Every finding on record at River City Living Community

Based on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for three residents (Resident #1, #2, and #3) out of three sampled residents. The facility census was 47.1. Review of the facility's Care Plan Comprehensive policy, undated, showed assessment of each resident is ongoing process and the care plan will be revised as the resident's condition changes. A well-developed care plan will be oriented to: involving resident, resident's family and other resident representatives as appropriate, assessing and planning for care to meet the residents medical, nursing, mental and psychosocial needs, involve the direct care staff with the care planning process relating to the resident's expected outcomes and addressing additional care planning areas that are relevant to meeting the resident's needs in the long term care setting.2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/22/26, showed staff assessed the residents with cognitive impairment, wanders daily, and has a diagnosis of dementia with behaviors.Review of the resident care plan, dated 03/10/26, showed staff assessed the resident as wanders, difficult to understand due to cognition, and staff must anticipate his/her needs. The care plan did not contain documentation for the interventions implemented after the inappropriate touching of his/her peer.Review of the resident's nurse notes, dated 04/17/26, showed staff documented the resident was in another resident's room with the door shut. The physician was notified and ordered 15-minute surveillance. During an interview on 04/20/26 at 11:36 A.M., Certified Nurse Aide (CNA) C said Resident #1 wanders daily and follows others around. He/She said he/she does not know what the care plan says for the resident's behaviors, and he/she does not have access to care plans. During an interview on 04/20/26 at 11:52 A.M., Licensed Practical Nurse (LPN) E said he/she does not update the care plans but believes the aides are able to access them. During an interview on 04/20/26 at 12:12 P.M., the MDS nurse said the resident follows other people around but did not have it in the care plan. He/She said he/she is responsible for updating the care plans. The MDS nurse said he/she is still new to the position and trying to get them updated as best as he/she can. 3. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident with cognitive impairment, does not exhibit behaviors, and has diagnoses of dementia and depression. Review of the residents' history and physical form in his/her referral packet, dated 2/13/26, showed staff documented a diagnosis of severe dementia with agitation, mood swings and recent altercation with a peer. Review of the resident's plan of care, dated 04/08/26, showed staff assessed the resident as at risk of inability to meet his/her needs due to his/her cognition. The plan of care did not contain documentation the resident required a secure unit, or staff direction for when resident exhibits behaviors.During an interview on 04/20/26 at 11:36 A.M., CNA C said the resident can get agitated and verbally aggressive. CNA C said he/she did not know what the care plan directed staff regarding the resident's behaviors. He/She said he/she does not have access to the care plans.During an interview on 04/20/26 at 11:42 A.M., Certified Medication Technician (CMT) D said he/she does not know what the care plan said regarding the resident's behaviors. During an interview on 04/20/26 at 12:12 P.M., the MDS nurse said the resident is exit seeking but it is not included in the care plan and should be. He/She said he/she is trying to get the care plans updated. 4. Review of Resident #3's admission MDS, dated [DATE], showed staff assessed the resident with cognitive impairment, did not exhibit behaviors. Review of the nurse notes showed staff documented: -On 04/04/26, agitation and confusion with stated intent to leave with restlessness and anxiety, exit seeking, going into peer rooms and applying the peers clothing, due to ongoing exit-seeking behaviors and safety concerns, resident relocated to secured memory care unit for increased supervision;Review of the residents plan of care, dated 04/13/26, showed staff assessed the resident is at risk for inability to meet his/her own needs related to his/her cognition. The care plan did not contain documentation the residents required a secure unit or direction for staff when residents exhibits behaviors.During an interview on 04/20/26 at 11:36 A.M., CNA C said Resident #3 wanders, gets fidgety, and disrobes after he/she is dressed for the day. CNA C said he/she did not know what the care plan directed staff regarding the resident's behaviors. He/She said he/she does not have access to care plans.During an interview on 04/20/26 at 12:12 P.M., the MDS nurse said the resident goes in and out of other resident rooms and he/she should have documented that in the resident's plan of care. He/She said he/she is trying to get the facility's care plans updated. 5. During an interview on 04/20/26 at 11:42 A.M., CMT D said behaviors specific to residents should be in their plan of care. He/She said he/she has access to the care plans but did not know what it said regarding the residents or their behaviors. He/She said he/she relies on verbal reports from the off going shift or the nurses. During an interview on 04/20/26 at 11:52 A.M., LPN E said he/she does not have the ability to modify the care plans but has access to them. He/She said behaviors should be included in the care plans, so staff know how to care for the residents when they have behaviors.During an interview on 04/20/26 at 12:12 P.M., the MDS nurse said he/she is responsible for updating the care plans and to assure they are accurate. He/She said he/she has been in the role for five months and is trying to make sure they are updated when they come due. Staff are informed of care plan changes as they are updated. He/She said he/she learns of resident changes by word of mouth, weekly risk meetings, and weekly review of the event notes. He/She said behaviors should be a part of the care plans and include elopement, cognition, and any interventions specific to the residents. He/She said he/she believes the aides have access to the care plans but isn't sure. During an interview on 04/20/26 at 12:28 P.M., the Director of Nursing (DON) said he/she has been in the role for three weeks and is still trying to put new plans into place. He/She expects care plans to include behaviors and interventions for resident specific behaviors. He/She said the MDS nurse is responsible for updating the care plans. During an interview on 04/20/26 at 12:32 A.M., the Administrator said resident specific behaviors should be a part of the care plan. He/She said the aides have access to the care plans and they are updated by the MDS nurse. #2987293

Based on observation, interview and record review, facility staff failed to protect one Resident (Resident #1's) right to be free from inappropriate touching when one resident (Resident #2), was found with his/her mouth on Resident #1's chest. The facility census was 47.1. Review of the facility's abuse policy, undated, showed it is the policy of the facility that each resident will be free from abuse. The residents will be protected from abuse, neglect and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection.2. Review of Resident #'1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/22/26, showed staff assessed the resident as cognitively impaired, wandered daily, and with a diagnosis of dementia with behaviors.Review of the resident's care plan, dated 03/10/26, showed the resident wandered on the secure unit, could be difficult to understand due to cognition, and staff must anticipate his/her needs. Review of the resident's progress notes, dated 4/17/26, showed Licensed Practical Nurse (LPN) A documented he/she was informed Resident #1 was in Resident #2's room with the door shut. Upon entering the room, it was observed that Resident #1 had their shirt up and Resident #2 was sucking on Resident #1's chest. The residents were separated and neither recalled the incident. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed resident as cognitively impaired, without behaviors, and diagnoses of dementia and depression. Review of the resident's plan of care, dated 04/08/26, showed resident was at risk for inability to meet his/her own needs related to his/her cognition. Review of the resident's progress notes, dated 4/17/26, showed Licensed Practical Nurse (LPN) A documented he/she was informed Resident #1 was in Resident #2's room with the door shut. Upon entering the room, it was observed that Resident #1 had their shirt up and Resident #2 was sucking on Resident #1's chest. The residents were separated and neither recalled the incident. 4. Review of facility investigation, dated 04/17/26, showed a visitor knocked on Resident #2's door. When there was no answer, the visitor opened the door and observed Resident #1 with his/her shirt up and Resident #2 mouth on Resident #1's chest. Review showed the residents were startled and Resident #2 went into the bathroom and Resident #1 exited the room. The visitor reported to the charge nurse then the administrator. During an interview on 04/18/26 at 3:20 P.M., LPN A said Resident #1 was a tag-a-long type personality and Resident #2 was a stronger personality. Resident #2 will say come along and Resident #1 will follow. Both residents are very confused. LPN A said he/she was informed of the inappropriate touching and then notified the physician and family. He/She also completed a head-to-toe assessment and did not observe any visible injuries. Neither resident recalled the incident. During an interview on 04/20/26 at 11:36 A.M., CNA C said Resident #1 and Resident #2 are attached at the hip and best friends. Resident #2 could be intrusive and overbearing with Resident #1, but he/she was unaware of any inappropriate interactions before the one on 4/17/26. During an interview on 04/20/26 at 11:42 A.M., Certified Medication Technician (CMT) D said he/she was informed by the visitor they witnessed Resident #2's mouth on Resident #1's chest and instructed the visitor to report to the administrator. The CMT said he/she also informed the administrator of the concern. He/She said Resident #1 and Resident #2 are always together. Resident #2 can be overprotective of Resident #1. CMT D said when the visitor informed him/her of the incident, Resident #1 was in the dining room away from Resident #2. He/She said the staff kept the residents apart after that. During an interview on 04/20/26 at 10:46 A.M., the administrator said he/she was informed about the interaction that occurred on 04/17/26 at 1:30 P.M. between Resident #1 and Resident #2 and immediately began an investigation. The administrator said both residents have dementia and live on the secured unit. He/She said the visitor reported Resident #2's mouth was on Resident #1's chest in Resident #2's room. He/She said Resident #2 can be flirtatious with others, but he/she has not seen behaviors of this type before. He/She said Resident #1 was unable to recall inappropriate touching between the two residents before. The administrator said Resident #2 was unable to recall the incident but told him/her that Resident #1 was his/her friend and when asked if they were alone in a room together, Resident #2 said, not today. He/She said staff did not construe anything sexual had occurred, so it was not reported. During an interview on 04/20/26 at 12:28 P.M., the Director of Nursing (DON) said he/she is unaware of inappropriate touching between Resident #1 and Resident #2. He/She said if staff observed inappropriate touching between residents he/she would expect staff to separate the residents and report to the charge nurse and/or the DON. During an interview on 04/19/26 at 9:02 A.M., Resident #1's family member said he/she did not think his/her loved one would have consented to this before he/she became sick. He/She said he/she couldn't say for sure how he/she would have felt when that occurred. #2987293

Based on interview and record review, facility staff failed to implement their grievance protocol for one resident (Resident #1) when he/she reported a missing tablet and staff failed to provide the resident with written actions, responses and rationales to his/her concerns. The facility census was 51.1. Review of the facility's Grievance Protocol policy, undated, showed the purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to ensure proper [NAME]-up through appropriate discipline. The Social Service Director is responsible for the program, although the administrator is ultimately responsible for the proper implementation of the program. Any member of the Social Services staff can complete the Grievance Compliant Report. The appropriate situations for the use of the Grievance Complaint Report are when resident articles that are lost or cannot be located, continual concern of lost resident items. This would include laundry concerns. The Social Service Director will obtain the original Grievance Complaint Report and forward a copy of the grievance to the appropriate discipline. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as cognitively intact and admitted to the facility on [DATE].Review of the facility grievance log, dated 01/16/26, showed staff documented the resident reported his/her tablet missing and staff were searching for the item. Review showed the facility did not have documentation a grievance form had been completed for the missing tablet and a copy was not provided to the resident or guardian.During an interview on 03/27/26 at 12:48 P.M., the resident said his/her tablet had been missing for a month or so. He/She said he/she reported the missing tablet to an unknown staff member. He/She said he/she had not been given a resolution to the missing tablet. During an interview on 03/26/26 at 2:44 P.M., the Social Service Director (SSD) said staff are directed to report any grievances to him/her or to direct residents to report their grievances directly to him/her. He/She said he/she did not consider a missing item as a grievance, so he/she did not complete a grievance form to be able to provide a copy to the resident. He/She said the resident's tablet was not found and had not been replaced. The SSD said the resident had not be provided with a resolution. He/She said he/she did not know a grievance was needed to be completed for a missing item. He/She said he/she was newer to the position and was possibly trained on the process, but did not recall. During an interview on 3/31/26 at 9:43 A.M., the administrator said the SSD was responsible for completing a grievance form provided to the resident and then provide the resident with a resolution within twenty-four hours. He/She said the resident's tablet had not been replaced. He/She said the resident should have had a resolution, but it slipped through the cracks. 2795138

Based on interview and record review, facility staff failed to implement their abuse and neglect policy to investigate an allegation of misappropriation of property for one resident (Resident #1) out of three sampled residents who reported an item missing. The facility census was 51.1. Review of the facility's Investigation policy, dated 2017, showed every allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source and misappropriated resident property must be thoroughly investigated. Review showed;-Resident, employees, family members, visitors and others may be interviewed about their knowledge of events;-All health care workers are mandatory reporters of abuse, so it is important to gather and report all the information that you have about the event(s);-The results of the investigation must be reported to the Administrator and other officials, according to State law, and the State Survey Agency within five days of the incident.Review of the facility's Investigation policy, dated 2017, showed results of the investigation must be reported to the administrator and other officials, according to State law, and the State Survey Agency within five days of the incident. Every allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source and misappropriated resident property must be thoroughly investigated. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as cognitively intact and admitted to the facility on [DATE].Review of the grievance log, dated 01/16/26, showed staff documented the resident reported his/her tablet was missing and staff were still searching for the item. Review of the resident's medical record, dated 01/01/26 through 01/31/26, did not contain documentation of an investigation for the missing tablet.During an interview on 03/27/26 at 12:48 P.M., the resident said his/her tablet had been missing for a month or so. He/She said he/she reported the missing tablet to an unknown staff member, but did not received a response to his/her grievance.During an interview on 3/31/26 at 9:43 A.M., the administrator said he/she did know about the resident was missing a tablet and staff searched for the item. He/She said he/she did interview staff if they knew about the resident's tablet but did not conduct a full investigation. He/She said he/she should have followed policy for misappropriation of property, but he/she thought the item would show up, since missing items typically do. He/She said he/she should have investigated the missing item, including interviewing other resident's. 2795138

