Every finding on record at Truman Healthcare & Rehabilitation Center

Based on interview and record review, the facility failed to provide services per standards of practice when the facility staff did not transcribe an order for a urine analysis (UA - a routine diagnostic test that evaluates the physical, chemical, and microscopic properties of your urine. It is primarily used to screen for kidney disease, liver issues, diabetes, and urinary tract infections (UTIs)) timely, when staff did not obtain a sample for the UA timely, and when staff did not notify the physician or document the reason for the delay in obtaining the UA for one resident (Resident #1) resulting in a\\n eight day delay in obtaining the UA sample. The facility census was 104.Review of the facility's policy titled, Lab and Diagnostic Test Results- Clinical Protocol, dated 11/2018, showed the following:-The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs;-The staff will process the test requisitions and arrange for the tests;-The laboratory, diagnostic radiology provider, or other testing sources will report results to the facility.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed an admission date of 03/27/25. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/24/26, showed the following:-Significant cognitive impairment;-Required moderate assistance for transfers.Review of the resident's Family Nurse Practitioner (FPN) note, dated 04/27/26, showed the following:-Visit type acute/follow-up;-Chief complaint of physical aggression;-The resident has bi-polar disorder and required a follow-up for aggressive behaviors. The resident continued to have aggressive behaviors and wandering behaviors;-Staff Obtain a UA with culture and sensitivity;-Follow-up with the resident on 04/30/26 for review of the results of the UA and see if behaviors have improved.Review of the resident's order form, dated 04/27/26, showed an order for a UA with culture signed by the FNP.Review of the resident's care plan, revised 05/04/26, showed staff did care plan related the ordered UA and follow-up. Review of the resident's FNP note, dated 04/30/26, showed pending UA with culture to investigate potential causes of increased behaviors;Review of the resident's physician order sheet (POS) showed an order, dated 04/30/26, for a UA culture and sensitivity and send to the lab (three days after the initial order.) Review of the resident's April 2026 Treatment Administration Record (TAR) showed the following:-An order, dated 04/30/26, for a UA culture and sensitivity and send to the lab;-Staff noted on 04/20/26, the order was not complete due to resident sleeping; t was sleeping;-Staff did not document any other attempts to obtain the urine sample for the UA.Review of the resident's FNP note, dated 05/04/26, showed the following:-He/she saw the resident for a follow up of the UA results that he/she ordered on 04/27/26 and increased agitation;-Staff had not obtained the UA;-Follow up once UA results are received. Review of the resident's May 2026 TAR showed staff did not document attempts to complete the UA order.Review of the resident's nurse notes, dated 04/27/26 to 05/06/26, showed staff did not document attempts made by the nursing staff to complete the UA order. During an interview on 05/06/26, at 12:32 P.M., the resident's FNP said the following:-He/she writes new orders on an order sheet and gives the order to the nurse;-The nurse enters the orders into the electronic medical record;-He/she ordered a UA for the resident due to increased aggressive behaviors that could be caused by a UTI;-He/she came to the facility on [DATE] and asked about the UA. Registered Nurse (RN) B told him/her that it had not been completed, and they would make sure the order was put in and the UA was completed;-He/she asked about it again on 05/04/26 due to not getting any results back;-The Director of Nursing (DON) told him/her the UA had not been completed. The DON said they would make sure it was completed. Staff gathered the urine sample on 05/05/26 (eight days after original order);-He/she was not sure why the UA was not completed timely. He/she did not know the staff had not completed the UA until she asked about it. The nurses did not tell him/her of any failed attempts to get the urine sample for the UA;-He/she expected to be contacted if the staff cannot get the urine sample in a timely manner.During an interview on 05/06/26, at 1:30 P.M., Medical Records/Certified Medication Technician (CMT) said the following:-He/she checked physician orders to make sure they were entered by the nurse;-She entered the orders if they were not already entered by the nurse;-He/she did not see the resident's order for a UA until 04/30/26 because the FNP asked if the UA had been completed;-He/she did not know why it was not entered by the nurse;-He/she told the DON the order had not been entered by staff, and it was entered;-The FNP gives the resident's nurse paper orders, the nurse is supposed to enter into the electronic medical record.During an interview on 05/06/26, at 3:21 P.M., Registered Nurse (RN) A said the following:-The FNP puts orders on an order sheet and then gives it to the resident's nurse to enter the computer;-The nurse should attempt to get the urine sample as soon as possible so it can be sent to the lab timely;-He/she lets the FNP know if they were unable to get the urine sample within 24 hours for further instructions;-He/she documents any unsuccessful attempts to get the UA completed and why it was unsuccessful. He/she lets the oncoming nurse for the next shift know if they were unable to get the UA. The next nurse is expected to make more attempts to get the urine sample;-He/she does not consider it timely for a urine sample to take more than 24 hours to collect.During an interview on 05/07/26, at 8:15 A.M., the RN B said the following:-The FNP gives the nurse any new orders for labs and the nurse enters it into the computer;-He/she did not remember the FNP giving him/her the order sheet for the resident. She remembered the FNP telling him/her that she wanted a UA completed on the resident on 04/30/26;-He/she did not enter the order into the computer;-He/she placed a hat to collect the resident's urine on the resident's toilet. The resident was incontinent sometimes and can be noncompliant;-He/she was not successful in collecting the resident's urine;-He/she did not document his/her attempts to collect the resident's urine;-He/she told the oncoming nurse for the next shift that he/she was not able to collect the urine;-He/she expected there to be more attempts made to collect the resident's urine;-He/she