Every finding on record at Pine Grove Manor

Based on interview and record review, the facility failed to ensure one resident (Resident #1), who was non-weight bearing on his/her left leg and required the use of a Hoyer (mechanical lift) for transfers, received adequate assistance to prevent accidents when Certified Nurse Aide (CNA) A and Certified Medication Technician (CMT) B performed an assisted transfer without the use of a mechanical lift or gait belt. The resident reported pain during the transfer and sustained a fractured fibula (calf bone). The sample was 7. The census was 52 The Administrator was notified on 07/01/26 of the past non-compliance, which occurred on 05/05/26. Nursing staff were in-serviced on resident transfers. The deficiency was corrected on 05/14/26. Review of the facility's Total Mechanical Lift policy, revised 06/2020, showed:-Purpose: A mechanical lift is used appropriately to facilitate transfers of residents;-Policy:-Nursing staff will be trained to use the mechanical lift;-At least two people are present while resident is being transferred with the mechanical lift. Review of the facility's Transfer of Residents policy, revised 06/2020, showed:-Purpose: To provide the form of transfer best suited to the residents' needs and to maintain resident safety during the procedure;-Policy:-A Licensed Nurse and/or the Director of Rehabilitation Services assess and determine lifting and transfer requirements and the procedure used for each resident. The procedure is recorded in the resident's care plan;-Residents must be lifted or transferred according to the determined procedure;-Residents who require assistance in transferring will be transferred using a gait/transfer belt or with a lift;-Members of the nursing staff are trained to use good body mechanics, knowing the properprocedures and properly operating assistive devices;-Mechanical lift procedures are used on any resident unable to independently pivot or transfer. Review of the facility's Gait Belt policy, revised 06/2020, showed:-Purpose: To provide assistance to clinical staff when moving a resident from one place to another and to increase the safety of residents by allowing clinical staff members to grip it and keep the resident from falling;-Policy: A gait belt may be used for residents who are too weak to walk or stand alone, or requires assistance during transfers;-Procedure: The gait belt is only used to assist with transfer or movement. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/18/26, showed:-Cognitively intact;-Lower extremity impairment on one side;-Dependent on assistance with sit to stand and chair/bed-to-chair transfers;-Diagnoses included periprosthetic fracture around the internal prosthetic left knee joint, unsteadiness on feet, other lack of coordination, and need for assistance with personal care. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident is at risk for falls related to history of falls, gait/balance problems, incontinence, psychoactive drug use, denial of safety needs, need for assistive devices for locomotion, and vision/hearing problems;-Interventions included on 03/20/26, changed to mechanical lift assist x 2. Review of the facility's investigation showed:-A typed statement for the resident, transcribed by Administrator, dated 05/06/26, showed on 05/05/26, CNA A entered his/her room with CMT B. The resident was a Hoyer lift and non-weight bearing on his/her left leg, but CNA A insisted him/her to stand for the transfer. CMT B asked if they should use a Hoyer lift, but CNA A said no because the resident could do it and was faking. As they stood him/her up, the resident said it hurt and CNA A responded, Well, you are hurting my back. CNA A made the resident fully transfer to bed bearing weight;-A typed statement for CNA A, transcribed by the Administrator, dated 05/06/26, showed CNA A entered the resident's room with CMT B. CNA A noticed the resident was sliding out of his/her chair. The resident was a Hoyer lift transfer, but the Hoyer lift was dead, so CNA A asked CMT B to assist in transferring the resident to bed. CNA A explained he/she didn't want the resident to fall and CNA A knew they weren't supposed to do it, but they were going to do a two-person transfer the resident. The resident did not complain of pain during the transfer;-A typed statement for CMT B, transcribed by Administrator, dated 05/07/26, showed CNA A asked CMT B to assist in transferring the resident due to him/her sliding out of his/her chair. CMT B went into the room and assisted CNA A in transferring the resident. They utilized a two-person transfer. CMT B was unaware the resident was a Hoyer lift transfer. The Hoyer lift was charging at the time of transfer;-An undated summary, showed on 05/06/26, the resident came to the Administrator's office to report that on 05/05/26 at 8:30 P.M., CNA A and CMT B entered his/her room and transferred him/her to the bed utilizing a two-person transfer. The resident required a Hoyer lift for transfers and was non-weight bearing on his/her left leg. Instead of utilizing the Hoyer lift, CNA A assisted the resident to stand, CMT B stated to CNA A, Shouldn't we use the Hoyer? CNA A told CMT B that they could two-person transfer the resident and stated that the resident could stand on his/her own and that the resident was faking. As they assisted him/her to stand, the resident complained that they were hurting him/her. CNA A then replied, Well, you are hurting my back. The transfer was completed and the resident was placed into bed. The resident's roommate was unable to give any kind of corroborating statement due to his/her limited cognition. The aides involved in the transfer were identified as CNA A and CMT B. Both CNA A and CMT B admitted that they transferred the resident utilizing a two-person transfer. Both denied there being any inappropriate communication between CMT B and the resident such as, You are faking, or rudeness. CNA A admitted that he/she was aware that the resident was non-weight bearing and required a Hoyer lift for transfers. CMT B denied knowing the resident's need for a Hoyer lift or that he/she was non-weight bearing on his/her left leg. CMT B stated that at no time did CNA A and CMT B discuss the resident required a Hoyer lift. CMT B just trusted CNA A and completed the transfer without further investigation. Skin assessment revealed bruising to the resident's left ankle. An x-ray on his/her left ankle was ordered. Results showed the resident had a left ankle fracture. The resident was sent to the emergency room (ER) following results. After completing investigation, it was determined that the resident was transferred incorrectly utilizing a two-person transfer and that the resident suffered a fracture to his/her left ankle, but the facility did not find that either aide intentionally caused harm or injury to the resident. Review of the resident's skin assessment, dated 05/06/26, showed:-Does the resident have any skin impairments: Yes;-Left knee (front) bruising and swelling, no open areas;-Left lower leg (front) bruising and swelling, no open areas;-Left ankle (outer) bruising and swelling, no open areas;-Left toes bruising and swelling, no open areas. Review of the resident's May 2026 progress notes, showed:-On 05/06/26 at 11:15 A.M., x-ray ordered due to concerns of worsening deformity of left knee joint;-On 05/06/26 at 2:59 P.M., patient complained of pain to left foot, foot was warm to touch, swelling and slight bruising noted. X-ray was ordered;-On 05/07/26 at 6:53 A.M., resident had an acute distal fibular shaft fracture. Physician gave orders to send to emergency room for further evaluation. Review of the resident's hospital Discharge summary, dated [DATE], showed diagnoses included closed fracture (broken bone that does not pierce the skin) of left ankle. During an interview on 06/29/26 at 12:51 P.M., the resident said he/she required a Hoyer lift for transfers. CNA A and CMT B came to his/her room to transfer. CMT B asked if they should use a Hoyer lift. The employees were on both sides of him/her and picked him/her up by lifting underneath his/her arms. The staff did not use a gait belt. They stood him/her up and turned him/her, and that was how his/her left ankle broke. It was hard to tell that it was broken because his/her left leg was broken prior to this. The resident was not sliding out of his/her chair at the time of the transfer. The resident told the staff his/her physician said to use a Hoyer lift and CNA A said, You know the resident, he/she is just faking it. That hurt the resident's feelings. During an interview on 06/30/26 at 11:23 A.M., the Assistant Director of Nursing (ADON) said the resident reported the improper transfer to CNA D on the morning of 05/06/26, then CNA D brought the resident to the Administrator. The resident reported that he/she was hurt by CNA A. The resident said he/she was not sliding out of his/her chair at any time. CNA A stepped to the door and requested help and CMT B came to assist. CNA A told CMT B the Hoyer was dead and CNA A told CMT B that they needed to do a two-person assist transfer before the resident fell. The resident said CNA A never went to look for a Hoyer lift. CNA A and CMT B transferred the resident by standing and pivoting him/her, even though the resident was non-weight bearing and should not have been standing. The ADON said the resident was non-weight bearing because he/she has a fracture to his/her left knee. The resident complained of pain in his/her left leg. The ADON did a skin assessment on the resident and found bruising and swelling to the resident's left knee and ankle. The ADON reported this information to the physician and obtained an order for an x-ray to left knee and left ankle. The x-ray results came back with a left ankle fracture and the resident was sent to the hospital for evaluation and treatment. During an interview on 06/30/26 at 3:32 P.M., the Interim Administrator and Interim Director of Nursing (DON) said the staff know a resident's transfer status by checking the resident's Kardex (quick-reference to a resident's specific care requirements) or care plan. If a resident is listed as a Hoyer lift transfer, they expected staff to use the Hoyer for all transfers. It was not appropriate to do a two-person assisted transfer without a Hoyer lift, if the resident was listed as a Hoyer. The facility had three Hoyer lifts in the facility on 05/05/26. If one Hoyer lift was dead, they expected staff to use one of the other two Hoyer lifts that were available. If all Hoyer lifts were dead, they expected the staff to charge the Hoyer and use the Hoyer lift for the transfer after it was charged. If the resident was sliding down in their wheelchair, they expected staff to reposition the resident in the wheelchair, wait until the Hoyer lift was charged, and then transfer the resident with the Hoyer. When staff performed one or two-person assisted transfers, they expected staff to use a gait belt during the transfers. They expected staff to follow the resident's Kardex and care plan for transfer status. They expected staff to be knowledgeable of and to follow facility policies. During an interview on 06/30/26 at 3:45 P.M., Physician E, the resident's primary care physician (PCP), said he/she expected staff to follow the resident's Kardex and care plan for transfer status. He/She expected staff to be knowledgeable of and to follow facility policies and procedures. 3011397

Based on interview and record review, the facility failed to ensure monthly medication reviews were completed and that the physician provided responses to recommendations for five of 18 residents sampled. (Residents' #1, #3, #6, #5, and #8). The census was 53.Review of the facility's Drug Regimen Review policy, revised January 2025, showed:-Purpose: -The intent is that the facility maintains the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing (DON);-Policy: -The pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications; -It may be necessary for the pharmacist to conduct the drug regimen review (DRR) more frequently, for example weekly, depending on the resident's condition and the risks for adverse consequences related to current medications. The requirement for the DRR applies to all residents (whether short or long-stay) without exception; -DRRs may be needed for residents who experience an acute change of condition. -The pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon; -Upon admission, medications will be reviewed with the attending physician to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications;-Definition(s): - Drug regimen review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The DRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The DRR also involves collaborating with other members of the interdisciplinary team (IDT), including the resident, their family, and/or resident representative; -Irregularity refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcomes of pharmaceutical services. An irregularity also includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy;-Procedure: -The pharmacist must review each resident's medication regimen at least once a month; -The pharmacist performing the DRR will review the resident's medical record to appropriately monitor the medication regimen and verify the medication each resident is taking is clinically indicated; -The Consulting Pharmacist will note in the resident's medical record that the pharmacy medication review regimen was completed; -If no irregularities were identified during the review, the pharmacist includes a signed and dated statement to that effect; -The consulting Pharmacist will report any irregularities such as unnecessary drugs (which include but are not limited to excessive dosage, excessive duration, inadequate monitoring, inadequate indications for use or adverse consequences of use) to the Facility's Medical Director, Director of Nursing, and the Attending Physician; -Irregularities must be addressed in a separate, written report. The report will include the resident's name, the relevant drug, and the irregularity the pharmacist identified; -The report may be in paper or electronic form; -The report will be submitted within three business days of review, unless the irregularity is an emergent issue requiring immediate action. If the irregularity is emergent, the Attending Physician will be contacted as soon as practicable from the time the irregularity is identified; -The Attending Physician will respond to any irregularities reported by the pharmacist by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken -If no action has been taken, the attending physician must document his/her rationale; -Documentation by the Attending Physician must occur within 30 days of issuance of the pharmacist's report, unless the irregularity is an emergent issue. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/26, showed:-Intact cognition;-Diagnoses included heart failure, hyperlipidemia (high cholesterol), diabetes, peripheral vascular disease (PVD, poor circulation), chronic obstruction pulmonary disease (COPD, lung disease), malnutrition, and wound infection. Review of the resident's care plan, in use during survey, showed: Focus: The resident is on diuretic therapy related to congestive heart failure: -Goal: He/She will be free of any discomfort or adverse side effects of diuretic therapy through the review date;-Intervention: Administer medication as ordered. Monitor Dose. May require modification in order to achieve desired effects while minimizing adverse consequences, especially when multiple antihypertensives are prescribed simultaneously. When discontinuing, gradual tapering may be required to avoid adverse consequences caused by abrupt cessation;-The resident's care plan did not address any other medications relating to drug regimen(s), monitoring, and/or review. Review of the resident's medical record, showed the following:-admission date of 5/1/25;-readmission date of 12/18/25;-A monthly medication review (MMR), dated 11/20/25, showed the Pharmacist recommendation to please consider getting a 25-OH vitamin D level at least annually to monitor the therapeutic level of Vitamin D therapy and since vitamin D deficiency is a common condition in the elderly or long- term care resident.-A monthly medication review (MMR), dated 2/22/26, showed the Pharmacist recommendation to consider starting Jardiance 10 milligram (mg) daily for renal protection in the setting of Type 2 diabetes.-No documentation of the physician's response(s) to the MMRs, dated 11/20/25 and 2/26/26;-No documentation of MMRs conducted for the months of September 2025, October 2025, December 2025, and January 2026. 2. Review of Resident #3's comprehensive MDS, dated [DATE], showed:-Intact cognition;-Diagnoses included dementia, bipolar disorder (a mental condition that cause extreme mood swings), psychotic disorder, depression, anxiety disorder, heart failure, hyperlipidemia, diabetes, other fracture, coronary artery disease (CAD, narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart), depression, peripheral vascular disease, chronic obstruction pulmonary disease, and malnutrition. Review of the resident's care plan, in use during survey, showed: -Focus: The resident is on antipsychotics and antidepressants for psychotic disturbances, and major depressive disorder. He/She is at risk for adverse reactions related to receiving the medications on a routine basis;-Goal: The resident will be on the lowest effective dose through review date;-Interventions: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Consult with pharmacy, physician to consider dosage reduction when clinically appropriate. Review of the resident's medical record, showed the following:-admission date of 2/7/20;-readmission date of 12/16/25.-A monthly MMR, dated 11/20/25, showed the Pharmacist recommendation to please consider getting a serum magnesium level annually (at the next regularly scheduled lab draw) since the patient is taking Pantoprazole (treats stomach ulcers and gastroesophageal reflux disease), which has been associated with decreased serum magnesium levels. Currently, there is not a serum magnesium level on the chart;-No documentation of the physician's response to the MMR, dated 11/20/25;-No documentation of MMRs conducted for the months of September 2025, October 2025, December 2025, January 2026, and February 2026. 3. Review of Resident #6's comprehensive MDS, dated [DATE], showed:-Intact cognition;-Diagnoses included dementia, bipolar disorder, hypertension (high blood pressure), deep venous thrombosis (DVT, a serious condition where a blood clot forms in a deep vein), hyperlipidemia, diabetes, chronic obstruction pulmonary disease, and malnutrition. Review of the resident's care plan, in use during survey, showed: Focus: The resident is on routine antidepressant medications for the treatment of bipolar disorder, current episode depressed, severe, without psychotic features. He/She is also on routine antipsychotic medications;-Goal: He/She will be free from discomfort or adverse reactions related to antidepressant therapy through the review date;-Interventions: Give antidepressant medications ordered by physician. Monitor/Document side effects and effectiveness. Review of the resident's medical record, showed the following:-admission date of 1/6/26;-readmission date of 1/31/26; -A monthly MMR, dated 2/26/26, showed the Pharmacist recommendation to consider discontinuing one of the duplicate orders for Famotidine today 20 milligrams (mg) at bedtime to ensure he/she receives the intended dose of 20 mg rather than 40 mg. -No documentation of the physician's response to the MMR, dated 2/26/26;-No documentation of MMRs conducted for the months of September 2025, October 2025, November 2025, December 2025, and January 2026. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed:-Diagnoses included diabetes, hearing loss, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves);-Cognitively intact. Review of the consultant pharmacist communication to physician form, dated 1/29/26, showed:-The resident is currently prescribed the following psychotropic medication, Invega Sustenna 156 mg IM (injection) given monthly. The above medications are prescribed in the context of the resident's qualifying diagnosis as indicated, schizophrenia. Based on the selected diagnosis and the resident's clinical history, any attempt at gradual dose reduction is currently contradicted. Previous evaluations and/or documented outcomes indicate the reduction of the current regimen would likely result in behavioral destabilization, functional decline, or increased risk to self or others. Therefore the resident is to be exempt from any trialed GDR at this time;-The document is not signed by the physician;-No physician response to recommendation/finding. Review of the consultant pharmacist communication to physician form, dated 2/26/26, showed:-Consider starting Jardiance 25 mg daily for renal protection and improved glycemic control given his/her recent A1c (long-term blood glucose level) of 7.6%;-The document is not signed by the physician;-No physician response to recommendation/finding. Review of the resident's medication administration record (MAR), dated March 2026, showed:-No order for Jardiance 25 mg;-The resident is no longer prescribed Invega Sustenna 156 mg IM monthly. 5. Review of Resident #8's medical record showed diagnosis that included bipolar disorder, schizophrenia, muscle spasms, chronic pain, and anxiety.Review of the residents Consultant Pharmacist Communication to Physician, dated, 12/30/25, showed:-The resident has a routine order for Diclofenac ER 75 mg (medication used to treat pain) by mouth twice daily, and his/her glomerular filtration rate (GFR) was only 24 milters (ml)/ minute (min), a blood test to determine kidney function (normal levels 90-120 ml/min). Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended in patients with advanced renal disease;-Review and assess the continued use of Diclofenac ER 75 mg and consider discontinuing this order if possible and or appropriate;-Consider stopping Diclofenac ER 75 mg orally twice daily;-Begin Diclofenac gel 1% to affected area;-Or continue order as written; The risk versus the benefits have been considered; The clinical rationale is provided.-Most muscle relaxants are poorly tolerated by older individuals due the anticholinergic (reduces body sections and muscle spasm in the bowel and bladder) side effects, sedation, or muscle weakness; The medication, Tizanidine 2mg (a muscle relaxant) orally, twice daily, has been given routinely since November 2023. Consider a trial discontinuation, use a tapered dose strategy. If continued use is warranted, check the appropriate exceptions listed: -Multiple sclerosis (MS, a disease that cause severe muscle weakness) -Spinal cord injury; -Cerebral palsy (CP) a disease that cause severe muscle weakness and contractures; -Chronic skeletal problems, and other agents have failed to relive pain adequately.-No physician response to recommendations. Review of the resident's MAR dated March 2026, showed:- An order, dated, 8/28/25, Diclofenac 75 mg ER, orally, twice a day;-Documented as administered 3/1 through 3/12/26;-An order, dated, 6/4/25, Tizanidine 2mg, orally, twice a day;-Documented as administered 3/1 through 3/12/26. 6. During an interview on 3/13/26 at 4:02 P.M., the DON and Administrator said the pharmacist gives the MMR to the physician and to DON. They would expect the physician to review the MMRs weekly. They would expect within a week of the MRR for the physician to sign off on the MRR. They would expect the physician to document a rationale if they decide not to follow the pharmacist's recommendation.

