Every finding on record at South County Health Care Center

Based on observation, record review and interview the facility failed to provide residents with a clean, comfortable and homelike environment by failing to maintain resident-use areas, bathing areas and common areas in a sanitary and orderly condition. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 80.The facility did not provide a policy for a safe, clean, and comfortable homelike environment.Review of the Resident Council minutes from the 02/11/26 meeting showed a concern with housekeeping and not getting the rooms cleaned. There was no follow-up included. Observation on 06/16/26 at 9:00 A.M., during the initial tour of the facility showed a strong a strong urine odor upon entering.Observations on 06/16/26 at 9:12 A.M. of the 300-hall showed:A dried tissue with black substance that had been streaked across the floor and left in front of the men's and women's bathrooms on the 300 hall;The female bathroom had an out of order sign posted on the door;The floor throughout the 300 hall was heavily streaked with a brown substance;The metal drain covers in the hallway had a black substance around edges;A 5-gallon bucket full of brown stained blankets sat in front of the dirty utility room;A gray, plastic square trash can with a brown stained blanket sat in front of the dirty utility room;A tied clear trash bag sat next to the 5-gallon bucket;A clear trash bag with a brown colored garment sat near the gray trash can;A white plastic laundry basket with resident blanket and clothing sat in the hall. Observations on 06/16/26 at 9:16 A.M. of room [ROOM NUMBER] showed:The floor in the bathroom had areas of brown stains on the floor;A black substance to floor around base of toilet;The bathroom door had scuff marks;The wall above the tile baseboard had an exposed area of concrete;The resident room trash can near the sink was full and overflowing;A white mesh bag with clothing, a pair of pants and a flat sheet on the floor in front of the sink; The sink was cluttered with personal items;There were dried brown spots and brown wheelchair tracks on the floor throughout the room;The floor was covered with black dirt like debris. Observation on 06/16/26 at 9:25 A.M. of the Nurse's Station on the Countryside Hall showed:A white, wheeled cart with yellowed handles had dried brown spots to handles and sides;An ice chest, filled with ice sat on top of the cart with the lid opened and leaning against the wall; A large metal ice scoop sat on the right side up on a piece of fabric next to the ice chest. Brownish water had pooled in the deepest part of the scoop Observations on 06/16/26, from 9:26 A.M. to 9:40 A.M. of the Countryside 100 Hall showed:The male bathroom had brown footprint outlines throughout on the floor. The toilet in the bathroom had a dark brown substance on the floor at base; A four-tile square in the middle of the 100 Hallway covered with four tiles. One tile was missing a corner, leaving a hole to the subfloor; A one-gallon jug of an industrial strength cleaner sat on the floor. The jug did not have anti-tamper type lid;Dried droplets of a black substance on the floor at the end of hall;Several dead bugs scattered on the floor at the end of the hall;The shower room had a thick black substance on the tile surface ledges and a reddish black substance on the tile walls, corners, and tile floors;Two wheelchair cushions and three wheelchair footrests on the floor and up against the radiator heater;The base of the toilet was covered in a brownish black substance; Brownish black spots to the outside rim of the toilet;The toilet paper roll sat on the floor with toilet paper holder;The baseboards had splatters of a black substance; A used towel lying on a bariatric shower seat;The bariatric shower seat had 2 pieces of duct like tape on the left leg;A bed in hallway with fitted sheet covered in small holes and brown stains;room [ROOM NUMBER] dried brown dirt like substance in front of chair on the floor and footprints throughout the room. A bath blanket covered with a dark brown substance lay on the floor in front of the sink; The closet at the end of the 100 hallway with door off placed and in the closet leaning against an open cardboard box with blue linen partially out and a plastic bag on the floor containing pillows; The sheet on the bed in room [ROOM NUMBER] bed had dark brown ring and two smaller brown spots. During an interview on 06/16/26 at 1:00 P.M., the DON and the Administrator said they expected the environment to be clean and sanitary.

Based on observation, record review and interview the facility failed to maintain hazardous cleaning chemicals in a secure manner to prevent resident access when an unattended one-gallon container of cleaning solution was observed on the floor in a resident accessible hallway. The product was identified by the manufacturer as causing serious eye irritation and potentially harmful if swallowed. The facility's assessment identified that 40 of the 80 residents had behavioral health needs, making resident access to hazardous chemical a foreseeable accident hazard. The facility census was 80.Observation on 06/16/26 at 9:26 A.M., showed an unattended one-gallon container of a purple cleaning solution sitting on the floor in the Countryside 100 and resident-accessible hallway. Review of the manufacturer's Safety Data Sheet identified the product as causing serious eye irritation and noted it may be harmful if swallowed. Review of the facility assessment identified 35 residents with behavioral symptoms and cognitive impairment and 40 residents with behavioral health needs. Failure to secure hazardous cleaning chemicals created the potential for residents to ingest, spill or otherwise be exposed to the cleaning solution, placing residents at risk for injury. During an interview at 06/16/26 at 1:00 P.M., the administrator said the jug of purple liquid was just the cleaner housekeeping puts into spray bottles.

Based on interview and record review, the facility failed to provide wound care and medications as ordered for one resident (Resident #1) out of 10 sampled residents. The facility census was 82.The facility policy titled, Transcription of Orders and Following Orders, dated May 2024, showed:- The Licensed/Registered nurse will review electronic medication administration records (MARs) and treatment administration records (TARs) on a routine basis to monitor for medications that were not administered to the resident due to unavailability, refusal, omission and etc.;- If a medication is marked as not given, the reasoning for not being given should be explained in the progress notes and the Resident Care Coordinator (RCC), the Director of Nursing (DON), Assistant Director of Nursing (ADON), Registered Nurse (RN), and the Administrator must be notified. The physician and legal guardian (if applicable) must also be notified. The nurses progress notes must document the plan/solution because of the medication not being administered and any adverse reactions that the resident may have;- For the electronic MARs/TARs, the medication will be documented as not given by selecting the corresponding chart code for the reason why it was not given, and a progress note will be written;- The nurse or Certified Medication Technician (CMT) in charge of medication administration must review all their designated MARs/TARs prior to the end of their shift were administered/treatments scheduled to be given on their shift were administered according to the physician's order and that all necessary interventions were taken in the event of an omission. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/23/26, showed:- Diagnoses of sepsis (the body's extreme response to an infection), chronic kidney disease (impaired kidney function), hypotension, (low blood pressure), and irritant contact dermatitis (skin inflammation caused by contact with substances and/or environmental factors that injure the skin); - Cognition intact;- Able to make needs known;- Independent with tasks of eating and oral hygiene;- Substantial/maximal assistance of staff for toileting, shower/bath, upper and lower body dressing, personal hygiene and putting on/off footwear;- Urinary catheter (a sterile tube place in the bladder to drain urine) in place;- Occasionally incontinent of bowel; - One stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) upon admission;- Open lesions other than ulcers, rash, cuts;- Surgical wound. Review of the resident's physician order sheet (POS), dated January through February 2026, showed:- An order, dated 01/21/26, for Ensure Plus (a nutritional supplement) two times a day, vanilla at breakfast and chocolate at dinner;- An order, dated 01/21/26, for Ensure Clear (a nutritional supplement) one time a day;- An order, dated 03/06/26, for ProSource Oral Liquid (a nutritional supplement) give 30 milliliters (ml) by mouth two times a day for wound healing;- An order, dated 01/21/26, for multivitamin-minerals one tablet by mouth one time a day for dietary deficiency;- An order, dated 01/21/26, for simethicone (medication used to treat excessive gas) 41.667 milligrams (mg) by mouth before meals and at bedtime for gas;- An order dated 01/21/26 for Loperamide HCl Oral Capsule 2 MG (Loperamide HCl) Give 1 capsule by mouth every 12 hours for diarrhea;- AN order dated 01/21/26 for Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG (an antibiotic) Give 1 tablet by mouth every 12 hours for lifelong suppression;- An order, dated 03/03/26, for midodrine (medication used to treat hypotension) 5 mg by mouth every 12 hours related to hypotension;- An order, dated 03/03/26, for pantoprazole sodium delayed release 40 mg by mouth one time a day for acid reflux;- An order, dated 01/21/26, to cleanse midline abdominal wound with wound cleaner, pat dry, apply betadine (used to treat minor wounds) and leave open to air two times a day for wound healing until 02/06/26;- An order, dated 01/22/26, to cleanse right hip wound with wound cleaner, pat dry, apply full strength Dakin solution (a wound treatment) to gauze and cover with absorbent dressing (ABD - dressing used to keep wounds dry) only if wound vac (vacuum-assisted closure used to conduct negative pressure wound therapy to promote healing) integrity is lost or off greater than 2 hours two times a day for wound healing;- An order, dated 01/22/26 for Negative Pressure Wound Therapy (NPWT) (a medical devices that use vacuum suction to treat acute or chronic wounds by removing fluid, reducing infectious material, and promoting healing) use with black foam - hip wound and white foam - sacral wound with continuous suction at 125MmHg one time a day every Tue, Fri for wound- An order, dated 01/22/26, for miconazole powder (a topical antifungal) apply to gluteal cleft (the deep vertical crease that separates the buttocks) to the perineum (the region between the anus and the genitals) topically two times a day related to irritant contact dermatitis due to fecal, urinary incontinence;- An order, dated 01/22/26, for Triad Hydrophilic Wound Dress External Paste (used for mild to moderate wound drainage) apply to gluteal cleft topically two times a day related to irritant contact dermatitis; - An order dated 01/22/26 to Cleanse Sacral wound with wound cleaner, pat dry, cover with pouch only if Vacuum integrity is lost or off greater than 2 hours two times a day for wound healing. Discontinued on 02/14/26. - An order, dated 02/14/26, cleanse right hip with wound cleaner, apply Dakin solution-soaked gauze to wound bed, cover with ABD and dry dressing twice a day when wound vac is off more than 2 hours every 12 hours as needed related to sepsis;- An order, dated 02/18/26 may remove wound vac for shower. Discontinued on 04/09/2026;- An order, dated 03/12/26, for wound care to clean right rip with wound cleanser, pat dry, apply calcium alginate (provides a moist environment for wound healing) and cover with a foam dressing and as needed (PRN) for dislodgement or drainage issues every day shift every Monday and Thursday for wound care until healed;- An order, dated 03/23/26, for zinc oxide external paste (helps protect the skin from moisture) apply to buttocks and rectal area topically two times a day for skin protectant until redness resolved, then PRN. Review of the resident's care plan, initiated on 04/07/26, showed:- At risk for adverse outcomes related to medication errors, including but not limited to incorrect medication administration, missed doses, wrong dose, wrong time, or documentation discrepancies, which may result in ineffective treatment, adverse drug reactions, or decline in condition. Review of the resident's TAR, dated January 2026, showed:- A treatment order for cleanse midline abdominal wound with 10 missed treatments out of 20 opportunities;- A treatment order for cleanse right hip wound with 10 missed treatments out of 20 opportunities;- A treatment order for cleanse sacral wound with 10 missed treatments out of 20 opportunities;- A treatment order for gluteal cleft wound with 10 missed treatments out of 20 opportunities. Review of the resident's MAR, dated January 2026, showed:- An order for simethicone tablets with six out of 40 missed opportunities. Review of the resident's TAR, dated February 2026, showed:- An order for wound vac on the sacral (triangular bone located above the coccyx) wound and hop wound change missed three times out of eight opportunities; - A treatment order for cleanse midline abdominal wound with three missed treatments out of 12 opportunities;- A treatment order to cleanse right hip wound with four missed treatments out of 28 opportunities;- A treatment order to cleanse sacral wound with four missed treatments out of 28 opportunities;- A treatment order for gluteal cleft wound with 16 missed treatments out of 56 opportunities;- A treatment order for wound dressing to gluteal hip wound with three missed treatments out of 12 opportunities. Review of the resident's TAR, dated March 2026, showed:- An order for wound vac on sacral wound and hip wound change missed two times out of two opportunities; - An order for dressing to sacral wound with two missed treatments out of 20 opportunities;- An order for gluteal cleft wound treatment with 13 missed treatments out of 20 opportunities. Review of the resident's TAR, dated March 2026, showed:- An order for dressing to sacral wound with one missed treatment out of eight opportunities;- An order for treatment to buttocks and rectal area with one missed treatment out of 17 opportunities. Review of the resident's MAR, dated March 2026, showed:- An order for Ensure Plus chocolate flavor at dinner with five out of 18 missed opportunities;- An order for Ensure Clear one time a day with two out of nine missed opportunities; - An order for ProSource Nutritional supplement two times a day with five out of 18 missed opportunities;- An order for pantoprazole sodium 40 mg one time a day with two out of nine missed opportunities;- An order for multivitamin-minerals tablet one time a day with two of nine missed opportunities;- An order for amoxicillin 875-125 mg tablet with three out of 18 missed opportunities; - An order for loperamide (medication used to treat diarrhea) capsule every 12 hours with three out of 18 missed opportunities; - An order for midodrine tablet every 12 hours with three out of 18 missed opportunities; - An order for simethicone tablets every 12 hours with nine out of 36 missed opportunities. Review of the residents' Progress Notes showed no documentation of missed medication and/or treatments. During an interview on 04/15/26 at 11:45 A.M., the Corporate Consultant said she would expect all nursing and certified medication technicians to document medications or treatments given and if not done, document the reason why and contact the physician if needed. MO2969985