Based on interview, and record review, facility staff failed to report an allegation of misappropriation of property for one resident (Resident #1) within twenty-four hours to the state agency Department of Health and Senior Services (DHSS). The facility census was 51.1. Review of the facility's Abuse and Neglect Reporting Instructions policy, undated, showed staff are directed to report immediately, no later than one hour of the event, because the Administrator or designee is required to report events of abuse to the DHHSS/[NAME] Abuse Hotline within two (2) hours of the vent occurring. It is critical to report the event within the regulatory time frames according to the State and Federal Regulations. Review showed the policy did not direct staff to report misappropriation of property within twenty-four hours. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as cognitively intact and was admitted to the facility on [DATE].Review of the grievance log, dated 01/16/26, showed staff documented the resident reported his/her tablet missing and staff were searching for it. During an interview on 03/27/26 at 12:48 P.M., the resident said his/her tablet was missing. He/She said he/she reported the missing tablet to an unknown staff member.During an interview on 3/31/26 at 9:43 A.M., the administrator said staff are directed to report missing items to the Social Service Director or to him/her. He/She said he/she did not know he/she was required to report missing items to DHSS. He/She said staff typically locate the missing items, so he/she did not think about reporting missing items. 2795138

Based on interview and record review, facility staff failed to obtain a discharge order, and provide the resident and/or his/her representative with a comprehensive Discharge Summary to include a summary of the resident's stay and course of treatment in the facility, including diagnosis, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultation results, including pending lab results, special instructions for ongoing care, a post discharge plan of care, advance directive information, and a reconciliation of medications for one resident (Resident #2) out of three sampled residents. The facility census was 44. 1. Review of the facility's Discharge/Transfer of Resident policy, undated, showed staff are directed as follows:-To provide safe departure from the facility and to provide sufficient information for aftercare of the resident;-Explain discharge guidelines and reason to resident and give copy of Transfer & Discharge Notice as required. Include resident representative;-The attending physician is required to write a discharge order. Telephone orders are acceptable;-Complete a discharge summary and post discharge plan of care form:-Include instructions for post discharge care and explain to the resident and/or representative;-Have resident and/or representative or person responsible for care sign discharge summary and post discharge care form;-Give copy of form to the resident and/or representative or person(s) responsible for care;-Place signed original form in the medical record.2. Review of Resident #2's five day MDS, dated [DATE], showed staff assessed the resident as admitted to the facility on [DATE], with a planned discharge for the resident to return to the community.Review of the resident's progress notes, dated 10/26/25, showed staff documented the resident was discharged to the community with medication and instructions. The record did not contain documentation a physician's order was not obtained, and a discharge summary was provided to the resident and/or his/her representative to include a safe departure from the facility, sufficient information for aftercare, a signed copy of discharge summary or post discharge plan by the resident or his/her representative. Review of the resident's Physician Order Summary (POS) undated, contained an order for physical therapy five times per week for five weeks. They did not contain a physician order for discharge.During an interview on 11/18/25 at 1:11 P.M., Licensed Practical Nurse (LPN) A said the discharge process started the day of the discharge for this resident, included obtaining physician order for discharge, and he/she was unaware of any follow up resources being set up like home health. During an interview on 11/18/25 at 2:18 P.M., the administrator said he/she expects the SSD to setup any resources needed, including home health, therapy services and transportation. He/She said the SSD would relay the information to the resident and/or her representative prior to discharge. He/She said there should be a progress note entered in the resident's medical record by the SSD and passed on in a report. He/She said he/she expected staff to get a physician order for discharge. He/She said there was not a single form with all the information included in the discharge summary.During an interview on 12/5/25 at 1:43 P.M., the administrator said there was no physician's order from the physician to discharge the resident to home in his/her electronic medical record.2667959

Based on interview and record review, facility staff failed to prevent an injury to one resident (Resident #3) when a Nursing Assistant (NA) used an electric nail file to apply acrylic nails to resident's fingernails and cut his/her finger which caused an infection and hospitalization. The facility census was 44.1. Review of facility's Care of Nails - Fingers and Toes policy, undated, showed the purpose of the policy is to provide cleanliness, comfort, and to prevent spread of infection. Nursing assistants may perform nail care on the residents who are not at risk for complications of infection. The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease. 2. Review of Resident #3's Quarterly Minimum Data Set, dated [DATE], a federally mandated assessment tool, showed staff assessed the resident cognitively intact and diagnosis of Diabetes.Review of the resident's care plan, revised 9/24/25, showed staff documented the resident was at risk for unstable blood sugars due to diabetes and required assistance with activities of daily living. Review of the residents nurses notes, dated 9/27/25, showed staff documented resident had pain in right hand and arm. Staff documented redness that traveled up the arm, tenderness and swelling to the area. Resident reported it as very painful. Physician notified and resident sent to emergency department for probable intravenous (IV) therapy (a medical procedure that involves administering fluids, medications, or nutrients directly into a patient's vein).Review of the resident's surgical orthopedics notes, dated 9/27/25, showed the resident presented to the emergency room with concerns for right index finger wound. Onset of symptoms 9/26/25 and rapidly progressed. Review showed marked erythema (redness of the skin) and edema noted to right index finger. There is a scabbed wound noted over the medial aspect of the distal interphalangeal (the joint at the very end of a finger or toe, just before the fingernail, which allows it to bend) joint of the right index finger. Review showed did not have fluctuation, drainage or abscess. Erythema extends up the dorsal aspect of the right hand. Resident was admitted for IV antibiotics for septic arthritis of right index finger and underwent index finger arthrotomy (a surgical procedure that involves opening a joint to diagnose or treat underlying conditions) with removal of infected tissue on 9/29/25. Intra-operative cultures of the right index finger showed Methicillin-resistant Staphylococcus aureus (MRSA) (caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). Review of the resident's nurse's notes, dated 10/03/2025 at 4:11 P.M., showed staff documented the resident returned from the hospital. Review of the resident's nurse's notes, dated 10/05/2025 03:19 A.M., showed staff documented the resident continued on antibiotics for infection in finger.During an interview on 10/27/25 at 4:15 P.M., the resident said NA A has done nail care for him/her a few times but only one of those times did he/she use the electric nail file. The resident said her/she does not think NA A meant to hurt him/her and it was an accident, but he/she did do it. During an interview on 10/10/25 at 9:00 A.M., the administrator said activities and other staff will paint and file resident's nails. He/She said one NA did acrylic nails on the resident. He/She said there were rumors going around that NA A hit the resident's skin with the electric nail file, but NA A denied hitting the resident's skin with the electric nail file. He/She said the residents wound did turn septic and he/she was admitted to the hospital. He/She said he/she spoke to NA A and told him/her to not do acrylic nails any longer. He/She said NA A is probably not supposed to clip nails either because he/she is not certified. During an interview on 10/27/25 at 4:10 P.M., NA A said he/she does the residents nails in the facility. He/She said typically he/she files them and paints them but said he/she does not cut them because most of the resident's want their nails to stay long. NA A said he/she did the resident nails for him/her. NA A said he/she did use a electric nail file on the resident once but denied that he/she cut the resident. He/She said there was no redness or injury and denied that the resident had pain. He/She said he/she did not know he/she was not supposed to use an electronic nail file on resident nails. NA A said he/she is not allowed to do nail care on diabetic residents, and he/she did not realize the resident was a diabetic. He/She said that he/she did observe what looked like an old burn or corn but that was on the resident's right hand middle finger. He/She said he/she was unsure of when he/she did the residents nails with the electric nail file because he/she does not have a good sense of time. During an interview on 10/28/25 at 2:25 P.M., the facility physician said he/she saw the resident on 9/26/25 at the facility and the resident complained of pain to his/her right index finger. The physician said the area was red and painful but was not warm to touch. He/She said septic arthritis is an infection that has traveled to the joint. He/She said it is possible that the infection could have been caused by nail care provided to the resident with an electric nail file. During an interview on 11/12/15 at 1:37 P.M., the hospital physician said if a Dremel tool connected with the resident's skin it could have led to the resident's finger infection. He/She said the wound did not resemble a burn. He/She said the resident's finger infection could have moved to the resident's joint and is likely what contributed to his/her sepsis. Patient received IV antibiotics and underwent index finger arthrotomy of the distal interphalangeal joint to remove infected tissue. #2636658

Based on interview and record review, facility staff failed to document they administered three residents (Resident #1, Resident #2 and Resident #3) out of three sampled residents medication as directed by the physician. The facility census was 44.1. Review of the facility's medication administration guidelines, dated 2/7/2013, showed it is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the information. The person administering the medication must chart medications immediately following the administration. The date, time administered, dosage, etc. must be entered in the medical record and signed by the person entering the data.2. Review of Resident #1's Quarterly Minimum Data Set, dated [DATE], a federally mandated assessment tool, showed staff assessed the resident with severe cognitive impairment, has a feeding tube, diagnoses of stroke, seizure or epilepsy, depression, cerebral palsy and anxiety.Review of the resident's POS, dated August 2025, showed physician orders directed staff to administer skin prep between Right great toe & 2nd digit twice a day and Isosource (a nutritionally-complete, calorically dense tube feeding formula) twice a day.Review of the resident's Medication Administration Record (MAR), dated August 2025, showed staff did not document they administered the resident's medications as directed for:-Skin prep (protects skin from further damage) on 08/18/25 and 08/30/25;-Isosource on 08/20/25;Review of the resident's Physician Order Sheet (POS), dated September 2025, showed physician orders directed staff to administer Gabapentin (anti-seizure medication)), Levetriracetam (anti-seizure medication), Valproic Acid (anti-seizure medication), Buspirone (cerebral palsy medication), and Risperidone (cerebral palsy medication)and to flush the residents feeding tube with water every four hours.Review of the resident's MAR, dated September 2025, showed staff did not document they administered the resident's medications Gabapentin , Levetriracetam, Valproic Acid, Buspirone, and Risperidone on 9/13/25 as directed by the physician. Review showed staff did not document they flushed the resident's feeding tube with water on 09/21/25. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact with a diagnosis of Diabetes.Review of the resident's POS, dated July 2025, showed physician orders directed staff to administer Novolog three times a day. Review of the resident's MAR, dated July 2025, showed staff did not document they administered the resident's Novolog Insulin (diabetes medication) on 7/5/25 as directed by the physician.Review of the resident's POS, dated September 2025, showed physician orders directed staff to administer Novolog three times a day.Review of the resident's MAR, dated September 2025, showed staff did not document they administered the resident's Novolog Insulin on 9/21/25 as directed by the physician.During an interview on 10/10/25 at 10:41 A.M., the resident said if he/she asks staff for his/her diabetes medication he/she will get it, if he/she doesn't ask he/she does not get it. He/She said often when he/she complains about not getting his/her insulin staff say it is documented in his/her chart he/she got it. 4. Review of Resident #3 Quarterly MDS, 9/19/25, showed staff assessed the resident as cognitively intact with diagnoses of diabetes, chronic pain syndrome, pneumonia.Review of the resident's POS, dated September 2025, showed physician orders directed staff to administer Hydrocodone one tablet every six hours, ipratropium/albuterol four times a day, and metformin one time a day.Review of the resident's Medication Administration Record (MAR), dated September 2025, showed staff did not document they administered the resident's medications for Hydrocodone (pain medication), Ipratropium/albuterol (bronchodilator medication) and Metformin (diabetes medication) on 9/15/25.#2636658

