Every finding on record at Seville Care Center

Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease, a serious type of pneumonia caused by Legionella bacteria. Failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents at risk of exposure which could lead to illness. The facility census was 45. 1. Review of the Centers for Medicare and Medicaid Services (CMS), QSO-17-30, dated 06/02/17 and revised 07/06/18, showed: -CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems;-Facilities must have water management plans and documentation that, at a minimum, ensure each facility:*Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;*Develops and implements a water management program that considers the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit;*Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained;*Maintains compliance with other applicable Federal, State and local requirements;*Note: CMS does not require water cultures for Legionella or other opportunistic water borne pathogens. Testing protocols are at the discretion of the provider. Review of the facility's Legionella Infection policy, dated 03/05/20, showed the facility must have a water management plan and documentation that, at a minimum to each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g.pseudomonas, Acinetobacter, burkholderia, stenotrophomonas, nontuberculous mycobacteria and fungi) could grow and spread in the facility water system;-Develop and implement a water management program that considers the ASHRAE (American Society of Heating, Refrigerating and Air Conditioning Engineers) industry standard and the CDC toolkit;-Specifies testing protocols and acceptable ranges for control measure and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Water Management Plan, undated, showed the facility will verify compliance with Water Management Program by reviewing scheduled monitoring monthly and each potentially hazardous condition will be addressed individually. Review showed the plan contained a risk assessment which identified dead legs in 207, 209, medical records, social services, empty resident room bathrooms and low-rise floor sinks in housekeeping closets as high-risk areas. Review showed environmental testing will be conducted if there is difficulty maintaining water systems within control limits or a case of healthcare associated Legionella was acquired in the facility. Review showed the plan also included instruction for staff to perform baseline Legionella testing at four specified sites within the facility. Review showed the plan did not contain: -A list of designated water management team members;-Documentation of monthly review of scheduled monitoring;-Documentation of baseline or annual Legionella testing;-Guidance related to areas identifies as high risk. Review of the facility's Infection Prevention and Control Program, dated 04/10/19, showed the program did not contain information related to Legionella. Review of the facility's Resident Room Water Temperature and Checklist for 01/07/26 through 03/29/26 showed facility staff tested water temperatures in random resident rooms on both wings of the facility. Review showed water temperatures checked on 01/07/26, 01/19/26, 01/29/26, 02/13/26 and 03/06/26. Review showed staff also tested water pH, chlorine and total dissolved solids, but did not indicate testing location. Review showed the checklists did not contain testing or inspection results of all areas identified as high risk. During an interview on 03/27/26 at 11:57 A.M., the maintenance director said he/she and housekeeping staff flush resident room water lines on an almost daily basis, but he/she only documents water checks every two weeks. The maintenance director said he/she tests the facility water pH and chlorine levels every two weeks, but he/she had not tested the water for Legionella. The maintenance director said he/she was familiar with the water management plan and had briefly reviewed it two weeks ago, but he/she was not familiar with specific high-risk areas identified in the plan. During an interview on 03/27/26 at 12:26 P.M., the Regional Administrator said the facility should have annual Legionella testing but he/she did not know who conducted the testing. During an interview on 03/27/26 at 2:07 P.M., facility owner said corporate level staff maintain one copy of a Water Management Policy template, but it is the facility administrator's responsibility to develop and implement a facility specific plan. During an interview on 03/30/26 at 12:34 P.M., the administrator said the water management plan should include how the water is tested monthly. The administrator said he/she thought Legionella testing was performed only if there was suspicion or a positive case of Legionella. The administrator said he/she reviewed the water management plan in early 2025 and did not make any changes. The administrator said the water management team included him/herself and the maintenance director and he/she did not know that needed to be documented. The administrator said he/she never discussed the water management plan with the maintenance director and was not familiar with the specific risk areas, control measures or corrective actions since the maintenance director took care of the water. Complaint #2965680

Based on interview and record review, facility staff failed to provide an appropriate emergency discharge notice when staff discharged one resident (Resident #1) to the hospital and refused to allow the resident to return to the facility. The facility census was 45.1.Review of the facility's Making and Emergency Transfer or Discharge policy, revised April 2007, showed staff are directed to only make an emergency discharge when it is in the best interest of the residents. To make an emergency discharge the facility will implement the following procedures:-Notify the residents attending physician;-Notify the receiving facility that the transfer is being made;-Prepare the resident for transfer;-Prepare a transfer form to send with the resident;-Notify the representative and other family members;-Assist in transportation.2. Review of Resident #1's face sheet, dated 3/16/26, showed the resident admitted to the facility on [DATE], and facility staff discharged him/her to the hospital 3/3/26.Review of the resident's progress notes, dated 3/4/26, at 4:04 P.M., showed staff documented an emergency discharge effective immediately to the local hospital for safety reasons.Review of the resident's Immediate Discharge Notice, dated 3/3/26, showed staff documented the location of discharge to the local hospital for resident and staff safety.During an interview on 3/16/26 at 9:05 A.M., the administrator said the resident was not in the building 24 hours and started to refuse care and to make threats and scare staff. He/She said the facility did an emergency discharge to the local hospital that day. He/She understands the hospital is not a discharge location, but he/she needs to protect his/her residents and staff. He/She said they are unable to take the resident back for the safety of staff and other residents. Complaint 2795777

Based on interview and record review, facility staff failed to prevent misappropriation of money from one resident, (Resident #1), out of five sampled residents, when the Director of Nursing (DON) stole $1700.00 from the resident, without the resident's consent. The facility census was 48. The administrator was notified on 12/10/25 of past Non-Compliance which occurred on 12/05/25. On 12/05/25, the administrator investigated and notified the police department of the theft. The administrator terminated the DON on 12/05/25; in-serviced all staff on the facility's abuse, neglect, and misappropriation policies on 12/05/25; and reimbursed the resident $1700.00. 1. Review of the facility's Abuse, Neglect, and Misappropriation Policy, updated 12/15/12, showed residents have the right to be free from abuse, corporal punishment and involuntary seclusion, and it is the facility's responsibility to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property, that if left unchecked, lead to abuse. Review showed misappropriation of resident property is defined as the pattern or deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/06/25, showed staff assessed the resident as cognitively intact. Review of the facility's investigation, dated 12/05/25, showed Resident #1 reported he/she gave $1700.00 to staff to lock up in the medication room upon admission. Staff searched the medication room, but did not locate the resident's money. Staff reviewed the camera footage, which showed the resident gave staff a resealable plastic bag containing money. Review showed Licensed Practical Nurse (LPN) A lock the resealable bag in a locked cabinet in the medication room. Review showed the DON was the only staff to access the locked cabinet in the medication room prior to staff becoming aware of the missing money. Staff documented a police officer came to the facility at approximately 10:40 A.M., interviewed the DON for approximately 30 to 40 minutes, and the DON confessed to the police officer he/she took the money because he/she was going to be evicted, but said there was only $940.00. Staff terminated the DON on 12/05/25 for admitting to stealing the resident's money out of the locked cabinet in the medication room. Review of the facility's camera footage showed on 12/03/25, at 8:59 P.M., the resident handed LPN A, a resealable plastic bag, and LPN A said, That is a lot of money. Review showed on 12/03/25, at 9:01 P.M., LPN A locked an item in the locked cabinet in the medication room. Review showed on 12/04/25, at 10:39 A.M., the DON entered the medication room, removed an item from the locked cabinet, looked at the camera, and left the medication room. Review of the facility camera footage on 12/03/25 at 9:01 P.M. to 12/04/25 at 10:39 A.M. did not show any other staff accessed the locked cabinet in the medication room. During an interview on 12/10/25, at 11:10 A.M, the administrator said the BOM notified him/her on 12/04/25, staff were unable to locate the resident's money in the medication room. He/She said during the investigation, the camera footage showed the DON was the only staff member to access the locked cabinet in the medication room after LPN A locked the resealable plastic bag with the resident's money in the cabinet. He/She said the DON denied knowing about the money. The administrator said the DON then admitted he/she knew about the money but denied taking the money. The administrator said he/she notified the police department, and after the police officer interviewed the DON, the DON admitted to the police officer he/she took the resealable plastic bag of money. The administrator said he/she terminated the DON, and the police officer was going to obtain a warrant for the DON's arrest. During an interview on 12/10/25, at 11:20 A.M., the BOM said the Activity Director told him/her the resident wanted some of his/her money. He/She said LPN A said he/she locked a resealable plastic bag containing the resident's money, in a locked cabinet in the medication room. The BOM said he/she, the Activity Director, and the DON searched the medication room, but were unable to locate the resealable plastic bag or the money. He/She said they notified the administrator, who came to the facility, started an investigation, and notified the police department. During an interview on 12/10/25, at 1:36 P.M., LPN A said the resident came to the facility from the hospital with money in a resealable plastic bag. He/She said he/she locked the resealable plastic bag in a locked cabinet in the medication room and notified the DON regarding the money. During an interview on 12/10/25, at 1:59 P.M., the resident said he/she had $1700.00 in a resealable plastic bag. He/She said LPN A took the resealable plastic bag and said he/she would lock it in the medication room. He/She said when he/she asked staff for the money, the staff told him/her they could not locate the resealable bag. He/She said he/she needed the money for his/her grandchildren for Christmas, and it hurt her, because he/she had to change his/her plans for giving his/her Christmas presents to his/her grandchildren to Valentine's Day. He/she said he/she was, sad and heartbroken, and never expected for someone to take his/her money. 2688650