Based on closed record review and interview, the facility failed to provide bathing/showers for one resident (Resident #1) of 10 sampled residents. The facility census was 82.The facility policy titled Resident Showers and dated June 2024, directed staff to: - Assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice;- Provide residents with showers as requested or as per facility schedule protocols and based upon resident safety; The facility did not provide a resident shower/bathing schedule. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated January 23, 2026, showed:- An admission date of 01/21/26;- Diagnoses of sepsis (a life-threatening medical emergency caused by an overwhelming immune response to infection, leading to tissue damage, organ failure, and death), chronic kidney disease (a serious, long-term condition where kidneys are damaged and cannot effectively filter blood, often leading to waste buildup), hypotension, (abnormally low blood pressure), and irritant contact dermatitis a common, non-allergic skin reaction caused by direct damage from substances like soaps, cleaners, or chemicals, resulting in a painful or itchy, red, cracked rash);- Cognitively intact;- Able to make needs known;- Substantial/maximal assistance of staff for toileting, shower/bath, upper and lower body dressing, personal hygiene and putting on/off footwear;- Foley catheter (a tube place in the bladder to drain urine) in place;- Occasionally incontinent of bowel; - One stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) upon admission;- Open lesions other than ulcers, rash, cuts;- Surgical wound. Review of Resident #1's care plan, dated 01/22/26, showed no interventions for assistance of staff for personal hygiene and/or activities of daily living. Review of facility shower records showed Resident #1 received a shower on 01/29/26, 03/03/26 and 04/02/26. There were no recorded bed baths. During an interview on 04/14/26 at 11:00 P.M., the Corporate Consultant (CC) said there was no shower schedule. Staff had been doing showers by randomly selecting residents and did not document. The CC said she would expect staff to have a shower schedule and record all showers and/or bed baths per facility policy. Cmp 2969985

