rail recommendation is less than 2 and 3/8 inch and greater than 60 degree angle;-Zone five (entrapment between split bed rails) did not contain recommended measurements;-Zone six (entrapment between the end of the rail and the side edge of the head or footboard) did not contain recommended measurements;-Zone seven (entrapment between head or foot board and the mattress) did not contain recommended measurements. Review of the Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care, dated 12/11/27, showed The Facts as to the proper dimensions and distances apart of various parts of the bed such as distance between bed frames and mattresses, bed rails and mattress to prevent entrapment by users of the bed showed to prevent entrapment, bed rails, mattresses, and bed frames must be configured so there are no gaps between the mattress and the rail, and no gaps between rails, and that the mattress fits snugly. Specifically, there should be no more than 4.75 inches (12.1 cm) between the mattress and the bed rail, and no more than 9.5 inches (24.2 cm) between bed rails, according to United States Food and Drug Administration (FDA) guidelines. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/26/25, showed staff assessed the resident as follows:-Moderately cognitively intact;-Required two staff for bed mobility and transfers; -Manual wheelchair use;-No paralysis on either side;-Staff did not assess bed rails and/or grab bars as used by resident. Review of the resident's care plan, dated 10/13/24, showed staff documented the resident had bilateral side positioning rails. Positioning rails will be measured by maintenance before application, maintenance to ensure that the rail is in good repair and working function. Nursing to ensure that rail is being used properly. Review of Resident #1's therapy notes, dated 10/16/24, showed therapy staff documented a recommendation of a second bed rail be placed on resident's bed to right side to assist with rolling. Staff documented he/she already has bed rail on left side of bed. Review of the Physician's Order Sheets (POS), dated 07/18/25, showed a physician's order for enablers to both sides of the bed.Review of the resident's bed rail assessment, dated 07/18/25, showed staff assessed the resident with weakness, and required increased safety measures due to medications. Review showed staff documented a pass rating from a pass/fail rating for zone one (within the rail), zone two (under the rail), zone three (between the rail and mattress), zone four (under the rail at the end of the rails), zone five (between split bed rail), zone six (between the end of the rail and the end of the rail and the side edge of the head or foot board), and zone seven (between the head or foot board and the end of the mattress) for the left bed rail. Review showed the bed rail assessment form did not contain documentation bed rails were appropriate for the resident. Review of the resident's nurse's notes, dated 8/5/25 at 11:11 A.M., showed staff documented the resident with a Change in Condition and notified the physician with the resident's altered mental status, fever, and functional decline. Review of the resident's nurse's notes, dated 8/5/25 at 11:31 A.M., showed staff documented resident at 10:30 A.M. with increased tremors, flushed, elevated temperature, slow speech, complaints of feeling cold, left arm color change to purple and red, mottling, and abnormal labs. Nurse Practitioner came in to assess resident and gave orders to send him/her to emergency room. Review of the resident's entry Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/15/25, showed the resident re-admitted to the facility on [DATE] from the hospital.Review of the resident's baseline care plan, dated 8/15/25, showed staff assessed the resident as follows:-Required mechanical lift for transfers;-Required assist of two staff for bed mobility, transfers, and toileting;-Had enablers/grab bars to both sides of the bed;-Exhibited behaviors to include hollering. Review of the resident's nurse's notes, dated 8/15/2025, showed staff documented the resident readmitted to facility from the local hospital. The resident appeared confused, uncertain of where he/she was. Peripherally Inserted Central Catheter (PICC) Line -a thin, flexible tube inserted into a vein in the arm and threaded to a large vein near the heart, used for long-term IV treatments such as antibiotics, chemotherapy, nutrition, or for frequent blood draws) to right upper extremity, [NAME]-close drain (a specific type of closed suction drainage system that removes excess fluid from a body cavity, often after surgery, to promote healing and prevent infection) to left hip with serosanguinous (a thin, watery fluid with a pinkish hue that mixes blood and serous fluid, indicating normal healing after a surgery) drainage noted in bag. Resident to receive intravenous (IV) antibiotics until 9/17/25 for abscess of left hip. Review of the resident's medical record showed staff failed to document an updated bed rail assessment for the resident's appropriateness for continued use of siderails after the resident's significant change in condition and returned to the facility from the hospital on [DATE]. Review of the resident's nurse's notes, dated 8/18/25, showed Licensed Practical Nurse (LPN) A documented Certified Nursing Assistant (CNA) B came to LPN A for assistance with the resident. LPN A found the resident knelt on the floor with his/her head against the bedrail and mattress. LPN A assessed the resident with no pulse, unresponsive. (Cardiopulmonary resuscitation) CPR initiated by LPN A. He/She called emergency medical services (EMS) while continued CPR. EMS arrived and assisted with CPR. Review of the EMS Report, dated 08/18/25, showed EMS dispatched to the facility, arrived on scene and informed by staff resident found on 3:00 A.M. rounds unresponsive. EMS documented upon arrival resident found face up on the floor, facility staff members continued CPR. Mechanic ventilation monitoring, initial rhythm check showed asystole. The medical director was notified and pronounced the resident deceased . The patient's family arrived on seen and reported the resident had been recently hospitalized for a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection, acute sepsis, and IV antibiotics at the facility.Review of the facility's investigation, undated, showed facility staff documented CNA B went into the resident's room and observed the resident on the left side of his/her bed with his/her neck on the bed and bed rail. He/She said the resident was not moving. LPN A documented CNA B requested the nurse for assistance with the resident. LPN A found the resident knelt on the floor with his/her head rested against the bed rail and mattress. LPN A assessed the resident no pulse and unresponsive and CPR initiated. While LPN A performed CPR, he/she called EMS to summon for assistance. EMS arrived and assisted with CPR. During an interview on 8/26/25 at 10:04 A.M., LPN A said CNA B came to get him/her because the resident was on the floor. The LPN said when he/she entered the room the resident was on the left side of the bed, on his/her knees, with his/her head resting between the siderail and the mattress. The LPN said he/she had to take the palm of his/her hand and forcefully removed the residents head from between the rail and the mattress. He/She said the residents head was trapped and was unsure if the resident suffocated but the resident was face down. The LPN said he/she called 911 and started chest compressions because the resident was unresponsive. During an interview on 08/26/2025 at 1:51 P.M., CNA B said he/she walked into the resident's room and saw him/her not moving. The CNA said the resident was sitting with his/her face leaned on the mattress and bed rail. He/she was on his/her knees. During an interview on 8/29/25 at 11:25 A.M. the Assistant Administrator said he/she was responsible for completing measurements for bed rails. He/She said he/she did a routine check of the resident's bed rails on 8/15/25 as part of their Quality Improvement Plan, but that he/she does not have documentation to show that anywhere. The Assistant Administrator said the 15th of the month is when he/she completes all routine checks it just happened to be the same day the resident came back from the hospital. During an interview on 09/02/25 at 4:17 P.M., the Physician said he/she would say the resident experienced a significant change in status after his/her recent hospitalization. He/She said the resident had a severe infection in his/her hip that caused the hospitalization that turned septic. He/She had received a report from the local hospital and had spoken with the facility and both reported to him/her the resident had delirium. The physician said they were all uncertain if it was acute from the infection or if it was going to be the resident's new baseline. During an interview on 9/3/25 at 12:30 P.M., the assistant administrator said that he/she does not remember what time of day on 8/15/25 that he/she assessed the residents bed rail. He/She said he/she also does