Based on interview and record review, facility staff failed to document they administered medications for three residents (Resident #1, Resident #2 and Resident #3). The facility census was 39. 1. Review of the facility's medication administration guidelines, dated 2/7/2013, showed residents receive their medications on a timely basis and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the information. The person administering the medication must chart medications immediately following the administration. The date, time administered, dosage, etc. must be entered in the medical record and signed by the person entering the data. 2. Review of Resident #1's Significant Change Minimum Data Set, dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as: -Severe cognitive impairment; -Feeding tube; -Diagnoses of stroke, seizure or epilepsy, depression, cerebral palsy and anxiety. Review of the resident's Medication Administration Record (MAR), dated March 2025, showed staff did not document medications administered to the resident's as directed for: -Ascorbic Acid (Vitamin C) on 3/16/25; -Gabapentin (anti-seizure medication) on 3/15/25, 3/25/25 and 3/29/25; -Levetriracetam (anti-seizure medication) on 3/25/25 and 3/29/25; -Lexapro (anti-depressant medication) on 3/25/25; -Valproic Acid (anti-seizure medication) on 3/15/25, 3/16/25 and 3/29/25; -Buspirone (cerebral palsy medication) on 3/15/25 and 3/29/25; -Risperidone (cerebral palsy medication) on 3/15/25, 3/16/25 and 3/29/25. Review of the resident's Medication Administration Record (MAR), dated April 2025, showed staff did not document medications administered to the resident's as directed for: -Ascorbic Acid (Vitamin C) on 4/29/25; -Valproic Acid (anti-seizure medication) on 4/13/25. Review of the resident's Medication Administration Record (MAR), dated May 2025, showed staff did not document medications administered to the resident's as directed for Gabapentin (anti-seizure medication) on 5/3/25. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the residents as: -Cognitively intact; -Diagnoses of Diabetes. Review of the resident's Medication Administration Record (MAR), dated March 2025, showed staff did not document they administered the resident's medications as directed for: -Lantus Solostar Insulin (diabetes medication) on 3/15/25 and 3/30/25; -Novolog Insulin (diabetes medication) on 3/15/25, 3/22/25, 3/30/25. Review of the resident's Medication Administration Record (MAR), dated April 2025, showed staff did not document they administered the resident's medications as directed for: -Lantus Solostar Insulin (diabetes medication) on 4/12/25 and 4/13/25; -Novolog Insulin (diabetes medication) on 4/13/25, 4/20/25 and 4/27/25. Review of the resident's Medication Administration Record (MAR), dated May 2025, showed staff did not document they administered the resident's medications as directed for: -Novolog Insulin (diabetes medication) on 5/3/25 and 5/4/25. During an interview on 5/6/25 at 12:15 P.M., the resident said he/she is not getting his/her insulin, he/she said the weekends are especially bad at giving his/her insulin. He/She said every weekend he/she is missing doses of insulin and the doses he/she does get, he/she goes and asks the nurse for. 4. Review of Resident #3's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Feeding tube; -Diagnoses of amyotrophic lateral sclerosis (ALS) (nervous system disease that weakens muscles). Review of the resident's Medication Administration Record (MAR), dated April 2025, showed staff did not document medications administered to the resident's as directed for: -Isosource (calorically dense complete nutritional formula - sole source of nutrition through tube feeding) on 4/22/25 and 4/27/25. Review of the resident's Medication Administration Record (MAR), dated May 2025, showed staff did not document medications administered to the resident's as directed for: -Isosource (calorically dense complete nutritional formula - sole source of nutrition through tube feeding) on 5/3/25 and 5/4/25. During an interview on 5/6/25 at 12:22 P.M., the resident said he/she is not getting all of his/her feedings on the weekends. 5. During an interview on 5/6/25 at 10:45 A.M., the Director of Nursing (DON) said he/she has gotten complaints about the weekend nurse not giving medications. He/She said he/she has spoken with administration about the issues with missing medication but he/she does not know if anything has been done. He/She said he/she expects all staff to follow physician orders. During an interview on 5/6/25 at 12:52 P.M., the administrator said his/her expectation is for staff to follow physician orders at all times and to document when medications are given. He/She said if it's not documented, it was not done. He/She said there have been some concerns with the weekend nurse, Registered Nurse (RN) A, but he/she has not been here very long and he/she needs more training. MO00253782

Based on interviews and record review, facility staff failed to notify the physician in a timely manner for two residents (Resident #1 and Resident #2) when Resident #1 made an accusation that Resident #2 touched him/her in an inappropriate manner. The facility census was 38. 1. Review of the facility's Resident condition change - observing, recording and reporting, not dated, showed staff were directed to observe, record and report any condition change to the attending physician so that proper treatment can be implemented. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 3/19/25, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of anxiety disorder. Review of the resident's nurses' notes, dated 5/05/25, showed staff documented resident tearful because he/she was touched inappropriately by another resident. Administrator notified and contacted Department of Health and Senior Services (DHSS) , corporate and the police department. Review showed staff did not document the physician notified. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately cognitively impaired; -Diagnosis of bipolar disorder. Review of the resident's nurse's notes, dated 5/05/25, showed staff documented resident placed on fifteen minute checks because of accusations made by another resident in regards to inappropriate touching and foul language. Administrator spoke with resident, DHSS, corporate and police. Review showed staff did not document the physician notified. Review of the facilities investigation, dated 5/5/25, showed staff did not document notification of the physician. During an interview on 5/6/25 at 12:52 P.M., the administrator said the physician should have been notified when the allegation of unwanted sexual contact was made but notification fell through the cracks. He/She said the Director of Nursing (DON) or himself/herself is responsible for notification of the physician, but he/she was in charge of the investigation. MO00253738

Based on interviews and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week. The facility's census was 40. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's time-keeping records for consecutive hours worked by an RN for December 2024, showed the facility did not have an RN for at least eight consecutive hours a day in the building on Tuesday, 12/31/24. Review of the facility's time-keeping records for consecutive hours worked by an RN for January 2025, showed the facility did not have an RN for at least eight consecutive hours a day in the building on the following dates: -Saturday, 01/04/25; -Sunday, 01/05/25; -Saturday, 01/11/25; -Sunday, 01/12/25: -Saturday, 01/18/25; -Sunday, 01/26/25. Review of the facility's time-keeping records for consecutive hours worked by an RN for 02/01/25 through 02/12/25, showed the facility did not have an RN in the building on Saturday, 02/01/25 or Sunday, 02/02/25. During an interview on 02/13/25 at 2:48 P.M., the Director of Nursing (DON) said he/she was aware of the requirement to have an RN in the building at least eight consecutive hours daily, but he/she had only been at facility for eight days and did not know who was responsible to ensure the RN coverage was being met prior. He/She said the administrator is currently responsible for scheduling RNs. During an interview on 02/13/25 at 3:07 P.M., the administrator said he/she was aware of the requirement to have an RN in the building at least eight consecutive hours daily. He/She said the previous DON was responsible for scheduling RNs and when the DON resigned in January, another staff was helping with the RN schedules, but he/she was ultimately responsible to ensure there was eight hours of RN coverage daily. The administrator said he/she realized there were several days without eight consecutive hours of RN coverage. He/She said on 02/01/25 and 02/02/25, the RN that was scheduled did not show up to work, and he/she did not have a back-up plan for RN coverage on those dates. MO00248703

Based on interviews and record review, facility staff failed to ensure services provided met professional standards of practice when staff failed to document and complete neurological checks for three residents (Resident #1, #2, and #3) of four sampled residents who had unwitnessed falls. The facility's census was 40. 1. Review of the facility's Event Investigation policy, dated March 2015, showed staff are directed to identify any injuries after a resident sustains an event, and directed staff to document the type of event, such as a fall, and a mental/neurological status after the event. Review of the facility's post-fall flow chart, undated, showed staff are directed as follows: -Charge nurse initiates a fall event in the electronic medical record (EMR). Describe if witnessed or observed on floor, neurological checks initiated or neurological checks not initiated; -Charge nurse enters initial vital signs, progress note, and any other orders: complete neurological checks on paper form then scan and upload into the EMR; -The policy did not indicate the time frame for staff to complete neurological checks after a fall. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/10/25, showed staff assessed the resident with mild cognitive impairment and had two or more non-injury falls since admission. Review of the facility's fall incident report, dated 12/13/24 through 02/13/25, showed the resident had an unwitnessed fall on 01/08/25 and 01/30/25. Review of the resident's progress notes, dated 01/08/25, showed staff documented the resident was found laying on floor next to his/her bed. Review showed staff did not document neurological checks were initiated. Review of the resident's progress notes, dated 01/30/25, showed staff documented the resident rolled out of bed and found on fall mat. Review of the resident's EMR showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 01/08/25 and 01/30/25. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, and had two or more non-injury falls since admission. Review of the facility's fall incident report, dated 12/13/24 through 02/13/25, did not show documentation of the resident's fall on 01/15/25. Review of the resident's progress notes, dated 01/15/25, showed staff documented the resident found laying on floor next to his/her bed, assessed by the nurse, and transferred to bed. Review showed staff did not document neurological checks were initiated. Review of the resident's EMR showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 01/15/25. 4. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, and did not have any falls since admission. Review of the facility's fall incident report, dated 12/13/24 through 02/13/25, showed the resident had an unwitnessed fall on 01/02/25. Review of the resident's progress notes, dated 01/02/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's EMR showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 01/02/25. 5. During an interview on 02/13/25 at 11:50 A.M., the Director of Nursing (DON) said he/she expects staff to document an event note with a nurse's note in the EMR and initiate a neurological assessment for any resident who had an unwitnessed fall or a fall with head injury, and if the resident is not sent to a hospital for evaluation, staff should complete the neurological checks for up to 72 hours. He/She said up until about a week prior, staff were directed to complete the neurological assessments on paper and upload to the residents' EMR. He/she said staff should have completed neurological checks for residents #1, #2, and #3 after each documented unwitnessed fall or documentation the resident was found. He/She said he/she is now responsible to oversee and audit post-fall documentation and completed neurological assessments. During an interview on 02/13/25 at 2:08 P.M., Licensed Practical Nurse (LPN) A said staff are directed to document an event note, a nurse's note in the EMR, and complete neurological checks if a resident had an unwitnessed fall. He/She said the neurological checks are completed and documented on paper for up to 72 hours. During an interview on 02/13/25 at 3:07 P.M., the administrator said he/she expects staff to complete neurological checks for 72 hours on any resident who had an unwitnessed fall since staff would be unsure if the resident sustained a head injury. He/She said the neurological checks were being completed on paper and scanned to the residents' EMR. He/She said the previous DON was responsible for post-fall audits and to ensure the neurological assessments were completed until he/she resigned on 01/10/25. Duiring an interview on 2/25/25 at 1:33 P.M., the DON said that he/she had just started his/her position recently. He/She said the guidance to complete the neurological checks for 72 hours comes from the facility software program which directs the nursing staff to complete neurological checks for 72 hours after a fall where the resident hits their head or if the fall is unwitnessed. During an interview on 2/25/25 at 2:15 P.M., the Physician said he/she would expect staff to complete neurological checks after a resident fall if the resident hits their head or if the fall was unwitnessed. He/She said the neurological checks should be completed for three days. MO00248703

Based on observation, interviews and record review, facility staff failed to ensure resident environment remained free of accident hazards when facility staff failed to ensure lighters were kept secure for three (Resident #1, #2, and #3) out of three sampled residents. The facility census was 60. 1. Review of the facility's Smoking-Residents policy, dated March, 2015, showed: -This facility shall establish and maintain safe resident smoking practices; -Smoking articles for residents with independent smoking privileges shall be permitted to keep cigarettes, pipes, tobacco, or other smoking articles in their possession; -Resident may only keep disposable safety lighters. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/19/24, showed staff assessed the resident as mild cognitive impairment and used tobacco. Review of the resident's care plan, dated 12/23/24, showed staff documented the resident is a smoker and able to keep cigarettes and lighter on his/her person. Review of the facility's smoking assessment, dated 09/11/24, showed staff documented the resident as a safe smoker. Observation on 01/17/24 at 9:49 A.M., showed the resident smoking outside. During an interview on 01/17/25 at 9:41 A.M., the resident said he/she kept his/her cigarettes and lighter in his/her room. 3. Review of Resident #2's Change in Condition MDS, dated [DATE], showed staff assessed the resident as mild cognitive impairment and used tobacco. Review of the resident's Physician Order Summary (POS), dated 12/30/24, showed an order for oxygen administered at two liters per minute per as needed for shortness of breath. Review of the resident's care plan, dated 11/08/24 showed staff documented the resident is a smoker and able to keep cigarettes and lighter on his/her person. Review of the facility's smoking assessment, dated 09/11/24, showed staff documented the resident was a safe smoker. Observation on 01/17/25 at 9:43 A.M., showed the resident pulled a pack of cigarettes containing a lighter out of his/her pocket. Observation on 01/17/24 at 9:49 A.M., showed the resident lit his/her cigarette and placed the lighter back in his/her pocket. Observation on 01/17/25 at 10:05 A.M., showed the resident had an oxygen concentrator in his/her room. During an interview on 01/17/25 at 9:43 A.M., the resident said he/she kept his/her cigarettes and lighter in his/her room. 4. Review of Resident #3's Admission MDS, dated [DATE], showed staff assessed the resident as mild cognitive impairment and used tobacco. Review of the resident's care plan, dated 12/23/24, showed staff documented the resident is a smoker and able to keep cigarettes and lighter on his/her person. Review of the facility's smoking assessment, dated 10/11/24, showed staff documented the resident was a safe smoker. Observation on 01/17/25 at 9:44 A.M., showed the resident pulled a pack of cigarettes, containing a lighter, out of his/her pocket. Observation on 01/17/25 at 11:17 A.M., showed the resident pulled a lighter out of his/her cigarette pack, lit his/her cigarette and placed the lighter back in the cigarette pack. During an interview on 01/17/25 at 9:44 A.M., the resident said he/she kept his/her cigarettes and lighter in his/her room. 5. During an interview on 01/17/25 at 10:07 A.M., the MDS Coordinator said per policy, resident's are allowed to keep disposable lighters in their room. He/She said the concern with resident's being allowed to keep lighters in their rooms, was the potential for the resident to smoke in the room. During an interview on 01/17/25 at 11:12 A.M., Certified Nurse Aide (CNA) A said he/she did not know resident's kept their lighters in their rooms. He/She said the safety concern with resident's keeping lighters in the room is the potential the resident could catch themselves or the building on fire. During an interview on 01/17/25 at 12:07 P.M., the administrator said per policy resident's are able to keep lighters on his/her person. He/She said if a resident kept the lighter on his/her person, and the resident was not alert or capable of making good decisions, there was a potential for a resident to catch things on fire, or smoke in their rooms. He/She said if a resident had oxygen in his/her room and used a lighter, there was a potential to cause an explosion. MO00247853

Based on observation, interview and record review, facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 39 with a capacity of 87. 1. Review of the facility's Food Preparation and Distribution policy, dated May 2015, showed measured utensils are used to serve proportions as described on menu. 2. Review of the facility menus, undated (Week 2, Day 10), showed the menus directed staff to provide the residents on regular diets six ounces of stroganoff, 1/2 cup (four ounces) of noodles and 1/2 cup of vegetable blend at the lunch meal. Observation on 10/01/24 at 12:41 P.M., showed [NAME] I served the residents a #6 scoop (5.3 ounces) of stroganoff, three ounces of noodles, and three ounces of mixed vegetables. Observation showed the portions were less than the menu directed portions. 3. Review of the facility menus, undated (Week 2, Day 10), showed the menus directed staff to provide the residents on pureed diets one #6 (5.3 ounces) scoop of stroganoff, one #10 (3.2 ounces) scoop of noodles, and one #16 scoop of pureed bread at the lunch meal. Observation on 10/01/24 at 12:41 P.M., showed [NAME] I served the two residents who received pureed meals one #10 (3.2 ounce) scoop of stroganoff, one #12 (2.6 ounces) of noodles and did not serve the residents pureed bread. Observation showed the portions were less than the menu directed portions. During an interview on 10/02/24 at 8:53 A.M., [NAME] I said the cook was responsible for setting serving utensils on the serving line. [NAME] I said cooks look at the menu for correct portion sizes. [NAME] I said the facility did not have a 1/2 cup scoop so he/she used a three ounce scoop. [NAME] I said he/she was not sure how many ounces were in 1/2 cup so he/she was not sure if he was under serving the residents. [NAME] I said he/she did not know why he/she served the incorrect portion sizes. [NAME] I said no bread was pureed for the lunch meal because the other cook forgot. During an interview on 10/02/24 at 9:00 A.M., the dietary manager (DM) said the cooks should serve food in accordance with menus and he/she is responsible to ensure the full meal is served. The DM said he/she did not know why staff did not serve the correct serving sizes. During an interview on 10/03/24 at 3:20 P.M., the administrator said the DM was responsible for ensuring staff served correct portions according to the menus. The administrator said he/she was not aware residents were not served correct portion sizes.

