Every finding on record at Ozark Care & Rehab Center

Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) from physical abuse when one staff member (Licensed Practical Nurse (LPN) D) yelled at, and physically forced, the resident into his/her chair. The resident resisted causing a skin tear and bruises on his/her forearm. The facility census was 79.The Administrator was notified on 07/15/26, at 5:12 P.M., of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 07/06/26. On 07/06/26, the Administrator suspended the accused Licensed Practical Nurse (LPN D). The Director of Nursing (DON) completed pain and skin evaluations on Resident #1 and evaluated the resident for signs/symptoms of adverse psychosocial effects. On 07/06/26, the DON interviewed all residents to ensure they felt safe with no negative findings and completed skin evaluations on non-verbal residents with no negative findings. On 07/06/26, the DON/designee educated all staff via in-servicing on the facility's abuse prevention policy and procedure, and appropriate de-escalation techniques. Staff began the full abuse investigation and completed interviews on 07/06/26. The facility implemented monitoring to ensure residents remained free of abuse. The IJ was corrected on 07/06/26. Review of the facility's policy titled, Abuse Prevention, revised 10/21/22, showed the following:-The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual;-Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress;-Physical abuse: an employee purposefully beating, striking, wounding, or injuring any consumer. In any manner whatsoever, an employee mistreating or maltreating a consumer in a brutal or inhumane manner;-An employee handling a consumer with any more force than is reasonable for a consumer's proper control, treatment, or management. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following:-admission on [DATE];-Diagnoses included restlessness and agitation. Review of the resident's elopement evaluation, dated 06/27/26, completed by Licensed Practical Nurse (LPN) A showed the following:-The resident had a cognitive impairment or diagnoses with impaired judgement or wayfinding (dementia, Alzheimer's disease, severe mood disorder);-History of elopement at home;-History of/attempted leaving the facility without informing staff;-The resident is independently mobile with or without an assistive device;-It is unknown if the resident exhibits wandering behavior. Review of the resident's admission assessment dated [DATE], showed Registered Nurse (RN) B documented the resident's skin was warm and dry, skin color within normal limits (WNL). No skin issues found. Review of the resident's progress notes showed the following information:-From 06/27/26-7/06/26 several nurses documented the resident was cooperative and pleasant. He/She was alert and oriented to person but otherwise confused. -On 07/06/26, at 11:13 A.M., LPN D documented the resident walked to the nurses' station, approached the nurse and asked him/her if it was normal to miss lunch. The nurse said, No sir, you should never miss a meal. It is not yet lunch time. The nurse offered the resident a snack but he/she refused. The resident said he/she understood and walked back to his/her room. Review of the resident's shower sheet, dated 07/01/26, showed the resident had no skin concerns. Review of the resident's skin assessment dated [DATE], showed the resident had no skin issues. Review of the resident's progress note dated 07/06/26 at 1:52 P.M., showed LPN D documented the following:-Certified Nurse's Assistant (CNA) E told LPN D Resident #1 wanted to make a complaint about missing meals;-LPN D asked the resident if everything was okay and the resident stated, Get the fuck out of my room before I hit you; -The resident proceeded to stand from the recliner, push LPN D backward and hit LPN D three times;-LPN D yelled out loud three times for Certified Medical Technician (CMT) F. While yelling for staff to assist, LPN D restrained the resident by grabbing the resident's bilateral (both) forearms and assisted the resident to the recliner;-CMT F, CNA E, and CNA G arrived in the room and assisted with restraining the resident;-CMT F and both CNAs occupied the resident while LPN D notified the Nurse Practitioner (NP) and DON;-The NP ordered Haldol (antipsychotic medication used to sudden onset psychosis (medical condition where a person loses touch with reality) and severe behavioral problems), 10 milligrams (mg), to be injected into the muscle, now;-The DON arrived to B wing to assess the situation. The DON attempted to reason with the resident;-The resident refused the Haldol injection from LPN D and the DON;-The resident proceeded to push LPN D and the DON out of the way and make his/her way to the 400 hall emergency exit door;-The DON and LPN D removed the resident's hands from the exit door bar to prevent other residents from eloping; -The DON, LPN D and CNA E assisted the resident back to his/her room then to bed;-The resident continued to be physically aggressive and combative;-10 mg of Haldol IM was administered to the resident's right gluteal (buttock) per order;-Chronic (continuing for a long time; constantly recurring) bruising noted to the resident's bilateral upper extremities;-Skin tear noted to the resident's right forearm; -The resident refused to allow nursing to assess and treat the skin tear;-The NP ordered staff to send the resident to the emergency room to evaluate and treat. During an interview on 07/15/26, at 12:13 P.M., LPN D said the following: -His/her statement was in the resident's progress note and he/she had no other statement to give;-The week prior, the social worker told the resident he/she would move off the locked unit;-Staff could redirect the resident but he/she was upset he/she still resided on the unit;-The resident hit LPN D in the shoulders and arms;-LPN D placed his/her hands on both of the resident's forearms and guided him/her to the recliner where the resident sat down;-The LPN did not use any force when he/she (LPN D) guided the resident to his/her chair; -The resident grabbed LPN D's left arm;-The resident was still combative with LPN D when CNA E and CNA G entered the room;-CNA E and CNA G held the resident's arms securing them against the chair arms until the resident calmed; -LPN D called the NP and received an order for Haldol;-LPN D went to the social worker's office and told the social worker the resident was fighting them and the resident wanted to leave the unit;-On his/her way back to the unit, LPN D asked the Dietary Manager (DM) to come to the resident's room as the DM was stronger than LPN D and would be able to hold the resident down so staff could administer the ordered Haldol injection; -The resident sat in his/her recliner when LPN D returned to the resident's room with the DON;-The resident yelled when LPN D entered the room and told LPN D to get out of his/her room;-The resident initially gave the DON permission to administer the injection but then changed his/her mind, stood up and walked out of his/her room; -The resident walked down the hall to the exit door and tried to exit the building by pushing on the emergency exit bar;-The resident was flailing his/her arms around, near other residents;-The DON held onto the resident's left arm while the LPN pried the resident's fingers off the bar;-The DON and LPN D assisted the resident to his/her room;-The resident was still agitated and yelling, but agreed to allow LPN D to administer the injection in his/her right buttock; -The LPN noticed the resident had a skin tear and bruising on his/her forearms but the resident would not allow staff to assess the injury; -The resident was not actively bleeding from the skin tear, but he/she had blood on his/her right forearm from the skin tear; -LPN D called the resident's family member who said the resident had a history of combative behaviors;-LPN D received an order from the NP to send the resident to the hospital for a psychological evaluation; -The DM did go to the resident's room after LPN D asked for his/her help, but he/she did not get to the resident's room until after LPN D had administered the injection to the resident; -A short time later, the DM told LPN D that the resident said LPN D had abused him/her and he/she wanted to press charges and called the police;-The DM reported the resident's allegation to the DON who suspended LPN D per protocol; -LPN D finished his/her documentation and left the building;-On 07/08/26, the administrator notified LPN D of his/her (LPN D) termination of employment;-LPN D said the resident resided on the memory care unit for a reason;-His/her actions toward the resident was not abuse as he/she was defending himself/herself from the resident. Review of the resident's care plan, revised 07/07/26, showed the following: -The resident had the potential to be physically aggressive, with a history of harm to others;-Staff should intervene when the resident became agitated, before agitation escalated, guide away from the source of distress, engage calmy in conversation, if response is aggressive, staff to walk calmly away, and approach later;-Potential for elopement risk/wanderer risk;-The resident had a skin tear on his/her right forearm with bruising and a potential for more skin tears and bruising related to paper-like skin and anticoagulation (a medical therapy that uses a blood thinner to slow down the body's process of making clots) use. Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/08/26, showed the following:-Severe cognitive impairment;-No physical, verbal or other behavioral symptoms directed toward others;-No wandering behavior. Review of the resident's physician order sheet and medication administration record showed the following:-An order dated 07/06/26, for Haloperidol Lactate Injection solution 5 milligram/milliliter (MG/ML). Inject 10mg into the muscle every 6 hours as needed for agitation for 14 days. -On 07/06/26, at 1:30 P.M., LPN D documented administration of Haloperidol Lactate to the resident. Review of the resident's progress notes showed the following:-On 07/06/26, at 2:00 P.M., a nurse documented the resident's bilateral upper extremities (BUE) were discolored with dark color with trace blood on his/her right arm. Resident refused skin check; -On 07/06/26 at 2:15 P.M., a nurse documented emergency medical services arrived at the facility to transport resident to the emergency department for an evaluation and treatment. The resident refused and said he/she was not leaving facility. EMS honored the resident's request, and left facility; -On 07/06/26, at 5:36 P.M., a nurse documented he/she entered the resident's room to assess his/her skin. The resident was very cooperative and pleasant during skin assessment. The skin assessment showed chronic dark purple and dark blue/black discoloration on the resident's BUE, and a skin tear on his/her right arm that measured approximately 1 centimeter (cm) by 0.5 cm by 0.01 cm. The skin tear was approximated (the outer borders of the skin line up side-by-side without a gap) and was scabbed over. The resident received Clopidogrel (blood thinner) and Aspirin (a low dose blood thinner). The resident denied pain with gentle palpation (using fingers or palms to gently press on various points, trying to localize a painful area) to his/her right arm. The skin tear was left open to air (no dressing to cover the wound). Staff notified the resident's medical provider and family. Review of the resident's progress note dated 07/07/26, at 6:10 A.M., showed a nurse documented the resident rested in bed with his/her eyes closed throughout most of the shift. When the resident interacted with staff, he/she was polite with no negative behaviors. The resident did not attempt to open outside doors during the night. An observation and interview on 07/14/26, at 11:00 A.M. and 07/15/26, at 10:24 A.M., showed the following:-Resident #1 sat in his/her recliner;-He/she had a large, quarter-sized raised area, on the top of his/her right forearm and a scab on the inside of his/her right forearm. -The top of the resident's right forearm showed dark purple discoloration around the raised area (larger than quarter-sized); -The resident said a couple of weeks ago; a nurse entered his/her room and called him/her a liar. The resident did not remember the nurse's name;-The nurse grabbed both of the resident's arms and would not let go when the resident tried to leave the room;-He/she wanted to talk to the social worker about an incident that occurred earlier in the day that involved the nurse;-When the nurse grabbed the resident, it hurt, and his/her wrist started to bleed and bruise;-No other staff held the resident's arms down or kept him from leaving his/her room;-The nurse was fired, and he/she felt safe at the facility now;-The resident wished staff would have asked him/her sooner for a statement (about the incident) while things were fresh on his/her mind. Review of the facility's Investigation Summary dated 07/07/26, showed the following:-On 07/06/26, at 1:30 P.M., staff notified the DON of an allegation of employee to resident verbal and physical abuse;-The resident and LPN D were grabbing onto each other and yelling at each other;-The DON notified the Administrator of incident and the alleged employee was suspended pending investigation;-Staff contacted the physician, responsible party, police department and the State Agency of the incident;-Staff completed the investigation and found the interaction between LPN D and the resident was inappropriate;-LPN D was terminated on 07/08/26. Review of the facility's complete investigation showed no documentation of an interview or statement from the resident regarding the incident that on 07/06/26. Review of CNA E's written statement, undated, showed the following: -CNA E told LPN D the resident wanted to talk to the social worker to file a complaint against LPN D for telling him/her he/she would not receive a meal tray;-LPN D told the CNA E the resident was not going to lie about him/her; -LPN D and CNA E entered the resident's room, and LPN D told the resident he/she was not going to lie about him/her which made the resident mad; -LPN D told the resident that he/she would not win against him/her;-The resident heard LPN D say this is bullshit and replied with Fuck you bitch; -LPN D said oh no, we ain't doing that and grabbed the resident to take him to him/her room; -LPN D grabbed the resident's arms and led him/her back to his/her room;-LPN D used the resident's arms to hold him/her down in the chair; -The resident's arms were bleeding; -CNA E put gauze on the resident's arm to stop the bleeding. During an interview on 07/15/26, at 11:26 A.M., CNA E said the following: -He/she went to Resident #1's room to pick up his/her lunch tray;-The resident told CNA E that he/she wanted to talk to the social worker because LPN D had told him/her that he/she was not getting any more meals;-CNA E then told LPN D, who sat at the nurses station, the resident wanted to talk to the social worker about not getting any more meals; -LPN D said he's not going to be lying on my name and stood up from the chair he/she sat in and walked to the resident's room;-LPN D entered the resident's room and said why are you lying on my name;-The resident started yelling and got up out of his/her chair; -LPN D grabbed both of the resident's forearms when he/she stood up. He/she held onto his/her arms, pressing his/her nails into his/her arms;-The resident then grabbed LPN D's forearms with both his/her hands, and held onto his/her arms as he/she held onto the resident's arms; -LPN D pushed the resident back into the chair he/she stood up from; -LPN D told the resident I'm calling the doctor to get you a shot and left the room; -The CNA E noticed the resident was bleeding from both of his/her forearms and went to the supply room for gauze; -When he/she returned, CNA E placed the gauze on the resident's arm to stop the bleeding. -CNA E said CNAs could not apply dressings to wounds and he/she was just trying to stop,/clean up the blood on the resident's arm. He/she did not do anything other than lay gauze on the resident's arms;While CNA E laid the gauze on the resident's arm, the resident said good lawsuit here, she did this to me; -The resident acted upset, and said he/she was going to sue LPN D;-CNA E was able to calm the resident by talking to him/her about a picture on his/her wall. After the resident calmed, CNA E left the resident's room; -The next time CNA E saw the resident, the DON held onto the resident's upper left arm and LPN D held onto the resident's upper right arm, walking the resident back to his/her room; -CNA E did not hold the resident's arms down, restraining him/her. The only time he/she touched the resident, was to apply gauze to his/her arm to stop the bleeding;-CNA E heard LPN D talking on the phone at the nurse's station. The LPN said yes, I did this. Yes, I restrained him/her. Yes, I put bruises on his/her arm. Yes, I made him/her bleed. The CNA did not know who the LPN was talking to;-LPN D then left the secured unit;-The resident had been pleasant and kind with staff prior to the incident with LPN D;-CNA E considered LPN D digging his/her nails into the resident's arms and restraining him/her, abuse; -The resident was confused, and the situation was avoidable. Review of CNA G's written statement, undated, showed the following: -The altercation started when LPN D went to Resident #1's room to confront him/her about lying on him/her;-When CNA G got to the resident's room, the resident and LPN D were yelling at each other and had a hold of each other;-CMT F came to the resident's room and was able to get the resident to let go of LPN D;-The resident wanted to talk to social services and LPN D told him/her that's not going to happen. You're not going to win against me. LPN D left the room;-LPN D returned to the resident's room and started yelling at the resident saying I talked to the doctor, and you are going to get a shot to sleep;-The resident started yelling that he/she wasn't getting a shot and tried to leave the room;-Staff were able to calm the resident down;-LPN D yelled that the resident was a threat and needed to be in his/her room;-LPN D lunged for the resident, grabbing onto his/her arms;-CMT F and CNA G tried to separate LPN D and the resident;-LPN D pushed the resident back into the room;-The CNAs bandaged the resident's arms because he/she was bleeding;-The resident had made his/her way to the exit door and was trying to elope;-The DON and LPN D were trying to keep the resident from escaping. The resident was running around and swung his/her arms trying to get away from them;-The resident went back to his/her room and LPN D administered the shot to the resident. During an interview on 07/15/26, at 12:48 P.M., CNA G said the following:-On 07/06/26, in the morning, Resident #1 came out of his/her room, confused about when staff served lunch;-CNA G heard the resident ask LPN D, who sat at the nurses station, about lunch. LPN D was rude to the resident, accused him/her of lying and told the resident, in a condescending tone, we feed everyone, why are you asking me if you are getting lunch?; -CNA E came out of the resident's room and went to the nurses' station where LPN D sat. CNA E said something to LPN D but CNA G did not hear what he/she said; -CNA G then heard LPN D say oh no, Resident #1 was not going to lie on him/her. He/she would not let him/her do that to him/her;-LPN D went to the resident's room to confront him/her;-CNA G heard LPN D yell for CMT F to help him/her; -CNA G entered to the resident's room to help LPN D and saw him/her and the resident standing in front of the resident's recliner yelling at each other;-LPN D was holding the resident's forearms with his/her hands and the resident was holding LPN D's forearms with his/her hands; -CMT F entered the room and asked the resident to let go of LPN D and he/she did; -LPN D then let go of the resident's forearms; -LPN D yelled at the resident and said he/she was calling the physician to get a shot for the resident;-LPN D told the resident he/she was not going to win against him/her. There was no way anyone would believe him/her (the resident) over LPN D. He/she was on the dementia unit and would not remember what was going on; -LPN D left the resident's room;-The resident was bleeding from his/her forearms. CNA E left the resident's room to get gauze. CNA G and CNA E used the gauze to stop the bleeding. The CNAs did not know where the resident's blood originated from, he/she just placed gauze on the resident's arms to stop the bleeding;-When the resident calmed down, he/she said he/she wanted to talk to social services to make a complaint;-LPN D returned to the resident's room and yelled, he/she (the resident) could not make a complaint, he/she would not let the resident twist the situation;-LPN D then told the resident he/she was going to give him/her a shot so he/she could go to sleep;-The resident got up from his/her chair and left the room;-The LPN followed the resident into the hall and said the resident was a danger to other residents then grabbed the resident's upper left arm; -Using his/her hand, CMT F knocked LPN D's arm down causing him/her to let go of the resident's arm;-The resident then walked to another hall and pushed the door to open it, causing the door to alarm;-The DON and LPN D were near the resident when he/she opened the door. The DON held onto the resident's upper left arm and LPN D held onto the resident's upper right arm and walked the resident back to his room. The CNA did not observe the LPN removing the resident's hands from the door;-CNA G told the DON that the way LPN D handled the resident was abuse;-CNA G and CNA E never restrained the resident and calmed the resident by talking to him/her;-Prior to that incident, the resident stayed in his/her room most of the time. He/she acted calm and was pleasant and friendly;-The resident had not exhibited behaviors until confronted by LPN D;-CNA G thought LPN D blew things out of proportion. During an interview on 07/15/26, at 12:13 P.M., LPN D said he/she did not raise his/her voice at the resident, did not call the resident names, did not tell the resident He/she won't win against me; did not say this is bullshit and did not say he/she restrained the resident and he/she would do it again. During an interview on 07/15/26, at 10:31 A.M., CMT F said the following: -A couple of weeks ago when CNA E went into Resident #1's room to pick up his/her lunch tray, the resident told CNA E that he/she wanted to speak with the social worker;-CMT F was in the hallway at the medication cart when CNA E approached the nurses station and told LPN D, who was sitting in a chair, about the resident's request; -When CNA E told LPN D the resident's request, he/she scooted his/her chair back, got up in a hostile/aggressive manner, and said One thing for certain, two things for sure, a resident is not going to sit here and lie on me. LPN D then walked to the resident's room to confront him/her;-CMT F heard yelling and CNA G told CMT F that LPN D was yelling for him/her;-CMT F ran to the resident's room and observed the resident sitting in his recliner. LPN D was standing over the resident holding onto both of the resident's forearms with her hands;-The resident also held onto both of LPN D's forearms with his/her hands;-The resident told CMT F to get that bitch out of his/her room, he/she was crazy;-CMT F asked the resident three times to let go of LPN D's arms. The resident then let go of after the third request;-CMT F asked LPN D to leave the resident's room but he/she would not leave;-The resident said he/she wanted out of the room and stood up from his/her chair. The resident was trying to get away from LPN D;-LPN D would not leave the room and continued to antagonize the resident by telling him/her you'll do what I say, he'll listen to me;-CMT F attempted to take the resident out of the room to talk to the social worker when LPN D put his/her hand out to stop the resident. CMT F blocked LPN D's arm from touching the resident; -The resident left his/her room and was in the hallway;-LPN D said the resident was not going to talk to the social worker because he/she was a danger to others and needed to stay in his/her room;-CMT F, CNA E and CNA G were walking the resident back to his/her room in an attempt to calm the resident, when LPN D grabbed the resident's left upper arm; -CMT F removed LPN D's hand from the resident by knocking it down and told LPN D to leave; -When the resident returned to his/her room, CMT F noticed the resident had a skin tear on his/her right forearm and it had been bleeding;-LPN D told the resident that he/she was getting a shot; -CMT F did not observe any other interactions between the resident and LPN D the rest of the day;-Later that day, CMT F heard the DM tell LPN D that the resident said he/she abused him/her. He/She replied he/she restrained the resident and would do it again if someone tried to mess with him/her;-CMT F told the DON that LPN D provoked the resident and the situation could have been prevented;-The resident was cordial, nice, easy going and always said good morning. The resident had not exhibited any behaviors while CMT F was working. Review of the DON's written statement, dated 07/06/26, showed the following: -On 07/06/26, at 1:15 P.M., LPN D said he/she was pinned down by the resident and he/she had to call for assistance from other staff;-LPN D obtained orders from the NP to give Haldol, 10mg, IM now;-The resident was upset and wanted out of the memory care unit. The resident asked to move last week;-The resident pointed at LPN D and said I'm not taking a shot from that nurse;-The resident gave permission for the DON to administer the Haldol but before she could, the resident got up from his/her recliner and yelled I'm not going to do this. I am leaving; -The resident exited his/her room and proceeded to another hall;-The resident had his/her fingers gripped onto the door's emergency push bar;-The resident activated the alarm on the door and the door opened;-Due to safety concerns, the DON and LPN D safely removed the resident's hands from the push bar and redirected the resident away from the exit;-The DON and LPN D assisted the resident back to his/her room while the resident was combative, swinging his/her arms and yelling that he/she wanted to go home;-LPN D administered the Haldol to the resident once they returned to his/her room;-At 2:16 P.M., the resident asked to speak to social services;-The resident was angry at LPN D;-The DON told the resident they initiated an investigation (into the incident). The resident replied, I feel better, and loudly exhaled;-The resident refused a skin assessment at that time;-On 07/06/26, at 5:45 P.M. the resident agreed to a skin and pain assessment;-Skin assessment findings: BUE skin thin and fragile. BUE had chronic discoloration of dark purple and dark blue/black;-Skin tear to right supervisor that measured approximately 1.0 cm by 0.5 cm by 0.01 cm. The skin tear was approximated and scabbed over;-Right forearm had no warmth felt or pain voiced;-Area cleaned and patted dry, left open to air;-The resident received Clopidogrel and Aspirin;-Family and provider updated. During an interview on 07/15/26, at 1:41 P.M., the DON said the following: -On 07/06/26, around 1:00 P.M., the SSD told the DON the resident pinned down LPN D and beat him/her up;-The DON went to the unit to support LPN D, and found LPN D preparing a Haldol injection for the resident;-LPN D looked distressed and upset. His/her hair was disheveled, his/her face was red, and LPN D looked as though he/she had been crying; -LPN D told the DON Resident #1 beat him/her up and he/she contacted the NP who ordered Haldol;-The DON went to the resident's room and asked the resident if he/she would take a shot ordered from the physician. The resident pointed at LPN D and said he/she was not taking it (the shot) from him/her;-The resident got up from his/her chair and left the room. The DON and LPN D followed the resident out of his/her room;-The resident walked past other residents to the exit door on one of the halls, saying I'm getting out of here;-The resident pushed on the door causing it to open, other residents then walked towards the door;-LPN D removed the resident's fingers from the push bar of the door; -The DON then held onto the resident's upper left arm and LPN D held onto the resident's upper right arm and walked the resident to his/her room as the resident pushed and kicked them; -Once back in the resident's room, the resident agreed to let LPN D administer the Haldol injection; -The DON noticed blood on his/her shirt from the resident; -After the injection, the DON and LPN D left the resident's room. LPN D called the resident's family who wanted the resident sent to the ER; -After the incident, CMT F came to the DON's office and told him/her that the incident needed to be investigated as he/she felt what LPN D had done was abuse; -CMT F told the DON that LPN D had provoked and antagonized the resident;-The DM came to the DON's office after CMT F left and said the resident was upset because LPN D would not let him/her talk to the SSD; -After the DM left her office, CNA E and CNA G reported LPN D provoked the resident's behavior; -The DON told LPN D he/she was suspended pending an investigation. LPN D laughed and said I'm not going to be found wrong; I'm going to be paid for this leave because you will find out I was right;-The DON returned to the resident's room, and told him/her she suspended LPN D and the resident sighed, and said I feel better.;-The resident let the DON complete a skin assessment at that time;-The resident told the DON he/she got into a fight with the nurse;-The resident had bruises on his/her arms and a skin tear on his/her right arm. The resident bruised very easily;-LPN D told the DON he/she had injuries from the resident, but the DON did not observe any injuries;-LPN D had long artificial fingernails that probably caused the skin tear on the resident's arm;-The DON asked LPN D to write a statement about the incident, and he/she replied don't call me or talk to me. My statement is on my nurses note;-Staff should never put their hands on a resident;-Staff should first attempt to redirect the resident or ask a staff member for assistance; -The incident involving LPN D rose to abuse. During an interview on 07/15/26, at 1:31 P.M., Social Service Director (SSD) said the following: -On 07/06/26, around 1:00 P.M., LPN D came to the SSD office and said the resident had put hands on him/her and the resident was a danger to other residents and needed moved out of the unit; -The SSD immediately reported what LPN D had told her to the DON;-Staff brought the resident to his/her office after the incident with LPN D;-The resident said LPN D called him/her a liar. The resident was upset and wanted to press charges against him/her because he/she had grabbed his/her arms;-The SSD noticed a new abrasion and bruising on the resident's right forearm; -The resident had been pleasant before and after the incident, and exhibited no behaviors;-It was never appropriate for staff to grab or hold a resident's arm in a forceful manner and that would be abuse. During an interview on 07/16/26, at 10:22 A.M., the Medical Director (MD) said the following: -He visited Resident #1 on 07/01/26. The resident did not appear confused and was pleasant during the visit; -The resident had a diagnosis of altered mental status and documented dementia from the previous facility;-Staff placed the resident on the secured unit due to his/her history of exit seeking behavior;-The resident had a similar altercation at a previous facility when he/she wanted to leave the facility;-When the physician saw the resident on 07/14/26, the resident had a large bruise on his/her right arm.-On 07/06/26, the DON notifi[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the residents remained free of accident hazards and received adequate assistance with assistive devices to prevent further accidents when the facility failed to ensure staff were trained on and operated mechanical lifts (Hoyer - a mobile, mechanical device designed to safety lift and transfer patients with limited mobility between beds, wheelchairs, toilets, or baths ) in a safe manner by standards of practice resulting one resident (Resident # 2) falling from the lift and suffering lacerations and continued numbness in chine. The facility census was 81.Review of the facility policy titled Fall Protocol, undated, showed the following:-Immediately do a physical assessment of the resident who has fallen to include vital signs and neurological assessments. Measure any bruising or impaired skin;-Investigate the incident;-Notify the on-call nurse, if significant injury occurs notify the physician;-Notify the responsible party;-Fill out a fall incident report;-Definition of fall is any unintentional change in position coming to rest on the floor or ground.1.Review of the Resident #2's face sheet showed the following information:-admission date of 02/15/23;-Diagnoses included heart failure, chronic pain, high blood pressure, and diabetes.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 02/21/26 showed the following information:-Cognitively intact-Dependent on assistance from staff for toileting, dressing, and mobility.Review of the resident's care plan, dated 10/18/24, showed the resident required the use of a Hoyer lift and assistance from two staff members for transfers.Observation and interview on 02/27/26, at 10:19 A.M., showed the following: -The resident laid in his/her bed with bruising around both eyes and a healed scar from his/her bottom lip to the underside of his/her chin;-The staff had been telling him/her and others that the manual Hoyer lift was not steady and could break or turn over;-He/she was in his/her wheelchair and the staff were going to transfer him/her to his/her bed;-During the transfer, while he/she was in the sling, in the air, the Hoyer seemed to get stuck on something and was hard to move across the floor. The aides had given the lift a big slam/push forward and the lift suddenly tipped over and landed on top of him/her;-After the fall, Certified Nursing Assistant (CNA) D ran out of the room to get help, and CNA E stayed beside him/her;-He/she does not remember much other than looking up and seeing several staff members standing around him/her;-He/she continued to have decreased sensation and numbness to the bottom half of his/her face, causing issues with eating and talking;-The staff don't use the manual Hoyer lift on him/her anymore due to fear. They now use another resident's Hoyer that was provided by hospice.Review of the facility's Event Report, dated 01/23/26, showed the following information:-The resident fell from the Hoyer lift and suffered from a laceration. The laceration required direct pressure to the wound to stop the bleeding;-No interventions used;-Two staff in the resident's room were assisting with a Hoyer transfer. Staff applied Hoyer straps and mechanically raised the resident up. In transition in the air, two staff rolled the Hoyer to the bed to release the resident onto the bed. When the resident's body was close to the edge of the bed the staff reported that the [NAME] lift tipped to the left resulting in the resident falling to the ground from the highest position on the lift. The resident hit his/her head and suffered from a laceration to his/her chin, and the back of his/her head. The Administrator called the hospital a day later and was told the resident received sutures to his/her chin, but did not require stitches to the back of his/her head.Observation and interview on 02/27/26, at 10:53 A.M., showed the following:-Certified Medication Technician (CMT) F, CMT A, and CNA G entered the resident's room;-CMT F said they would be using the hospice Hoyer for a safer transfer of the resident from the bed to the wheelchair;-The Hoyer sling was under the resident and positioned above the resident's head;-CMT F and CMT A hooked up the straps from the Hoyer sling to the Hoyer lift;-CMT F questioned what color sling straps to use and rather or not the middle strap should be attached;-CMT A instructed CMT F to attach all straps for safety;-CMT F operated the Hoyer lift and lifted the resident into the air, while CMT A and CNA G guided and supported the resident;-The resident was seen to be leaning toward his/her right and his/her neck was crooked due to Hoyer sling placement being above his/her head;-CMT F guided the Hoyer lift toward the resident's wheelchair with the legs to the Hoyer lift in the open position;-Once arriving above the resident's wheelchair, CNA G and CMT A obtained the sling and resident and guided and positioned the resident into proper placement;-CMT F began lowering the Hoyer lift without locking the wheels.During an interview on 02/27/26, at 11:30 A.M., CNA G said the following:-He/she was told that the resident was a three-person transfer;-He/she was new at the facility and was told the resident had fallen out of the manual Hoyer lift and was instructed to use the hospice lift, as it was safer;-The facility Hoyer lifts don't seem stable and he/she was afraid to put people in them;-He/she knows how to operate a Hoyer lift, but did not have any specific training on that;-Hoyer lifts should be locked when staff are putting the sling straps on/off, when lifting the resident, and again when lowering the resident onto the desired location; -He/she was told that the facility was going to order some newer, sturdier Hoyer lifts but he/she had not seen them yet. During an interview on 02/27/26, at 12:20 P.M. and 2:10 P.M., CNA D said the following:-He/she was not aware of any unsafe medical equipment;-He/she was present during the incident with the resident, and had never had an issue with transferring the resident with the manual Hoyer lift before;-No one was operating the Hoyer lift when the Hoyer lift tipped over;-He/she was on the left side of the resident, CNA E was on the right side of the resident, and both were pulling on the sling to try to get the Hoyer lift to move. That was when the Hoyer lift flipped over;-There should be one staff member operating the Hoyer lift, and one staff member guiding and positioning the resident;-He/she thought the maintenance department would inspect and repair any broken equipment.During an interview on 02/27/26, at 2:15 P.M., CMT A said the following:-When operating a Hoyer lift, the legs must be open, and there must always be two staff members. One staff member should operate the Hoyer lift while the other staff member guides and positions the resident;-If staff members were holding onto the Hoyer sling and attempting to operate the lift by pulling on the sling, that would cause an accident.During an interview on 02/27/26, at 2:31 P.M., Licensed Practical Nurse (LPN) B said the following:-When operating a Hoyer lift, the legs must be open, there must be two staff members, and the legs must be locked with raising or lowering the resident;-One staff member should operate the Hoyer lift, and one staff member should be guiding and positioning the resident;-It would not be acceptable for staff members to operate the lift by pulling on the Hoyer sling;-The maintenance department would inspect and repair any broken equipment if there were a need.During an interview on 02/27/26, at 2:54 P.M., CNA E said the following:-He/she was present at the time of the incident;-When operating a Hoyer lift, the legs must be open, there must be two staff members, and the legs must be locked when raising or lowering the resident;-One staff member should operate the Hoyer lift, and one staff member should be guiding and positioning the resident;-On the day of the incident, CNA D was operating the Hoyer lift and moving the lift toward the resident's bed when the lift just tipped over on top of the resident;-He/she was on the other side of the resident's bed and was not guiding the resident or lift;-If the lift had not had someone operating it and the staff pulled on the sling versus the lift, he/she did not think that could cause the lift to tip over;-This is not the first incident that he/she has had with someone falling out of a Hoyer lift;-The facility Hoyer lifts are in working order, they're just old.During an interview on 03/02/26, at 2:13 P.M., the Medical Director said the following:-He did not recall being notified of the incident with the resident, but could have been via fax;-He expected two staff members to operate a Hoyer lift;-Pulling on the Hoyer lift by the Hoyer sling could cause a balance concern and cause an accident;-He did not recall what the ultimate cause of the fall was. According to his notes, the facility said the lift broke;-He has continued to see the resident and is aware of his/her lasting lack of sensation to the lower portion of his/her face.During an interview on 03/02/26, at 2:30 P.M., the Maintenance Director said the following:-It was the maintenance departments responsibility to perform inspections and maintenance on facility owned Hoyer lifts;-He completed safety checks on the Hoyer lifts once a month. He had not done this monthly check yet;-The staff have not told him of any concerns on any broken Hoyer lifts. If that were the case the lift would be tagged for non-use until it was operable again.During an interview on 03/02/26, at 3:42 P.M., the Assistant Director of Nursing (ADON) said the following:-She expected two staff to operate a Hoyer lift;-One staff member should be operating the Hoyer lift and the other staff should be guiding and positioning the resident;-The Hoyer lift legs should be open during movement. The Hoyer lift legs should be locked with lifting or lowering a resident.During an interview on 03/02/26, at 4:35 P.M., the Administrator said the following:-She expected two staff to operate the Hoyer lift;-One staff member should be operating the Hoyer lift, and the other staff should be guiding and positioning the resident;-She was called down to the resident's room directly after the incident. She did not make any observations of the Hoyer lift being broken, or see any reason to believe the Hoyer lift malfunctioned;-The involved staff did not indicate to her that they were pulling on the Hoyer sling. If that was the case, that would not be an acceptable transfer;-Her conclusion of the incident was that the Hoyer lift just tipped over during use;-It took seven staff members to get the Hoyer lift off of the resident the day of the incident;-Staff are to continue using the Hoyer lift, as there is nothing wrong with it;-She was aware that the resident has a lasting lack of sensation in his/her lower portion of the face.Complaints 2724937 and 2725032