not remember if it was before or after the resident returned from the hospital. The assistant administrator said he/she could not recall if the resident was in the bed or not when he/she assessed the bed rails. The Assistant Administrator said since he/she was not one hundred percent confident with any of the answers then he/she does not want to say either way as these are routine for him/her so he/she does not remember. He/She said a residents' ability to use bed rails are done by a therapy evaluation and he/she was just the one who puts them on or takes them off. The assistant administrator said that would be a nursing question as to who assessed the residents need or appropriateness for the bed rails after the resident returned from the hospital. During an interview on 9/3/25 at 1:03 P.M., Registered Nurse (RN) A said nursing staff get the bed rail measurements from maintenance, and nursing staff are responsible to complete the nursing assessment portion of the bed rail assessments. He/She said the bed rail policy states they are to reassess residents after a significant change for to ensure the resident can still safely use the bed rails. RN A said he/she is not sure if the resident had a significant change or not because he/she does not know the resident well enough to know that. RN A said he/she has just been filling in here for a few months from a sister facility. He/She said the nursing assessment sheet they fill out says pass or fail after the questions are answered and if there are no fails that would suggest the resident is appropriate for the use of side rails. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint #2599782

Based on interview and record review, facility staff failed to meet professional standards when staff failed to transcribe wound care orders for two resident's (Resident #3 and #4) who had wounds. Facility staff failed to document they provided wound care as ordered for one resident (Resident #4) of one sampled resident. The Facility's censes was 90. 1. Review of the Facility's Consulting Physician/Practitioner Orders policy, undated, showed: -Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but is not limited to, a resident's: wound clinic physician and Nurse practitioner, clinical nurse specialist, or physician assistant to any of the above physicians; -For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: document the verification order by entering the order to include the time, date, and signature on the physician order sheet. Review of the Facility's Wound Treatment Management policy, undated, showed wound treatments will be provided in accordance with physician orders, including the cleaning method, type of dressing, and frequency of dressing changes. 2. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/16/25, showed staff assessed the resident as follows: -Cognitively intact; -Substantial maximal assistance with personal hygiene; -At risk for Pressure ulcer; -Stage three pressure ulcer; -Received Pressure ulcer care. Review of the resident's plan of care, dated 01/28/25, showed staff are directed to complete treatments as ordered. Review of the Physician Order Sheet (POS), dated April 2025, showed the following orders dated 03/15/2025: -Sodium Hypochlorite (1/4 strength) External Solution, apply to coccyx topically every shift for cleanse with normal saline, apply sodium hypochlorite moistened gauze abdominal pad, secure with medipore tape and change three times daily, ordered 02/14/25; -Collagenase 250 UNIT/Gram (U/GM) Apply to right hip topically every shift for wound care, cleanse right hip with normal saline, apply nickel size of collagenase to wound bed, lightly pack with kerlix and cover with Abdominal pad and affix with medipore tape three times a day. Review of the wound clinic noted, dated 04/11/25, showed staff documented the following: -Wound #2: Coccyx; cleanser: normal saline, 5 milliliters (ml) one times daily for 15 days; cleanser: soap and water one time daily for 15 days, gently cleanse wound with mild soap and rinse well with water, pat dry; primary dressing: Iodoform gauze strip 1/2 inch, three times daily for 15 days, Pack wound lightly using Iodoform strip. Use single continuous strip, do not cut/use multiple pieces. Cover with secondary dressing. Size will vary depending on size of wound opening; secondary dressing: abdominal pad, 5 by 9 (in/in), three times daily for 15 days; secure with: mediopore tape, 1 by 10 (in/yd), three times daily for 15 days. Review of the POS did not contain the new orders for Wound #2 Coccyx; cleanser: normal saline, 5 milliliters (ml) one times daily for 15 days; cleanser: soap and water one time daily for 15 days, gently cleanse wound with mild soap and rinse well with water, pat dry; primary dressing: Iodoform gauze strip 1/2 inch, three times daily for 15 days, Pack wound lightly using Iodoform strip. Use single continuous strip, do not cut/use multiple pieces. Cover with secondary dressing. Size will vary depending on size of wound opening; secondary dressing: abdominal pad, 5 by 9 (in/in), three times daily for 15 days; secure with: mediopore tape, 1 by 10 (in/yd), three times daily for 15 days. Review of the Treatment Adminiostration Record (TAR), dated April 2025, showed: -Sodium hypochlorite administered 04/11/25 at 7 A.M., 3:00 P.M., and 11:00 P.M.; -Sodium hypochlorite administered 04/12/25 at 7 A.M., 3:00 P.M., and 11:00 P.M.; -Collagenase 250 U/GM administered 04/11/25 at 7 A.M., 3:00 P.M., and 11:00 P.M.; -Collagenase 250 U/GM administered 04/12/25 at 3:00 P.M. and 11:00 P.M During an interview on 04/14/25 at 10:27 A.M., the wound nurse said the resident has a stage four (the most severe, characterized by full-thickness skin and tissue loss, potentially exposing muscle, tendon, ligament, cartilage, or bone) pressure wound. He/She said the resident's orders were not correct in the system because the nurse who received the orders did not change them after the wound clinc nurse saw him/her. The wound nurse said he/she puts in the orders if they are given to him/her, but he/she only works part time. He/She said it is the responsibility of the nurse who is in charge of that unit to update the orders in the system. He/She said it is important for orders to be right, to ensure proper healing. During an interview on 04/14/25 at 11:36 A.M., LPN A said he/she did not receive this residents orders. LPN A said he/she is not sure who received the orders or why they were not put in. He/She said it is the responsibility of the nurse who receives the order, to put it in as soon as possible. 3. Review of Resident #4's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -At risk for pressure ulcer; -Stage three (deep wound characterized by full-thickness skin loss, where subcutaneous fat is visible, but bone, tendon, or muscle is not) pressure ulcer; -Received pressure ulcer care. Review of the residents plan of care, dated 02/03/25, showed the plan did not address the resident's wounds. Review of the Wound Clinic orders, dated 04/08/25, showed staff documented the following: -Wound #1: Left anterior lower leg: cleanser: normal saline, five milliliters (ml) one times daily for 30 days; cleanser: soap and water one time daily for 30 days, gently cleans wound with mild soap and rinse well with water, pat dry; primary dressing: Thermoform, one time daily for 30 days, apply Xerform to wound bed, keep off edges if able. May use double or triple layer if wound bed is drying out too fast/sticking to wound; secondary dressing: four by four inch/inch (in/in) sterile gauze woven one time per day for 30 days; secondary dressing: 4-inch sterile kerlix, 4.5 by 4.1 inches/Yard (in/yd) one time daily for 30 days; secured with: Medipore tape, four by two in/yd one time daily for 30 days. -Wound #3: Left inferior back: cleanser: normal saline, five ml one times daily for 30 days, cleanser: soap and water one time daily for 30 days, gently cleans wound with mild soap and rinse well with water, pat dry; primary dressing: Calcium Alginate silver four by eight inchesone times daily for 30 days, Apply single layer of calcium alginate to wound bed. Dressing should soak up any additional drainage, transforming to a gel; secondary dressing: Abdominal pad, 8 by 10 (in/in) one times daily for 30 days; secondary dressing: Medipore tape, four by two (in/yd) one times daily for 30 days. -Wound #4: Right inferior back: cleanser: normal saline, five ml one times daily for 30 days; cleanser: soap and water one time daily for 30 days, gently cleans wound with mild soap and rinse well with water, pat dry; primary dressing: Calcium Alginate silver four by eight (in/in) one times daily for 30 days, Apply single layer of calcium alginate to wound bed. Dressing should soak up any additional drainage, transforming to a gel; secondary dressing: Abdominal pad, 8 by 10 (in/in) one times daily for 30 days; secondary dressing: Medipore tape, 4 by (in/yd) one times daily for 30 days; -Wound #6: Right sacrum: cleanser: normal saline, five ml one times daily for 30 days; cleanser: soap and water one time daily for 30 days, gently