Based on interview and record review, facility staff failed to notify two resident's (Resident #2 and #3's) physician out of three sampled residents after staff documented they assessed the residents with abnormal blood pressure (BP) readings. The facility's census was 46.1. Review showed the facility did not provide a policy in regard to vital signs (measurements of the body's basic functions to include blood pressure). Review of the facility's Significant Condition Change and Notification policy, undated, showed: -The purpose is to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as a significant change in the resident's physical, mental or psychosocial status;-Examples include a significant change in/or unstable vital signs, other abnormal assessment findings;-The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays.2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment, dated 09/18/25, showed staff assessed the resident as moderate cognitive impairment, and diagnoses to include high blood pressure.Review of the resident's care plan, dated 09/25/25, showed staff assessed the resident with hypertension, and interventions to administer anti-hypertensive medications (medications used to lower blood pressure) as ordered, monitor for side effects such as orthostatic hypotension (low blood pressure), obtain blood pressure readings prior to medication administration, and report to the physician as necessary. Review of the resident's Physician's Order Sheet (POS) dated 09/05/25 through 09/30/25, showed the following orders: -Amlodipine (to lower blood pressure) 10 milligram (mg) tablet by mouth once daily;-Carvedilol (to lower blood pressure) 25 mg tablet by mouth two times daily, hold if BP less than (<) 100/60;-Hydralazine HCL (to lower blood pressure) 25 mg tablet by mouth three times daily, hold if BP < 100/60.Review of the resident's Physician's Order Sheet (POS) dated 10/01/25 through 10/09/25, showed the following orders: -Amlodipine 10 mg tablet by mouth once daily;-Carvedilol 25 mg tablet by mouth two times daily, hold if BP < 100/60;-Hydralazine HCL 25 mg tablet by mouth three times daily, hold if BP < 100/60.Review of the resident's progress notes, dated 09/30/25 through 10/09/25, showed staff documented: -09/30/25 at 5:56 P.M., Hydralazine not administered for BP of 96/57 millimeters of mercury (mmHg);-10/03/25 at 5:09 P.M., Hydralazine not administered for BP of 77/46 mmHg;-10/07/25 at 5:56 P.M., Hydralazine not administered for BP of 74/42 mmHg;-10/08/25 at 5:43 P.M., Hydralazine not administered for BP of 83/46 mmHg;-10/09/25 at 12:28 A.M., The resident's family approached the nurse's desk with concerns that the resident's blood pressure had been consistently low, and questioned if the resident could get an appointment with his/her primary care physician. The nurse assured the family that staff would monitor and pass along their concern to the day staff. Review of the resident's electronic medical record (EMR) dated, 10/08/25 at 8:35 P.M., showed staff documented the resident was assessed with a BP reading of 93/56 mmHg. Review of the resident's EMR, dated 09/30/25 through 10/09/25, showed the record did contain documentation staff notified the resident's physician of the abnormal blood pressure readings below 100/60, or that staff had withheld administration of the resident's blood pressure medication due to abnormal blood pressure readings.During an interview on 10/16/25 at 10:43 A.M., the Director of Nursing (DON) said his/her expectation is for the nurse to notify the physician of the resident's abnormal blood pressure readings that were <100/60, and document with a progress note that the physician was notified. The DON said he/she would also expect staff to follow up on the documented progress note regarding the family's concern.During an interview on 10/16/25 at 2:33 P.M., the resident's physician said he/she would expect staff to notify him/her of the resident's abnormal blood pressure readings on 09/30, 10/03, 10/07, and 10/08. The resident's physician said staff did not notify him/her of the resident's low blood pressures. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and diagnoses to include heart failure, and hypertension.Review of the resident's care plan, dated 08/20/25, showed staff assessed the resident with heart failure, and interventions to give cardiac medications as ordered, monitor, document and report to the physician as needed.Review of the resident's POS, dated 09/11/25 through 09/30/25, showed an order for Losartan Potassium (to lower blood pressure) 25 mg tablet by mouth once daily, hold if BP < 100/60, and Carvedilol (to lower blood pressure) 3.125 mg tablet by mouth two times daily, hold if BP <100/60. Review of the resident's progress notes, dated 09/11/25 through 09/18/25, showed staff documented: -09/11/25 at 2:53 P.M., Carvedilol held for BP of 94/50 mmHg;-09/12/25 at 8:39 A.M., Carvedilol held for BP of 89/67 mmHg;-09/13/25 at 9:21 A.M., Carvedilol held for BP of 83/74 mmHg;-09/15/25 at 7:54 A.M., Carvedilol held for BP of 99/68 mmHg.Review of the resident's EMR, dated 09/11/25 through 09/18/25, showed staff documented the resident was assessed with the following blood pressure readings: -09/13/25 at 11:55 P.M., BP of 84/67 mmHg;-09/14/25 at 6:43 A.M., BP of 90/80 mmHg;-09/15/25 at 10:07 A.M., BP of 99/68 mmHg;-09/18/25 at 11:39 P.M., BP of 95/56 mmHg.Review of the resident's EMR, dated 09/11/25 through 09/18/25, showed the record did contain documentation staff notified the resident's physician of the abnormal blood pressure readings below 100/60, or that staff had withheld administration of the resident's blood pressure medications due to abnormal blood pressure readings.During an interview on 10/16/25 at 10:43 A.M., the DON said he/she would expect staff to document they notified the physician of the resident's low blood pressures, particularly since staff documented blood pressures of <100/60 for five consecutive days.During an interview on 10/16/25 at 2:33 P.M., the resident's physician said staff did not notify him/her of the resident's low blood pressure readings from 09/11/25 through 09/18/25 and he/she would expect staff to notify him/her so he/she could address it.4. During an interview on 10/15/25 at 4:08 P.M., Licensed Practical Nurse (LPN) B said if staff checks a resident's blood pressure and obtains a reading of <100/60, the nurse is expected to assess the resident, notify the physician and document the notification and any other interventions with a progress note.During an interview on 10/16/25 at 10:43 A.M., the DON said if a Certified Medication Technician (CMT) checks a resident's blood pressure and obtains a reading of <100/60, he/she expects the CMT to notify the nurse, the nurse to follow up/assess the resident, notify the physician, and document the physician notification with a progress note.During an interview on 10/16/25 at 10:55 A.M., CMT E said nurses and CMTs are expected to check a resident's blood pressure before they administer blood pressure medications, and hold the medication as directed by the POS if the BP is <100/60. CMT E said if he/she obtains a blood pressure of <100/60, he/she would recheck the blood pressure, hold the medication, document the reason in a progress note, tell the nurse, and the nurse is expected to further assess the resident and notify the physician.During an interview on 10/16/25 at 2:33 P.M., the physician said he/she expects facility staff to hold administration of residents' blood pressure medications as directed on their POS, and also expects staff to notify him/her each time they do not administer a medication for low blood pressures so he/she can follow up, re-assess the resident and adjust medications as necessary. The physician said staff are aware they can notify him/her at any time via secured message, phone call or fax. During an interview on 10/16/25 at 3:12 P.M., the administrator said staff are aware they can contact the physician at any time if a resident experiences a medical change, and he/she would expect the nurse to notify the physician immediately of any blood pressures that were odd, out of range, and as directed on the POS.Complaint# 2642356

Based on interview and record review, facility staff failed to keep one resident (Resident #1) free from verbal and emotional abuse when Licensed Practical Nurse (LPN) A yelled at the resident to shut up multiple times, directly in his/her face. The facility census was 50. The administrator was notified on 4/25/25 of past Non-Compliance, which occurred on 4/09/25 when staff reported the allegation. Staff immediately suspended LPN A pending the results of the investigation, assessed the resident for physical and psychological harm, conducted an investigation, in-serviced staff on abuse and neglect, and terminated the employee on 4/09/25. 1. Review of the facility's Abuse, Prevention and Prohibition policy, dated 11/2018, showed the facility prohibits the mistreatment, neglect, or abuse of residents. Review showed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, to include a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Review of the facility's investigation, dated 4/09/25, showed the administrator documenred the resident said the nurse told him/her to, Shut up, shut up, shut up,. Review showed the administrator documented the resident got very excited when asked questions. Review of the facility's investigation, dated 4/09/25, showed a signed statement from CNA B, dated 4/09/25, showed he/she documented, the resident was screaming and LPN A went into the residents' room and told the resident he/she needed to shut up twice, and LPN A said he/she wasn't dealing with this tonight! Review of resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/13/25, showed staff assessed the resident with cognitive impairment, Dementia, Anxiety Disorder, Depression, Bi-Polar Disorder, Psychotic Disorder, and Schitzophrenia. Review of resident's care plan, dated 9/26/24, showed staff assessed resident with pain, impaired cognition, anxiety, a communication/hearing deficit, and needed assistance with activities of daily living (ADL's). Staff directed to assess resident for signs of non-verbal pain, to include grunting, moans, yelling out, irritability restlessness, and squirming. Staff were directed to ensure or provide a safe environment, monitor and document and physical or non-verbal indicators of discomfort or stress, allow adequate time to respond, do not rush, and use brief consistent words/cues. Staff directed to provide assistance of one to two staff for bed mobility, transfers, toileting, bathing, and dressing. During an interview on 4/18/25 at 12:22 P.M., the administrator said CNA B notified him/her that CNA B had witnessed abusive behavior by LPN A towards the resident. He/She said CNA B told him/her CNA B witnessed LPN A yelling Shut up! Shut up! Shut up! I'm not putting up with this tonight, at the resident, with LPN A's face in close proximity to the resident's. The administrator said he/she suspended LPN A pending the investigation, and terminated him/her after completing the investigation. The administartor said he/she interviewed the resident on 4/09/25, and the resident told him/her LPN A yelled, Shut up! Shut up! Shut up!. The administrator said the resident appeared physically distraught during the interview. During an interview on 4/18/25 at 9:35 A.M., CNA B said said he/she and CNA C were putting the resident's roommate to bed, and the resident was screaming. CNA B said he/she and CNA C left the room, and he/she saw LPN A go into the resident's room. CNA B said he/she saw LPN A with his/her face close to the resident's face, yelling, Shut up! Shut up! Shut up! I'm not dealing with this tonight! During an interview on 5/02/25, LPN A denied he/she yelled at the resident, or said, Shut up. LPN A said he/she is aware of the allegations. LPN A said he/she was not feeling well that night, and was short with the aides, but denies being rude or rough with the resident. MO00252488

Based on interview and record review, the facility staff failed to develop an abuse and neglect policy which met the required time frame to report immediately, but not later than two hours after an allegation of abuse or neglect. The facility census was 49. 1. Review of the facility's Policy & Procedure Abuse and Neglect Prevention policy, revised on 02/15/2012, showed: -The resident has the right to be free from verbal, sexual, and physical, and mental abuse, corporal punishment, and involuntary seclusion; -Once the facility administration becomes aware of any of these alleged violations, the home must report immediately to the designated state agency, CMS indicates that the term immediately means as soon as possible, but no more than 24-hours after the alleged incident is discovered. The facility's policy did not include direction the facility is required to report all alleged violations-immediately but not later than, two hours- if the alleged violation involves abuse or results in serious bodily injury, 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury. During an interview on 01/16/25 at 1:25 P.M., the Director of Nursing said he/she is aware abuse and neglect time frames for reporting is two hours but is not sure what their policy states. During an interview on 01/16/25 at 1:28 P.M., the administrator said this was the most recent policy provided by the new owners but she was not aware of what the policy said. The administrator said she had not looked at or reviewed the policy.