Based on observation, interview and record review, the facility failed to ensure physician orders were followed by not accurately coding one resident (Resident # 8's) medication as not given on the medication administration record (MAR) and by failure to document if one resident (Resident #7's) medications, treatments, and skin assessments were completed on the MAR. In addition, the facility failed to ensure that skin assessments were completed as physician ordered for two residents (Residents #5 and #48). The resident sample is 18. The census was 53.Review of facility's physician order policy, last revised, June 2020, showed: -Purpose: This will ensure that all physician orders are complete and accurate; -Procedure: -A licensed nurse will transcribe telephone orders with date, time, and signature of the person receiving the orders; -Orders will include a description complete enough to ensure clarity of the physician plan of care; -Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order; -Medication and treatment orders will be transcribed onto the appropriate resident administration record; -Documentation pertaining to physician orders will be maintained in the resident's medical record, current month's administration will be maintained in the medication administration record and the treatment administration record (TAR). 1. Review of Resident #8's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 12/13/25, showed: -Cognitively intact; -Diagnoses included anxiety, depression and bipolar disorder (a mental disorder that cause severe mood swings). Review of the resident's MAR dated March 2026, showed; -An order dated, 2/20/26, clonazepam (anxiety medication) 0.5 milligrams (mgs), give one tablet every evening at 4:00 P.M.; -Clonazepam 0.5 mg documented as administered on 3/12/26 at 4:00 P.M. Review of the resident's controlled drug administration record, showed the resident's clonazepam 0.5 mg was last documented as administered on 3/11/26 at 4:00 P.M. and 11 tablets remained. During an interview on 3/13/26 at 7:50 A.M., the resident said he/she did not receive his/her clonazepam dose on 3/12/26 at 4:00 P.M. The resident said he/she tried to tell the night shift staff that he/she did not receive his/her clonazepam. The staff member informed the resident that the clonazepam was documented as administered. The resident said he/she did not sleep all night due to not receiving his/her clonazepam dose. During observation and interview on 3/13/26 at approximately 8:20 A.M., the nurses' medication cart narcotic box was opened by Licensed Practical Nurse (LPN) A. The resident's card of clonazepam 0.5 mg showed 11 tablets remaining. LPN A said he/she worked 3/12/26 and thought he/she had given the resident his/her clonazepam. LPN A said he/she must have signed it off as given in the electronic medical record but did not actually give the clonazepam. During an interview on 3/13/26 at 3:50 P.M., the Director of Nursing (DON) said she expected the staff to accurately document a medication was administered on the resident's MAR and on the controlled substance sheet. She expected staff not to just click off that the medication was given and pay attention to what medication is being administered. 2. Review of Resident #7's medical record, showed: -admitted : 5/17/24; -Diagnoses included: Dementia, high blood pressure, high cholesterol, dysphasia (swallowing difficulty), seizures, depression, hemiplegia (paralysis of one side of the body), and major depressive disorder. Review of the March 2026 electronic physician order sheet (ePOS), showed: -An order, dated 12/22/25, for Lorazepam Intensol Oral Concentrate 2 milligrams (mg)/milliliters (ml), give 0.25 ml every six hours for anxiety; -An order, dated 12/30/25, to observe resident closely for significant behaviors: 0-No Behaviors, 1-Agitation, 2-Anxiety, 3-Nervousness, 4-Compulsiveness, 5-Physical Aggression, 6-Combative, 7-Excitation/Irritability, 8-Verbal Aggression, 9-Panic, 10-other; every shift for Anxiety/Agitation. Code the appropriate number that reflect any and all behaviors. Notify Physician if a behavior increases or a new behavior is noted. -An order, dated 12/30/25, to observe resident closely for significant side effects: 0-No Side effects,1-Dizziness, 2-Drowsiness, 3-Confusion, 4-Fatigue, 5-Syncope (feeling faint due to blood flow change), 6-Dysathea (speech disorder), 7-Nightmares, 8-Agitation, 9-Tremors, 10-Ataxia (uncoordinated movement), 11-Mania (extreme sustained high energy), 12-Blurred Vision, 13-Other; every shift for anxiety. Code the appropriate number that reflect any and all side effects. Notify Physician if any side effects are noted. -An order, dated 6/23/25, to assist resident with dressing and undressing every shift related to limitations from diagnosis of hemiplegia and hemiparesis (weakness on one side of the body) following cerebral infarction (a type of stroke) affecting left dominant side every shift; -An order, dated 6/16/25, for weekly skin assessments every day shift every Thursday. Complete under assessment tab; -An order, dated 4/22/25, for anti-itch 0.5-0.5% lotion. Apply to both upper extremities (BUE) topically every shift for pruritus (severe, persistent itching); -An order, dated 4/22/25, for [NAME] Cream moisture (barrier cream). Apply to peri-area (between the genital and anal areas) topically two times a day for preventative skin treatment. Review of the resident's MAR, dated 2/1/26 through 2/28/26, showed: - An order, dated 12/22/25, for Lorazepam Intensol Oral Concentrate 2 mg/ml, give 0.25 ml every six hours for anxiety; -Documentation showed, seven out of the 112 opportunities were blank. Review of the resident's nurse's administration record (NAR), dated 2/1/26 through 2/28/26, showed: -An order, dated 12/30/25, to observe resident closely for significant behaviors: 0-No Behaviors, 1-Agitation, 2-Anxiety, 3-Nervousness, 4-Compulsiveness, 5-Physical Aggression, 6-Combative, 7-Excitation/Irritability, 8-Verbal Aggression, 9-Panic, 10-other; every shift for Anxiety/Agitation. Code the appropriate number that reflect any and all behaviors. Notify Physician if a behavior increases or a new behavior is noted. -Documentation showed, four out of the 56 opportunities were blank; -An order, dated 12/30/25, to observe resident closely for significant side effects: 0-No Side effects,1-Dizziness, 2-Drowsiness, 3-Confusion, 4-Fatigue, 5-Syncope, 6-Dysathea,7-Nightmares,8-Agitation,9-Tremors,10-Ataxia,11-Mania,12-Blurred Vision,13-Other; every shift for anxiety. Code the appropriate number that reflect any and all side effects. Notify Physician if any side effects are noted. -Documentation showed, four out of the 56 opportunities were blank; -An order, dated 6/23/25, to assist resident with dressing and undressing every shift related to limitations from diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side every shift; -Documentation showed three out of the 56 opportunities were blank; Review of the resident's treatment administration record (TAR), dated 2/1/26 through 2/28/26, showed: -An order, dated 6/16/25, for weekly skin assessments every day shift every Thursday. Complete under assessment tab; -Documentation showed, two out of the four opportunities were blank; -An order, dated 4/22/25, for anti-itch 0.5-0.5% lotion. Apply to BUE topically every shift for pruritus; -Documentation showed, four out of the 56 opportunities were blank; -An order, dated 4/22/25, for [NAME] Cream moisture. Apply to peri-area topically two times a day for preventative skin treatment; -Documentation showed, four out of the 56 opportunities were blank. Review of the resident's NAR, dated 3/1/26 through 3/11/26, showed: - An order, dated 12/22/25, for Lorazepam Intensol Oral Concentrate 2 mg/ml, give 0.25 ml every six for anxiety; -Documentation showed, three out of the 40 opportunities were blank. Review of the resident's TAR, dated 3/1/26 through 3/11/26, showed: -An order, dated 6/16/25, for weekly skin assessments every day shift every Thursday. Complete under assessment tab; -Documentation showed one out of the one opportunity was blank; -An order, dated 4/22/25, for anti-itch 0.5-0.5% lotion. Apply to both BUE topically every shift for pruritus; -Documentation showed three out of the 20 opportunities were blank; -An order, dated 4/22/25, for [NAME] Cream moisture. Apply to peri-area topically two times a day for preventative skin treatment; -Documentation showed three out of the 20 opportunities were blank. 3. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Diagnoses included diabetes, hearing loss, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves); -Cognitively intact. Review of the resident's MAR, dated March 2026, showed: -An order, dated 7/10/25, for weekly skin assessment to be completed on Wednesday night shifts; -The skin assessment for 3/4/26 and 3/11/26 were not documented as completed. Review on 3/12/26, of the resident's electronic medical record (EMR), showed: -The most recent skin assessment under the assessments tab was dated 2/19/26. 4. Review of Resident #48's quarterly MDS, dated [DATE], showed: -Diagnoses included dementia, diabetes, and bipolar disorder; -Moderately impaired cognition. Review of the resident's MAR, dated March 2026, showed: -An order, dated 7/11/25 for weekly skin assessments to be completed on Monday evening shift; -The skin assessment for 3/2/2026 and 3/9/26 were not documented as completed. Review on 3/12/26, of the resident's EMR, showed the most recent skin assessment under the assessments tab was dated 2/24/26. 5. During an interview on 3/13/26 at 3:56 P.M., the Administrator and DON said they would expect weekly skin assessments to be completed if there is an order from the physician. The skin assessments are to be completed in the assessment's tab in the EMR and documented as completed in the resident's MAR. They would expect medication to be administered per the physicians' orders. They would expect the nurse to document why the medication was not administered and notify the physician. 2792436

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL, bathing, dressing, eating, transferring and toileting) care was provided for four of 18 sampled residents. The facility failed to ensure one resident was toileted in a timely manner (Resident #28), failed to ensure two residents received at least two showers a week and were assisted by staff (Residents #4 and #38), and failed to ensure one resident was assisted with unwanted facial hair removal (Resident #5). The census was 53. Review of the facility's showering a resident policy, undated, showed:-Purpose: a shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors;-Policy: residents are offered a shower at a minimum of once weekly and given per resident request. Review of the facility's perineal (care to the surface area between the thighs, extending from the pubic bone to tail bone) care policy, dated 6/2020, showed:-Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown;-Policy: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need. 1. Review of Resident #28's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated, 12/22/25, showed:-Severe cognitive impairment;-Impairment on one side of upper and lower extremity;-Dependent on staff for toilet hygiene, bathing, personal hygiene, upper and lower body dressing;-Requires maximum assist rolling left and right;-Frequently incontinent of bowel and bladder;-Diagnoses included dementia, depression and hemiplegia (weakness to one side of the body). Review of the resident's care plan, in use at the time of survey, showed:-Focus: the resident has self-care ADL performance deficit related to hemiplegia, dementia and pain.-Interventions: the resident is totally dependent of staff for toilet use, personal hygiene, dressing, transfers and bathing. Observation and interview on 3/10/26 at 12:45 P.M., showed the resident lay in bed, eating his/her lunch tray. The resident had a strong odor of urine, and when he/ she raised his/her left arm, the resident had strong body odor. Certified Medicine Technician (CMT) J administered the resident medication. At 12:55 P.M., the Certified Nursing Assistant (CNA) B and CNA I came into the room and turned the resident to his/her left side. The resident's brief, two quilted bed pads and fitted sheet were saturated with urine. CNA B said, Whew, that's a lot when the resident was turned. The resident had an open wound to his/her right buttock and an open wound on his/her left buttock with no dressing. CNA B said the last time he/she checked on the resident was around 8:00 A.M. CNA B said he/she did not want to disturb the resident this morning because he/she was sleeping and frequently is in pain. During an interview on 3/11/26 at 12:15 P.M., Licensed Practical Nurse (LPN) A said all incontinent residents should be checked on and repositioned every two hours. During an interview on 3/13/26 at 11:17 A.M., CMT J said all incontinent residents should be checked on every two hours. Resident #28 should have been changed and gotten out of bed at the beginning of the shift. During an interview on 3/13/26 at approximately 2:00 P.M., CNA I said incontinent residents should be checked every two hours and the resident has never refused care for him/her. During an interview on 3/14/26 at 3:50 P.M., the Director of Nursing (DON) said she expected staff to check on all incontinent residents to be checked on every two hours. 2. Review of Resident # 4's, quarterly MDS, dated , 12/25/25, showed:-Cognitively intact;-Requires partial to moderate assistance from staff for bathing, personal hygiene and toilet hygiene;-Frequently incontinent of bladder and occasionally incontinent of stool;- Diagnoses included stroke, dementia, diabetes, kidney failure and depression. Review of the resident's care plan in use at the time of survey, showed:- Focus: the resident has self-care ADL performance deficit related to Parkinson's disease, myasthenia gravis (an auto immune disease that causes muscle weakness) and refuses assistance;-Interventions: the resident requires toilet and personal hygiene assistance. The resident uses a walker and requires supervision to partial assistance from staff. Observation and interview on 3/9/26 at 9:20 A.M., showed the resident lay in bed and had a strong body odor, uncombed, oily hair, and an unshaven face with approximately one half an inch of facial hair. The resident said he/she would walk to the shower room down the North Hall using his/her walker. The shower room was usually cluttered with equipment and the resident said he would try to move the equipment but usually wasn't able to. The resident finds the obstructed shower room to be a deterrent to take a shower. He/She has asked staff to help him/her getting set up in the shower, but they never do. The resident said he/she was incontinent of urine and frequently was incontinent of stool and would like to take a shower. The resident said his/her poor hygiene added to his/her depression. Observation on 3/10/26 at 8:10 A.M., and 3/11/26 at approximately 10:00 A.M., showed the resident lay in bed and had a strong body odor, uncombed, oily hair, and an unshaven face with approximately one half an inch of facial hair. During an interview on 3/11/26 at approximately 12:00 P.M, CNA K said the resident didn't really want any help with his/her showers. CNA K said the resident did his/her own thing. He/She was not aware that the resident was having difficulty getting his/her showers completed. CNA K was aware that the resident was incontinent of urine and stool but said the resident provided his/her own care. During an interview on 3/14/26 at 3:50 P.M., the DON said everyone that lives in the facility requires assistance from staff with their hygiene needs including Resident # 4. All residents are expected to be clean, dry and odor free. 3. Review of Resident #38's annual MDS, dated [DATE], showed:-Diagnoses included type two diabetes, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and cerebral palsy (group of disorders affecting a person's ability to move and maintain balance and posture),-Severe cognitive impairment. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: the resident has an ADL self-care performance deficit;-Goal: the resident will maintain current level of function in through the review date;-Interventions: personal hygiene/oral care: maximum assistance from staff needed. Review on 3/12/26, of the resident's MAR, dated 3/2026, showed:-An order, dated 12/2/25, showers scheduled every Monday and Thursday evening shift;-On 3/2/26 and 3/9/26, the resident's showers were not marked as given. Observation on 3/9/26 at 10:05 A.M., showed the resident in bed awake. The resident had a strong sweat like odor emitting from him/her. Observation on 3/12/26 at 1:17 P.M., showed the resident in bed awake watching tv. The resident had a strong sweat like odor emitting from him/her. During an interview on 3/13/26 at 8:21 A.M., LPN G said Resident #38 was not resistive to care. He/She would expect the resident to receive his/her scheduled showers and to be odor free. During an interview on 3/13/26 at 4:45 P.M., the Administrator and DON said they would expect residents to receive their scheduled showers and showers as needed. They said Resident #38 was not resistive to care. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed:-Diagnoses included type two diabetes, hearing loss, and schizophrenia;-Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: resident has an ADL self-care performance deficit;-Goal: resident will maintain current level of function in bed mobility, transfers, eating, and dressing through the review date;-Interventions: personal hygiene/oral care: dependent on one staff with personal hygiene and oral care. Observation on 3/9/26 at 10:00 A.M., showed the resident in bed awake. The resident's chin had long white curly hairs. Observation on 3/10/26 at 7:25 A.M., showed the resident walking out of his/her room to go to the dining room for breakfast. The resident's chin had long white curly hairs. During an interview on 3/10/26 at 7:35 A.M., the resident said he/she wanted his/her chin hairs removed. During an interview on 3/13/26 at 8:21 A.M., LPN G said both CNAS and LPNs could assist residents with removing unwanted facial hair. He/She would expect staff to ask the resident their grooming preference during showers. During an interview on 3/13/26 at 1:56 P.M., CNA F said during showers or bed baths CNAs could remove the resident's unwanted facial hair. During an interview on 3/13/26 at 4:45 P.M., the Administrator and DON said nursing staff should assist residents with removing unwanted facial hair. They would expect staff to ask both the male and female residents. 2792436