was off after 04/30/26 and did not follow up to see if the UA was completed.During an interview on 05/06/26, at 2:04 P.M., the Assistant Director of Nursing (ADON) said the following:-The FNP gives new or updated orders to the resident's nurse or to a nursing supervisor on an order sheet. The nurse enters the orders into the computer;-The nurse should attempt to get a urine sample pretty soon after getting an order for a UA, at least during their shift;-The nurse should let the FNP know if they are unable to get the sample within 24 hours;-The nurse should inform the oncoming nurse for the next shift if they could not get the sample, for the next nurse to try;-The nurses document attempts to get the urine sample in a nurses note or on the TAR;-He/she did not know why there was a delay in collecting the UA sample. He/she did know the resident has behaviors and believed it may have been difficult to get it;-He/she did not know why there were no attempts documented in the chart;-He/she collected the sample from the resident on 05/05/26 with the DON. He/she did not know that the order for the UA from 04/27/26 was not entered into the computer until 04/30/26. He/she would have expected the UA order to be put in as soon as possible and at least by the end of the shift. During an interview on 05/06/26, at 3:45 P.M., the Administrator said the following:-The FNP gives the nurse new orders on a paper order sheet;-The nurse enters the orders into the computer;-The nurse should attempt to get the urine sample for a UA as soon as possible;-The nurse should document any attempts made to get the urine sample in the resident's medical record;-The nurse should have multiple attempts to get the urine sample. The nurse needs to inform the FNP if they cannot get the UA completed.Complaint 3000706

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required two-hour time frame when staff failed to report an allegation of employee to resident abuse when visitor reported one staff (Certified Nursing Assistant (CNA) B) yelled and cussed at one resident (Resident #1). The facility census was 100.Review of the facility's policy titled, Abuse Prevention Program, not dated, showed the following:-Zero tolerance of verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, visitors, or other residents;-Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that she will never see her family again;-Mental abuse includes, but is not limited to, humiliation, harassment, and threat of punishment or deprivation;-New employees will be instructed on reporting any indications of abuse, neglect, mistreatment, or misappropriation of resident property immediately upon discovery to their supervisor;-If an alleged or suspected incident of abuse, neglect, mistreatment, or misappropriation of resident property occurs, the Administrator, or designee, will report to the following: the information is to be completed by each facility in accordance with Federal, State, and Local Laws: Missouri requires a call be made to the Elderly Abuse and Neglect Hotline, etc.1.Review of Resident #1's face sheet (a brief summary of the resident's medical and admission history) showed the following: -admission date of 02/25/26;-Diagnoses included Alzheimer's disease, dementia with other behavioral disturbance (a general term for a number of neurological conditions that cause a decline in cognitive abilities), and high blood pressure.Review of the resident's care plan, initiated on 02/27/26, showed the following:-Staff should monitor the resident for cognitive factors, emotional factors, and environmental factors that may contribute to new behaviors;-The resident has the potential to be physically aggressive related to Alzheimer's disease;-When the resident becomes agitated intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; and if response is aggressive, staff to walk calmly away, and approach later;-The resident has potential to be verbally aggressive related to Alzheimer's disease;-The resident has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's.Review of the resident's discharge Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 04/10/26, showed the following: -Severe cognitive impairment;-The resident exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, and/or other behavioral symptoms not directed toward others.Review of the resident's medical record showed staff documented a late entry on 04/09/26, at 1:44 P.M., the resident had gotten aggressive with multiple staff when he had been redirected. He has cornered a certified medical technician (CMT) and grabbed him/her by the wrists. Resident wandered in and out of other residents' rooms and was not able to stay seated for longer than about a minute. The resident was not easily redirected. Resident had stern an angry demeanor. Staff will continue to monitor and support.During an interview on 04/14/26, at 2:41 P.M., Registered Nurse (RN) C said the following:-An altercation occurred between Certified Nurse Aide (CAN) B and the resident 04/09/26, at approximately 12:50 P.M.;-RN C did not witness the altercation between the resident and CNA B;-A family member visiting another resident reported to RN C that CNA B had been inappropriate with Resident #1;-The visitor said CNA B yelled and cussed at Resident #1 saying he/she wanted Resident #1 taken out in f***** handcuffs and I'll knock you on your ass;-RN C spoke with CNA B about the situation and CNA B denied saying that to the resident;-CNA B left the office, then returned, taking her belongings and left the building;-The Director of Nursing (DON) was present when CNA B came to the office and took her belongings and left;-RN C said that he/she reported the incident to the Administrator the day it occurred;-RN C said he/she felt the incident was abuse and told the DON that it should be reported to the state. During an interview on 04/23/26, at 12:28 P.M., CNA B said the following:-CNA B told the resident to quit fucking hitting me;-CNA B also told the resident he/she is lucky that he/she doesn't go out of there in handcuffs;-CNA B said neither the Director of Nursing (DON) or the Administrator reached out to her for a statement about the incident;-There is never an appropriate time to yell or cuss at a resident;-The words she used towards Resident #1 could be considered abuse. Review of DHSS records showed the home did not self-report the allegation of employee to resident abuse reported by a visitor to RN C. During an interview on 04/14/26, at 2:22 P.M., Certified Nursing Assistant (CNA A) said the following:-Staff yelling/cussing at a resident was considered abuse;-If CNA A heard a staff