Based on interview and record review, the facility failed provide pharmaceutical services that included accurate documentation and safe administering of all medications when staff failed to obtain a physician's order before leaving one resident's (Resident #1) medications at bedside and when the staff that signed off on the medication administration was not the staff member who administered the medication. The facility census was 81.Review of the facility policy titled Medication Administration Policy and Safety Tips, undated, showed the following:-Nurses must use acceptable nursing practices when administering medications;-Never leave medications in a resident's room, unless there is an order from a physician stating may leave at bedside;-stay with resident until resident has taken medication. If the resident refuses, then take the medication with you when leaving the room period do not leave the medication in the room. 1. Review of the Resident #1's face sheet (a brief profile) showed the following:-admission date of 05/01/19;-Diagnoses included chronic obstructive pulmonary disease (COPD- a progressive incurable lung disease), Parkinson's disease (a movement disorder of the nervous system that worsens over time), type II diabetes mellitus (a chronic condition where the body resists insulin and fails to maintain healthy blood sugar levels), borderline personality disorder (a serious, long-term mental health condition marked by extreme instability in moods, self-image, behavior, and relationships), high blood pressure, post-traumatic stress disorder (PTSD -a treatable mental health condition triggered by experiencing or witnessing terrifying, life-threatening events like combat, abuse or disasters), attention deficit hyperactivity disorder (ADHD - persistent patterns of inattention, hyperactivity, and impulsivity that interfere with daily functioning) and bipolar disorder (a chronic mental health condition characterized by intense mood swings ranging from mania to depression).Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool administered by staff), dated 11/13/25, showed the resident was cognitively intact.Review of the resident's care plan, last revised 02/27/26, showed the following:-At risk for adverse side effects from the use of psychotropic drugs;-Goal for relief without adverse effects, and monitoring for gradual dose reductions and lowest effective dose.Review of the resident's current Physician Order Sheet (POS) showed the following:-An order, dated 11/01/23, for pantoprazole (used to treat reflux) tablet, delayed release 40 milligram (mg), give one tablet once a morning during morning med pass;-An order, dated 07/02/24, for Mag 64 (magnesium chloride - supplement) tablet, delayed release, 64 mg, one tablet twice a day, morning med pass and night med pass;-An order, dated 06/16/25, for ondansetron HCI (anti-nausea medication) tablet 8 mg, one tablet once a morning at morning med pass;-An order, dated 11/01/23, for multivitamin tablet one tablet once a morning at morning med pass;-An order, dated 11/14/25, for Lipitor (used to lower cholesterol) tablet 20 mg, one tablet once a morning at morning med pass;-An order, dated 12/10/25, for bethanechol chloride (used to treat bladder dysfunction) tablet 10 mg, one tablet three times a day morning med pass, mid-day med pass, and night med pass;-An order, dated 11/01/23, for aspirin tablet 81 mg, one tablet once a morning at morning med pass;-An order, dated 01/30/26, for amlodipine (used to treat high blood pressure) tablet 2.5 mg, one tablet once a morning at morning med pass.Review of the resident's progress note dated 02/27/26, at 9:35 A.M., showed the following:-Certified Medication Technician (CMT) A requested this nurse to deliver medication to the resident;-LPN B entered the room, woke the resident up, and reported he/she had the resident's medications. The resident told LPN B to put the medications on the table, and he/she would take them if LPN B would get him/her milk. LPN B went to get a carton of milk for the resident, returned, and placed a straw in the milk carton. LPN B left the room;-The resident advised after the trays were passed his/her medication was missing. LPN B went to talk with the resident about missing medication. The resident had his/her breakfast and reported the pills were missing. Resident wanted to speak to the Administrator, but the Administrator was not in the building at that time.Review of the resident's progress note for 02/27/26, at 11:58 A.M., showed LPN B noted the resident had located the missing pills next to him/her and apologized to LPN B.Review of the resident's February 2026 Medication Administration Record (MAR) for the morning medication pass on 02/27/26, showed staff documented administration of the resident's pantoprazole, Mag 64, ondansetron HCI, multivitamin, Lipitor, bethanechol chloride, aspirin, and amlodipine.During an interview on 03/02/26, at 11:01 A.M., the resident said the following:-He/she tells staff to stay and observe him/her taking medications, but they will not;-On 02/27/26, the resident woke up and realized he/she had not taken morning medications. LPN B came in and said he/she had taken the medications. The resident did not remember and then found the medications next to him/her in the bed and notified LPN B.During an interview on 03/02/26, at 2:04 P.M., Certified Nurse Assistant (CNA) C said the following:-Staff should not leave medications at bed side with a resident. It was not safe;-On 2/27/26, he/she answered the resident's call light. The resident advised medications had been delivered while he/she was awake. He/she then fell asleep, woke up to eat breakfast, and the medications were missing;-CNA C notified LPN B about the alleged missing medications. During an interview on 03/05/26, at 8:19 A.M., CMT A said the following:-Medications were not to be left at the bedside without a physician's order;-The only medications the resident has physician's order to be left bedside are eye drops, nasal spray, and ointments;-He/she signed the medications out on the MAR but asked LPN B to deliver them to the resident. During an interview on 03/02/26, at 3:00 P.M., LPN B said the following:-On 02/27/26, CMT A requested he/she deliver the resident's morning medication pass;-He/she delivered the medications to the resident;-The resident said he/she would take the medications if LPN B would get the resident milk;-LPN B left the room and brought back a carton of milk, put a straw in the carton and left the room without observing the resident take the medications;-Staff should not leave a resident's medications bedside without a physician's order. He/she should have watched the resident take the medications. During an interview on 03/02/26, at 3:42 P.M., the Assistant Director of Nursing (ADON) said the following:-CMT's generally pass medications at the facility unless the nurse needs to cover or during the night shift;-Staff should not leave medications at bedside unless there is a physician's order to do so. During an interview on 03/02/26, at 4:36 P.M., the Administrator said the following:-CMT's pass medications at the facility unless the nurse is covering or during the night shift;-Staff should not leave medications at bedside unless there is a physician's order to do so;-To her knowledge, the resident does not have a physician's order to leave his/her medication pass bedside. Complaint 2733413

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were investigated immediately and steps were taken to protect all residents during the investigation when staff failed to be begin an immediate full and documented investigation and allowed the alleged staff member continue to work independently when one resident (Resident #1) made an allegation of staff to resident abuse. The facility census was 82.Review of the facility's policy titled Abuse and Neglect Policy and Procedure, revised 03/20/25, showed the following:-It is the policy and the right of each resident to be free from abuse, neglect, misappropriation of property and exploitation;-All reports of resident abuse will be reported to the local, state, and federal agencies and thoroughly investigated by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and/or designee. Findings of all investigations are documented and reported;-All investigations will be thoroughly investigated. The Administrator, DON and/or designee shall initiate the investigation;-The administrator, DON and/or designee shall ensure that the resident and the person reporting the suspected violation are protected from retaliation;-Any employee who has been accused of resident abuse is placed on leave at the time of the allegation;-The individual conducting the investigation at a minimum reviews the documentation and the evidence; interviews and obtains statements from the person reporting the incident; interviews the resident or the resident's representative; interviews and obtains statements from staff members who had contact with the resident during the alleged incident; interviews no less than ten residents with whom the accused employee provides care or services; reviews all events leading up to the alleged incident; and documents the investigation completely and thoroughly;-Within five working days of the incident, the Administrator will provide a follow up investigation report to the state surveying agency;-The investigation report will provide sufficient information to describe the results of the investigation and indicate any corrective action taken;-The follow up investigation report will provide as much information as possible.1. Review of Resident #1''s face sheet (admission data) showed the following:-admission date of 11/08/22;-Diagnoses included vascular dementia (damaged blood vessels that reduce the amount of oxygen to the brain and cause a decline in thinking skills), diabetes mellitus (chronic disease in which blood sugar levels are too high), and high blood pressure.Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/31/25, showed the following:-Moderate cognitive impairment;-Rejection of care occurred 4 to 6 days a week; -Resident used a wheelchair and required staff assistance with transfers and mobility.Review of a facility statement written by Certified Medication Tech (CMT) B, dated 01/17/26, showed the following: -At 11:37 A.M., on 01/17/26, CMT B entered resident's room to administer scheduled medications, check blood sugar, and administer insulin;-The resident became irate after administration and claimed injury to his/her hand;-The resident then began swatting and throwing water;-The nurse was called to the room to inspect the alleged injuries to the resident and found none to be present.During an interview on 01/22/26, at 11:24 A.M., CMT B said the following:-The resident said CMT B hurt his/her hand after insulin was administered;-He/she informed Licensed Practical Nurse (LPN) A of the resident accusing him/her of hitting them;-The ADON was also informed of the accusation;-He/she was told to continue passing medications and left the room;-He/she worked the next day and was placed on the locked unit away from the resident;-He/she had not been suspended from work;-It would be considered abuse if a staff hit a resident's hand.Review of facility staffing sheets showed CMT B worked after the allegation of abuse was made on 01/17/26 and on 01/18/26.Review of a facility statement written by LPN A, dated 01/17/26, showed the following: -CMT B called him/her to the resident's room;-He/she noted CMT B had wet hair and water on his/her shirt;-CMT B stated he/she gave the resident insulin and medications, and the resident became agitated and threw water on him/her;-The resident was yelling and saying CMT B had hurt his/her hand;-The resident had a couple light bruises on both hands as usual. The nurse noted no new injury and reported incident to the ADON.During interviews on 01/22/26, at 10:40 A.M. and 12:50 P.M., LPN A said the following:-The resident said CMT B hurt his/her hand, but no injuries were noted;-The resident getting his/her hand hit would be abuse so he/she reported to the ADON right away;-He/she should have made a progress regarding the allegation;-The progress note should include the event, any notifications, and a resident assessment.Review of a facility statement written by Certified Nurse Assistant (CNA) C, dated 01/17/26, showed the following: -He/she heard resident hollering.;-Staff went to the resident's room, and the resident said staff hurt his/her hand.During an interview on 01/22/26, at 12:05 P.M., CNA D said the following:-On 01/17/25, about 12:00 P.M., CMT B came to the nurses' station and reported the resident was arguing with him about medication;-He/she went to the resident's room with another staff to get the resident up for lunch;-The resident said, He gave me that bruise, and pointed at CMT B;-He/she immediately told the ADON and LPN A;-The ADON and LPN A told him/her that CMT B needed to stay away from the resident;-CMT B should not have continued working after abuse allegation;-He would consider it possible abuse if a resident accused staff of giving them a bruise.Review of a facility statement written by ADON, undated, showed the following: -On 01/17/16, he/she was at the nurses' station desk when CMT B stated, I took a shower;-CMT B and LPN A told him/her how the resident became upset while CMT B was obtaining a blood sugar and administering insulin;-The resident threw a cup of water at CMT B;-His/her understanding of the situation was that the resident had said CMT B had hurt her finger during the finger stick which he/she says often after having fingerstick completed;-He/she assessed the resident and noted old bruising on top of both hands but there was no new bruising to his/her hands or fingers. Review of a facility statement written by the Administrator, dated 01/17/26, showed the following: -The Administrator was working as a charge nurse on another unit when he/she was notified someone hurt the resident's hand;-The Administrator asked the resident if someone hurt him/her today and he/she responded, the man that got me out of bed grabbed my hand too tight. Review of the resident's progress note dated 01/17/26, at 11:32 A.M., showed Licensed Practical Nurse (LPN) A documented the Certified Medication Technician (CMT) gave the resident his/her medications, completed a blood sugar check, and administered insulin. The resident got upset and threw water on the CMT. Resident educated that staff are here to help him/her and staff will not tolerate this kind of behavior. Resident yelled at this nurse to get out of his/her room. Nurse left resident in the recliner with the call light in reach. (The LPN did not document the resident's allegation of possible abuse, notifications, or resident assessment) Review of the resident's electronic medical record showed no entries related to an assessment, notifications, or further information related to the abuse allegation.Review showed the facility did not provide full completed investigation upon request.Review of DHSS records on 01/22/26 showed the facility had not submitted an investigation into the allegation of abuse. Interview and observation of the resident on 01/22/26, at 3:00 P.M., showed the following:-Resident sat in a recliner in his/her room;-The ADON observed and measured bruises on the resident's hands. The resident's right hand showed a circular reddish purple colored bruise on top of the hand measuring 6.3 centimeters (cm) by 4.7 cm and a lighter purple colored bruise measuring 3.8 cm by 3 cm;-The resident's left hand had a 2 cm by 2 cm purple bruise located on the inner wrist with 4 circular purple bruises approximately 1 cm by 1 cm scattered on the top of the resident's hand;-The resident's abdomen did not show any visible discolorations;-The resident reported he/she obtained the bruising to hands when staff helped him/her out of bed.During an interview on 01/22/26, at 12:02 P.M., CMT G said hitting or hurting a resident's hand would be abuse.During an interview on 01/22/26, at 11:57 A.M. LPN F said the following:-A progress note should be entered to include a resident assessment and notification to the physician and family;-Hitting a resident's hand was considered abuse.During an interview on 01/22/26, at 12:55 P.M., Registered Nurse (RN) H said the following:-Hitting a resident's hand would be considered abuse;-A resident should be assessed after an allegation of abuse and checked for bruises or marks;-A progress note should be entered and include notifications to physician and administration, resident assessment, and what was reported.During an interview on 01/22/26, at 1:05 P.M., the ADON said the following:-If he she received an allegation of abuse, he/she would make sure the resident was safe and immediately contact the Administrator;-The state should be notified of abuse within two hours;- LPN A and CMT B reported the resident was upset at CMT B during the medication pass and threw water on him/her;-LPN A reported he/she would provide medications and blood glucose checks for the resident instead of CMT B;-The ADON heard CNA D report bruising to LPN A as he/she was leaving the nurses' station;-He/she checked the resident and noted older bruising on both hands, but it did not appear suspicious;-He/she did not hear about any possible abuse until after leaving the facility for the day;-A progress report should be completed and include what happened, notifications to the physician, management, and family, and a skin assessment;-The resident should be monitored to assess for any new bruising.During interviews on 01/22/26, at 10:20 A.M., and on 01/22/26, at 1:50 P.M. and 2:55 P.M., the Administrator said the following:-Staff heard the resident yelling and CMT B asked for assistance while passing medications;-The resident said CMT B hurt him/her and pointed to his/her stomach. The resident then reported CMT B hurt his/her finger;-LPN A and the ADON assessed the resident and then reported the incident to the Administrator;-Resident was noted to have bruising on the top of both hands and some bruising to the stomach;-The hand bruising was possibly related to lab draws and the bruising to stomach was due to insulin injections;-CMT B continued to work on the resident's hall after the incident but did not care for the resident;-CMT B was not suspended pending an investigation;-He/she had staff statements and was investigating;-He/she received the report someone hurt the resident from CNA D sometime after lunch;-LPN A reported the ADON and him/her investigated the report and there was no new bruising;-A progress report should be made and include a resident statement, family and physician notifications, and a resident assessment;-The ADON completed a skin assessment on paper, but it should be on a skin assessment tool;-CMT B should have been suspended after the abuse allegation.#2719718