Based on observation, interview, and record review, the facility failed to assess resident activity preferences and to provide an ongoing activity program that supports residents in their choices of activities (Residents #2, #4, #5, #10, #16, #25, and #48). In addition, the facility failed to provide one to one (1:1) activities to three residents who were identified as having the potential to benefit from them (Residents #6, #7, and #9). The sample was 18. The census was 53. Review of the facility's Activities Program policy, dated 6/2020, showed:-Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning;-Policy: The facility provides an activity program designed to meet the needs, interests, and preferences of residents. The activities are varied and work to address the needs and interests identified through the assessment process. The activity program may address areas including, but not limited to social activities, indoor and outdoor activities, activities away from the facility, religious programs, opportunity for resident involvement for planning activities, creative activities, educational activities, and exercise activities;-Procedure: Activities are developed for individual, small group, and large group participation. The activity schedule is posted, in large print, in a location accessible to residents, their family, and staff;-The initial activity assessment is completed by the Director of Activities or his or her designee within seven days of admission. After completion of the initial Activity Assessment and the Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), an individualized care plan will be developed and implemented for each resident. 1. Observation of the main dining room on 3/9/26 at 1:05 P.M., showed Mardi Gras decorations hanging on the wall and resident birthdays for February 2026 posted on a bulletin board. Observations of the North hall near the main dining room, on 3/9/26 at 1:00 P.M., and 3/10/26 at 7:15 A.M. and 3/12/26 at 9:13 P.M., showed an activity calendar for February 2026 posted on a bulletin board. Observations on 3/10/26 at 8:56 A.M., 10:26 A.M., and 12:45 P.M., showed no activities provided to residents. Observations on 3/11/26 at 2:20 P.M., 3:44 P.M., 4:04 P.M., and 5:17 P.M., showed no activities provided to residents. Observations on 3/12/26 at 9:09 A.M., 10:11 A.M., 11:23 A.M., and 1:15 P.M., showed no activities provided to residents. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included anxiety, depression, bipolar disorder (a mental disorder that causes extreme mood swings), schizophrenia (a mood disorder that distorts reality) and post-traumatic stress disorder (PTSD, a mental condition that is triggered by experiencing or witnessing traumatic events). Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's activity participation or preferences. Review of the resident's medical record, showed no activity assessment. Observation on 3/9/26 at 9:41 A.M., showed an activity calendar, dated February 2026, outside of the resident's bathroom door. During an interview, the resident said there are no activities taking place. It had been about two weeks since the last Activities Director left. He/She comes out for activities only when it interests him/her, which isn't very often. He/She pays for a car ride out of his/her personal money to go to Wal-Mart, just to get out of this place. 3. Review of Resident #4's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included stroke, dementia, diabetes, kidney failure, and depression. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's activity participation or preferences. Review of the resident's medical record, showed no activity assessment. Observation on 3/9/26 at 9:20 A.M., showed the resident in bed and the room was dark. During an interview, the resident said he/she does nothing all day long. He/She goes to dialysis and that is the only time he/she goes out anywhere. He/She would like to participate in something that he/she is interested in. He/She used to put large puzzles together. The facility used to have a small bus that would take residents places, and he/she thought it would be nice to have that again. Observation on 3/9/26 at 9:20 A.M. and 3/11/26 at 5:15 P.M., showed an activity calendar dated February 2026, posted on the outside of the resident's bathroom door. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed:-Diagnoses included diabetes, hearing loss, and schizophrenia;-Cognitively intact. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's activity participation or preferences. Review of the resident's medical record, showed no activity assessment. During an interview on 3/9/26 at 10:00 A.M., the resident said there are not enough activities provided. He/She wants more activities to be provided. 5. Review of Resident #10's quarterly MDS, dated [DATE], showed:-Diagnoses included multiple sclerosis (MS, autoimmune disease) and insomnia;-Cognitively intact. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's activity participation or preferences. Review of the resident's medical record, showed no activity assessment. During an interview on 3/9/26 at 9:10 A.M., the resident said there are not enough activities provided and he/she would like more. 6. Review of Resident #16's quarterly MDS, dated [DATE], showed:-Diagnoses included hypertension (high blood pressure), insomnia, and anemia (increase in number of red blood cells);-Cognitively intact. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's activity participation or preferences. Review of the resident's medical record, showed no activity assessment. During an interview on 3/9/26 at 8:56 A.M., the resident said there are not enough activities provided. There are not enough activity staff to do activities. 7. Review of Resident #25's quarterly MDS, dated [DATE], showed:-Diagnoses included diabetes, bipolar disorder, depression, and hypertension;-Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: The resident is independent in activity attendance and chooses what to participate in;-Interventions: Invite the resident to scheduled activities. Provide with activities calendar. Notify resident of any changes to the calendar of activities. During an interview on 3/9/26 at 9:54 A.M., the resident said there are not enough activities. He/She would like more activities to keep him/her from being bored. 8. Review of Resident #48's quarterly MDS, dated [DATE], showed:-Diagnoses included dementia, diabetes, and bipolar disorder;-Moderately impaired cognition. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's activity participation or preferences. Review of the resident's medical record, showed no activity assessment. During an interview on 3/9/26 at 9:52 A.M., the resident said the facility did not have enough activity staff to conduct activities. He/She would like more activities and is bored most of the time. 9. During an interview on 3/13/26 at approximately 1:30 P.M., the Activity Director said her first day working for the facility was on 3/9/26. The activity calendar for March 2026 had not been made yet, and it was still in the process of being created. She expected activities to be scheduled and provided to residents. She expected a current activity calendar to be given to the residents and posted where they can read it. 10. During an interview on 3/13/26 at 4:21 P.M., the Administrator and Director of Nursing (DON) said they expected activities to be offered and provided to residents. They expected an up-to-date activity calendar to be given to each resident and posted in areas where the residents can see it. They expected resident care plans to reflect the resident's activity preferences. The Activity Director is responsible for conducting the activity assessment upon admission to the facility and annually. 11. Review of Resident #6's comprehensive MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included dementia, bipolar disorder, hypertension, and malnutrition. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's activity participation or preferences. Review of the facility's 1:1 Activity List, undated, showed the resident scheduled to receive 1:1 activities on Wednesdays and Saturdays. Review of the resident's medical record, showed no documentation of activities offered or provided to the resident. Observations of the resident throughout the survey, from 3/9/26 through 3/13/26, showed the resident not engaged in any 1:1 activities. 12. Review of Resident #7's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Diagnoses included Alzheimer's Disease, (dementia), stroke, dementia, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), seizure disorder, malnutrition, and anxiety disorder. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's activity participation or preferences. Review of the facility's 1:1 Activity List, undated, showed the resident scheduled to receive 1:1 activities on Mondays and Thursdays. Review of the resident's medical record, showed no documentation of activities offered or provided to the resident. Observations of the resident throughout the survey, from 3/9/26 through 3/13/26, showed the resident not engaged in any 1:1 activities. 13. Review of Resident #9's quarterly MDS, dated [DATE], showed:-Short and long-term memory impairment;-Diagnoses included anxiety disorder, aphasia (communication disorder), seizure disorder, mild cognitive impairment, malnutrition, and Rett's syndrome. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's activity participation or preferences. Review of the facility's 1:1 Activity List, undated, showed the resident scheduled to receive 1:1 activities on Wednesdays and Saturdays. Review of the resident's medical record, showed no documentation of activities offered or provided to the resident. Observations of the resident throughout the survey, from 3/9/26 through 3/13/26, showed the resident not engaged in any 1:1 activities. 14. During an interview on 3/13/26 at approximately 1:30 P.M., the Activity Director said she had not started conducting 1:1 activities for the residents on the 1:1 Activity List. Residents #6, #7, and #9 are on the 1:1 Activity List and would benefit from 1:1 activities. 15. During an interview on 3/13/26 at 4:21 P.M., the Administrator and DON said they expected 1:1 activities to be provided to residents who have been determined to benefit from them. 2792436

Based on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 53. Review of the facility's Storage of Controlled Substances policy, last revised August 2020, showed:-Policy: Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations;-Procedures: -At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerator times, is conducted by two licensed personnel and is documented; -Controlled substance inventor is regularly reconciled to the medication administration record (MAR) and documented on a control count sheet or similar form or in accordance with facility policy; -Current controlled substance accountability records are kept in the MAR of a designated book. 1.Review of the South Hall Nurses narcotic book count sheets, dated 3/1 through 3/10/26 showed:-Eight out of 19 shifts did not have a start shift narcotic count documented;-Three out of 19 shifts had no nurse signature on the shift change count. 2. Review of the North Hall Nurses narcotic book count sheets, dated 3/1 through 3/10/26 showed:-Six out of 19 shifts did not have a start shift narcotic count documented;-Five out of 19 shifts did not have an end of shift narcotic count documented;-On 3/8/26 through 3/10/26 the shift count was handwritten on the back of the shift count sheet and was illegible. 3. During an interview on 3/10/26 at 7:15 A.M., Licensed Practical Nurse (LPN) G said the narcotic count is completed by one oncoming nurse and one off going nurse. Every part of the narcotic count sheet should be filled in. LPN A thought there was nowhere else to document the count, so someone started writing on the back of the narcotic count sheet. The narcotic count should be clear, accurate and legible. 4. During an interview on 3/13/26 at 3:30 P.M., the Director of Nursing (DON) said she expected the entire narcotic sheets to be completed. Narcotic counts are completed by one oncoming nurse and one off going nurse every shift every day. She expected staff to find another narcotic sheet to document on and not write on the back of one.

Based on observation, interview and record review, the facility failed to store and serve food in accordance with professional standards for food service safety. The facility failed to maintain kitchen equipment in a clean condition and failed to ensure that the floors were swept and mopped during five of five days of observation. The facility also failed to ensure that a pipe was repaired from the underneath the sink and that the floor was repaired. The census was 53.1. Observations of the kitchen on 3/9/26 at 8:57 A.M., 3/10/26 at 3:33 P.M, 3/11/26 at 7:20 A.M., 3/12/26 at 10:48 A.M., and 3/13/26 at 1:10 P.M. showed:-Stove: -Caked-on stains along the front and on the top of the stove; -Heavy caked-on stains and spots on the burners on the stove; -Oven: -Heavy caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, top, and sides of oven;-Reach in cooler: -Noticeably dirty and streaked spots going down the front of the doors;-Reach in freezers: -Noticeably dirty and streaked spots going down the front of the doors;-Floor: -Noticeably dirty with food crumbs, dirt, debris and stains; -Raised/buckled area by the dishwasher. Review of the kitchen cleaning schedules/logs (undated) showed:-Daily/after each use cleaning schedule form; Blank;-Weekly cleaning schedule: Blank;-Monthly cleaning schedule form: Blank 2. Observations of the sink by the dishwasher on 3/9/26 at 8:57 A.M., 3/10/26 at 3:33 P.M, 3/11/26 at 7:20 A.M., 3/12/26 at 10:48 A.M., and 3/13/26 at 1:10 P.M. showed a metal pan that contained dirty water that leaked from a pipe from under the sink. 3. During an interview on 3/13/26 at 1:20 P.M., with the Dietary Manager (DM) and the Registered and Dietitian (RD), the DM said general cleaning was being done every day via sweeping and mopping the floor, wiping down the top and front of the stove, cleaning and wiping down the inside and outside of the oven, reach in coolers and freezers refrigerator and all other general appliances. She did not have a filled-out cleaning schedule/log but planned to start making sure one is filled out for the weekly and monthly schedules. Deep cleaning was not being done by the staff. She has been doing a deep cleaning herself. She planned to have the staff to start deep cleaning at least one time a week. Maintenance was aware of the leaking pipe. They have to order a part for the repair. The RD said equipment should be clean and in proper working order and the kitchen floor should be clean and repaired. They were already aware the floor needed to be repaired. 4. During an interview on 3/13/26 at 4:06 P.M., with the Administrator and the Director of Nursing (DON), the Administrator said she expected the kitchen equipment to be maintained and floors to be maintained in a clean condition. She expected the floor to be kept clean and repaired. The pipe underneath the sink should be repaired.

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such service, consistent with professional standards of practice for two residents (Resident # 57 and Resident #2) The sample size was 18. The census was 53.Review of facility's Pain Management policy, last revised, June 2020, showed:-Purpose: To ensure accurate assessment and management of the resident's pain;-Policy: A licensed nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status; Facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain;Procedure: The licensed nurse will administer pain medication as ordered and document medication administered on the medication administration record (MAR); Nursing staff will implement timely interventions to reduce the increase in severity of pain. 1.Review of the Resident #57's medical record showed:-An admission date 3/2/26;-Diagnoses included osteomyelitis (infection in the bone) of the vertebra (multiple bones that make up the spine) and thoracic (rib cage) region, encounter for surgical aftercare following surgery on the nervous system (brain, spinal cord, and nerves) and diabetes. Review of the resident's baseline care plan, dated, 3/2/26, did not address the resident's presence of pain. Review of the resident's physician orders, dated March 2026, showed:-An order, dated, 3/2/26, oxycodone (pain medication)10 milligrams (mgs), give one tablet, every four hours as needed for severe pain;-An order, dated, 3/2/26, oxycodone 5 mgs, give one tablet, every four hours for pain. Observation and interview on 3/10/26 at 8:35 A.M., showed the resident lay in bed. The resident requested pain medication from Certified Medication Technician (CMT) J. CMT J said he/she will tell the nurse. The resident said his/her pain level is a 10 out of 10. The resident said the staff is late with his/her pain medication all the time. 2. Review of Resident #2's, quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 12/25/25, showed:-The resident is cognitively intact;-Diagnoses included anxiety, depression, bipolar disorder (a mental disorder that causes extreme mood swings), schizophrenia (a mood disorder that distorts reality), and post-traumatic stress disorder (PTSD), a mental condition that is triggered by experiencing or witnessing traumatic events;-Receives scheduled and as needed (PRN) pain medication. Review of the resident's physician orders, dated March 2026, showed:-An order, dated, 12/20/25, oxycodone 10 mgs, give one tablet, every six hours as needed for moderate pain. During observation and interview on 3/10/26 at 8:46 A.M., the resident lay in bed rubbing his/her left hip area. The resident said he/she asked for pain medication from the CMT about an hour ago. The resident said his/her pain level was an 8 out of 10. The resident said the staff are late with his/her pain medication all the time. 3. During an interview on 3/10/26 at 8:45 A.M., CMT J said only the nurses are allowed to give pain medications. He/She wasn't sure who the nurse was for the North Hall. CMT J thought it was the Assistant Director of Nursing (ADON) since the nurse on the schedule had not shown up. CMT J said he/she had not had a chance to tell the nurse on the other hall or the ADON that the residents required pain medication on the North Hall. 4. Observation and interview on 3/10/26 at 9:25 A.M., showed Licensed Practical Nurse (LPN) C entered the building and said he/she was taking an assignment due to a nurse not showing up. He/She was assigned the North Hall. At 10:32 A.M., LPN C said he/she had given Resident #2 and Resident #57 their pain medication at about 10:22 A.M. LPN C said he/she was not aware the residents were waiting so long for pain medications and would have given it sooner. The residents should get their pain medications within fifteen minutes of asking for it. 5. During an interview on 3/13/26 at 3:50 P.M., the Director of Nursing (DON) said residents should not have to wait more than fifteen minutes for pain mediation once they have requested it. Waiting nearly two hours was unacceptable. The nurse for the North Hall had not shown up for his/her shift, so the ADON was supposed to work the floor, but then he/she left after he/she found out that he/she had to work the floor. They had to call in another nurse. The nurse on the other hall or the DON could have given the pain medications if the CMT had informed them. The DON expected all residents to receive all their medications in a timely manner.

Based on observation and interview, the facility failed to post the nurse staffing information daily in a prominent place readily accessible to residents and visitors. The census was 53. Review of the facility's nursing department staffing, scheduling, posting policy, dated 6/2020, showed:-Procedure: The facility will post the following information on a daily basis: facility name, current date, the total number and actual hours worked for nursing staff;-The facility will post the nurse staffing data specified above, on a daily basis at the beginning of each shift. Data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors. Observations on 3/10/26 at 10:32 A.M., 3/11/26 at 10:00 A.M., and 3/12/26 at 9:12 A.M., showed the nurse staffing sheet hung on a bulletin board behind the first floor nurse's station. The document was blank and had a date of 3/6/26 written on it. During an interview on 3/13/26 at 7:10 A.M., the Administrator said Certified Medication Technician (CMT) E, who is the staffing coordinator, was responsible for posting the daily nurse staffing numbers. She would expect this to be posted every day at the first floor nurse's station. During an interview on 3/13/26 at 7:11 A.M., CMT E said she was responsible for posting the daily nurse staffing. She said she had been documenting the daily nurse staffing in a binder but was not posting it.

Based on observation, interview and record review, the facility failed to have a system in place to ensure drugs and biologicals were labeled with a date opened and expiration date. Issues were identified with one out of three mediations carts reviewed. The census was 53.Review of the facility's Storage of Medications policy, last revised, August 2020, showed:-Certain medication or package types such as ophthalmics (eye) require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency;-Drugs dispensed in the manufacturer's original container will carry the manufacturer's original expiration date; Once opened, these products will be acceptable to use until the manufacturer's expiration date is reached and unless the mediation is an ophthalmic medication;-When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated;-The nurse shall place a date opened sticker on the mediation and record the date opened and new date of expiration; The expiration date of the vial or container will be 30 days from opening unless the manufacturer recommends another date, or regulations or guidelines require different dating. Observation on 3/10/26 at 9:35 A.M., the South Hall Certified Medication Technician (CMT) cart showed:-Six vials of Timolol maleate 0.5 % eye drops (medications used to treat high pressure in the eye) with the manufacturer seal broken, no open date or expiration date;-Two vials of Latanoprost 0.005% eye drops (medication used to treat high pressure in the eye) with the manufacturer seal broken, no open date or expiration date;-One vial of Brimodine 0.2% eye drops (medication used to treat high pressure in the eye) with the manufacturer seal broken, no open date or expiration date. During an interview on 3/10/26 at 9:37 A.M, CMT J said all eye drops should have an open date and an expiration date. All eye drops are good for 30 days once opened. The staff member who opens the eye drops is responsible to place the open and expiration date. During an interview on 3/13/26 at 3:50 P.M., the Director of Nursing (DON) said she would expect eye drops to have an open date and an expiration date to ensure the efficacy of the medication.