Based on interview and record review, the facility failed to protect three residents (Residents #1, #2, and #3) of three sampled residents from sexual abuse when the Assistant Director of Nurses (ADON) offered and provided his/her personal medications to the residents in exchange for sexual activity and inappropriate touching. The facility also failed to protect Resident #1, with a history of substance abuse, from abuse when the Activities Director (AD) took the resident in his/her personal vehicle to purchase marijuana. The AD and resident then used the marijuana together while in the vehicle. The facility census was 86. The administration was notified on 3/25/26 at 1:30 P.M. and 3/26/26 at 1:00 P.M. of the Immediate Jeopardy situations which began on 03/18/26. The IJ was removed on 3/26/26, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect Policy dated 06/12/24, showed:- Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations;- It includes verbal abuse, sexual abuse, physical abuse, and mental abuse;- Sexual abuse can include rape, sodomy, and coerced nudity. Review of the facility's investigation dated 03/18/26, showed:- The ADON informed the Administrator (ADM) Resident #1 was purchasing marijuana from staff member, AD and an investigation was started;- As the investigation was on-going, Resident #1 was observed to be smoking marijuana outside in the yard at the facility;- The ADM searched the resident's room and found marijuana and a bottle of Xanax (a benzodiazepine drug used to treat anxiety) 0.5 milligram (mg) that contained 28 pills, that belonged to the ADON;- The ADON was questioned and said Resident #1 had taken them from his/her purse while he/she was on duty;- The ADM questioned Resident #1 about the drugs found in his/her room. Resident #1 said the ADON gave him/her the Xanax in exchange for sexual favors. Resident #1 said the ADON gave two other residents drugs also;- Resident #1 provided multiple pages of text messages between him/her and the ADON in which they discussed sexual activity and the ADON providing Xanax to the resident;- The Administrator was told Resident #2 and #3 had also received Xanax;- Resident #2 confirmed the ADON had provided him/her with Xanax and touched the resident inappropriately;- Resident #3 told the Administrator the ADON had provided him/her, two Xanax and the ADON fondled his/her genitalia;- A statement from housekeeper (HK) A showed he/she was not aware of the relationship with the ADON but had witnessed Resident #1 and the AD riding in a vehicle together and consuming marijuana. Review of the facility's On-Board Training, completed on hire, showed:All policies are delivered and signed prior or on start date with all new hires. The policies provided include but are not limited to: Social Media Policy, Possession of Prescribed and Over the Counter Medications while on Duty, Behavioral Emergency Policy, Sexual Harassment, Abuse and Neglect, Elder Abuse Reporting:- The ADON signed and dated the above policies on 03/13/26;- HK A signed and dated the above policies on 11/26/25;- CNA B signed and dated the above policies on 11/20/25;- AD signed and dated the above policies on 04/24/25. Review of Resident #1's Pre-admission Screening and Resident Review (PASRR- federally mandated screening process for individuals with serious mental illness (SMI), intellectual disability/developmental disability (IDD/DD), and/or related condition), dated 08/30/22 showed:- The resident has a history of aggression, manipulative behavior, and sexually inappropriate behavior.- The resident has a diagnosis of a closed head injury due to a motor vehicle accident.- The resident has a history of using and abusing multiple substances including opioids, benzodiazepines (a class of central nervous system (CNS) depressant), alcohol, stimulants and amphetamines (a CNS stimulant).- Alcohol and substance abuse began at age [AGE].- The resident has a history of requesting Xanax (a benzodiazepine) and Adderall (combination of amphetamine and dextroamphetamine).- The resident is mildly intellectually disabled (MID - an Intelligence Quotient of 50-70). Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 02/4/26 showed:- admission date of 12/27/25;- Cognitively intact;- Required supervision with activities of daily living (ADLs);- Had a legal guardian. Review of Resident #1's Physician Order Sheet (POS) dated March 2026, showed:- Diagnoses of Personality Disorder (a mental health disease causing difficulties with relationships), MID, opioid dependency, and Bi-Polar Disorder with Psychotic features (severe form of mental disease-causing mania and depression and hallucinations and delusions);- No order for Xanax. Review of Resident #2's PASRR dated 05/07/21, showed:- The resident had a history of substance abuse;- Has very disorganized thinking and flight of ideas;- Has delusions and paranoia. Review of Resident #2's Quarterly MDS dated [DATE], showed:- admission date of 07/30/25;- Had some cognitive impairment;-Required supervision with daily ADLs. Review of Resident #2's POS dated March 2026, showed:- Diagnoses of depression and mania, schizoaffective disorder (chronic mental health condition marked by hallucinations and delusions);- No order for Xanax. Review of Resident #3's Quarterly MDS dated [DATE], showed:- admission date of 01/27/26;- Cognitively intact;- Required substantial assistance with ADLs. Review of Resident #3's POS dated March 2026, showed:- Diagnoses of Personality Disorder, substance abuse, depression, Schizophrenia, and paraplegia (loss of motor function in the lower half of the body);- No order for Xanax. During an interview on 03/23/26 at 11:00 A.M., the ADM said on 03/18/26 the ADON told him Resident #1 told him/her he/she purchased marijuana from staff members AD and certified nurse aide (CNA) A. The ADON told the ADM the information had been provided by Resident #1. Later that day, the ADM was informed by the Assistant Maintenance (AM), Resident #1 had been outside smoking marijuana. The ADM said he completed a contraband search of Resident #1's room and found marijuana and a bottle of Xanax 0.5 milligram (mg) prescribed to the ADON. He said the ADON told him the resident had taken them from his/her purse. During the investigation, Resident #1 said the ADON had given the Xanax to him/her and two other residents. Resident #1 showed the ADM text messages from the ADON to Resident #1. The texts were sexually explicit in content and showed conversation regarding the ADON providing money for the resident to purchase marijuana from unknown staff. The ADM said the ADON was suspended pending the investigation. He had not been aware of this relationship. During an interview on 03/23/26 at 11:40 A.M., Resident #1 said he/she is a drug addict and if offered drugs will consume them. The resident said he/she is stuck in the facility and still wants drugs. Resident #1 said the ADON offered him/her Xanax and as payment he/she wanted to have sex with him/her. The ADON also gave him/her Adderall and Tramadol (a drug used to treat pain). The ADON told the resident to meet him/her in an empty room to get the drugs. Resident #1 said when he/she would get to the room, the ADON would rub his/her genitalia to get the resident excited. The resident said he/she had intercourse with the ADON one time, and the ADON had performed oral sex once. The resident said he/she only had sex for the drugs. Resident #1 said he/she had talked to Resident #2 who told him/her the ADON had given Xanax to Resident #2 and rubbed his/her genitalia. During an interview on 03/23/26 at 12:07 A.M., Resident #2 said the ADON had given him/her two Xanax. Resident #2 said he/she is a drug addict, so if free drugs are offered, he/she will take them. The ADON had rubbed the resident's hair, shoulders and butt and moved his/her hand to the resident's genital area, but the resident walked away. The ADON attempted to kiss Resident #2 multiple times, but the resident said he/she would step away. Resident #2 said the ADON had provided Resident #3 Xanax pills as well. During an interview on 03/23/26 at 4:00 P.M., Resident #3 said the ADON gave him/her two Xanax pills saying they would help with seizures. Resident #3 took one of the pills and he/she did not like how his/her body reacted. Resident #3 said he/she was in a sedated state when the ADON came back in his/her room and the ADON started to rub his/her genitalia. The resident said he/she pushed the ADON's hand away and he/she left. Resident #3 said he/she threw the other pill away. During an interview on 03/23/26 at 2:00 P.M., the ADON said Resident #1 stole medication from his/her purse while it was at the nurse's station. The ADON said he/she had not been informed of any allegations of sexual abuse, but the texts on the resident's phone were not from him/her. He/she said Resident #1 had been bothering HK A and the ADON had informed the ADM about the matter. The ADON said he/she was hanging around Resident #1 during his/her shifts to keep the resident away from HK A. The ADON did not say how Resident #1 got his/her phone number, or how the resident had an explicitly sexual text conversation with the ADON's personal cell number. The ADON denied the relationship. The ADON did not confirm his/her statements in the investigation about drugs in the facility. During an interview on 03/25/26 at 1:00 P.M., the AM said he/she observed Resident #1 outside in the back of the building, smoking what appeared to be marijuana. The AM said after informing the ADM, they entered the resident's room and found marijuana and a bottle of prescription medication of Xanax with the ADON's name on it. Resident #1 told the AM and ADM the ADON had given him/her the medication. During an interview on 03/23/26 at 1:30 P.M., Resident #1's Guardian (PA) said he/she wanted the resident to get therapy due to this mess. The PA said Resident #1 has a history of substance abuse and the facility should have protected him better. During an interview on 03/23/26 at 3:20 P.M., the DON said all the staff had been trained upon hire and there had been continual in-servicing on abuse and neglect. 2. The facility did not provide a policy on residents riding in staff personal vehicles or staff consuming marijuana with residents. Review of the facility's investigation dated 03/18/26, regarding the ADON offering pills for sexual favors, identified the following:- A statement from HK A, regarding any knowledge of Resident #1 owning or doing drugs, showed he/she was not aware of the relationship with the ADON, but had witnessed Resident #1 and the AD riding in a vehicle together and consuming marijuana;-No other investigation as to Resident #1 riding in the AD's vehicle while consuming marijuana or the AD driving while under the influence. During an interview on 03/23/26 at 11:00 A.M., the ADM said all staff were asked to write a statement for the situation regarding the ADON giving residents his/her Xanax. HK A wrote a statement saying the AD asked him/her to accompany him/her to the local store. When HK A got in the AD's personal vehicle, Resident #1 was in the front seat. HK A wrote the AD took them to a local dispensary first and went in and got marijuana to smoke in the car. The AD and Resident #1 smoked the marijuana in the car. The AD drove the car from the dispensary to the store while smoking the marijuana. The ADM said he had authorized the AD to take Resident #1 to the store but did not contact the Guardian for permission prior to and did not know any drugs were going to be purchased. The ADM said he would not have known about it, except HK A wrote it in a statement. During an interview on 03/23/26 at 11:40 A.M., Resident #1 said he/she had consumed marijuana with the AD and had made a deal to trade his/her prescribed Ambien (a medication used to promote sleep) for the costs. The resident said it was possible to purchase and consume marijuana at the facility. Resident #1 said he/she is a drug addict and if offered drugs will consume them. During an interview on 03/25/26 at 12:15 P.M., HK A said the AD told him/her to accompany him/her to the store to help with shopping. Resident #1 was in the AD's car. The AD told HK A the ADM had allowed the resident to go on the outing. The AD drove straight to the local dispensary from the facility. HK A said the AD and the resident went into the dispensary and came out with a purchase. The AD and the resident consumed the marijuana while in the vehicle and driving to the store. HK A said during the drive to the store, the AD told the resident that Resident #1 had to pay the AD back for the marijuana with an Ambien. Resident #1 agreed. HK A said he/she did not witness the exchange. HK A said he/she did not report the AD and Resident #1 sharing the marijuana, because he/she didn't know he/she was supposed to. HK A said he/she did not remember being told to report residents and staff doing drugs but confirmed his/her signature on the onboarding documents. During an interview on 03/23/26 at 1:30 P.M., Resident #1's PA said he/she wanted the resident to get therapy due to this mess. The PA said no one contacted him/her for permission for Resident #1 to leave the building with the AD in her personal car. He/she had not been aware of the resident going in a private vehicle with staff and consuming drugs. He/she would have expected the staff to have the resident's best interest at the forefront and to notify him/her prior to any outing. Allowing a person with a history of substance abuse and poor decision-making abilities access to drugs could have been detrimental to the resident. Allowing a staff member to drive a resident while under the influence of drugs could have been fatal for everyone. During an interview on 03/26/26 at 2:50 P.M., the facility physician said he/she does not recommend the use of marijuana with the residents due to the other medications the residents are taking. There would be a possibility of dangerous side effects and other problems, and it is not federally legal. The doctor said it is also a serious problem to enable a resident with a history of substance abuse to use again. It could be a huge setback in recovery. He/she said the staff member that had driven while under the influence was dangerous. At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO2809436

Based on observation, interview and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of food-borne illness. This had the potential to affect all residents. The facility census was 92.Review of the facility's Dietary Equipment Operations and Sanitation Policy, last reviewed 02/02/24, showed:-The Dietary Manager shall record all cleaning and sanitation tasks for the Dietary Department;-The dietary employee should complete the tasks assigned for the day shift;- All surfaces and equipment shall be washed in sanitizing solution;-Tray carts, dish carts, and utility carts should be washed after each meal, using sanitizing solution and a clean cloth;-Clean grill surface with grill stone and diluted degreaser or grill cleaner after each use;-Rinse thoroughly with water;-Wash with mild soap and water, then rinse with water;-Wash back and side guards with soap and water;-Clean counters with mild detergent and water;-Dust, mop, or sweep floors;-Mop floors with cleaning agent and warm water, according to directions on the label.The facility did not provide a policy for food storage.Observation on 08/04/25 at 11:50 A.M. showed:-Coffee counter with debris, opened sweetener packets and an opened water bottle;-Work shelf and counter with a fragment of foil, two empty soda bottles sitting next to trays of clean coffee mugs;-A three-tiered cart with debris and a personal, reusable drinking cup with a straw/lid.Observation on 08/04/25 at 11:55 A.M. of the refrigerator showed:- A box with 12, 32 ounce (oz) cartons of apple juice with no dates;- A box with 14, 32 oz cartons of apple juice with no dates;-One gallon plastic resealable bag of opened cheese slices, not labeled or dated;-A box of four, unopened, four-pound sliced cheese packages with no expiration dates;-A box of two, unopened, four-pound sliced cheese packages with no expiration dates;-Three, unopened five-pound bags of shredded cheese, package date of 5/02/25, with no expiration date; -One opened five-pound bag of shredded cheese in a plastic resealable bag with no date;-Three, unopened, five-pound packages of shredded cabbage and carrots, with a best if used by date of 07/24/25;-Four, unopened, five-pound packages of shredded cabbage and carrots, with a best if used by date of 07/23/25.Observation on 08/04/25 at 12:15 P.M. showed:-The Prep counter with debris, ink pen lids, and paper clips;-A tray with four paper wrapped straws, a penny, a strand of hair, and three thermometers with no caps.Observation on 08/04/25 at 12:18 P.M. showed:-The cereal/utensil counter with debris, several sweetener packets, paper clips, and wadded pieces of paper;-The floor with debris, sweetener packets, and salt/pepper packets;-Cooking stove with black grease and grime, food particles and back splash with thick brown/black splatter;- A metal tray cart sitting next to the stove with a butter wrapper and a soiled knife on it.During an Interview on 08/04/25 at 12:20 P.M., the Dietary Manager (DM) said he/she started as the DM the first part of July and took classes online. He/She goes by first in and first out with the use of stored food. The food is marked with date item arrived and when it expires. Refrigerated items should be used by the end of the week received. Observation of the freezer on 08/04/25 at 12:46 P.M. showed:-An opened bag of hash rounds with no label and no expiration date;-Two unopened ten-pound bags of frozen diced potatoes with an expiration date of 07/05/25;- Four unopened large bags of frozen diced peppers and onions, unknown weight, with expiration dates of 09/30/24.Observation on 08/05/25 at 10:25 A.M. showed:- Cereal counter with cereal debris, a scoop lying on the counter, paper clips, and two dietary cards;- Work counter, above the container storage area, with a tray containing paper clips and uncapped thermometers;- On the counter below, a packet of thickener, two serving spoons, a personal drinking cup with lid and straw, six dietary cards, and a used plastic sandwich bag.Observation on 08/05/25 at 10:40 A.M. showed the refrigerator with four, unopened, five-pound packages of shredded cabbage and carrots, with best if used by date of 07/23/25.During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing said they would expect the kitchen to be clean, floors, counters, and stove to be clean and free of grime, the refrigerator and freezer to be free from expired items, and food labeled with dates.