cleans wound with mild soap and rinse well with water, pat dry; primary dressing: Calcium Alginate silver four by eight (in/in) one times daily for 30 days, Apply single layer of calcium alginate to wound bed. Dressing should soak up any additional drainage, transforming to a gel; secondary dressing: Abdominal pad, 8 by 10 (in/in) one times daily for 30 days; secondary dressing: Medipore tape, 4 by 2 (in/yd) one times daily for 30 days. -Wound #7 Coccyx: cleanser: normal saline, five ml one times daily for 30 days; --Primary dressing: Calcium Alginate silver two by eight (in/in) one times daily for 30 days, Apply single layer of calcium alginate to wound bed. Dressing should soak up any additional drainage, transforming to a gel; secondary dressing: Bordered foam, three by three (in/in) one time a day for 30 days. Review of the POS, dated April 2025, showed physicain orders dated 03/25/25 as follows: -Left Anterior leg: wash with soap and water, pat dry, apply two by two xeroform to wound bed keeping off edges, cover with gauze and wrap with kerlix, secure with medipore daily every shift and as needed if soiled; -Left Inferior Back: cleanse with soap and water, pat dry, apply calcium alginate, cover with abdominal pad and medipore tape once daily every shift and as needed if soiled; -Right Inferior Back: wash with soap and water, pat dry, apply calcium alginate silver 4x8, cover with abdominal pad and medipore tape daily every shift and as needed; -Left Sacrum: wash with soap and water, pat dry, apply calcium alginate silver 4 by 8, cover with abdominal pad and medipore tape daily every shift and as needed; -Right Sacrum: wash with soap and water, pat dry, apply calcium alginate silver 4 by 8, cover with abdominal pad and medipore tape daily every shift and as needed. Review of the POS showed staff did not document new wound orders to include cleansing with normal saline and the use of calciaum aleinate silver for the left inferior back wound. Observation on 04/14/25 at 11:58 A.M., showed LPN A entered the resident's room to provide wound care. Observation showed the resident's left lower anterior leg did not have a bandage over the wound when the nurse entered. LPN A did not use normal saline to cleanse wound # 1, #3, #4, #6, #7. He/She cleaned the resident's left anterior lower leg wound with wound cleanser. He/She placed xeroform over the wound and covered with an adhesive bandage. He/She cleansed wound # 3, #4, #6 with water and covered with a foam dressing. During an interview on 04/14/25 at 1:35 P.M., LPN A said he/she was the one who received the orders for this resident on 04/08/25. He/She said it is the responsibility of the person receiving the orders to put them in when they get them. He/She said it was an oversight he/she did not check the orders and adjust them in the computer. He/She said the order changes to add calcium alginate with silver. He/she said orders should be carried out as prescribed. LPN A said he/she did not clean any of the wounds with normal saline because it was not put on the orders. LPN A said he/she cleaned the leg wound with wound cleaner instead of soap and water, because it was an oversight. LPN A said he/she didn't realize he/she placed the wrong bandages, he/she said it was done in error. He/She said it is important to follow orders to assure proper healing. During an interview on 04/14/25 at 2:18 P.M., the Director of Nursing (DON) said it is the responsibility of nurse who receives the order to put the orders in as soon as they can. The DON said he/she expects the orders to be placed in the chart within 24 hours. He/She said he/she expects the nurses to follow the orders as prescribed, unless they don't have the proper supplies. He/She would expect them to contact the physician and obtain new orders if they do not have the correct supplies and place a note in the resident's chart. He/She was not aware staff were not putting in orders timely or performing wound treatments as prescribed. During an interview on 04/15/25 at 9:45 A.M., the administrator said whoever receives the orders should be updating the orders as soon as they receive them. He/She expects staff to perform wound care as ordered by the physician. MO00252596

Based on observation, interview, and record review, facility staff failed to perform appropriate hand hygiene, and glove changes during wound care, failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for one resident (Resident #4) with wounds out of one sampled residents. The facility's census was 90. 1. Review of the Facility's Hand Hygiene policy, undated, showed staff are directed as follows: -All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors; -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves; -Hand Hygiene Table: Use alcohol based hand rub, between resident contacts, after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE), including gloves, before and after handling clean or soiled dressings, linens, etc, before performing resident care procedures; after handling items potentially contaminated with blood, bodily fluids, secretions, or excretions, and when, during resident care, moving from a contaminated body site to a clean body site. Review of the Facility's Enhanced Barrier Precaution policy, undated, showed staff are directed as follows: -An order for EBP will be obtained for residents with any of the following: -Wounds (Chronic wounds such as pressure ulcers); -Implementation of EBP: -Make gowns and gloves available immediately near or outside of the resident's room; -PPE for EBP is only necessary when performing high-contact care activities. Review of the Center for Disease Control (CDC's) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated April 2024, showed: -Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. -EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: -Wounds or indwelling medical devices, regardless of MDRO colonization status -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. 2. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/10/25, showed staff assessed the resident as follows: -Cognitively intact; -At risk for Pressure ulcer; -Stage three pressure ulcer; -Receives Pressure ulcer care. Review of the resident's POS, dated April 2025, showed the POS did not contain direction for staff on EBP. Review of the resident's plan of care, dated 02/03/25, showed staff assessed the resident at risk for pressure ulcers and did not contain direction for staff on EBP. Review of the wound nurse notes, dated 04/08/25, showed staff documented the following: -Wound one on left lower leg, anterior; -Wound three on left back, inferior; -Wound four on right back, inferior; -Wound five on left sacrum; -Wound six on right sacrum; -Wound seven on coccyx. Observation on 04/14/25 at 11:41 A.M., showed Licensed Practical Nurse (LPN) A opened the treatment cart and removed a package of rolled gauze. He/She removed a pair of scissors from his/her bag. He/She did not clean the scissors, perform hand hygiene or apply gloves before he/she opened the package of gauze and cut the gauze into squares with the scissors. He/She placed the gauze on the nurse treatment cart without a barrier. During an interview on 04/14/25 at 1:35 P.M., LPN A said he/she should have performed hand hygiene and applied gloves before he/she handled the gauze, should have cleaned the scissors before cutting the gauze and should have placed a barrier before he/she put the gauze on the treatment cart. LPN A said he/she didn't think about it. He/She said it is a cross-contamination concern because it was used during a wound treatment. During an interview on 04/14/25 at 2:18 P.M., the Director of Nursing (DON) said he/she would expect staff to perform hand hygiene and apply gloves before opening the gauze. He/She said staff should use clean scissors to cut the gauze and all items should be placed on a barrier. He/She said it is important to keep all supplies used for treatments clean to prevent cross contamination. Observation on 04/14/25 at 11:58 A.M., LPN A entered the resident's room to perform wound care. The resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room.He/She placed the wound care supplies both on the resident's bed and bed side table without a barrier. He/She did not put on a gown before he/she removed the residents bandage to wounds #3, #4, #5, #6, and #7 on the resident buttock. He/She placed the dirty bandages on the resident's bed. He/She replaced his/her gloves, and did not perform hand hygiene. He/She used a washcloth to cleanse wound #3, #4, #5, #6, #7 on the residents buttock. He/she placed the washcloth on the resident's bedside table. He/She used the same gloves to cleanse wounds #3, #4, #5, #6, #7 with wound cleanser and gauze. He/She replaced his/her gloves and did not perform hand hygiene. He/She used the same gloves to open the packing container, tear off pieces, and packed the two wounds on the resident's right buttock. He/She removed his/her gloves and did not perform hand hygiene before he/she applied new gloves and covered the wounds on the right side of his/her buttock with