Based on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by not identifying ongoing psychological and counseling needs for two residents (Resident #4 and Resident #2) and by not addressing one resident's behavior (Resident # 38). The sample was 18. The census was 53.Review of the facility's Behavior Management policy, last revised June 2020, showed:-Purpose: To implement the most desirable and effective interventions to change, modify, decrease or eliminate behaviors that are distressing to the resident, and or are decreasing or negatively impacting the resident's quality of life. To ensure that facility staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being that meet each resident's needs and include individualized approaches to care;-Policy: -The concept of behavior management is an interdisciplinary process. The key components of this process are: -Identifying residents whose behaviors may pose a risk to self or others; -Developing individual and practical care strategies based on assessed needs; -Implementing the behavior management program; -Ongoing assessment, monitoring, and evaluations of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs; -The goal of any behavior management process is to maintain function and improve quality of life; -The goal of the interdisciplinary team is to promptly identify behavior management issues and develop an effective management program; -It is important to understand that behavior management is not behavior modification; -Behavior management means the interdisciplinary team seeks to accommodate the resident with behavioral problems as much as is practical in the facility; -The facility must provide necessary behavioral health care and services which include: -Ensuring the necessary care and services are person-centered and reflect the resident goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety; -Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being; -Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community; -Meaningful activities are those that address the resident's customary routines, interests, preferences, and enhance the resident's well-being; -Providing an environment and atmosphere that is conductive to mental and psychosocial well-being; -Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated. Review of the facility's Activities policy, last revised, June 2020, showed:Purpose: Is to encourage residents to participate in activities to make life more meaningful, to stimulate, and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable, social, physical, and emotional functioning. Review of the facility's Licensed Social Worker job description, last revised, December 2023, showed:-The Social Service Worker is responsible for fostering a climate, policies, and routines that enable residents to maximize their individuality, independence, and dignity; This climate should provide residents with the highest practical level of physical, mental, and psychosocial well-being and quality of life;-The Social Service Worker is responsible for identing psychosocial, mental, and emotional needs along with providing, developing, and/or aiding in the access of services to meet those needs;-The Social Service Worker is to work with the interdisciplinary team and administration to promote and protect resident rights and the psychological well-being of each resident. 1.Review of Resident #4's, quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 12/25/25, showed:-Cognitively intact;-Required partial to moderate assistance from staff for bathing, personal hygiene and toilet hygiene;-Frequently incontinent of bladder and occasionally incontinent of stool;- Little interest in doing things, is feeling down, depressed and hopeless, has trouble falling asleep, or staying asleep, or sleeping too much, is tired or having little energy, nearly every day;- Diagnoses included stroke, dementia, diabetes, kidney failure and depression;-No activities assessment noted. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident requires antidepressant medication for depression;-Interventions: Monitor/document/report to physician ongoing signs and symptoms of depression unaltered by antidepressant medications; Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal thoughts, negative mood or comments, slowed movement, agitation, disrupted sleep, fatigue, tiredness, does not enjoy usual activities, changes in cognition, changes in appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, and constant reassurance.-The resident's care plan did not address activities. Review of the resident's quarterly social service assessment, dated, 6/23/25, showed:-The resident has very few visitors and has declined since the passing of his/her wife last year;-The resident gets along with his/her roommate and is kind to others but does not socialize or participate in activities;- A brief overview was provided with referrals and outside resources (example: talking books, community wheelchair transportation, and/or counseling services): Blank. Review of the resident's social history, dated, 9/11/25, showed:-The resident is being seen by a psychiatrist and psychologist;-The resident has fired the psychologist at least three times. Review of the resident's progress notes dated 9/11/25 through 3/13/26, showed no further social service notes. Review of the resident's psychiatric Nurse Practitioner progress notes showed:-On 12/1/25 at 4:26 P.M., the resident was seen, chart and medications reviewed. Mood fair. Poor hygiene. Some re-direction needed. Isolative to room;-On 2/3/26 at 11:22 A.M., the resident was seen, medications reviewed, mood fair, isolative to room, and disheveled. Some redirection needed. No change; -On 3/7/26 at 11:43 A.M., the resident was seen, medications reviewed, isolated, sleep fair, appetite decreased. No change. Continue current medications. During observation and interview on 3/9/26 at 9:20 A.M., the resident lay in bed and the room was dark. The resident had a strong body odor, uncombed, oily hair, and an unshaven face with approximately one half an inch of facial hair. The resident said he/she will walk to the shower room down the North hall using his/her walker. The shower room is usually cluttered with equipment and the resident said he will try to move the equipment but usually isn't able to. The resident finds the obstructed shower room to be a deterrent to take a shower. He/She has asked staff to help him/her getting set up in the shower, but they never do. The resident said he/she is incontinent of urine and frequently is incontinent of stool and would like to take a shower. The resident said his/her poor hygiene adds to his/her depression. The resident said he/she does nothing all day long. He/She goes to dialysis, and that is the only time he/she goes out anywhere. The resident said he/she would like to participate in something that he/she is interested in. The resident said he/she used to put large puzzles together. The facility used to have a small bus that would take you places, and the resident thought he/she it would be nice to have that again. The resident said his/her spouse died about two years ago, and he/she is very and is still experiencing a lot of grief and sadness over his/her death. The resident feels as though he/she has no purpose in life anymore. During observation and interview on 3/11/26 at 5:15 P.M., the resident lay in bed and the room was dark. The resident had a strong body odor, uncombed, oily hair, and an unshaven face with approximately one half an inch of facial hair. The resident said he/she does not feel like any medication is helping his/her depression. The resident thinks that the psychiatrist is only seeing him/her to manage his/her medication and not have a meaningful conversation. He/She was assigned a psychologist a few months back but did not care for the psychologist's demeanor. The resident was provided another psychologist and has not seen that person in a very long time. The resident tried to call the new psychologist twice and left messages and e-mailed him/her once. The resident wanted to talk to someone about his/her ongoing grief and depression. The facility social worker is only in the building a couple of days a week and when the social worker is in the building, he/she is running around helping others. The resident said the nursing staff were always busy and understaffed to sit and talk with the resident. The resident feels ignored and neglected. The resident said he/she deserves better. One staff member told him/her once to stop playing the victim. During an interview on 3/11/26 at 12:15 P.M., Licensed Practical Nurse (LPN) A said he/she provided direct care to the resident. LPN A was not aware that the resident lost his/her wife and was still grieving. The resident isolated him/herself in the room, participated in no activities, had his/her room dark and refused to take showers. Those are all signs of depression. The resident is being seen by the psychiatrist, but that did not seem to help the resident entirely.During an interview at 3/11/26 at approximately 12:00 P.M, Certified Nurse's Aide (CNA) K said the resident didn't really want any help with his/her showers. The resident did his/her own thing. CN K was not aware that the resident was having difficulty getting his/her showers completed. CNA K was aware that the resident is incontinent of urine and stool but said the resident provides his/her own care. The resident always stayed in his/her room except to come out for dialysis.During an interview on 3/13/26 at 9:10 A.M., the Social Service Director (SSD) said she is only in the building a couple of days a week. She was aware that the resident lost his/her spouse. The resident has expressed some feelings of grief to the SSD. She was not aware of a new psychologist and that the resident was trying to reach out to that person. The SSD said the resident refuses some care, but the SSD did not know the resident felt neglected. The facility offers grief support but has not encouraged the resident to participate. The SSD said she should be making more notes in the resident's medical record related to conversations with the resident and behaviors the resident is having. The SSD's office was recently moved to where she is not readily accessible to residents. She expected the nursing staff to also inform her of any ongoing issues with the resident. During an interview on 3/13/26 at 3:50 P.M., the Director of Nursing (DON) and the Administrator said the resident would probably benefit from some one-on-one intense counseling and grief support. Everyone who lives in the facility required assistance from staff with their hygiene needs. When residents are clean and well-groomed, that helps with their mood. 2. Review of Resident #2's, quarterly MDS, dated , 12/25/25, showed:-Cognitively intact;-Diagnoses included: Anxiety, depression, bipolar disorder (a mental disorder that causes extreme mood swings), schizophrenia (a mood disorder that distorts reality), and post traumatic stress disorder (PTSD), a mental condition that is triggered by experiencing or witnessing traumatic events;-No activities assessment completed. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident requires antidepressant medication for depression;-Interventions: Monitor/document/report to physician ongoing signs and symptoms of depression unaltered by antidepressant medications; Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal thoughts, negative mood or comments, slowed movement, agitation, disrupted sleep, fatigue, tiredness, does not enjoy usual activities, changes in cognition, changes in appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, and constant reassurance;-The residents care plan did not address activities. Review of the resident's handwritten psychologist notes, dated, 12/29/25, 1/12/26, and 1/19/26 showed:Primary diagnosis: Depression, circled;-Thought content: Logical and coherent, circled;-Mood: Anxious and depressed, circled;-Orientation: Fully, circled;-Attitude: Cooperative, engaged and responsive, circled.-Capable of benefitting from treatment specified, checked;-Treatment strategies, interventions and goals was illegible. During an interview on 3/9/26 9:41 A.M., the resident said there were no activities taking place. It had been about two weeks since the last Activities Director left. The resident will come out for activities only when it interests him/her, which isn't very often. The resident pays for a car ride out of his/her money and goes shopping just to get out of this place. During an interview on 3/12/26 at 11:15 A.M., the resident said he/she did not like the psychologist he/she is seeing at the facility. The resident has not had one meaningful conversation with the psychologist. The psychologist only talked about his/herself going to the gym and going on vacation. The resident said he/she has witnessed a lot of horrible things in life, and the psychologist does not ask about any of the issues he/she is having. The resident thinks the psychologist is only there for the paycheck. The resident has tried to reach out to the SSD to get someone different, but the SSD never answers the phone and his/her voicemail is full. Observation on 3/12/26 at 1:28 P.M., showed the SSD's number was called, and the phone was not answered and went to voicemail. The message said the voicemail box was full and that a message could not be left. During an interview on 3/13/26 at 9:10 A.M., the SSD said her phone has been broken since May 2025. She did not give out a personal cell number. SSD spoke with the resident all the time and was not aware the resident did not like the psychologist. The SSD could not read the psychologist's notes and would expect them to be legible to review the plan of care for the resident. During an interview on 3/13/26 at 3:50 P.M., the DON and the Administrator said they would expect the SSD's phone to work the resident could have reached her about concerns related to the psychologist. The psychologist's notes should be legible. 3. Review of Resident #38's annual MDS, dated [DATE], showed:-Diagnoses included diabetes, schizophrenia, and cerebral palsy (group of disorders affecting a person's ability to move and maintain balance and posture),-Severe cognitive impairment. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: The resident has an activities of daily living (ADL) self-care performance deficit;-Goal: The resident will maintain current level of function through the review date;-Interventions: eating: Supervision, he/she will eat other's food if not supervised. He/She loves to eat. Transfer: Supervision at all times. He/She will go into others personal space. Review on 3/9/26, of the resident's progress notes, showed:-A note, dated 10/13/25, the resident has been observed several times this week going into a staff member's office and going into resident rooms eating their food. He/She had to be redirected several times during the day from wandering in and out of other resident rooms. He/She was observed last week coming out of someone's office while they were not in there with brown matter around his/her mouth. He/She was later discovered to have eaten out of the trash. Observations on 3/10/26, of the resident, showed:-At 7:26 A.M., the resident was standing in the 2nd floor hallway by the elevator along with two other residents, waiting to go downstairs for breakfast. No nursing staff were in the immediate area. The resident walked down the hallway and into the human resources (HR) office;-At 7:28 A.M., the Payroll HR Staff ushered the resident out of the office and shut the door;-At 7:34 A.M., the resident walked back down the hallway into the TV room, grabbed a bag of orange chips out of the trash can and ate three chips out of the bag; -At 7:39 A.M., the resident walked from the TV room into room [ROOM NUMBER], opened a dresser drawer, pulled out an open bag of chips, and ate the chips;-At 7:43 A.M., the resident seated at a table in the TV room, licking his/her fingers. During an interview on 3/12/26 at 8:47 A.M., the DON said the resident had eaten out of the trash can last year but had not displayed that behavior since, due to appropriate staff oversight. On 3/10/26, the facility was short staffed in the morning, and there was no CNA assigned to the 2nd floor at the time of the observed behavior. During an interview on 3/13/26 at 8:52 A.M., the Social Service Director said the resident needs consistent attention and monitoring from staff. Her expectation would have been that the 2nd floor was appropriately staffed. She expected the resident to be seen by psychiatric services due to having a history of behaviors. During an interview on 3/13/26 at 4:10 P.M., the Administrator and DON said the resident was removed from psychiatric services over the summer due to no longer being prescribed psychiatric medication. The resident is food driven and has behaviors of taking food from other residents and from staff offices. They expected the resident to have staff oversight to prevent the resident from eating out of the trash can. The resident would benefit from more activities to keep him/her preoccupied. The Payroll HR staff should not have shut his/her office door or ignored the resident. 4. During an interview on 3/13/26 at 1:28 P.M., the Activities Director said activities were beneficial to all residents and should be custom to what the resident likes. Activities could be a diversion for some residents with behaviors. Activities were designed to help all residents meet their psychosocial needs. 5. During an interview on 3/13/26 at 3:50 P.M., the DON and the Administrator said they expected the entire interdisciplinary team to work as a whole to identify and meet the resident's psychosocial needs. It is expected that the resident is offered activities that interest the resident. They expected documentation in the resident's medical records from all departments related to the resident's care and concerns.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care in accordance with professional standards of practice by failing to ensure oxygen tubing was dated and/or stored properly when not in use for two residents (Residents #48 and #6) and by failing to ensure physician orders for oxygen use included flow rate and usage instructions for one resident (Resident #6). The sample was 18. The census was 53. Review of the facility's Oxygen Administration policy, dated 6/2020, showed:-Purpose: To prevent or reverse hypoxemia (low oxygen levels in the blood) and provide oxygen to the tissues;-Policy:-Initiation of oxygen: A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include oxygen flow rate, method of administration, usage of therapy (continuous or as needed (PRN)), titration instructions (if indicated), and indication for use;-Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use;-Oxygen is stored in clean, dry locations away from direct sunlight, open flames, electric heating elements, and other sources of ignition. 1. Review of Resident #48's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/6/26, showed:-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), dementia, and diabetes;-Moderately impaired cognition. Review of the resident's care plan, in use at the time of the survey, showed no documentation regarding oxygen therapy via concentrator (medical device that filters room air to deliver oxygen). Review of the resident's physician order summary (POS), dated 3/2026, showed:-An order, dated 5/27/25, for oxygen at 2 liters (L) via nasal canula (NC) as tolerated, titrate for oxygen saturations greater than or equal to 92%;-No physician order for changing oxygen tubing. Observation on 3/9/26 at 8:53 A.M., showed the resident's oxygen tubing and NC on the floor next to the resident's oxygen concentrator. The oxygen tubing undated. Observation on 3/10/26 at 7:31 A.M., showed the resident's oxygen tubing and NC on top of the oxygen concentrator, uncovered. The oxygen concentrator was dusty. The oxygen tubing undated. Observation on 3/10/26 at 10:14 A.M., showed the resident in bed with eyes closed and NC in his/her nose. The oxygen concentrator on and set to 4 L. The oxygen tubing undated. Observation on 3/11/26 at 11:38 A.M., showed the resident's oxygen tubing and NC on the floor next to the oxygen concentrator. The oxygen tubing undated. 2. Review of Resident #6's comprehensive MDS, dated [DATE], showed:-Cognitively intact;-Use of continuous oxygen therapy;-Diagnoses included dementia, bipolar disorder, hypertension (high blood pressure), deep venous thrombosis (DVT, a serious condition where a blood clot forms in a deep vein), high cholesterol, diabetes, COPD, and malnutrition. Review of the resident's care plan, in use at the time of the survey, showed no documentation regarding oxygen therapy use. Review of the resident's POS, dated 3/2026, showed:-An order, dated 1/7/26, for oxygen via NC for oxygen saturations less than 88% on room air every shift;-An order, dated 2/1/26, for oxygen every shift related to acute respiratory failure with hypoxia;-No physician order for oxygen flow rate or specifying oxygen use as continuous or PRN. Observations on 3/9/26 at 10:10 A.M., on 3/10/26 at 9:52 A.M.,12:38 P.M., and 4:06 P.M., on 3/12/26 at 7:55 A.M.,10:15 A.M., and 11:50 A.M., and on 3/13/26 at 8:17 A.M., showed the resident in his/her bed with eyes closed and oxygen on via NC. The oxygen concentrator set at 2.5 L. 3. During an interview on 3/13/26 at 8:16 A.M., Licensed Practical Nurse (LPN) G said oxygen tubing should be stored properly when not in use. When not in use, oxygen masks and nasal cannulas should be placed in a plastic bag with the resident's name on it. Oxygen tubing should be changed once a week on the night shift. 4. During an interview on 3/13/26 at 4:45 P.M., the Administrator and Director of Nursing (DON) said they expected oxygen tubing to be stored properly. They expected oxygen tubing and nasal cannulas to be off the floor when not in use. They expected oxygen tubing to be changed once a week on the evening shift. They expected oxygen tubing to have the date on it. They expected physician orders for oxygen use to include the flow rate for staff to know the amount of oxygen to administer to the resident.