Based on interview and record review, the facility failed to ensure a Certified Background Check (CBC), the Employee Disqualification List (EDL) and Nurse Aide (NA) Registry were checked prior to the employment start date for six employees out of the ten sampled employees. This deficient practice had the potential to affect all residents. The facility census was 92.Record review of the facility's policy titled, Screening-Applicant, Employee, Volunteer and Vendor (Missouri), revised on 06/12/25, showed: - Pre-employment screening; Human Resources Department (HR) will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any federal or state healthcare programs, is eligible to work in the United States, and if applicable is duly licensed or certified to perform the duties of the position for which they applied;- Applicants shall complete a request for criminal records check and request for consent to employee disqualification check form. Human Resources staff will conduct the following screens on potential employees prior to hire;- The results of each background check must be maintained in the applicant's file;- Using the request for criminal records check, a criminal background check should be done through the Missouri Highway Patrol's Missouri Automated Criminal History Site. If a check is made through the Family Care Safety Registry showing the applicant is registered and a no finding letter is received and printed, that will satisfy the Missouri Criminal background check requirement, and no check needs to be done with the Missouri Highway Patrol;- No applicant may begin work until the criminal background check is completed unless otherwise approved by the Reliant Care Management Company, LLC (RCMC) executive director of Human Resources;- The Certified Nurse Aide (CNA) registry must be checked on all applicants regardless of position for which they are applying. Any applicants listed with background problems, or a federal indicator may not be hired for any position; - RCMC and the facilities it manages will periodically conduct a background check of existing employees to determine whether the employee is an excluded provider of any federal or state healthcare programs and if applicable is duly licensed or certified to perform the duties of the position.1. Review of Employee B's personnel file showed:- Hire date of 10/16/24;- The facility failed to check the CBC, EDL and Nurse Registry until 10/21/24.2. Review of Employee C's personnel file showed:- Hire date of 01/31/25;- The facility failed to check the CBC, EDL and Nurse Registry. 3. Review of Employee D's personnel file showed:- Hire date of 09/02/24;- The facility failed to check the NA registry.4. Review of Employee E's personnel file showed:- Hire date of 12/03/24;- The facility failed to check the CBC, EDL and Nurse Registry until 03/06/25.5. Record review of Employee F's personnel file showed:- Hire date of 10/10/24;- The facility failed to check the CBC until 08/06/25.6. Review of Employee G's personnel file showed:- Hire date of 12/03/24;- The facility failed to check the CBC, EDL and NA registry until 03/26/25.During an interview on 08/07/25 at 5:15 P.M., the Administrator said that Employee C, Employee E and Employee F did not have an updated CBC, EDL, NA registry check since their hire dates. She said that when an applicant fills out an application, they send off for the background checks that day, and that last week you could get in the queue and print off the information, and this week they are 4 days behind on processing and the checks aren't able to be printed off. She also said NA registry checks are done only on Certified Nurse Aides (CNAs) and Certified Medication Technicians (CMTs) and run through Training Management and Updated (TMU). She said corporate did a complete audit of background checks in April 2025.During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect all employees to have a CBC/EDL and NA registry check completed before hire.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 92.Review of the facility’s policy titled, “Environmental Rounds”, revised on 06/29/23, showed: - Environmental rounds are to be done daily by the Department Heads; - The Department Head should be inspecting the room for potentially hazardous items and any areas that may not be in compliance with state and federal guidelines; - Environmental rounds include the resident rooms, drawers and bathrooms. Staff will look for items during these rounds which pose a possible risk to residents and/or staff. Review of the facility's Safe and Homelike Environment Policy, last reviewed 06/05/24, showed: - In accordance with resident rights, the facility will provide a safe, comfortable and homelike environment; - The facility will create and maintain, to the extent possible, a home-like environment that deemphasizes the institutional character of the setting; - Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment; - Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms in need of cleaning to the Housekeeping Department; - Even light levels should be utilized in common areas and hallways to avoid patches of low light; - Report any furniture in disrepair to maintenance promptly; - Report any unresolved environmental concerns to the Administrator. Observation on 08/04/25 at 1:45 P.M., of room [ROOM NUMBER] showed a sign on the mirror which read out of order. The sink was half-filled with dark brown water, the area around the sink was stained with a brown substance, the cabinet underneath had chipped paint and rusted areas, and the extra bed in the room was unmade- exposing a mattress with black grime and stains. Observations on 08/05/25 at 10:15 A.M., 08/06/25 at 9:02 A.M., and 08/07/25 at 5:18 P.M. showed the entire length of the 100-hall floor sticky to walk on. Observation on 08/05/25 at 10:15 A.M., of the shower room located on the 100-hall, across from room [ROOM NUMBER], showed: - Lighting in the room dim; - All floor corners had a buildup of brown debris and grime; - Shower floor made of approximately 2 inch by 2 inch tiles with grout in between the tiles covered in a black, grimy substance; - Shower walls made of approximately 4 inch by 4 inch tiles with grout and caulk covered in a black, grimy substance; - Wall shelf in the shower with grout and caulk covered in a black, grimy substance; - Orange-stained caulk in the back right and left sides of the back wall; - The shower room floor with brown streaks; - Toilet with the seat in the upright position, splattered with a brown substance underneath the lid and in the bowl; - No toilet paper on the holder or in the vicinity; - Toilet assist bars covered in a grayish grime; - A large, white PVC (polyvinyl chloride-a thermoplastic material) pipe shower chair with a toilet seat with the right front wheel bent and leaning inward and all four legs taped together with white tape; - A metal/plastic shower bench chair with the left legs taped together. Observation on 08/05/25 at 10:22 A.M. of the 100-hall shower room with tub, across from room [ROOM NUMBER] showed: - A bathtub with dirt and debris, a pair of gloves, a bench shower chair, adjustable grab bar, and the water spigot broken off and lying in the tub; - Flooring grout/caulk covered in a black, grimy substance; - A toilet with dried brown substance on the toilet seat; - No toilet paper on the holder or in the vicinity; - Toilet hat lying on the floor, behind the toilet; - Privacy curtain in the toilet area worn, missing hooks at the top, drooping down on both upper right and left sides, with the bottom of the curtain tied up in a knot; - Shower floor tiles approximately 2 inch by 2 inch squares with a black, grimy substance covering the grout/caulk; - Three cracked shower floor tiles by the drain, two tiles missing by the drain and one tile missing from the right rear area of the shower; - A brown-stained area on the right side of the drain; approximately nine tiles across and six tiles wide; - Shower head lying on the shower floor with no holder for the shower head. Observation on 08/07/25 at 9:45 A.M. of the shower room on 100-hall, across from room [ROOM NUMBER], showed: - Shower room and shower floor with a black, grimy substance covering grout/caulk throughout; - Soiled clothes, a sheet, and towel lying on the shower room floor; - A wet washcloth lying in the corner on the wall shelf; - Black debris in the floor corners of the toilet area, water behind the toilet, and a red/brown tinged gauze dressing lying on the floor beside the toilet; - A toilet brush sitting on the floor in a clear solution; - Three wire hangers lying on a shower chair. Observation on 08/07/25 at 9:52 A.M. of the shower room with tub on 100-hall, across from room [ROOM NUMBER] showed: - Shower room and floor caulk/grout covered in a black, grimy substance throughout; - A washcloth with a dried red/brown substance lying on the shower room floor; - A soiled towel laying in the corner of the shower room floor; - A towel with a brown substance lying on the shower chair; - A worn privacy curtain worn with missing hooks and tied up at the bottom; - A toilet hat lying on the floor behind the toilet. Observation on 08/07/25 at 10:00 A.M. of the male restroom labeled 100-15 showed: - A toilet with a black, grimy substance inside the toilet bowl, around the toilet area and the surrounding floor; - The floor covered in a sticky substance with brown, grimy footprints throughout; - A sink with brown grime and stains. Observation on 08/07/25 at 5:45 P.M. of Room124 showed a section of wall with two pieces of broken tile, approximately three by five inches, by the entryway. During an interview on 08/04/25 at 12:15 P.M., Resident #72 said that he/she was afraid to use the shower room because the floor was all busted up. During an interview on 08/04/25 at 12:20 P.M., Resident #18 said the shower rooms were dirty, soap dispensers were not filled and trash cans were full and overflowing. During an interview on 08/07/25 at 9:45 A.M., Housekeeper B said shower rooms are cleaned every day in the 100 hall area, and up front they are cleaned every other day. Housekeeper B said he/she takes out the trash, sprays a disinfecting spray, wipes down surfaces and cleans the floors and used air freshener. Housekeeper B said he/she has a scrubber and scraper to clean the black grime from the floor and grout. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect resident rooms to represent a home like environment, to be clean and odor free, and to be repaired as needed. They said they would expect shower rooms to be clean, toilets to be free of stains, showers and floors to be free of black, grimy substances and cracked tiles to be repaired or replaced. They would expect shower chairs to be in good working order and not taped together. They expect hallway grout to be clean and the tiles to be level.