Based on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use. This failure has the potential to affect all residents. The census was 39 with a capacity of 87. 1. Review of the facility's Safe Food Handling policy, dated May 2015 showed all food, including bulk items, should be tightly sealed with an identifying label and date. 2. Observation on 10/01/24 at 10:01 A.M., showed the reach in refrigerator contained: -A plastic container of pineapple which was not in its original container and was undated; -A plastic container of hot dogs which was undated; -An opened and undated bag of lettuce; -An opened and undated container of tuna salad; -A cardboard flat of eggs which contained five broken eggs; -A zipper bag of meat, dated 09/01/24, and labeled use until gone which was open to the air; -A zipper bag of cooked hot dogs, labeled with a use by date of 09/29/24; -A one gallon container of soy sauce which was open to the air. Observation on 10/01/24 at 10:06 A.M., showed the left side of the 3-door reach in freezer contained two bags of beef patties and one bag of fish which were open to the air and undated. Observation on 10/01/24 at 10:18 A.M., showed the dry goods storage room contained: -An opened and undated bag of pasta elbows; -An opened and undated bag of cookie crumbs; -An opened and undated bag of tortilla chips; -A zipper bag dated 08/05/24 and open to the air contained an opened bag of gravy mix. During an interview on 10/02/24 at 8:53 A.M., [NAME] I said the cooks were responsible for making sure all food items were labeled, dated and not open to the air. During an interview on 10/01/24 at 10:27 A.M., the Dietary Manager (DM) said all open items should be labeled and dated. The DM said open canned items were good for seven days and cooked items were good for three days. The DM said no food items should be open to the air. The DM said he/she and the cooks were responsible for food storage. During an interview on 10/03/24 at 3:20 P.M., the administrator said the DM was responsible for ensuring all food items were labeled and dated. The administrator said food items should not be stored open the air. The administrator said prepared food items were good for three days.

43327 Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to store oxygen and nebulizer equipment in a manner to prevent spread of infection for six residents (Resident #1, #2, #3, #5, #13 and #15) of seven sampled residents who used oxygen, when staff failed to cleanse a suction machine for one (Resident #1) of one sampled resident who required as needed suctioning and when staff failed to use appropriate hand hygiene during wound care for two residents (Resident #27 and #36) of three sampled residents with wounds. The facility census was 39. 1. Review of the facility's Oxygen Administration policy, dated March 2015 showed: -Label humidifier with date and time opened; -The policy did not contain direction or guidance on oxygen tubing or nebulizer tubing storage in resident rooms. Review of the facility's Suctioning policy, dated March 2015, showed the policy did not contain direction for when to cleanse the suction machine. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as: -Comatose; -Required tracheostomy (artificial opening to aide in breathing) care and to be suctioned; -Diagnosis of respiratory failure and stroke. Review of the resident's Physician Order Sheet (POS), dated October 2024, showed the physician the following orders: -Ipatropium-albuterol (medication used to open the airway) solution for nebulization, 0.5 mg-3 mg/3 mL, 3 mL vial twice a day as needed via tracheostomy; -Change tracheostomy tubing and mask weekly; -Suction as needed for secretions, shortness of air or respiratory distress. Observation on 10/01/24 at 10:29 A.M., showed the resident's nebulizer tracheostomy mask and a nebulizer mask uncovered face down on the nightstand. The tubing and/or mask did not contain a date. The suction machine on an overbed table with yellow contents inside. Observation on 10/02/24 at 3:09 P.M., showed the resident's nebulizer tracheostomy mask and a nebulizer mask uncovered face down on the nightstand. The tubing and/or mask did not contain a date. The suction machine on an overbed table with yellow contents inside. Observation on 10/03/24 at 7:38 A.M., showed the resident's nebulizer tracheostomy mask and a nebulizer mask uncovered face down on the nightstand. The tubing and/or mask did not contain a date. The suction machine on an overbed table with yellow contents inside. During an interview on 10/04/24 at 9:00 A.M., Registered Nurse (RN) D said the resident gets suctioned periodically. The contents should be dumped and equipment cleansed after each episode. He/She had not noticed the suction machine contained contents and does not know when the last time the resident was suctioned. RN D said suction machine contents can build up with germs and will start to smell if not cleansed after each use. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Long and short-term memory problems; -Did not require oxygen; -Diagnosis of heart disease. Review of the resident's POS, dated October 2024, did not contain an order for oxygen use or maintenance of the tubing. Observation on 10/01/24 at 10:21 A.M., showed an oxygen concentrator tubing curled up around the bedframe and nasal prongs touched the floor. The tubing did not contain a date or placed into a dated plastic container. Observation on 10/02/24 at 3:29 P.M., showed the resident wore oxygen via nasal cannula. The tubing did not contain a date. Observation on 10/03/24 at 7:55 A.M., showed an oxygen concentrator tubing on the bed and not stored in a plastic container or dated. 4. Review of Resident #3's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Used oxygen; -Diagnosis of irregular heartbeat. Review of the resident's POS, dated October 2024, showed the physician order as follows: -Oxygen at 2 liters as needed for shortness of breath; -Change oxygen tubing monthly. Observation on 10/01/24 at 10:53 A.M., showed oxygen tubing on the oxygen concentrator not in a plastic container. Observation on 10/02/24 at 3:22 P.M., showed undated oxygen tubing on the oxygen concentrator undated and not in a plastic container. Observation on 10/03/24 at 7:58 A.M., showed undated oxygen tubing on the oxygen concentrator undated and not in a plastic container. 5. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately impaired cognition; -On oxygen; -Diagnosis of heart failure and lung disease. Review of the resident's POS, dated October 2024, showed the physician order as follows: -Ipatropium-albuterol solution for nebulization, 0.5 mg-3 mg/3 mL, 3 mL vial daily as needed and fpur times a day; -Change nebulizer and oxygen tubing weekly. Observation on 10/01/24 at 10:42 A.M., showed a nebulizer machine on the floor next to the residents bed. Observation on 10/01/24 at 11:32 A.M, showed the resident in the television room with oxygen on via nasal cannula. The oxygen tubing did not contain a date. Observation on 10/02/24 at 3:15 P.M., showed the resident in the television room with oxygen on via nasal cannula. The oxygen tubing did not contain a date. Observation on 10/02/24 at 3:26 P.M., showed the resident's nebulizer machine on the floor next to the bed. Observation on 10/03/24 at 7:56 A.M., showed the resident's nebulizer machine on the floor next to the bed. 6. Review of Resident #13's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Diagnosis of lung disease. Review of the resident's POS, dated October 2024, showed an order for oxygen to be used at two liters as needed at bedtime. Observation on 10/02/24 at 12:59 P.M., showed the oxygen tubing on the resident's bed undated and not stored in a dated plastic container. During an interview on 10/02/24 at 1:07 P.M., the Director of Nursing (DON) said the resident did have oxygen in his/her room but is not wearing it. He/She only needed it when he/she was ill. 7. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -No oxygen; -Diagnosis of heart disease. Review of the resident's POS, dated October 2024, showed an order to change oxygen tubing weekly. Observation on 10/01/24 at 10:50 A.M., showed the residents oxygen nasal prongs on the floor. The humidifier and tubing did not contain a date and the tubing not stored in a plastic container. Observation on 10/02/24 at 3:25 P.M., showed the residents oxygen nasal prongs on the floor. The humidifier and tubing did not contain a date and the tubing not stored in a plastic container. Observation on 10/03/24 at 07:57 A.M., showed the residents oxygen nasal prongs on the floor. The humidifier and tubing did not contain a date and the tubing not stored in a plastic container. 8. During an interview on 10/04/24 at 8:02 A.M., Certified Medication Technician (CMT) E said tubing should be put in a plastic bag and not left on the floor. The tubing is changed every Sunday. During an interview on 10/04/24 at 8:12 A.M., Certified Nurse Aid (CNA) F said oxygen tubing is changed and dated weekly. He/She said it is not always getting done and was not sure why. During an interview on 10/04/24 at 09:00 A.M., RN D said he/she did not have any training regarding the facility protocol for oxygen storage but the tubing should not be on the floor and the nebulizers should not be on the floor so that germs don't collect on them. He/She did not know about dating the tubing or storage bags. He/She said tubing for oxygen and nebulizers should be changed at least weekly and usually done on the weekends. During an interview on 10/04/24 at 9:11 A.M., RN A said oxygen tubing should be stored in a bag and changed weekly and the bag should be dated. During an interview on 10/04/24 at 10:49 A.M., the DON said oxygen tubing, nebulizer tubing and tubing storage bags should be dated when tubing is changed weekly by the nurses. There should be an order for oxygen and to change the tubing weekly. Nebulizer machines should not be on the floor and suction machines should be cleansed after each use. He/She said he/she just recently obtained an assistant and will now be able to do more frequent rounds with the MDS nurse and assistant. Failing to store oxygen equipment properly and clean the suction machines can lead to buildup of germs that cause infections. During an interview on 10/04/24 at 11:48 A.M., the administrator said oxygen masks and tubing should be stored in a dated bag when not in use and changed per physician order by the nurses to keep bacteria out of them. 9. Review of the facility's hand hygiene policy, dated March 2015, showed the policy did not contain direction on when to perform hand hygiene or use/change gloves. Review of the facility's Wound Care and Treatment policy, dated March 2015, showed: -Hand washing must be done as outlined in the guidelines; -Apply gloves, remove soiled dressing, remove gloves and wash hands; -Apply clean gloves, apply clean dressing after cleansing and label the dressing with initials, date and time; -Wash hands. 10. Review of Resident #27's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -At risk for developing pressure injuries; -Diagnosis of anoxic brain damage (brain cell damage due to lack of oxygen). Observation on 10/02/24 at 9:17 A.M., showed RN D applied a gown and gloves and entered the resident room to perform wound care. He/She removed the dressing from the resident's right heel wound, cleansed the wound, applied a clean dressing and secured it with tape. With the same soiled gloves, RN D cleansed the posterior calf wound, applied a clean dressing and secured it with tape. With the same soiled gloves, he/she gathered his/her trash and unused supplies, removed his/her gloves and gown and exited the room. He/she did not perform hand hygiene until after he/she exited the room. During an interview on 10/02/24 at 9:26 A.M., RN D said he/she should have performed hand hygiene and changed his/her gloves between dirty and clean and between wounds to decrease risk of infection spread but was nervous and does not like to be watched. 11. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -At risk for developing pressure injuries; -Presence of one stage III (a full thickness tissue loss that extends into deeper tissue and fat, but does not expose bone, tendon, or muscle) unhealed pressure wound; -Received pressure ulcer care; -Diagnosis of cerebral palsy, pressure ulcer to sacrum. Observation on 10/02/24 at 9:36 A.M., showed RN D applied a gown and gloves and entered the resident's room to provide wound care. He/She removed the dressing from the resident's sacrum, cleansed the wound, applied a clean dressing and secured it with tape. He/She did not perform hand hygiene between dirty and clean tasks. During an interview on 10/02/24 at 9:44 A.M., RN D said he/she should have performed hand hygiene and changed his/her gloves between dirty and clean tasks. He/She said he/she knows how to do his/her job but does not like being watched. 12. During an interview on 10/04/24 at 8:24 A.M., the Infection Preventionist said nurses should wash their hands prior to performing wound care, if soiled, and between glove changes to prevent contamination of wounds and the spread of germs. During an interview on 10/04/24 at 10:49 A.M., the DON said hand hygiene should be performed between dirty and clean tasks, between different areas of the body and before leaving the room to decrease spread of infections and germs. During an interview on 10/04/24 at 11:48 A.M., the administrator said hand hygiene should be performed between patients, when they leave a room, before care, and between glove changes or when removing gloves to keep bacteria out of the wounds or spreading of germs.