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #9 and Resident #6) received appropriate gastrostomy tube (g-tube, a tube surgically inserted into the abdomen used for liquid nutrition, fluids and medications) care to avoid potential complications from the tube feeding. Facility staff failed to label the water flush bag and failed to ensure the resident's head of bed was elevated to prevent aspiration (choking). The facility also failed to include Resident #6's tube feeding care on the care plan. The sample was 18. The census was 53.Review of the facility's Tube Feeding/Total Parenteral Nutrition (TPN)/Partial Parenteral Nutrition (PPN) operational manual revised, 9/24/24, showed:-Purpose: -To ensure that the facility meets the nutritional guidelines and residents' nutritional requirements per physician orders;-Policy: -A physician order is required to administer enteral tube feedings/total parenteral nutrition/partial parenteral nutrition. Commercial formula tube feedings will only be used for residents as prescribed; -Procedure: -The physician's order for enteral tube feedings, TPN, or PPN are considered diet orders and should be communicated by the nursing staff to the Nutrition Services Department utilizing the Diet Order & Communication Form. -Upon receipt of a Nutrition Communication Form for a resident to receive enteral tube feedings, TPN, or PPN, the dietary manager should contact the dietitian to review the nutritional adequacy of the order. -The physician order and information communicated to the Nutrition Services Department should include:-Type of formula. -Amount of formula and fluid; and; -Frequency and amount of feeding;-The manual did not address labeling the water flush bag, and/or head of bed requirements. 1. Review of Resident #9's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/26, showed:-admission date of 11/4/25;-Section K: -Feeding tube: -While a resident: Yes;-Diagnoses included aphasia (a condition characterized by either partial or total loss of the ability to communicate verbally or using written words), epilepsy (seizure disorder), malnutrition, and anxiety disorder. Review of the resident's medical record showed:-readmission date of 1/6/26; -Severely impaired cognition;-Additional diagnoses included Rett's syndrome (a progressive neurodevelopmental disorder that causes progressive loss of motor skills and language), scoliosis (a side-to-side curvature of the spine), adult failure to thrive, and cachexia (general weight loss and wasting occurring in the course of a chronic disease), gastrostomy status (surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage). Review of the resident's undated care plan, in use during the survey showed: -Focus: The resident requires tube feeding related to nothing by mouth (NPO) status. He/She aspirated in the past;-Goal: The resident's insertion site will be free of signs and symptoms of infection through to the review date. The resident will maintain adequate nutritional and hydration status, as evidenced by weight stable, no signs or symptoms of malnutrition or dehydration through review date;-Interventions: Clean insertion site daily as ordered, monitoring for signs and symptoms of infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to physician if symptoms arise. Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. Every shift check residual before medication administration. If residual volume is greater than 60 milliliters (ml), hold feeding and notify Physician. Every shift, continuous enteral on at 8 P.M. and off at 8 A.M. Formula: [NAME] Farms 1.4; Rate: 60 ml an hour, times12 hours a day to provide a minimum volume of 720 ml a day. Provides 1,008 calories, 45 grams of protein, and 1,016 ml. Every shift flush enteral tube with 30 mls water pre/post medication administration and 5-10 mls water between each medication. Every shift for g-tube status related to gastrostomy status, flush enteral tube every four hours with 100 mls water. Every shift may hold tube feeding for activities of daily living (ADL) care, medication administration, gastrointestinal (GI) rest, activities and per resident request for up to four hours a day. Document how long tube feeding was held each shift in supplemental documentation. Every day shift cleanse g-tube site. Monitor/document/report to Physician as needed (PRN): aspiration- fever, shortness of breath (SOB), tube dislodged, infection at tube site, self-extubation (removal of the tube), tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Obtain and monitor lab/diagnostic work as ordered. Report results to Physician and follow up as indicated. Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate). Give 30 ml via g-tube two times a day for weight maintenance. Registered Dietician (RD) to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The resident is dependent on staff for all g-tube. See Physician orders for current feeding orders. Speech therapy (ST) evaluation and treatment as ordered. The resident is dependent with tube feeding and water flushes. He/She needs the heads of bed (HOB) elevated 30 degrees during and thirty minutes after the tube feed. Two times a day, [NAME] Farms 1.4 times 325 ml (one carton) times two bolus feeds a day (at lunch and dinner) with 70 ml free water flush before and after each bolus administration. Review of the resident's electronic physician order sheet (ePOS), dated March 2026 showed:-An order, dated 11/4/25, for every night shift, check total volume infused every 24 hours on night shift (12:00 A.M.). Enter total in supplemental documentation;-An order, dated 1/2/26, for every night shift, for g-tube status change, enteral tubing, bag, and syringe at the beginning of formula infusion each day;-An order, dated 1/18/26, for every shift, continuous enteral on at 8 P.M., and off at 8 A.M., Formula: [NAME] Farms 1.4, rate: 60 ml an hour, times 12 hours a day to provide a minimum volume of 720 ml a day. Provides 1008 calories, 45 grams of protein, and 1016 ml;-An order, dated 1/23/26, for every shift, flush enteral tube every four hours tube feeding is running with 100 ml of water;-An order, dated 11/4/25, every shift, flush enteral tube with 30 ml of water, pre/post medication administration and 5-10 ml water between each medication;-An order, dated 11/4/25, every shift, head of bed up 30 degrees while in bed;-An order, dated 11/4/25, every shift may hold tube feeding for ADL care, medication administration, GI rest, activities and per resident request for up to four hours a day. Document how long tube feeding was held each shift and supplemental documentation;-An order, dated 1/18/26, for two times a day [NAME] farms 1.4 times 325 ml (one carton) times two bolus feeds a day (at lunch and dinner) with 70 ml free water flush before and after each bolus administration provides 910 calories 40 grams of protein and 926 ml;-An order, dated 3/13/26, every shift, head of bed up 30 to 45 degrees while in bed. Observations of the resident showed:-On 3/11/26 at 7:47 A.M., the resident lay in his/her bed in his/her room, with the head of bed elevated. The tube feeding pump was on and attached to the resident. The tube feeding formula bag was labeled showed no rate documented on the tube feeding formula bag and no label for the water flush bag; On 3/12/26 at 7:48 A.M.; The resident sat in his/her stroller in his/her room. The tube feeding pump was on and attached to the resident. The tube feeding formula bag was labeled. The resident's tube feeding pump showed cassette error on the pump and no label for the water flush bag; -On 3/13/26 at 8:00 A.M. and 8:25 A.M., the resident lay in his/her bed awake. The tube feeding pump was on and attached to the resident. The resident lay at the foot of his/her bed while his/her head rested on the foot rail. The water flush bag was not labeled. During an interview on 3/13/26 at 8:25 A.M., Licensed Practical Nurse (LPN) G said he/she was not the resident's nurse, but he/she was familiar with the resident. The head of the resident's bed was elevated, but the resident's head was not elevated, but it should have been. The head of the bed should have been elevated to a 30-to-45-degree angle. The resident moves around a lot. When LPN G has worked with the resident, he/she would normally report to work between 7:30 A.M. and 8:00 A.M., because the resident's tube feeding should be shut down at 8:00 AM, and LPN G could have the Certified Nurse's Assistant (CNA) get the resident up. When the resident is in his/her stroller, he/she does very well and doesn't move around as much, like he/she does in the bed. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed:-admission date of 1/6/26;-readmission date of 1/31/26;-Intact Cognition;-Section K: -Feeding tube: -While a resident: Yes;-Diagnoses included dementia, bipolar disorder (a major mental disorder characterized by episodes of mania, depression, or mixed mood), hypertension (high blood pressure), deep venous thrombosis (DVT, a serious condition where a blood clot forms in a deep vein), hyperlipidemia (high cholesterol), diabetes, chronic obstruction pulmonary disease (COPD, lung disease), and malnutrition. Review of the resident's undated care plan, in use during the survey showed his/her g-tube not addressed. Review of the resident's ePOS, dated March 2026 showed:-An order, dated 2/26/26, for enteral feed every 12 hours. May use Jevity 1.5 tube feeding until Osmolite 1.5 is delivered. Start at 8:00 P.M., off at 8:00 A.M., at 35 ml for 12 hours;-An order, dated 2/1/26, for every four hours, 60 mls water flush every four hours; -An order, dated 2/1/26, every night shift, change enteral tubing, bag and syringe at the beginning of formula infusion each day;-An order, dated 2/1/26, every shift, check residual before medication administration. If residual volume is greater than 60 ml, hold feeding and notify physician;-An order, dated 2/1/26, every shift, flush enteral tube with 30 ml of water, pre/post medication administration and 5-10 ml water between each medication;-An order, dated 2/1/26, every shift, HOB up 30 degrees while in bed;-An order, dated 2/1/26, in the evening the Osmolite 1.5 tube feeding at 35 ml/ an hour per g-tube for 12 hours; Observations of the resident showed:-On 3/12/26: -At 7:55 A.M., the resident in his/her bed asleep, with the head of the bed elevated. The tube feeding pump was on and attached to the resident. The feeding formula was infusing. The water flush bag was not labeled; -At 10:15 A.M., the resident in his/her bed asleep with the head of the bed elevated. The tube feeding pump was on and attached to the resident. The g-tube was flushing. The tube feeding pump showed flushing, 100 ml every four hours. The water flush bag was not labeled; -At 11:50 A.M. the resident in his/her bed awake with the head of the bed elevated. The tube feeding pump was on and connected to the resident. The water flush bag was not labeled;-On 3/13/26: -At 8:17 A.M. and 8:25 A.M., the resident in his/her room in his/her bed asleep with the head of bed slightly elevated, approximately 15 degrees. The tube feeding pump was on and connected to the resident. The g-tube was flushing. The tube feeding pump showed flushing, 100 ml every four hours. The water flush bag was not labeled. During an interview on 3/13/26 at 8:25 A.M., LPN G said it looked like to him/her that the head of the resident's bed was not elevated enough. It looked like it was elevated to 15 to maybe 30 degrees. It should had been elevated at least 45 to 90 degrees. It should be 45 and 90 degrees to prevent the resident from aspirating and/or choking possibly. When a resident has a g-tube, both the tube feeding formula bag as well as the water flush bag should include the resident's name, the formula name, the time and date the item was hung, as well as rate and how often. 3. During an interview on 3/13/26 at 4:06 P.M., with the Administrator and the Director of Nursing (DON), the DON said the head of bed should be elevated to 30 to 45 degrees when the resident is receiving a tube feeding. The water flush bag, just like the tube feeding formula, should be properly and accurately labeled to include, the resident's name, date, time hung, the person hung it, as well as the rate and how often. The tube feeding formula and the water flush bag needs to be labeled for tube feeding to ensure the proper amount is being infused per physician orders.

Based on observation, interview, and record review, the facility failed to ensure one resident had weekly skin assessments completed, and was repositioned and cleaned after being incontinent of urine for an extended period. The facility failed to ensure treatments orders were accurate and completed on a newly identified pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) (Resident #28). The sample size was 18. The census was 53.Review of the facility's Pressure Injury Prevention policy, last revised, June 2020, showed:-Purpose: To identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure injury and minimize complications;-Policy: The facility will identify residents at risk for pressure injuries and provide care and services to promote the prevention of pressure injury development;-Procedure:--Risk identification and assessment:---The licensed nurse will compete a Braden Scale assessment (an assessment tool used to identify pressure injury risk) upon admission and quarterly to identify resident at risk for skin breakdown;---The licensed nurse will conduct a skin assessment for a resident upon admission, readmission, weekly, and as needed; Results of the weekly skin assessment will be documented in the electronic medical record (EMR);---If the resident is identified as having a wound any time other than admission, the wound monitoring record will be implemented for each identified wound;---Certified Nursing Assistants will inspect the resident's skin during activities of daily living (ADL) care and report unusual findings to the licensed nurse. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed b facility staff, dated, 12/22/25, showed:-Severe cognitive impairment;-Impairment on one side of upper and lower extremity;-Dependent on staff for toilet hygiene, bathing, personal hygiene, upper and lower body dressing;-Requires maximum assist rolling left and right;-Frequently incontinent of bowel and bladder;-Diagnosis included dementia, depression and hemiplegia (weakness to one side of the body).-The resident is at risk for pressure injury and has no unhealed pressure injuries;-The resident is not on a turning or repositioning schedule and does not have a pressure relieving device for the chair. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has self-care activities of daily living performance deficit related to hemiplegia, dementia and pain.-Interventions: The resident is totally dependent of staff for toilet use, personal hygiene, dressing, transfers and bathing.-Focus: The resident is at risk for pressure ulcer development related to having a history of pressure ulcers, impaired mobility, incontinent of bowel and bladder, at times wearing two incontinent products at time, rejection of care, and contractures;-Interventions: Follow facility policies and protocols for the prevention of skin breakdown; Notify the nurse immediately of any new areas of skin breakdown; Redness, blisters, bruises, discoloration noted during bath or daily care; Pressure reducing mattress in place. Review of the resident's Braden score risk assessment, dated, 12/22/25, showed the resident is at moderate risk of developing a pressure wound. Review of the facility wound report dated, 1/1 through 3/9/26 did not have the resident listed. Review of the resident's skin assessment, dated, 2/16/26, showed:-The resident had no skin impairments;-No further skin assessments were available to review. Observation and interview on 3/10/26 at 12:45 P.M., showed the resident lay in bed, eating his/her lunch tray. The resident had a strong odor of urine and when he/she raised his/her left arm, the resident had strong body odor. Certified Medicine Technician (CMT) J administered the resident's medication. At 12:55 P.M., Certified Nursing Assistant (CNA) B and CNA I came into the room and turned the resident to his/her left side. The resident's brief, two quilted bed pads and fitted sheet were saturated with urine. CNA B said, Whew, that's a lot when the resident was turned. The resident had an open wound to his/her right buttock that was approximately the size of a quarter with a red wound bed. The resident also had an open wound on his/her left inner buttock, the size of a dime, with a red wound bed. Both wounds did not have a dressing. CNA B said the last time he/she checked on the resident was around 8:00 A.M. CNA B said he/she did not want to disturb the resident this morning because he/she was sleeping and frequently is in pain. CNA B and CNA I said the open areas were new. At approximately 1:15 P.M., Licensed Practical Nurse (LPN) G entered the room and observed the resident's buttocks. LPN G said the wounds were new and would consider the wounds to be stage two (partial thickness skin loss that appears shallow, open, and red). Review of the resident's treatment administration record (TAR), dated 3/1 through 3/31/26, showed:-An order dated, 3/10/26, cleanse wound to right buttock with wound cleaner, pat dry, apply collagen sheet (a specialized dressing) cut to size of wound, cover with dry dressing, daily, until healed;-On 3/11/26, the right buttock wound treatment was documented as not completed;-No treatment order noted for the resident's left inner buttock wound. During observation and interview on 3/12/26 at 10:45 A.M, CNA I assisted the resident to stand in the bathroom. The resident held onto the bathroom rail and CNA I lowered the resident's pants and incontinent brief. There was no dressing to the resident's right buttock wound or left buttock wound. CNA B said he/she would go tell the nurse that there was no dressing. CNA I said there was no dressing to the resident's wound when CNA I assisted the resident with getting dressed at 7:30 A.M. CNA I wasn't sure if he/she told the nurse about the missing dressing at that time. During an interview on 3/13/26 at approximately 2:00 P.M., CNA I said incontinent residents should be checked every two hours and the resident has never refused care for him/her. During interviews on 3/12/26 at 10:50 A.M. and 12:15 P.M., LPN A said the residents' weekly skin assessments should be completed in the EMR under the assessment tabs. Even if there are no skin issues, the assessment form was required to be completed. There was some confusion as to who is to complete the treatments. LPN A thought the Assistant Director of Nursing (ADON) was going to be the facility Wound Nurse and was responsible for the wound treatments. If the Wound Nurse did not complete the treatments, then it was the responsibility of the floor nurse to complete the treatments. The resident being left and not repositioned for extended periods of time probably contributed to the resident developing the pressure wound. There should be two treatments orders in for the resident. The resident has two pressure wounds. The CNAs should let the nurse know immediately when a dressing is missing to a resident's wound. LPN A was not made aware that the dressing was missing at 7:30 A.M. All incontinent residents should be checked on and repositioned every two hours. During an interview on 3/13/26 at 3:50 P.M., the Director of Nursing (DON) said she expected staff to check on all incontinent residents every two hours. Skin assessments should be completed by the floor nurse in the EMR weekly. The ADON was going to be the facility Wound Nurse, but the ADON has quit this week. The DON expected the floor nurses to complete wound treatments when the Wound Nurse was not available. The resident had two separate wounds, and there should be two treatment orders. The DON expected the CNAs to inform the nurse immediately when a dressing was missing.

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by not obtaining dressing change orders on admission and transcribing the wound physician orders for one resident (Resident #57). The sample was 18. The census was 53.Review of facility's physician order policy, last revised, June 2020, showed:-Purpose: This will ensure that all physician orders are complete and accurate;-Procedure:--A licensed nurse will transcribe telephone orders with date, time, and signature of the person receiving the orders;--Orders will include a description complete enough to ensure clarity of the physician plan of care;--Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order;--Medication and treatment orders will be transcribed onto the appropriate resident administration record;--Documentation pertain to physician orders will be maintained in the resident's medical record, current month's administration will be maintained in the medication administration record (MAR) and the treatment administration record (TAR). Review of the Resident #57's medical record showed:-An admission date 3/2/26;-Diagnoses included osteomyelitis (infection in the bone) the vertebra (multiple bones that make up the spine) and thoracic (rib cage) region, encounter for surgical aftercare following surgery on the nervous system (brain, spinal cord, and nerves) and diabetes. Review of the resident's baseline care plan, dated, 3/2/26, did not address the resident's surgical incision. Review of the resident's progress noted dated, 3/2/26, at 3:00 P.M., the resident has a surgical incision with a dressing. The resident has sutures noted to back and spine. The dressing is noted as clean, dry and intact. No active bleeding or drainage noted. Review of the resident's physician wound assessment report dated, 3/5/26, showed:-Location: Bilateral (both) midline back;-Etiology (cause): Surgical;-Treatment: Clean wound with normal saline; apply calcium alginate (a highly absorptive specialized dressing) and Mupirocin (medication used to treat infections) ointment and cover with dry dressing, daily. Review of the resident's physician order sheets, dated, 3/2 through 3/9/26, showed no dressing change orders for the resident's surgical back incision. During an observation and interview on 3/9/26 at 12:30 P.M., the resident lay in bed. The resident said his/her dressing had not been changed since the doctor changed it on 3/4/26. Certified Nursing Assistant (CNA) D assisted the resident to his/her left side and the resident's upper back had a large white dressing on it. The dressing was not dated. CNA D said the dressing was not dated. Observation on 3/10/26 at 2:50 P.M., showed the resident lay in bed. The resident said his/her dressing was not changed since 3/4/26. Licensed Practical Nurse (LPN) C assisted the resident by turning him/her to his/her left side. The resident had a large, white dressing to his/her upper back dated 3/8/26. The dressing had a moderate amount of yellow drainage on the dressing. The dressing was loose, and LPN C lifted the corner of the dressing, which showed sutures and staples were to the resident's upper back. There was redness to the suture and staple line. During an interview on 3/11/26 at 12:15 P.M., LPN A said he/she admitted the resident when he/she arrived at the facility. LPN A placed the medication orders in the system, and the evening nurse was responsible for obtaining dressing change orders from the wound physician. LPN A said the evening nurse did not obtain the dressing orders on admission. A nurse or the Assistant Director of Nursing (ADON) make rounds with the wound physician on Thursdays and place the recommended wound treatments in the resident's orders. All dressings should be dated when they are changed. During an interview on 3/13/26 at 3:50 P.M., the Director of Nursing (DON) said she expected the nurses to enter a dressing change order into the system on admission. She would expect the wound physician orders to be transcribed into the resident's medical record by the nurse rounding with the physician. She expected the dressings to be accurately dated when changed. The ADON was responsible for ensuring the wound orders were in place and that the treatments were being completed. The ADON quit this week. The floor nurses were currently responsible for obtaining the orders and completing wound treatments.