a foam bandage. He/She tore a piece of packing from the same contaminated package. He/She held the packing in his/her right hand while he/she cleaned the residents left buttock wound. He/She then replaced the left glove while he/she still held the packing in the right glove. He/She packed the two left buttock wounds. He/She replaced his/her gloves and did not perform hand hygiene before he/she opened the resident's bandage and placed the bandage on the left buttock cheek wounds. He/She washed his/her hands and dried them with a paper towel. He/She used the same paper towel to place a piece of gauze on the resident's left lower leg wound. He/She applied gloves and cleaned the resident wound with the gauze. He/She removed the gloves and did not perform hand hygiene before he/she applied new gloves. He/She removed the scissors from his/her pocket and cut the petrolatum-based gauze to fit the wound. He/She changed his/her gloves and did not perform hand hygiene before he/she placed the bandage on the wound. He/She did not clean the resident's bed or bedside table before he/she left the resident's room. During an interview on 04/14/25 at 1:35 P.M., Licensed Practical Nurse (LPN) A said it is important to change gloves and perform hand hygiene any time you move from one task to another during wound care. He/She said it is especially important after removing the old bandages on multiple wounds. He/She said each wound should be treated separately to avoid cross contamination. He/She said anytime gloves are changed staff should wash their hands or sanitize to prevent cross contamination. LPN A said he/she usually does change gloves and perform hand hygiene between each task and usually cleans each wound individually, but he/she did forget to during this wound treatment. He/She said dirty rags and supplies should be placed in the trash and not on the resident's bed or bedside table. He/She said if other surfaces become in contact with soiled dressings, gauze or rags then those surfaces should be cleaned. During an interview on 04/14/25 at 2:18 P.M., the DON said his/her expectation is that staff clean their hands before they begin the wound treatments. He/She expects staff to change gloves and perform hand hygiene after removing the soiled bandages and any time they go from one task to another. He/She said staff should perform hand hygiene any time the remove their gloves or before applying new ones. He/She said individual wounds should be treated individually. He/She said each order would be considered an individual wound. He/She said staff should treat each wound individually to prevent cross contamination. He/She said bandages, gauze and wash cloths should be placed into the appropriate bags and soiled items should not be placed on resident beds or bedside tables. He/She said placing items on other surfaces can cause cross contamination. The DON said he/she would expect staff to clean surfaces exposed to soiled bandages, gauze or washcloths. He/She said if a residents wound qualifies for EBP precautions he/she would expect the nurse or staff to put on a gown and gloves before providing wound care to the resident. The DON said he/she was not aware some staff were not wearing the gowns before performing resident care. During an interview on 04/15/25 at 9:45 A.M., the Administrator said he/she expects nurses to change gloves and perform hand hygiene between clean a dirty task. He/She said any time gloves are changed hands should be cleaned. He/She said each wound should be treated separately to prevent cross contamination. He/She said staff should be placing all dirty items used for wound care in a bag and not on beds or bed side tables. He/She said if items are placed on beds and bedside tables, staff should clean and disinfect the surfaces to prevent the spread of bacteria. During an interview on 04/14/25 at 2:18 P.M., the DON said it is his/her expectation that residents with wounds that require EBP, such as chronic wounds, should have EBP precautions in place. They should have a sign on their door to alert staff and should have PPE in close proximity. He/She said it is the nurse's job to place the signs on the resident doors. The DON said he/she is not familiar with this resident's wounds so is not sure why this resident does not have a sign on his/her door. During an interview on 04/15/25 at 9:45 A.M., the Administrator said any resident who is on EBP should have a sign on the door and PPE available. He/She said staff should wear gowns and gloves when providing direct care. The Administrator said he/she was not familiar with this resident's wounds and could not say for sure if he/she required EBP. MO00252596

Based on interview and record review, facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for resident (Resident #1) with a signed full code physician order. The facility census is 86. The administrator was notified on [DATE] of past noncompliance Immediate Jeopardy (IJ) which occurred on [DATE]. Administration immediately in-serviced nursing staff on CPR, code status, and two-way radio communication policies. The IJ was corrected on [DATE]. Review of the facility's CPR policy, undated and reviewed/revised on [DATE], directed staff to adhere to residents' rights to formulate advance directives. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives. Review of the facility's Communication of Code status, undated, directed to follow facility policy regarding a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate and advance directive. When an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to: -Full Code; -Do Not Resuscitate (DNR); -Do Not Hospitalize. The designated sections of the medical record are: -Outside of the hard chart - Red = DNR, [NAME] = Full Code; -Face sheet - Advanced Directives; -Point Click Care - Code status. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Diagnoses to include Dementia (a general term for memory loss and other cognitive declines that interfere with daily life), Alzheimer's (a neurodegenerative disorder that primarily affects the brain, causing a progressive decline in cognitive function, particularly memory and language), Non Traumatic Brain Disorder (brain damage caused by internal factors rather than external trauma like a blow to the head), Coronary Artery Disease, and Heart Failure; -Expired [DATE] in facility. Review of the resident's care plan, revised [DATE], showed the resident was a full code. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed a physician order for a full code. The record did not contain orders for hospice services. Review of the resident's nurses notes, dated [DATE], showed staff documented at 5:00 A.M. the resident did not have a pulse and confirmed resident had expired. Review of the facility's investigation, dated [DATE], showed staff documented staff entered the resident's room, found the resident unresponsive and vital signs were low. Review showed staff documented they could not find the resident's code status and thought the resident was a DNR. Review showed staff did not verify the resident's code status, did not perform CPR and the resident expired. Review showed staff terminated Registered Nurse (RN) A from the facility on [DATE] for not following facility policy. During an interview on [DATE] at 10:14 A.M., RN A said he/she was the only nurse on the unit and the medication technician had given him/her report. The medication technician had told him/her the resident was on hospice or was going on hospice. RN A entered the resident's room for the 5:00 A.M., medication pass and the resident was unresponsive. RN A said he/she was confused and did not know what to do or who to call when the resident was unresponsive and he/she thought the resident would be a DNR code status, because he/she was going on hospice. RN A said he/she knew where to look in the computer and on the book for a resident's code status, but did not look. He/She said he/she felt' the resident was already gone because he/she was unresponsive and he/she was not thinking straight. RN A said he/she has never experienced this scenario before. RN A said when the resident no longer had a pulse he/she did not initiate CPR. During an interview on [DATE] at 1:49 P.M., Certified Medication Technician B said he/she gave report to RN A and they discussed that the resident's family was considering hospice services due to decline, but he/she was not on hospice at that time. During an interview on [DATE] at 8:03 P.M., the resident's durable power of attorney said the resident was not on hospice and was a full code, he/she was not made aware that CPR was not performed and he/she would have expected CPR to be administered. During an interview on [DATE] at 6:41 P.M., the administrator said the resident was found unresponsive and staff failed to start CPR once the resident no longer had a pulse. The staff believed the resident was on hospice and was not a full code, if a resident is a full code staff need to initiate CPR when the resident has no pulse. The administrator said the resident was not on hospice. During an interview on [DATE] at 9:25 P.M., the Director of Nursing (DON) said RN A thought the resident was a DNR and did not do CPR once the resident no longer had a pulse. He/She said all facility staff should verify code status even if the resident is on hospice and perform CPR if they are a full code. During an interview on [DATE] at 4:36 P.M., the physician said he/she was aware the resident had expired, but was not aware of the circumstances. He/She expects all facilities and staff to follow the resident's wishes on code status and perform CPR. He/She said residents on hospice can still be a full code, staff need to ensure the resident's code status regardless of hospice or not. MO00251856