Based on interview and record review, the facility failed to maintain a surety bond (a purchased bond for security of residents' personal funds) sufficient to ensure the protection of resident funds. The facility census was 92.Review of the facility's Resident Trust policy, last reviewed 06/12/25, showed:-The facility shall allow residents to access personal possessions and funds during regular business hours, Monday through Friday;-The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed;-The facility shall provide assurance of financial security by means of a surety bond. The bond shall be in an amount equal to at least one and one-half times the average total of the reconciled monthly balances. A copy of current bond shall be kept in a file in the facility by the Resident Trust Clerk.Review of the residents' personal funds account for the period July 2024 through July 2025 showed an average monthly balance of $40,973.07. An average monthly balance of $40,973.07 rounded to the nearest thousand equaled $41,000.00, at one- and one-half times will equal the required bond amount of at least $61,500.00.Review of the facility's current surety bond, effective 05/06/25, showed the facility held a bond in the amount of $50,000.00, which was insufficient by $11,500.00. During an interview on 08/07/25 at 8:25 P.M., the Administrator said the surety bond amount should be one-and one-half times the amount of the resident trust balance to meet the regulatory requirement. She said corporate was in the process of increasing the bond to $100,000.00.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care and failed to implement enhanced barrier precautions (EBP) during perineal care (peri care-the cleaning of the genitals and anus of the body) and foley catheter (a small flexible tubing inserted into the bladder to drain urine) care for one resident (Resident #78) out of one sampled resident. The facility census was 92.Review of the facility’s policy, “Enhanced Barrier Precautions”, revised on 05/18/24, showed: - It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention and transmission of multidrug-resistant organisms; - These are precautions used with all residents, such as hand hygiene, cleaning equipment, proper injection procedures, disposing of sharps, etc. Personal Protective Equipment (PPE) is used as part of standard precautions where there is an expectation of possible exposure to infectious material; - EBP is a strategy in nursing homes to decrease transmission of CDC-targeted and epidemiologically important MDROs when contact precautions do not apply; - EBP (gown and gloves) must be used for high-contact resident care activities for residents with any of the following: infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO; - EBP should be considered for high-contact resident care activities for residents with any of the following: infection or colonization with a non-CDC targeted MDRO when contact precautions do not otherwise apply; - High contact resident care activities include, but are not limited to, dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, indwelling device care or use, or wound care. - Wounds that require EBP are chronic wounds, including, but not limited to, pressure ulcer, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. These are wounds that generally require a dressing. Any wound care requires EBP; - Indwelling medical devices include, but are not limited to, central lines, urinary catheters, feeding tubes, and tracheostomies; - Make gowns and gloves available immediately near or outside of the resident’s room. Note: face protection may also be needed if performing activities with the risk of splash or spray (i.e., wound irrigation, tracheostomy care); - Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room); - Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room; - The facility infection control preventionist is responsible for the enforcement of this policy. 1. Observation on 08/07/25 at 10:35 A.M., of Resident #78’s peri and Foley catheter care showed: - Certified Nurse Aide (CNA) O entered the resident’s room and did not put on gloves and a gown; - CNA O performed hand hygiene, placed a trash bag at the end of the bed, and lowered the resident’s blankets; - CNA O performed hand hygiene, put on gloves, cleaned the resident’s peri area, did not change gloves, did not perform hand hygiene, and cleaned the Foley catheter from the insertion point down the tubing; - CNA O did not change gloves, did not perform hand hygiene, and rolled the resident onto his/her right side; - CNA O did not change gloves, did not perform hand hygiene, obtained a clean wipe from the container and cleaned the right buttock, did not perform hand hygiene, did not change gloves, obtained a clean wipe from the container and cleaned the left buttock, did not perform hand hygiene, did not change gloves, obtained a clean wipe from the container and cleaned the rectal area, did not perform hand hygiene, and did not change gloves; - CNA O changed gloves and performed hand hygiene; - CNA O placed a clean incontinent pad under the resident and rolled the resident back onto his/her left side; - CNA O removed the used pad from underneath the resident; - CNA O changed gloves, did not perform hand hygiene, pulled the blanket up around the resident’s shoulders, removed gloves, performed hand hygiene, and exited the room. 2. Observation on 08/07/25 at 3:00 P.M. of Resident #78’s peri care and wound care showed: - Licensed Practical Nurse (LPN) L entered the resident’s room; - LPN L did not don gown for EBP; - LPN L did not clean and sanitize the bedside table, placed paper towels on the bedside table for a clean barrier, placed calmoseptine (a multi-purpose barrier cream) and boarder foam gauze (a type of dressing) on the clean barrier; - LPN L performed hand hygiene and put on gloves; - LPN L removed the soiled dressing, changed gloves, and did not perform hand hygiene; - LPN L cleaned fecal material from the resident’s buttocks, changed gloves, and did not perform hand hygiene; - LPN L continued to clean additional fecal material from the resident’s buttocks, changed gloves, and did not perform hand hygiene; - LPN L placed a clean incontinent pad under the resident and rolled the resident onto his/her left side; - LPN L removed the incontinent pad soiled with fecal material, arranged the clean incontinent pad, performed hand hygiene, and changed gloves; - LPN L applied calmoseptine to the resident’s buttock wound, changed gloves, and did not perform hand hygiene; - LPN L applied the border foam dressing on the resident’s buttock wound; - LPN L picked up trash from the floor, changed gloves, and did not perform hand hygiene, - LPN L pulled the blankets up around the resident’s shoulders and adjusted the other blankets; - LPN L removed gloves, performed hand hygiene, and exited the room. During an interview on 08/07/25 at 3:15 P.M., LPN L said he/she had never heard of EBP. Supplies should be kept outside the room by the door, and he/she should wash or sanitize his/her hands in between glove changes. During an interview on 08/07/25 at 8:25 P.M., the Director of Nursing (DON) and the Administrator said they would expect staff to sanitize and or wash their hands with glove changes and that they would expect TB assessments to be completed accurately when they are due. The DON said staff should wear EBP when dealing with open wounds, cleaning dirty things such as emptying a foley, during colostomy care, and staff should wear gloves during Foley catheter care.

Based on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures. This deficient practice affected four residents (Resident #10, #16, #47 and #78) out of 19 sampled residents and four residents (Resident #14, #44, #72 and #74) outside the sample, and had the potential to affect all residents in the facility. The facility census was 92. Review of the facility’s Dietary Food Policy, last reviewed 07/05/23, showed: - Meals will be prepared in adequate, yet not excessive amounts for all diets as determined by the current diet census; - The employees with food preparation responsibilities are trained and are able to obtain information from daily menus and determine the proper amount of food required to serve; - Foods will be served at proper temperature to ensure food safety; - Hot foods should be above 135 degrees Fahrenheit (°F), but preferably 160-175°F; - Cold foods should be less than 41 °F; - All salads will be refrigerated until time of service; - All sandwiches will be served at appropriate temperatures. Observation on 08/06/25 of the “Resident’s Choice” lunch meal showed: -Test tray delivered at 12:15 P.M.; -Slice of fresh watermelon, 63.1 °F; -Two, unidentifiable slices of lunchmeat inside a hotdog bun, 61.8 °F; -Penne noodles with broccoli, 78 °F; -Slaw made with mayonnaise, 62.9 °F. Observation on 08/06/2025 at of the dinner meal showed: -Test tray delivered at 5:00 P.M.; -Cheese quesadilla, (one thin, dry tortilla with a very small amount of melted, dry cheese) 107 °F; -White rice with cubed tomatoes and corn scattered on top, 120° F; -A piece of chocolate cake with a dry texture topped with chocolate frosting. Observation on 08/07/2025 of the lunch meal showed: -The test tray delivered at 11:55 A.M.; -Five, one-inch in diameter meatballs with sauce, 97.3 °F; -A one-half cup serving of plain mashed potatoes,113 °F; - Approximately one-fourth cup of green beans, 91.2°F; - Approximately one cup of canned peaches, 61.3 °F. During an interview on 08/04/25 at 11:55 A.M., Resident #72 said the food is cold, every single time at every meal. During an interview on 08/04/25 at 12:00 P.M., Resident #10 said the food is not good, and is always cold. During an interview on 08/04/24 at 12:08 A.M., Resident #14 said the food is not good, it's always cold and it's the same thing every day. During an interview on 08/04/25 at 12:12 P.M., Resident #16 said the food is trash, the meat is tough, and the meals are not real meals, the portions are small. The resident said he/she doesn't eat at the facility very often, he/she buys his/her own food. During an interview on 08/04/25 at 12:15 P.M., Resident #44 said the food is terrible and bland. During an interview on 08/04/25 at 12:20 P.M., Resident #74 said the food is the worst, the chicken is always so hard, you can't even cut it up. During an interview on 08/04/25 at 2:05 P.M., Resident #78 said food is questionable and had no taste. During an interview on 08/04/25 3:30 P.M., Resident #47 said for the last three months, it had seemed they were getting smaller portions. During an interview in Resident Council on 08/05/25 at 1:13 P.M., the residents collectively said sometimes the food is good and sometimes it's not. Examples included, dietary staff not using real eggs, cold French fries, and other items and melted ice cream. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) said they would expect food to be palatable and within the appropriate temperature range.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent, when medications were administered. There were 27 opportunities with three errors made, for an error rate of 11.11%. This affected one resident (Resident #2) out of 19 sampled residents and one resident (Resident #27) outside the sample, with the potential to affect all residents. The facility census was 92.Review of the facility's policy, Administration of Insulin, revised on 05/14/24, showed:- All insulin will be administered in accordance with physician's orders;- Procedure: Review the insulin order; resident name, medication name, medication dosage, time to be administered, and route of administration, perform hand hygiene, prepare insulin dose, explain procedure and provide privacy, administer insulin at appropriate times, document on the medication administration; record the time and location of the insulin injection;- Insulin pens contain multiple doses of insulin but are used for a single resident only;- Procedure: Gather supplies, perform hand hygiene, don gloves, verify resident, examine the appearance of the insulin, attach pen needle, prime the insulin pen-dial two units by turning the dose selector clockwise, with the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle, if not repeat until at least one drop appears, set the insulin dose, inject the insulin, remove gloves and perform hand hygiene, document the dosage, site and time in the medication record along with nurse signature, document any teaching, and/or demonstrations done when planning for discharge.Review of Humalog insulin pen (insulin in a pen-type device) directions showed:- Remove cap;- Attach needle:- Prime pen by turning dose selector to select two units;- Press and hold button to make sure drop of insulin appears;- Select dose;- Give injection;- After dose counter reaches zero, count to five;- After injection, remove needle and place in sharps container. 1. Observation on 08/06/25 at 11:35 A.M. showed:- Certified Medication Technician (CMT) M obtained the finger stick blood sugar for Resident #27;- CMT M obtained the insulin Humalog insulin pen from the medicine cart and adjusted the pen to the amount of insulin ordered;- CMT M did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident. 2. Observation on 08/06/25 at 11:45 A.M. showed:- CMT M obtained the finger stick blood sugar for Resident #2;- CMT M obtained the Humalog insulin pen from the medicine cart and adjusted the pen to the amount of insulin ordered;- CMT M did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident. 3. Observation on 08/06/25 at 11:50 A.M. showed:- CMT M administered a second dose of Humalog insulin to Resident #2;- CMT M did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident. During an interview on 08/06/25 at 1:46 P.M., CMT M said he/she never knew to prime insulin pens before administering insulin and did not know that was a thing, but will from now on. He/She is insulin certified.During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said that they would expect insulin pens to be primed prior to insulin administration.