Based on observation, interview, and record review, the facility failed to ensure bathrooms on the second floor were cleaned routinely, affecting one of 18 sampled residents (Resident #10). The sample was 18. The census was 53 Review of the facility's Housekeeping policy, dated 8/2020, showed:-Purpose: To ensure that the facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors;-Policy: All rooms of the facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents;-Procedure: The housekeeping department is responsible for completing the daily, weekly, and monthly cleaning procedures. 1. Observations of the second floor bathrooms, on 3/9/26 at 9:57 A.M., showed:-The toilet in the bathroom by the emergency exit door had brown and yellow matter on the seat. A strong bowel movement (BM) odor permeated from the bathroom;-The shower room floors had various dark stains. Small hairs were on the ground of the shower in various areas. The toilet seat had brown matter smeared on it;-The bathroom across from the nurse's station had a strong BM odor. The toilet seat dirty with dark matter smeared on it. The toilet contained toilet paper with a brown substance in it. Observations of the second floor bathrooms on 3/12/26, showed:-At 8:35 A.M., the shower room toilet unflushed with toilet paper and urine in the toilet and on the seat. The shower floor had various hairs and dark matter stains;-At 11:24 A.M., the shower room toilet had brown smears on it and a strong BM odor. The floor of the shower had hair and various dark matter stains. 2. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/14/26, showed:-Diagnoses included multiple sclerosis (MS, autoimmune disease) and insomnia;-Cognitively intact. During an interview on 3/9/26 at 9:20 A.M., the resident said the bathrooms on the second floor are dirty and are not cleaned often enough. There is only one shower room open and the shower is dirty sometimes. 3. During an interview on 3/13/26 at 8:16 A.M., Licensed Practical Nurse (LPN) G said he/she expected the toilets and showers on the second floor to be clean for residents to use them. The housekeeping staff is responsible for cleaning the bathrooms. He/She did not believe there were enough housekeeping staff and that is why the bathrooms are often dirty. 4. During an interview on 3/13/26 at 1:53 P.M., Housekeeper H said there is normally one housekeeper assigned to clean the second floor. Bathrooms are expected to be cleaned on each housekeeping shift. He/She expected the toilets and showers to be clean. 5. During an interview on 3/13/26 at 4:43 P.M., the Administrator and Director of Nursing (DON) said they expected bathrooms to be clean to prevent infection control issues. They expected showers and toilets to be clean. The housekeeping staff were responsible for cleaning the bathrooms at least once a day and as needed. 27924362788490

Based on interview and record review, the facility failed to offer and vaccinate eligible residents for pneumococcal pneumonia (pneumonia caused by bacteria) for two out of five residents reviewed (Resident #2 and Resident #27), and influenza (flu) vaccine for one out of five residents (Resident #4) sampled for immunizations. The census was 53.Review of the facility's Pneumococcal Disease Prevention policy, last revised, June 2020, showed:-Purpose: To ensure that the facility prevents and control the spread of pneumococcal disease in the facility;-Policy: -The facility will offer training to facility staff upon hire and inform residents on precautions and best practices to control the infection and spread pneumococcal disease in the facility; -The pneumococcal vaccine is recommended for all adults 65 ears of age and older; -Before offering the pneumococcal immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; -The resident or the legal representative has the opportunity to refuse immunization, with such refusal being noted in the resident's medical record; -The resident medical record includes documentation that indicated, at a minimum, the following: -That the resident or resident's legal representative was provided education regarding the benefit and potential side effects of pneumococcal immunization; -That the pneumococcal vaccination- informed consent or refusal will be placed in the resident's medical record; -That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contradictions or refusals. Review of the facility's Influenza Prevention and Control policy, last revised, June 2020, showed:-Purpose: To ensure that the facility prevents and controls the spread of influenza;-Policy: -The facility will offer training to facility staff upon hire and inform residents on precautions and best practices to control the infection and spread influenza in the facility; -Before offering the influenza immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; -Residents are offered an influenza immunization during the flu season annually, unless the immunization is contraindicated, or the resident has already been immunized; -The resident or the legal representative has the opportunity to refuse immunization, with such refusal being noted in the resident's medical record; -The resident medical record includes documentation that indicated, at a minimum, the following: -That the resident or resident's legal representative was provide education regarding the benefit and potential side effects of influenza immunization; -That the influenza vaccination- informed consent or refusal will be placed in the resident's medical record; -That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contradictions or refusals. 1.Review of Resident #2's medical record showed:-Diagnoses included heart failure, chronic obstructive pulmonary disease (COPD), a lung disease, and kidney disease;-No documentation the resident received the pneumococcal vaccine, and no documentation staff offered the vaccine or vaccine education to the resident. 2.Review of Resident #27's medical record showed:-Diagnoses included COPD and high blood pressure;-No documentation the resident received the pneumococcal vaccine, and no documentation staff offered the vaccine or vaccine education to the resident. 3. Review of Resident #4's medical record showed:-Diagnoses included kidney disease, Parkinson's disease, Myasthenia Gravis (an auto immune disease that affects the muscles), diabetes, and bladder cancer.-No documentation the resident received the influenza vaccine, and no documentation staff offered the vaccine or vaccine education to the resident. During an interview on 3/13/26 at 3:50 P.M., the Director of Nursing (DON), who is also the Infection Preventionist (IP), said all residents should be offered the influenza yearly. All residents should have the pneumococcal vaccine offered if eligible. Refusals of the vaccines and any education provided should be documented in the resident's medical record. All vaccines administered to the resident should be documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to provide cardiopulmonary resuscitation (CPR, life saving measures) effectively to include rescue breaths, to a resident when the supplies needed to run a code were not available on the crash cart. This resulted in a delay of up to 9 minutes from the time CPR was initiated until rescue breaths and oxygen could be administered, for one resident (Resident #1). Staff were not knowledgeable on how to work the suction machine, resulting in an occluded airway. In addition, staff failed to ensure Emergency Medical Services (EMS) was in the room and ready to take over compressions before stopping CPR. Eighteen residents were identified to be a full code. The census was 48. The Interim Administrator was notified on [DATE] at 2:50 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's Medical Emergencies - Code Blue, policy, dated [DATE], showed:-Purpose: To ensure the prompt and effective response by facility personnel during medical emergencies through the use of the Code Blue procedure;-The facility will provide an appropriate level of response to the resident during medical emergency;-A medical emergency is defined as any of the following conditions requiring immediate medical intervention and the initiation of the Code Blue procedure:--Respiratory or Cardiac Arrest;-The facility will perform CPR in accordance with the guidelines set forth by the American Heart Association (AHA);-Once CPR is initiated, it will continue until paramedics arrive;-First Responder:--The first of facility personnel to arrive and find a resident with any of the above conditions will:---Call for help;---Send available staff to call a Code Blue and retrieve emergency medical equipment;---Assess the resident's level of consciousness, circulation, airway, and breathing; begin CPR according to current practice. Note: The first responder should not leave the victim to call for help unless absolutely necessary according to the situation;---When the second responder arrives, have the second responder place the cardiac arrest board under the resident and assist with two-rescuer CPR.-Subsequent Responder(s):--Activate the Emergency Response System - Call 911;--Direct all needed personnel to the Code Blue site;--Send a staff member to the entrance door to wait where the ambulance is expected to arrive;--The Registered Nurse (RN) to respond will lead the code unless responsibility is transferred to another licensed staff member;--Note: One person CPR will be maintained until there is a second responder available to begin two person CPR;---CPR will continue until the paramedics arrive and assume responsibility;-Licensed Nurse:--In the absence of an Attending Physician, it will be the responsibility of the first licensed staff member responding to the code to lead and coordinate the resuscitation efforts until paramedics arrive. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:-Severe cognitive impairment; -Diagnoses included pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction), sepsis (infection in the blood), dysphagia (inability to swallow), and aphasia (inability to speak or understand). Review of the resident's care plan, in use at the time of survey, showed: -Focus: Full code;-Goal: Initiate CPR;-Interventions: Signed proper documents, consult nurse staff on changes in health. Review of the resident's electronic Physician Order Sheet, (ePOS), showed an order, dated [DATE], for full code status. During an interview on [DATE] at 2:53 P.M., Licensed Practical Nurse (LPN) B said usually night shift checks the crash cart, but he/she did not see a sign off sheet on the cart for verification. Review of the crash cart check list showed an Ambu bag (self-inflating resuscitator) with mask and oxygen tank listed as items that should be on the crash cart. Staff initialed all supplies available on [DATE]. Review of the AHA Adult Basic Life Support Algorithm for Healthcare Providers, dated 2020, showed:-Check for responsiveness;-Look for no breathing or only gasping and check pulse;-If no breathing or only gasping, pulse not felt: Start CPR;-Perform cycles of 30 compressions and two breaths. Use Automated External Defibrillator (AED) as soon as it is available. Review the AHA CPR Science Based Guidelines, dated 2025, showed:-CPR - is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest;-For healthcare providers and those trained: conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30 compressions to two breaths. In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120 per minute and to a depth of at least 2.0 inches (5.0 centimeters) for an average adult. Observation on [DATE] at 2:20 P.M., showed during the resident's wound care, the Wound Doctor exited the room and the Director of Nursing (DON) remained with the resident. The resident stopped breathing. The DON checked the resident for breaths and a heartbeat. He then began chest compressions. At 2:21 P.M., LPN B brought the crash cart to the room followed by LPN A with the backboard. The Wound Doctor responded to the room. The DON continued chest compressions, but no rescue breaths were provided because an Ambu bag was not available on the crash cart. At 2:24 P.M., staff connected the oxygen tubing and searched the crash cart and said they could not locate the pen needed to turn on the oxygen tank, so no oxygen was being administered. Chest compressions continued, no rescue breaths given. At 2:26 P.M., a staff member brought an AED to the room, CPR was paused as the AED was applied. The AED said, no pulse found. Chest compressions continued. At 2:28 P.M., the AED instructed staff to administer two breaths. LPN B searched through the crash cart and said there was no mask for the Ambu bag, so no breaths were given. Chest compressions continued. At 2:29 P.M., staff returned with the Ambu mask, attached it to the Ambu bag, and two breaths given via the Ambu bag. CPR continued. At 2:31 P.M. fire/EMS arrived outside of the room. Staff stopped CPR before fire/EMS was ready to take over. Fire/EMS personnel entered the room, and no CPR was in progress. EMS asked if they were calling it staff said the resident still needed CPR. At 2:32 P.M., Fire/EMS resumed CPR. At 2:56 P.M, EMS exited the room. During an interview on [DATE] at 11:10 A.M., the DON said at the time he started CPR, the resident had no pulse and no respirations. He verified before starting. He could not palpate a pulse. During an interview on [DATE] at 2:53 P.M., LPN B said he/she is the one who got the crash cart. When attempting to set up the Ambu-bag, the mask was not on the cart. He/She had to get it from the nurse's desk. By the time he/she got back, the DON and Wound Doctor had connected the AED and were opening suction. During an interview on [DATE] at 2:58 P.M., LPN A said when attempting to get the Ambu-bag ready, he/she could not locate the mask that attached to the bag. It was not on the cart, so LPN B ran to get it. He/She was attempting to get the oxygen set up, but he/she could not find the pen needed to turn on the oxygen tank. The resident expired. During an interview on [DATE] at 12:50 P.M., the Wound Doctor said the AHA requires two respirations with every 30 beats. There should have been rescue breaths provided. He was not sure if a delay of breaths would have changed the outcome for this resident because the resident had a lot of secretions in his/her mouth, so he/she needed suction more than anything. The breaths would not have made it through to his/her lungs. During an interview on [DATE] at 1:18 P.M., LPN A said during the code, he/she was working on setting up the oxygen tank. They oxygen needs the key to get the oxygen on. He/She found the key in a sandwich bag. He/She was able to get the oxygen on and working, but there was a delay in getting the oxygen to the resident because it was connected to the Ambu bag and there was a delay in getting the mask. After the oxygen was set up, he/she then started working on setting up the suction machine. Once he/she got it set up, he/she tested it with some saline, and it was not working. Nothing came through when he/she tested it. He/She even put his/her hand over the end to get the suction to work, but he/she was never able to get it to work. Then 911 came and that is the last he/she did with it. He/She was never able to use the suction on the resident, and he/she did not recall anyone else using the suction. It took about five minutes to get to set up, and it did not work. During an interview on [DATE] at 10:01 A.M., with the DON and Interim Administrator, the DON said he was the one running the code. His responsibility in running the code is to assign duties and make sure proper compression are given, proper rate, etc. Breaths should be given at a rate of two every 30 compressions. During the code, staff were eventually able to give breaths, but initially they did not have the mask available to give breaths. He was not sure why there was no mask. Regarding the checklist, the check list does show that staff checked off the mask was present on the crash cart during the check on the [DATE]. Night shift are the ones who check the crash cart. It is a concern that staff marked the mask as available when it was not. He noticed the resident was not breathing and he was aware of his/her code status. The pen/key needed to turn on the oxygen was available on the cart and he would expect staff to know how to use it to turn on the oxygen tank. It was located on the side of the crash cart. Staff were able to eventually get the oxygen flowing during the code. When EMS arrives, compressions should continue until they are ready to take over. If stopped too soon, there is a risk of delay in compressions and potentially death. During an interview on [DATE] at 1:40 P.M, the Medical Director said he was informed after the fact the resident was coded, and staff was unsuccessful in resuscitation. He expects the facility staff to follow policy and AHA standards of practice when giving CPR. Depending on the situation, if the resident has excess secretions, suction could be beneficial to clear the airway, but it depends on what is most urgent at the time. In general, research says rescue breaths are beneficial if they can be completed while also maintaining routine compressions. NOTE: At the time of the abbreviated 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).

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to prime pre-filled insulin pens before insulin administration for two residents (Residents #6 and #4). The sample was 7. The census was 48. Review of the facility's Medication Administration of Insulin policy, revised May 2014, showed: -Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes;-The type of insulin, dosage requirements, strength, method of administration must be verified before administration, to assure that if corresponds with the order on the medication sheet and the physician's order;-The policy did not address the use of insulin pens. 1. Review of Resident #6's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/25/25, showed:-Cognitively intact;-Diagnoses included diabetes, obstructive sleep apnea (OSA), adult failure to thrive, obesity, and kidney disease. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident has diabetes and is insulin dependent;-Goal: Resident will have no complications related to diabetes through the review date;-Interventions included: Educated on diabetes chronic disease, monitor for hypoglycemia (low sugars)/hyperglycemia (high sugars) symptoms. Review of the electronic Physician Order Sheet (ePOS), showed an order, dated 4/22/25, for insulin aspart (short-acting insulin)100 Units (U)/milliliters (ml), inject 12 U subcutaneously before meals. Review of the manufacturer's guidelines for prefilled insulin pens, undated, showed:-Do an air shot before each injection. Before each injection, a small amount of air may collect in the cartridge. To avoid injecting air and ensure proper dosing, an air shot must be completed before each injection;-Turn the dose button to select four U with a new cartridge or one U with a cartridge already in use;-Hold the pen with the needle pointing up. Tap the cartridge holder gently with finger a few times to make sure any air bubbles collect at the top of the cartridge;-Keep the needle pointing up, press the dose button, all the way in, until a click is heard or felt. The display will return to zero. A drop of insulin must appear at the needle tip. If a drop of insulin at the needle tip is not seen, repeat the steps until a drop of insulin is at the needle tip;-It is very important that a drop of insulin is seen at the needle tip before injection. This will ensure accurate dosing. Observation on 12/18/25 at 8:32 A.M., showed License Practical Nurse (LPN) A sanitized his/her hands and put on a fresh pair of gloves. LPN A wiped the prefilled insulin pen with an alcohol pad and placed a needle onto the pen. LPN A did not prime the insulin pen. LPN A dialed the pen to 12 U and administered the insulin to the resident while he/she was halfway through eating breakfast. During an interview on 12/19/25 at 7:47 A.M., LPN A said he/she was unaware if he/she primed the insulin pen before administering the medication. 2. Review of Resident's #4's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnosis includes peripheral vascular disease (poor circulation), cognitive communication deficit (inability to understand or express impaired thinking), protein-calorie malnutrition (inadequate intake of protein and calories), infection of the skin and subcutaneous tissues (common bacterial on skin), diabetes, and kidney disease. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident has diabetes and requires hypoglycemic medication daily;-Goal: Resident will have no complications related to diabetes through the review date;-Interventions included: Educated on diabetes chronic disease, fasting serum blood sugars as ordered by doctor. Review of the ePOS, showed an order, dated 9/16/25, for Basaglar KwikPen (insulin glargine, long-acting insulin), subcutaneous solution pen-injector 100 U/ml, inject 15 U subcutaneous in the morning. Review of the manufacture's guidelines for KwikPen Pre-Filled Insulin Pen, dated November 2022, showed:-Prime before each injection;-Priming then pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly;-If the pen is not primed before each injection, you may get too much or too little insulin;-To prime the pen, turn the dose knob to two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding the pen with needle pointing up. Push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Observation on 12/19/25 at 8:12 A.M., showed LPN B did not prime the insulin pen before administering the insulin to the resident. During an interview on 12/19/25 at 8:12 A.M., LPN B said he/she did not prime the insulin pen before using it on the resident. The purpose of priming first is to ensure the pen is functional prior to administering insulin. During an interview on 12/19/25 at 12:03 P.M., the Director of Nursing (DON) said he expects staff to prime insulin two units, per the facility's policy. The needle hub is filled up with air and by not priming it, the residents received air instead of the recommend dose of insulin ordered. 2694223