Based on interview and record review, the facility staff failed to ensure provision and documentation of education regarding the benefits, risks, potential side effects associated with the COVID-19 (a disease caused by a novel coronavirus) vaccine for facility staff. The facility census was 39 residents. 1. Review of the facility's Immunization policy dated 02/26/22 showed the policy did not contain direction for COVID-19 vaccine for facility staff. Review of the facility's COVID-19 for LTC policy dated 05/15/23 showed the policy did not contain direction for COVID-19 vaccine for facility staff. 2. During an interview on 10/02/24 at 09:36 A.M., the administrator said the business office manager quit on 10/02/24. The business office does the new hire paperwork to include review of COVID-19 status for employees. During an interview on 10/02/24 at 01:45 P.M., the Infection Preventionist said he/she is new to the role since August. He/She said he/she believes the business office obtains staff COVID-19 information on hire and he/she only tracks the resident information. He/She does not know if any education is provided. During an interview on 10/03/24 at 09:10 A.M., the administrator said the facility does not document education regarding the COVID-19 benefits, risks and potential side effects and/or offer or alert staff to how to obtain the vaccine.

Based on interview and record review, staff failed to maintain a professional standard of care when staff failed to obtain physician ordered blood work for four (Resident #1, #2, #4 and #5) of six sampled residents. The facility census was 39. 1. Review of the facility policies showed staff did not provide a policy for obtaining blood work. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/01/24, showed the resident had a diagnosis of diabetes. Review of the resident's Physician Order Sheet (POS), dated October 2024, showed the physician ordered a Hemaglobin A1C (measures average blood sugar over last two to three months) blood test to be obtained every three months on 05/28/24. Review of the resident's medical record showed the resident last Hemaglobin A1C blood test result on 05/30/24. Review showed the record did not contain a Hemaglobin A1C blood test as ordered in August 2024. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed a diagnosis of heart disease and diabetes. Review of the resident's POS, dated October 2024, showed the physician ordered a complete blood count ((CBC), blood test that can help diagnose conditions such as low iron, infection and leukemia), complete metabolic profile ((CMP) measures chemical balance in the blood), Depakote level (a measure of anti-seizure medication in the body), and Hemaglobin A1C every three months. Review of the resident's medical record did not contain documentation a three-month CMP, CBC, Depakote level, or hemaglobin A1C was obtained as ordered. 4. Review of Resident #4's Quarterly MDS, dated [DATE], showed a diagnosis of hypertension. Review of the resident's POS, dated October 2024, showed the physician ordered a CBC and CMP to be obtained every three months on 05/28/24, . Review of the resident's medical record, showed the record did not contain a CBC or CMP for September 2024 as directed by the physician order. 5. Review of Resident #5's Quarterly MDS, dated [DATE], showed a diagnosis of hypertension, heart failure and lung disease. Review of the resident's POS, dated October 2024, showed the physician ordered a CBC, CMP and Depakote level to be obtained every three months on 06/04/24. Review of the resident's medical record, showed the record did not contain a CBC, CMP or Depakote level for September 2024 as ordered by the physician. 6. During an interview on 10/04/24 at 9:00 A.M., Registered Nurse (RN) D said once a laboratory (lab) order is recieved, the order is transcribed into the electronic health record and the contracted lab website. When the lab technicians come onsite to draw blood, the technicians review the orders and obtain the blood. When the bloodwork results are returned to the facility, the physician is called by the charge nurse for emergent issues and faxed for non-emergent issues with a copy of the results inserted into a physician folder to sign off on weekly. He/She is not sure who uploads the documents into the computer but the results should be available for those that need the results to refer to and does not know why residents #1, #2, #4 or #5's blood work has not been done or uploaded into the system. RN D said he/she thinks the Director of Nursing (DON) is responsible to make sure the overall lab process is completed properly. During an interview on 10/04/24 at 10:49 A.M., the DON said he/she was not aware the blood work was not completed as ordered on resident #1, #2, #4, or #5. He/She said he/she feels there is a disconnect between the agency nurses and the facility process. He/She said he/she is new to the DON role at the facility and needs to go through and do a lab audit to ensure no other residents have been affected by missed blood work. During an interview on on 10/04/24 at 11:48 A.M., the administrator said he/she just recently hired a medical record staff member to upload documents which should help with keeping the electronic health record up to date. He/She was not aware there was issues with the blood work getting completed but would expect nursing to follow up on all physician orders.

Based on observation, interviews, and record review, facility staff failed to provide an ongoing activity program on the weekends and evenings and failed to provide a program that met the needs of two dependent residents (Resident #6, and #1). The facility census was 39. 1. Review of the facility's Activity, Volunteer and Recreational Services, dated March, 2012, showed the facility provides an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical , mental, and psychosocial well-being of each resident. The activity program must be directed by a qualified professional (Activity Director) who is directly responsible to the Administrator. 2. Review of the facility's activity calendar, dated September 2024, showed the weekend activities as follows: -On 09/07/24 10:00 A.M. bible study, 1:00 P.M. snack time, and 2:00 P.M. puzzles; -On 09/14/24 10:00 A.M. bible study, 1:30 P.M. snack time, and 2:30 P.M. color me pretty; -On 09/21/24 10:00 A.M., bible study, 1:30 P.M. snack time, and 2:30 P.M. story time; -On 09/28/24 10:00 A.M. bible study, and 3:00 P.M., movie time. Review of the facility's activity calendar, October 2024, showed the weekend activities as follows: -On 10/05/24 10:00 A.M. bible study and 3:00 P.M. puzzles; -On 10/12/24 10:00 A.M. bible study and 2:30 P.M. read; -On 10/19/24 10:00 A.M. bible study and 2:30 P.M. crossword; -On 10/26/24 10:00 A.M. bible study and 2:30 P.M. music. 2. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Mild cognitive impairment; -Activity preferences not assessed. Review of the resident's care plan, dated 09/27/24, showed the care plan did not contain the resident's activity preferences. During an interview on 10/02/24 at 3:06 P.M., the resident said there are no real organized activities on the weekends and he/she would really enjoy having the activities because there is not much to do. During an interview on 10/04/24 at 8:00 A.M., Certified Medication Technician (CMT) C said weekend activities are sometimes done on Saturdays but mostly it's just games or coloring. Staff sometimes do nail polish with the resident. He/She said the staff are expected to do the activity with the residents but just don't have time. 3. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/31/24 showed staff assessed the resident as comatose with diagnosis of persistent vegetative state. Review of the residents medical record showed the facility Observation Detail Section F form, dated 09/07/24, showed: -The preference for customary routine and activities was not assessed; -The staff assessment of daily and activity preferences was not assessed. Review of the resident's care plan, dated 10/01/24, showed staff documented: -Likes to look out the window during the day when awake; -Have access to the outside view when possible; -Place in wheelchair three times a week and out of his/her room and about facility per family request; -Keep curtain/shades open in room; -Have lights to remain on during cloudy days; -Have radio turned to gospel music during the day; -Is a Baptist; -Always enjoyed watching television especially football and basketball; -Enjoys Christian music and sitting outside but not in the sun; -Has a great sense of humor and loves a good joke; -Provide one-on-one sessions; -Provide activities that resembles his/her prior lifestyle; -Vary the environment when possible. Observation on 10/01/24 at 10:29 A.M., showed the resident on his/her back in bed with the curtains closed and the room dark. A sign hung on the wall by the bed stated the resident is able to blink twice for yes and once for no. Observation on 10/02/24 at 3:09 P.M., showed the resident in bed with the curtains closed and the room dark. Observation on 10/03/24 at 7:38 A.M., showed the resident in bed. Staff entered the room, administered the resident's medication, left the room and did not turn on television or gospel music for the resident. During an interview on 10/04/24 at 9:08 A.M., the Director of Nursing (DON) said the resident's family wants the room curtains to remain open when care not provided to let the resident look outside. During an interview on 10/04/24 at 8:24 A.M., Registered Nurse (RN) A said the resident enjoys looking out the window, so staff should keep the window shades open during the day and closed at night. He/She likes to watch everyone and should be taken out of room once in a while. During an interview on 10/04/24 at 10:29 A.M., the Activity Director said he/she will take the resident outside when the nursing staff get him/her out of bed. He/She said the resident has not been out of bed this week. The resident will listen to gospel and enjoys staff talking to him/her. He/She said if there was more regular staff and not as much agency, there might be more consistency with the resident getting out of bed. During an interview on 10/04/24 at 11:48 A.M., the Administrator said activities should be available during the day, evenings and weekends. He/She said the lack of activity director training and use of agency staff has made activities participation difficult. The agency staff may not know that activities are to be done. 43327

Based on observation, interview and record review, facility staff failed to ensure nursing staff had the appropriate skills and competencies to meet the care needs for the residents by not providing in-services, re-evaluating and documenting skills and competencies on a regular basis for each employee and failed to ensure nurse aides received the required 12 hours in-service education annually. The facility census was 39. 1. Review of the facility's Orientation and Training policy, dated April 2011 showed: -Each department head is responsible for the job-specific training required. -The policy did not include how often the education should be provided, how the education is to be documented or a list of inservices to include: abuse and neglect, dementia care, resident rights, communication, behavioral health or specialized resident needs to include: gastrostomy tube (tube placed into the stomach to deliver nutrition and/or hydration) use and care of, tracheostomy (artificial opening of the neck to help the person breath) use and care of, hospice/palliative care, enhanced barrier precautions, oxygen use and storage, ostomy (opening or stoma in the body to allow waste to exit a different way), emergency preparedness, weight loss and nutrition, and chemotherapy (cancer treatment). Review of the Facility Assessment, dated 08/30/24, showed staff identified: -Staff should receive initial training upon hire, ongoing professional development, and periodic competency assessments; -Certified Nurse Aides (CNA's) ongoing education focuses on enhancing skills in areas such as dementia care, infection control, and resident rights; -Licensed Practical Nurses (LPN's) ongoing education includes updates on medication management, wound care advancements, and palliative care practices; -Registered Nurses (RN's) ongoing education includes advanced clinical skills, leadership development, and specialized areas such as geriatric care and chronic disease management; -Staff are encouraged to participate in regular in-service training sessions, workshops, and online courses to stay current with best practices, regulatory changes, and emerging trends in long-term care. Topics include infection control, new therapeutic approaches, advancements in medical technology, and updates on regulatory requirements; -Competency assessments may include hands-on demonstrations, written exams, and peer evaluations covering critical areas such as medication administration, emergency response, and specialized care techniques; -Staff training programs and competency assessments include: initial training, continuing education, skill competency assessments, specialized training, and leadership development; -Regular performance evaluations help identify areas where individual staff members may excel or need improvement; -Some residents have unique care needs, such as those requiring wound care for pressure ulcers, or tube feeding; -A subset of the resident population may be receiving palliative or hospice care; -The resident population may include individuals from diverse cultural and religious backgrounds, each with specific needs regarding diet, activities and spiritual care. It is crutial for the facility to provice culturally competent care; -Many residents have dietary restrictions or specific nutritional needs; -To effectively meet the diverse care needs of the resident population, staff members must possess a wide range of competencies that are essential for ensuring that residents receive high-quality person-centered care and include: wound care, dementia care, medication administration, palliative and end of life care, behavioral health management, infection prevention and control, rehabilitation and therapy services, nutrition and dietary management and emergency preparedness. Review of the facility's in-service annual training showed: -07/10/24 in-service topic: F600, F607, F609, and F610 training regarding abuse and neglect to include reporting, definitions, examples, timeframes for reporting. The inservice included directions for resident money and photographs/videos of residents. Staff documented the inservice started at 09:00 A.M., and did not contain an end time or length of training; -07/15/24 in-service topic: COVID-19 (a disease caused by a novel coronavirus) Personal Protective Equipment (PPE): Donning (application of). The training form did not contain a start or end time or length of training; -09/10/24 in-service topic: Influenza/COVID-19 vaccines, drug testing and infection. Staff documented the in-service started at 09:00 A.M., and did not contain an end time or length of training; -09/10/24 in-service topic: Wound care/skin assessments. Staff documented the in-service start time at 09:10 A.M., and did not contain an end time or length of training; -The annual training did not contain documentation of skills and competencies to meet the care needs for the residents or documentation of the required 12-hour nurse aide training. Review of the facility's Matrix for Providers (a federally required resident population assessment tool), undated, showed the following resident specialized care needs: -Seven residents required hospice services; -One resident required tracheostomy care and use; -Two residents required wound care; -Two residents received nutrition and hydration using a gastrostomy tube; -Two residents had weight loss. Observation during initial tour on 10/01/24, showed the resident population included the following specialized services: gastrostomy tubes, tracheostomies, ostomies, chemotherapy treatments, oxygen use, enhances barrier precautions, COVID-19 isolation, dependent care, dementia/behavioral needs and residents who smoked cigarettes. During an interview on 10/03/24 at 2:36 P.M., the administrator said he/she is unable to locate any further staff trainings. During an interview on 10/04/24 8:11 A.M., Certified Medication Technician (CMT) D said he/she did not receive any training on oxygen, COVID, dementia care, abuse and neglect, hand hygiene/PPE or transfer technique. CMT D said he/she is relying on his/her past experience to know how to handle those situations. During an interview on 10/04/24 at 8:24 A.M., RN A said he/she received some training on hire such as watching a couple of videos, other than that he/she said staff are thrown out with a CNA. He/She said tracheostomy care, ostomy care, gastrostomy tube care and use are things he/she learned in school but not at the facility. He/She was not able to identify a spare tracheostomy tube should be kept at the bedside of a resident who had a tracheostomy. During an interview on 10/04/24 8:30 A.M., CNA G said he/she did not receive any training on oxygen, COVID 19, dementia care, abuse and neglect, hand hygiene/PPE or transfer technique. CNA G said he/she is relying on his/her own knowledge in her current position. During an interview on 10/04/24 at 9:00 A.M., RN D said he/she worked in a intensive care unit (ICU) before and knows how to care for residents with a tracheostomy and gastrostomy tube. He/She has not received any training at the facility and in most facilities, the management staff expect agency staff to know everything when they arrive at the building and are just put into an empty position. During an interview on 10/04/24 at 10:49 A.M., the Director of Nursing (DON) said when staff are hired or an agency staff works, the staff member is paired with someone from the facility. He/She said there is a written report at the nurse station that gives guidance and direction for individual care needs and a binder that includes specific trainings for all staff and agency staff to review at the nurse station. There is a consistency problem related to the amount of agency staff the facility uses but if the agency staff says they don't' know how to do something, they will be shown by on the spot training. He/She said agency does their own competencies with their staff so the facility does not do them and the facility just assumes they are competent to perform safe care. He/She said he/she is responsible to ensure staff are appropriately trained to care for residents and obtain the required trainings. He/she said he/she has only been at the facility a few months and has not started tracking the hours, but the trainings will be laid out in a calendar for each employee. During an interview on 10/04/24 at 11:48 A.M., the administrator said he/she is responsible for everything in this building and has only been here a few months. CNA's are required to have 12 hours of training a year and just recently the facility has been given a list of yearly trainings to be completed from the corporate office. He/She does not know what was done prior to his/her starting at the facility.