Based on observations, interviews and record review, the facility failed to ensure all allegations of possible abuse were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of staff to resident abuse alleged by one resident (Resident #1) to DHSS. The facility census was 82.Review of the facility's policy titled Abuse and Neglect Policy and Procedure, revised 03/20/25, showed the following:-It is the policy and the right of each resident to be free from abuse, neglect, misappropriation of property and exploitation;-All reports of resident abuse will be reported to the local, state, and federal agencies and thoroughly investigated by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and/or designee. Findings of all investigations are documented and reported;-If resident abuse is suspected, the suspicion must be reported immediately to the Administrator, DON, and/or their designee and to other officials according to state law;-The Administrator, DON, or the individual making the allegation immediately report his or her suspicion to the state licensing agency responsible for surveying/licensing the facility; the resident's representative; the facility medical director and/or resident's physician; and law enforcement, when appropriate;-Immediately is defined as within two hours of an allegation of abuse or allegation resulting in serious bodily injury and within 24 hours for allegations not involving abuse or resulting in serious bodily injury.1.Review of Resident #1''s face sheet (admission data) showed the following:-admission date of 11/08/22;-Diagnoses included vascular dementia (damaged blood vessels that reduce the amount of oxygen to the brain and cause a decline in thinking skills), diabetes mellitus (chronic disease in which blood sugar levels are too high), and high blood pressure.Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/31/25, showed the following:-Moderate cognitive impairment;-Rejection of care occurred 4 to 6 days a week; -Resident used a wheelchair and required staff assistance with transfers and mobility.Review of a facility statement written by Certified Medication Tech (CMT) B, dated 01/17/26, showed the following: -At 11:37 A.M., on 01/17/26, CMT B entered resident's room to administer scheduled medications, check blood sugar, and administer insulin;-The resident became irate after administration and claimed injury to his/her hand;-The resident then began swatting and throwing water;-The nurse was called to the room to inspect the alleged injuries to the resident and found none to be present.During an interview on 01/22/26, at 11:24 A.M., CMT B said the following:-Management should be notified immediately of any abuse and state within 2 hours;-The resident said CMT B hurt his/her hand after insulin was administered;-He/she informed LPN A of the resident accusing him/her of hitting them;-The ADON was also informed of the accusation;-It would be considered abuse if a staff hit a resident's hand.Review of a facility statement written by LPN A, dated 01/17/26, showed the following: -CMT B called him/her to the resident's room;-He/she noted CMT B had wet hair and water on his/her shirt;-CMT B stated he/she gave the resident insulin and medications, and the resident became agitated and threw water on him/her;-The resident was yelling and saying CMT B had hurt his/her hand;-The resident had a couple light bruises on both hands as usual;-The nurse noted no new injury and reported the incident to the ADON.During an interview on 01/22/26, at 10:40 A.M., LPN A said the following:-He/she would notify the administration immediately of any abuse;-Abuse should be reported to the state within two hours;-The resident said CMT B hurt his/her hand, but no injuries were noted;-The resident getting his/her hand hit would be abuse so he/she reported to the ADON right away.Review of a facility statement written by Certified Nurse Assistant (CNA) C, dated 01/17/26, showed the following:-He/she heard the resident hollering;-Staff went to the resident's room, and the resident said staff hurt his/her hand.During an interview on 01/22/26, at 12:05 P.M., CNA D said the following:-He/she would report abuse immediately to the nurse;-Abuse allegations should be reported to the state within two hours;-On 01/17/25, about 12:00 P.M., CMT B came to the nurses' station and reported the resident was arguing with him about medication;-He/she went to the resident's room with another staff to get the resident up for lunch;-The resident said, He gave me that bruise, and pointed at CMT B;-He/she immediately told the ADON and LPN A;-He would consider it abuse if a resident accused staff of giving them a bruise.Review of the resident's progress note dated 01/17/26, at 11:32 A.M., showed Licensed Practical Nurse (LPN) A documented the certified medication technician (CMT) gave the resident his/her medications, completed a blood sugar check, and administered insulin. The resident got upset and threw water on the CMT. Resident educated that staff were here to help him/her and staff would not tolerate this kind of behavior. Resident yelled at this nurse to get out of his/her room. Nurse left resident in the recliner with the call light in reach. (The LPN did not document the resident's allegation of injury to hand caused by staff.) Review of DHSS records showed the facility did not report the allegation of possible abuse on 01/17/26. Review of an undated facility statement written by ADON showed the following:-On 01/17/26, he/she was at the nurses' station desk when CMT B stated, I took a shower;-CMT B and LPN A told him/her how the resident became upset while CMT B was obtaining a blood sugar and administering insulin;-The resident threw a cup of water at CMT B;-While talking to CMT B and LPN A, he/she observed CNA D talking with the resident, but could not hear what they were saying;-His/her understanding of the situation was that the resident had said CMT B had hurt his/her finger during the finger stick which he/she says often after having fingerstick completed;-He/she assessed the resident and noted old bruising on top of both hands but there was no new bruising to his/her hands or fingers.Review of a facility statement written by the Administrator, dated 01/17/26, showed the following: -The Administrator was working as a charge nurse on another unit when he/she was notified someone hurt the resident's hand;-The Administrator asked the resident if someone hurt him/her today and he/she responded, the man that got me out of bed grabbed my hand too tight;-The Administrator asked the resident if the employee giving the medication hurt him/her and the resident responded no; -CMT B was who he/she stated to the previous staff that had hurt him/her. CMT B did not get the resident out of bed that morning. During an interview on 01/22/26, at 10:20 A.M., the Administrator said the following:-Staff heard the resident yelling and CMT B asked for assistance while passing medications;-The resident said CMT B hurt him/her and pointed to his/her stomach;-The resident then reported CMT B hurt his/her finger;-LPN A and the ADON assessed the resident and then reported the incident to the Administrator;-Resident was noted to have bruising on the top of both hands and some bruising to the stomach;-The hand bruising possibly related to lab draws and the bruising to stomach was due to insulin injections.Interview and observation of the resident on 01/22/26, at 3:00 P.M., showed the following:-The resident sat in a recliner in his/her room;-The ADON observed and measured bruises on the resident's hands;-The resident's right hand showed a circular reddish purple colored bruise on top of the hand measuring 6.3 centimeters (cm) by 4.7 cm and a lighter purple colored bruise measuring 3.8 cm by 3 cm;-The resident's left hand had a 2 cm by 2 cm purple bruise located on the inner wrist with 4 circular purple bruises approximately 1 cm by 1 cm scattered on the top of the resident's hand;-The resident reported he/she obtained the bruising to hands when staff helped him/her out of bed.During an interview on 01/22/26, at 10:52 A.M., CNA E said the following:-He/she would report abuse to the charge nurse as soon as possible;-Abuse should be reported to the state as fast as possible.During an interview on 01/22/26, at 12:02 P.M., CMT G said the following:-He/she would report abuse to the nurse as soon as possible;-Abuse should be reported to the state within 24 hours;-Hitting or hurting a resident's hand would be abuse.During an interview on 01/22/26, at 11:57 A.M. LPN F said the following:-He/she would notify the supervisor immediately of an allegation of abuse;-The state should be notified of any abuse allegations within 2 hours;-Hitting a resident's hand was considered abuse.During an interview on 01/22/26, at 12:55 P.M., Registered Nurse (RN) H said the following:-He/she would report abuse to the supervisor immediately;-The state should be notified of abuse within two hours;-Hitting a resident's hand would be considered abuse.During an interview on 01/22/26, at 1:05 P.M., the ADON said the following:-The state should be notified of abuse within two hours;-LPN A and CMT B reported the resident was upset at CMT B during the medication pass and threw water on him/her;-He/she did not hear about any possible abuse until after leaving the facility for the day;-He/she was not sure if the abuse allegation should have been reported due to the resident having dementia.During interviews on 01/22/26, at 1:50 P.M. and 2:55 P.M., the Administrator said the following:-Staff should report abuse to the administration as soon as possible;-An abuse allegation should be reported to the state within two hours;-He/she received the report someone hurt the resident from CNA D sometime after lunch;-LPN A reported the ADON;-He/she should have reported and followed policy in relation to the initial abuse report on 01/17/26.Complaint #2719718

Based on observation, interview and record review, the facility failed to maintain an ongoing monitoring process to include accurate documentation, destruction and accountability of expired or unusable medications, and failed to ensure medications that could not be returned to the pharmacy were destroyed in a timely manner for 34 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34). The facility census was 78.Review of the facility's policy titled Narcotic Control Logging, Documentation, Count and Discrepancies, undated, showed the following:-It is the policy to ensure the proper handling and tracking of controlled medications;-Controlled medications will be subject to special receipt, record-keeping, medication assistance, change of shift count verification, storage, and disposal procedures;-Nurse must sign the individual narcotic sheet for every card received. Do not put two cards on one individual narcotic sheet;-The nurse must sign their name and document doses received;-All expired and discontinued narcotics should be removed from the count as soon as possible and given to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) for disposal;-The DON as well as the ADON destroy the narcotics, then yellow them out in the narcotic logbook;-All narcotics will be stored under a double lock system;-The destruction/disposal process of controlled medications should always include two licensed nurses;-Discontinued controlled medications shall be retained in a securely locked area with restricted access until disposed of by the DON and ADON;-Documentation on the narcotic record will include the date of disposition, names and signature of both nurses disposing of the medication, and the method of disposition;-Documentation on the Medication Disposal Log will include the resident name, medication name, prescription number, disposal date, disposal amount, reason for disposal, and method of disposal. 1. Observation on 10/31/25, at 10:00 A.M., in the DON/ADON's office showed the following:-A locked 4 drawer metal file cabinet;-The top drawer contained bubble packs, pill packs, vials, and bottles containing liquid medication of discontinued controlled substances for approximately 34 different residents. Not all medications contained the individual narcotic sheet;-The second, third, and fourth drawers contained discontinued albuterol Sulfate inhalation solution (used to treat breathing difficulties), various cough suppressants, boxes of lidocaine patches (used to treat pain), Pepto-Bismol, and over the counter vitamins. 2. Review of Resident #1's medical record showed the resident expired on 10/20/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-Three full bottles containing 100 milligrams (mg) per 5 milliliters (ml) of morphine sol (used to treat pain), 20 mg/ml, dated of 10/13/25, with the resident's name;-A medication card with 30 tablets of temazepam (used to treat insomnia), 15 milligrams (mg), dated 10/13/25, with the resident's name;-Three full bottles containing 30 ml of lorazepam sol (used to treat anxiety), 2mg/ml, dated 10/13/25, with the resident's name. 3. Review of Resident #2's medical record showed the resident expired on 10/04/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 30 tablets of lorazepam (used to treat anxiety), 0.5 mg, dated 10/01/25, with the resident's name and no controlled substance accountability sheet. 4. Review of Resident #3's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 11 tablets of Tramadol (used to treat pain), 50 mg, dated 01/09/25, with the resident's name and no controlled substance accountability sheet. 5. Review of Resident #4's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-Three boxes containing 5 patches per box of Fentanyl (used to treat pain), 25 microgram (mcg) per hour (hr), dated 06/23/25, with the resident's name and no controlled substance accountability sheet;-Two medication cards with 20 tablets per card (40 tablets total) of pregabalin (used to treat pain and anxiety), 25 mg, dated 10/07/25, with resident's name and no controlled substance accountability sheet. 6. Review of Resident #5's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-Two full bottles containing 20 milliliters (ml) of morphine sol (used to treat pain), dated of 09/10/25, with the resident's name and no controlled substance accountability sheet. 7. Review of Resident #6's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-One full bottle containing 30 ml of lorazepam sol (used to treat anxiety), 2mg/ml, dated 05/15/25, with the resident's name and no controlled substance accountability sheet;-A medication card with 30 tablets of lorazepam, 0.5 mg, dated 05/15/25, with the resident's name and no controlled substance accountability sheet;-A medication card with 27 tablets of lorazepam, 0.5 mg, dated 10/01/25, with the resident's name and no controlled substance accountability sheet. 8. Review of Resident #7's medical record showed the resident expired on 05/23/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-Two full bottles containing 100 mg per 5 ml of morphine sol (used to treat pain), 20 mg/ml, dated of 05/22/25, with the resident's name and no controlled substance accountability sheet;-One half empty bottle containing 50 mg per 5 ml of morphine sol, 20 mg/ml, dated of 05/22/25, with the resident's name and no controlled substance accountability sheet;-Two full bottles containing 30 ml of lorazepam sol , 2mg/ml, dated 05/22/25, with the resident's name and no controlled substance accountability sheet;-One half empty bottle containing 15 ml of lorazepam sol, 2mg/ml, dated 05/22/25, with the resident's name and no controlled substance accountability sheet. 9. Review of Resident #8's medical record showed the resident expired on 04/22/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 30 tablets of lorazepam, 0.5 mg, dated 12/16/24, with the resident's name and no controlled substance accountability sheet. 10. Review of Resident #9's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A box containing 180 ml of ipratropium bromide/albuterol sulfate inhalation sol (used to treat wheezing), 0.5mg & 3mg/3ml, dated 09/20/24, with the resident's name. 11. Review of Resident #10's medical record showed the resident expired on 10/20/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 30 tablets of lorazepam, 0.5 mg, dated 10/15/25, with the resident's name and no controlled substance accountability sheet. 12. Review of Resident #11's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 30 tablets of lorazepam, 0.5 mg, dated 09/03/25, with the resident's name and no controlled substance accountability sheet. 13. Review of Resident #12's medical record showed the resident was discharged on 05/29/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 11 tablets of alprazolam (used to treat anxiety), 0.25 mg, dated 05/07/25, with the resident's name and no controlled substance accountability sheet. 14. Review of Resident #13's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 17 tablets of lorazepam, 0.5 mg, dated 05/07/25, with the resident's name and no controlled substance accountability sheet. 15. Review of Resident #14's medical record showed the resident expired on 05/15/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication tin a metal file cabinet:-Two full bottles containing 100 mg per 5 ml of morphine sol, 20 mg/ml, dated of 05/14/25, with the resident's name and no controlled substance accountability sheet;-One half empty bottle containing 50 mg per 5 ml of morphine sol, 20 mg/ml, dated of 05/14/25, with the resident's name and no controlled substance accountability sheet;-Two full bottles containing 30 ml of lorazepam sol, 2mg/ml, dated 05/14/25, with the resident's name and no controlled substance accountability sheet;-One half empty bottle containing 15 ml of lorazepam sol, 2mg/ml, dated 05/14/25, with the resident's name and no controlled substance accountability sheet. 16. Review of Resident #15's medical record showed the resident expired on 07/03/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-One full bottle containing 30 ml of lorazepam sol, 2mg/ml, dated 07/02/25, with the resident's name and no controlled substance accountability sheet. 17. Review of Resident #16's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-One full bottle containing 30 ml of lorazepam sol, 2mg/ml, dated 07/15/25, with the resident's name and no controlled substance accountability sheet. 18. Review of Resident #17's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-10 vials containing 5 mg of haloperidol (used to treat hallucinations), 5mg/ml, dated 06/26/25 with the resident's name and no controlled substance accountability sheet. 19. Review of Resident #18's medical record showed the resident was discharged on 06/14/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-One full bottle containing 30 ml of haloperidol lactate (used to treat hallucinations), 1mg/0.5 ml, dated 06/10/25 with the resident's name and no controlled substance accountability sheet. 20. Review of Resident #19's medical record showed the resident expired on 10/29/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 29 tablets of lorazepam, 0.5 mg, dated 09/24/25, with the resident's name;-A medication card with 16 tablets of lorazepam, 0.5 mg, dated 09/24/25, with the resident's name. 21. Review of Resident #20's medical record showed the resident expired on 05/21/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 23 tablets of lorazepam, 0.5 mg, dated 05/08/25, with the resident's name and no controlled substance accountability sheet;-A medication card with 30 tablets of lorazepam, 0.5 mg, dated 05/08/25, with the resident's name and no controlled substance accountability sheet. 22. Review of Resident #21's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 29 tablets of lorazepam, 0.5 mg, dated 04/25/25, with the resident's name and no controlled substance accountability sheet. 23. Review of Resident #22's medical record showed the resident expired on 09/27/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 30 tablets of tramadol, 50 mg, dated 02/10/25, with the resident's name and no controlled substance accountability sheet;-A medication card with 24 tablets of tramadol, 50 mg, dated 02/10/25, with the resident's name and no controlled substance accountability sheet. 24. Review of Resident #23's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 22 tablets of tramadol, 50 mg, dated 10/29/24, with the resident's name and no controlled substance accountability sheet. 25. Review of Resident #24's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 7 tablets of tramadol, 50 mg, dated 06/13/24, with the resident's name and no controlled substance accountability sheet;-A medication card with 30 tablets of tramadol, 50 mg, dated 06/13/24, with the resident's name and no controlled substance accountability sheet;-A medication card with 1 tablet of lorazepam, 0.5 mg, dated 09/23/24, with the resident's name;-A medication card with 6 tablets of lorazepam, 0.5 mg, dated 09/23/24, with the resident's name and no controlled substance accountability sheet. 26. Review of Resident #25's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 30 tablets of tramadol, 50 mg, dated 11/25/24, with the resident's name and no controlled substance accountability sheet;-A medication card with 30 tablets of tramadol, 50 mg, dated 11/25/24, with the resident's name and no controlled substance accountability sheet. 27. Review of Resident #26's medical record showed the resident expired on 08/20/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-One half empty bottle containing 50 mg per 5 ml of morphine sol, 20 mg/ml, dated of 07/30/25, with the resident's name and no controlled substance accountability sheet;-One half empty bottle containing 15 ml of lorazepam sol, 2mg/ml, dated 07/30/25, with the resident's name and no controlled substance accountability sheet. 28. Review of Resident #27's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-One half empty bottle containing 15 ml of lorazepam sol, 2mg/ml, dated 01/29/24, with the resident's name and no controlled substance accountability sheet;-One full bottle containing 30 ml of lorazepam sol, 2mg/ml, dated 01/29/24, with the resident's name and no controlled substance accountability sheet. 29. Review of Resident #28's medical record showed the resident was discharged on 03/29/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 29 tablets of lorazepam, 0.5 mg, dated 08/20/24, with the resident's name and no controlled substance accountability sheet. 30. Review of Resident #29's medical record showed the resident expired on 05/15/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 30 tablets of lorazepam, 0.5 mg, dated 04/29/25, with the resident's name and no controlled substance accountability sheet;-A medication card with 30 tablets of lorazepam, 0.5 mg, dated 03/29/25, with the resident's name and no controlled substance accountability sheet;-A medication card with 30 tablets of lorazepam, 0.5 mg, dated 02/04/25, with the resident's name and no controlled substance accountability sheet;-A medication card with 18 tablets of lorazepam, 0.5 mg, dated 07/31/24, with the resident's name and no controlled substance accountability sheet. 31. Review of Resident #30's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 30 tablets of lorazepam, 0.5 mg, dated 10/18/24, with the resident's name and no controlled substance accountability sheet;-A medication card with 17 tablets of lorazepam, 0.5 mg, dated 10/18/24, with the resident's name and no controlled substance accountability sheet. 32. Review of Resident #31's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 29 tablets of tramadol, 50 mg, dated 02/21/25, with the resident's name and no controlled substance accountability sheet. 33. Review of Resident #32's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-One box containing 2 patches of Fentanyl, 25 microgram (mcg) per hour (hr), dated 06/27/25, with the resident's name and no controlled substance accountability sheet. 34. Review of Resident #33's medical record showed the resident currently admitted to the facility. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-A medication card with 30 tablets of tramadol, 50 mg, dated 09/18/24, with the resident's name and no controlled substance accountability sheet. 35. Review of Resident #34's medical record showed the resident expired on 08/19/25. Observation on 10/31/25, at 11:45 A.M., in the DON's office showed the following medication in a metal file cabinet:-One box containing 5 patches of Fentanyl, 25 mcg per hr, dated 08/18/25, with the resident's name and no controlled substance accountability sheet. 36. Review showed the facility did not provide a logbook containing documentation of previously destroyed controlled substances. 37. During an interview on 10/31/25, at 10:02 A.M., the ADON said the following:-The ADON has currently held his/her position at the facility for two weeks;-He/she was not aware of the number of medications inside the locked file cabinet;-The DON and ADON destroy all controlled medications and log them in the Drug Destruction Logbook;-He/she has not destroyed any medications with the DON. During an interview on 10/31/25, at 10:10 A.M., Licensed Practical Nurse (LPN) A said the following:-LPN A said all discontinued medications are given to the DON to be destroyed;-The DON keeps the medications locked in his/her office in a file cabinet until they are destroyed;-LPN A has not witnessed any medications being destroyed;-The DON and ADON destroy medications by placing the medications in the Drug Buster solution. During an interview on 10/31/25, at 10:30 A.M., LPN B said the following:-All discontinued medications are given to the DON to be destroyed;-The DON keeps the medications locked in his/her office in a file cabinet;-LPN B has not witnessed any medications being destroyed. During an interview on 10/31/25, at 1:40 P.M., the Physician said that he/she expected staff to follow policy and dispose of medications timely per policy. The Physician said that turn-over at the facility has been high and he/she said that nobody took responsibility for destroying medications like they should have done. Staff have been too busy doing other tasks. The medications should have been destroyed at the end of every month. During an interview on 10/31/25, at 2:30 P.M., the Pharmacist said that discontinued and expired medications should be destroyed at the facility by two nurses per their policy. He/she would not expect the facility to keep the medications any longer than 30 days as there is no reason to not destroy the medications and it puts the facility at a risk for diversion. During an interview on 10/31/25, at 3:00 P.M., the DON said the following:-The DON has held his/her position at the facility for six months;-The DON and ADON are responsible for destroying all medications including controlled medications;-The DON has not destroyed any medications with the ADON;-The DON has not been able to locate the Drug Destruction Log, therefore he/she has been keeping the medications locked in the file cabinet in his/her office until a new log has been obtained;-The DON said that discontinued medications were to be put in the Drug Buster solution to be destroyed;-The DON said that the medications should be destroyed every 30 days;-The DON said that the number of discontinued medications the facility had on hand was not acceptable. During an interview on 10/31/25, at 03:30 P.M., the Administrator said the following:-The DON and ADON are responsible for destroying discontinued medications timely;-The medications should be destroyed by using the Drug Buster solution;-The medications should be destroyed every 30 days;-The number of discontinued medications the facility had on hand was not acceptable.Complaint # 2655878