Based on observation, interview and record review, the facility failed to protect each resident's right to be free from any physical restraint when Resident #2 was found by staff with the sleeves of his/her long sleeve shirt tied together at the end, preventing freedom of movement, and resulted in limiting normal access to the use of his/her hands. The census was 48.Review of the facility's Restraints policy, dated 6/2020, showed:-Purpose: Residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used;-Physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed rails, beds against walls, restrictive clothing, etc.;-The facility will ensure that restraints will not be imposed for purposes of discipline or convenience;-Restraints may only be used if/when the resident has a specific medial symptom that cannot be addressed by another less restrictive intervention and a restraint is required to treat the medical symptoms, protect the resident's safety, and help the resident attain the highest level of his/her physical or psychological well-being. During an interview on 12/18/25 at 1:00 P.M., the Interim Administrator said Resident #2 was found by the day shift Certified Nurse Assistant (CNA) today with his/her hands tied. The resident was wearing a long-sleeved shirt and was in bed. Review of Resident #2's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 6/14/25, showed:-Resident is rarely/never understood;-Severely impaired cognitive skills for daily decision making;-Physical behavioral symptoms directed towards others occurred 1 to 3 days;-Other behavioral symptoms not directed towards other occurred 1 to 3 days;-Behavioral symptoms impact on resident: Significantly interferes with the resident's care;-Functional limitation in range of motion impairment on both sides, upper and lower extremity;-Dependent for eating, oral hygiene, toileting hygiene, shower/baths, upper and lower body dressing, putting on/taking off footwear, and personal hygiene;-Dependent to roll left and right, char/bed-to-chair transfers, and tub/shower transfers;-Not attempted/resident did not perform activity: sit to lying, lying to sitting on side of bed, sit to stand, toilet transfer, walk 10 feet;-Always incontinent of bowel and bladder;-Primary medical condition category: Non-traumatic brain dysfunction (damage to the brain from internal causes like stroke, infection, lack of oxygen (anoxia/hypoxia), tumors, or toxins, rather than an external impact (like a fall or blow);-Diagnoses included hemiplegia or hemiparesis (weakness and/or paralysis on one side of the body), malnutrition, and anxiety disorder. Review of the resident's medical record, showed:-An order dated 6/23/25 to assist resident with dressing and undressing every shift related to limitations from diagnosis of hemiplegia and hemiparesis following a stroke affecting the left side;-No documentation of any type of restraint used;-No order for any type of physical restraint. Review of the resident's quarterly MDS, dated [DATE], showed:-Severely impaired cognition;-Physical behavioral symptoms directed towards others occurred 1 to 3 days;-Rejection of care occurred 1 to 3 days;-Functional limitation in range of motion impairment on both sides, upper and lower extremity;-Dependent for eating, oral hygiene, toileting hygiene, shower/baths, upper and lower body dressing, putting on/taking off footwear, and personal hygiene;-Dependent to roll left and right, char/bed-to-chair transfers, and tub/shower transfer;-Not attempted/resident did not perform activity: sit to lying, lying to sitting on side of bed, sit to stand, toilet transfer, walk 10 feet;-Always incontinent of bowel and bladder;-Primary medical condition category: Non-traumatic brain dysfunction;-Diagnoses included hemiplegia or hemiparesis, non-Alzheimer's dementia, malnutrition, and anxiety disorder. Review of the resident's care plan, last revised on 10/22/25, showed:-The resident has potential to demonstrate physical and verbal behaviors related to dementia with psychotic disturbances;--Goal: Will not harm self or others;--Interventions included: When he/she becomes agitated intervene before agitation escalates. Engage calmly in conversations;-Activity of daily living (ADL) self care performance deficit related to Alzheimer's disease;--Goal: maintain current level of function;--Interventions included: 1-2 staff participation for bed mobility. Totally dependent on staff for bathing, bed mobility, personal hygiene and dressing;-The care plan did not direct staff to use any form of restraint;-The care plan did not address the resident's behavior of rubbing his/her scalp until the area was bald. During an interview on 12/18/25 at 1:11 P.M., CNA F said he/she was the CNA assigned to the resident on the day shift. His/Her shift started at 7:00 A.M., and he/she did not get report from the off going CNA from night shift. He/She did not need to provide care to the resident until later in his/her shift. When he/she fed the resident breakfast, he/she just sat up the head of the bed and fed him/her. He/She did not have to uncover the resident. About an hour ago he/she went in to provide care, uncovered the resident, and saw the resident's sleeves were tied together at the wrist. The resident wore a long sleeve shirt, and his/her hands were inside the sleeves with the ends of the sleeves tied in a knot. It was not something that could have happened on accident. It was tied in knot that someone would have had to tie. The resident was in bed on his/her back. It looked like his/her hands were just down resting in front of him/her. He/She had the ability to raise and lower his/her arms together, but would not be able to use his/her hands. The resident does grab at times but does not hit. He/She moves around a lot and reaches for staff. He/She is not interviewable. He/She can talk, but has no recollection of things that happened even recently in the past so he/she could not say what happened. He/She did not appear to be in distress. Observation of the resident on 12/18/25 at 1:23 P.M., showed the resident in her room in a reclining medical chair. He/She was unable to answer questions. He/She wore a long sleeve shirt and his/her arms flung around. He/She rubbed the right side of his/her head in a repetitive manner with a large bald spot visible on the right side of his/her head where he/she was rubbing. CNA F said the resident rubbing his/her head was a behavior that he/she has, and the bald spot on the right side of his/her head was from rubbing. During an interview on 12/18/25 at 2:14 P.M., CNA G said today CNA F asked for assistance with the resident. They walked in the room and uncovered the resident, and both saw his/her shirt tied, the sleeves knotted. The knot was not something that could have been accidental. CNA G said he/she had not been in that room prior to that. He/She stayed with the resident while CNA F got the nurse. The nurse came back with him/her. Staff do everything for the resident, he/she is total care. He/she can talk some but could not say what happened overnight. During an interview on 12/18/25 at 1:26 P.M., with Licensed Practical Nurse (LPN) A and LPN B, LPN A said the resident is total care for all activities of daily living (ADLs) and transferring. He/She is incontinent. His/her bald spot is from the rubbing. LPN B said he/she is the nurse who responded to the resident's room when CNA F reported he/she found the resident's sleeves tied. He/She did go in once before that to give the resident his/her ordered medication and he/she was sitting up, covered up to his/her shoulder and the CNA was feeding him/her breakfast. His/Her arms were under the blanket. He/She assessed the resident. He/She does have bruising to the right side of his/her face and arm, but that was from a prior fall. No new injuries noted. The resident does have some behaviors. He/She yells out and is resistive to care at times. He/She will hit at times. During an interview on 12/19/25 at 6:26 A.M., CNA I said he/she worked on the other hall on the night shift on the night of December 17th through the morning of the 18th. He/She did not work on the resident's hall at all that night and did not know anything about the sleeves being tied. During an interview on 12/19/25 at 8:13 A.M., the Interim Administrator said the Director of Nursing (DON) called the night shift yesterday and interviewed them about the resident's sleeves being tied. During an interview on 12/19/25 at 8:18 A.M., the DON said when he talked to the resident's assigned CNA, CNA D said nothing unusual happened overnight. The resident was his/her normal talkative self when put to bed. He/She got the resident dressed in the morning. When he mentioned the resident's sleeves being tied together, CNA D said he/she did not know anything about it. During an interview on 12/19/25 at 8:26 A.M., LPN C said he/she was the resident's nurse on the night shift the night of December 17th through the morning of the 18th. He/She did not have to go into the resident's room. The resident does not need any nursing care on the night shift. The resident's door is always open, and he/she could be seen from the open door and seemed peaceful. No issue was reported to him/her regarding the resident. During an interview on 12/19/25 at 10:10 A.M., the Interim Administrator and DON said it was never determined who tied the resident's sleeves together. They would expect residents to be free from restraints.

Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining safe water temperatures in resident rooms on the North and South halls between 105 degrees Fahrenheit (F) and 120 F for 16 (Residents #49, #14, #12, #15, #54, #34, #8, #3, #27, #5, #43, #258, #18, #11, #52, and #40) of 31 sampled residents. The hot water temperatures in these resident room bathrooms ranged from 141 to 153 degrees F. The census was 55. The administrator was notified on 3/28/24 at 7:00 P.M., of an immediate jeopardy (IJ), which began on 3/28/24. The IJ was removed on 3/29/24 as confirmed by surveyor verification. Review of the facility's Safety of Water Temperatures Policy, dated December 2009, showed: -Policy Statement: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents; -Policy Interpretation and Implementation; -Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more that 105-120 degrees Fahrenheit, or the maximum allowable temperature per state regulation; -Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log; -Maintenance shall conduct periodic tap water temperature checks and record the water temperatures in a safety log; -If at any time water temperatures feel excessive to the touch, staff will report this finding to the immediate supervisor; -Direct-care staff shall be informed of risk factors for scalding/burns that are more common in the elderly, such as: -decreased skin thickness; -decreased skin sensitivity; -peripheral neuropathy; -reduced reaction time; -decreased cognition; -decreased mobility; -decreased communication; -The length of exposure to warm or hot water, the amount of skin exposed, and the resident's current condition affect whether or not exposure to certain temperatures will cause scalding or burns. Therefore, ongoing resident observation and assessment during prolong exposure to warm or hot water will help to determine the safety of the situation. 1. Observation on 3/28/24 between 8:30 A.M., and 2:00 P.M., of the hot water heater in the mechanical room, behind the oxygen room, showed: -Information on the water heater read, Temperature setting: -Low = 100 degrees F; -Triangle shape = 120 degrees F; -A = 130 degrees F; -B - 140 degrees F; -C = 150 degrees F; -D = 160 degrees F; -Hot = 170 degrees F; -Very hot = 180 degrees F; -Time to produce 2nd and 3rd degree burns on adult skin; -A = More than 30 seconds; -B = Less than 5 seconds; -C = 1 and 1/2 seconds; -D = 1/2 second; -Very Hot = Instantaneous. -The temperature gauge set on very hot. Observation on 3/28/24 between 10:30 A.M., and 2:00 P.M., of the hot water heater in the mechanical room, behind the linen room, showed the temperature gauge set between hot (170 degrees F) and very hot (180 degrees F). During an interview on 3/28/24 at 2:00 P.M., the Maintenance Director said the residents had been complaining of the water being too cold and he would go in and turn the water heaters up a notch each time someone complained about the temperatures. The hot water heater behind the oxygen room served the south hall rooms and the hot water heater behind the linen room served the north hall rooms. These were the only water heaters in the west building. During an interview on 3/28/24 at 2:20 P.M., the Corporate Regional Nurse acknowledged the gauge behind the oxygen room was set at very hot. It should not have been set that high. During an interview on 3/28/24 at 2:25 P.M., the Administrator acknowledged the water heater behind the linen room was set between hot and very hot. The Maintenance Director should not be turning up the temperature on the water heaters without checking the actual temperature of the water in the rooms. 2. Review of Resident #49's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/19/24, showed: -Moderately impaired cognition; -Diagnoses included dementia and Alzheimer's disease; -Walk 10 feet: Independent; -Walk 50 feet with two turns: Independent; -Walk 150 feet: Independent. Review of Resident #14's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: Cerebral infarction (stroke) with residual deficits; -Used a wheelchair/scooter; -Able to wheel 50 feet with two turns: Independent; -Wheel 150 feet: Independent. Observation of Resident #49 and Resident #14's shared bathroom on 3/28/24 at 10:50 A.M., showed the water temperature at the sink measured 142.7 degrees F, using a digital thermometer. 3. Review of Resident #12's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included dementia; -Used a wheelchair/scooter; -Able to wheel 50 feet with two turns: Dependent; -Wheel 150 feet: Dependent. Review of Resident #15's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included dementia; -Used a wheelchair/scooter; -Able to wheel 50 feet with two turns: Independent; -Wheel 150 feet: Independent. Observation of Resident #12 and Resident #15's shared bathroom on 3/28/24 at 11:01 A.M., showed the water temperature at the sink measured 144.6 degrees F, using a digital thermometer. 4. Review of Resident #54's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included seizures; -Walk 10 feet: Supervision; -Walk 50 feet with two turns: Supervision; -Walk 150 feet: Supervision. Review of Resident #34's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included vascular dementia; -Walk 10 feet: Independent; -Walk 50 feet with two turns: Independent; -Walk 150 feet: Independent. Observation and interview of Resident #54 and Resident #34's shared bathroom on 3/28/24 at 11:42 A.M., showed the water temperature at the sink measured 145 degrees F, using a digital thermometer. Resident #54 said sometimes the water is too hot. 5. Review of Resident #8's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included stroke and overactive bladder; -Used a wheelchair/scooter; -Able to wheel 50 feet with two turns: independent; -Wheel 150 feet: independent. Review of the resident #3's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: vascular dementia, bipolar and schizophrenia; -Walk 10 feet: Independent; -Walk 50 feet with two turns: Independent; -Walk 150 feet: Independent. Observation of Resident #8 and Resident #3's shared bathroom on 3/28/24 at 12:54 P.M., showed the water temperature at the sink measured 145.2 degrees F, using a digital thermometer. 6. Review of Resident #27's quarterly MDS, dated [DATE], showed: -Moderately cognitively impaired; -Diagnoses included: Dementia, paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) and major depressive disorder; -Walk 10 feet: Independent; -Walk 50 feet with two turns: Independent; -Walk 150 feet: Independent. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Diagnoses included bowel disease and schizophrenia; -Walk 10 feet: Independent; -Walk 50 feet with two turns: Independent; -Walk 150 feet: Independent. Observation of Resident #27 and Resident #5's shared bathroom on 3/28/24 at 1:00 P.M., showed the water temperature at the sink measured 147.2 degrees F, using a digital thermometer. 7. Review of Resident #43's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included mild cognitive impairment; -Used a wheelchair/scooter; -Able to wheel 50 feet with two turns: Dependent; -Wheel 150 feet: Dependent. Review of Resident #258's quarterly MDS, dated [DATE], showed: -Moderate cognitively impaired; -Diagnoses included: Dementia, paranoid schizophrenia and major depressive disorder; -Walk 10 feet: Independent; -Walk 50 feet with two turns: Independent; -Walk 150 feet: Independent. Observation of Resident #43 and Resident #258's shared bathroom on 3/28/24 at 1:03 P.M., showed the water temperature at the sink measured 141.2 degrees F, using a digital thermometer. 8. Review of Resident #18's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart disease; -Used a wheelchair/scooter; -Able to wheel 50 feet with two turns: Independent; -Wheel 150 feet: Independent. Review of Resident #11's quarterly MDS, dated [DATE], showed; -Cognitively impaired; -Diagnoses included dementia and stoke; -Used a wheelchair/scooter; -Able to wheel 50 feet with two turns: Dependent; -Wheel 150 feet: Dependent. Observation on of Resident #18 and Residents #11's shared bathroom on 3/28/24 at 1:30 P.M., showed the water temperature at the sink measured at 152.4 degrees F, with a digital thermometer 9. Review of Resident #52's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included viral hepatitis and fractures; -Used a wheelchair/scooter; -Able to wheel 50 feet with two turns: Independent; -Wheel 150 feet: Independent. Review of Resident #40's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included depression and neurogenic bladder; -Used a wheelchair/scooter; -Able to wheel 50 feet with two turns: Independent; -Wheel 150 feet: Independent. Observation of Resident #52 and Resident #40's shared bathroom on 3/28/24 at 1:30 P.M., showed the water temperature at the sink measured 153 degrees F, using a digital thermometer. 10. During an observation and interview on 3/28/24 at 2:00 P.M., Certified Nursing Aide (CNA) A said there were two residents who wandered and could wander into the bathroom and turn the water on. CNA A said the water temperature was not that hot. CNA A and the surveyor entered room [ROOM NUMBER] and checked the water. CNA A turned the water on and within a few seconds, said the water was hot. The water temperature was checked by the surveyor using a digital thermometer. The temperature read at 141 degrees F and was confirmed by CNA A. CNA A said they use the bathroom to provide care to residents, such as bed baths and incontinence care. CNA A said normally if the water was hot, he/she would mix in cold water. CNA A said he/she could not say if a confused resident would know to turn the cold water on to mix with the hot water. During an interview on 3/28/24 at 2:00 P.M., the Maintenance Director said he did not know the water temperatures were so high in the resident rooms on the North and South halls. He took water temperatures monthly with a laser thermometer in resident rooms. He did not know laser thermometers could be unreliable for taking water temperatures. He did not have a different type of thermometer. During an observation and interview on 3/28/24 at 2:05 P.M., the Director of Nursing (DON) said there are 13 residents who wander and could turn the water on in the bathroom, and two of the 13 residents go into the bathroom and play in the water. A water temperature above 110 would be considered hot. The residents have thinner skin and would be at risk for getting burnt. The DON and surveyor went to room [ROOM NUMBER] and the water temperature at the sink measured 139.5 (F). During an interview on 3/28/24 at 2:20 P.M., the Corporate Regional Nurse said she knew the temperatures should not be over 120 degrees F. She did not know the Maintenance Director was using a laser thermometer. He should not have been using this type of thermometer to take water temperatures. She did not know the water temperatures were so high. During interviews on 3/28/24 at 2:10 P.M. and 2:25 P.M., the Administrator said Maintenance staff was responsible for taking water temperatures monthly and keeping documentation of them. The water temperature should be between 105 and 120 degrees F. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions 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 the exit, the deficiency was lowered to the E level. This statement does not denote 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).