Based on observation, interview, and record review, the facility failed to assess residents for the risk of entrapment and review possible risks and benefits of bed rails prior to installation or use. The facility also failed to obtain informed consent from the resident and/or the resident's representative for two residents (Resident #80 and #101) out of 19 sampled and for two residents (Resident #46 and #74) outside the sample. The facility census was 92. Review of the facility's Proper Use of Bed Rails policy, last reviewed on 06/26/25, showed: - If bed rails are used, the facility will ensure correct installation, use and maintenance of the bed rails; - As part of the comprehensive assessment, components will be considered when determining the resident’s needs and whether the use of bed rails meets the needs; - Components include: medical diagnoses, size/weight, medications, surgical interventions, existence of delirium, cognition, mobility, fall risk and ability to toilet self safely; - Resident assessment must include an evaluation of the alternatives that were attempted prior to installation or use of bed rail, and how alternatives failed to meet resident’s assessed needs; - The resident assessment must also assess the resident’s risk from using bed rails; - The resident assessment should assess the resident’s risk of entrapment between the mattress and bed rail or in the bed rail itself; - The facility will assess to determine if the bed rail meets the definition of a restraint; - Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails; - The facility will assure correct installation and maintenance of bed rails prior to use, which includes bed rails, mattress and bed frame compatibility, appropriate bed dimensions, installing rails as per manufacturer’s instruction and specifications to ensure proper fit, ensure bed frame, bedrail and mattress do not leave a gap wide enough to entrap a resident’s head or body and checking bed rails regularly; - Conduct routine preventative maintenance on beds and bed rails to ensure they meet current safety standards and are not in need of repair. Review of the facility’s “Bed Maintenance and Inspection” policy, last reviewed 05/14/24, showed: - The Maintenance Director, or designee, will be responsible for keeping records of bed inspections and maintenance; - A list of bed frames, mattresses and bed rails will be maintained, including the manufacturer of each; - Bed rails shall be securely and properly installed according to manufacturer’s requirements; - Bed frame, mattress and bed rail inspections will be conducted upon each item entering facility and placed on a regular scheduled inspection and maintenance cycle according to manufacturer’s recommendations and time frame. Review of the Federal Drug Administration (FDA) documents titled, “Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts,” showed the potential risks of bed rails may include: - Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; - More serious injuries from falls when patients climb over rails; - Skin bruising, cuts, and scrapes; - Inducing agitated behavior when bed rails are used as a restraint; - Feeling isolated or unnecessarily restricted; - Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. 1. Review of Resident #46’s electronic medical record showed: - admitted on [DATE]; - Diagnoses of abnormal posture, muscle weakness, other lack of coordination, abnormalities of gait (the pattern of how someone walks) and mobility and unspecified osteoarthritis (joint inflammation that occurs when the flexible tissue at the ends of bones wear down); - No documentation of a signed consent form explaining the risks and benefits of bed rail use; - No documentation of a completed entrapment assessment. Review of the resident’s care plan, last revised 03/03/25, showed: - Bed rail use not care planned; - Impaired mobility, impaired activities of daily living (ADLs). Observations of the resident on 08/04/25 at 12:22 P.M. and on 08/07/25 at 5:05 P.M. showed the resident in bed with a half bed rail up on the left, upper side of the bed. 2. Review of Resident #74’s electronic medical record showed: - admitted on [DATE]; - Diagnoses of encephalopathy (any brain disease that alters brain function or structure), and tremors (involuntary rhythmic and shaking of body parts, often occurring due to neurological conditions); - No documentation of a signed consent form explaining the risks and benefits of bed rail use; - No documentation of a completed entrapment assessment. Review of the resident’s care plan, revised on 02/04/25, showed: - Bed rail use not care planned; - Ambulatory and performs own activities of daily living (ADLs) with stand by assist and set up assistance as needed. Observation of the resident on 08/04/25 at 12:35 P.M. and on 08/07/25 at 5:35 P.M. showed the resident sitting in a chair in his/her room watching TV with his/her roommate. Half rail up on left side of bed. During an interview on 08/07/25 at 5:35 P.M., the resident said he/she did not use the bed rail and wasn’t sure why it was there. 3. Review of Resident #80’s electronic medical record showed: - admitted on [DATE]; - Diagnoses of failure to thrive (a syndrome of decline characterized by weight loss, decreased appetite, poor nutrition and inactivity), dementia (a group of thinking and social symptoms that interfere with daily living), cognitive communication deficit (difficulty with language comprehension, language expression reasoning attention or memory), muscle weakness; - A physician's order, dated 03/31/25, for half bed rail per resident request; - No documentation of a signed consent form explaining the risks and benefits of bed rail use; - No documentation of a completed entrapment assessment. Review of the resident’s care plan, last revised 03/03/25, showed half side rail to assist with turning and repositioning. Observation on 08/04/25 at 2:15 P.M. showed the resident lying in bed, call light draped around a raised, half rail on the right side of the bed; Observation on 08/07/2025 at 3:17 P.M. showed the resident not in the room, call light draped around a raised, half rail on the right side of the bed. 4. Review of Resident #101’s electronic medical record showed: - admitted on [DATE]; - Diagnoses of psychosis (a mental disorder characterized by a disconnection from reality), schizophrenia (a disorder that affects a person’s ability to think, feel and behave clearly) and chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe); - Side rail assessment completed on 2/24/25, indicated NO side rails; - No documentation of a signed consent form explaining the risks and benefits of bed rail use. Review of the resident’s care plan, last updated 03/04/25, showed half side rail up to assist with turning and repositioning. Observation on 08/04/25 at 2:00 P.M. showed the resident lying in bed with a half rail on the left side of the bed. Observation on 08/07/2025 at 1:05 P.M. showed the resident lying in bed with a half rail on the left side of the bed. The resident said he/she used it to get up and out of bed. The resident grabbed the rail to give an example, and the rail wobbled. The space between the half rail and mattress was approximately six inches and the metal bed frame was larger than the mattress. During an interview on 08/07/2025 at 1:08 P.M., the Administrator acknowledged the gap and said there was a big space, and she would have expected an assessment to assure the handrail was a proper fit, but it had not been done. During an interview on 08/07/2025 at 12:50 P.M., the Maintenance Director said he/she made sure the handrails were maintained but had not done an actual assessment. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect bed rails to have a physician’s order, an accurate and current assessment completed, for bed rails to be assessed and maintained by maintenance and that bed rails should be assessed to ensure that the mattress/bed and bed rail(s) are not posing a hazard.

Based on observation, interview, and record review, the facility failed to obtain orders for continuous positive airway pressure machine (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) settings and tubing changes for one resident (Resident #26) out of one sampled resident with a CPAP and failed to obtain a physician's order prior to oxygen use and orders for nasal cannula (a small, flexible tube that contains two open prongs that sits in the nostrils and attaches to an oxygen source) and humidifier (used to increase the moisture level) changes for one resident (Resident #93) out of one sampled resident with oxygen. The facility census was 92.The facility did not provide a policy.1. Review of Resident #26's medical record showed:- An admission date of 07/08/25;- Diagnoses of paranoid schizophrenia (a mental health condition where a person has strong false beliefs and hears or sees things that aren't real, often feeling suspicious or fearful of others), disorganized schizophrenia (a type of schizophrenia that causes confused speech, unusual behavior, and trouble organizing thoughts), schizoaffective disorder, unspecified (a mental health condition with symptoms of both schizophrenia and a mood disorder, such as depression or mania), manic episodes, severe with psychotic symptoms (periods of extremely high energy, little need for sleep, risky behavior, and possible hallucinations or delusions), congestive heart failure (when the heart can't pump blood as well as it should, causing fluid buildup in the body), borderline intellectual functioning (slightly below-average intelligence that can make learning and daily tasks more difficult).Observation on 08/05/25 at 2:49 P.M. showed the resident with CPAP in his/her room. During an interview on 08/05/25 at 2:49 P.M., the resident said he/she was unsure if the CPAP got cleaned, but the staff fill it up for him/her and it is used every night.Review of the resident's Physician's Order Sheet (POS), dated 07/08/25, showed:- No order for CPAP;- No order to clean CPAP;- No order to clean tubing;- No order for changing of CPAP parts;- No order for CPAP settings.Review of the resident's comprehensive care plan, revised 07/15/25, showed it did not address CPAP, settings, cleaning, changing parts, or tubing. 2. Review of Resident #93's medical record showed:- An admission date of 07/08/24;- Diagnoses of pneumonia, unspecified organism (an infection in the lungs, cause not identified), vitamin B deficiency, unspecified (low levels of vitamin B in the body, exact type not specified), hyperlipidemia, unspecified (high levels of fats or cholesterol in the blood, cause not specified), transient cerebral ischemic attack, unspecified (a short-term mini-stroke where blood flow to part of the brain is briefly blocked, exact cause not identified), unspecified atrial fibrillation, cardiac arrhythmia, unspecified (an irregular heartbeat starting in the upper chambers of the heart, cause not specified), heart failure, unspecified (the heart is not pumping blood as well as it should, cause or type not specified), heart disease, unspecified (a problem with the heart, exact condition not specified), cerebral infarction, unspecified (a type of stroke where part of the brain is damaged due to lack of blood flow, cause not specified), peripheral vascular disease, unspecified (poor blood circulation in the arteries of the arms, legs, or other body parts, cause not specified), chronic obstructive pulmonary disease, unspecified (COPD-a long-term lung disease that makes it hard to breathe, type not specified), dyspnea, unspecified (shortness of breath, cause not specified).Observations showed:- On 08/04/25 at 3:06 P.M., the resident wore oxygen at two liters per minute via nasal cannula with oxygen tubing dated 07/18/25;- On 08/06/25 at 1:03 P.M., the resident wore oxygen at two liters per minute via nasal cannula with oxygen tubing dated 08/01/25. Review of the resident's POS, dated 04/28/25, showed:- No order for oxygen settings;- No order to check oxygen bubbler (humidifier);- An order to change oxygen tubing every Friday and as needed for leakage, contamination, and infection.Review of the resident's comprehensive care plan, revised 07/15/25, did not address oxygen use.During an interview on 08/04/25 at 3:06 P.M., Resident #93 said staff change his/her oxygen tubing monthly.During an interview on 08/06/2025 at 1:03 P.M., Resident #93 said his/her tubing (now dated 8/1/25) was just changed yesterday. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) said they would expect residents with a CPAP to have orders and they should include the settings and how to clean it. The facility had called to get settings as they were not on the discharge paperwork, but had not received a call back. Oxygen tubing should be changed according to orders and be dated appropriately.

Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) tubing and drainage bag was maintained by failing to have orders to properly care for one resident (Resident #39) out of 19 sampled residents. The facility census was 92.The facility did not provide a policy. 1. Review of Resident #39's medical record showed:- admitted on [DATE];- Diagnoses of urinary system disorder, low back pain and hematuria (blood in urine), dysuria (painful or uncomfortable urination), and acute kidney failure (kidneys suddenly cannot filter waste from the blood). Review of the Physician's Order Sheet (POS), dated 08/06/25, showed no orders for an indwelling urinary catheter or catheter care. Review of the resident's annual Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 05/03/25, showed:- Section H0100 checked No for indwelling device;- Section H0300 checked Always for Urinary Continence. Review of the resident's Care Plan, last revised 08/06/25, showed:- Resident has functional mixed bladder incontinence, retention of urine, hematuria and disorder of the urinary system;- Resident will be continent at all times and during waking hours;- Clean peri-area (genital area) with each incontinent episode;- Encourage fluids during the day to promote prompted voiding response;- Establish voiding patterns;- Care Plan did not address indwelling urinary catheter. Observation on 08/04/25 at 1:00 P.M. showed Resident #39 with a urinary catheter (a thin, flexible tubing that drains urine from the bladder) attached to a leg bag while lying in bed. Observation on 08/06/25 at 10:10 A.M., showed Resident #39 resting in bed with urinary catheter attached to leg bag.During an interview on 08/06/25 at 10:10 A.M., Resident #39 said the catheter would hurt at times and he/she has called the ambulance before, but the hospital would just place a new catheter. Resident said he/she would be having surgery on Friday to place a suprapubic catheter (a drainage tube inserted into the urinary bladder through a small incision above the pubic bone). The facility staff had said they couldn't remove the catheter without an order. Staff did not clean it. The resident said he/she was used to doing it on his/her own, but if a new bag was needed, the staff would get one. A gravity bag was used at night and the resident would put it on and take it off every morning. The resident said staff would get the supplies needed and he/she would keep the area clean with wipes. During an interview on 08/06/25 at 10:32 A.M., Licensed Practical Nurse (LPN) L said the resident would not let him/her touch the resident and that the Director of Nursing (DON) would mostly take care of the catheter. The resident avoided LPN L so he/she just made sure it was draining properly by sending another staff in to check. During an interview on 08/06/25 11:01 A.M., the DON said the resident would get frequent urinary tract pain and would tell staff he/she wasn't urinating and would call 911. They had tried the pain clinic but they wouldn't prescribe medications, so the resident wanted to see a new doctor. The resident would wear a leg bag during the day, but if he/she would lay down, the urine would flow back into the tube, so he/she tends to get frequent urinary tract infections (UTI), even though he/she had been educated. The DON said there were no orders for the catheter or catheter care. During an interview on 08/07/25 at 8:25 P.M., the Administrator and DON said they would expect residents with a urinary catheter to have a physician's order and to be care planned appropriately.

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Resident #26, #39, #93, and #101) out of 19 sampled residents. The facility census was 92. Review of the facility's Comprehensive Care Plan Policy, last reviewed 10/31/25, showed:- It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident;- The care plan process will include an assessment of the resident's strengths and needs;- The comprehensive care plan will describe, at minimum, services that are to be furnished to maintain the resident's highest practicable physical, mental and psychosocial well-being;- Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment;- Any specialized services as a result of the Pre-admission Screening and Resident Review (PASARR-a federal requirement that helps to ensure individuals are not inappropriately placed in nursing homes for long-term care) recommendations;- Resident goals for admission, desired outcomes and preference for future discharge;- Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated;- The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS- federally mandated assessment completed by the facility staff) assessment;- The comprehensive care plan will include measurable objectives and time-frames to meet the resident's needs as identified in the comprehensive assessment. 1. Review of Resident #26's medical record showed: - An admission date of 07/08/25;- Diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), morbid obesity (overweight), obstructive sleep apnea (intermittent air flow blockage during sleep) and asthma.- Physician's Order Sheet (POS), dated 08/05/25, showed no orders for Continuous Positive Airway Pressure (CPAP) machine, how to care for it, or appropriate settings;- Care Plan, dated 07/15/25, showed altered respiratory status and breathing difficulty, and did not address CPAP. Review of the resident's admission MDS, dated [DATE], showed:- Section O marked no for oxygen. During an interview on 08/05/2025 at 2:49 P.M., Resident #26 said he/she was unsure if the CPAP gets cleaned, but he/she uses it every night and they fill it up for him/her. 2. Review of Resident #39's medical record showed:- An admission date of 04/26/22;- Diagnoses of urinary system disorder, low back pain and hematuria (blood in urine), dysuria (painful or uncomfortable urination), and acute kidney failure (kidneys suddenly cannot filter waste from the blood).- POS, dated 08/06/25, showed no orders for a urinary catheter or catheter care;- Care Plan, last revised on 08/06/25, did not address indwelling catheter. Review of the resident's annual MDS, dated [DATE], showed:- Section H checked no for indwelling device;- Section H checked always for Urinary Continence. Observation of the resident on 08/04/25 at 1:00 P.M. showed a urinary catheter (a thin, flexible tubing that drains urine from the bladder) attached to a leg bag while lying in bed. During an interview on 8/04/25 at 1:00 P.M., Resident #39 said he/she has had a catheter for a long time, prior to being here, and had always taken care of it.During an interview on 08/06/2025 at 10:10 A.M., Resident #39 said the catheter caused pain, but the facility staff had said the catheter cannot be removed without an order. Staff had never cleaned it, but if he/she needed a new bag, they would get one. He/She uses a gravity bag at night and would put it on and take it off every morning. Resident said he/she rinses the gravity bag and when it started to look cloudy, would ask for another one.During an interview on 08/06/2025 at10:32 A.M., Licensed Practical Nurse (LPN) L said the resident won't let them touch him/her. The Director of Nursing (DON) mostly takes care of the catheter. The resident avoids the LPN so they just make sure it's draining properly by sending another staff member in to check on him/her. During an interview on 08/06/2025 at 11:01 A.M., the DON said she just noticed there were no orders for Resident #39's catheter and there should have been orders for catheter care. 3. Review of Resident #93's medical record showed: - An admission date of 07/08/24;- Diagnoses of dyspnea (difficulty breathing), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block the airflow and make it difficult to breathe) and heart disease;- POS, dated 08/06/25, showed no order for oxygen; - Care Plan did not address oxygen. Review of the resident's annual MDS, dated [DATE], showed Section O marked no for oxygen.Observation of the resident on 08/04/2025 at 3:06 P.M. showed oxygen at two liters per minute via nasal cannula and dated 07/18/25.During an interview on 08/06/2025 at 1:03 P.M., Resident #93 said his/her tubing (now dated 08/01/25) was just changed yesterday. 4. Review of Resident #101's medical record showed:- An admission date of 02/24/25;- Diagnoses of psychosis (a mental disorder characterized by a disconnection from reality), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and COPD;- POS, dated 8/07/25, showed no orders for side rails;- Side rail assessment completed on 2/24/25 and indicated no side rails.Review of the resident's care plan, dated 03/04/25, showed side rails not addressed.Observation on 08/04/25 at 2:00 P.M., showed the resident lying in bed with half side rail up on the left side of the bed.Observation on 08/07/25 at 1:05 P.M., showed the resident with half rail on left side of bed. The space between the bed rail and mattress approximately six inches, and the bed rail wobbled when the resident grabbed it. Metal bedframe observed because the mattress was smaller than the frame. During an interview on 08/07/25 at 1:05 P.M., the resident said he/she used it to get up and out of bed.During an interview on 08/07/25 at 1:08 P.M., the Administrator said he/she would have expected there to be an assessment to assure the handrail was a proper fit, but it had not been done. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing said they would expect care plans to reflect the resident's status and be updated accurately.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff) for five residents (Resident #2, #26, #39, #93 and #96) out of 19 sampled residents. The facility census was 92. Review of the facility's “MDS 3.0, Care Assessment Summary and Individualized Care Plans” policy, last reviewed 11/06/23, showed (The MDS 3.0) is an assessment tool that addresses the wholistic person, including functional status, quality of life, and individual plan of care to address and meet needs of the individual resident. 1. Review of Resident #2's medical record showed: - admission date of 05/15/25; - Diagnoses of Tracheoesophageal Fistula (an abnormal connection between the esophagus and trachea), bipolar disorder (a disorder with episodes of mood swings ranging from depressive lows to manic highs), chronic kidney disease (longstanding disease of the kidneys that leads to kidney failure due to the inability to filter wastes from the blood) and asthma. Review of the resident's Physician's Order Sheet (POS), dated 08/07/25, showed no orders for tracheostomy. Review of the resident's admission MDS assessment, dated 06/09/25, showed Section E marked YES for having a tracheostomy while a resident. Observation on 08/04/25 at 2:20 P.M. showed Resident #2 seated at a table with no tracheostomy. During an interview on 08/05/25 at 12:10 P.M., the Director of Nursing (DON) said they do not have anyone with a tracheostomy (a surgically inserted tube used to maintain an open airway). 2. Review of Resident #26's medical record showed: - admission date of 07/08/25; - Diagnoses of schizophrenia (a disorder that affects a person’s ability to think, feel and behave clearly), morbid obesity (overweight), obstructive sleep apnea (intermittent air flow blockage during sleep) and asthma. Review of the POS, dated 08/05/25, showed: - No orders for Continuous Positive Airway Pressure (CPAP) machine; - No orders for how to care for a CPAP machine or appropriate settings to use. Review of the resident’s admission MDS, dated [DATE], showed Section O marked no for oxygen. Observation on 08/05/25 at 2:49 P.M., showed the resident had a CPAP in his/her room. During an interview on 08/05/25 at 2:49 P.M., the resident said he/she was unsure if the CPAP got cleaned but the staff fill it up for him/her and it is used every night. 3. Review of Resident #39's medical record showed: - admission date of 04/26/22; - Diagnoses of urinary system disorder, low back pain and hematuria (blood in urine), dysuria (painful or uncomfortable urination), and acute kidney failure (kidneys suddenly cannot filter waste from the blood). Observation of the resident on 08/04/25 at 1:00 P.M. showed a urinary catheter (a thin, flexible tubing that drains urine from the bladder) attached to a leg bag while lying in bed. Review of the resident's POS, dated 08/06/25, showed no order for a urinary catheter. Review of the resident’s annual MDS, dated [DATE], showed: - Section H checked no for indwelling device; - Section H checked always for Urinary Continence. 4. Review of Resident #93's medical record showed: - admission date of 07/08/24; - Diagnoses of dyspnea (difficulty breathing), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block the airflow and make it difficult to breathe) and heart disease. Observation of the resident on 08/04/25 at 3:06 P.M., showed oxygen at two liters per minute via nasal cannula and dated 07/18/25. During an interview on 08/06/25 at 1:03 P.M., Resident #93 said his/her tubing (now dated 8/1/25) was just changed yesterday. Review of the resident's POS, dated 08/06/25, showed no order for oxygen. Review of the resident's annual MDS assessment, dated 07/03/25, showed Section O marked no for oxygen. 5. Review of Resident #96's medical record showed: - admission date of 06/03/25; - Diagnoses of dementia (a group of thinking and social symptoms that interfere with daily functioning), Parkinson's disease (a disorder of the central nervous system that affects movement and often including tremors), Alzheimer's (a progressive disease that destroys memory and other important mental functions), disorientation (a state of confusion), and bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's undated, unsigned and incomplete Discharge Recapitulation showed: - Reason for discharge was inappropriate behaviors and elopement risk; - Resident discharged to another facility. Review of the resident's discharge MDS, dated [DATE], showed discharge to hospital with return anticipated. Review of the resident's Progress Notes, dated 07/21/25, showed medication had been given. No discharge notes. During an interview on 08/07/2025 at 6:50 P.M., the Administrator said Resident #96 had been exit seeking, had said something to another resident that had scared them, and it was decided, along with Resident #96’s family member, that he/she should be moved to a different facility and that is what happened. There was no documentation of this. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) said they would expect the MDS to be completed accurately per the RAI manual. During an interview on 08/15/25 at 11:13 A.M., the MDS Coordinator said he/she is at the facility about three to four times a month. When there, the MDSs’ that are due will have the assessment components completed. He/She would expect the MDS to be coded accurately and the Resident Assessment Instrument (RAI-an instrument that helps nursing home staff gather definitive information on resident’s strengths and needs) manual is followed.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing, of a transfer or discharge to a hospital, for four residents (Resident #1, #6, #16 and #65) and failed to complete a discharge summary that included a recapitulation of the resident's stay that consisted of but not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for one resident (Resident #98) out of 19 sampled residents. The facility census was 92.Review of the facility's Transfer/Discharge and Therapeutic Leave Policy, last reviewed on 06/12/25, showed:- Residents sent emergently to the hospital are considered transfers because the resident's return is generally expected;- Before any resident is transferred or discharged , the facility must notify the resident and the resident's representative, the reason for transfer or discharge in writing, in a manner they understand;- The written notice shall include reason for transfer, effective date of transfer and location to which resident is transferred or discharged ;- When a resident is transferred to the hospital or other location, the facility must provide to the resident or legal representative, a written copy of the bed hold policy;- When a resident is discharged or transferred, the Interdisciplinary Discharge Summary (recapitulation), must be completed. Review of the Bed Hold Policy, last reviewed 06/12/25, showed:- When resident is discharged to the hospital or goes on therapeutic leave, the facility will provide to the resident or legal representative, a copy of the bed hold policy;- If a resident was transferred with the expectation of returning to the facility and the resident cannot return, the facility must follow requirements for a discharge. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and returned to the facility on [DATE];- No documentation that written notification was provided to the resident and/or the resident representative at the time of transfer. During an interview on 08/07/25 at 10:33 A.M., the Director of Nursing (DON) said a transfer and bed hold had not been sent because resident went out as an emergency. 2. Review of Resident #6's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and had not yet returned on 08/07/25;- No documentation that written notification was provided to the resident and/or the resident's representative at the time of transfer. During an interview on 08/07/25 at 7:07 P.M., the DON said there was not a bed hold/transfer sheet completed for the resident. 3. Review of Resident #16's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned to the facility on [DATE];- No documentation that written notification was provided to the resident and/or the resident's representative at the time of transfer. 4. Review of Resident #65's medical record showed: - admitted on [DATE];- Transferred to the hospital on [DATE] and returned to the facility on [DATE];- No documentation that written notification was provided to the resident and/or the resident's representative at the time of transfer. 5. Review of Resident #98's medical record showed:- admitted on [DATE];- discharged home on [DATE], as therapy goals had been met;- No recapitulation of stay. During an interview on 08/07/25 at 1:15 P.M., the DON said she is not sure who was responsible for the bed holds, transfers and discharges since the new owners took over. During an interview on 08/07/25 at 8:25 P.M., the Administrator and DON said they would expect a notification of transfer and bed hold to be given to the resident and/or resident's representative in writing when discharged to the hospital. The discharged residents should have a recapitulation of stay along with a progress noted completed with the reason for discharge.