Based on observation, interview, and record review, the facility failed to the resident's right to be free from physical and verbal abuse by staff when one staff member (Certified Nurses Aide (CNA) B) grabbed the arm and wrist of one resident (Resident #1) and cursed at this resident. A sample of seven residents was selected for review out of a facility census was 64. Review of the facility's Abuse and Neglect Policy and Procedure, undated showed the following: -It is the policy and the right of each resident to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation of an individual of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being; -Physical abuse includes, but is not limited to, hitting, slapping, punching, biting and kicking. Corporal punishment, which is physical punishment, used to connect or control behavior. Corporal punishment includes, but is not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object; -Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to the residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 5/26/25; - Diagnoses included cancer, nutritional deficiency, dementia with agitation, depression, and Parkinson's (a progressive neurogenerative disorder that primarily affects the brains ability to control movement, leading to a range of motor and non-motor symptoms). Review of the resident's baseline care plan, dated 05/26/25 showed the following: -Resident had confusion; -Resident was elopement risk; -Resident had a history of falls; -Resident required help from staff for most activities of daily living; -Resident used a walker and wheelchair for mobility. Review of the resident's progress note dated 05/28/25, at 10:24 A.M., showed the following: -A nurse documented the resident was very agitated, exit seeking, and setting off the emergency exit door alarms; -Multiple attempts by staff to redirect were unsuccessful; -The resident struck a CNA in the face while attempting to redirect. Review of the facility's investigation, dated 05/31/25, showed the following: -On 05/28/25, the Assistant Director of Nursing (ADON) was notified at approximately 9:15 A.M. that CNA B said the resident, a new resident in Special Care Unit (SCU) had hit him/her; -The ADON went and spoke with CNA B who did not give more information than the resident hit him/her in the face. There was no redness or bruising noted. CNA B was moved from B to C wing at that time; -The ADON requested CNA B fill out an incident report and write a statement and notified the Administrator; -At approximately 1130 A.M., the Administrator instructed the Director of Nursing (DON) and the Maintenance Supervisor to look at the cameras surrounding the incident due to different stories and the staff walking out; -At approximately 11:38 A.M., the DON asked the Administrator to come to the camera room to view the incident. When the Administrator viewed the cameras, it was seen that at approximately 9:00 A.M., on 05/28/25, the resident and CNA B were in the dining room on B wing. The resident, was in his/her wheelchair self-propelling and touching cups and dishes on the table. CNA B came into the dining room and told the resident Stop touching stuff, if you need something you need to ask. The resident continued to touch Items on the table and dish cart. CNA B repeatedly told the resident to stop and he/she physically removed his hands off of dishes, drink cart, etc. CNA B attempted to remove the resident from the dining room by pushing his/her wheelchair and the resident put his/her feet down to stop CNA B from moving him/her. CNA B removed the residents hands from the dish cart again and the resident responded, Fuck you bitch. CNA B responded fuck you too. CNA B then leaned down in front of the wheelchair to move the resident and the resident hit the CNA in the face. CNA B told the resident to stop and began pushing his/her arms away and grabbing his/her arms and trying to move him/her out of the dining room. CNA B eventually walked out of the dining room and the resident continued touching cups and plates on the drink cart and dining room table; -The Administrator completed self-report. Observation of the facility provided video showed the following: -Staff identified the resident as Resident #1 and the staff member as CNA B; -The resident was sitting in the dining room next to a cart; -CNA B approached the resident and said You want something on there you need to ask; -The CNA then began to move the resident's wheelchair without permission or explanation. The CNA said you need to get out, we need to clean; -The CNA continued to try and move the resident's wheelchair. The resident attempted to stop the CNA by placing his/her feet on the ground. The CNA's began to jerk the wheelchair in a attempt to move the resident. The CNA did so multiple times, including lifting up the front of the wheelchair so the reisdent's feet did not touch the ground; -The resident continued to resist and made a comment to the CNA. The CNA replied with fuck you; -During the process, the resident reached out to a different cart. The CNA pushed the resident arm abruptly back towards the resident and told the resident to stop; -The resident reached again and the CNA moved his/her arm abruptly and into the resident's lap. The CNA then began to try and grab/move the resident's feet/legs. The resident swung at the CNA; -The CNA reached out to slap at and grab both of the resident's hands said stop and that shit hurts; -The CNA tried to move the resident again, then walked out of the dining room saying I'm not playing you. -The resident resistant the CNA's actions and appeared irritated. The CNA did not ask for assistance or leave and reapproach. During an interview on 06/03/25, at 11:22 A.M., CNA B said the following: -Cursing at a resident would be considered verbal abuse; -Any physical redirection like holding/grabbing a resident's arm or hand or pushing a resident's arm or hand away would be considered abuse; -He/she did not like working in the special care unit (SCU); -The morning of 05/28/24, at around 9:00 A.M., breakfast was over so the staff had to get all the residents out of the dining room to clean up; -The resident sat in his/her wheelchair near a cart of dirty dishes in the dining room; -CNA B asked the resident to get out of the dining room; -The resident planted his/her feet on the floor and would not leave the dining room; -He/she tried to turn the resident around and he/she kept dragging his/her feet; -The resident started moving his/her arms and legs and tried to hit him/her and caught him/her off guard and hit him/her in the face; -He/she was irritated and grabbed the resident's arms and said please stop socking him/her and don't hit him/her; -He/she did not know what really happened after the resident socked him/her in the face; -The resident was cursing at him/her; -He/she denied cursing back at the resident; -Staff are not allowed to get physical with residents or curse at resident this would be considered abusive. During an interview on 06/03/25, at 1:52 P.M., Licensed Practical Nurse (LPN) A said CNA B would sometimes have an attitude toward staff members. During an interview on 06/03/25, at 3:41 P.M., Assistant Director of Nursing (ADON) said the following: -He/she reviewed the camera footage of CNA B and the resident and stated CNA B handled the situation wrong; -CNA B should have left the resident alone and not attempted to move him/her after he/she refused; -The resident was allowed to be in the dining room and CNA B should of never attempted to force him to leave that area. During an interview on 06/03/25, at 4:32 P.M., the Director of Nursing (DON) said the following: -He/she reviewed the camera footage of the interaction between CNA B and the resident and CNA B's actions where inappropriate and he/she felt it was abuse; -CNA B should have never cursed and resident A, he/she should have left the resident alone. MO00254917

Based on observation, interview, and record review, the facility failed to post the current daily nurse staffing information in a clear and readable format and in a prominent place readily accessible to all residents and visitors. The facility census was 66. Review of the facility's Nursing Staff of Duty, undated, showed the form included the following; -Date, census, number of residents in house and number of residents in hospital; -Registered nurse (RN) hours; -RN and Licensed practical nurse (LPN) hours for 7:00 A.M. to 7:00 P.M. shift and 7:00 P.M. to 7:00 A.M. shift; -Certified medication technician (CMT) hours for 7:00 A.M. to 3:00 P.M., 3:00 P.M. to 7:00 P. M., and 7:00 P.M. to 7:00 A.M. shifts; -Certified nursing assistant (CNA) and nursing assistant (NA) hours for 7:00 A.M. to 3:00 P.M., 3:00 P.M. to 7:00 P.M., 7:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts; -Restorative Aide and Bath Aide hours. Observations on 03/17/25, at 11:05 P.M., on 03/18/25, at 10:27 A.M. and 12:23 P.M., and on 03/19/25, at 8:42 A.M., showed daily nurse staffing information posted on a clipboard near the front entrance across from the main office with sheets dated 02/19/25, 02/20/25, 02/23/25, 02/24/25, 03/02/25, 03/03/25, 03/04/25, 03/05/25, and 03/08/25. Observations on 03/19/25,, at 10:50 A.M. and 11:53 A.M., and on 03/20/25, at 8:25 A.M., showed the clipboard that held the daily nurse staffing information was empty with no daily nurse staffing posted. During an interview on 03/19/25, at 10:15 A.M., LPN A said the following: -Daily nurse staffing sheets were posted at the front of the facility by the receptionist desk; -C Wing night shift nurse completed the form at midnight daily; -Newly hired nurses may not know this was their responsibility; -The nurse responsible for training a new nurse on C Wing should educate them on when and how to fill the form and where to post the form; -The nurse staffing sheets on the clipboard should be current; -The Director of Nursing (DON) was responsible for ensuring the nurse staffing sheet was posted daily. During an interview on 03/19/25, at 11:39 A.M., LPN B said the following: -Daily nurse staffing sheets were posted in the front of the facility; -C Wing night nurses completed these daily at midnight; -The nurse staffing sheets posted should be current; -The front office staff and DON were responsible for ensuring the forms were completed daily. During an interview on 03/19/25, at 12:00 P.M., the former Administrator said the following: -The daily nurse staffing hours were posted on a clipboard across from the main office; -The form was filled out daily by the C Wing night shift nurse at midnight; -The form posted should be current; -The receptionist checked the form daily and if not completed, notified the nurses; -He/she was responsible for ensuring the form was completed daily. Review of the daily nurse staffing hours in a binder at the receptionist desk showed no forms for 02/21/25, 02/22/25, 02/25/25 through 03/01/25, 03/06/25, 03/07/25, and 03/09/25 through 03/19/25. During an interview on 03/19/25, at 1:42 P.M., the Receptionist said the following: -The daily nurse staffing hours were posted on a clipboard across from his/her desk; -The night shift nurse completed this form daily; -He/she did not know who was responsible for checking them daily and had not been told this was one of the receptionist job duties. He/she just took them down and placed them in a binder; -The DON was responsible for ensuring the form was completed daily. During an interview on 03/20/25, at 1:24 P.M., the Administrator said the following: -The daily nurse staffing hours were posted on a clipboard by the front office; -The night shift nurses were responsible for completing these daily at midnight; -She was responsible for ensuring the forms were completed daily. MO00249185

Based on interview and record review, the facility failed to report an allegation of staff to resident abuse to the Department of Health and Senior Services (DHSS) within the required two hour timeframe when a staff member Certified Nursing Assistant (CNA) C allegedly witnessed CNA D being rough with one resident (Resident #1) and failed to report an allegation of misappropriation within the required twenty-four hour timeframe when staff received an allegation from one resident (Resident #2) of multiple personal items taken from his/her room. Seven residents were sampled. The facility census was 66. Review of the facility's policy titled Abuse and Neglect Definition and Policy, updated 11/27/17, showed the following: -Abuse is the infliction of physical, sexual, or emotional injury or harm including financial exploitation by any person, firm or corporation; -A person commits the crime of financial exploitation of an elderly or disabled person if such person knowingly and by deception, intimidation, or force obtains control over the elderly or disabled person's property with the intent to permanently deprive the elderly or disabled person of the use, benefit or possession of his or her property thereby benefiting such person or detrimentally affecting the elderly or disabled person; -All allegations of abuse and neglect or allegations of neglect, exploitation or mistreatment, misappropriation of resident property, including Injuries of unknown origin Injury will be reported to the Administrator and Director of Nursing (DON) Immediately after an allegation is made; -All allegations of abuse and neglect or allegations of neglect, exploitation or mistreatment, and misappropriation of resident property that result In serious bodily Injury, will be reported to the State Survey Agency In accordance with federal requirement Immediately, but no later than 2 hours after an allegation Is made. If the alleged violation does not Involve abuse and does not result In serious bodily Injury It will be reported to the State Survey Agency In accordance with federal requirements no later than 24 hours. Investigation results will be provided to the State Survey Agency no later than 5 working days after reporting; -Any reasonable suspicion of a crime against a resident will be reported to the Administrator or DON immediately. Suspicious crimes Involving serious bodily Injury will be reported Immediately but no later than 2 hours to State Survey Agency and one or more law enforcement entitles. Suspicious crime that do not Involve serious bodily Injury will be reported to State Survey Agency and one or more law enforcement entitles no later than 24 hours. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 09/22/99; -Diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures (sudden, brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms)), severe intellectual disabilities and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy (a group of conditions that affect movement and posture) where all four limbs are affected, resulting in limited voluntary movement, muscle stiffness, and potentially other developmental disabilities like intellectual impairment, seizures, or vision/hearing/speech problems). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/26/24, showed the following: -The resident had severe cognitive impairment; -The resident was dependent on staff for activities of daily living (ADL - dressing, eating, bathing, etc.) with the exception of requiring maximum assist from staff for eating; -The resident required maximum assistance from staff to roll left and right, go from sitting to lying and lying to sitting. The resident was dependent on staff for transfers and wheelchair mobility. Review of the resident's care plan, revised 12/11/24, showed the following: -The resident was at risk for falls and required assistance with all ADLs. The resident had poor safety awareness and depended on staff for assistance with ADLs and safety precautions; -Provide care without judgement; -Provide space for increased participation at any time the resident desired; -Assist with cares at anytime while maintaining dignity and privacy; -Assist with dressing; -Continue to praise and encourage active participation without judging; -He/she was a two person assist with transfers with a Hoyer lift (mechanical lift); -He/she required moderate assistance with meals. He/she was dependent on staff for transfers, dressing, grooming, locomotion, toileting, hygiene and bathing. Review of the facility's investigation, dated 03/15/25, completed by the former Administrator, showed the following: -On 03/15/25, at 2:02 P.M., the former Administrator became aware of a complaint against another CNA for yanking around a resident and being aggressive. The CNA was sent home and placed on suspension pending investigation. The former Administrator obtained written statements from the staff that was in the building at the time; -At 3:00 P.M., a full head to toe assessment was completed on the resident that showed a small circle on his/her right knee approximately 5 cm. by 5 cm; -On 03/16/25, several staff and residents were interviewed; -On 03/19/25, the investigation was completed and the conclusion of the investigation was that it was a personality conflict. CNA D had been an employee at the facility for nine years with no write-ups. The former Administrator provided abuse and neglect education to staff; -The former Administrator did not document reporting the allegation of abuse to DHSS. Review of the resident's nurse's progress note dated 03/15/25, at 3:30 P.M., showed staff completed a skin assessment. Skin was warm, dry, and intact. There was an approximately 5 centimeter (cm) by 5 cm circular red spot on the right knee cap that was blanchable (capable of becoming pale or white when pressed). The resident did not grimace or recoil when the area was touched. Review of CNA C's written statement, dated 03/15/25, showed the following: -He/she was working on B Hall with CNA D and CNA D was in a hateful mood; -CNA D kept having an attitude towards the residents and was upsetting them; -When he/she walked in to the resident's room, CNA D was yanking the resident around changing the resident and being aggressive; -He/she assisted CNA D with getting the resident into the Hoyer lift (mechanical lift) and the resident's chair. During an interview on 03/18/25, at 2:28 P.M., CNA C said the following: -On 03/15/25, at approximately 7:00 A.M., he/she entered the resident's room and saw CNA D on the mat in front of the resident and CNA D yanked the resident's legs over the CNA's shoulders and pulled the resident's pants and brief up hard. The CNA then put the resident's legs down and pushed the resident over on the resident's side and placed the Hoyer pad under the resident. The CNA then yanked the resident back over. He/she felt the CNA was tossing the resident around like a rag doll; -He/she left the hall and reported to the receptionist and the receptionist told him/her to tell the nurse. He/she reported to the receptionist within 30 minutes; -He/she reported the incident to the nurse after breakfast sometime after 8:00 A.M.; -The nurse called the Administrator and the owner came to the facility immediately and took his/her statement. Review of Registered Nurse (RN) E's typed statement, dated 03/15/25, showed the following: -After CNA D left, CNA C informed the RN that CNA D was rude and disrespectful to him/her and the residents. CNA C said CNA D was aggressive with a resident when they were changing the resident. CNA C said that CNA D was yanking a non-verbal resident, putting the resident's legs up and over CNA D's shoulder with force and used force when he/she rolled the resident over. The CNA said it was like CNA D was throwing the resident around like a rag doll; -CNA C said he/she was scared to say something to anyone because he/she was a new staff member and did not want any confrontation; -The resident was okay when staff checked on him/her after the incident and appropriate personnel were notified. During an interview on 03/18/25, at 3:42 P.M., RN E said the following: -On 03/15/25, between 12:30 P.M. and 1:00 P.M., CNA C reported to him/her that CNA D was yanking on the resident, used force, and threw the resident around like a rag doll; -CNA C reported the incident happened before lunch; -CNA C should have reported the incident to him/her immediately; -CNA C said there was a conflict between him/her and CNA D and he/she was afraid to tell anyone about the incident; -He/she notified the former Administrator immediately and assessed the resident; -He/she had already sent CNA D home before the report. During an interview on 03/19/25, at 9:06 A.M., the Receptionist said the following: -On 03/15/25, CNA C reported to him/her around 10:00 A.M. that CNA D was being rude to CNA C and he/she told the CNA to report this to the nurse; -Around 12:00 P.M., the CNA told him/her that CNA D was being rough with the resident when they were changing the resident and he/she told the CNA to report this to RN E. The CNA did not say what time the incident occurred. Review of DHSS records showed the facility self-reported the allegation of abuse on 03/15/25 ,at 4:15 P.M. (over two hours after the CNA was aware of the potential abuse). During an interview on 03/19/25, at 10:52 A.M., the Social Services Designee (SSD) said the following: -He/she did not know what time CNA C witnessed the incident between CNA D and the resident; -He/she went with the former Administrator to assess the resident between 1:00 P.M. and 3:00 P.M. on 03/15/25; -CNA C should have immediately reported to the charge nurse. During an interview on 03/19/25, at 12:00 P.M., the former Administrator said the following: -CNA C told him/her about the incident involving the resident and CNA D on 03/15/25, at 2:02 P.M. and said the incident happened that morning; -CNA C did not report the incident immediately. 2. Review of Resident #2's face sheet showed the following: -admitted on [DATE]; -The resident had a responsible party; -Diagnoses included respiratory infection, diabetes and chronic cough. Review of the resident's significant change MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident required set up assistance from staff for eating and oral hygiene and substantial to total assistance for all other ADLs; -The resident used a wheel chair for mobility and required moderate to total assist from staff for transfers and bed mobility. Review of the resident's care plan, updated 03/13/25, showed the following: -The resident required limited to extensive assist with ADLs; -Provide care without judgement; -Provide space for increased participation at anytime the resident desired; -Assist with bathing as needed; -Assist with dressing as needed; -Continue to praise and encourage active participation without judging; -The resident required limited to extensive assistance with dressing, bathing, transfers, toileting and personal hygiene and limited assist for all transfers. Review of a Grievance Form dated 03/13/25, at 8:38 A.M., showed the following: -The resident filed a grievance that one lip balm was removed from a closed set, three sharpies missing from a zipper bag bag that had ten in it to begin with, and about ten teddy bears and stuffed animals had gone missing; -The grievance was reported to the DON, Administrator, and all management staff on 03/13/25 and was not reportable to an outside agency; -The grievance was resolved on 03/13/25, at 12:15 P.M. The resident came up to the SSD office asking him/her for help to connect his/her computer to the wifi. The internet was working by the time him/her and the resident got back to the resident's room. The SSD saw right below the resident's computer screen in a small white porcelain dish was the fanta lipstick that was missing from the pack. The resident said that was from the old set and he/she had the SSD look at it. The SSD opened the lid and twisted the bottom up showing it had barely been used. The resident said it was still the old one and not the new one. The SSD could still see the straight edge of the lip balm showing barely used. During an interview on 03/20/25, at 8:44 A.M., the resident said the following: -He/she had several items including clothing, skin care items, electric toothbrushes, nail clippers and stuffed animals taken from his/her room; -He/she reported this to the former Administrator within the past 2 to 3 months and the former Administrator told him/her to make a list of items and then never followed up with him/her; -He/she thought a staff member took his/her belongings but did not know who it was. During an interview on 03/20/25, at 9:47 A.M., the SSD said the following: -The resident reported someone took his/her stuffed animals and red fanta lip balm; -The resident reported items were disappearing from his/her room, but since the resident did not see the items taken or who took the items, the SSD put the resident reported items missing on the grievance form on 03/13/25; -He/she found a tube of red fanta lip balm in the resident's room and the resident said it was an old stick; -He/she reported this to the Administrator and DON in the morning meeting; -He/she did not report the allegation of misappropriation to DHSS; -The report of the stuffed animals should have been reported to DHSS, but not the lip balm. He/she did not know how long the facility had to report misappropriation. During an interview on 03/20/25, at 10:05 A.M., the Administrator said the following: -The former Administrator did not notify him/her about the resident's report of misappropriation; -If the resident reported items disappearing from his/her room, he/she considered this misappropriation and the allegation should have been reported to DHSS. 3. During an interview on 03/18/25, at 1:52 P.M., CNA F said if he/she witnessed abuse, he/she immediately reported to the charge nurse. The Administrator reported to DHSS within two hours. During an interview on 03/18/25, at 2:06 P.M., CNA G said if he/she witnessed abuse, he/she notified the charge nurse immediately. The DON reported to DHSS within 24 hours. During an interview on 03/18/25, at 2:28 P.M., CNA C said if he/she witnessed abuse, he/she reported to his/her supervisor immediately. The DON or Administrator reported to DHSS within 24 hours. During an interview on 03/18/25, at 4:06 P.M., CNA H said if he/she witnessed abuse, he/she reported to the charge nurse immediately. The DON reported to DHSS within 2 hours. During an interview on 03/18/25, at 4:14 P.M., CNA D said if he/she witnessed abuse, he/she reported to the charge nurse immediately. The Administrator reported to DHSS within 2 hours. During an interview on 03/20/25, at 11:06 A.M., CNA J said if a resident reported misappropriation, he/she reported to the charge nurse immediately and helped the resident look for the item. The Administrator reported allegations of abuse to DHSS within 2 hours. During an interview on 03/19/25, at 9:06 A.M., the receptionist said if he/she witnessed abuse, he/she reported immediately to the charge nurse. The Administrator reported to DHSS within 2 hours. During an interview on 03/19/25, at 9:54 A.M., Certified Medication Tech (CMT) I said if a resident reports misappropriation, he/she reported to the charge nurse immediately and the Administrator or DON reported to DHSS within 2 hours. If he/she witnessed abuse, he/she reported to the charge nurse immediately. The Administrator or DON reported to DHSS within 2 hours. During interviews on 03/19/25, at 10:15 A.M. and on 03/20/25, at 12:30 P.M., Licensed Practical Nurse (LPN) A said if a CNA witnessed abuse, they reported to the charge nurse immediately. He/she reported to the DON and the DON reported to DHSS within 2 hours. If a resident reported misappropriation, he/she reported this to the Administrator and made a nurse's progress note about the resident's report. The DON reported to DHSS within 2 hours. During interviews on 03/19/25, at 11:39 A.M., and on 03/20/25, at 11:26 A.M., LPN B said if a staff member witnessed abuse, they reported to the charge nurse immediately. The charge nurse reported to the DON or Administrator immediately and the DON or Administrator reported to DHSS immediately. If a resident reported misappropriation, he/she reported this to the SSD and the SSD or Administrator reported to DHSS. He/she did not know how long the facility had to report misappropriation to DHSS. During an interview on 03/18/25, at 3:42 P.M., RN E said if staff witnessed abuse, they reported immediately to the charge nurse who then immediately reported to the Administrator. The Administrator reported to DHSS within 2 hours. During interviews on 03/19/25, at 10:52 A.M., and on 03/20/25, at 9:47 A.M., the SSD said the following: -If staff witnessed abuse they immediately reported to the charge nurse. The charge nurse reported to the DON or Administrator and they reported to DHSS within 2 hours; -If a resident had an allegation of misappropriation, he/she completed a grievance form and reported to the Administrator; -All allegations of misappropriation should be reported to DHSS, but he/she did not know how much time the facility had to report allegations of misappropriation. During an interview on 03/19/25, at 12:00 P.M., the former Administrator said he/she reported to DHSS within 2 hours. The DON was responsible for ensuring nursing staff knew when to report allegations of abuse, but he/she was ultimately responsible for ensuring all staff knew abuse and neglect policies. During interviews on 03/20/25, at 8:20 A.M., 10:05 A.M., and 1:24 P.M., the Administrator said the following: -All allegations of abuse and misappropriation should be reported to DHSS within 2 hours; -If a staff member witnessed abuse, they should report to the charge nurse immediately. The charge nurse reports to the DON or Administrator and they reported to DHSS within 2 hours. MO00251130, MO00251329