Based on observation, interview and record review, facility staff failed to ensure services provided met professional standards of practice when staff did not contact the physician for a pain medication refill order in a timely manner for one resident (Resident#30) of one sampled resident. Facility staff failed to follow physician orders when staff did not document the administration of medications and tube feedings for one resident (Resident #45). Staff failed to complete and document neurological checks for three (Resident #1, #18, and #30) of six sampled residents who had unwitnessed falls, as directed by the facility policy. The facility's census was 49. 1. Review of the facility's policy, Physicians Medication Orders, revised April 2010, showed drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less then three days prior to the last dosage being administered to ensure refills are readily available. 2. Review of Resident #30's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 12/04/24, showed staff assessed the resident as follows: -Cognitively intact; -Resident on scheduled pain regimen; -Resident has frequent pain. Review of the Physician Order Sheet (POS), dated 11/22/24, showed an order for Buprenorphine (controlled substance used to treat pain) HCI 150 micrograms (MCG) every 12 hours for nonmalignant pain. Review of the Controlled Drug Receipt/Record/Disposition Form, dated 12/02/2024, showed staff documented the last Buprenorphine dose administered to the resident on 01/04/25. Review showed the form did not contain documentation staff ordered a refill of the medication. Review of the nurses' note, dated 01/05/25, showed staff documented the resident did not have any Buprenorphine. Staff received an order from the on-call doctor for Hydrocodone-Acetaminophen ((APAP) (narcotoc pain medication) 10/325 milligrams (mg) one tablet twice daily for three doses or until Buprenorphine available. Review of the resident's Medication Administration Record (MAR), dated January 2025, showed an order for Hydrocodone-Acetaminophen oral tablet 10-325 MG, one tablet every day and night for pain. Review showed staff did not document they adminstered the medication after 01/06/25. Review of the resident's MAR, dated January 2025, showed it did not contain documentation staff administered the residents Buprenorphine or Hydrocodone-Acetaminophen 01/07/25, 01/08/25, and 01/09/25. During an interview on 01/14/25 at 1:30 P.M., the resident said he/she had a pain medication pouch they were using, but that prescription ran out, and he/she was told insurance does cover that medication any longer. The resident said he/she did not get other pain medication while they waited for this to get figured out. He/She said they went about three days without a substitute pain medication. The resident said he/she has a Tylenol order but it does not work, and a muscle relaxer also. The resident said it was uncomfortable for her to have to go without pain medication. During an interview on 01/16/25 at 10:25 A.M., the Medical Director (MD) said the expectation is medication refills be ordered about a week before they run out. The MD said a resident does not have to go without pain medication. He/She said there is always someone on call to sign for narcotics, if needed. The MD said it would be uncomfortable for the resident to not have the pain medication for the few days. During an interview on 01/16/25 at 1:20 P.M., the Director of Nursing (DON) said medication should be ordered between seven and 10 days before the last pill is used. The DON said the nurse is expected to contact the pharmacy and they will automatically send to the doctor for the refill and signature. If the medication is not available, then it should be pulled from the emergency medication kit (ekit). The DON said she/he was not aware the resident went without pain medication, but there is no reason when it can be pulled from the ekit. During an interview on 01/16/25 at 1:25 P.M., the administrator said the expectation is for medications be ordered at least a week before they are to run out. The administrator said the nurse should request an order for something for the resident to take while they are waiting on the medication to come or be refilled. If the medication doesn't come promptly then they should pull from the ekit. The administrator was not aware the resident went with out medication while he/she waited for the refill. 3. Review of the facility's policy titled, Administering Medications, revised April 2010, showed staff are directed as follows: -Medications shall be administered in a safe and timely manner, and as prescribed; -Medications must be administered in accordance with the orders, including any required time frames; -The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones; 4. Review of Resident #45's admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted [DATE]; -Cognition not assessed; -Diagnoses Stroke, Traumatic brain injury, and Thyroid Disorder. -Received 51 percent (%) or more total calories via tube feeding, and received 501 cubic centimeters (cc) or more average daily fluid intake via tube feeding. Review of the resident's care plan, dated 12/17/24, showed the resident required tube feeding, is dependent with tube feeding and water flushes, and follow physician orders for current feeding. Review of the resident's POS, dated November 2024 through January 2025, showed the physician ordered medications and nutrition to be administered via Gastric Tube ((G-Tube) a surgically inserted tube which provides nutrition, hydration, or medicine directly into the stomach) as follows: -Hydrocortisone (to treat hormone imbalance) five mg tablet, give three tablets in the morning; -Levothyroxine (to treat Thyroid Disorder) 50 mcg tablet, give one tablet in the morning; -Famotidine (to treat heartburn and indigestion) 20 mg tablet, give one tablet two times per day; -Caffeine 200 mg tablet, give one tablet two times per day; -Desmopressin Acetate (to reduce the amount of urine made) 0.1 mg tablet, give one tablet two times per day; -Jevity 1.5 Cal (sole-source nutrition for tube feeding) 240 cc, give bolus (a single large dose) four times per day; -Flush tube with at least 75 milliliters (ml) water before and after feeding. Review of the resident's MAR, dated November 2024, showed the MAR did not contain documentation staff administed the Hydrocortisone or Levothyroxine at 6:00 A.M. on 11/23/24, 11/24/24, 11/26/24 and 11/27/24, and the Jevity or water flushes on 11/23/24, 11/24/24, and 11/27/24. Review of the resident's MAR, dated December 2024, showed the MAR did not contain documentation staff administed the Hydrocortisone, Levothyroxine, Caffeine, Desmopressin, Famotidine, Jevity, or water flushes at 6:00 A.M. on 12/02/24, 12/11/24, and 12/12/24. Review of the resident's MAR, dated January 1st through 14th 2025, showed the MAR did not contain documentation staff administed the Hydrocortisone, Levothyroxine, Caffeine, Desmopressin, Famotidine, Jevity, or water flushes at 6:00 A.M. on 1/07/24 and 1/12/24. During an interview on 01/15/25 at 8:56 A.M., LPN D said if the nurse did not administer a medication, feeding, or water flush, he/she is supposed to document the reason with a code such as refused, medication not available, other, and if applicable, he/she is expected to also document a nurse's note with explanation. He/She said if there is a hole or missing initials on the resident's MAR, it means the medication, feeding or water flushes did not get completed During an interview on 01/16/25 at 12:52 P.M., the DON said he/she expects staff to always follow the physician's orders and if there was a hole in the MAR then the medication or tube feeding was not given. He/She said no one currently double checks for blank spots on the MAR because there should always be either an inital or code in each spot, and regardless of the reason for non-administration of a medication or feeding, there should never be a blank spot on the MAR. During an interview on 01/16/25 at 1:02 P.M., the administrator said he/she expects staff to always follow the physician's orders. 5. Review of the facility's Fall Prevention policy, dated 04/12/2009, showed if the fall is not witnessed or the resident hit his/her head, initiate neurological checks based on the schedule on the neurological status evaluation per facility policy. 6. Review of the facility's policy titled, Neurological Assessments, dated 10/2001, showed when a resident has an unwitnessed fall, accident/injury involving head trauma, the nurse is to perform a neurological assessment. Review showed the nurse is required to complete checks- every 15 minutes for one hour, every 30 minutes for one hour, every hour for six hours, every four hours times two, every eight hours times seven for a total of 72 hours. 7. Review of Resident #1's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for transfers from chair to bed/bed to chair; -Diagnosis of Stroke, Parkinson's Disease, and Traumatic Brain Injury. Review of the resident's nurses' notes, dated 11/22/24, showed staff documented the resident found on his/her stomach, on the left side of the bed, with blankets under him/her and a fall mat in place. Review showed the resident said I tried to roll over in bed and fell out. Review of the resident's electronic medical record (EMR) showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 11/22/24. 8. Review of Resident #18's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Impairment on one side upper and lower extremity; -Independent for chair/bed-to-chair transfers. Review of the resident's nurses' notes, dated 10/04/24, showed staff documented the resident found sitting on the floor next to the side of the bed. Review showed staff documented the fall unwitnessed. 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 10/04/24. 9. Review of Resident #30's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Impairment to lower extremity both sides; -Partial/moderate assist with chair/bed-to-chair transfer. Review of the resident's nurses' notes, dated 09/05/24, showed staff documented the resident yelled help and found sitting on the floor in front of his/her wheelchair by the bed. Review of the resident's nurses' notes, dated 12/01/24, showed staff documented the resident found sitting on the floor by his/her bed by staff. Review showed the resident said I transferred myself to the bed and I slid off onto the floor. Review of the resident's EMR showed the record did not contain documentation staff completed the neurologoical checks after the resident's fall on 09/05/24 and 12/01/24. 10. During an interview on 01/16/25 at 9:08 A.M., the MDS/Care plan Coordinator said per facility protocol, staff are expected to conduct and document neurological checks/assessments on a resident after any unwitnessed fall. He/She said the neurological checks are not documented on paper, and the charge nurse usually initiates the assessment in the residents' EMR's. During an interview on 01/16/25 at 12:10 P.M., LPN D said when a resident falls the nurse will assess the resident. He/She said neurological checks are usually case by case on unwitnessed falls and are started depending on if the resident is alert and oriented and can tell him/her exactly what happened and whether they did or did not hit their head. He/She said if resident is not alert and orientated and the fall was unwitnessed then neurological checks are started. He/She it is the nurse's responsibility on duty to start neurological checks. He/She said the importance of starting neurological checks is to ensure there is not head injury. During an interview on 01/16/25 at 12:44 P.M., the DON said neurological checks should be started on any resident who has an unwitnessed fall. He/She said it does not matter whether the resident is alert and orientated, if it is unwitnessed, then neuros should start by the nurse on duty at that time. He/She said the importance of neuros is to see if mental status changes or grips strengths to ensure not a head injury. During an interview on 01/16/25 at 12:50 P.M., the administrator said in regards to unwitnessed falls, if a resident falls and they are alert and orientated and can tell you they didn't hit their head then the on duty nurse can assess and make the call if the resident needs to be started on neuro checks. 39644 50422