member yelling/cussing at a resident he/she would immediately report it to the charge nurse;-All allegations of abuse, neglect, and misappropriation were reported to the state in two hours;-CNA A did not see the altercation between CNA B and the resident;-CNA A was assisting another resident when he/she heard yelling by Resident #1 and CNA B;-CNA A saw CNA B walk out of the unit following the screaming;-CNA A did not hear what CNA B said to the resident. During an interview on 04/14/26, at 3:13 P.M., Certified Medical Technician (CMT) D said the following:-CMT D did not witness the incident between CNA B and Resident #1;-A family member visiting another resident reported to CMT D that they heard CNA B say to the resident if you hit me I will f****** hit you back;-CMT D said staff cannot tell a resident that they will hit them back, that would be considered abuse;-The state required all allegations of abuse and neglect to be reported within two hours.During an interview on 04/14/26, at 3:28 P.M., the Director of Nursing (DON) said the following:-The DON went to the unit after hearing that CNA B had been yelling;-Family members visiting another resident heard CNA B yelling at Resident #1;-Staff told the DON that Resident #1 had his/her arm around CNA B's neck;-The DON did not hear what CNA B had yelled at the resident;-The DON did not speak with CNA B regarding the incident;-Some things that probably should not have been said, were said by CNA B while trying to get away from the resident;-The DON did not feel that CNA B yelling at Resident #1 was abuse;-There was no appropriate time or situation for a staff member to yell or cuss at a resident.During an interview on 04/17/26, at 1:59 P.M., the Staff Coordinator (SC) said the following:-He/she reported all allegations of abuse and neglect to the DON immediately;-Staff were required to report abuse and neglect allegations to the state within two hours;-Staff told him/her a family member reported hearing CNA B yelling at Resident #1;-Staff had reported the incident to the Administrator and the DON;-SC reached out to CNA B regarding the incident.During an interview on 04/17/26, at 3:52 P.M., the Administrator said the following:-Staff reported to the Administrator that CNA B became upset with Resident #1 when the resident grabbed CNA B's wrist;-Staff reported that CNA B told Resident #1 that he/she was not putting up with this shit;-CNA B attempted to remove the resident's hand from his/her wrist when the resident said, I'm going to take you f****** down;-CNA B said to the resident, you need to be in handcuffs;-It was not appropriate for staff to tell a resident they needed to be in handcuffs;-The altercation did not rise to abuse because CNA B was trying to get out of the situation;-Staff had not reported hearing CNA B cussing or threatening Resident #1;-The Administrator was not told that visitors had heard CNA B cussing or yelling at the resident;-The Administrator or charge nurse on call were responsible for reporting abuse and neglect allegations.Complaint #2979068

Based on interview and record review, the facility failed to ensure all allegation of possible abuse were thoroughly investigate when staff failed to complete a timely written investigation of an allegation of employee to resident abuse when a visitor reported one staff (Certified Nursing Assistant (CNA) B) cussed and threatened one resident (Resident #1). The facility census was 100.Review of the facility's policy titled, Abuse Prevention Program not dated, showed the following:-If an incident occurs, or there is any allegation that an incident might have occurred, of abuse, neglect, mistreatment, or misappropriation of resident property, the Administrator, or designee, will investigate;-The person doing the investigation will complete a resident abuse/neglect investigation report;-The administrator will sign and maintain all completed resident abuse/neglect investigation reports and all investigations will remain confidential, except that the findings and actions shall be reported according to state requirements;-All individuals participating in the investigation shall report their findings to the Administrator and complete the information in writing on the Resident Abuse/Neglect Investigation Report form;-The administrator will involve the Social Service Designee in the investigative process to provide the necessary medically related social services appropriate for the resident.1.Review of Resident #1's face sheet (a brief summary of the resident's medical and admission history) showed the following: -admitted on [DATE];-Diagnoses included Alzheimer's disease, dementia with other behavioral disturbance (a general term for a number of neurological conditions that cause a decline in cognitive abilities), and high blood pressure.Review of the resident's care plan, initiated on 02/27/26, showed the following:-Staff should monitor the resident for cognitive factors, emotional factors, and environmental factors that may contribute to new behaviors;-The resident had the potential to be physically aggressive related to Alzheimer's disease;-When the resident became agitated intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; and if response is aggressive, staff to walk calmly away, and approach later;-The resident had potential to be verbally aggressive related to Alzheimer's disease;-The resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's.Review of the resident's discharge Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 04/10/26, showed the following: -Severe cognitive impairment;-The resident exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, and/or other behavioral symptoms not directed toward others.Review of the resident's medical record showed staff documented a late entry on 04/09/26, at 1:44 P.M., the resident had gotten aggressive with multiple staff when he had been redirected. He has cornered a certified medical technician (CMT) and grabbed him/her by the wrists. Resident wandered in and out of other residents' rooms and was not able to stay seated for longer than about a minute. The resident was not easily redirected. Resident had stern an angry demeanor. Staff will continue to monitor and support.During an interview on 04/14/26, at 2:41 P.M., Registered Nurse (RN) C said the following:-An altercation occurred between Certified Nurse Aide (CAN) B and the resident 04/09/26, at approximately 12:50 P.M.;-RN C did not witness the altercation between the resident and CNA B;-A family member visiting another resident reported to RN C that CNA B had been inappropriate with Resident #1;-The visitor said CNA