Based on interview and record review, facility staff failed to report to the Department of Health and Senior Services (DHSS) neglect of one resident (Resident #1), when facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for the resident with a signed full code physician order. The facility's census was 86. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, undated, showed staff are directed as follows: -Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; -The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law; -The facility will report all alleged violations to the state agency within specified time frames: immediately, but not later than two hours after the allegation is made, if the events that cause the allegations 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. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Diagnosis of Dementia, Alzheimer's, Non Traumatic Brain Disorder, Coronary Artery Disease, and Heart Failure; -Expired [DATE] in facility. Review of the resident's care plan, revised [DATE], showed staff documented the resident as a full code. Review of medical records showed the Physician Order Sheet (POS), dated [DATE], showed a physician order for full code. Review of the resident's nurses notes, dated [DATE], showed staff documented at 5:00 A.M. the resident did not have a pulse and confirmed resident had expired. Review of the facility's investigation, dated [DATE], showed staff documented they entered the resident's room, found the resident unresponsive and vital signs were low. Review showed staff documented they could not find the resident's code status and thought the resident was a DNR (do not resuscitate). Review showed staff did not verify the resident's code status, did not perform CPR and the resident expired. Review showed staff terminated Registered Nurse (RN) A from the facility on [DATE] for not following facility code status policy. During an interview on [DATE] at 10:14 A.M., RN A said he/she was the only nurse on the unit and the medication technician had given him/her report. The Medication technician had told him/her the resident was on hospice or was going on hospice. RN A entered the resident's room for the 5:00 A.M., medication pass and the resident was unresponsive. RN A said he/she was confused and did not know what to do or who to call when the resident was unresponsive and he/she thought the resident would be a DNR code status, because he/she was going on hospice. RN A said he/she knew where to look in the computer and on the book for a resident's code status, but did not look. He/She said he/she felt' the resident was already gone because he/she was unresponsive and he/she was not thinking straight. RN A said he/she had never experienced this scenario before. RN A said when the resident no longer had a pulse he/she did not initiate CPR. During an interview on [DATE] at 9:25 P.M., the Director of Nursing (DON) said he/she did not believe this was neglect and therefore not reportable to DHSS. The DON said he/she would expect staff to perform CPR if the resident was a full code and had no pulse. During an interview on [DATE] at 11:08 A.M., the administrator said the incident did not meet the criteria for reporting to DHSS, because the investigation showed it was not neglect. He/She said the nurse would have provided CPR if he/she had checked accuracy of the information he/she was given. The administrator said if a resident is a full code staff need to initiate CPR when the resident has no pulse MO00251856

Based on observation, interviews, and record review, facility staff failed to store medications in a safe and effective manner in three medication rooms and one medication cart. The facility census was 91. 1. Review of the facility's Medication Storage policy, undated, showed it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation moisture control, and security. 2. Observation on 11/12/24 at 4:08 P.M., the Booneslick hall medication room contained: -One 10 inch medical tubing with the expiration date of 04/17/23; -One three mililiter (ml) needleless syringe with an expiration date of 07/31/22. 3. Observation on 11/12/24 at 4:10 P.M., showed the Smithton Village hall medication room contained one topical antiseptic bottle with an expiration date of October 2024. 4. Observation on 11/14/24 at 2:00 P.M., showed the [NAME] and [NAME] hall medication room contained one Safety Lok Vacuntainer (a blood collection syringe) needle with an expiration date of 08/31/24. 5. Observation on 11/14/24 at 2:15 P.M., showed the [NAME] and [NAME] medication cart contained 25 Nitroglycerin 0.4 mg tablets with an expiration date of June 2024 and 25 Nitroglycerin 0.4 mg tablets with anexpiration date of October 2024. During an interview on 11/14/24 at 2:12 P.M., Certified Medication Technician (CMT) A said there is no written process for checking medication carts for expired medication. He/She said staff are supposed to go though them weekly, evening shift usually takes all the cards out of the cart and checks for loose pills. During an interview on 11/15/24 at 8:45 A.M., LPN C said CMT's do a weekly medication cart audit and nurses audit for medications that need to be removed from the cart or refilled. He/She was not sure how this was documented. 6. During an interview on 11/14/24 at 2:15 P.M., Licensed Practical Nurse (LPN) B said there are no destruction logs for non narcotic medications. Medications are destroyed in drug buster or placed in the main medication room for management to destroy. Nurses and CMT's are responsible for checking medication rooms and carts. During an interview on 11/15/24 at 10:03 A.M., the Director of Nursing said the pharmacy comes and reviews the medication cart and storage rooms for expired medications. The medication technicians go through the carts ever Wednesday and are to check for expired medications then. Expired medications should be destroyed. During an interview on 11/15/24 at 11:02 A.M., the Administrator said there should not be any expired medications in the cart or storage rooms. The CMT's should be going through the cart daily and will go through them weekly. Nurses will go through the medication storage rooms, and the pharmacy also comes in and reviews the medication storage. 50361

Based on interviews, and record review the facility staff failed to ensure the resident's call lights were answered in a timely manner. The facility's census was 91. 1. Review of the facility's Call lights: Accessibility and Timely Response policy, undated, showed all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 2. Review of room [ROOM NUMBER], Bed 2's the electronic call light report showed: -On 11/06/24 at 9:47 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 10:43 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 1:01 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 6:42 P.M., room [ROOM NUMBER] Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 8:41 P.M., room [ROOM NUMBER], Bed 2 alerted staff six times, response received at 9:21 P.M., after 40 minutes; -On 11/07/24 at 9:20 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/07/24 at 10:13 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/07/24 at 12:50 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/07/24 at 8:32 P.M., room [ROOM NUMBER], Bed 2 alerted staff seven times, response received at 9:07 PM, after 35 minutes; -On 11/08/24 at 9:26 A.M , room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes.; -On 11/08/24 at 11:08 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/08/24 at 8:11 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/09/24 at 10:19 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/09/24 at 11:12 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes.; -On 11/09/24 at 3:03 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/09/24 at 8:35 P.M., room [ROOM NUMBER], Bed 2 alerted staff eight times, response received at 9:12 P.M., after 37 minutes; -On 11/10/24 at 10:42 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/10/24 at 1:47 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/10/24 at 3:53 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/11/24 at 6:19 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/12/24 at 12:56 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/12/24 at 7:53 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/12/24 at 8:59 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes. 3. Review of room [ROOM NUMBER], Bed 1's the electronic call light report showed: -On 11/09/24 at 2:59 P.M., room [ROOM NUMBER], Bed 1 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/12/24 at 6:38 P.M., room [ROOM NUMBER], Bed 1 alerted staff nine times before it automactically shut off after 45 minutes. 