Based on interview 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 a week. The facility census was 49. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates on: -Thursday 07/04/24; -Friday 07/05/24; -Saturday 07/06/24; -Sunday 07/07/24; -Wednesday 07/10/24; -Saturday 07/13/24; -Sunday 07/14/24; -Monday 07/15/24; -Tuesday 07/16/24; -Saturday 07/20/24; -Sunday 07/21/24; -Saturday 07/27/24; -Sunday 07/28/24. 3. Review of the facility's RN staff schedule, dated August 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates on: -Saturday 08/03/24; -Thursday 08/08/24; -Saturday 08/10/24; -Sunday 08/11/24; -Thursday 08/15/24; -Friday 08/16/24; -Saturday 08/17/24; -Sunday 08/18/24; -Monday 08/19/24; -Thursday 08/22/24; -Saturday 08/24/24; -Sunday 08/25/24; -Saturday 08/31/24. 4. Review of the facility's RN staff schedule, dated September 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Sunday 09/01/24; -Monday 09/02/24; -Saturday 09/07/24; -Sunday 09/08/24; -Saturday 09/14/24; -Sunday 09/15/24; -Monday 09/16/24; -Thursday 09/19/24; -Friday 09/20/24; -Saturday 09/21/24; -Sunday 09/22/24; -Thursday 09/26/24; -Saturday 09/28/24; -Sunday 09/29/24. 5. Review of the facility's RN staff schedule, dated October 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates on: -Friday 10/04/24; -Monday 10/07/24; -Saturday 10/12/24; -Sunday 10/13/24; -Sunday 10/27/24. 4. Review of the facility's RN staff schedule, dated November 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates on: -Saturday 11/02/24; -Sunday 11/03/24; -Saturday 11/09/24. 4. Review of the facility's RN staff schedule, dated December 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates on: -Saturday 12/28/24; -Sunday 12/29/24. 5. During an interview on 01/16/25 at 12:48 P.M., the Director of Nursing (DON) said he/she was not aware of any days currently without eight consecutive RN coverage, at least not since he/she started at the facility in November. During an interview on 01/16/25 at 12:50 P.M., the administrator said he/she was aware of the regulation of having RN in building eight consecutive hours daily. He/She said when he/she first took over as administrator he/she knew the regulation was not being met and he/she was trying his/her best to make sure it was understood midnight starts a new day and night shift would not count as eight consecutive hours. He/She said recent missed days may have been because the nurses took off over the weekend and they didn't have coverage. He/She said it is important to have RN in building for the continuation of care and having the extra oversight of the building.

Based on observation, interviews and record review, facility staff failed to properly complete weekly skin assessments, and failed to notifiy the physician and obtain a treatment order for one resident (Resident #6) of one sampled resident who developed a new facility-acquired pressure ulcer to the resident's right buttock. The facility's census was 49. 1. Review of the facility's policy titled, Pressure Ulcer/Pressure Injury Prevention, dated April 2018, showed, if a pressure ulcer/pressure injury is present, provide treatment to heal it and prevent development of additional pressure ulcers/pressure injuries. 2. Review of the facility's policy titled, Wound Assessment, dated April 2018, showed the facility is to assess each wound initially at the time of admission or at the time the wound is identified, and each wound will be assessed weekly thereafter or with any significant noted change in the wound. The wound assessment and documentation should include: -Anatomic location includes anatomic landmarks; -Size- specify length, width, depth, tunneling/undermining; -Drainage, include amount, color and consistency; -Pain or tenderness which may be indicators of underlying tissue destruction, or vascular insufficiency; -Peri-wound (skin surrounding the wound) skin condition; -Odor. 3. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/19/24, showed staff assessed the resident as follows: -Cognitive; -At risk for developing pressure ulcer; -One Stage three (full-thickness skin loss potentially extending into the subcutaneous tissue layer) Pressure Ulcer not present on admission; -Frequently incontinent of urine and bowel movement. Review of the resident's care plan, dated 11/25/24, showed staff assessed the resident with a potential for impairment to skin integrity, a Stage two (partial thickness loss of skin with a red or pink wound bed) pressure ulcer on his/her left buttock dated, 11-8-24. Staff are directed to administer treatments as ordered and monitor for effectiveness. Document location of wound, amount of drainage, peri-wound area, pain, edema, and circumference measurements weekly. Review of the resident's mobile wound care physician's visit report, dated 11/26/24, showed the wound physician documented the left buttock wound as a Stage two Pressure Ulcer and received an outcome of resolved, the peri-wound skin texture, moisture, and color are normal. Review of the resident's weekly skin assessment dated [DATE], 12/11/24, 12/18/24, 12/25/24, 01/05/25, and 01/08/25, showed Registered Nurse (RN) E documented ongoing treatment to stage two on left buttocks, no new skin issues noted, skin clean/dry/intact. The weekly skin assessments did not contain a complete wound assessment to include measurements or description of the wound. Review of the resident's Physician's Order Sheet (POS), dated 11/27/24 through 01/13/25, showed the POS did not contain documentation of a physician's ordered wound treatment for the resident's buttock area. Review of the resident's Treatment Administration Record (TAR), dated 12/01/24 through 01/13/25, showed the TAR did not contain documentation staff provided wound treatments to the resident's buttock area. Review of the resident's nurses' notes, dated 11/27/24 through 01/13/25, showed the nurse's notes did not contain documentation in regards of the resident's pressure ulcer. During an interview 01/14/25 at 10:38 A.M., the resident said he/she had an open area but facility staff have not been doing any treatments to the area. Observation on 01/14/25 at 10:46 A.M., showed the resident's right buttock with an open area partially covered with a pink substance. During an interview on 01/14/25 at 10:46 A.M., Licensed Practical Nurse (LPN) G said he/she was not aware the resident had an open area which required a treatment, and his/her skin assessment is not typically done on the day shift. Review of the resident's mobile wound care physician's visit report, dated 01/14/25 at 4:46 P.M., showed the wound physician documented the patient seen today as a consultation for evaluation of the patient's wound, and assessed the wound as follows: -Wound to right buttock Stage three pressure injury/pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer) with a status of not healed; -Initial wound encounter measurements are 1.1 centimeter (cm) length x 0.6cm width x 0.1 cm depth, with an area of 0.66 square cm, volume of 0.066 cubic cm; -Small amount of sero-sanguineous drainage (thin, pink, watery fluid); -Wound bed has 76-100 percent pink, granulation tissue; -The peri-wound skin texture, moisture, and color are normal. During an interview on 01/15/25 at 2:34 P.M., LPN D said the nurses are responsible to perform weekly skin assessments and if he/she identifies a new wound, he/she should measure and document his/her observation of the wound. The LPN said the wound care doctor was seeing the resident for the left buttuck wound that was healed on 11/26/24. The LPN said about two weeks prior, he/she noticed the resident had a new wound on his/her buttock and did not have a treatment order, but the wound physician was unavailable, and he/she just got busy and did not assess the wound, or attempt to obtain an order from the resident's physician in the absence of the wound physician. During an interview on 01/15/25 at 2:52 P.M., RN E said when he/she performed the resident's weekly skin assessments, he/she did not measure or assess the wound, and did not verify there was a treatment order in place. The RN said he/she just wrote what he/she documented on the previous skin assessment. During an interview on 01/16/25 at 9:19 A.M., the resident's physician said he/she expects staff to call him/her for a new wound treatment in the absence of the wound physician, as he/she is ultimately responsible for the resident's medical care. During an interview on 01/16/25 at 12:52 P.M., the Director of Nursing (DON) said the nurses are responsible to perform the resident's weekly skin assessment, document his/her current observations under the assessments tab in the electronic medical record (EMR), and sign the TAR when finished. He/She said if the nurse notices an open area, he/she should obtain measurements, describe the wound (color, drainage, odor), complete an incident/communication form with physician, document who he/she contacted regarding wound, and obtain a treatment order from the physician until the physician is able to physically assess the resident. The DON said he/she expects the nurses' documentation to be accurate, and the nurses should always verify if there is an active treatment in place. During an interview on 01/16/25 at 1:02 P.M., the administrator said the nurses are responsible to perform the resident's weekly skin assessments, document accurately under the assessments tab in the EMR and sign the TAR once complete. He/She said if a nurse identifies a new wound on a resident, he/she expects the nurse to document the assessment and contact the physician for a treatment order.