Based on interview and record review, the facility failed to take steps to protect all residents after staff failed to report that a staff member (Certified Nursing Assistant (CNA) D) acted in an abusive manor by roughly caring for one resident (Resident #1) and the CNA continued to work independently with residents. The facility also failed to investigate an allegation of misappropriation of property for one resident (Resident #2). Seven residents were sampled and the facility census was 66. Review of the facility's policy titled Abuse and Neglect Definition and Policy, updated 11/27/17, showed the following: -The Administrator or his/her designated representative will immediately initiate a thorough investigation after an allegation is made; -The results of the investigation will be reported to State Survey Agency within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action will be taken; -Any employee with allegations of abuse will immediately be placed on unpaid suspension until conclusion of the investigation. If an abuse complaint is substantiated, the employee will be terminated per employer policy; -Appropriate concerns will be hot-lined to the Missouri Department of Health and Senior Services (DHSS) and local law enforcement; -Residents will be removed from harm and protected, according to circumstances of report. 1. Review of Resident #1's face sheet, a document that gives a patient's information at a quick glance, showed the following: -admission date of 09/22/99; -Diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures (sudden, brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms)), severe intellectual disabilities and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy (a group of conditions that affect movement and posture) where all four limbs are affected, resulting in limited voluntary movement, muscle stiffness, and potentially other developmental disabilities like intellectual impairment, seizures, or vision/hearing/speech problems. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 10/26/24, showed the following: -The resident had severe cognitive impairment; -The resident was dependent on staff for Activities of Daily Living (ADL - dressing, eating, bathing, etc.) with the exception of requiring maximum assist from staff for eating; -The resident required maximum assistance from staff to roll left and right, go from sitting to lying and lying to sitting. The resident was dependent on staff for transfers and wheelchair mobility. Review of the resident's care plan, revised 12/11/24, showed the following: -Provide care without judgement; -Provide space for increased participation at any time the resident desired; -Assist with cares at anytime while maintaining dignity and privacy; -Assist with dressing; -Continue to praise and encourage active participation without judging; -He/she was a two person assist with transfers with a Hoyer lift (mechanical lift).\; -He/she was dependent on staff for transfers, dressing, grooming, locomotion, toileting, hygiene and bathing. Review of the facility's investigation, dated 03/15/25, completed by the former Administrator, showed the following: -On 03/15/25, at 2:02 P.M., the former Administrator became aware of a complaint against another CNA yanking around a resident and being aggressive. The CNA was sent home and placed on suspension pending investigation. The former Administrator obtained written statements from the staff that was in the building at the time. Review of the resident's nurse's progress notes showed the following: -On 03/15/25, at 3:30 P.M., staff completed a skin assessment. Skin was warm, dry, and intact. There was an approximately 5 centimeter (cm.) by 5 cm. circular red spot on the right knee cap that was blanchable (capable of becoming pale or white when pressed). The resident did not grimace or recoil when the area was touched. Review of the facility's abuse investigation, received 03/19/25, showed the allegation was made after CNA D had left the facility; Review of Registered Nurse (RN) E's typed statement, dated 03/15/25, showed the following: -RN E was notified of a staffing issue related to CNA D stating he/she was going to lunch and then leaving; -After CNA D left, CNA C informed the RN that CNA D was rude and disrespectful to him/her and the residents. CNA C stated that CNA D was aggressive with a resident whey they were changing the resident. CNA C said that CNA D was yanking a non-verbal resident, putting the resident's legs up and over CNA D's shoulder with force and used force when he/she rolled the resident over. The CNA said it was like CNA D was throwing the resident around like a rag doll; -CNA C said he/she was scared to say something to anyone because he/she was a new staff member and did not want any confrontation. During an interview on 03/18/25, at 3:42 P.M., RN E said on 03/15/25, between 12:30 P.M. and 1:00 P.M., CNA C reported to him/her that CNA D was yanking on the resident and used force and threw the resident around like a rag doll; -He/she had already sent CNA D home before the report. Review of CNA C's written statement, dated 03/15/25, showed he/she knew the resident needed to still get up so he/she headed to the resident's room. When he/she walked in, CNA D was yanking the resident around changing the resident and being aggressive . He/she assisted CNA D with getting the resident into the Hoyer lift and the resident's chair. During an interview on 03/18/25, at 2:28 P.M., CNA C said the following: -On 03/15/25, at approximately 7:00 A.M., he/she entered the resident's room and saw CNA D on the mat in front of the resident and CNA D yanked the resident's legs over the CNA's shoulders and pulled the resident's pants and brief up hard. The CNA then put the resident's legs down and pushed the resident over on the resident's side and placed the Hoyer pad under the resident. The CNA then yanked the resident back over. He/she felt the CNA was tossing the resident around like a rag doll; -The nurse asked CNA D to leave the facility around 11:00 A.M. During an interview on 03/19/25, at 10:52 A.M., the Social Services Designee (SSD) said he/she did not know what time CNA C witnessed the incident between CNA D and the resident. CNA C should not have allowed CNA D to continue caring for the resident. CNA D should have been sent home immediately and not cared for residents until lunch time. During an interview on 03/19/25, at 12:00 P.M., the former Administrator said the following: -CNA C told him/her about the incident involving the resident and CNA D on 03/15/25, at 2:02 P.M. and said the incident happened that morning; -CNA D remained in the building until some time between 12:00 P.M. and 12:30 P.M.; -CNA C was on B hall with CNA D until 11:20 A.M. and then CNA D was alone on the hall until he/she left the facility; -The residents were technically not protected due to CNA D continuing to provide cares after CNA C observed the incident. During an interview on 03/20/25, at 1:24 P.M., the Administrator said the following: -CNA C should not have allowed CNA D to continue caring for the resident and CNA D should not have stayed in the facility caring for other residents; -When CNA D left the facility, the CNA was not sent home due to an allegation of abuse. 2. Review of Resident #2's face sheet showed the following: -admission date of 02/02/22; -Diagnoses included respiratory infection, diabetes, and chronic cough. Review of the resident's significant change MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident required set up assistance from staff for eating and oral hygiene and substantial to total assistance for all other ADLs; -The resident used a wheel chair for mobility and required moderate to total assist from staff for transfers and bed mobility. Review of the resident's care plan, updated 03/13/25, showed the following: -The resident required limited to extensive assist with ADLs; -Provide care without judgement; -Provide space for increased participation at anytime the resident desired; -Assist with bathing as needed; -Assist with dressing as needed; -Continue to praise and encourage active participation without judging; -The resident required limited to extensive assistance with dressing, bathing, transfers, toileting and personal hygiene and limited assist for all transfers. Review of a Grievance Form dated 03/13/25, at 8:38 A.M., showed the following: -The resident filed a grievance that one lip balm was removed from a closed set, three sharpies missing from a zipper bag that had ten in it to begin with, and about ten teddy bears and stuffed animals have gone missing; -The grievance was reported to the Director of Nursing (DON), Administrator and all management staff on 03/13/25 and was not reportable to an outside agency; -The grievance was resolved on 03/13/25 at 12:15 P.M. The resident came up to the SSD office asking him/her for help to connect his/her computer to the wifi. The internet was working by the time him/her and the resident got back to the resident's room. The SSD saw right below the resident's computer screen in a small white porcelain dish was the fanta lip balm that was missing from the pack. The resident said that was from the old set and he/she had the SSD look at it. The SSD opened the lid and twisted the bottom up showing it had barely been used. The resident said it was still the old one and not the new one. The SSD could still see the straight edge of the lip balm showing barely used. During an interview on 03/20/25, at 8:44 A.M., the resident said the following: -He/she had several items including clothing, skin care items, electric toothbrushes, nail clippers and stuffed animals taken from his/her room; -He/she reported this to the former Administrator within the past 2 to 3 months and the former Administrator told him/her to make a list of items and then never followed up with him/her; -He/she thought a staff member took his/her belongings but did not know who it was. During an interview on 03/20/25, at 9:47 A.M., the SSD said the following: -The resident reported someone took his/her stuffed animals and red fanta lip balm; -The resident reported items were disappearing from his/her room, but since the resident did not see the items taken or who took the items, the SSD put the resident reported items missing on the grievance form on 03/13/25; -The Administrator or DON should have investigated the allegation, but he/she did not know if this was done. During interview on 03/20/25, at 10:05 A.M. and 1:24 P.M., the Administrator said the following: -The former Administrator did not notify him/her about the resident's report of misappropriation; -If the resident reported items disappearing from his/her room, he/she considered this misappropriation and an investigation should have been initiated immediately; -The former Administrator did not complete an investigation. 3. During an interview on 03/18/25, at 1:52 P.M., CNA F said if he/she witnessed abuse, he/she got the resident to safety. During an interview on 03/18/25, at 2:06 P.M., CNA G said if he/she witnessed abuse, he/she got the resident to safety. During an interview on 03/18/25, at 2:28 P.M., CNA C said if he/she witnessed abuse, he/she protected the resident. During an interview on 03/18/25, at 4:06 P.M., CNA H said if he/she witnessed abuse, he/she intervened. During an interview on 03/18/25, at 4:14 P.M., CNA D said if he/she witnessed abuse, he/she protected the resident. During an interview on 03/20/25, at 11:06 A.M., CNA J said if a resident reported misappropriation, the Administrator investigated. During an interview on 03/19/25, at 9:06 A.M., the receptionist if he/she witnessed abuse, he/she protected the resident. During an interview on 03/19/25, at 9:54 A.M., Certified Medication Tech (CMT) I said if a resident reported misappropriation, the Administrator or DON completed an investigation. If he/she witnessed abuse, he/she separated the resident from the abuser. During interviews on 03/19/25, at 10:15 A.M., and on 03/20/25, at 12:30 P.M., Licensed Practical Nurse (LPN) A said if a CNA witnessed abuse, they should remove the staff member. The accused staff member should be either removed from the hall or the building immediately. If a resident reported misappropriation, the Administrator completed an investigation. During interviews on 03/19/25, at 11:39 A.M., and on 03/20/25, at 11:26 A.M., LPN B said if a staff member witnessed abuse, they should protect the resident. The staff member who witnessed the abuse should not go on and assist the accused party with cares. They should separate and get the resident to safety and then the accused party was suspended immediately. If an incident happened before breakfast, the accused party should not be in the building until lunch time. The SSD investigated all allegations of misappropriation. During an interview on 03/18/25, at 3:42 P.M., RN E said if staff witnessed abuse, they should intervene. During interviews on 03/19/25, at 10:52 A.M., and on 03/20/25, at 9:47 A.M., the SSD said if staff witnessed abuse they got the resident to safety. The Administrator investigated all allegations of misappropriation. During an interview on 03/19/25, at 12:00 P.M., the former Administrator said the following: -If staff witnessed abuse they should stop the abuse; -Staff who witnessed abuse should not assist the accused party with cares before reporting the incident; -An accused staff member was suspended immediately pending investigation; -He/she had not received any reports of misappropriation; -If he/she received a report of misappropriation, he/she started an investigation immediately. During interviews on 03/20/25, at 8:20 A.M., 10:05 A.M., and 1:24 P.M., the Administrator said the following: -If he/she received an allegation of abuse, the staff member was suspended immediately and he/she started an investigation; -If he/she received an al legation of misappropriation, he/she started an investigation immediately. -Investigations included interviews with staff and residents, assessing the resident, notifying the resident's responsible party and physician and informing the resident and the resident's responsible party of the outcome of the investigation. MO00251130, MO00251329

Based on observations, interviews, and record review, the facility failed to ensure all food stored in the main kitchen was free from possible contamination when staff failed ensure food was appropriately labeled and dated, and not expired or past used by date. The failure had the potential to increase the prevalence and spread of food borne illnesses and infection for all 68 facility residents. Review of the facility's policy titled, Cold Food Storage Chart, undated, indicated that opened foods must be dated with the open date and leftovers must be labeled with the date it was made and what it is. 1. During an observation on [DATE], at 10:42 A.M., the following was observed in the reach-in refrigerator and verified by the Dietary Manager (DM) during the initial kitchen tour: -Opened 5-pound (lb.) container of cottage cheese with no date of opening, with a Styrofoam cup inside the container. -One-gallon mayonnaise open with used date [DATE]; -One-gallon BBQ sauce open and dated [DATE]; -One-gallon Honey Mustard dated [DATE]; -One-gallon Pimento Spread opened with used by date of [DATE]; -A squeezed bottle of white sauce dressing which the DM identified as Ranch dressing, with no date and no identifying label; -One-gallon freezer bag with shredded meat which the DM identified as turkey. The DM did know how long the turkey was in the refrigerator; -An opened five lb. bag of shredded cheddar cheese. The bag was left open exposed to air. There was no date of opening or use by date; -An open undated five lb. bag of parmesan cheese that was left open and exposed to air; -An one-gallon bag of sliced cheese with no date; -Three undated storage bags of cooked biscuits. -One-gallon bag of cooked pancakes with no date, -One-gallon bag of chopped celery brown in color with slimy substance in the bag with no date; -Aluminum pan of cooked green peppers with no use by date; -An open one-quart carton of almond milk with manufacturer's instructions to use within seven to ten days. During an interview on [DATE], at 10:42 A.M., the DM said these items should have been dated correctly with an open date and a use-by date. Leftovers should only be kept for three days. Observation of the walk-in refrigerator on [DATE], at 11:13 A.M., showed a crate of 36 undated thawed Mighty Shakes. Review of the manufacturer's instructions indicated thawed shakes should be consumed within 10 days after thawed. During an interview on [DATE], at 4:24 P.M., the Administrator said his/her expectation was that the dietary staff follow the policy for labeling of food and disposing of food appropriately to ensure the residents are served safe and quality food.

40902 Based on observation, record review, and interview, the facility failed to provide respiratory care per standard of practice for all residents when staff failed to administer oxygen as ordered for one resident (Resident #62) and when staff failed to ensure oxygen supplies were stored and changed appropriately when not in use for two residents (Resident #37 and #55). Review of the facility's policy titled Ozark Nursing and Care Center, undated, showed all oxygen tubing must be kept in a baggie when not in use. 1. Review of Resident #62's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included tobacco use, shortness of breath, and chronic obstructive pulmonary disease (COPD - an ongoing lung condition caused by damage to the lungs). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 09/15/24, located in the resident's EMR under the MDS tab, showed the resident had no cognitive impairment. Review of the resident's Care Plan, dated 10/14/24, located in the EMR under the Care Plan tab showed the resident was at risk for ineffective breathing patterns related to shortness of breath and COPD. Interventions in place were to administer oxygen at two liters per minute (LPM) via nasal cannula continuously. Review of the resident's Physician Orders, dated 10/14/24, located in the EMR under the Orders tab, showed staff to administer oxygen 2 LPM via nasal cannula continuously. Observations on 12/10/24, at 2:05 P.M., on 12/11/24, at 10:36 A.M., and on 12/12/24, at 9:06 A.M., showed the resident was seated in a recliner using a nasal cannula and the oxygen canister was set at four LPM. During an observation and interview on 12/12/24, at 9:06 AM, Licensed Practical Nurse (LPN) 2 said the resident should be on 2 LPM. He looked at the resident's oxygen canister and stated it was set at 4 LPM. He/she did sign off on the Medication Administration Record (MAR) today that the resident was receiving 2 liters, but he/she did not actually look at the liters at that time, but should have. During an interview on 12/12/24, at 12:22 P.M., the Nurse Practitioner (NP) said he/she expected staff to follow physician orders for oxygen administration and administer the correct LPM. During an interview on 12/12/24, at 2:19 P.M., the Director of Nursing (DON) said he/she expected staff to administer oxygen according to physician orders. 2. Review of Resident #37's Admission Record, undated, located under the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included COPD with (acute) exacerbation. Review of the resident's annual MDS, with an ARD of 11/03/24, located in the EMR under the MDS tab, showed the resident was cognitively intact. Review of the resident's Care Plan, dated 10/14/24, located in the EMR under the MDS tab revealed, showed resident at risk for ineffective breathing patterns related to shortness of breath due to COPD. Intervention included change oxygen tubing weekly on Wednesday nights and date the new tubing. During an observation 12/09/24, at 12:44 P.M., the resident's updraft apparatus lay on the bedside table and was not dated or stored in a plastic bag. During an observation 12/10/24, at 2:30 P.M., the resident's updraft apparatus was laying on the bedside table and was not dated or stored in a plastic bag. During an observation on 12/11/24, at 11:58 P.M., the resident received an updraft treatment and the apparatus was dated 12/04/24. 3. Review of Resident #55's undated Admission Record, located under the Profile tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included of chronic respiratory failure with hypoxia (low levels of oxygen in body tissues). Review of the resident's Care Plan, dated 10/14/24, located in the EMR under the MDS tab revealed, showed resident at risk for ineffective breathing patterns related to shortness of breath due to COPD. Intervention included change oxygen tubing and humidifier weekly on Wednesday nights and date the new tubing and humidifier. Review of the resident's quarterly MDS, with an ARD of 11/02/24, located in the EMR under the MDS tab, showed the resident was cognitively intact. During an observation 12/09/24, at 1:44 P.M., the resident's nasal cannula was draped over the over bed table and no date on tubing. During an observation 12/10/24, at 4:30 P.M., the resident's oxygen was in use and the tubing was not dated. During an observation on 12/11/24, at 10:45 A.M., the resident was using the oxygen and the tubing was dated 12/04/24. 4. During an interview on 12/12/24 at 1:45 P.M., LPN 2 said the oxygen nasal cannulas and updraft apparatus should be stored in a bag, and the tubing and bag should be dated. During an interview on 12/12/24, at 1:57 P.M., LPN 1 said the oxygen nasal cannulas and updraft apparatus should be stored in a bag, and the tubing and bag should be dated. During an interview on 12/12/24, at 2:45 P.M., the DON said the oxygen nasal cannulas and updraft apparatus would be stored in a clean clear plastic bag dated and initialed, along with dating and initialing the oxygen tubing.

Based on observation, record review, and interview, the facility failed to ensure medications were not left at bedside for a resident that was not assessed to self-administer medications for one resident (Resident #36) out of 21 residents in the sample. Review of the facility's policy titled, Medication Administration undated, showed the following regarding self-administration of medication by residents: -The resident must be alert and oriented and be familiar with taking his/her own medication. The medication must be kept in a locked box or locked drawer. -The resident must have a physician's order for self-administration. -A list of the medication was kept in the resident's MAR and his/her medical record. This list was monitored by the charge nurse every month and when there was any change of orders. -The charge nurse will also check the lock box periodically, but at least weekly. -The resident had a medication administration sheet that he/she kept to document when he/she took any medication. 1. Review of Resident #62's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included tobacco use. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 09/15/24, and located in the resident's EMR under the MDS tab, showed the resident had no cognitive impairment. Observations on 12/10/24, at 2:05 P.M., on 12/11/24, at 10:36 A.M., and 12/12/24, at 9:06 A.M., showed the resident had an inhaler inside a blue sleeve lying on the bedside table next to his/her recliner. Review of the resident's Care Plan, dated 05/16/24, and located in the resident's EMR under the Care Plan tab, showed staff did not care plan self-administration of medications. During an observation and interview on 12/12/24, at 9:06 A.M., Licensed Practical Nurse (LPN) 2 said the resident was not assessed to self-administer any medications. He/she observed the inhaler lying on the bedside table next to the resident's recliner and said he/she was not aware the resident had it. The inhaler should not be in he resident's room. During an interview on 12/12/24, at 12:22 P.M., the Nurse Practitioner (NP) said there should be no medications at a resident's bedside unless they have been assessed to self-administer. During an interview on 12/12/24, at 2:19 P.M., the Director of Nursing (DON) said no medications should be at a resident's bedside.