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse, when Certified Nurse Assistant (CNA) A sexually assaulted the resident. The facility failed to protect the resident from further abuse when CNA D witnessed the assault, did not intervene, and did not report it immediately. CNA A worked an additional 18 overnight shifts after the sexual abuse was observed. The facility census was 52. The Administrator was notified on [DATE], 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 policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Policy, undated, showed it is the policy of the facility each resident will be free from abuse, Review showed abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Residents will be protected from abuse, neglect, and harm while they are residing at the facility. An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. No abuse abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed a diagnosis of dementia. Review of the facility's investigation, dated [DATE], showed staff documented: -A report of an alleged sexual assault received, and an investigation started on [DATE] which allegedly occurred on [DATE] between 04:30 A.M. and 05:30 A.M. -CNA D's written statement showed he/she witnessed CNA A having sexual intercourse with the resident. CNA D documented he/she witnessed it from the window outside the resident's room between 4:30 A.M. and 5:30 A.M. on [DATE]. CNA A entered the resident's room and walked to the resident's bedside and began to rub the resident's legs through the comforter. CNA A then bent down and kissed the resident on the mouth. CNA A then guided the resident out of bed and into the bathroom, they stopped in the doorway where CNA A and the resident hugged and kissed for a while then went into the bathroom and stayed for a while. CNA A left the bathroom and the resident ran out of the bathroom naked to his/her bed, laid in a fetal position, with his/her buttocks faced outward towards the edge of the bed. CNA A returned to the room with a wet towel and wiped the resident's private areas. CNA A then walked to the closet and got clothes out for the resident, walked back to his/her bed, raised the bed to his/her waist level, and began to perform sexual intercourse with the resident. CNA D documented when CNA A finished with sexual intercourse, CNA A cleaned the resident's private area with the wet towel. Review of the local law enforcement report, dated [DATE], showed the police officer documented: -On [DATE], a police officer responded to the facility at 1:43 P.M. for a report of a sexual offense. The officer documented the administrator said he/she was notified on [DATE] at 3:00 P.M. by CNA D of a sexual assault and CNA D had a video of the assault. The administrator told the officer he/she started an investigation on [DATE]. CNA D said he/she suspected CNA A of assaulting the resident for a while, but did not report it because he/she wanted proof before reporting. CNA D said he/she was in the courtyard recording through the window, witnessed CNA A enter the resident's room between 4:30 A.M. and 5:30 A.M. and observed CNA A rub the residents leg and bend down to kiss him/her. CNA D said he/she saw CNA A take the resident from his/her bed and headed to the bathroom, stopped at the bathroom entry and hugged and kissed passionately. CNA D said CNA A and the resident were in the bathroom for a while, when the CNA A left the room and the resident came out of the restroom naked, possibly with a T-shirt covering his/her chest area. CNA D said CNA A returned to the resident's room with a washcloth and wiped the resident's genitals from front to back multiple times. CNA D told the officer CNA A raised the resident's bed higher, unzipped his/her pants and penetrated the resident. CNA D told the officer CNA A penetrated the resident for a long time. CNA D said he/she did not know if CNA A penetrated the resident in his/her genital or anal area. CNA D said CNA A went to the restroom after the assault. CNA D said later in the morning he/she assisted the resident to the restroom and observed a blood like substance in the toilet. CNA D informed he/she had the video, but the video was dark. CNA D said he/she did not know how to find the date and time of occurrence, because he/she did not know how to search for it on his/her phone. CNA D said the resident thought CNA A was his/her deceased spouse and called the CNA by his/her spouse's name. Review showed the officer documented he/she spoke with the (Sexual Assault Nurse Examiner) SANE nurse on [DATE] around 3:30 P.M. and the nurse told the officer the resident had a bruise on his/her elbow, but the resident denied consent on anything further; -On [DATE], the family member said he/she was informed on [DATE] by facility staff the resident was assaulted. The family member said the resident had a diagnosis of dementia and would call other resident's at the facility by his/her deceased spouse's name. He/She said the resident was examined by the emergency room staff and by a SANE nurse. The family member said he/she left the resident in the examination room with the SANE nurse. The family member said he/she was called back to the room about fifteen minutes later to attempt to calm the resident. The family member said he/she did not believe the examination was conducted due to the short period of time before being called back to the room; -On [DATE], CNA D provided the detective with a copy of his/her written statement he/she provided to the facility. CNA D confirmed he/she had a video of the sexual assault on his/her phone. CNA D gave his/her cell phone to be downloaded for the investigation. CNA D said he/she had suspected CNA A of having inappropriate relations with nursing home residents for a while, but did not have proof of anything, so he/she did not report his/her concerns because he/she did not want to make false accusations and ruin CNA A's reputation. CNA D said he/she witnessed CNA A enter the resident's room the morning of [DATE]. CNA D said he/she was in the courtyard and could see into the resident's room and recorded the incident. He/She said the recordings were poor quality and CNA D contacted various businesses to find someone to enhance the quality of the video, but was unable to. CNA D said he/she was concerned the video's would delete after a month, so he/she reported the incident to the administrative staff at the facility; -On [DATE], the phone was examined and the detective was provided a thumb drive containing three files with three videos; -The videos were recorded on [DATE] at 4:34 A.M., 5:38 A.M., and 5:43 A.M.; -CNA A was arrested on [DATE] due to probable cause. Review of the resident's nurses note, dated [DATE] at 6:19 P.M., late entry, showed staff documented due to alleged sexual misconduct the resident was sent to the hospital for evaluation by the SANE nurse. Review showed the hospital staff notified the facility they were unable to complete the exam because the resident became combative and uncooperative. Resident returned to facility accompanied by family member. Review of the local police department Probable Cause Statement, dated [DATE], showed the detective documented: -CNA D told the detective he/she witnessed CNA A enter the resident's room and kiss the resident on the mouth while he/she laid on the bed. CNA A then led the resident towards the bathroom. CNA A and the resident hugged and kissed while they stood in the doorway of the bathroom, then both entered the bathroom, and remained for a while with the door closed. Both CNA A and the resident then exited the bathroom. The resident laid on the bed while CNA A engaged in sexual intercourse with the resident. CNA D said because of the resident's dementia, the resident would often think CNA A was his/her spouse and call CNA A by his/her spouse's name. CNA D said the sexual act was recorded on video and provided the video to law enforcement. -CNA A told the detective he/she was aware the resident had dementia and the resident was unable to care for himself/herself due to his/her mental state. CNA A admitted to having sexual intercourse with the resident. Review of CNA A's work schedule showed he/she worked from 3 P.M., to 7 A.M., on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review showed he/she worked 7 P.M., to 7 A.M. on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 9:23 A.M., the detective said CNA A admitted to having sexual intercourse with the resident. The detective said CNA A admitted he/she knew the resident had a diagnosis of dementia. The detective said CNA A said he/she cared for the resident, which is why he/she had sexual intercourse with the resident. The detective said CNA A told him/her the sexual intercourse with the resident only happened one time. During an interview on [DATE] at 3:11 P.M., CNA D said he/she witnessed CNA A enter the resident's room, rub the resident's leg, then lean down and kiss the resident. He/She said CNA A walked the resident to the bathroom and began kissing the resident in the doorway, before entering the bathroom. CNA A and the resident stayed in the bathroom for a little bit and then the CNA left the resident's room. He/She said the resident walked out of the bathroom with his/her shirt off, and used it to cover his/her upper body, and without pants or underwear. He/She said he/she videotaped the incident, but it was not clear, so he/she was going to take it to a professional to try and enhance the video. During an interview on [DATE] at 2:28 P.M., the Director of Nursing (DON) said staff are directed to remove the resident to an area of safety and immediately report to the charge nurse and then up the change of command. He/She said staff are directed to assess the resident, notify the physician and responsible party. During an interview on [DATE] at 2:27 P.M., the administrator said staff are directed to remove the resident to an area of safety and immediately report to the charge nurse and then up the change of command. He/She said staff are directed to assess the resident, notify physician, responsible party and the State agency, then begin the investigation. He/She said the staff are educated on abuse and neglect annually and upon hire. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious 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 G 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). MO 00236810 MO 00236820

Based on interview and record review, facility staff failed to report an allegation of sexual abuse for one resident (Resident #1) to the administrator on 4/17/24, after witnessing the event. The alleged perpetrator worked 18 additional shifts before the nurse aide reported what was seen to the administrator on 5/13/24. The administrator failed to report the allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two hour timeframe. The facility census was 52. The Administrator was notified on 06/26/24, of an Immediate Jeopardy (IJ) which began on 04/17/24. The IJ was removed on 05/30/24 as confirmed by surveyor onsite verification. 1. Review of the facility's policy titled, Investigation, undated, showed staff were directed to: -It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated; -There are instances where an alleged violation of abuse, neglect, misappropriation of resident property and exploitation would be considered to a reasonable suspicion of a crime. In these cases, the facility is obligated to report to the Administrator, to the state survey agency, and to other officials in accordance with State Law; -The hotline (State Licensing Agency) will be notified by phone within two hours of the receipt of the report for the alleged offense, if serious bodily injury; -The facility shall complete the following report forms for the internal investigation, within twenty four hours to five days. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/25/24, showed staff assessed the resident with a diagnosis of dementia. Review of the facility's investigation, dated 05/13/24, showed staff documented Certified Nurse Assistant (CNA) D reported on 05/13/24 at 2:30 P.M. CNA A sexually assaulted the resident on 04/17/24 between 04:30 A.M. and 05:30 A.M. Review showed staff documented they notified DHSS on 05/13/24 at 7:31 P.M. Review of CNA A's work schedule showed he/she worked from 3 P.M., to 7 A.M., on 4/17/24, 4/19/24, 4/23/24, 4/24/24, 4/25/24, 4/30/24, 5/6/24, 5/7/24, 5/8/24, and 5/9/24. Review showed he/she worked 7 P.M., to 7 A.M. on 4/20/24, 4/21/24, 4/26/24, 4/27/24, 5/4/24, 5/5/24, 5/11/24, and 5/12/24. During an interview on 05/29/24 at 3:11 P.M., CNA D said he/she witnessed CNA A enter the resident's room, rub the resident's leg, then lean down and kiss the resident. He/She said CNA A walked the resident to the bathroom and began kissing the resident in the doorway, before entering the bathroom. He/She said the resident walked out of the bathroom with his/her shirt off, covering his/her upper body, and without pants or underwear. CNA D said he/she videotaped the incident, but it was not clear, so he/she was going to take it to a professional to try and enhance the video. He/she did not intervene because he/she wanted to have proof and did not know that he/she could intervene. CNA D said he/she was not able to find anyone to enhance the video, so he/she decided not to wait any longer to report the incident and spoke with the administrator about the sexual abuse he/she witnessed approximately one month prior. CNA D said he/she waited to report because he/she wanted to have proof of the allegation before reporting the sexual abuse. CNA D said he/she did not know when he/she last attended an abuse in-service and did not know the timeframe to report abuse or neglect. During an interview on 5/14//24 at 9:30 A.M. the former administrator said he/she did not report within the two hour time frame because he/she had initially been told the allegation of sexual abuse had been reported and investigated. The administrator said he/she was later told the allegation of sexual abuse had not been reported, so he/she reported late. During an interview on 05/29/24 at 2:27 P.M., the current administrator said staff are directed to remove the resident to an area of safety and immediately report to the charge nurse and then up the change of command. He/She said staff are directed to assess the resident, notify physician, the responsible party and the State agency, then begin the investigation. He/She said the facility had two hours to report potential abuse to the State agency. During an interview on 05/29/24 at 2:27 P.M., the Director of Nursing said staff are directed to remove the resident to an area of safety and immediately report to the charge nurse and then up chain of command. He/She said staff are directed to assess the resident, notify physician and the responsible party and the State agency, then begin the investigation. He/She said allegations of abuse and neglect should be reported to the State agency within two hours. He/She said the incident occurred prior to his/her employment. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious 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). MO00236810 MO00236820