Based on observation, interview, and record review, facility staff failed to protect residents' privacy when staff failed to provide privacy during perineal care for two residents (Resident #1 and # 9) out of two sampled residents. The facility's census was 49. 1. Review of the facility's policy titled, Resident Rights, dated October 2009, showed employees shall treat all residents with kindness, respect, and dignity, and each resident has the right to privacy and confidentiality. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 11/03/24 showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent on staff for dressing, toileting hygiene, and personal hygiene. Review of the resident's care plan, dated 11/14/24, showed staff are directed to assist the resident with transfers, dressing, toileting, and personal hygiene. Observation on 01/15/25 at 1:35 P.M., showed Certified Nursing Assistant (CNA) A and Nursing Assistant (NA) B transferred the resident from his/her chair to bed, and provided perineal care to the resident with the resident's roommate in his/her bed positioned facing the resident. CNA A and NA B did not pull the privacy curtain between the residents' beds to provide privacy during perineal care. During an interview on 01/15/25 at 2:10 P.M., CNA A said he/she should have pulled the privacy curtain between the two residents, especially since the resident's roommate was awake in the room, but he/she was just nervous and forgot to pull the curtain. During an interview on 01/15/25 at 2:12 P.M., NA B said the privacy curtain should be pulled during perineal care, and he/she realized the privacy curtain between the resident and his/her roommate's bed was not closed, but he/she did not think to prompt CNA A to pull the curtain either. 3. Review of Resident #9's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent on staff for dressing, toileting hygiene, and personal hygiene. Review of the resident's care plan, dated 11/23/24, showed staff are directed to assist the resident with transfers, dressing, toileting, and personal hygiene. Observation on 01/13/25 at 1:33 P.M., showed CNA A and CNA C transferred the resident from his/her chair to bed, and provided perineal care to the resident, the resident's window blinds raised and open, and a car drove by the driveway that led to the rear parking lot of the building. The CNAs did not lower and close the window blinds to provide privacy during perineal care. Observation on 01/15/25 at 1:58 P.M., showed CNA A and NA B transferred the resident from his/her chair to bed, and provided perineal care to the resident, the resident's window blinds raised and open, with clear view of a driveway that led to the rear parking lot of the building. Staff did not lower and close the window blinds to provide privacy during perineal care. During an interview on 01/15/25 at 2:10 P.M., CNA A said he/she should have lowered and closed the resident's window blinds for privacy during perineal care but he/she was nervous and just did not think about it. During an interview on 01/15/25 at 2:12 P.M., NA B said he/she should have lowered the blinds to ensure the resident's privacy during perineal care but he/she just did not think about it at the time. 4. During an interview on 01/15/25 at 2:34 P.M., Licensed Practical Nurse (LPN) D said staff should close the privacy curtain, as well as close and lower the window blinds in a resident's room to ensure the resident's privacy during perineal care. During an interview on 01/16/25 at 12:52 P.M., the Director of Nursing (DON) said staff should knock prior to entering a resident's room, pull the privacy curtain, use a sheet to cover the resident, lower and close the window blinds in the room to provide privacy and maintain modesty to each resident during perineal care. He/She said staff should absolutely pull the privacy curtain particularly if the resident's roommate is inside the room during care. During an interview on 01/16/25 at 1:02 P.M., the administrator said staff should knock prior to entering a resident's room, pull the privacy curtain, use a sheet to cover the resident, and close the window blinds in the room to provide privacy to the resident during perineal care.

Based on interview and record review, facility staff failed to ensure the activities program was directed by a qualified professional. The facility census was 49. 1. Review of facility's policies showed staff did not provide a policy in regards to qualifications for the Activity Director position. 2. Review of the facility's Activities Designee job description, undated, showed the Activity Director must receive Activity Designee certification within six months of hire. 3. Review of the facility maintained personnel records showed the Activity Director with a hire date of 05/17/24. During an interview on 01/15/25 at 11:45 A.M., the Activity Director said he/she does not have his/her Activity Director certification. He/She said he/she has been the Activity Director Since June 2024 and states the Activity Director course has been talked about but he/she is not currently enrolled in any courses at this time. During an interview on 01/16/25 at 12:41 P.M., the Director of Nursing (DON) said he/she was not aware the Activity Director did not have his/her Activity Director certification. He/She said the Activity Director was hired before he/she came and he/she does not do anything with the hiring process. He/She said he/she was not aware of a time frame the Activity Director needed their certification. During an interview on 01/16/25 at 12:43 P.M., the Administrator said he/she was aware the current Activity Director did not have his/her Activity Director certification. He/She said there is another staff who works part time/two days a week and has his/her certification and he/she thought that would carry over.

Based on observation, interview, and record review, facility staff failed to review and revise the comprehensive care plan for one resident (Resident #2) out of two sampled resident care plans, when the resident wandered into another resident room. The facility census was 51. 1. Review of the facility's Comprehensive Care Plan policy, dated 02/01/24, showed staff are directed as follows: -The Minimum Data Set (MDS), a federally mandated assessment tool, Coordinator or designee shall act in a case management role by knowledge of ongoing care needs; -The policy did not contain direction or guidance when the care plan should be updated when changes in resident care is observed. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/29/24, showed staff assessed the resident as: -Cognitively impaired; -Used a wheelchair; -Inattentive, had disorganized thinking and wandered; -Diagnosis of dementia and anxiety. Review of resident's Wandering Assessment, dated 08/28/24, showed staff assessed the resident as: -Disoriented; -Does not understand surroundings; -Independent with an aide of cane or walker; -Diagnosis of Alzheimer Disease; -Known wanderer/history of wandering. Review of resident's Wandering Assessment, dated 11/27/24, showed staff assessed the resident as: -Disoriented; -Forgetful/short attention span; -Does not understand surroundings; -Independent with an aide; -Diagnosis of Alzheimer Disease; -Known wanderer/history of wandering. Review of the nurse notes dated, August 2024 through December 2024, showed staff documented: -On 10/24/24, resident wanders the facility often; -On 10/26/24, propels self about facility and frequent redirection; -On 11/10/24, assist with transfers to wheelchair, propels self about facility requiring redirection at times; -11/13/24, assist with transfers to wheelchair, propels self about facility; -11/14/24, assist with transfers to wheelchair, propels self about facility requiring redirection at times; -11/27/24, resident propels self about the facility and needs frequent redirection. Review of the resident's care plan, dated 7/18/24, showed the care plan did not contain direction or guidance for when the resident wanders into other resident rooms or potentially unsafe areas. Observation on 12/04/24 at 10:34 A.M., showed the resident propelled his/herself in a wheelchair from the nurse station onto 200 hallway. He/She passed a staff member and entered room [ROOM NUMBER]. During an interview on 12/04/24 at 09:30 A.M., the administrator said on 12/02/24 a family member reported Resident #2 went into another resident room. During an interview on 12/04/24 at 10:00 A.M., Certified Nurse Aide (CNA) A said the resident wanders anywhere and everywhere. He/She said they try to keep him/her out of other rooms and areas he/she is not to be in but he/she is always on the go. He/She said he/she is not sure what the care plan says about his/her wandering but would think it should be in there. He/She gets a report from the nurses and off-going staff for care needs of the residents. During an interview on 12/04/24 at 10:07 A.M., Certified Medication Technician (CMT) B said the resident is constantly wandering and goes into other rooms. CMT B said he/she is not sure what the care plan says regarding his/her wandering. During an interview on 12/04/24 at 11:42 A.M., The MDS Coordinator said he/she is responsible to update the care plans and thought the resident's care plan addressed wandering. He/She said wandering should be a part of the care plan. Care plans are usually updated at least every three months and with any changes to care. He/She said the point of care chart has direction for staff to do a safety check on the resident every two hours but does not include wandering. During an interview on 12/04/24 at 12:23 P.M., the Administrator said the care plans are the responsibility of the MDS Coordinator and should be updated when changes in care occur, to include wandering. He/She said this resident started to wander about 6 months ago and his/her care plan should have been updated at that time. Staff are educated on the resident care needs during their orientation upon hire. MO00245979

Based on record review and interviews, the facility staff failed to ensure one resident (Resident #1) out of three residents were allowed to make choices about aspects of their lives when staff did not allow the resident who is his/her own responsible party and assessed to smoke a cigarette independently as a consequence for his/her behavior. The facility census was 44. 1. Review of the facility's Resident Rights policy, undated, showed residents have the right to a dignified existence and self-determination. Review of the facility's smoking policy, dated 01/08/23, showed: -Resident's will be assessed at the time of admission and reassessed at a minimum quarterly or with a significant change to determine the level of assistance and supervision required to ensure resident safety; -Resident's who are determined by the care plan team to be able to smoke without supervision may smoke at-will in the designated smoking area only; -Any and all residents that are not deemed capable of smoking unsupervised, will be given the opportunity to smoke with supervision at the facility's designated smoking times; -Smoking areas will be designated as the front right patio unless inaccessible to residents will be approved to smoke on the front porch; Review of the facility smoking policy disclaimer, undated, showed any and all residents that display undesirable behaviors such as hitting, kicking, screaming, cussing, disrupting, etc. will lose the smoking opportunity immediately following the incident. Independent smokers will be defined as any individual that is alert and oriented, their own person, and care planned to be capable of smoking independently. The policy did not contain direction to place the resident onto supervised scheduled smoking. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/02/24 Showed staff assessed the resident as: -Cognitively intact; -Smoked; -No impairment in functional range of motion; -Diagnosis of cancer. Review of the residents medical showed the resident signed the facility smoking policy disclaimer, dated 01/08/24. Review of the residents care plan, dated 02/01/24, showed staff assessed the resident sometimes hits his/her self in the face due to frustration and verbally loud when upset. Staff were directed to explain/reinforce why behaviors are inappropriate and/or unacceptable. Review showed to follow smoking per facility protocol. Review showed the care plan did not contain direction to remove smoke privileges or ensure resident is moved to supervised smoking only if exhibits a behavior. Review of the residents smoking assessment, dated 05/06/24, showed staff assessed the resident as: -Cognitively intact; -Holds cigarette safetly; -Able to light cigarrette independently; -Able to extinguish a cigarette independently; -Clothing is free from ashes/burns. Review of the residents nurse notes, dated 05/01/24 through 05/09/24, showed staff documented: -On 05/03/24 at 01:45 P.M., when the nurse came to the nurse station to get his/her cigarettes, the resident began to yell obscenitity's at another nurse due to the fact they did not have the keys to the room where the cigarettes were kept. The Director of Nursing (DON) tried to intervene when the resident threatened to call the state. The DON explained to the resident until he/she was calm, he/she was unable to go out. The resident began hitting the wall yelling he/she wanted to smoke. The resident yelled at the DON and was explained again once he/she calmed down and stopped the behavior he/she may go to smoke. The resident currently sitting in the hallway crying and begging to smoke. -On 05/03/24 at 01:57 P.M., this nurse went to nurse station to get supplies when the resident said I want my cigarettes nurse explained he/she did not have the keys to the medication room. The resident said how long am I supposed to sit here and wait? Informed a few minutes until the other nurse can get up here and help you. The resident said that's bullshit. This nurse went to the DON office to let him/her know of the resident's behaviors, upon exiting the DON office and heading to the nurse station the resident was outside the DON office and said the other nurse is on break, am I supposed to wait. This nurse replied yes, you will have to wait, he/she is the one with the keys, and will be back shortly. The resident said I'm supposed to wait on the nurse to be able to smoke. The DON stepped into the hallway from his/her office and said to the resident, you signed a smoking policy that states if you have behaviors we have the right to revoke your liberal smoking, and that is what we are doing. The DON said we are not punishing you, you signed a smoking policy agreeing not to have behaviors along with other circumstances. The resident then started punching the wall repeatedly saying this is bullshit, and started to cry. Revew showed the resident then said I'm sorry can I go out to smoke and was told no, you may not. The resident went to the Business Office Manager (BOM) and expressed his/her need to go to smoke and he/she cant help they got mad. A few moments later the resident asked well when is the next supervised smoke break. The DON said he/she did not know, but explained to the resident he/she will get to smoke later, not right now. Resident yelled and wheeled backwards ran over another residents feet and hit his/her knee. Physician made aware of behaviors. -On 5/03/24 at 10:30 P.M., the resident called the facility and demanded that the nurse come outside and make Resident #2 come in from their smoke break because he/she is talking to him/her and about him/her and it needs to be dealt with. The nurse went outside where this resident sat by the drive and Resident #2 on the porch. Both residents continued to yell and fuss to another. Both residents continued to [NAME] back and forth and this nurse stated if this arguing couldn't stop smoke break would come to an end for the night. -On 05/05/24 at 05:40 P.M., the resident called the facility and asked if they would be going out to smoke and this nurse explained smoke break was at 06:00 P.M. The resident then came to the desk and asked who would smoke with them and explained the aides were doing resident care and one was picking up hall trays and when available they would take the residents outside. The resident said well I guess I need to go back to my prison cell because that's what it feels like, like I'm not wanted or allowed to be out of my room and you can just call for outside time. I have every right to feel this way because no one likes me and everyone has it out for me because I like to smoke. Observation on 05/09/24 at 01:45 P.M., showed the resident on the patio with five peers and one staff member during supervised smoke break. During an interview on 05/02/24 at 12:52 P.M., the resident said he/she was upset because his/her independent smoking privileges were taken away and now can only smoke with the supervised smokers. He/She said he/she gets set off easily and stays in his/her room due to it. He/She said they are currently being treated for cancer, and smoking is one thing he/she has left and when staff take that away, it increases his/her anxiety. He/She said when he/she was independently smoking, he/she would sit outside on the front porch where there was shade due to the sun and the chemotherapy medications could make him/her burn. The resident said he/she now has to sit on the patio with the other smokers where there is constant sun. He/she said he/she turns in his/her smoking materials like the policy says, but the materials should be available when he/she desires them. During an interview on 05/09/24 at 03:00 P.M., the DON said he/she thought the policy covered the ability to take the resident from independent to supervised smoking when the resident has behaviors. During an interview on 05/09/24 P.M., the administrator said the policies were in place prior to him/her joining the facility. He/She said based off the policy as it read, the residents priveledges should not have been changed. The administrator said he/she has offered a secondary place for Resident #1 to smoke if he/she does not want to be bothered, but is currently on supervised smoking sessions. MO00235610