4. Review of room [ROOM NUMBER], Bed 2's electronic call light report showed: -On 11/06/24 at 6:31 P.M., room [ROOM NUMBER] Bed, 2 alerted staff eight times, response received at 7:06 P.M., after 35 minutes; -On 11/07/24 at 6:30 P.M., room [ROOM NUMBER] Bed, 2 alerted staff nine times before it automactically shut off after 45 minutes. -On11/08/24 at 6:30 P.M., room [ROOM NUMBER] Bed, 2 alerted staff nine times before it automactically shut off after 45 minutes. -On 11/09/24 at 6:28 P.M., room [ROOM NUMBER] Bed, 2 alerted staff nine times before it automactically shut off after 45 minutes. -On 11/10/24 at 9:11 A.M., room [ROOM NUMBER] Bed, 2 alerted staff eight times, response received at 9:47 A.M., after 36 minutes; -On 11/11/24 at 1:52 A.M., room [ROOM NUMBER] Bed, 2 alerted staff seven times, response received at 2:22 A.M., after 30 minutes; -On 11/11/24 at 6:42 P.M., room [ROOM NUMBER] Bed, 2 alerted staff nine times before it automactically shut off after 45 minutes. -On 11/12/24 at 6:37 P.M., room [ROOM NUMBER] Bed, 2 alerted staff seven times, response received at 7:09 P.M., after 32 minutes. 5. Review of room [ROOM NUMBER]'s electronic call light report showed: -On 11/06/24 at 8:56 A.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 11:04 A.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 3:43 P.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 6:08 P.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/07/24 at 5:43 P.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/08/24 at 12:47 P.M., room [ROOM NUMBER] alerted staff six times, response received at 1:16 P.M., after 37 minutes; -On 11/08/24 at 2:46 P.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/09/24 at 1:00 P.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/09/24 3:42 P.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/09/24 at 4:44 P.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/09/24 at 5:44 P.M., room [ROOM NUMBER] alerted staff nine times, response received at 6:26 P.M., after 42 minutes; -On 11/10/24 at 11:46 A.M., room [ROOM NUMBER] alerted staff nine times before it automactically shut off after 45 minutes; -On 11/10/24 at 4:12 P.M., room [ROOM NUMBER] alerted staff seven times, response received at 4:47 P.M., after 35 minutes; -On 11/11/24 at 3:16 A.M, room [ROOM NUMBER] alerted staff eight times, response received at 3:54 A.M., after 38 minutes. 6. During an interview on 11/12/24 at 10:52 A.M., Resident #17 said call lights are often not answered due to short staff, he/she had to yell and finally had staff show up. During an interview on 11/12/24 at 11:04 A.M., Resident #71 said call lights take more than 30 minutes at times especially at night, you just have to wait. During an interview on 11/13/24 at 1:36 P.M., Resident #17 said last weekend his/her call light did not work for the entire weekend. He/she said the facility did not know why the call light did not work. He/she said the staff did not provide an alternate way for him/her to let staff know that he/she needed assistance. They said he/she had to scream to get help. He/she said that he/she was concerned that resident well-being was at risk. He/she said an accident could happen at any time and the staff might not know to help. All Resident Council members who attended the meeting voiced agreement with his/her statement. During an interview on 11/14/24 at 2:18 P.M., Certified Nurse Aid (CNA) H said he/she receives a page when a call light is requested. The pagers go off nine times and then they time out if it is not answered. During an interview on 11/14/24 at 2:23 P.M., CNA D said pagers beep until the call is answered and call lights should only take a few minutes. During an interview on 11/14/24 at 3:29 P.M., CNA I said our pagers keep going off until the call is answered. Call lights should take no longer the five minutes, but is hard to get to them if there is not two aids on shift. During an interview on 11/14/24 at 3:35 P.M., Licensed Practical Nurse (LPN) J said he/she has never seen a pager go off so long it shuts off. He/She when acting as charge nurse there is a screen they pull up to see if lights are late, but sometimes it doesn't work. During an interview on 11/15/24 at 9:28 A.M. the Assistant Director of Nursing said call lights should be done in 30 minutes, if staff don't reset the light it may show unfinished. During an interview on 11/15/24 at 9:52 A.M., the Director of Nursing said call lights should take no more than 5 minutes but could take up to 30 minutes. He/She said the pagers do not reset on their own. During an interview on 11/15/24 at 11:09 A.M., the Administrator said call lights should be done within a reasonable amount of time, but could take 20 minutes during busy times. He/She said if it shows announced nine times the call light was never answered. Residents should not have to request multiple times if left unanswered. MO00244931

Based on interview and record review, staff failed to maintain a professional standard of care when staff failed to document follow-up when a medication unavailable, document physician notification when the medication unavailable, and document any adverse effects from lack of medication administration for one (Resident #36) out of five sampled residents. The facility census was 91. 1. Review of the facility's Medication Error policy, dated 2024, showed: -The facility shall ensure medications will be administered according the physician orders and in accordance with accepted standards and principles which apply to professionals providing services; -Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following: Resident's condition, drug category, or frequency of error (if an error occurring repeatedly such as an omission of a resident's medication several times); -The facility will consider factors indicating errors in medication administration, including, medication administered not in accordance with the prescriber's order to include medication omission; -If a medication error occurs, the nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible, monitor and document the resident's condition, document actions taken in the medical record, and once the resident is stable, the nurse reports the incident to appropriate supervision and completes and occurrence report. Review of the facility's Medication Reordering policy, dated 2024, showed: -The facility will utilize a systemic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident; -Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner; -Each time a nurse is administering medications an observes six or less doses left of one kind, that nurse will reorder the medication, time permitting. Review of the facility's Documentation in the Medical Record policy, dated 2024, showed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of the facility's Notification of Changes policy, dated 2024, showed the facility must consult with the resident's physician when there is a change requiring such notification. 2. Review of Resident #36's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/19/24, showed staff assessed the resident as: -Cognitively impaired; -No behaviors or rejection of care; -Received antipsychotic medication in the lookback period; -Diagnosis of Schizophrenia, Bipolar depression, anxiety and depression. Review of the resident's Physician Order Sheet (POS), dated August 2024 through November 2024, showed: -On 2/20/24 an order for Aristada (antipsychotic medication used to treat Schizophrenia) intramuscular, prefilled syringe, 662 milligram (mg) per 2.4 milliliters (ml). Inject 2.4 ml intramuscular every four weeks on Friday morning and discontinued 10/28/24; -On 10/28/24 an order for Aristada intramuscular prefilled syringe, 662 mg per 2.4 ml. Inject 2.4 ml intramuscular every four weeks on Friday morning. Review of the resident's medical record, dated August 2024, showed the MAR did not contain documentation the Aristada was administered. Review of the resident's Medication Administration Record (MAR), dated September 2024, showed staff documented see progress notes on 09/06/24. Review showed the MAR did not contain documentation staff administered the resident Aristada as directed. Review of the resident's progress notes, dated 09/06/24, showed staff documented the medication Aristada on order from the pharmacy. Review showed the progress notes did not contain documentation staff notified the physician the medication not available, did not contain documentation staff monitored for adverse effects or follow up with pharmacy. Review of the resident's MAR, dated October 2024, showed staff documented see progress notes on 10/04/24. Review showed the MAR did not contain documentation staff administered the resident Aristada as directed. Review of the resident's progress notes, dated October 