40902 Based on record review and interview, the facility failed to develop and implement a complete care plan for each resident when staff failed to care plan smoking on the facility's property for two residents (Resident #12 and #62) of two residents reviewed for smoking. Review of the facility's policy titled, Care Plan Policy, dated 03/23/18, showed initial care plans are written shortly after admission (or re-admission) and are reviewed every three months so new problems can be dealt with at the time. 1. Review of Resident #12's Face Sheet tab of the electronic medical record (EMR) showed the following: -admitted on 01/31/24; -Diagnoses included nicotine dependence. Review of the resident's Care Plan, dated 03/21/24 and located in the Care Plan tab of the EMR, showed the staff did not care plan related to the resident's nicotine dependence and smoking. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 08/14/24, and located in the Resident Assessment Instrument (RAI) tab of the EMR, showed the resident was cognitively intact. During an interview on 12/09/24, at 2:13 PM, the resident said he/she can only smoke when his/her family member comes to visit. During an interview on 12/11/24, at 11:00 A.M., Family Member (FM) 1 said he/she comes to the facility three times a week and sits with the resident as he/she smokes. The resident can smoke safely, but does not light his/her own cigarettes or dispose of them without help. 2. Review of Resident #62's Face Sheet, located in the EMR under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included tobacco use. Review of the resident's Care Plan, dated 05/16/24 and located in the resident's EMR under the Care Plan tab,s showed staff did not care plan related to tobacco use or smoking. Review of the resident's significant change MDS, with an ARD of 09/15/24, located in the resident's EMR under the MDS tab, showed resident had no cognitive impairment. During an interview on 12/12/24, at 1:57 P.M., the Director of Nursing (DON) said the resident did not have a care plan for smoking. 3. During an interview on 12/12/24, at 1:18 P.M., the MDS Coordinator (MDSC) said if a resident did smoke, it should be documented and care planned for nicotine use. 4. During an interview on 12/11/24, at 12:16 P.M., the Director of Nursing (DON) said only family members may assist residents who smoke and staff may not assist residents with smoking. Smoking is discussed during the care plan meeting and should be care planned. 5. During an interview on 12/11/24, at 1:34 P.M., the Administrator said smoking should be on the care plan upon admission and updated as needed.

Based on observation, record review, and interview, the facility failed to ensure effective pain management was provided for every resident when staff failed to keep pain medication in stock and failed to follow-up on pain relief after administering as needed pain medication for one resident (Resident #14) reviewed for pain of 21 sampled residents. 1. Review of Resident #14's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (MS - a chronic autoimmune disease that affects the central nervous system, which includes the brain, spinal cord, and optic nerves) and lower back pain. Review of the resident's Care Plan, dated 10/30/20, located in the resident's EMR under the Care Plan tab, showed the resident had had chronic pain. Interventions included for staff to address complaints of pain promptly and administer as needed (PRN) medication for breakthrough pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 10/08/24, located in the EMR under the MDS tab , showed the following: -No cognitive impairment; -Frequent pain that occasionally interfered with day-to-day activities. Review of the resident's Physician Orders, dated 12/12/24, located in the EMR under the Orders tab, showed the following: -An order, dated 09/26/23, for oxycodone (used to treat moderate to severe pain) 10 milligram (mg), PRN, every four hours for breakthrough pain. -An order, dated 12/09/24, for lidocaine (topical pain medication) adhesive patch, medicated 5%, topical, apply patch to lower back in morning (AM), leave on for 12 hours, and remove. Review of the resident's Medication Administration Report (MAR), dated December 2024, located under the Reports tab, showed on 12/09/24, 12/10/24, and 12/11/24, staff did not administer the resident's lidocaine medication due to medication being unavailable. Review of the resident's Controlled Drug Record/Disposition Form, dated November 2024 and December 2024, located on the medication cart, showed the resident oxycodone 10mg was administered on 12/11/24, at 8:48 AM. During an observation and interview on 12/11/24, at 11:50 A.M., the resident approached Certified Medication Technician (CMT) 1, who was standing at the medication cart, and stated his/her back hurts like hell. CMT 1 told the resident they were still waiting on the pharmacy to fill the lidocaine order and get the patches to the facility. CMT 1 did not alert or report anything to the nurse on duty about the resident's pain. The resident said he/she had been administered oxycodone, but it was no longer effective. During an interview on 12/11/24, at 2:28 P.M., CMT 1 said when a resident stated they had a pain scale of 5 or higher he/she would ask if they want something for pain and she would administer the medication and then go back within about 30 minutes to an hour to reassess. When a resident reported the medication was not effective he/she would report that to the nurse, and they would document that in a progress note. He/she administered the resident's an oxycodone, but did not document that on the MAR and did not go back to reassess if it was effective or not. He/she did not report to the nurse that the resident said the oxycodone was not effective. During an interview on 12/12/24, at 1:57 P.M., the Director of Nursing (DON) said he/she was unaware the resident was complaining of pain and that his/her PRN oxycodone was not effective. He/she takes pain very seriously and that any complaint by a resident about pain should be addressed. Anytime a resident stated they were in pain she expected staff to administer pain medication and that should be a priority. He/she expected nursing staff to reach out to the physician if what the facility was doing was not enough to relieve pain.

Based on interview and record review, the facility failed to ensure the Director of Nursing (DON) did not serve as a charge nurse or certified nurse aide (CNA) when the facility census was greater than 60. The facility census was 68. Review showed the facility did not provide a policy regarding the responsibilities of the DON position. 1. Review of the facility provided nurse schedules and staff rosters, dated August 2024, showed the following: -On 08/09/24, the DON worked as a charge nurse on the 3:00 P.M. to 7:00 P.M. evening shift. The facility census was 72; -On 08/13/24, the DON worked as a certified nurse aide (CNA)/nurse aide (NA) on the 6:30 P.M. to 11:00 P.M. evening shift. The facility census was 71; -On 08/16/24, the DON worked as a Licensed Practical Nurse (LPN)/Certified Medication Technician (CMT) on the 6:30 A.M. to 3:00 P.M. day shift. The facility census was 71; -On 08/19/24, the DON worked as a CNA/NA on the 6:30 P.M. to 11:00 P.M. evening shift. The census was 73; -On 08/23/24, the DON worked as a CNA/NA on the 6:30 P.M. to 11:00 P.M. evening shift. The census was 71. During an interview on 09/12/24. at 10:48 A.M., the DON said she worked the following shifts: -On 08/09/24 as a charge nurse; -On 08/13/24 as a CNA; -On 08/16/24 as a LPN/CMT; -On 08/19/24 as a CNA/NA; -On 08/23/24 as a CNA/NA. During an interview on 09/12/24, at 08:30 A.M., LPN A said the DON worked as a charge nurse or CNA when needed. During an interview on 09/12/24, at 9:46 A.M., the Minimum Data Set (MDS - federally mandated assessment tool completed by facility staff) Coordinator said the following: -Administration staff works the floor as nursing staff at times; -The DON worked on the floor as a CNA and charge nurse at times; -Duties for DON are difficult to complete since she works so much. During an interview on 09/12/24, at 10:48 AM, the DON said she was behind on her DON duties due to covering the floor. During an interview on 09/12/24, at 10:48 A.M., Administrator said she was aware of the DON working shifts as charge nurse and aides. 51208

Based on record review and interview, the facility failed to ensure the facility promoted each resident's right to self-determination when staff failed to provide bath/showers as preferred for four residents (Resident #5, Resident #6, Resident #7 and Resident #8) out of a sample of 14 residents. The facility had a census of 68. Review of the facility's policy titled, Shower Protocol, undated showed the following: -A and B wing shower schedule: Monday and Thursday hall one and two receive showers and Tuesday and Friday hall three and four receive showers. Wednesday is a make up day; -Document in the computer if shower given or not; -If resident refuses, fill out refusal form and have charge nurse chart refusal; -Shower list should be done daily and turned into front office with refusal forms. 1. Review of Resident #5's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD-a group of lung disease that blocks airflow and makes it difficult to breathe), pain in right knee, and Alzheimer's disease. Review of the resident's care plan, revised 04/25/24, showed the following: -Required limited to extensive assistance with activities of daily living (ADL's-dressing, grooming, bathing, eating and toileting) as needed; -Provide assistance with bathing as needed. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/23/24, showed the following: -Severely impaired cognitive skills; -Required partial/moderate assistance with toileting and personal hygiene; -Required substantial/maximal assistance with showering/bathing. Review of the resident's shower sheets, dated 08/01/24 through 09/05/24, showed the resident received, or was offered, a shower on the following days: -On 08/01/24, the resident refused a shower; -On 08/14/24, the resident received a shower (14 days after attempted shower); -On 08/27/24, the resident received a shower (13 days after prior shower); -On 09/03/24, (the resident received a shower (7 days after prior shower). During an interview on 09/05/24, at 1:50 P.M., the resident said the following: -He/she did not get showers; -The facility had a shower staff person awhile ago and he/she received showers two times a week; -He/she would like a showers at least one time a week; -He/she feels grungy when he/she does not receive his/her showers. During an interview on 09/05/24, at 3:12 P.M., the Director of Nursing (DON) said the resident should have received a shower before 14 days past. 2. Review of Resident #6's face sheet showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included pain in right shoulder, edema, major depressive disorder and generalized anxiety disorder. Review of the resident's care plan, revised 08/07/24, showed the following: -Required limited to extensive assistance with ADLS; -Required assistance with bathing as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact skills; -Required set up or clean up assistance with showers and bathing. Review of the resident's shower sheets, dated 08/01/24 through 09/05/24, showed the resident received a shower on the following days: -On 08/09/24 (at least nine day after prior shower); -On 08/14/24 (five days after prior shower); -On 08/16/24; -On 08/22/24 (six days after prior shower); -On 08/26/24; -On 09/02/24 (six days after prior shower); -On 09/08/24 (six days after prior shower). During interviews on 09/05/24, at 9:25 A.M. and 1:53 P.M., the resident said the following: -The shower aide quit; -He/she would like a shower at least twice a week; -He/she did not feel clean when he/she gives himself/herself a bath and he/she needed a staff person in the shower room with him/her to help. During an interview on 09/05/24, at 3:12 P.M., the DON said the resident should have stand-by assistance with showering. 3. Review of Resident #7's face sheet showed the following: -admitted [DATE]; -Diagnoses included heart failure, repeated falls, and generalized anxiety disorder. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact skills; -Supervision assistance required with tub/shower transfer. Review of the resident's care plan, dated 07/02/24, showed the following: -Needed minimum assistance and supervision with ADL's; -Provide assistance with bathing body parts he/she is unable to do; -Provide shower/bath two times a week. Review of the resident's shower sheets, dated 08/01/24 through 09/01/24, showed the resident received a shower on the following days: -On 08/07/24 (at least seven day since previous shower); -On 08/13/24, staff documented the resident refused a shower (six days after prior shower); -On 08/27/24, staff documented the resident refused a shower (twenty days after prior shower and 14 days after last documented shower attempt); -On 08/28/24 (21 days after prior shower); -On 08/29/24. During an interview on 09/05/24, at 1:53 P.M., the resident said the following: -Staff's lack of help was reason he/she did not get showers; -He/she said it did not feel good to not receive a shower. During an interview on 09/05/24, at 3:12 P.M., the DON said the resident should have had a shower, or show offer, more frequently. 4. Review of Resident #8's face sheet showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included anxiety disorder, overactive bladder, repeated falls, and unsteadiness on feet. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact skills; -Supervision required for shower/bathing. Review of the resident's care plan, revised 08/21/24, showed the following: -Needed minimum assistance and supervision with ADL's; -Provide assistance with bathing body parts the resident is unable to do; -Provide the resident a shower/bath two times a week. Review of the resident's shower sheets, dated 08/01/24 through 09/05/24, showed the resident received a shower on the following days: -On 08/08/24 (at lest eight days since prior shower); -On 08/28/24 (20 days after prior shower); -On 09/04/24, staff documented the resident refused a shower (seven days after prior shower). During an interview on 09/05/24, at 1:45 P.M., the resident said the following: -He/she must give the staff a hard time to get a shower; -You are lucky to get a shower and that is not right; -He/she did not feel clean, which bothers him/her, when he/she did not get showers; -Staff do not give him/her a reason for not receiving a shower. During an interview on 09/05/24, at 3:12 P.M., the DON said the resident should have a shower before 20 days. 5. During an interview on 09/12/24, at 8:32 A.M., Certified Nurse Aide (CNA) F said he/she was assigned as the shower aide that day, but someone called in so he/she was pulled to work the floor as a CNA. 6. During an interview on 09/12/24, at 8:38 A.M., CNA G said the residents were not receiving showers as scheduled due to not enough staff. 7. During an interview on 09/05/24, at 10:27 A.M., Licensed Practical Nurse (LPN) D said the following: -The shower aide gets pulled from the floor due to staff turnover at times; -The nurse aides usually get a few showers completed each day. 8. During an interview on 09/05/24, at 10:30 A.M., Certified Nurse Aide (CNA) B said the following: -There have been decreased showers for residents since the shower aide quit: -The other shower aide works on the B wing as a CNA since the facility is short staffed. 9. During an interview on 09/05/24, at 1:56 P.M., Licensed Practical Nurse (LPN) C said the following: -Staff frequently pull the shower aides to work on the floor; -Showers are not happening. 10. During an interview on 09/10/24, at 5:30 A.M., LPN E said the following: -The residents' showers are iffy lately due to not a lot of staff. A lot of staff quit a month or two ago; -It is hit and miss with staff completing residents' showers; -Some residents complain of not receiving showers; -Staff try to give residents' one shower per week. Residents should get a shower twice per week; -Facility staff aware the residents' showers are not getting done. 11. During an interview on 09/05/24, at 3:12 P.M., the DON said the following: -There has not been a set shower aide during the day due to staffing; -The is no designated staff per hall for showers; -She expected the residents to have a shower more than every 10 to 12 days in between. 12. During an interview on 09/05/24, at 3:12 P.M., the Administrator said she expected residents to receive a shower before more than every 10 or 12 days. MO00240126, MO00241649 51208