Based on observation, interview, and record review, facility staff failed to promote the healing of one sampled resident's (Resident #1) pressure ulcer by failing to implement a physician order [REDACTED].#16) pressure ulcer. Furthermore, facility staff failed to accurately assess one resident's wounds (Resident #3), failed to document an initial wound assessment, failed to conduct weekly wound assessments for one resident (Resident #3), failed to obtain a treatment order in a timely manner for one resident (Resident #3), and failed to position one resident off an existing pressure ulcer (Resident #3) The facility census was 54. 1. Review of the facility's wound care and treatment policy, dated March 2015, showed staff are directed as follows: - Set up the supplies on a clean surface at the bedside. cover the surface with a clean, impervious barrier before putting the supplies down. Supplies are never placed on the bed but the soiled trash bag may be; - Clean the wound according the order, then remove gloves and wash hands; - Wound prevention strategies include to minimize friction and shear through proper positioning, transferring, and turning, and to develop and implement method of communicating position changing; - Positioning and pressure reduction include using a foot cradle for pressure-reduction and positioning. The foot should not have contact with the mattress surface. 2. Review of Resident #1's minimum data set (MDS), a federally mandated assessment tool completed by staff, showed staff completed a quarterly MDS on 5/8/17. Additional review showed staff did not complete an MDS assessment for August 2017. Review of the resident's quarterly MDS, dated [DATE], showed staff identified the following following: - Cognition intact; - [DIAGNOSES REDACTED]. - Not at risk for skin breakdown. Review of the resident's plan of care, reviewed on 2/21/17, showed staff identified the following care needs: -Pressure ulcer actual or at risk due to [DIAGNOSES REDACTED]. -At risk of breakdown related to [MEDICAL CONDITION] with repair; -Diabetic foot monitoring; -Unstageable deep tissue injury wound to left heel and follow the treatment administration record (TAR) instructions for wound care. Review of the resident's skin assessment, dated 6/13/17, showed staff assessed the resident as at risk to develop pressure ulcers. Review of the resident's physician order [REDACTED]. Review of the resident's TAR, dated 7/1/17-7/31/17, showed a treatment for [REDACTED]. Review of the resident's POS, dated 8/1/17-8/31/17, showed a treatment order for skin prep to left heel daily and heel boot while in bed. Review of the resident's TAR, 8/1/17-8/31/17, showed a treatment for [REDACTED]. Additional review of the resident's TAR, showed the TAR did not contain the physician order [REDACTED].>Review of the resident's wound assessments showed staff assessed the resident's wound as follows. - 6/8/17: Left heel pressure sore, 6 centimeters (cm) x 8 cm. Unstageable, purplish fluid filled blister. Heel protectors, skin prep daily, heel boot; - 6/15/17: Left heel deep tissue injury (DTI), unable to stage (UTS), measured 6.0 cm x 7.5 cm x 0 cm. Skin prep daily, offload heels, and low air loss (LAL) mattress; - 6/22/17: Left heel DTI and UTS, measured 6.5 cm x 8.0 cm x 0 cm, stable dry eschar (dead tissue which detaches from healthy skin). Skin prep daily, off load heels while in bed, podus boot (provides pressure reduction), and LAL; - 6/29/17: Left heel DTI and UTS, measured 7.0 cm x 8.0 x 0 cm, purple, intact, and fluid reabsorbing. Skin prep daily, walking podus boot, heel protectors while in bed; - 7/6/17: Left heel DTI and UTS, measured 5.8 cm x 7.4 cm x 0 cm, liquid filled blister with less liquid. Skin prep daily; - 7/13/17: Left heel DTI and UTS, measured 5.5 cm x 6.5 cm x 0 cm, eschar with granulation (new tissue forming on a wound). Debrided by the nurse practitioner and ordered changed to Dakins wet to dry (a solution which irrigates and cleans wounds) twice daily for one week; - 7/20/17: Left heel DTI and UTS, measured 4.2 cm x 5.6 cm x 0 cm; -7/27/17: Left heel DTI and UTS, measured 4.0 cm x 5.6 cm x 0 cm. Changed treatment to skin prep daily; - 8/3/17: Left heel DTI and UTS, measured 4.0 cm x 5.6 cm x 0 cm. Skin prep daily; - 8/10/17: Left heel DTI and UTS, measured 4.0 cm x 5.0 cm x 0 cm. Skin prep daily, heel boot, and walking podus boot; - 8/17/17: Left heel DTI and UTS, measured 4.0 cm x 4.5 cm x 0 cm. Skin prep daily. Observation on 8/23/17 at 12:47 P.M., showed the resident's low air loss mattress without air and flat. Observation on 8/23/17 at 3:45 P.M., showed licensed practical nurse (LPN) B entered the resident's room to perform a wound treatment. Observation showed the resident in bed and without a heel boot on his/her left foot. Additional observation showed the resident's mattress without air and flat, and showed the resident's left heel lay directly on the mattress. After the LPN completed the resident's wound treatment, the LPN instructed the resident it was ok to not wear anything on his/her left heel while in bed, so the wound could be open to air. Observation on 8/24/17 at 10:59 A.M., showed the resident lay in his/her bed and the low air loss mattress without air and flat. Additional observation showed the resident's left heel without a boot and the heel laying directly on the mattress. Observation on 8/24/17 at 4:03 P.M., showed the resident lay in his/her bed and showed the resident's left heel without a heel boot and laying directly on the mattress. During an interview on 8/24/17 at 9:05 A.M., the resident said he/she does not wear a boot on his/her left heel while in bed. The resident said staff do not ask or instruct him/her to wear the boot or ask him about keeping his/her heel off of the mattress. During an interview on 8/24/17 at 12:02 P.M., LPN B said he/she was not aware the resident had a physician order [REDACTED]. The LPN said if the resident has a physician order [REDACTED]. LPN B said he/she is not sure what type of mattress the resident currently has. During an interview on 8/24/17 at 1:25 P.M., the director of nursing (DON) said the resident's heel boots while in bed is a current order and he/she expects staff to encourage the resident to wear the heel boot while in bed. The DON said the resident does have a LAL mattress. Observation on 8/24/17 at 1:35 P.M., showed the DON walked in the resident's room and examined the mattress. Observation showed the DON identified the mattress as not having air and examined the LAL mattress control panel attached to the foot board of the bed. Observation showed the panel with a yellow warning light on, indicating the mattress had low pressure, and showed no sound from the control panel. Observation showed the DON reset the LAL mattress control panel and noise began to come from the panel. During an interview on 8/24/17 at 1:40 P.M., the DON said he/she was not aware the resident's LAL mattress was not functioning correctly. During an interview on 8/29/17 at 12:47 P.M., the resident's physician said the resident has a current order to wear a heel boot on his/her left heel. The physician said he/she expects staff to ensure the resident is wearing the heel boot as ordered. 3. Review of Resident #16's Entry Tracking Record MDS, dated [DATE], showed the resident was admitted to the facility on [DATE]. Review of the resident's medical records showed the medical records did not contain a plan of care. Review of the resident's POS, dated 08/18/17-08/31/17, showed the following: - [DIAGNOSES REDACTED]. - Wound vac (negative pressure wound therapy) to right buttock, cleanse with wound cleanser, place wound vac gauze and clear opsite (adhesive film), run at 125 mmHg (suction pressure). Change every three days and as needed; - Wet to dry dressing, change as often as needed due to loose bowel movement and as needed. Review of the resident's wound tracking form, dated 08/24/17, showed staff identified a stage 4 pressure ulcer wound to the resident's right buttock, which measured 9 cm x 11 cm x 7 cm and had less than 5% slough (yellow tissue on the wound). Review of of the resident's TAR, dated 08/20/17-08/31/17, showed staff applied a wet to dry dressing on 08/24/17. During an interview on 08/25/17 at 10:55 A.M., the resident said his/her wound dressing came off in the middle of the night and said he/she told staff at least two times this morning and staff has not replaced the wound dressing. The resident said he/she has had to lay on his/her left side since early this morning due to not having a wound dressing on his/her wound. The resident said staff do not consistently change his/her wound dressing. Observation on 08/25/17 at 10:59 A.M., showed the resident lay on his/her left side with a large open wound to the resident's right buttock without a wound dressing. Observation showed the wound packing out of the wound and on his/her mattress, and showed red and yellow staining on the resident's sheet. Observation on 08/25/17 at 11:58 A.M., showed the resident's call light on. The resident lay on his/her left side, and the resident's wound remained without a wound dressing. During an interview on 08/25/17 at 11:59 A.M., the resident said he/she pressed the call light around 30 minutes ago and said no staff has come to replace his/her wound dressing. During an interview on 08/25/17 at 1:47 P.M., LPN B said a certified nursing aid (CNA) told him/her this morning about the resident's wound dressing falling off, but said he/she could not remember what time he/she was told. The LPN said he/she did not immediately go check on the resident because he/she was helping another resident at the time and then forgot to check the resident. The LPN said he/she should have replaced the resident's wound dressing right after he/she was notified. During an interview on 08/25/17 at 2:48 P.M., the DON said he/she would expect staff to replace the resident's wound dressing right after the staff was notified the wound dressing came off. During an interview on 08/29/17 at 8:42 A.M., the resident said the evening nurse turned off his/her wound vac last night due to the wound vac beeping, but does not remember what time it was turned off. The resident said the staff on the third shift turned it back on when they started working the shift. During an interview on 08/29/17 at 9:58 A.M., the DON said if the resident's wound vac is not working correctly, he/she expects staff to remove the wound vac and apply a wet to dry dressing to the resident's wound as ordered. During an interview on 08/29/17 at 1:04 P.M., LPN E said he/she did turn off the resident's wound vac the night before because it was beeping and was worried it was not functioning correctly. The LPN said he/she does not recall what time he/she turned off the wound vac, but it was toward the end of his/her shift. The LPN said he/she did not think about putting the wet to dry wound treatment on the resident's wound, but said if it was ordered, he/she should have applied it. During an interview on 08/31/17 at 11:30 A.M., registered nurse (RN) F said he/she does not remember if the resident's wound vac was on or off when he/she came into work on 08/28/17. The RN said if the wound vac was not working, staff are expected to apply a wet to dry treatment on the resident's wound. 4. Review of the facility's Wound Care and Treatment policy, dated March 2015, showed the following definitions: - Stage 1: Redness only, no break in skin; - Stage 2: Partial thickness, skin loss involving epidermis or dermis. Ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater; - Stage 3: Presents full thickness skin loss involving damage or neurosis of subcutaneous tissue, which may extend down to, but not through, underlying fascia. The ulcer clinically as a deep crater with or without undermining of adjacent tissue; - Stage 4: Full thickness skin loss with extensive destruction, tissue neurosis or damage to muscle, bone or supporting structures such as tendon or joint capsule; - Eschar Covered Wound: Unstageable wound covered with dry, devitalized tissue; - Enzyme Debridement: Neurotic tissue. 5. Review of Resident #3's MDS, dated [DATE], showed staff assessed the resident with severely impaired cognitive skills, totally dependent on two plus persons for assistance with bed mobility and transfers, and always incontinent of bladder and bowel. Review of the resident's plan of care, dated 08/16/17, showed staff documented the resident had a pressure ulcer to his/her right trochanter, and scar tissue to right hip and coccyx. Staff are directed to conduct weekly skin assessments, provide treatments as ordered, preventative treatment with stock cream, and continue to off load. Review of the resident's weekly skin assessments showed staff documented on 08/11/17 the resident's skin was intact with no new skin issues to report. Further review showed staff documented on 08/15/17 the resident had an existing skin issue, areas on right hip, right shin, and coccyx continue to heal with treatment. Review of the resident's skin assessments showed staff documented: -08/11/17 Stage II pressure ulcer to right inner shin, 4 centimeters (cm) by 2 cm by 0 cm, wound bed pink; -08/11/17 Stage II pressure ulcer to right hip, 1 cm by 1 cm, no depth recorded, wound bed pink/red; -08/17/17 Stage II new pressure ulcer to coccyx, 3 cm by 1 cm by 0 cm, wound bed beefy red; -08/17/17 Stage II pressure ulcer to right hip, 2 cm by 1 cm by 0 cm, pink wound bed with minimal slough; -08/17/17 Stage II to right inner shin, 4 cm by 2 cm, no depth recorded, pink wound bed. Review of the resident's Physician order [REDACTED]. Observation on 08/24/17 at 10:30 A.M. showed RN H wore gloves, removed the dressing over the resident's right hip pressure ulcer and discarded it. Observation showed a pink scarred area, with an unstageable area approximately 2 cm by 1 cm of slough, with eschar in the middle. RN H described the tissue as necrotic, but said he/she was unsure what stage the wound was. RN H cleansed the wound with wound cleanser and gauze and applied [MEDICATION NAME] to the wound. Observation showed the resident's right inner shin with a small superficial open area. RN H cleansed the wound and applied a foam dressing. RN H removed the dressing from the resident's coccyx. Observation showed an area of pink skin with a darker pink, superficial open area in the middle, approximately 3 cm by 1 cm. RN H described the wound appeared to have the first layer of skin off so a stage I. RN H cleansed the wound and applied [MEDICATION NAME] with tape. Further observation showed RN H positioned the resident to lay on top of his/her right hip unstageable pressure ulcer. During an interview on 8/25/17 at 1:47 P.M., LPN B said he/she was not sure when a wound assessment should be completed after a wound is first identified. The LPN said wound assessments should be completed weekly and was not sure what components should be included in a wound assessment. During an interview on 08/25/17 at 1:50 P.M., LPN B said the resident's hip was pink and white on 08/22/17, and did not contain slough. He/she said facility staff provide the wound treatment once a week and hospice provides it the other two days. LPN B said he/she would contact hospice if the wounds' appearances changed. LPN B said staff turn the resident every two hours, and lay the resident down after meals. He/she said staff should not position the resident on the affected side. During an interview on 8/29/17 at 9:58 A.M., the DON said he/she expects staff to complete an initial wound assessment within the same shift the wound was identified. The DON said he/she expects wound assessments to be completed weekly and to include staging, measurements, and description of wound. The DON said he/she expects staff to contact the physician immediately after the wound is discovered to obtain a wound treatment.