Based on interview and record review, the facility failed to follow appropriate discharge procedures by not completing a discharge recapitulation or documentation of the reason for discharge by the physician for one resident (Resident #96) out of three closed record reviews. The facility census was 92. Review of the facility's Transfer/Discharge, Immediate Discharge and Therapeutic Leave policy, last reviewed 06/12/25, showed:- The facility may discharge or transfer a resident if needs can not be met;- Resident no longer needs the service provided by facility;- The safety of individuals in facility is or would be endangered;- The resident failed, after reasonable and appropriate notice, to pay for stay at facility;- The facility ceases to operate;- When resident is transferred or discharged due to welfare and needs can not be met or health has improved, the attending physician must document in medical record, the reason for transfer/discharge, specific needs the facility could not meet, specific services the receiving facility will provide to meet those needs;- When resident is transferred or discharged due to safety or health of individuals in facility being endangered, a physician must document the reason for transfer and discharge;- When a resident is discharged or transferred, the Interdisciplinary Discharge Summary (recapitulation) must be completed. Review of Resident #96's medical record showed:- admission date of 06/03/25;- Diagnoses of dementia (a group of thinking ad social symptoms that interfere with daily functioning), Parkinson's disease (a disorder of the central nervous system that affects movement and often including tremors), Alzheimer's (a progressive disease that destroys memory and other important mental functions), disorientation (a state of confusion), and bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the undated, unsigned and incomplete Discharge Recapitulation showed:- Reason for discharge was inappropriate behaviors and elopement risk;- Resident discharged to another facility. Review of the resident's Progress Notes on 07/21/25 showed medication had been given. No discharge notes. Review of the discharge Minimum Data Set (MDS-a federally mandated assessment completed by the facility), dated 7/22/25, showed discharge to hospital with return anticipated. During an interview on 08/07/2025 at 6:50 P.M., the Administrator said Resident #96 had been exit seeking, had said something to another resident that had scared them, and it was decided, along with Resident #96's family member, that he/she should be moved to a different facility and that is what happened. There was no documentation of this. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) said they would expect a recapitulation of stay to be completed and a progress note to be completed at the time of discharge.

Based on interview and record review, the facility failed to ensure that residents' code statuses were listed in the chart, care planned and up to date with the most accurate information for four residents (Resident #1, #16, #65 and #101) out of 19 sampled residents. The facility census was 92.Review of the facility’s policy, “Advanced Directives-Missouri, revised on [DATE], showed: - Individuals have the right to make decisions concerning their care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives as permitted under state statutory and case law; - It is the policy of this facility to follow the directions given by each resident with regard to accepting or refusing medical or surgical treatment to the extent permitted by law; - At the time of admission as a resident of the facility, the resident or their legal representative will be provided with information on Advance Directives; - There shall be documented in the resident’s medical record whether the resident has executed any advanced directives, and copies shall be made a permanent part of the resident’s medical record; - The resident’s attending physician shall be timely notified by the Director of Nursing (DON) or designee if the resident has any advanced directives and requested to write appropriate orders; - If a resident is being readmitted to the facility as a resident, and previously provided copies of advance directives, they shall be verified as being current to this admission; - It is the responsibility of the Administrator to review the advance directives of each resident and to instruct all employees of the facility with regard to each resident’s advanced directives and any related physician’s orders. 1. Review of Resident #1's medical record showed: - admitted on [DATE]; - The Physician's Order Sheet (POS), with an order, dated [DATE], for Full Code; - Care Plan, last revised, [DATE], with Do Not Resuscitate (DNR-revive from potential or apparent death) interventions; - A full code status sheet signed on [DATE]. 2. Review of Resident #16’s medical record showed: - admitted on [DATE]; - No code status listed next to the resident’s name in the facility's online charting system for electronic health records; - No code status listed on the POS, last order review [DATE]; - No code status listed on the care plan, initiated on [DATE] and revised on [DATE]. 3. Review of Resident #65’s medical record showed: - admitted on [DATE]; - No code status listed next to the resident’s name in the facility's online charting system for electronic health records; - No code status listed on the POS, last order review [DATE]; - Full code listed on the care plan, date initiated [DATE], last revised [DATE]. 4. Review of Resident #101's medical record showed: - admitted on [DATE]; - The POS, with an order, dated [DATE], for Full Code; - Care Plan, undated, with DNR interventions; - No signed documentation for code status. During an interview on [DATE] at 5:40 P.M., Licensed Practical Nurse (LPN) L said that code statuses are listed on the POS, on the front screen of the electronic medical record when you search by resident’s name, and in their care plans. He/She also said there is a book with residents’ names and code statuses at the nursing station, but isn’t for sure where it is. During an interview on [DATE] at 5:43 P.M., Certified Medication Technician (CMT) N said code statuses are in the electronic medical record and in a book at the Nurse’s station, but he/she doesn’t know where the book is. During an interview on [DATE] at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect residents to have a code status order and the code status to be documented consistently throughout the chart.