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to consistently assess and document complete, thorough, and accurate weekly skin assessments and when staff failed to complete weekly wound tracking for three residents (Resident #1, Resident #2, and Resident #3) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of a sample of four residents. The facility census was 68. Review of the facility's policy titled Skin Integrity/Wound Policy, dated 01/19/24, showed the following: -The Director of Nursing (DON)/designee will perform weekly skin assessments for all reported residents with alteration of skin integrity related to ulceration of skin and document stage, size, description, color. and odor; -Weekly skin assessments on all residents will be completed and documented by the charge nurse. Weekly skin assessment documentation will include size, description, color, odor, and any change in skin condition. Any ulcerations will be expected to be documented with measurements, once weekly in the computer system by the charge nurse; -The charge nurse will notify the physician and DON/designee upon discovery of any change in skin condition, measure, accurately document and initiate treatment promptly; -The DON/designee will audit all new admissions records for accuracy related to skin within 72 hours after admission; -All charge nurses are required to complete documentation as instructed. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included chronic kidney disease stage four, local infection of the skin and subcutaneous (something is located or inserted beneath the skin) tissue, and cognitive communication deficit. Review of resident's current Physician Order Sheet (POS) showed the following: -An order, dated 10/18/23, for staff to apply phisoderm anti-blem gel (skin cleanser), use to cleanse genital area, groin area, and buttocks two times daily; -An order, dated 11/07/23, for staff to apply calmoseptine (moisture barrier ointment that can help treat and prevent minor skin irritations) 0.44-20.6% to coccyx areas three times daily (TID). Review of the facility's pressure ulcer list showed the resident acquired a pressure ulcer on 07/29/24. The list did not contain any documentation of the type, location, or measurements of the new pressure ulcer. Review of the resident's weekly skin assessment, dated 07/29/24 at 10:49 A.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location is moist pannus (excess skin), groin, and gluteal (buttock); -Moisture associated skin damage (MASD); -MASD location: gluteal with treatment in place; -Interdry treatment under pannus; -Skin turgor (tension) normal; -Resident at risk for developing pressure ulcers/injuries marked yes; -Skin and ulcer/injury treatments: nutrition or hydration intervention, pressure reducing device for chair and bed, and turning/repositioning program. (Staff did not identify a new pressure ulcer or provide a description of the new pressure ulcer.) Review of the resident's progress notes, dated 07/29/24 through 08/03/24, showed staff did not document regarding the pressure ulcer. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/03/24, showed the following: -Cognitively intact skills; -At risk for development of pressure ulcers; -No pressure ulcers; -Pressure reducing device for chair and bed; -Application of nonsurgical dressings other than to feet; -Applications of ointment/medications other than to feet. (Staff did not identify the pressure ulcer on the MDS assessment.) Review of the resident's progress notes, dated 08/04/24 through 08/14/24, showed staff did not document regarding the pressure ulcer. Review of the resident's medication record, dated 08/04/24 through 08/14/24, showed staff did not complete a weekly skin assessment for the resident. (The prior skin assessments was completed on 07/29/24.) Review of the resident's care plan, revised 08/14/24, showed the following: -Incontinent of bowel and bladder and at risk for pressure ulcers; -Pressure ulcer to his/her buttock and receiving treatment; -History of pressure ulcers in the past; -Licensed nurse to audit the resident's skin weekly; -Apply calmoseptine to peri-area as preventative moisture barrier; -Examine skin while bathing for any concerns or abnormalities; -The resident has an overall decline, not getting up as much. Review of the resident's medication record, dated 08/15/24 through 08/31/24, showed staff did not complete a weekly skin assessment for the resident. (The prior skin assessments was completed on 07/29/24.) Review of the resident's progress notes, dated 08/15/24 through 08/31/24, showed staff did not document regarding the pressure ulcer. Review of the DON's weekly wound tracking sheet, dated 08/26/24 through 08/30/24, showed the DON measured the resident's right buttock/coccyx ulcer. The ulcer measured 1.2 centimeters (cm) long by 2 cm wide by 0.1 cm deep. (The tracking did not contain any additional information regarding the wound or a description of the wound.) Review of the resident's medication record, dated 09/01/24 through 09/08/24, showed staff did not complete a weekly skin assessment for the resident. (The prior skin assessments was completed on 07/29/24.) Review of the resident's progress notes, dated 09/01/24 through 09/08/24, showed staff did not document regarding the pressure ulcer. Review of the resident's weekly skin assessment, dated 09/09/24 at 10:13 A.M., showed a nurse documented the following: -Skin temperature warm; -Skin color normal; -Skin moisture location dry; -Skin turgor normal; -The resident at risk for developing pressure ulcers/injuries marked yes; -Skin and ulcer/injury treatments: nutrition or hydration intervention, pressure reducing device for chair and bed, and turning/repositioning program. (Staff did not provide a description of the new pressure ulcer or measurements of the pressure ulcer.) During an interview on 09/10/24, at 10:08 A.M., the resident lay in his/her bed and said he/she reportedsoreness to his/her coccyx (tailbone area) wound if barrier cream was not applied. During interviews on 09/10/24, at 9:59 A.M. and 11:37 A.M. the Assistant Director of Nursing (ADON) said the following: -The resident has a chronic wound. Staff treat it and a few weeks later the wound returns which is part of his/her disease process; -She did not know the resident's wounds were not measured weekly and she had not seen the resident's wound; -She did not find any other weekly skin assessments from 07/29/24 through 09/09/24. During interviews on 09/10/24, at 09:28 A.M., 10:08 A.M., and 12:11 P.M., and on 09/12/24, at 10:48 A.M., the DON said the following: -She did not measure the resident's wounds from 07/29/24 through 08/26/24; -The resident had a bariatric chronic wound on his/her bottom which closed and opened; -On 08/26/24, she measured the wound at 1.2 cm long by 2 cm wide. She did not measure the wound since due to she worked as an aide on the floor; -She expected nurses to complete the resident's weekly skin assessments and document on skin concerns. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included pain, edema (swelling), and chronic obstructive pulmonary disease (COPD-lung disease that causes breathing problems and restricted airflow). Review of the resident's progress note dated 07/07/24, at 10:04 A.M., showed Licensed Practical Nurse (LPN) A documented the resident arrived to the facility from the hospital at 9:05 A.M. He/she notified the on-call nurse practitioner (NP). The resident was readmitted to the facility under the medical director. Review of the DON's skin document showed the resident readmitted with MASD on 07/07/24. Review of the resident's admission observation dated 07/08/24, at 10:28 A.M., showed LPN A documented the following: -Skin color normal; -Skin temperature warm; -Skin moisture dry; -Skin turgor normal; -MASD-moisuture associated skin damage; -Describe each skin integrity condition checked in detail, include location, color, size, drainage, redness, exudate, shape and degree: staff documented buttocks; -Did the resident have any pressure ulcer (s) or injury check the sacrum (triangle shaped bone between the hip bones) , heels, hips, ankles, elbows and ears and any other bony prominences-staff marked no; -The resident had no other pressure ulcers or injury. (Staff did not provide a description, measurements, or location of MASD.) Review of the resident's weekly skin assessment dated [DATE], at 1:59 A.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location dry; -Skin turgor normal; -The resident at risk for developing pressure ulcer/injuries; -The resident's skin was clean, dry, and intact. The resident denied any bumps, bruises, cuts, scrapes, scratches, scabs, or abnormalities at this time. (Staff did not provide a description, measurements, or location of MASD.) Review of the resident's skilled daily nurses note dated 07/13/24, at 3:56 P.M., showed a nurse documented the following: -Skin desensitized to pain/pressure; -Open lesions; -MASD; -Shear to buttocks; -Staff did not document any other information regarding the resident's skin. (Staff did not provide a description, measurements, or location of MASD, lesions, or shear.) Review of the resident's skilled daily nurses note dated 07/14/24, at 10:19 A.M., showed a nurse documented the following: -Skin desensitized to pain/pressure; -MASD; -Shear to buttocks; -Staff did not document any other information regarding the resident's skin. (Staff did not provide a description, measurements, or location of MASD.) Review of the resident's daily skilled nurses note dated 07/14/24, at 12:32 P.M., showed a nurse documented the following: -Skin color normal/intact with no problems; -Staff did not document any other information regarding the resident's skin. (Staff did not provide a description, measurements, or location of MASD.) Review of the resident's daily skilled nurses note dated 07/14/24, at 11:15 P.M. showed a nurse documented the following: -Skin color normal/intact with no problems; -Staff did not document any other information regarding the resident's skin. (Staff did not provide a description, measurements, or location of MASD.) Review of the resident's weekly skin assessment dated [DATE], at 11:11 P.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location dry; -Skin turgor normal; -Staff did not document any other information regarding the resident's skin. (Staff did not provide a description, measurements, or location of prior identified MASD.) Review of the resident's skilled daily nurses note dated 07/15/24, at 11:09 A.M., showed the MDS Coordinator documented the following: -Skin color normal/intact with no problems; -Area that is sore to bottom, barrier cream for preventative/protection. -Staff did not document any other information regarding the resident's kin. (Staff did not provide a description or measurements of sore.) During an interview on 09/12/24, at 9:46 A.M., the MDS Coordinator said she did not remember what she meant by area sore to bottom. Review of the resident's medical record, dated 07/15/24, to 08/04/24, showed staff did not complete or document a weekly skin assessment on the resident. Review of the resident's weekly skin assessment dated [DATE], at 05:20 A.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location dry; -Skin turgor normal; -Staff did not document any other information regarding the resident's skin. (Staff did not prior identified MASD or sore.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact skills; -At risk for development of pressure ulcers; -No presence of pressure ulcers; -Pressure reducing device for chair and bed; -Application of nonsurgical dressing other than to feet; -Application of ointments/medications other than to feet. Review of the resident's weekly skin assessment dated [DATE], at 1:17 A.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color locations normal; -Skin moisture location dry; -Pressure area on coccyx stage 2 (partial-thickness skin loss with exposed dermis); -Skin turgor normal; -Resident at risk for developing pressure ulcers/injuries; -Skin and ulcer/injury treatments wound care, nutrition or hydration intervention, pressure reducing device for chair, and turning/repositioning; -Staff did not document any other information regarding the wound. (Staff did not provide a description or measurements of the stage 2 pressure ulcer.) Review of the resident's weekly skin assessment dated [DATE], at 4:05 A.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location dry; -Stage 2 on coccyx; -Skin turgor normal; -The resident at risk for developing pressure ulcers/injuries; -The resident had breakdown on coccyx, resident turned and repositioned every two hours, and bedside ointment applied. Resident states understanding, continuing to monitor. (Staff did not provide a description or measurements of the stage 2 pressure ulcer.) Review of the resident's weekly skin assessment dated [DATE], at 3:00 A.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location dry; -Additional details-intact; -Skin turgor normal; -The resident at risk for developing pressure ulcers/injuries; -Staff did not document any other information regarding the resident's skin. (Staff did not provide a description or measurements of the stage 2 pressure ulcer.) Review of the resident's progress note dated 08/27/24, at 9:54 A.M., showed LPN C documented a CNA informed him/her that the resident's bottom was worse. The had several open areas and excoriated areas on both sides of his/her buttocks. Treatment applied at this time. Staff to address with the provider. Review of the resident's POS, dated 08/30/24, showed an order for mepilex (foam bandage) 4 by 4 topical to coccyx every three days and when soiled until wounds are healed, once a morning every three days AM med pass. Review of the resident's weekly skin assessment dated [DATE], at 4:23 A.M. showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location dry; -Skin turgor normal; -The resident at risk for developing pressure ulcers/injuries; -Coccyx area reddened with what appears as MASD, skin remains intact at this time, barrier cream applied, resident turned and repositioned every two hours this shift and as needed. (Staff did not provide a description or measurements regarding the MASD or follow-up on the stage-2 ulcer.) Review of the resident's care plan, revised 09/02/24, showed the following: -Incontinent of bowel and bladder and at risk for pressure ulcers; -Reddened coccyx/MASD barrier cream applied; -Staff to conduct skin audit weekly by licensed nurse; -Apply calmoseptine to peri-area as preventative moisture barrier. Review of the DON's wound tracking document, dated 09/02/24 through 09/06/24, showed the resident's wound on his/her left buttock measured 0.5 cm long by 0.5 cm wide by 0.1 cm in depth. Review of the resident's weekly skin assessment dated [DATE], at 12:21 P.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location dry; -Skin turgor normal; -Staff did not document any other information regarding the resident's skin. (Staff did not provide a description or measurements previously identified MASD or ulcer on left buttock.) Observation and interview on 09/10/24 at 10:25 A.M. showed the following: -The resident sat in a chair in his/her room said he/she did not have a dressing on his/her coccyx wound; -The resident stood up from his/her chair and the DON performed wound care to the resident's coccyx; -Observation showed no dressing on the coccyx wound;. -The DON measured the resident's wound on the coccyx at 0.4 cm long x 0.3 cm wide and no depth; -The DON applied barrier cream to the resident's coccyx wound. During an interview on 09/10/24, at 12:46 P.M., LPN C said on 08/27/24 the resident's wound was to both sides of his/her buttock, excoriated and opened. Both sides were red. The skin sloughed off and resident had shearing areas on both sides. He/she had not seen the wound since then. During interviews on 09/10/24, at 9:28 A.M., 10:25 A.M., and 12:11 P.M., and on 09/12/24, at 10:48 A.M., the DON said the following: -The resident had a chronic wound on his/her buttock which heals and comes back; -The week of 09/2/24 through 09/6/24 she measured the wound at 0.5 cm long by 0.5 cm wide by 0.1 cm deep; -She did not have a specific date for when the resident's wound started, she only measured the wound on 09/02/24; -On 09/10/24, during the observation with the surveyor, the resident did not have an ordered bandage on. The DON said the resident should have a bandage on and the nurses should contact the physician if a change was needed; -On 09/10/24, the resident's wound was not open or draining. During interviews on 09/10/24, at 9:59 A.M. and 11:37 A.M., the Assistant Director of Nursing (ADON) said the following: -She was not aware the DON did not measure the resident's wound weekly and had not seen the resident's wound since she had worked night shift; -The nurses should document in the comment section on the weekly wound assessment of the wound's location, if an infection, description of the wound and if a new wound. 3. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included multiple sclerosis (a chronic disease of the central nervous system), acquired absence of left leg above knee, and chronic pain. Review of the resident's current POS showed an order, dated 10/18/23, for calmoseptine ointment 0.44-20.6% topical, apply topically to coccyx two times daily. Review of the resident's progress note dated 06/30/24, at 7:18 P.M., showed a nurse documented 4 cm diameter wound found on the resident's coccyx. The resident's wound was a stage 2 with no drainage noted. Nurse applied calmoseptine applied to the wound bed. Staff passed this information on to the second shift. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderately impaired cognitive skills; -The resident had a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device; -At risk for development of pressure ulcer; -One or more unhealed pressure ulcer at stage one or higher; -One stage 2 pressure ulcer; -Pressure reducing device for chair and bed; -Nutrition or hydration intervention to manage skin problems; -Applications of ointments/medications other than to feet. Review of the resident's medical record dated 07/01/24 to 07/19/24, showed staff did not document completion of a skin assessment. Review of the resident's weekly skin assessment dated [DATE], at 3:07 P.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location moisture to the buttocks, groin; -Redness noted to the groin and buttocks at this time; -Skin turgor normal; -The resident at risk for developing pressure ulcers/injuries; -Staff did not document any other information regarding the resident's skin. (Staff did not document a description of the resident's previously identified wound or follow-up on the the wound.) Review of the resident's weekly skin assessment dated [DATE], at 3:58 P.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location moist, MASD to buttocks; -Skin turgor normal; -Resident at risk for developing pressure ulcers/injuries; -Skin and ulcer/injury treatments-wound care, pressure reducing device for chair and bed, turning/repositioning program; -Staff did not document any other information regarding the resident's skin. (Staff did not document a description of the resident's previously identified wound or follow-up on the the wound.) Review of the resident's weekly skin assessment dated [DATE], at 3:53 P.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin turgor normal; -Resident at risk for developing pressure ulcers/injuries; -Redness to buttocks; -Skin and ulcer/injury treatments-nutrition or hydration intervention, pressure reducing device for chair and bed, turning/repositioning program; -Staff did not document any other information regarding the resident's skin. (Staff did not document a description of the resident's previously identified wound or follow-up on the the wound.) Review of the DON's weekly wound tracking document, dated 08/12/24 through 08/16/24, showed the resident's left buttock wound measured 0.8 cm long by 1 cm wide by 0.1 cm in depth. Review of the resident's weekly skin assessment dated [DATE], at 11:57 A.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location moist-MASD; -MASD to perianal area due to incontinence and leaking from catheter (tube that drains urine from the bladder); -Skin turgor normal; -Resident at risk for developing pressure ulcers/injuries; -Skin and ulcer/injury treatments-wound care, pressure reducing device for chair and bed ,and turning/repositioning program; -Staff did not document any other information regarding the resident's skin. (Staff did not document a description of the resident's previously identified wound or follow-up on the the wound.) Review of the resident's care plan, revised 08/24/24, showed the following: -Resident at risk for pressure ulcers related to mobility; -Staff conduct a systematic skin inspection weekly. Pay particular attention to the bony prominence; -Staff should keep the resident clean and dry as possible; -Staff should report any signs of skin breakdown (sore, tender, red or broken areas); -MASD to perineal area. Review of the resident's weekly skin assessment dated [DATE], at 10:19 A.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location moist buttocks; -Resident at risk for developing pressure ulcers/injuries-staff marked no; -Staff did not document any other information regarding the resident's skin. (Staff did not document a description of the resident's previously identified wound or follow-up on the the wound.) Review of the resident's weekly skin assessment dated [DATE], at 4:53 P.M., showed a nurse documented the following: -Skin temperature location warm; -Skin color location normal; -Skin moisture location dry; -Skin turgor normal; -Resident at risk for developing pressure ulcers/injuries; -Skin and ulcer/injury treatments - wound care, nutrition or hydration intervention, and pressure reducing device for chair and bed; -Staff did not document any other information regarding the resident's skin. (Staff did not document a description of the resident's previously identified wound or follow-up on the the wound.) Observation and interview on 09/10/24, at 10:35 A.M., with the DON and resident showed the following: -The resident lay in his/her bed; -The resident said his/her wound was not as sore as it had been; -The wound was resolved, there was nothing to measure. During interviews on 09/10/24, at 9:28 A.M. and 12:11 P.M., and on 09/12/24, at 10:48 A.M., the DON said the following: -On 08/16/24, the resident's coccyx wound measured 0.8 cm long by 0.1 cm wide. She did not have current measurements. The resident's wound had not got worse since his/her last observation; -She did not measure the resident's wound during the dates of 06/30/24 through 08/16/24; -She expected the nurses to document and complete weekly assessments on the resident. During interviews on 09/10/24, at 9:59 A.M. and 11:37 A.M the ADON said the following: -She did not know the DON did not measure the resident's wound weekly; -She did not find the resident's 08/03/24 weekly skin assessment. 4. During an interview on 09/10/24, at 10:17 A.M., LPN D said the following: -Nurses complete assigned weekly skin assessments; -Nurses assess the resident's skin and document in the computer; -The CNA's or the shower aide inform the nurse of any skin concerns; -Nurses should assess a resident's wound for tunneling, type of tissue, if the wound is open or closed, any redness, signs of an infection, or if new wound; -Nurses turn in the weekly skin assessments to the DON or ADON; -Nurses approximate a wound if it is open; -He/she believes the DON is responsible for tracking and measuring wounds weekly; -Nurses report any changes in skin or open areas in the shift report; -Tracking and measuring wounds is important to know if the treatment works, if small or worse, infections and need to look at changing treatment -The DON informs the physician with a new skin area. 5. During an interview on 09/10/24, at 12:34 P.M., LPN I/Infection Preventionist said the following: -The DON was responsible for weekly wound tracking; -She did not know the weekly wound tracking was not getting done; -Staff meet weekly and discuss wounds; -Nurses complete assigned weekly skin assessments which are in the computer; -Staff should document in the comments section on the weekly skin assessment of any open areas and bruises; -Staff should document of the wound location, size, any signs of infection or redness, drainage, and call the provider if needed. 6. During an interview on 09/10/24, at 11:11 A.M., and the MDS Coordinator said the following: -She reviewed weekly skin assessments which are in the computer; -The nurses complete the weekly skin assessments; -She asked the nursing staff about any wounds; -The DON was responsible for the weekly wound tracking; -The aides report any open areas to the nurses; -Staff conduct weekly meetings to discuss wounds, weight loss, and concerns; -The weekly meetings include the Administrator, DON, Infection Preventionist, ADON, Dietary Manager, social services staff, and medical record staff; -Staff discussed if a resident's wound was better, worse, or healed; -She updated the care plans regarding wounds. 7. During interviews on 09/10/24, at 9:59 A.M. and 11:37 A.M., the ADON said the following: -The aides should report any changes in a resident's skin to the nurse; -The nurses complete assigned weekly skin assessments and document in the computer; -Nurses notify the physician of skin changes and get an order for treatment; -Nurses or aides notify her or the DON of any changes to a resident's skin; -The DON was responsible for monitoring wounds; -The shower aides complete a shower sheet and include wounds and give to the DON; -The DON measures the wounds and keeps the measurements in a notebook; -Staff have a weekly meeting which included reviewing wounds, falls, and other concerns; -Staff should measure a resident's wound weekly; -The MDS Coordinator updates the care plans. 8. During interviews on 09/10/24, at 9:28 A.M., and on 09/12/24, at 10:48 A.M., the DON said the following: -She was behind on the weekly wound tracking due she worked the floor as a charge nurse; -She is responsible to complete the weekly wound tracking; -She should assess residents' wounds weekly; -She measured residents' wound when she works as an aide or charge nurse, but did not document; -She should complete weekly wound measurements and assessments and document in the medical record. -When the nurses complete the weekly skin assessments, they should conduct full head to toe assessment and look for bruising, rash, open areas and current open areas; -Nurses should document approximation size of a wound, what it looks like, treatment in place, and if improving or not. 9. During an interview on 09/12/24, at 9:16 A.M., the Nurse Practitioner for the facility said the following: -She expected skin assessments and measurements of wounds to be completed; -She expected staff to check residents skin and document weekly. 10. During an interview on 09/12/24, at 1:22 P.M., the Medical Director said the following: -He expected staff to complete the weekly wound measurements; -He expected staff to complete the weekly skin assessments and document on wounds. 11. During an interview on 09/12/24, at 9:46 A.M. the Administrator said the following: -Staff should report any open areas or pressure ulcers to the her and the DON; -Weekly tracking is to monitor wounds; -Staff meet weekly on Thursdays to discuss falls, wounds, and other areas of concerns; -The DON missed weekly meetings due to working the floor and night shift in the nursing department; -She was not aware of missed weekly skin assessments. 51208

Based on record review and interview, the facility failed to protect each resident's right to be free from neglect when staff failed to check on one resident (Resident #1), who resided in the locked special care unit (SCU), for over 11 hours. Staff found the resident under his/her bed, unresponsive, with dried blood and emesis present. The resident was sent to the hospital and later passed away. The facility did not have a system in place to ensure on-site nursing staff monitored care provided by the aides and to ensure nurse aides performed walking rounds per facility policy. The facility census was 71. The Administrator and the Director of Nursing (DON) were notified on 07/26/24, at 6:15 P.M., of an Immediate Jeopardy (IJ) which began on 07/23/24. The IJ was removed on 07/26/24 as confirmed by surveyor onsite verification. Review of the facility's policy titled Abuse and Neglect Definition and Policy, undated, showed the following: -Neglect is the failure to provide services to an eligible adult by any person, firm, or corporation with a legal or contractual duty to do so, when such failure presents either an imminent danger to the health, safety, or welfare of the client or a substantial probability that death or serious physical harm would result. Review of the facility's Certified Nurses Aide (CNA) Responsibilities, undated, showed the following: -At the beginning and end of each shift, the CNAs will do walking rounds with the on-coming/off-going CNA; -The CNA on duty will give report to on-coming CNA of what happened during the shift. -Bedridden or overnight, CNAs to check residents every two hours and as needed. Review of the facility's Charge Nurses Daily Routine, undated, for 7:00 P.M. to 7:00 A.M., showed the nurses should do walking rounds several times per shift to make sure residents needs are meet and address any issues. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted [DATE]; -Diagnoses included anxiety, heart disease, cognitive communication deficit, and dementia. -Resided on the SCU. Review of the resident's Baseline Care Plan, with observation date of 07/18/24 and competition date of 07/24/24, showed the following: -Resident was an elopement risk. -Resident was diabetic. -Resident was confused. -Dependent on staff assistance for bathing, dressing, and using the toilet; -Used a wheelchair for ambulation; -Incontinent of bowel and bladder. -Moderate assistance of staff with transfers chair/bed to chair; -Impaired vision; -Resident has delusions. -Resident was high fall risk. Review of the resident's Social Worker History and Assessment, dated 07/18/24, showed the following: -Family involved; -Vision impairment; -One staff assistance for transfers and activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Used a walker for mobility; -Psychosocial needs - Calmer than he/she has ever been in life; -Goals - Like to see the resident get stronger so he/she could take care of self a little more, but with the dementia the family realizes it may not happen; -Family's attitude and expectation of placement - Hope the resident is content and well cared for. Review of the resident's progress notes showed the following: -On 07/18/24, admission note, staff noted resident had arrived to the facility from another facility with family. The resident was alert and oriented to self. Per family, the resident was unable to see out of right due to glaucoma (chronic eye disease that occurs when fluid build up in the eye puts pressure on the optic nerve and retina). The facility completed a full assessment and vitals (all within normal range) on the resident. -On 07/24/24, at 7:04 A.M., Licensed Practical Nurse (LPN) A found the resident laying on his/her back under his/her bed on the ground with coffee ground like emesis (an indication of old and coagulated blood in the gastrointestinal tract) on his/her mouth and floor. The resident was also bleeding from the nose. The LPN got the resident out from under the bed to assess him/her. The resident was not responsive to talking, physical touch, or pain stimuli. The resident's right eye was bloodshot. The resident's pulse was weak and thready and read in the 180 beats per minute (bpm) range (normal range 60 to 100 bpm). The resident's blood pressure read was 99/69 millimeters of mercury (mm/Hg) (normal range less than 120/80 mm/Hg), temperature was 95.5 degrees Fahrenheit (F), pulse ox (a quick and non-invasive monitoring technique that measures the oxygen saturation in the blood) was 86% (normal range 95% to 100%) on room air, and respiration of 32 per minute (normal range 12 to 20 respirations per minute). Staff placed call to the Nurse Practitioner (NP) and received an order to send the resident to the hospital. Emergency Medical Services (EMS) arrived at approximately 7:20 A.M. and resident left facility at approximately 7:30 A.M. Review of the facility's investigation, undated, showed the following: -On 07/24/24, at approximately 7:05 A.M., LPN A found the resident laying under his/her bed on his/her back with coffee ground like emesis on his/her mouth and floor. The resident was also bleeding from the nose. LPN A got the resident out from under the bed. The resident was incontinent of urine with a brown ring on the bed's urine-stained sheets. Registered Nurse (RN) F assessed the resident. -The resident was not responsive to talking, physical touch, or pain stimuli. The resident's right eye was bloodshot and his/her pulse was weak. Staff took the resident's vitals and contacted the NP. Staff received an order to send the resident to the hospital. EMS was called and arrived at the facility at approximately 7:20 A.M. and left the facility with the resident at 7:30 A.M. -Staff received an update from the hospital that the resident had a stroke and was placed on comfort care. -An investigation was initiated for an injury of unknown origin and the CNA was placed on suspension during the investigation as staff reported they did not believe the resident was changed or checked on during the night. -RN D said he/she was not notified of a fall or any change in condition. While he/she was on the hall he/she was not present for any of the resident's incontinent checks. All staff present provided written statements. -All staff who provided care within the last 24 hours were questioned and none witnessed any fall or change in condition. -The Director of Nursing (DON) contacted CNA E. The CNA said he/she put resident to bed around 8:30 P.M. or 9:00 P.M. The CNA said he/she could not recall when he/she checked on the resident and said he/she forgot to check on him/her after that. Review of CNA E's statement, dated 07/25/24, showed the following information: -He/she arrived to the facility at approximately 6:50 P.M. and put two residents to bed. -He/she put Resident #1 to bed at 7:30 P.M. and failed to change the resident for the rest of the shift; -At one point he/she charted on residents, including Resident #1 without checking on the resident; -The next shift arrived and report was given. He/she helped get two residents up for breakfast and clocked out. During an interview on 07/26/24, at 2:30 P.M., CNA E said the following: -He/she worked the 7:00 P.M. to 7:00 A.M. shift and normally worked the SCU. -There were 17 to 21 residents in the SCU. -The nurses come back at 8:00 P.M. and 6:00 A.M., or if staff use their cell phone or the intercom to ask for assistance. -Staff are supposed to round on each resident every two hours and as needed. -He/she emailed his/her written statement to the Assistant Director of Nursing (ADON) and stated he/she put the resident to bed at approximately 7:30 P.M. to 8:30 P.M., and the resident was fine with no concerns; -He/she was distracted that evening due to personal things going on in his/her life and did not lay eyes on that resident for the rest of the night; -CNA G came to relieve him/her for approximately 25 minutes; -CNA G was in the same spot when he/she returned; -On 07/23/24 to 07/24/24, he/she should have checked on the resident every two-hours if not more and as needed. -He/she gives report at the nurses' station, but staff should be doing walking round to each resident room, per facility protocol, and that does not typically happen; -CNA E said he/she does think that night, 07/23/24 to 07/24/24, he/she neglected the resident. During an interview on 07/30/24, at 10:05 A.M., CNA G said the following: -He/she was a CNA on the overnight shift, 11:00 P.M. to 7:00 A.M., and works mostly on the A wing. He/she works on the SCU occasionally; -While on shift, his/her job was to do rounds three times a night to check residents who are incontinent and in between usual rounds he/she goes up and down the halls looking into rooms to ensure residents don't need anything or the residents haven't fallen; -While on shift he/she will give a break to the CNA on the other halls; -He/she does not remember walking the SCU hall or checking on residents; -He/she does not remember ever seeing the resident; -CNA E did not voice any concerns prior to his/her break; -He/she did not check on the resident or any of the residents during the time he/she was covering the hall. Review of LPN A's written statement, dated 07/24/24, showed the following: -LPN A entered the resident's room to check the resident's blood sugar level. The room was dark and he/she did not see the resident in the bed. When the light was turned on LPN A observed the resident lying on his/her back under the bed. LPN A observed dried blood around and under the resident's head and face from his/her nose and mouth. -LPN pulled the resident out from under the bed and tried to get a response. LPN A told a CNA to go get the nurse from the other hall and have them call 911. -The resident did not respond to verbal/tactile stimuli with no response to sternal rub. -The resident's skin was ice cold to touch and his/her pants and brief were soaking wet. The bed was also wet with brown ring on sheet. -Last time he/she saw the resident was on 07/23/24. The resident was alert and responsive. During an interview on 07/25/24, at 2:20 P.M., LPN A said the following: -The resident was a new admission who arrived to the facility on the 07/18/24. -The resident was alert and oriented with confusion. The resident was very quiet and reserved. -The resident was a maximum (max) assist of one staff. -The resident needed help with incontinent care, toileting transfers, and staff helped the resident eat meals. The resident needed incontinent care/toileting at least every two hours. -At night staff are supposed to check on the residents at least every two hours. -Staff should check to make sure residents are in bed, breathing, and are clean and dry. -On 07/24/24, he/she went over to the SCU to check blood sugars and start medication pass. -The resident was usually up by the nurses' station sitting in a wheelchair. That morning LPN A had to go to the room to find the resident. -When he/she entered the room, it was dark with little light he/she did not see the resident in bed. -He/she turned the light on and the resident was under the bed, feet out, and the other half of his/her body under the bed. There was blood under the bed. -LPN A told the CNA to go get RN F and call 911; -It looked like coffee ground emesis next to the resident's his/her head, dried blood on his/her face, and the emesis on the floor was dry. The blood had coagulated next to the resident's head. -The resident did not respond. -The resident's shirt, pants, and brief were sopping wet. The resident's bedding was wet and brown ringed. -The resident had a temperature of barely 95 degrees, his/her pupils were fixed, and he/she was non-responsive. -RN F and an LPN entered the room to help. -Staff notified the physician and family. -The nurse and aide that had been present the night before had already left. -It appeared to him/her the resident had been down quite a while and he/she had to tell EMS that he/she did not know the last time the resident had been checked on. -The resident could not have been been checked on during shift change. -If the aides had done walking rounds the aides would have found the resident. -CNA E should have been checking on the resident at least every two hours. -It is never appropriate for the aides to not check on residents throughout the day and more so at night. Review of RN F's typed statement, undated, showed the following; -At approximately 7:05 A.M., LPN A found the resident laying under his/her bed on his/her back with coffee like emesis on his/her mouth and on the floor. The resident was also bleeding from nose. LPN A then pulled the resident out from the bed and LPN A notified RN F to come and assess the resident. -The resident was not responsive to talking, physical touch, or pain stimuli. The resident's right eye was bloodshot. His/her pulse was weak and thready and read in the 180's bpm. His/her blood pressure reading was 99/69 mmHg and temperature was 95.5 degrees F. The resident's pulse ox was 86% and respirations were 32 per minute. Staff placed call to the NP and received an order to send resident out to the hospital. RN G called the EMS who arrived at approximately 7:20 A.M. EMS left with the resident at 7:30 A.M. During an interview on 07/30/24, at 11:40 A.M., RN F said the following: -On the overnight shift, the nurses for A hall and C hall split the SCU hall to provide cares and pass medication. -The SCU hall has one CNA on the overnight shift and CNAs from A hall and C hall will cover during a break. -CNAs should round on all residents every two hours and as needed. CNAs need to place eyes on residents to ensure they are still breathing. -If that CNA goes on a lunch break the CNA that comes into the SCU to cover should walk the halls to ensure no resident is on the floor. -The nurses responsible for the SCU should walk the halls and ensure the residents are okay and when they go into the SCU during the overnight shift they should always find the CNA on that hall. -On 07/24/24, soon after he/she came on shift a CNA said LPN A needed him/her in the SCU due to a resident bleeding on the floor; -When he/she got to the resident's room, the resident was lying on the floor on his/her back with blood coming from nose and mouth. It looked like coffee ground emesis and very dry. -The resident looked green, had a temp of 95.5 degrees F and heart rate was in the 180's bpm. -The resident showed no response to pain stimuli. -Staff called the NP and got an order to send to the hospital. -Staff called the family and the DON. -The resident and resident's bedding was soiled and wet; -This resident was a new admission who should have been checked on and charted on. -It did not look like anyone rounded on the resident for awhile. During an interview on 07/25/24, at 3:00 P.M., RN D said the following: -He/she had worked as needed (PRN) for four to five months and usually works C hall, but gets pulled to A hall every so often; -Usually at night there is a nurse on A hall and C hall and they will split the SCU with med pass and cares. -The overnight CNA is responsible for rounding on the residents at least every two hours. -When the staff are checking on the residents they are repositioning, checking if they are wet or dirty, and if the residents need anything looking for all needs. -If staff see any change in condition they are to call the nurse. -It is not okay for the CNA to put a resident to bed and never check on the resident again. -RN D entered the SCU that night at approximately 12:30 A.M., and then again at 2:30 A.M., and put all the medications in the medication cart that the pharmacy had delivered. -He/she did not see CNA E and assumed CNA E was in a room helping a resident. -He/she did not go down the halls or pass by the resident's room either time he/she was in the SCU. -RN D entered the SCU again at 5:30 A.M. to give the 6:00 A.M. medications and CNA E was getting residents up. -The resident did not have any early morning meds. He/she did not pass by the resident's room. The resident's room was at the end of the hall. -The resident was relatively new so he/she did not really know the resident's routine yet. -During the overnight shift CNA E called the RN at around 3:00 A.M. to see if someone could come and give him/her a break and CNA G went over and relieved CNA E for about 20 minutes. -CNA G did not return with any concerns. -CNA G should have checked on all the residents by at least walking by each room and at least looking in the room. -When the nurses go off shift any changes or concerns are reported to the oncoming nurse. -The CNA's are supposed to give report to the CNA coming on of any concerns and if they were not able to get a resident up for the day. -He/she does not go searching for the aides unless he/she needed them. -He/she is able to see the aides on A hall and C hall doing their work and rounding, but on the SCU it a little more difficult to monitor the aides whereabouts and if he/she goes back to the SCU and he/she do not see the aide he/she trusts the CNAs are in a room taking care of the residents. Review of the ADON's typed statement, undated, showed upon reviewing the security cameras on the SCU hall the evening of 07/23/24, CNA E was seen pushing the resident to his/her room in his/her wheelchair at 7:30 P.M. CNA E was in the room for several minutes and then exited the resident's room. During an interview on 07/26/24, at 3:30 P.M., the ADON said the following: -She watched the camera footage and saw where CNA E pushed the resident in his/her wheelchair from the nurses' station to his/her room at 7:30 P.M. and never reentered the resident's room again. -From 7:30 P.M. to 11:00 P.M., no one entered the resident's room. During an interview on 07/26/24, at 3:44 P.M., the DON said she watched the video from 11:00 P.M. to 6:00 A.M. and did not see any staff go into the resident's room during this time. During an interview on 07/25/24, at 12:50 P.M., CNA C said the following: -He/she worked on the SCU. -He/she usually worked the 3:00 P.M. to 11:00 P.M., shift. -Staff should check on residents every two hours and as needed. -Staff should always check the residents throughout the night. -There was no nurse back in the SCU on the overnight shift. -The resident was quiet, alert and oriented with confusion, and one max assist with ADLs. -Staff would always check on the resident at least every two hours and he/she was usually incontinent of both bowel and bladder. -If there was a yellow and brown ring in the bed sheets it would be a sign the resident had not been changed in awhile. -He/she worked over on B Hall, 3:00 P.M. to 11:00 P.M. shift, on 07/23/24 and would have been on the SCU, but got moved to A hall at 7:00 P.M. when CNA E came on shift for the 7:00 P.M. to 7:00 A.M. shift. -The resident was in his/her recliner still awake and was fine before he/she left the SCU. -CNAs chart ADLs on every shift in the electronic medical record. During an interview on 07/25/24, at 3:45 P.M., CNA B said the following: -He/she usually worked in the SCU. The residents in the SCU have dementia. -All the SCU residents need some assistance with ADLs. -He/she liked to do rounds when going off shift with the on-coming CNA. He/she walked to every room and tell the aide coming on how each resident did that day. -When coming on after night shift there is usually no report and no going room-to-room. Sometimes an aide will give report. -He/she checks on residents every two hours and there are residents who need to be checked every hour the heavy wetters, residents who drink a lot. -It is not okay to not check on the residents. -The resident required one staff max assistance for cares. If staff assisted the resident with toileting every two hours he/she would not be incontinent. -The resident would not ask for help or to go to the bathroom. -When CNA B worked nights the resident was always wet when doing rounds and incontinent care was performed. -On 07/24/23, LPN A came into the SCU to do blood sugar checks. -He/she went in the resident's room behind LPN A and another aide. -He/she saw the resident in the floor under the bed had dry dry blood and dry blood on the floor. There was also a ring of brown and yellow on the wet sheets. -The resident was fine the day before. During an interview on 07/30/24, at 2:36 P.M., the Medical Director said the following: -The resident had not been at the facility very long and had passed away. -The CNAs should be checking in on residents a minimum of every two hours to ensure they are alive and breathing. -During a break an aide, who covers for the aide, should do their job at the appropriate standard of care. The patient should never be unchecked for eight hours. -The nurse should be going into the B hall and should check on all the residents. -The nurse should make a cursory round and check on the residents. There is no excuse for not checking on all residents. -This was negligence. During an interview on 07/26/24, at 3:44 P.M., the DON said the following: -At 7:19 A.M., RN F called and reported how staff found the resident; -RN F reported the resident was lying flat on his/her back under the bed unresponsive and had dried blood from nostril and mouth. He/she thought the resident may have vomited as there was a coffee ground like emesis by the resident's mouth and by his/her head on the floor. -RN F had already called 911, the physician's office, and the resident's family. -The DON came in and checked the cameras. The resident was in a room at the end of the hall. -Staff should do rounds on every resident every two hours and as needed. -CNA E should have checked on all the residents at least every two hours and as needed. -CNA G should have walked down the halls and at least looked into each resident room while covering for CNA E during his/her break; -RN D should have walked down each hall and checked on the residents and checked to see where and what CNA E was doing. During interviews on 07/25/24, at 12:35 P.M., and on 07/26/24, at 2:20 P.M. and 6:15 P.M., the Administrator said the following: -CNA's should be doing rounds every two hours and as needed checking on all residents; -The resident was a new admissions and nurses should have been charting in the progress notes every shift for three days; -Nurses should have checked on all residents in the SCU at least one time during their shift. -The DON did look at the camera footage for that night from 11:00 P.M. to 7:00 A.M., and the footage showed nobody entered the resident's room. -The resident should have been checked on at least every two hours and as needed. CNA E should have checked on the resident several times throughout the night shift. -The resident should never have been left without care. -If any staff entered the SCU they should have checked on all the residents even if just doing a walk by the room. -CNA G, who relieved CNA E, should have walked the halls and looked in on all the residents while he/she was in the SCU. 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). MO00239499