2024, showed staff document the medication not available and waiting for delivery from the hospital on 10/04/24. On 10/24/24 staff documented resident was given Aristada in the left buttock and tolerated well. A note found in the nurses station after the medication was given, said resident received the medication on 10/19/24. Staff called the nurse practitioner, notified the family and the Director of Nursing (DON). Staff to monitor vital signs every four hours for three days. Dates changed per nurse practitioner so resident did not receive the injection on the first. The progress notes did not contain doucmentation staff contacted the pharmacy or attempts to ensure the medication was given/obtained timely as ordered by the physician. Review of the resident's MAR, dated November 2024, showed staff documented see progress notes on 11/01/24. Review showed the MAR did not contain documentation staff administered the resident Aristada as directed. Review of the resident's progress notes, dated November 2024, showed the progress notes did not contain documentation staff notified the physician the resident did not recieved the medication, the medication was not available, did not contain documentation staff monitored for adverse effects or follow up with pharmacy. Review of a photocopied Aristada medication label provided by the medical records staff on 11/13/24, showed the following handwritten on it: -Given 08/16/24; -Due 09/13/24; -Reorder from outside hospital; -Called the outside hospital to follow up on 09/27/24, they will expedite the shot to the facility, please give it; -Tracking number and notation stating at post office and been there since 10/08/24. -The document showed a typed sentence that showed its been hanging in the office window since given on 08/16/24. During a phone interview on 11/14/2/4 at 11:04 A.M., the pharmacy staff said the medication was filled and shipped to the facility on [DATE], 09/30/24, and 10/22/24. During an interview on 11/14/24 at 2:46 P.M., Licensed Practical Nurse (LPN) G said there has been issues getting the medication. The medication had been shipped and required a signature for the facility to receive. He/She said there was not anyone who signed for the medication so the medication went back to the post office. When it was not picked up, it went back to the outside hospital. He/She said the notes should indicate adverse effects, physician notification and process taken to get the medication. He/She thought the documentation was there. During an interview on 11/15/24 at 9:32 A.M., the DON said the resident's Aristada comes from an outside hospital in Kansas City and was delivered. He/She said no staff signed for the medication because staff have never had to do that before, and the medication was sent back to the post office. The family was called to see if they could pick up the medication from the post office but has been a process. It was ordered from the outside hospital again, was delivered and administered, then came in again a week later and given again. At that time the physician was notified and the resident was placed on monitoring in October. The nurse was educated on documentation and a medication error investigation was completed. Staff are expected to get a hold order when medications are not available, document adverse effects and document any follow up and notify the physician for further guidance. The DON said the facility has reached out to the outside hospital to assistance getting the medication timely and working with the family to pick up the medication so it may be administered timely. During an interview on 11/15/24 at 11:00 A.M., the Administrator said the the resident is out of a medication, the nurse should notify the physician and ask for other options in the meantime. He/She said negative behaviors or outcome for lack of medication, should be recorded in the nurse notes. The Administrator said he/she was aware of the issue and feels the staff should have received a hold order and has addressed it with the staff.

Based on observation, interview and record review, facility staff failed to allow sanitized kitchenware to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. This includes three additional kitchenettes. Facility staff also failed to maintain the kitchen ceiling free from flaking paint and dry wall tape to prevent potential food contamination. The facility census was 86. 1. Review of the facility's Dietary Cleaning Procedure policy, undated, showed staff are instructed as follows: -Keep floor of kitchen free of debris; -Wet or damp dishes or tableware will be allowed to dry completely before setting table or using; -Staff will use a clean as you go technique to keep the facility and neighborhood kitchen areas clean, functional and attractive. 2. Observation on 10/23/23 at 10:52 A.M., during initial kitchen tour, showed visible buildup of crumbs and debris across the pantry floor. Observation on 10/24/23 at 9:20 A.M., of the main kitchen showed: -Visible buildup of crumbs and debris across the pantry floor; -Visible buildup of crumbs and debris across the kitchen floor; -Visible buildup of crumbs and debris on the shelf holding the microwave; -Visible buildup of crumbs and debris on the top of the surface of the ice machine. During an interview on 10/24/23 at 11:00 A.M., the Dietary Manager (DM) said staff fill out a cleaning schedule form every day when finished cleaning the kitchen. 3. Observation on 10/24/23 at 11:40 A.M., of the Flat Branch kitchenette showed: -Hydration bar shelves with a buildup of food and a crumpled straw cover; -Sink and area below streaked and covered with food and debris. 4. Observation on 10/24/23 at 11:45 A.M., of the Boonslick Trail kitchenette showed: -Serving cart with dirty dishes and a buildup of food and debris; -Floor with sticky substance. 5. Observation on 10/24/23 at 11:50 A.M., of the Smithton kitchenette showed: -Bar cart with crumbs and debris; -Floor with sticky substance; -Sink top with spilled milk and food crumbs; -Front of sink with streaks of a sticky substance. 6. Review of the facility's Dishwashing Machine Use policy dated August 2010, showed the policy directed staff to allow kitchenware to air dry after they are washed. Observation on at 10/24/23 at 12:30 P.M., showed multiple metal food preparation and service pans of various sizes stacked together wet on the storage shelves by cook's station. During an interview on 10/24/23 at 12:33 P.M., the DM and the evening cook said staff should allow all dishes to air dry before they are put away. During an interview on 10/27/23 at 12:48 P.M., the DM said he/she monitors the kitchen and kitchenette with walk throughs, he/she sees the kitchen more because he/she is in there more. He/She requires temp logs and audits those. He/She said wet dishes must sit on the rack until they're dry, then put them away this helps to avoid mold and bacteria growth. Staff have been educated on not stacking wet dishes, he/she does not believe they were wet stacked but that they looked wet because the clean dishes are right by prep sink and it splashed the dry dishes. During an interview on 10/27/23 at 2:00 P.M., the administrator said staff should allow dishes to air dry before they are put away. The administrator said the DM and Registered Dietician are responsible for the main and neighborhood kitchens and they should do audits at least weekly to ensure staff are maintaining their duties. 7. Observation on 10/24/23 during the Life Safety Code tour showed flaking, peeling paint and drywall tape around three ceiling vents above the food prep counters. During an interview on 10/24/23 at 12:18 P.M., the DM said the ceiling was like that when he/she started working five months ago. The DM also said the flaking paint and tape were reported to the previous administrator and maintenance director by Dietary Aide (DA) T. During an interview on 10/24/23 at 12:20 P.M., the maintenance director said he/she did not know about the flaking paint on the kitchen ceiling. During an interview on 10/26/23 at 10:55 A.M., the administrator said the maintenance director is responsible for maintaining the building, including the kitchen ceiling. 39644 45564