B yelled and cussed at Resident #1 saying he/she wanted Resident #1 taken out in f***** handcuffs and I'll knock you on your ass;-RN C spoke with CNA B about the situation and CNA B denied saying that to the resident;-CNA B left the office, then returned, taking her belongings and left the building;-The Director of Nursing (DON) was present when CNA B came to the office and took her belongings and left;-RN C said that he/she reported the incident to the Administrator the day it occurred;-No staff were asked to write a statement regarding the incident;-Administration did not start an investigation of the incident;-RN C he/she felt the incident was abuse.During an interview on 04/23/26, at 12:28 P.M., CNA B said the following:-CNA B told the resident to quit fucking hitting me;-CNA B also told the resident he/she is lucky that he/she doesn't go out of there in handcuffs;-CNA B said neither the Director of Nursing (DON) or the Administrator reached out to her for a statement about the incident;-There is never an appropriate time to yell or cuss at a resident;-The words she used towards Resident #1 could be considered abuse. Review of the resident's medical record showed staff did not document investigating the allegation of abuse. Review of DHSS records showed the home did not investigate the allegation of employee to resident abuse.During an interview on 04/14/26, at 3:13 P.M., Certified Medical Technician (CMT) D said the following:-A family member visiting another resident reported to CMT D that they heard CNA B say to the resident if you hit me I will f****** hit you back;-CMT D said staff cannot tell a resident that they will hit them back, that would be considered abuse;-He/she was not aware of administration investigating the incident between CNA B and Resident #1.During an interview on 04/17/26, at 1:59 P.M., the Staff Coordinator (SC) said the following:-Staff reported the incident to the Administrator and the Director of Nursing (DON);-He/she did not ask CNA B to provide a written statement of the incident.During an interview on 04/14/26, at 3:28 P.M., the DON said the following:-The DON did not speak with CNA B regarding the incident;-The DON did not feel that CNA B yelling at Resident #1 was abuse;-The DON did not obtain a written statement of the incident from CNA B or any other staff;-The DON did not know if an investigation had been opened regarding the incident between CNA B and Resident #1.During an interview on 04/17/26, at 3:52 P.M., the Administrator said the following:-She did not speak with CNA B about the incident prior to or after CNA B quitting;-CNA B attempted to remove the resident's hand from his/her wrist when the resident said, I'm going to take you fucking down;-CNA B said to the resident, you need to be in handcuffs;-It was not appropriate for staff to tell a resident they needed to be in handcuffs;-The Administrator asked staff if they heard or saw the altercation between Resident #1 and CNA B and all reported not hearing or seeing anything;-The Administrator was not told that visitors had heard CNA B cussing or yelling at the resident;-The Administrator or charge nurse on call were responsible for completing investigations alleging abuse and neglect.Complaint #2979068

Based on observation, interview, and record review, the facility failed to maintain an environment as free of accidents as possible when staff failed to provide standby and/or supervision assistance for one resident (Resident #2) resulting in the resident falling. The facility census was 100. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting, dated 2001, showed the following:-All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator;-The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident;-The following data, as applicable, shall be included on the Report of Incident/Accident form: the date/time the accident/incident took place; the nature of the injury/illness (fall); the circumstances surrounding the accident or incident; where the accident or incident took place; the names of witness and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured person's attending physician was notified, as well as the time the physician responded and his/her instructions; the date/time the injured person's family was notified and by whom; the condition of the injured person, including his/her vital signs; the disposition of the injured (transferred to hospital, put to bed, sent home, returned to work, etc); any corrective action taken, follow-up information; and the signature and title of the person completing the report;-The nurse supervisor/charge nurse and/or the department director or supervisor shall complete an incident report in the electronic record. 1.Review of Resident #2's face sheet (a brief summary of the resident's medical and admission history) showed the following: -admission date of 03/24/26;-Diagnoses included coronary artery disease (CAD - a narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart), Parkinson's disease (brain disorder causing unintended or uncontrolled movements), and neuropathy (abnormality of the nervous system).Review of the resident's entry Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 03/28/26, showed the resident was cognitively intact.Review of the resident's care plan, initiated 03/25/26, showed the following: -The resident had impaired physical mobility R/T loss of extremity and post operation discomfort;-The resident received antidepressant meds, anticonvulsant meds, and opioid pain meds which could increase risk for falls;-The resident required assistance with transfers.Review of the resident's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 03/27/26, showed the following:-Acquired absence of right leg below knee, unsteadiness on feet, and muscle weakness (generalized);-Resident referred to PT due to new onset of compromised physical exertion level during activity, decrease in functional mobility, decrease in strength, decreased coordination, falls/fall risk, functional limitation with ambulation, increased need for assistance from others, pain, reduced dynamic balance, reduced static balance, and vertigo;-Fall risk;-Resident feels unsteady when standing and when walking;-Sit to stand with supervision or touching assistance; -Toilet transfer with supervision or touching assistance.Review of the resident's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 03/27/26, showed the following:-Needed for assistance with personal care and muscle weakness (generalized);-Resident presents with decreased strength, balance, and activity tolerance resulting in decreased independence and increased