Based on interviews and record review, facility staff failed to notify the physician in a timely manner for one resident (Resident #1) who stated he/she felt like harming himself/herself. The facility census was 44. 1. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, dated February 2023, showed staff were directed to do the following: -Any resident with a behavior that has been identified would present a potential danger to either himself/herself or other residents will be placed on increased visual monitoring, unless other immediate interventions are needed; -The charge nurse will notify the attending physician and family of the behavior. 2. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/22/23, showed staff assessed the resident as follows: -Cognitively intact; -Did not exhibit signs of feeling down, depressed or hopeless or thoughts he/she would be better of dead, or of hurting themselves in some way; -Diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and manic depression (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Review of the resident's care plan showed staff documented the following: -11/13/23: Resident uses an antidepressant medication related to depression. Contact the medical director for signs or symptoms of depression unaltered by antidepressant medications, including suicidal ideation's, negative mood or comments, changes in condition and anxiety; Review of the resident's medical record, dated 12/04/23, showed staff documented the resident said he/she is depressed and felt like he/she was going to self-harm. Staff contacted the guardian and the Director of Nursing (DON). Staff documented they contacted the guardian to switch the resident's room and to resolve the conflict between the resident and another resident but the guardian denied the request because he/she felt it would allow the resident to not learn how to resolve conflicts. Review of the progress not did not contain documenation staff notified the resident's physician of his/her statement of self-harm. Review of the resident's medical record, dated 12/04/23 through 12/05/23, showed staff documented they performed 15 minute checks on the resident. Review of the progress note did not contain documenation staff notified the resident's physician of his/her statement of self-harm. During an interview on 12/11/23 at 1:42 P.M., the resident said he/she told staff he/she wanted to hurt himself/herself about a week ago, but did not have a plan. The resident said staff came in and spoke with him/her in regard to the statement of self-harm to see if he/she had a plan and he/she said he/she did not have a plan. He/She said he/she had not made statements of self-harm to the staff prior to 12/04/23. During an interview on 12/11/23 at 2:05 P.M., the resident's guardian said the resident had a history of attention seeking behaviors. He/She staff did contact him/her in regard to the statement of self-harm and he/she believed it was for attention. He/She said the facility contacted him/her a few moments before the resident harmed himself/herself and he/she spoke with the resident. He/She said the facility staff calmed the resident down while on the phone with him/her and the resident was fine. He/She said the resident was upset with another resident. He/She said the two physician's from the hospital diagnosed the resident with severe personality disorder and attention seeking disorder. He/She said the hospital did not keep the resident because they did not believe the resident intended to harm themselves. During an interview on 12/12/23 at 10:29 A.M., Registered Nurse (RN) C said he/she did not know the facility's protocol for when a resident makes a statement in regard to self-harm, including whether or not to the physician should be notified. During an interview on 12/12/23 at 2:41 P.M., the administrator said if a resident makes a statement in regard to self-harm, staff is expected to report it to the nurse supervisor, assess the resident, contact the resident's physician and obtain an order for a mental health evaluation. The Administrator said staff did not notify him/her the resident made a statement of self-harm. The Administrator said staff should have notified the resident's physician. During an interview on 12/12/23 at 2:47 P.M., the Director of Nursing (DON) said staff is expected to notify the physician if a resident makes a statement of self-harm. The DON said the charge nurse is responsible for contacting the physician, but he/she did not follow up to verify the physician was contacted. He/She said the resident was placed on 15 minute checks after the resident made the statement of self-harm. During an interview on 12/21/23 at 1:02 P.M., The physician said he/she would expect staff to contact him/her if a resident made a statement of self-harm. He/She said he/she would work with the facility and the resident to come up with a plan to ensure the resident's safety. During an interview on 12/21/23 at 1:09 P.M., Psychiatric Nurse Practitioner (NP) said the resident has a history of saying he/she wants to self-harm. The facility staff did not contact him/her when the resident said he/she felt like harming himself/herself. The NP said he/she would not always expect staff to contact him/her after a resident made a statement of self-harm. The NP said it depended on the circumstances and if there was a plan or intent. The NP said he/she would expect staff to contact him/her if unsure whether the resident would actually harm himself/herself. MO00228574

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. The facility census was 44. 1. Observation on 11/13/23 at 12:15 P.M., showed Cook N served residents the noon meal per the Week one, Day two preplanned menu. Observation also showed -regular menu listed baked mostaccioli serving size as a six ounce spoodle, staff served the entree using a four ounce spoodle -regular menu listed apple crisp serving size as a #6 dip (5.33 ounces), staff served the fruit using a four ounce spoodle -pureed menu listed baked mostaccioli serving size as a #6 dip, staff served the pureed entree using a #8 dip (four ounces) -pureed menu listed italian vegetables serving size as a #12 dip (2.67 ounces), staff served the pureed vegetables using a #8 dip (four ounces) -pureed menu listed apple crisp serving size as a #6 dip, staff served the pureed entree using a #16 dip (two ounces) -pureed menu listed bread serving size as a #20 dip (1.6 ounces), staff served the pureed entree using a #8 dip (four ounces) During an interview on 11/14/23 at 8:21 A.M., Resident # 23 said the meal portions were small and he/she would prefer to be provided with larger portions at meal times. During an interview on 11/14/23 at 2:13 P.M., Resident #37 said the portion sizes were too small and would like larger portions, so he/she did not feel hungry after the meal. During an interview on 11/13/23 at 12:35 P.M., Cook N said there were no #6 or #12 scoops available in the kitchen. He/She also said he/she did not know what the scoop sizes meant so he/she could not use an alternative serving utensil. He/She said he/she usually checks serving sizes but did not know why he/she did not check this time. During an interview on 11/13/23 at 12:40 P.M., the Dietary Manager said the staff member serving the meal should verify correct scoop sizes according to the menu. He/She added that he/she could not locate #6 or #12 scoops in the kitchen. The dietary manager said he/she is responsible for ensuring menus are followed. During an interview on 11/15/23 at 10:50 A.M., the administrator said kitchen staff should have the proper kitchen wares to serve meals according to the menus. The administrator said he/she did not know the kitchen staff did not have all of the proper scoops they needed.

Based on observation, interview and record review, facility staff failed to maintain kitchen exhaust fans, lighting devices and ceiling surfaces in a clean sanitary manner to prevent the potential for cross-contamination. The facility census was 44. 1. Observation of the kitchen on 11/13/23 at 11:05 A.M., showed: -The ceiling above the three part sink had a large unfinished, repaired area. Observation showed the gypsum wallboard was unpainted and the joints were not taped or sealed, leaving gaps in the ceiling. Observation also showed the patched area was not flush and large areas hung below the ceiling level, exposing gypsum material; -Two ceiling exhaust fans had large accumulations of dust and grease; Six fluorescent tube light fixtures had missing covers, exposing twelve light bulbs; During an interview on 11/14/23 at 11:05 A.M., the dietary manager said the dietician told him/her about dirty kitchen exhaust fans and broken light covers in the resident dining room. The dietary manager said the dietician did not mention the missing light covers in the kitchen. During an interview on 11/15/23 at 12:15 P.M., the maintenance director said he/she was responsible for the kitchen ceiling, exhaust fans and light covers. The maintenance director said he/she was working on the exhaust fans but was not finished. The maintenance director said he/she had not had time to finish the repairs to the kitchen ceiling. The maintenance director said he/she knew about missing and broken light covers throughout the facility but he/she did not have any replacements. The maintenance director also said he/she has only been at the facility one month so he/she does not know the purchasing process yet. During an interview on 11/15/23 at 10:50 A.M., the administrator said he/she knew about the patched area of the kitchen ceiling. The administrator said the maintenance director was working on the ceiling and exhaust fans, but had not finished his/her work. The administrator said all kitchen lights should be covered and he/she did not know about the missing light covers in the kitchen.