Based observation, interview and record review, the facility failed to ensure one resident was free from verbal abuse and intimidation (Resident #3). On 9/25/23 at 4:48 A.M., Certified Nurse Aide (CNA) A went into the resident's room and cursed at the resident to lay in his/her bed, calling the resident derogatory names and verbally threatening physical harm to the resident. The census was 65. The administrator was notified on 10/26/23, of the past non-compliance. The facility provided training and in-services for all staff regarding the facility's abuse prevention and resident rights policies. Review of the facility's Abuse Policy, revised 9/1/18, showed: -Purpose: The facility maintains a no tolerance policy on any form of abuse towards our residents. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors and friends, or other individuals; -Definitions: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish; -Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm and saying things to frighten a resident; -Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/25/23, showed: -Cognitively impaired; -Diagnoses included non-traumatic brain dysfunction (Injuries to the brain that are not caused by an external physical force to the head, can be caused by illness, oxygen deprivation, metabolic disorders, etc.), dementia, anxiety disorder, psychotic disorder (a loss of contact with reality) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the facility's self-report, dated 9/27/23, showed: -Incident Dated 9/25/2023, at 4:48 A.M. -Incident Discovered on 9/27/2023; -Administrator and the Director of Nursing (DON) started to investigate a complaint on an employee, CNA A on the morning of 9/27/2023. During the investigation on 9/27/2023, it was discovered CNA A went into the resident's room and started cursing at the resident to lay in his/her bed, calling him/her retarded, and verbally threatening the resident to not come back out of his/her room. No actual violence was detected; however many verbal insults and cursing were picked up on the audio system of the cameras. Investigation concluded with the termination of CNA A's employment for verbal abuse. Effective immediately. Review of the facility's Verbal Abuse Investigation, dated 9/27/23, showed; -On 9/27/23, the Administrator and DON watched the video camera on the East 2 hall, date/time stamped 9/25/23, at 4:48 A.M. The resident was seen walking in the hallway by his/her room by him/herself, when staff member, CNA A came up the hallway towards the resident. CNA A had a hurried march from the end of the hallway toward the resident, and was overheard on the audio verbally threatening the resident. CNA A called the resident retarded, and stated, I told you not to come out of that room again, you better get your ass in that room. CNA A said, I told you not to open that goddamn door again, and he/she would break the resident in the god damn head. As CNA A continued to curse at the resident, the resident backed into his/her room with CNA A following closely behind the resident into his/her room; -The resident had a full body assessment, completed by the DON on 9/27/23, and he/she was found to be free from lacerations, hematomas, abrasions, burns, swelling and bruises. The resident was alert and oriented to self, did not recall any incident. When asked if anyone hurt him/her, he/she said No. When asked if anyone said mean things to him/her, he/she said, No. When asked if anyone cursed at him/her, he/she said, No. When asked if he/she felt safe, he/she said, Yes.; -Six additional residents were interviewed and no residents witnessed abuse by CNA A. During an interview on 10/12/23 at 10:10 A.M., and at 2:59 P.M., the Administrator said he received a complaint about a staff person. Resident #2 said CNA A was acting peculiar with his/her waistband at the nurse's station and he/she reported it. While checking the validity of the statement, the audio only picked up, What are you doing? CNA A said his/her waistband was messed up. Resident #2 exited the hallway, and then CNA A walked down the hall, yelling, scolding the resident for being in the hallway. CNA A was contacted following the viewing of the tape, on the 27th, he/she was told they have evidence on camera of the verbal abuse, and he/she said, Oh! It was shocking to him/her it was caught on camera. When asked about his/her pants, he/she said his/her drawstring was messed up. CNA A did not deny the allegation; it was a very short exchange. He said he did not get a statement because the CNA had not returned to the facility and was immediately terminated. Observation of a copy of the facility camera footage, showed the resident slowly exited his/her room, his/her back to the camera as he/she peered down the hallway towards CNA A. CNA A, who wore blue scrubs, was at the opposite end of the hallway and walked towards the resident. The resident then entered the hallway, and stood facing CNA A, who continued walking towards the resident. CNA A walked in a fast pace towards the resident. CNA A was visibly taller in stature and build than the resident. The resident turned and walked back into his/her room. CNA A continued his/her quick pace towards the resident's room. CNA A entered the resident's room and said, Now get your ass in this room or I will break your goddamn head! Both the resident and CNA A were inside the room, out of the camera's view. CNA A's voice became louder. He/She said I'm tired of you going out of the goddamn door, don't come out there no more. You're fucking retarded. CNA A continued to speak loudly, in an aggressive tone, but the comments were unintelligible. He/She then exited the resident's room, closed the resident's room door and continued back down the hallway. During an interview on 10/12/23 at 3:00 P.M., the DON said when reviewing the camera/audio footage, the body language of CNA A was intimidating, the verbiage and his/her tone, calling the resident derogatory, awful names was shocking. Staff had the ability to walk away, the resident had always been a timid person and was not hard to redirect. CNA A used a very violent tone towards the resident. During an interview on 10/13/23 at 10:20 A.M., CNA A said he/she accidentally spoke to a resident in a way he/she should not have. He/She spoke to the resident in a verbally aggressive manner, but it was not on purpose. CNA A confirmed he/she had on blue scrub pants the morning of the incident. Prior to his/her interaction with the resident, he/she had been startled by a different resident while sitting in the nurse's station. He/She was surprised when the other resident walked up on CNA A because he/she thought everyone was in bed. CNA A said he/she got upset because the other resident lied on everyone. CNA A was worried the resident would tell a lie about him/her. He/She was taken off guard, and when he/she saw Resident #3, he/she spoke to the resident in a way he/she should not have. It was not intentional. The resident was childlike, and was sometimes easy to redirect. The resident mainly came out of his/her room to look for food. During an interview on 10/12/23 at 2:59 p.m., the Administrator said he expected staff to follow their Abuse Policy. When he overheard CNA A verbally abuse the resident, he/she was immediately terminated. MO00225071

Based on observation, interview and record review, the facility failed to provide care and services to prevent the development and promote the healing of pressure ulcers for one of one sampled residents. The facility identified one resident with a pressure ulcer, who was included in the sample of 13. (Resident #1). The census was 69. Review of Resident #1's face sheet, showed the following: -An admission date of [DATE]; -[DIAGNOSES REDACTED].), rhabdomyolysis (the rapid destruction of skeletal muscle), [MEDICAL CONDITION] (decreased mental function due to a medical disease), [MEDICAL CONDITION] (joint disease caused by cartilage loss in a joint.), paralysis agitans ([MEDICAL CONDITION] disorder of the central nervous system characterized by tremor and impaired muscular coordination.), senile dementia (a general loss of cognitive abilities) and depression disorder. Review of the resident's Braden Scale (a tool used to predict pressure sore risk) dated 11/19/10, showed the resident scored 12 (the resident at high risk for developing pressure ulcers.) Facility staff assessed the resident's sensory perception, moisture, activity, mobility, nutrition and friction/shear risk factors with this tool. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/15/11, showed the following: -Short and long term memory problems; -Cognitive impairment; -Required total assistance for transfers, dressing, eating, bathing and toileting; -Frequently incontinent of bowel and bladder; -No pressure ulcers. Review of the resident's care plan, last updated on 5/15/11, showed the resident at risk for skin breakdown related to prior history of skin breakdown, decreased bed mobility and incontinence. Review of the nurse's notes dated 6/3/11 at 2:10 P.M., showed the resident lay in bed and staff noted a reddened area to coccyx (tail bone) and [MEDICATION NAME] ointment (skin protectant) applied. The note did not contain any further description of the area staff treated. During an interview on 7/21/11 at 9:30 A.M., the Director of Nursing (DON) said when a resident was at risk for skin breakdown some of the interventions included putting the resident on an every two hour turn schedule and having an air mattress on the resident's bed. Review of the physician order [REDACTED]. Review of the nurse's notes dated 6/4/11 through 6/22/11, showed no documentation of the resident's skin. Review of the resident's weekly skin assessment dated [DATE], showed the box checked yes for an open lesion/sore spot located on the resident's buttock. No further description of the resident's skin documented. Review of the resident's weekly wound tracking worksheet dated 6/17/11, showed the following: -A slightly reddened area on the resident's buttock was assessed; -[MEDICATION NAME] ointment was the treatment. Review of the resident's monthly summary dated 6/19/11, showed the resident's skin was dry and fragile. No further documentation of skin breakdown. During an interview on 7/22/11 at 9:30 A.M., the DON said the charge nurse was responsible for completing the monthly summary for the residents. She did not know why the resident's open area on his/her coccyx was not documented. She said if the resident had a pressure ulcer she would expect it to be documented. Review of the resident's POS, dated 6/22/11, showed an order to apply [MEDICATION NAME] every shift to the peri/coccyx area. Review of the nurse's notes dated 6/23/11 (no time indicated), showed the nurse practitioner (NP) and primary care physician (PCP) were notified related to an open area on the resident's coccyx. The area measured 3.0 centimeters (cm) by 2.0 cm. Review of the POS [REDACTED]. Review of the weekly skin assessment dated [DATE], showed the resident's pressure ulcer measured 3.0 cm by 2.0 cm. Staff did not document the location of the pressure ulcer. Review of the weekly wound tracking worksheet dated 6/23/11, showed the resident had a previous week and current week stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed.) The pressure ulcer located on his/her coccyx measured 7.0 cm by 4.0 cm with slough (dead tissue) present. The treatment for [REDACTED]. During an interview on 7/22/11 at 9:30 A.M., the administrator and DON said there have been inconsistencies with measuring wounds in the past and they thought having the DON do the weekly wound assessment would help prevent further measuring inconsistencies. The administrator and DON were unable to explain the inconsistent measurements for the resident's wound. Review of the weekly skin assessment dated [DATE], showed the resident had a pressure ulcer located on his/her buttock. No measurements documented. No further review of the pressure ulcer. Review of the POS [REDACTED]. Review of the POS [REDACTED]. Review of the physician's progress notes, showed the NP wrote on 6/28/11, the resident had an unstageable pressure ulcer, with grey/yellow foul smelling eschar (dead decaying tissue) with macerated (wet) skin. Review of the nurse's notes dated 6/28/11 at 10:40 P.M., showed staff cultured and measured the pressure ulcer that day. The pressure ulcer measured 9.9 cm by 7.5 cm. The wound bed contained yellow slough with purulent (containing pus) drainage noted. The area around the pressure ulcer was red and chafed. Review of the wound culture lab results dated 6/29/11, showed the pressure ulcer contained a heavy growth of the organism proteus mirabilis (bacterium). Review of the POS [REDACTED]. Review of the weekly wound tracking worksheet dated 6/30/11, showed a facility acquired pressure ulcer box checked for unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) previous week and unstageable current week. The location of the pressure ulcer was the resident's coccyx which measured 10.0 cm by 7.5 cm with 3.0 cm tunneling at four O'clock (reference on the standard clock used when assessing pressure ulcers.) The treatment was Santyl ointment. Review of the POS [REDACTED]. Review of the physician's progress notes dated 7/1/11, showed the resident's PCP documented a large coccyx wound, positive for proteus mirabilis found in wound cultured, sensitive to the medication Keflex. Review of the physician's progress notes dated 7/3/11, showed the resident's PCP documented a deep pressure ulcer, with scheduled debridement on 7/5/11. The resident's had poor nutrition status and agreed to schedule the placement of a feeding tube (a tube inserted into the stomach to provide nutrition, fluids and medications). Review of the POS [REDACTED] -Transport the resident to the hospital on [DATE]; -Nothing by mouth after midnight on 7/4/11. Review of the weekly skin assessment dated [DATE], showed the resident had a pressure ulcer. No measurements or location documented. Review of the resident's medical record prior to being discharged to the hospital on [DATE], showed no assessment or documentation of the resident's pressure ulcer. Review of the POS [REDACTED] -Gastrostomy tube ([DEVICE], a tube surgically inserted through the abdomen to provided nutrition, hydration and medication) [MEDICATION NAME] feeding three times a day of Fibersource (nutritional supplement) 250 milliliters (ml), add one can of water 250 ml to feeding; -Continuous feeding at 65 ml per hour 9:00 P.M., through 6:00 A.M.; -Flush with 100 ml water after each feeding; -Flush the gastrostomy tube every four hours from 9:00 P.M. through 6:00 A.M., with 100 ml of water. -Cleanse the gastrostomy tube site daily with normal saline and apply triple antibiotic ointment, cover with a dry dressing; -Pureed diet. Review of the nurse's notes dated 7/6/11, no time indicated, showed the resident returned from the hospital after getting his/her gastrostomy tube placed and pressure ulcer debrided. The resident had an open area to his/her coccyx. See skin assessment. (The facility could not locate the skin assessment referenced here) Review of the resident's monthly summery dated 7/9/11, showed the resident had dry and fragile skin, no information regarding the pressure ulcer. Review of the weekly wound tracking worksheet dated 7/8/11, showed the resident had a previous week and current week stage IV pressure ulcer located on his/her coccyx. The pressure ulcer measured 10.0 cm by 7.5 cm with 1.5 cm tunneling at 12 O'clock, 3.0 cm tunneling at four O'clock and 1.5 cm tunneling at 6 O'clock. The treatment was Santyl ointment. Review of the weekly skin assessment dated [DATE], showed the resident had a pressure ulcer. No documentation of the location of the pressure ulcer or measurements on this sheet. Review of the weekly wound tracking worksheet dated 7/15/11, showed the resident had a previous week and current week stage IV pressure ulcer located on his/her coccyx. The pressure ulcer measured 10.0 cm by 7.5 cm with 1.5 cm tunneling at 12 O'clock, 3.0 cm tunneling at four O'clock and 1.5 cm tunneling at 6 O'clock. The treatment was Santyl ointment. During an interview on the initial tour on 7/19/11 at 9:00 A.M., LPN A said the resident had a gastrostomy tube, an indwelling catheter and a coccyx pressure ulcer, stage unknown at the time of tour. Observation on 7/19/11 at 12:00 P.M., showed the resident not in bed. No pressure relieving device on the resident's bed, just a two tone pressure reduction mattress used on all residents in the facility. During an interview on 7/19/11 at 1:00 P.M., LPN A said the resident went to the wound clinic and would return later that evening. Observation on 7/20/11 at 7:30 A.M., showed the resident lay in bed on his/her left side with a pillow tucked under his/her back. The head of the resident's bed was elevated 30 degrees. No pressure relieving device on top of the resident's mattress. The resident had an indwelling urinary catheter (a catheter inserted into the bladder to drain urine) draining amber colored urine. The resident's bilateral contracted hands had wash clothes rolled up that the resident held on to. A tube feeding machine stood next to the resident's bed. Review of the Braden Scale dated 7/20/11, showed the resident scored 15 meaning the resident was at risk for developing pressure ulcers. Observation on 7/20/11 at 9:30 A.M., LPN C entered the room to do the treatment on the resident's pressure ulcer located on the coccyx. LPN C removed the dressing which contained serosanguinous (light bloody) drainage. LPN C said he/she does the resident's treatment every day he/she worked. When he/she assessed the wound he/she saw slough and bone and the wound was a beefy red color. LPN C cleansed the wound with wound cleanser and applied Santyl ointment to a four by four gauze pad then applied a bigger dressing over the four by four gauze pad and taped it down. The resident had a [MEDICATION NAME] 25 mcg on his/her back dated 7/19/11. Observation on 7/20/11 at 12:30 P.M., showed the resident sat in his/her wheelchair in the dining room. A certified nurses aide (CNA) fed the resident lunch which consisted of pureed hamburger, spinach, potatoes, ice cream, milk and orange drink. The resident ate about three bites of each item per the CNA. Observation on 7/20/11 at 1:20 P.M., showed the resident sat in his/her wheel chair in the dining room. The resident sat on a Roho cushion (pressure relief device). Observation on 7/20/11 at 1:35 P.M., showed the resident sat in his/her wheel chair in his/her room. Observation on 7/20/11 at 2:00 P.M., showed the resident lay on his/her left side, with a pillow tucked under his/her back. Observation on 7/21/11 at 6:35 A.M., showed the resident lay in bed on his/her back, no pressure relieving device was on the mattress. Observation on 7/21/11 at 9:00 A.M., showed the resident lay in bed on his/her back. No pressure relieving device was on the mattress. The resident's catheter drained amber colored urine. During an interview on 7/21/11 at 9:50 A.M., the resident's PCP said according to the notes in the chart he would expect the facility to follow the orders from the wound clinic and a pressure relieving device on the resident's mattress would help with circulation. During an interview on 7/21/11 at 11:30 A.M., the medical director of the facility said he/she was not familiar with the resident. He/she said he would expect the facility to follow the resident's PCP orders and he/she would expect to see an alternating pressure mattress on the resident's bed with a stage IV pressure ulcer to the coccyx area. During an interview on 7/21/11 at 12:00 P.M., the DON said she could not believe the over lay pressure relieving device was not on the resident's bed. The resident moved rooms on 7/12/11 and the device was not moved with the resident. The resident now had the pressure relieving device on his/her bed. She also said the turn schedule was left in the old room as well. The DON said the resident's turn schedule was now taped above his/her bed. Observation on 7/21/11 at 12:35 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident cried and said his/her buttock hurt so bad, that it felt like a razor blade. CNA D entered the room and told the resident he/she would lay him/her down right after he/she made the resident's bed. A tan colored pressure relieving device lay on the resident's bed. CNA D and CNA E transferred the resident to bed and positioned the resident on his/her left side. Observation on 7/21/11 at 2:00 P.M., showed the resident lay on his/her left side, with the head of the bed elevated 30 degrees and a pressure relieving device in bed, under the resident. Observation on 7/22/11 at 7:40 A.M., showed the resident lay in bed on his/her left side a top a low air loss pressure relieving mattress. Observation on 7/22/11 at 7:45 A.M., showed LPN F and RN G entered the room to change the resident's pressure ulcer dressing. The old dressing contained serosanguineous drainage. LPN F measured the pressure ulcer as 5.4 cm by 7.4 cm by 1.2 cm with 1.9 cm tunneling at seven O'clock and 7.4 cm tunneling between two and five O'clock. LPN F said the pressure ulcer had slough present and he/she could also see bone. LPN F cleansed the pressure ulcer with wound cleanser and applied Santyl ointment to the pressure ulcer. LPN F then applied a four by four gauze pad and a larger dressing over it and taped it down. LPN F and RN G turned the resident to his/her left side and placed a pillow under the resident's back. During an interview on 7/22/11 at 9:30 A.M., the administrator and DON said the resident should not have been on a regular mattress (two tone) because it would cause less circulation to the pressure ulcer and that would slow the healing of the pressure ulcer. An air mattress would relieve the pressure off the resident's skin and improve circulation. The CNA's were responsible for assessing the resident's skin every time they give a shower. The shower sheets were given to the charge nurse when the CNA completed them. She would expect the charge nurse to follow up on all abnormalities the CNA reported. She does not routinely keep the shower sheets, because it would be too much paperwork. During an interview on 7/22/11 at 9:30 A.M., the DON said Nurse B was responsible for updating the care plans quarterly. The resident's pressure ulcer should have been updated in the care plan and Nurse B should have completed a significant change MDS for the three major changes for the resident which included the pressure ulcer, gastrostomy tube and an indwelling catheter. She did not know why the significant change MDS was not completed in a timely manner. During an interview on 7/22/11 at 12:55 P.M., the NP said she ordered a pressure relieving device for the resident's bed in March 2011. She said when the wound was debrided on 7/5/11, the resident's bone was visible. She could not recall if the resident was on a pressure relieving device when she saw the wound on 6/28/11. She said laying on a regular mattress from 7/12/11 through 7/21/11, would not affect the pressure ulcer on the coccyx as long as the resident was turned from side to side every two hours. The NP said it would affect the pressure ulcer if the resident was laying on his/her back. She said if the resident was on a regular mattress with a stage IV pressure ulcer it would delay the healing time and provide more pressure to the wound, which would contribute to the wound getting worse. Review of the facility's skin protocol last updated 1/1/01, showed the following: -Purpose: to maintain and improve the skin's condition; -Upon admission and readmission a skin risk assessment tool (Braden Scale) will be done with a quarterly follow-up. Any new admission will have weekly skin risk assessments for the first four weeks; -If low score on the Braden Scale then attending physician must be notified and orders for an air mattress will be obtained. Air mattress must be checked daily for proper inflation; -Treatment will be followed based on physician's orders [REDACTED]. -All incontinent residents will be on a weekly skin assessment and the treatment book should be documented accordingly; -Incontinent care: use peri-wash then barrier cream after each incontinent occurrence; -Tub bath or shower should be scheduled at a minimum of twice a week for personal hygiene; -Any skin break down should be noted and reported to the charge nurse. Charge nurse to call the attending physician. -Use lambs wool or chair cushion on all wheelchairs and geri chairs to relieve pressure; -Immobile residents will be repositioned at minimum every two hours or more frequently if necessary; -A nutritional evaluation will be completed and if necessary, orders for nutritional supplement, feeding assistance, feeding device and vitamin and minerals will be ordered from the attending physician; -Staff education.