risk for falls and functional completion;-Fall risk and vertigo;-Toileting hygiene with partial/moderate assistance; -Shower/bathe self with partial/moderate assistance; -Tub/shower transfer with supervision or touching assistance; -Toilet transfer with supervision or touching assistance.Review of the resident's medical record showed staff documented the following: -On 03/28/26, at 10:05 A.M., the skilled evaluation showed no impairment using upper extremities. The resident had impairment on both sides of lower extremities. The resident's gait was unsteady. The resident had poor balance when standing;-On 04/03/26, at 2:23 P.M., Registered Nurse (RN) H documented the resident had been in the shower room at 1:45 P.M, and fell to buttocks during transfer, resulting in busting open his amputation site. Staff called 911, hospital contacted, Director of Nursing (DON), and Administrator. Resident left by ambulance at 2:15 P.M.During an interview on 04/14/26, at 4:23 P.M., the resident said the following: -The resident came to the facility for rehabilitation after a recent below the knee amputation;-On 04/03/26, staff assisted the resident to the shower room;-Once at the shower room door the aide that had been assisting the resident was told by a nurse that the resident did not need assistance with showering;-The resident said that he/she did need assistance because of his/her instability and the aide agreed with the resident;-The nurse told the aide according to the resident's plan of care, it said the resident was independent with showers;-The resident told the aide that he/she did not want to get them in trouble, and he/she would shower on his/her own;-After showering the resident had transferred him/herself to the toilet to get dressed;-The resident lost his/her balance, falling against the toilet.During an interview on 04/17/26, at 9:20 A.M., Therapy Tech (TT) E said the following:-The resident required assistance with shower transfers due to the wet floor;-Staff should provide stand-by assistance for the resident during transfers.During an interview on 04/17/26, at 9:44 A.M., the Director of Rehab (DOR) said the following;-The resident required assistance with activities of daily living and transfers due to a recent amputation;-Staff should assist the resident with showers and transfers;-The DOR shared resident evaluations/recommendations with department heads during weekly meetings;-Any resident receiving therapy should have stand by assistance while showering.During an interview on 04/17/26, at 11:46 A.M., Certified Nurse Aide (CNA) F said the following: -The resident required transfer assistance with toileting and showers;-He/she helped the resident after his/her fall by holding towels and pressure on the resident's stump;-He/she did not know why the resident was in the shower room alone.During an interview on 04/17/26, at 12:38 P.M., Nursing Assistant (NA) G said the following:-The resident required supervision for transfers;-The resident asked for assistance with transfers in the shower.During an interview on 04/17/26, at 12:54 P.M., Licensed Practical Nurse (LPN) H said the following:-The resident required one person assistance with everything including showers;-LPN H did not know if the resident required a sit-to-stand or Hoyer lift to transfer.During an interview on 04/17/26, at 1:08 P.M., NA I said the resident required supervision when showering.During an interview on 04/17/26, at 3:03 P.M., the Director of Nursing (DON) said the following: -Staff reported to the DON that the resident had fallen while transferring off the toilet;-The resident lost his/her balance causing him/her to fall;-The resident required transfer assistance to the bed and toilet;-The DON did not know if staff provided standby assistance while the resident was in the bathroom.During an interview on 04/17/26, at 3:17 P.M., the MDS Coordinator said the following:-Staff came to the MDS Coordinator's office to let her know the resident had fallen;-The MDS Coordinator had pressure on the resident's leg until EMS arrived;-The resident fell after using the restroom;-The resident was alone when the resident fell;-The resident did not like anyone in the restroom while he/she was using it;-The MDS Coordinator did not know what type of assistance the resident required;-The MDS Coordinator relayed the fall information to the nurse on duty.During an interview on 04/22/26, at 1:10 P.M., the Facility Physician said the expectation would be for the resident to have standby or supervision assistance due to the residents recent below the knee amputation.During an interview on 04/17/26, at 3:52 P.M., the Administrator said the following: -Staff reported that the resident had fallen while pulling up his/her clothing after using the bathroom;-She did not know if the resident's plan of care showed the resident needed stand by assistance or if he/she was independent while using the restroom.Complaint #2982358

Based on observation, interview, and record review, the facility failed to provide meals in a timely manner in accordance with each residents' preferences when staff failed to provide a meal tray to one resident (Resident #2) during scheduled mealtimes. The facility census was 100.Review of the facility's policy titled, Frequency of Meals, dated 2001, showed the following: -Each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and the plan of care;-The facility will serve at least three meals or their equivalent daily at schedule times. There will not be more than a fourteen-hour span between the evening meal and breakfast.1.Review of Resident #2's face sheet (a brief summary of the resident's medical and admission history) showed the following: -admission date of 03/24/26;-readmission date of 04/09/26;-Diagnoses included coronary artery disease (CAD - a narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart), Parkinson's disease (brain disorder causing unintended or uncontrolled movements), and neuropathy (abnormality of the nervous system).Review of the resident's entry Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 03/28/26, showed the resident was cognitively intact.Review of the resident's care plan, initiated 03/25/26, showed the following: -The physician has prescribed a carb consistent diet for the resident;-The resident will maintain a stable weight and be free of nutritional deficit;-The resident will consume 75% of ordered diet each day;-The resident had the potential for weight loss/gain;-Staff should minimize risk for significant weight loss/gain through the next review date.During an interview on 04/14/26, at 4:23 P.M., the resident said the following: -The resident came to the facility for rehabilitation after a recent below the knee amputation;-The resident ate his/her meals in his/her room due to his/her diagnosis, which caused his/her hands to shake;-On 04/11/26, at 7:30 A.M., staff came to the resident's room to pick up the resident's dinner tray;-The resident did not receive a dinner tray on 04/11/26;-On 04/12/26, at 9:30 A.M., the resident had to chase down his/her breakfast tray after not receiving one.During an interview on 04/17/26, at 9:20 A.M., Therapy Tech (TT) E said the resident reported not getting a dinner tray on 04/11/26.During an interview on 04/17/26, at 9:44 A.M., the Director of Rehab (DOR) said the resident reported to the DOR that he/she did not receive a dinner tray on 04/11/26.During an interview on 04/17/26, at 11:46 A.M., Certified Nurse Aide (CNA) F said the following: -CNA's are responsible for taking meal orders for residents that eat in their rooms;-The meal orders are given to kitchen staff who prepare the trays;-CNA's deliver the hall trays to the residents and collect the trays when the residents are finished;-CNA's are responsible for making sure each resident gets a meal.During an interview on 04/17/26, at 5:03 P.M., [NAME] J said the following: -Nurse aides take meal orders from residents eating in their rooms and return them to the kitchen staff;-Kitchen staff place the resident's meal card with the resident's menu;-The cook reviews the orders and marks the residents who receive hall trays off the facility roster before the meals are served;-For residents eating in the dining room, resident meal cards are left in the kitchen and are marked off the rooster after their meal has been served;-If a name is not marked off the roster the cook checks with the charge nurse as to why the resident did not eat.During an interview on 04/17/26, at 12:17 P.M., the Dietary Manager (DM) said the following: -CNA's are responsible for taking meal orders from the residents who eat in their rooms;-The orders are given to kitchen staff who prepare the trays and take them down the hall for CNA's to pass to residents;-When the kitchen staff do not receive a menu from a resident, kitchen staff are to go to the resident's hall and speak with nursing staff about why the resident did not eat;-The resident reported that he/she did not receive dinner on 04/11/26;-The resident also reported he/she had to come to the dining room on 04/12/26, to get breakfast because staff did not take his/her order or deliver a tray to his/her room;-Kitchen staff are to speak with the charge nurse when a resident does not get a meal.During an interview on 04/17/26, at 12:38 P.M., Nursing Aide (NA) G said the following:-Nursing staff were responsible for taking residents meal orders and providing them to the kitchen staff;-Kitchen staff prepare the trays and bring them to the halls;-CNA's and NA's passed out meal trays to the residents;-NA G goes to each room to make sure all residents receive a tray or are in the dining room for meals.During an interview on 04/17/26, at 12:54 P.M., Licensed Practical Nurse (LPN) H said the following:-Staff ask residents who want to eat in their rooms and report that to the kitchen staff;-The kitchen staff keep track of who eats and who doesn't.During an interview on 04/17/26, at 1:08 P.M., NA I said the resident had missed two meals, one lunch and one dinner. NA I could not recall what days this occurred.During an interview on 04/17/26, at 3:44 P.M., the Social Service Staff (SS) said the following:-The resident came to the SS office and reported on 04/11/26, at 7:30 P.M., an aide came to his/her room to get his/her meal tray;-The resident said he never received a dinner tray.During an interview on 04/17/26, at 3:03 P.M., the Director of Nursing (DON) said the following: -Aides were responsible for letting kitchen staff know which residents were eating in their rooms;-Staff had not reported to the DON that the resident had not received two meals after returning to the facility;-Staff were responsible for making sure residents are served all meals.During an interview on 04/17/26, at 3:52 P.M., the Administrator said kitchen staff were responsible for making sure all residents receive their meals.Complaint #2982358

Based on observation, interview, and record review, the facility failed to ensure food was protected from possible contamination at all times while stored, prepared, and served, when staff failed to wear hairnets appropriately while preparing resident's food and staff failed to use proper hand washing and glove use while preparing residents food. The facility census was 102.1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility's policy titled Code of Dress and Personal Appearance, dated 2020, showed the following: -All dining services employees will comply with printed and posted personal hygiene guidelines, sanitation practices, and dress codes of the community;-The Dining Services Manager will enforce that employees will use effective hair restraints, such as hairnets, hair bonnets, and beard guards, to prevent contamination of food or food contact surfaces Observation on 12/19/25, at 11:45 A.M., showed the following: -Dietary Aide (DA) A stood in front of the warming table placing uncovered, prepared plates on trays. He/she placed a cover on the plates and placed the trays in the hall cart. DA A had substantial facial hair and was not wearing a beard net;-DA A then walked to the dishwashing area, grabbed a beard net and donned the beard net. The beard net did not cover all of DA's the facial hair. The DA continued to place prepared plates of food on the trays, covered them, and placed them on the hall tray;-The Dietary Manager (DM) stood behind the warming table and prepared the plates of food and placed them on top of the serving table. The DM wore a hairnet, but his/her bangs were not covered by the hair net;-The DM was facing DA A while the DA did not have a beard net on or when the beard net did not cover the DA's beard. The DM did not have the DA adjust his/her beard net. During an interview on 12/19/25, at 11:56 A.M., [NAME] B said the following:-Staff should wear hair and beard nets at all times while in the kitchen;-Hair and beard nets should completely cover staff's hair and beards;-Staff should not wear hair or beard nets with bangs out or not covering their beard while serving food because this could contaminate the residents' food;-If he/she saw staff not wearing hair and beard nets appropriately, he/she would correct the staff member and tell the DM. If it was the DM he/she would tell the Administrator. During an interview on 12/19/25, at 