Based on observation, interview and record review, facility staff failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for five residents (Residents #21, #24, #25, #34 and #43), when facility staff did not honor residents dietary preferences. The facility census was 44. 1. Review of the facility's policy titled, Resident's Rights, dated Month 2009, showed staff employees shall treat all residents with kindness, respect, and dignity. Residents are entitled to exercise their rights and privileges to the fullest extent possible. Review of the facility's policy titled, Resident Food Preferences, dated December 2008, showed the Dietician will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests. The Food Services Department will offer a limited number of food substitutes for individuals who do not want to eat the primary meal. 2. Review of Resident #21's Admission Minimum Data Set (MDS) a federally mandated assessment tool, dated 10/04/23, showed staff assessed the resident as severely cognitively impaired. Review of resident's dietary card (individualized card used by facility staff to quickly identify resident likes/dislikes), undated, showed staff documented the resident disliked rice. Observation on 11/15/23 at 12:42 P.M., showed a large portion of rice on the resident's plate. Observation showed the dietary card, with listed preferences, next to the resident's plate. 3. Review of Resident #24's Annual MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired. Review of resident's dietary card, undated, showed staff documented the resident disliked broccoli. Observation on 11/13/23 at 12:34 P.M., showed staff served the resident steamed broccoli. Observation showed the dietary card, with listed preferences, on the meal tray. Observation on 11/15/23 at 12:20 P.M., showed staff served the resident steamed broccoli. At this time the resident said, this is awful, left the dining room and did not eat his/her meal. 4. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of resident's dietary card, undated, showed staff documented the resident disliked rice. Observation on 11/15/23 at 12:22 P.M., showed staff served the resident rice. Observation showed the dietary card, with listed preferences, next to the resident's plate. 5. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of resident's dietary card, undated, showed staff documented the resident disliked rice. Observation on 11/15/23 at 12:43 P.M., showed staff served the resident rice. Observation showed the dietary card with listed preferences next to the resident's plate. During an interview on 11/16/23 at 7:24 A.M., the resident said staff served him/her rice yesterday, even though he/she does not like rice. 6. Review of Resident #43's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of resident's dietary card, undated, showed staff documented the resident disliked pork. Observation on 11/15/23 at 12:24 P.M., showed staff served the resident pork loin. Observation showed the dietary card with listed preferences next to the resident's plate. During an interview on 11/15/23 at 12:30 P.M., the resident said he/she does not like pork. The resident said he/she has told staff multiple times and staff continue to serve him pork. The resident said staff do not ask him/her if he/she wants an alternative on days the facility serves pork. During an interview on 11/15/23 at 2:34 P.M., dietary aide (DA) J said he/she helps serve residents their food. The DA said the dietary cards show the residents likes/dislikes, and diet order. The DA said he/she looks at the cards every time he/she puts food on the trays. The DA said if the facility is serving one of the residents' dislikes, the cook asks what the resident would like instead, and if available will serve the alternate option. The DA said he/she does not serve residents, their disliked items, but sometimes he/she is not who puts the food on the plates, so he/she has to serve it out. The DA said the cook has the dietary card and puts the card on the resident's tray. The DA said the cooks should be looking at the dietary card, when preparing the residents' plates. The DA said he/she does not know why the residents were served their dislikes. During an interview on 11/15/23 at 2:50 P.M., the Dietary Manager (DM) said the dietary cards contain the residents' names, room numbers, ordered diets, and food likes/dislikes. The DM said the DA's, Cooks and Nurse Aides (NA) look at the dietary cards during meal service. The DM said the cook clearly did not look at the residents' dietary cards when he/she prepared resident plates. The DM said staff can't memorize all residents dislikes, but should read the residents dietary cards. The DM said the dietary cards should be reviewed during meal preparation, to see if the facility is preparing a food a resident may not like. During an interview on 11/16/23 at 10:18 A.M., the Director of Nursing (DON) said dietary cards are used to identify resident food allergies, likes/dislikes, and ordered diets. The DON said dietary staff should pay attention to the dietary cards when food is served, and the nursing staff staff should pay attention when they deliver the food. The DON said an alternative food item should be served if the resident doesn't like a certain food. The DON said the Aides should observe the food on the tray and if a resident's dislike is on the tray, the Aides should take the tray back to dietary staff and let the dietary staff know the resident needs a new tray. During an interview on 11/16/23 at 9:38 A.M., the Administrator said staff should abide by the residents' preferences. It is not dignified to disregard the preferences of the residents. 42815

Based on observation and interview, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, doors, door frames, lighting devices, and an effective pest control program. The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for environmental concerns. 2. Observations on 11/13/23 and 11/14/23 during the Life Safety Code tour showed: -a broken hall light cover outside resident room [ROOM NUMBER]; -a large accumulation of dead insects in the hall light between resident rooms [ROOM NUMBERS]; -a large brown stain on the ceiling outside resident room [ROOM NUMBER]; -a broken light cover outside resident room [ROOM NUMBER]; -a missing hall light cover between resident rooms [ROOM NUMBERS]; -a cracked hall light cover outside resident room [ROOM NUMBER]; -a large unfinished ceiling patch over the North nurse station; -a large accumulation of dead insects in the hall light between resident rooms [ROOM NUMBERS]; -a large accumulation of dead insects in the hall light outside resident rooms 411; -a missing light cover over the South nurse station; -two hall light covers missing on the 500 hall; -four cracked/broken light covers in the resident dining room; -a broken hall light cover outside the business office; -two large stains on the main hall ceiling between the entrance and the administrators office; -two area of cracked, peeling ceiling texture between the entrance and the administrators office. 2. Observation on 11/13/23 at 12:25 P.M., showed black marks on the floor in the room [ROOM NUMBER]. Observation on 11/13/23 at 12:32 P.M. showed a large reddish brown stain on tile floor in room [ROOM NUMBER]. Observation on 11/13/23 at 2:42 P.M., showed room [ROOM NUMBER] with a heavily stained recliner. Observation on 11/13/23 at 2:53 P.M., showed three flies land on multiple items in room [ROOM NUMBER]. Observation on 11/13/23 at 3:01 P.M., showed room [ROOM NUMBER] had missing paint on the door and around the bottom of the walls and black marks on the walls. Observation on 11/13/23 at 3:02 P.M., showed a large accumulation of dead insects in the hall light outside resident rooms [ROOM NUMBERS]. Observation on 11/13/23 at 3:04 P.M., showed a brown water stain on the drywall between resident rooms [ROOM NUMBERS]. Observation on 11/13/23 at 3:06 P.M., showed insects flew in and out of a large cracked light cover between resident rooms [ROOM NUMBERS]. Observation on 11/13/23 at 3:08 P.M., showed light shone through an unsealed, rusted exit door at end of the 100 hall. Observation on 11/13/23 at 3:14 P.M., showed room [ROOM NUMBER] had peeled up linoleum and a large hole in the drywall behind the headboard of the bed. Observation on 11/13/23 at 3:16 P.M., showed room [ROOM NUMBER] had black marks on the exterior bathroom door and floors, and the middle drawer was broken. Observation showed the bathroom wall had black marks and missing paint, a black substance around the base of the toilet and debris buildup in the crevices of the bathroom tile. Observation on 11/14/23 at 8:07 A.M., showed room [ROOM NUMBER] had black marks on the walls and black and brown marks on the floor. Observation showed the bathroom had missing and chipped paint. Observation on 11/14/23 at 9:08 A.M., showed room [ROOM NUMBER] with five dark blue mismatched tiles near the bathroom entry, the remainder of the floor had speckled white tiles. Observation on 11/14/23 at 9:21 A.M., showed the resident doors and door frames, fire door and walls of the 400 hall had missing and chipped paint. Observation on 11/14/23 at 9:25 A.M., showed room [ROOM NUMBER] had black marks and trash on the floor. Observation showed the toilet seat had scratches and brown substance around the base on the floor. Observation on 11/14/23 at 2:17 P.M., showed room [ROOM NUMBER] had black marks and scratches on the floor, a dirty privacy curtain, and black marks and dents in the walls. The bathroom door and frame had missing and chipped paint, stains on the floor, the base of the toilet had a brown substance around it and the wall had blacks marks. Observation on 11/15/23 at 8:50 A.M., showed three flies landed on food trays and beds in room [ROOM NUMBER]. Observations at 12:42 P.M. and 2:30 P.M., showed flies flew around the room. Observation on 11/16/23 at 8:37 A.M., showed the Director of Nursing (DON) entered the room. The flies flew around the DON's face and the DON swatted at the flies. Observation on 11/15/23 at 9:12 A.M., showed room [ROOM NUMBER] with had gouged walls to the right of the window, and black smudges between the gouges. Observation on 11/16/23 at 8:28 A.M., showed 100 hall shower room door and door frame had gouges and missing paint. Observation on 11/16/23 at 8:29 A.M., showed the door between 100 hall and dining room had gouges and missing paint. During an interview on 11/14/23 at 12:15 P.M., the maintenance director said he/she started at the facility one month ago. The maintenance director said he/she is aware of the missing light covers in resident areas and the kitchen but he/she does not have any replacement covers. The maintenance director said he/she has been working on repairing the building but is not sure of the facility's purchasing process yet. During an interview on 11/15/23 at 9:27 A.M., Certified Nurse Aide (CNA) C and CNA D said staff should document environmental concerns on a maintenance form. They said they have not filled out the log, but have reported concerns to the nursing staff. They said they did not feel like the facility was homelike due to the condition of the environment. During an interview on 11/15/23 at 10:50 A.M., the Administrator said the Maintenance Director is responsible for building maintenance. The administrator said he/she and the maintenance director have been working to address building issues and they recognize they still have work to do. During an interview on 11/16/23 at 8:46 A.M., Housekeeper (HSKR) K said when he/she cleans rooms and sees something that needs to be fixed, he/she goes to find the maintenance staff. HSKR K said if maintenance is not in the building, there is a piece of paper on the maintenance door, staff are supposed to write on. HSKR K said he/she thinks maintenance is supposed to clean and maintain light covers. During an interview on 11/16/23 at 8:52 A.M., Certified Medication Technician (CMT) A said he/she had noticed the flies. The CMT said everyone is aware of the flies, but he/she is not aware of what is being done about the flies. The CMT said he/she fills out a maintenance sheet and lets the nurse and maintenance know then something needs fixed. The CMT said it had been awhile since he/she filled out a maintenance request. During an interview on 11/16/23 at 9:08 A.M., the Maintenance Director said he/she audits the resident rooms once a week and documents environmental concerns. The Maintenance Director said he/she noticed the condition of the resident rooms and hallways and is in the process of completing repairs, because he/she does not feel like the resident rooms are homelike. The Maintenance Director said he/she has not received any reports in regard to fly concerns. During an interview on 11/16/23 at 10:18 A.M., the DON said if a Aide sees flies the charge nurse should be notified. The DON said the charge nurse should notify him/her and he/she would report it to the Administrator. 42815 45489 45564