Based on interview and record review, the facility failed to maintain a current and accurate facility assessment when facility staff failed to review and update the comprehensive facility assessment at least annually. The facility census was 71. Review showed the facility did not provide a policy regarding the facility assessment. 1. Review of the facility assessment showed staff completed the current facility assessment in 2023. The staff did not document a review of the facility assessment since April 2023. During an interview on 07/26/24, at 4:40 P.M., the Administrator said the following: -The facility assessment is supposed to be updated annually and the last time she updated it was 04/26/23. -She did not do the annual update in 2024. -She is responsible for reviewing and completing the facility assessment. -The facility staff should review the facility assessment yearly. -Departments heads and the physician should be involved and discuss the facility assessment. -The facility assessment should have been reviewed and updated in April 2024.

Based on interview and record review, the facility failed to ensure all residents were free from significant medication errors when staff continued to administer a medication for 12 days, instead of 5 days as ordered, which resulted in a gastrointestinal bleed and contributed to the death of one resident (Resident #1). A sample of eight residents were reviewed. The facility census was 65. The Administrator and Director of Nursing (DON) were notified on 03/06/24 at 12:10 P.M., of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 02/07/24. On 02/07/24, the DON and Assistant DON (ADON) reviewed the resident's chart and began an investigation, educated the employee involved and nursing staff, and in-serviced all facility staff on 02/20/24. The facility implemented daily chart monitoring to ensure medication orders are entered and followed correctly. The IJ was corrected on 02/20/24. Review of the facility's policy, titled Passing Medication, undated, showed the following: -Objective to administer medication to the resident in the most efficient and error free method possible. Procedure: -Open the proper resident's Medication Administration Record (MAR); -Remove the resident's pill card/packet from the corresponding slot in the medication bin; -Lay the pill cards/packet on the top of the medication cart and check each pill against the med-sheet. The order of the pills should correspond with the order on the MAR. Staff to check right person, right med, right route, right time, and right dosage; -Punch out the medication directly into the medication cup on top of the med-cart. Punch out the medication in the highest numbered bubble and work down on subsequent passes initialing the MAR as each medication is punched from the card; -After each medication is punched, place cards face down in subsequent order. When all medication is punched from the cards return all pill cards to the proper location in the medication bin with pharmacy labels front facing; -Cross-check the information on the pill cards/packet and the MAR; -Check the identifying picture on the MAR against the resident; -Administer the medication to the resident. Review of the facility policy, titled Medication Errors and Drug Reactions, undated, showed the following: -Purpose to safeguard the resident and provide emergency care as necessary; -All nurses administering medications should be familiar with drug reactions, effects and contraindications. If you are not sure, check the drug reference manual before administering an unfamiliar drug. Review of the Prescribers Digital Reference (PDR.net) Drug Information, dated 2024, showed the following information for the medication Naprosyn: -Common brand names include Aleve, Naprosyn, naproxen sodium (non-steroidal anti-inflammatory used to relieve mild pain and reduce inflammation); -Nonsteroidal anti-inflammatory drugs (NSAIDs); -Administer with milk, food, or antacids to minimize gastrointestinal (GI) irritation; -Severe adverse reactions can include peptic ulcer, GI bleeding, or GI perforation; -Moderate adverse reactions can include bleeding; -NSAIDs, including naproxen, can cause serious GI adverse events including inflammation, bleeding, ulceration, and GI perforation of the esophagus, stomach, small intestine, or large intestine, which can be fatal; -Other factors that increase the risk of GI bleeding in patients treated with NSAIDs include longer duration of NSAID therapy, older age, and poor general health status; -Most postmarketing reports of fatal GI events occurred in elderly or debilitated patients; -To minimize GI risks in NSAID-treated patients, use the lowest effective dosage for the shortest possible duration, and avoid administration of more than one NSAID at a time. -Maximum dosage of 1,500 milligrams (mg)/day for limited periods for the treatment of mild pain to moderate pain, including minor aches and pains associated with arthralgia (joint pain), dental pain, headache, musculoskeletal pain (including backache), and/or the common cold. 1. Review of Resident #1's face sheet (a brief information sheet about the resident) showed the resident admitted on [DATE], with diagnoses including: -Alzheimer's disease (progressive disease that destroys memory and other important mental functions), -hypertension (high blood pressure), -aphasia (loss of the ability to produce and/or comprehend language, due to injury to brain areas), -Pick's disease (kind of dementia similar to Alzheimer's but far less common, often affects personality first), -age-related osteoporosis (condition in which bones have lost minerals, especially calcium, making them weaker, more brittle, and susceptible to fractures (broken bones) without current pathological (caused by disease) fracture (broken)), -procedural hypothyroidism (occurs when the thyroid doesn't produce enough thyroid hormones as a result of a medical procedure, like surgery to remove all or part of the thyroid gland), and -macular degeneration (degenerative condition affecting the central part of the eye and resulting in distortion or loss of central vision). Review of the resident's quarterly Minimum Data Sheet (MDS - a federally mandated comprehensive assessment completed by facility), dated 12/16/23, showed the following: -Severe cognitive deficit; -Diagnoses included Alzheimer's disease, hypertension, and Pick's disease. Review of the resident's Physician's Orders Sheet (POS), dated 01/20/24 to 02/29/24, showed the following: -An order, dated 01/26/24, for Naprosyn tablet (non-steroidal anti-inflammatory used to relieve mild pain and reduce inflammation) 500 mg, one tablet orally. Staff to administer one tablet three times per day for five days. The order was entered by by Licensed Practical Nurse (LPN) A. Review of the resident's progress notes, dated 01/26/24, showed staff did not document regarding the new order for Naprosyn. Review of the resident's care plan, dated 03/28/23, showed staff did not update the care plan regarding the pain medication or reason for the medication after it was ordered on 1/26/24. Review of the resident's MAR (report detailing the drugs administered to a patient by a healthcare professional at a treatment facility), dated January 2024 and February 2024, showed the following: -An order, dated 01/26/24, for Naprosyn 500 mg, give one tablet three times per day for diagnosis of age-related osteoporosis without current pathological fracture; -Staff documented the medication as administered three times per day during the morning medication pass, the mid-day medication pass, and the evening med pass on 01/26/24, 01/27/24, 01/28/24, 01/29/24, 01/30/24, 01/31/24, 02/01/24, 02/02/24, 02/03/24, 02/04/24, 02/05/24, 02/06/24 (for a total of 12 days); -Staff documented the medication as administered the morning dose on 02/07/24. Review of the resident's nursing progress notes, dated 01/26/24 to 02/07/24, showed staff documented the following: -Staff did not document progress notes from 01/26/24 to 02/05/24; -On 02/07/24, at 8:47 A.M., the nurse was called to the bathroom by the Certified Nursing Aide (CNA) G , stating the resident's stools did not look right. The resident was in the bathroom with a large amount of pudding consistency stool that was black/red in color and tested positive for blood. The resident's abdomen was firm, non-tender with hyperactive bowel sounds. The resident was leaning forward and moaning, but did not answer to questions. Staff was instructed to put the resident back in bed and check often. Staff left message for family to call back and notified the resident's Nurse Practitioner (NP); -On 02/07/24, at 9:32 A.M., spoke with the family and they wished for the resident to be placed on hospice. They did not want the resident to go through the process of emergency room (ER) transfer and laying in the ER for hours. Staff notified the NP of the family's request; -On 02/07/24, at 9:44 A.M., orders received from NP for Protonix (medication used to treat various stomach issues) 40 mg one tablet twice per day for 14 days and discontinue Naprosyn at once. Staff entered the orders into the electronic medical record (EMR); -On 02/07/24, at 11:01 A.M., an order was received from the NP to give Levsin (used to treat stomach ulcers) 0.125 mg times one dose now. Staff administered dose at 10:55 A.M.; -On 02/07/24, at 5:47 P.M., the resident had one episode of coffee ground emesis (vomit). The resident is again pale and a little lethargic. Review of the resident's care plan, dated 03/28/23, showed staff updated the care plan with the following: -Handwritten entry, dated 02/07/24, medication error was discovered on 02/07/24 by registered nurse (RN) and NP. Naproxen was given for longer period than ordered and no stop date had been checked in the computer and medication was re-ordered. Nurse that put the order in was educated, as well as other staff on the floor. The pharmacy was notified of error and also education given to their staff. Resident had bloody stool. Family was notified of blood stool, as well as medication error. Hospice was chosen by family. DON and Administrator discussed options of sending to hospital for treatment or treating at the facility with comfort care. The family chose treatment at the facility. Review of the facility provided investigation, dated 02/07/24, showed the following: -LPN A took an order on 01/26/24 and entered into computer correctly, but the discontinue date was not checked. The order stated the medication was for 5 days only and was sent to the pharmacy that way. The pharmacy sent 15 tabs on 01/26/24; -The LPN re-ordered the medication by clicking the re-order button. The pharmacy filled without a new order. The LPN did not put the order on the 24 hour reporting sheet. The LPN failed to write any progress note in the EMR on the initial order and did not put on the 24 hour reporting sheet. The order was placed on clipboard without documentation that it was completed. -The resident had three bowel movements with occult (hidden) blood found. The family was notified and chose hospice. Upon medication review with the NP, the RN discovered the medication error regarding naproxen. The original order was on 01/26/24 for naproxen 500 mg three times per day for five days. The resident received 27 doses in total, rather than 15 doses ordered. -The family was notified of the medication error with the new orders to discontinue the naproxen and start Protonix. The family was talked with in length by the DON and Administrator and given the choice of treatment in facility or send out to the hospital. The family wanted the resident to be comfortable at the facility. Review of the resident's nursing progress notes, dated 02/08/24, showed staff documented the following: -On 02/08/24 at 10:05 A.M., staff documented at 7:30 A.M. the staff assisted the resident up to his/her wheelchair, then took to the dining room. The family was at the facility to assist with liquids as he/she could. The resident was very pale and did respond to some verbal stimulus; -On 02/08/24 at 11:39 A.M., staff documented at 11:00 A.M., the staff assisted the resident to the bathroom where he/she voided a medium amount, no blood was noted, but smell was overpowering. The smell was like old blood; -On 02/08/24 at 1:38 P.M., the resident was in the dining room for lunch, staff attempted to feed the resident, the resident took one tiny bite of mashed potatoes and gravy, then refused anything else. The resident did drink a glass of ice water and cranberry juice. After lunch staff assisted the resident to his/her bed, he/she was dry when laid down; -On 02/08/24 at 11:25 P.M., new orders were received for Protonix twice per day for 14 days, then change to once daily. Review of a resident's provider progress note, dated 02/08/24, showed the resident had a GI bleed yesterday. The resident was on Naproxen 500 mg three times day for 12 days and was only supposed to be given for 5 days. The resident was now on hospice. Staff stated the resident was doing better with no further bloody stools. Naproxen had been stopped and now on Protonix given twice per day. Review of the resident's nursing progress notes, dated 02/10/24 at 4:02 P.M., showed staff documented the nurse was called to the resident's room by family. The resident was not breathing and there were no heart tones for one full minute. Staff called a second nurse to verify. Time of death was 3:12 P.M. During an interview on 03/06/24 at 5:45 A.M., LPN C said staff should follow physician orders when administering medications. Staff should notify the DON if they have any concerns related to medications or medication orders. During an interview on 03/06/24 at 5:50 A.M., the ADON said staff are expected to follow physician orders when providing medication. He/she said the physicians are in the facility once to twice per week. He/she did not know of any residents that received medications past the discontinued date. During an interview on 03/06/24 at 8:45 A.M., Certified Medication Tech (CMT) D said staff should follow physician orders in the MAR when providing medications. Staff should not give any medication after day 5 if the medication is only ordered for 5 days. Staff should not give the medication for 12 days. He/she said that he/she scans each medication package when preparing medications and verifies in the MAR the medication being provided. The nurses enter physician orders. If any questions on medication orders, CMTs should ask the charge nurse or the DON. During an interview on 03/06/24 at 8:50 A.M., LPN B said that when nurse puts in a medication order the pharmacy also verifies the order. The medication should not be given after discontinue date. Staff should notify the physician, family, and DON if there was a medication error. Staff should monitor for adverse reactions of all medications administered. All medications can cause side effects in the residents. There is a binder at the nurse station to use regarding how to enter orders in the electronic medical record system. The nurse should enter the order and verify the entry and should mark the discontinuation box if it is not a continuous order. The CMT and nursing staff should contact the charge nurse or DON for medication order questions. Nurses should verify with the physician. During an interview on 03/06/24 at 11:10 A.M., CMT E said staff should verify the medication order before administering any medication. He/she said medication should not be given past the ordered stop date. Medications should not be given for 12 days if the order was for 5 days. He/she said could cause a severe reaction in a resident. During an interview on 03/06/24 at 11:20 A.M., LPN A said staff should not give a medication for 12 days if it was ordered for 5 days. Side effects could be severe if medication not given according to the physician orders. During an interview on 03/06/24 at 9:00 A.M., the DON said medications should be given according to physician orders. Medications should be stopped when ordered to be stopped. The medication error for the resident started when the nurse entered the order into the EMR and failed to mark the stop date. The order was sent to the pharmacy and should have been double checked. The ADON is to get copies of new orders, but she was not given that new order. When staff became aware the medication was given past five days, the resident's family did not want intervention and requested comfort cares with hospice. The staff reviewed with the pharmacy, and they said they filled the prescription twice and the said that the second time the nurse that they say called for the refill was not working. The EMR system automatically makes an order open-ended. The staff followed the MAR and provided the medication that was available and he/she does not know why the staff administered the medication past the 5 day. The order was written correctly, but the MAR did not have the discontinuation date. During an interview on 03/06/24 at 9:30 A.M., the resident's NP said that he/she was made aware the resident received 12 days of Naprosyn instead of 5 days, when the resident had bloody stools. The NP said the error contributed to the GI bleed and overall contributed to the resident death. The family wanted hospice and not hospital procedures. If the resident was sent to the hospital would likely have had a procedure that would have been hard on him/her in his/her advanced dementia state. The expectation is that staff follow provider orders. During the NPs review he/she said that the pharmacy should not have sent the second refill. During an interview on 03/06/24 at 9:55 A.M., the Administrator said staff are expected to follow physician orders. Staff are to provide medications at the right time and frequency, such as for only 5 days. MO00232717