12:01 P.M., [NAME] C said the following:-Staff should wear hair and bear nets when they enter the kitchen;-Hair and beard nets should cover all the hair and beard;-Staff should not wear a hair net with their bangs hanging out;-If staff wore hair and beard nets incorrectly, they could contaminate the residents' food;-If he/she saw staff not wearing a hair or beard net appropriately, he/she corrected the staff member and told the DM. If the staff member was the DM, he/she would tell the Administrator. During an interview on 12/19/25, at 12:04 P.M., DA A said the following:-Staff wore hair and beard nets while in the kitchen;-Hair and beard nets should cover all the hair and beard;-If staff wore hair and beard nets with their hair hanging out or did not wear a beard net, they could contaminate the residents' food;-If he/she saw staff not wearing a hair or beard net appropriately, he/she corrected the staff member and told the DM. If the staff member was the DM, he/she told the DM to correct it;-He/she forgot to put his/her beard net on when he/she returned to the kitchen;-He/she should have worn his/her beard net while preparing the trays in the kitchen. During an interview on 12/19/25, at 2:05 P.M., the DM said the following:-Staff wore hair and beard nets at all times while in the kitchen;-Hair nets should cover all a staff member's hair, and the beard net should cover the whole beard and mustache;-If she saw staff not wear hair and beard nets correctly, he/she corrected the staff member;-She expected her staff to correct each other and her if they saw hair and beard nets not worn correctly;-If staff did not wear hair and beard nets correctly, they could contaminate the residents' food;-She did not have her hair net on correctly when serving food because her bangs were hanging out and should have been covered;-DA A wore a beard net but the beard net did not cover his/her all his/her facial hair; -She was responsible for ensuring staff wore their hair and beard nets appropriately. During an interview on 12/19/25, at 3:07 P.M., the Director of Nursing (DON) said the following: -Staff should wear hair and beard nets in the kitchen and they should cover all of their hair;-The DM was responsible for ensuring staff wore hair and beard nets appropriately. 2. Review of the FDA 2013 Food Code showed the following: -Hands are particularly important in transmitting foodborne pathogens;-Food employees with dirty hands and/or fingernails may contaminate the food being prepared;-Any activity which may contaminate the hands must be followed by thorough handwashing;-Bare hands should never contact exposed, ready-to-eat food;-Thorough handwashing is important in keeping gloves or other utensils from becoming vehicles for transferring microbes to the food. Review of the facility's policy titled Proper Hand Washing and Glove Use, dated 2020, showed the following: -All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines;-All employees will wash hands upon entering the kitchen from any other location, after all breaks (including bathroom and smoking breaks), and between all tasks. Hand washing should occur at a minimum of every hour;-Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident;-Gloves are to be used whenever direct food contact is required;-Hands are washed before donning gloves and after removing gloves;-Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment;-Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again;-When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash and re-glove. Observation on 12/19/25, at 11:45 A.M., showed the following: -The DM wore gloves while she prepared plates of food, touching the utensils with the gloved hands;-The DM walked away from the serving area, doffed her gloves and donned a new pair without washing her hands and continued to prepare plates of food, touching the utensils with the gloved hands;-The DM opened a bag of hamburger buns and reached in the bag with her gloved hands and took a bun out, separated the top from the bottom bun and placed it on a plate. The DM did not doff the already contaminated gloves, wash her hands, and don new gloves;-Cook C used tongs to place a hamburger on the bun and the DM touched the top bun with her contaminated gloves to place it on top of the hamburger and cut the hamburger in half;-Cook C handed the DM a plate with two grilled cheese sandwiches and the DM touched both sandwiches with her contaminated gloves and cut them in half;-The DM then touched the top hamburger bun again with her contaminated gloves;-The DM gave both plates to DA A for service to residents. During an interview on 12/19/25, at 11:56 A.M., [NAME] B said the following: -When staff took gloves off, they should wash their hands before donning a new pair of gloves;-If staff took gloves off and then put new gloves on without washing their hands, their gloves would be contaminated and could contaminate the residents' food;-If he/she saw staff take gloves off and not wash their hands prior to donning new gloves, he/she would correct the staff member and tell the DM. If it was the DM, he/she would tell the Administrator. During an interview on 12/19/25, at 12:01 P.M., [NAME] C said the following:-When staff took gloves off, they washed their hands before they donned new gloves;-If staff did not wash hands between glove changes, the new gloves would be contaminated and could contaminate the residents' food;-If he/she saw a staff member not wash their hands between glove changes, he/she corrected the staff member and told the DM. If the staff member was the DM, he/she would tell the Administrator. During an interview on 12/19/25, at 12:04 P.M., DA A said the following:-When staff doffed gloves, they should wash their hands before donning a new pair;-If staff doffed gloves and donned a new pair without washing their hands, the new gloves would be contaminated and could contaminate residents' food;-If he/she saw staff take their gloves off and put a new pair on without washing their hands, he/she corrected the staff member and told the DM. If the staff member was the DM, he/she told the DM to correct it. During an interview on 12/19/25, at 2:05 P.M., the DM said the following: -Staff should wash hands when entering the kitchen, between tasks, when going from a dirty to a clean process, when they took off their gloves and prior to donning gloves;-Staff should not take their gloves off and put a new pair of gloves on without washing their hands as the new gloves would be contaminated and could contaminate the residents' food;-She expected her staff to correct each other and her if they saw each other taking off their gloves and not washing their hands before donning new gloves;-She did not wash her hands between a glove change, but she should have done this;-She should not have touched the hamburger bun or the grilled cheese with those gloves as they were contaminated;-She was responsible for ensuring staff washed their hands between glove changes. During an interview on 12/19/25, at 3:07 P.M., the DON said the following:-Staff should wash their hands between glove changes and when going from a dirty to a clean process;-Staff should not take off their gloves and put new gloves on without washing hands and then touch food. This could contaminate the residents' food;-The DM was responsible for ensuring staff washed their hands between glove changes.Complaint 2690751