Based on interview and record review facility staff failed to implement a system to monitor the effectiveness of one resident's (Resident #1's) blood thinning medication. The resident was admitted to the facility on [DATE] with orders for blood thinning medication due to a past history of an irregular heartbeat and a stroke. Facility staff failed to implement their system to collect routine blood samples to monitor the resident's [MEDICATION NAME] time (PT) and international normalized ratio (INR - used to determine the clotting tendency of blood as a result of [MEDICATION NAME] use). In addition, facility staff failed to transcribe and follow a physician's orders [REDACTED]. The resident's PT and INR became elevated (blood too thin), the resident experienced [MEDICAL CONDITION], and required hospitalization for administration of a blood transfusion and correction of the [MEDICATION NAME] overdose. The facility census was 74. 1. Review of Resident #1's "Immediate" plan of care dated 02/18/11, showed staff planned the following interventions related to the increased risk for bleeding/bruising as a result of aspirin and anticoagulant therapy: -Observe for signs and symptoms of bleeding including tarry stools, blood in urine, bruising and petechia (small red or purple spot caused by bleeding into the skin); -Observe for adverse reactions such as fever, [MEDICAL CONDITION], nausea, vomiting, diarrhea and hemorrhage (bleeding). Review of the resident's Physician order [REDACTED].M., showed the resident's physician directed staff to administer [MEDICATION NAME] 10 milligrams (mg) to the resident on 02/23/11 and then 5 mg daily. The physician directed staff to check the resident's INR on "Friday" (2/25/11). Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/25/11, showed facility staff assessed the resident as follows: -History of [MEDICAL CONDITIONS] (stroke); -History of [MEDICAL CONDITION] Fibrillation (irregular heartbeat); -Received anticoagulant therapy; -Dependent on two staff to complete Activities of Daily Living (ADLs), including bed mobility, transfers, toilet use and bathing; -Dependent on one staff person to dress and for personal hygiene. During an interview on 04/20/11 at 2:00 P.M., the Director of Nursing (DON) said it was their normal practice to a draw blood sample on all newly admitted residents on [MEDICATION NAME] to check the PT/INR monthly if the physician did not give other orders. Review of the resident's PT/INR results, dated 02/25/11 showed the resident's PT at 15.3 (normal listed as 11.3-14.3) and INR at 1.22 (normal listed as 0.8-1.2). Further review of the PT/INR results showed facility staff faxed the results, dated 02/25/11, to the physician on 02/28/11. On 02/28/11 the physician recorded on the bottom of the laboratory results to increase the resident's [MEDICATION NAME] dose from 5 mg to 6 mg and recheck the PT/INR "in one week" (3/7/11) and faxed the order back to the facility. Review of the resident's laboratory results showed staff did not obtain a repeat PT/INR one week after the 02/25/11 results as ordered. In addition, review of the laboratory results showed staff did not obtain monthly PT/INR results as was their normal practice to monitor the resident's PT/INR levels. The resident's laboratory results showed staff did not obtain a blood sample between 02/25/11 and 04/06/11 to show on-going monitoring of the resident's PT/INR levels. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the resident's nurse's notes, dated 04/05/11 at 2:29 P.M., showed staff recorded the resident became "weak, tired and dizzy" and had a "large amount of blood-colored" stool. Staff recorded they notified the physician who directed staff to draw a blood sample to check the resident's complete blood count (CBC). Staff did not record information to show they reviewed the resident's PT/INR levels or discussed this with the resident's physician. Review of the resident's nurse's notes, dated 04/06/11 at 10:53 A.M., showed Registered Nurse (RN) A recorded the resident had a "large amount of dark red blood in and around the toilet." RN A recorded the resident's physician was at the facility and directed staff to send the resident to the emergency room for evaluation and treatment. During an interview on 04/20/11 at 11:15 A.M. the resident's family member said the resident required a blood transfusion while in the hospital. The family member said the resident was very ill and he/she did not know if the resident was "going to make it." During an interview on 04/20/11 at 11:20 A.M. the resident's physician said he directed staff to recheck the resident's PT/INR after he increased the dose on 02/28/11. He said staff did not recheck the PT/INR as he directed and the resident experienced [MEDICAL CONDITION]. He said when he assessed the resident at the facility on 04/06/11, "there was so much blood" he directed staff to send the resident to the hospital immediately. Note: At the time of the complaint investigation, the violation was coded at "J", Immediate and Serious Jeopardy Level. By 4/25/11, the facility had implemented measures that adequately addressed the jeopardy by ensuring all residents with blood thinning medications receive necessary laboratory services per physician order. The grid placement was lowered to a "D" level. This statement does not denote that the facility has complied with Section 198.026.1 RsMO, regarding prompt remedial action for a violation of a Class I standard. See below for remaining deficient practice: As of the 4/25/11 exit conference, the facility failed to do the following: -inservices to all licensed staff regarding the implementation of their system to collect routine blood samples to monitor the resident's PT/INR; -inservices to all licensed nurses regarding their policy for ordering labs, entering lab orders, transferring lab orders from the POS to the Treatment Administration Record (TAR) and the protocol for completing lab requisitions. MO 793

Based on observation, interview, and record review, facility staff failed to provide timely and detailed assessments, obtain physician orders, and implement new interventions to promote healing for existing pressure ulcers, and prevent new pressure ulcers from forming for one (Resident #2) out of two sampled residents with pressure ulcers. The facility census was 73. 1. Review of Resident #2's hospital records, dated 2/23/11, showed hospital staff recorded the resident acquired the following wounds prior to admission to the facility: - Stage II pressure ulcer on the coccyx (tailbone) 1 cm by 1 cm; - Left anterior foot wound (no stage or measurements); - Left lateral ankle wound, unstageable (no measurements); - Left posterior heel, unstageable (no measurements). Review of the resident's Braden Scale assessment (used to predict pressure ulcer risk), dated 2/23/11, showed staff assessed the resident was at high risk to develop pressure ulcers. Review of the resident's admission Clinical Health Status record, dated 2/23/11, showed facility staff documented the following: -Dry and red right heel (not measured); -One centimeter "open area" on buttock; -"Black, dead skin" on left heel, eight centimeters (cm) by four cm; -"Areas" on top of left foot (not measured or described). Review of the resident's immediate plan of care, dated 2/24/11, showed the staff planned the following interventions: - Turn and reposition the resident every two hours; - Provide ulcer care as ordered; - Encourage different bed positions. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/27/11, showed staff assessed the resident as follows: -[DIAGNOSES REDACTED]. -Totally dependent on staff for mobility, dressing, eating, toilet use, and hygiene; -Did not ambulate; -One stage I pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence); -Zero stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister). Staff did not accurately identify the skin areas on the resident's MDS as documented on the admission Clinical Health Status record. Review of the Physician order [REDACTED]. -Cleanse wound on coccyx, apply wound dressing to absorb and debride dead tissue, and cover; -Apply Prevalon boots (pressure relieving heel protectors) to both lower legs: on two hours, and off two hours every day. Review of the POS [REDACTED]. Review of the facility's Skin Care policy (undated) showed the policy directed staff to complete the following: -Provide a systemic approach and monitoring process for skin integrity/pressure ulcer care; -Prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcer formations, and developing interventions; -Promote healing of pressure ulcers; -Review at risk residents, and those with wounds on a routine schedule on a weekly basis. Review of the facility's Weekly Skin Conditions form showed staff recorded the following: -On 3/3/11 staff did not complete an assessment of the resident's skin; -On 3/10/11 staff recorded the resident's bottom was pink/red/purple with an "open area" on the resident's coccyx, left heel continued with black area. Staff did not record consistent measurements or other descriptions of the areas to show on-going monitoring for improvement or decline of the pressure ulcers. -On 3/17/11 staff recorded the resident's coccyx pressure ulcer was red with a purple center, top layer of skin gone; noted other wounds to bilateral heels. Staff did not record consistent measurements or other descriptions of the areas to show on-going monitoring for improvement or decline of the pressure ulcers. Further review showed staff did not document any assessments of the wound on the resident's left lower leg that staff identified on admission. Staff did not record any measurements or other description of the left lower leg area to show on-going monitoring for improvement or decline of the pressure ulcer. Review of the Wound Evaluation book staff used to track and monitor pressure ulcers, showed it did not contain measurements, descriptions, or on-going assessments of the resident's multiple pressure ulcers for improvement or decline of the resident's pressure ulcers. During an interview on 4/7/11 at 1:00 P.M., the Director of Nursing (DON) said staff did not keep the Wound Evaluation book "up to date." She said staff should measure all of the wounds and describe them weekly. She said staff should document their assessments in the nurses notes and the wound evaluation book. The DON could not find any measurements, after admission, of the wounds to the residents lower legs or heels until 3/20/11. During an interview on 4/7/11 at 1:30 P.M. Licensed Practical Nurse (LPN) A said the charge nurse was responsible to measure all wounds once a week and document the findings in the nurses notes. LPN A said staff should notify the Physician if they assessed a change in a wound, or if the wound did not respond to treatment. Review of the resident's nurses notes showed staff recorded the following: -On 2/26/11 at 11:03 A.M.- Treatment administered to sacrum (base of the spine) as ordered. Area of black eschar (dead, leathery tissue) noted to left heel, right heel soft. Dressing to top of left foot dry and intact. -On 3/17/11 (no time)- Resident's bottom noted to be "very red" with deep purple center, top layer of skin was gone, minimal amount of clear yellow drainage, and first documented (22 days after admission) the pressure ulcer measured 10 cm by 6 cm by 0 cm. Nursing staff did not document they notified the Physician of the change in the resident's pressure ulcer on the coccyx/sacrum. -Nursing staff did not document assessments, or measurements, to show on-going monitoring for the pressure ulcers on the resident's left heel, left foot, or left lower leg until 3/20/11 (25 days after admission) and did not document they notified the resident's physician of the changes until this date. Further review of the nurses notes, dated 3/20/11 (25 days after admission), showed staff did not document assessments of the following areas until this date: -Left lateral lower leg #1 (proximal) 7.2 cm by 1.1 cm 100% black eschar; - Left lateral lower leg #2 (middle) 1.0 cm by 0.6 cm by 0 cm, purple discoloration; -Left lateral lower leg #3 (distal) 4.1 cm by 1.0 cm 100% black eschar; -Left hip 5.0 by 3.3 cm intact blister, blister bed is purple; -Left upper inner buttock 8.0 by 7.6 by 0 cm: ulcer bed 20% slough (dead tissue) 40% pink granulation tissue (new skin tissue) 40% purple discoloration, with tissue that "appears to be similar to a ruptured blister." Review of the skin assessment dated [DATE] showed staff did not record an assessment or measurement of the left heel pressure ulcers. Review of the resident's POS, dated 3/20/11, showed the Physician changed the treatments to the residents coccyx, and added orders for treatment of [REDACTED]. Review of the resident's nurses' notes, dated 3/23/11, showed staff recorded they sent the resident to the hospital for evaluation of an elevated temperature and pulse rate. Review of the admission notes from the hospital, dated 3/23/11, showed hospital staff recorded assessments of the following when the resident was admitted to the hospital: -Left heel 4.0 cm by 5.0 cm with eschar (dry scab of dead skin); unstageable; -Right upper foot 0.5 cm by 0.5 cm by 0.2 cm; full thickness wound; -Left inner ankle 0.5 cm by 0.6 cm; suspect deep tissue involvement; -Left lower leg (superior) 7.0 cm by 1.0 cm by eschar; unstageable; -Left lower leg (inferior) 3.0 cm by 0.7 cm by eschar; suspect deep tissue involvement; -Right inner knee 1.0 cm by 0.3 cm by 0.1 cm; -Left hip 4.5 cm by 1.8 cm by eschar; -Left buttock 6.5 cm by 5.0 cm by eschar; unstageable -Sacrum 2.5 cm by 1.5 cm by eschar; unstageable. During an interview on 4/7/11 at 1:00 P.M., the DON said staff should try different pressure ulcer treatments if the wounds did not show improvement "for a few weeks." The DON said the "regular" charge nurse, who measured wounds, did not work for several weeks. She said the replacement nurses did not complete adequate assessments of the resident's wounds. The DON said the resident acquired a wound on his/her hip, inner knee, and two on the left lower leg while at the facility. During an interview on 4/18/11 at 4:20 P.M., the Physician said the resident had poor nutrition and muscle mass, and was a "huge" risk to develop pressure ulcers. He said the resident required surgical debridement (removal of dead tissue) of several of the pressure ulcers. MO 330