Based on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for four residents (Resident #7, #30, #41, and #46). The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for baseline care plans. 2. Review of Resident #7's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. 3. Review of Resident #30's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. 4. Review of Resident #41's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. 5. Review of Resident #46's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. During an interview on 11/16/23 at 9:02 A.M., the Administrator said the Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, Coordinator is responsible for all care plans, including baseline care plans. The Administrator said he/she did not know the required timeframe for completing baseline care plans. During an interview on 11/16/23 at 9:32 A.M., the MDS Coordinator said he/she is the only one responsible for completing baseline care plans and he/she tries to get them done within 48 hours, unless they are admitted on a Friday afternoon/evening, then he/she completes them first thing Monday morning. The MDS Coordinator said he/she did not know Resident #7 and #30 did not have completed baseline care plans, and he/she missed Resident #41's.

Based on observation, interview and record review, facility staff failed to ensure eight residents (Residents #5, #7, #11, #23, #32, #34, #36 and #37), who were unable to complete their own activities of daily living (ADLs), received the necessary care and services to maintain good personal hygiene. The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for ADLs. 2. Review of Resident #5's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/31/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not reject care; -Dependent on staff for toileting, bathing, dressing, bed mobility and transfers; -Always incontinent of bowel and bladder; -Diagnosis of dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of resident's care plan, dated 9/5/23, showed staff documented the resident required assistance from one staff member for personal hygiene. Observation on 11/14/23 at 8:02 A.M., showed the resident ate breakfast in his/her room. Observation showed under the resident fingernails with a black debris. Observation on 11/15/23 at 8:50 A.M., showed the resident ate breakfast in his/her room. Observation showed under the resident fingernails with a black debris. 3. Review of Resident #7's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not reject care; -Required maximal assistance from staff for bed mobility; -Dependent on staff for toilet hygiene, bathing, dressing, personal hygiene and all transfers; -Always incontinent of bowel and bladder; -Diagnoses of Bipolar Disorder, Psychotic Disorder and Scizophrenia. Review of resident's care plan, dated 7/26/23, showed staff documented the resident required assistance from one staff member for personal hygiene. Observation on 11/13/23 at 12:41 P.M., showed the resident fed himself/herself in the dining room. Observation showed under the resident fingernails with a black debris and disheveled tangled hair. Observation on 11/14/23 at 8:02 A.M., showed the resident fed himself/herself breakfast in his/her room. Observation showed under the resident fingernails with a black debris. Observation on 11/15/23 at 8:50 A.M., showed the resident fed himself/herself breakfast in his/her room. Observation showed under the resident fingernails with a black debris. Observation on 11/15/23 at 12:42 P.M., showed the resident fed himself/herself lunch in his/her room. Observation showed under the resident fingernails with a black debris. Observation on 11/16/23 at 8:32 A.M. showed the resident finished breakfast in his/her bed with black debris under his/her fingernails. 4. Review of Resident #11's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not reject care; -Required partial to moderate assistance from staff members with bathing or showers; -Did not document personal hygiene assistance. Review of the resident's care plan, dated 09/12/23 showed staff documented the resident required assistance from one staff member for personal hygiene. Review showed staff are directed to check the resident's nail length and trim and clean nails on bath day and as necessary. Observation on 11/13/23 at 2:47 P.M., showed the resident with unkempt facial hair. Observation showed under the resident fingernails long and with black debris. Observation on 11/14/23 at 9:25 A.M., showed the resident with unkempt facial hair. Observation showed under the resident fingernails long and with black debris. Observation on 11/15/23 at 10:10 AM., showed the resident with unkempt facial hair. Observation showed under the resident fingernails long and with black debris. During an inteview on 11/15/23 at 3:46 P.M., the resident said staff has not trimmed or cleaned his/her nails. He/She said he/she does not like when his/her nails are dirty and he/she prefers to be shaved, but staff does not always shave him/her. 5. Review of Resident #23's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not reject care; -Required supervision or touch assistance from staff members for bathing/showering. Review of the resident's care plan, dated 10/09/23, showed staff documented the resident requires assistance from one staff member for bathing/showering at least twice weekly and as necessary. Review showed staff were directed to check the resident's nail length and trim and clean nails on bath day and as necessary. Review of the resident's shower sheet, dated 11/4/23, showed staff documented the resident received a shower and needed his/her toenails cut. Observation on 11/13/23 at 3:31 P.M., showed the resident fingernails long and with a red substance on two of the nails. Observation on 11/14/23 08:07 AM., showed the resident with disheveled hair. Observation showed the resident fingernails long and with a red substance on two of the nails. Observation on 11/15/23 at 10:09 A.M., showed the resident fingernails long and with a red substance on two of the nails. Observation on 11/16/23 at 7:15 A.M., showed the resident fingernails long and with a red substance on two of the nails. During an interview on 11/15/23 at 10:09 A.M., the resident said he/she prefers shorter nails and the staff has not asked if he/she would like his/her nails trimmed. 6. Review of Resident #32's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not reject care; -Required supervision from staff with eating; -Required assistance from staff for toileting hygiene, bathing and dressing; -Frequently incontinent of bowel and bladder; -Diagnoses of Dementia. Observation on 11/15/23 at 12:26 P.M., showed the resident ate his/her lunch in the dining room. Observation showed the resident fingernails with a black built up debris. Observation on 11/16/23 at 8:41 A.M., showed the resident sat at the dining room table with black debris built up under his/her fingernails. 7. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not reject care; -Required assistance from staff for showers/bathing and upper body dressing -Totally dependent on staff for lower body dressing; -Required assistance from staff for personal hygiene. Review of the resident's care plan, dated 11/01/23, showed staff documented the resident requires extensive assistance from one to two staff for bed mobility and hygiene and is totally dependent on staff for toileting, dressing, and bathing. Observation on 11/13/23 at 12:37 P.M., showed the resident fingernails long and with debris, smelled of urine, long eye brow hairs, and a white substance on the front of his/her pants. Observation showed the resident had unkempt facial hair and greasy unbrushed hair. Observation on 11/14/23 at 8:01 A.M., showed the resident fingernails long and with debris, smelled of urine, long eye brow hairs, and a white substance on the front of his/her pants. Observation showed the resident had unkempt facial hair and greasy unbrushed hair. Observation on 11/15/23 at 9:52 A.M., showed the resident fingernails long and with debris, smelled of urine, long eye brow hairs, and a white substance on the front of his/her pants. Observation showed the resident had unkempt facial hair and greasy unbrushed hair. During an interview on 11/16/23 at 7:24 A.M., the resident said he/she preferred short hair and facial hair, and for his/her nails cut short, but there has not been staff available to cut his/her hair. 8. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Required assistance from staff for showering/bathing and upper and lower body dressing; -Did not document assistance required for personal hygiene. Review of the resident's care plan, dated 09/19/23, showed staff documented the resident as dependent on staff for bathing and required total assistance from staff with personal hygiene. Staff is directed to check nail length and trim and clean on bath days and as necessary. Observation on 11/14/23 at 5:46 P.M., showed the resident fingernails with debris, a red substance on his/her hands, debris in his/her facial hair, and white debris on his/her shirt. Observation on 11/15/23 3:34 P.M., showed the the resident fingernails with debris, a red substance on his/her hands, unbrushed hair, debris in his/her facial hair and black debris on his/her shirt. Observation on 11/16/23 at 7:12 A.M., showed the resident with long fingernails and unbrushed hair. 9. Review of Resident #37's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required assistance from staff with showers/bathing and upper and lower body dressing; -Did not document personal hygiene assistance; -Did not reject care. Review of the resident's shower sheet, dated 11/12/23, showed staff documented did not require nail trimming. Review of the care plan, dated 08/25/23, showed staff documented the resident required assitance from staff for bathing, dressing and personal hygiene. Review showed staff are directed to check nail length, trim and clean on bath day and as necessary. Observation on 11/14/23 at 2:16 P.M., showed the resident with fingernails long, long nose hairs and unkempt facial hair. Observation on 11/15/23 at 3:35 P.M., showed the resident with long fingernails, long nose hairs, and unkempt facial hair. During an interview on 11/15/23 at 3:35 P.M., the resident said staff has not trimmed his/her nails or his/her nose hairs and he/she would like it done. The resident said he/she asks staff for shaves and nails trims, but staff does not always provide the care. During an interview on 11/15/23 at 9:27 A.M., Certified Nurse Aide (CNA) C and CNA D said staff should brush residents hair when getting them out of bed and wash faces and hands after every meal. They said staff should check nails as often as possible and trim the nails when needed and on shower days. They said resident's should be shaved on shower days and as needed, and clothing should be changed when dirty or if needed. During an interview on 11/15/23 at 4:00 P.M., Licensed Pratical Nurse (LPN) H said nurses are responsible for providing nail care for residents who are diabetic. The LPN said the aides trim the other residents nails on shower days. The LPN said CNA's should wash the residents faces every morning and after every meal and should check the residents nails and trim them if needed. The LPN said the resident should not have to eat meals with dirty nails as it poses an infection control concern. The aides are responsible for shaving the residents facial hair on shower days and changing the residents clothes when visibly soiled or when the resident requests. The LPN said if a resident refuses care the aides should reapproach, and should document refusals on the shower sheets. During an interview on 11/16/23 at 9:38 A.M., the Administrator and Director of Nursing (DON) said the aides and other nursing staff should provide nail care, including trimming and cleaning, shaving and nose hair trimming as needed. They said staff should be checking nails and facial hair when providing care. They said clothing should be changed in the morning and when dirty or soiled. 42815