Based on interview, and record review, the facility failed to protect the resident's right to be free from neglect when they failed to ensure the facility van driver properly secure the required safety belt around one resident (Resident #1) while the facility driver transported the resident in the facility van. As a result, the resident's wheelchair tipped upside down on top of him/her and the resident sustained lacerations to his/her head, ear, and arm when the driver made a sharp turn. The facility census was 83. The administrator was notified on 6/27/23 of Past Non-Compliance which occurred on 6/14/23. On 6/14/23, the administrator identified Driver A neglected to safely secure a resident's wheelchair in the facility van during a transport which resulted in injury to the resident. Upon discovery, staff suspended the employee, conducted an investigation, notified appropriate parties, and terminated the Driver. Facility staff reviewed their abuse and neglect policies, and in-serviced all employees on abuse and neglect. Staff corrected the deficient practice on 6/21/23. 1. Review of the Facility's Abuse, Neglect, and Exploitation Policy, dated 8/15/22, showed neglect means failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Facility's Vehicle Use by Qualified Drivers General Procedures Policy, undated, showed staff are directed if the elder is transported in a manual wheelchair the qualified driver will secure the device in the van per securement device manufacturer's recommendation. Review of the Facility's Q-Straint Series Securement Device User Instructions Manual, undated, showed staff are directed as follows: -Place wheelchair face forward in securement area; apply wheel locks or turn power off; -Attach tie downs into floor anchorages and ensure they are locked in; -Attach the four tie-down hooks to solid frame members or weldments near seat level, Ensure tie-downs are fixed at approximately 45 degrees, and are within angles shown in. Do not attach hooks to wheels, plastic, or removable parts of the wheelchair; -Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs to take up additional webbing slack; -Attach Lap belts-Use integrated stiffeners to feed belt through openings between seat backs and bottoms and/or armrests to ensure proper belt fit around occupant; -Attach shoulder belt-extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt; -Ensure belts are adjusted as firmly as possible, but consistent with user comfort Review of the facility's investigation summary, dated 6/14/23. showed staff documented at approximately 4:00 P.M. the facility's front door concierge reported to the Administrator Driver A had reported to him/her the resident's wheelchair became unstrapped/unsecured and tipped over while Driver A turned a corner while driving. Staff immediately notified the physician and responsible party and sent the resident to the hospital for evaluation. Review showed the investigation found Driver A had the resident in the facility van and at approximately 3:15 P.M. on 6/14/23 as the driver turned into the dialysis clinic parking lot to pick up another resident, his/her wheelchair tipped over and landed on top of him/her. Driver A pulled over, placed the resident back into the wheelchair, and drove back to the facility to report the incident. The resident reported the driver only placed two tie-downs on his/her wheelchair. Driver A reported they did not get trained and a seat belt was not available in the facility van. Further investigation by Driver B found the seat belt was folded up in the storage compartment and had not been used for the transport. The Maintenance Director provided training to Driver A upon hire. The investigation found Driver A did not properly secure the resident with the seat belt into the van as training directed. Review showed the facility terminated Driver A on 6/15/23 for not properly securing the resident with correct restraints during transportation as instructed, which resulted in injury to the resident. Review of Driver A's statement, dated 6/14/23 showed he/she documented he/she picked up the resident from the hospital at 3:10 P.M. and then went to pick up a second resident at the dialysis clinic. At 3:15 P.M. as he/she turned into the parking lot at the dialysis clinic, the resident slid out of his/her wheelchair because he/she was unable to control his/her body. Driver A documented he/she then pulled over and assisted the resident back into the wheelchair. He/She noticed the resident's wheelchair arm had broken off, the resident had a knot on the right temple, a laceration behind the right ear, and scrapes on both knees. After the resident was safely back in the wheelchair, the second resident was assisted into the van and both were returned to the facility. Then once back at the facility, Driver A reported what happened to the supervisor. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/12/23, showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance of two or more staff members with bed mobility transfers, and dressing; -Functional Limitations on one side; -Required a wheelchair for mobility. During an interview on 6/27/23 at 10:30 A.M., the resident said Driver A only placed two tie-downs when they left the facility. He/She said Driver A placed one tie-down on the left front wheel and the other on the right rear wheel. The resident said Driver A did not apply any other tie-downs and Driver A did not apply the resident's seat belt. The resident said on the way to the appointment the driver took a corner and his/her wheelchahir tipped over a little towards his/her right side and his/her right arm hit the lift and caused a skin tear. The resident said at that point the driver looked in the mirror and said, It is like a roller coaster isn't it? On the way back from the appointment the driver again only placed the two tie-downs and no seat belt. As the driver took a sharp corner, the resident's wheelchair tipped upside down and landed on top of him/her. The resident said his/her head hit the lift and his/her head and ear began to bleed. The driver at that point stopped, picked him/her up, and placed him/her back in the wheelchair. Driver A said, You are bleeding. Let's get you back to the facility. During an interview on 6/27/23 at 11:07 A.M., the maintenance director said he/she was responsible to train all new hires on transports. He/She said not only does he/she provide the education, but he/she also completes a ride along with them until he/she feels they are doing the transport accurately and safely. The maintenance director confirmed Driver A was an employee that he/she had trained. He/She said a safe transfer is one where the wheelchair would be tied down in four places to include both front wheels and on the back in two places and they should also have a seat belt on. The tie-downs should always be on a solid piece of the wheelchair and never on the wheel itself. The driver should also always check the resident after applying the tie downs to ensure they are secured before moving the van. He/She said he/she had never received any reports of straps not tightening or coming loose. He/she also said the facility van had never had an issue with the seat belt. During an interview on 6/27/23 at 12:05 P.M., Driver B said the maintenance director trained him/her when he/she took over the transport position, which included visual education along with a two week ride along. He/She said this was a new position for him/her at this facility but he/she was not new to transport as he/she owns a transport business. Driver B said he/she was the one who looked over the van when Driver A returned from this incident and found everything was in the van and everything was fully functional. Driver B did find the seat belt had been folded up in the bag and was in the storage compartment and had not been in use. During an interview on 6/27/23 at 12:30 P.M., the Administrator said the investigation determined Driver A failed to follow the facility policy and procedures by not using functionally available seat belt and all four tie-downs in the van to transport the resident which resulted in injury to the resident. The administrator said Driver A was terminated. During an interview on 7/6/23 at 12:52 P.M. Driver A said first and formost he/she wanted to report he/she was never trained on transport. After he/she was informed that the investigation showed he/she was educated on transport upon hire then he/she said, Yes that is true I was trained when I was hired, but then I was out for a while and when I returned I was not trained again. Driver A reported he/she had picked the resident up from the hospital after his/her appointment and then went to pick up a second resident from the dialysis clinic. He/She said when he/she turned into the dialysis parking lot the resident's wheelchair tipped over so he/she then pulled over to check on the resident. He/She said the resident had hit his/her head and there was blood from a laceration on the right temple, ear, and right arm as well as both knees were scraped up. Driver A said he/she helped the resident back into the wheelchair then assisted the other resident from dialysis onto the van and returned both the residents back to the facility. He/She said then once back to the facility he/she found his/her supervisor to report what had occurred. Driver A said he/she secured the wheelchir to the van, but did not apply the seat belt. Driver A said the seat belt was not available in the van, and this van had never had one. He/She said it was a borrowed van from another facility and not the one he/she normally did transports in. He/She said he/she had never reported the van did not have a seat belt because the facility kept telling him/her they were buying a new van so he/she assumed the reason they were to purchase one was because there was no seat belt in this one. Driver A said he/she hasn't used any seat belt to secure residents in wheelchairs since he/she began to transport with the borrowed van. MO00220099