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed and served in a manner to protect against contamination and in accordance with standards of practice when staff failed to know the required temperature and sanitation levels and failed to regularly test the temperature and sanitation level and ensure the appropriate water temperature was reached on the dishwashing machine; staff failed maintain the stove, griddle, coffee pot, and the hand washing sink clean and free from debris; and when staff consumed food in the kitchen and dishwashing areas. The facility census was 104. 1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the the data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The ware washing machine had been tested and the information on the data plate represented the parameters that ensured effective operation and sanitization and that need to be monitored. Review of the facility's policy titled Sanitization, revised 11/2022, showed the following: -Dishwashing machines were operated according to manufacturer's instructions; -General recommendations for heat and chemical sanitization were low-temperature dishwasher (chemical sanitization) with wash temperature of 120 Fahrenheit (F), final rinse with 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse, and the chemical solution maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Review of the facility's PPM Sanitizer Record Log, dated 03/2025, showed the following: -Columns for breakfast, lunch, and dinner with wash, rinse, PPM, and initials; -The log did not include temperature or PPM parameters for the dishwashing machine; -On 03/03/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/08/25, 03/16/25, 03/18/25 and 03/25/25 in the breakfast column wash and rinse were 100 F and PPM measured 100; -On 03/01/25 and 03/02/25 breakfast column, wash was 110 F, rinse was 100 F and PPM measured 100; -On 03/10/25 through 03/14/25, 03/17/25, 03/19/25 through 03/24/25 and 03/26/25 through 03/31/25 in the breakfast column, wash and rinse were 100 F and PPM measured 110; -On 03/09/25 in the breakfast column, wash and rinse was 110 F and PPM measured 200; -On 03/02/25 through 03/08/25 and 03/10/25 through 03/31/25 in the lunch column, wash was 100 , rinse was 110 F and PPM was 100; -On 03/01/25 in the lunch column wash measured 100 F, rinse was 110 F and PPM measured 200; -On 03/10/25 in the lunch column wash and rinse was 110 F and PPM measured 100; -On 03/01/25 through 03/17/25 in the dinner column, wash and rinse were 100 F and PPM measured 50; -Staff did not document wash or rinse temperature or the PPM in the dinner column from 03/18/25 through 03/31/25. Review of the facility's PPM Sanitizer Record Log, dated 04/2025, showed the following: -On 04/01/25, breakfast and lunch column, on 04/07/25 and 04/28/25 breakfast lunch and dinner column, and on 04/09/25 and 04/10/25, wash and rinse were 100 F and PPM was 100; -On 04/01/25 dinner column, wash and rinse were 110 F and PPM was 50; -Staff did not document wash or rinse temperature or PPM for breakfast, lunch and dinner from 04/02/25 through 04/06/25 and dinner on 04/09/25 and 04/10/25. Observation on 04/10/25, at 11:58 A.M., showed a kitchen staff member tested the dishwashing machine and the wash and rinse was 100 F and sanitation measured between 100 and 200 PPM. Observation on 04/11/25, at 10:01 A.M., showed wash temperature 88 F, rinse 98 F and PPM 200. During an interview on 04/11/25, at 10:01 A.M., Dietary Aide (DA) C said the following: -The temperature for wash and rinse cycles should be 120 F and sanitation should be 240 PPM; -He/she was educated on this when he/she was hired; -If the dishwashing machine did not reach the required temperature or sanitation, he/she reported this to the Dietary Manager (DM) and the DM reported to the Administrator; -He/she also let the Maintenance Supervisor know; -The dishwashing machine just gets the temperature the facility's boiler gave it; -If the dishwashing machine did not reach the proper temperatures or sanitation, the dishes would not be clean and sanitized and could lead to cross contamination and resident illness; -Wash temperature 88 F and rinse 98 F was not appropriately; -He/she was instructed to double wash the dishes and he/she did this a lot of the times and sometimes three times if there was food particles stuck; -The DM was responsible for ensuring the dishwashing machine operated appropriately. During an interview on 04/11/25, at 10:50 A.M., the Maintenance Supervisor said the following: -He was not familiar with the dishwashing machine; -The dishwashing machine was rented and contracted through EcoLab and EcoLab did the maintenance on the machine; -Wash and rinse should be a minimum of 120 F. He did not know what the sanitation PPM should be; -The DAs were instructed to run the dishes through the machine two to three times to ensure they were clean; -If the temperature or sanitation were not at the appropriate levels, kitchen staff should report this to the DM or him; -Either he or the DM called EcoLab for service. EcoLab was just in the facility on 04/10/25 and said the dishwashing machine was still not getting to the appropriate temperature; -Anything under 120 F was not the correct temperature and the dishes may not be sanitized or cleaned properly and could cause illness in the residents; -The DM was responsible for ensuring kitchen staff were educated on the appropriate temperature and sanitation levels of the dishwashing machine; -The PPM Sanitizer Record Log should include the minimum wash and rinse temperature and PPM level for sanitation so staff knew when they were not correct. The log should be filled out daily for breakfast, lunch and dinner. During an interview on 04/11/25, at 11:53 A.M., DA D said the following: -The wash temperature should be 120 F and the PPM 125 to 150. He/she did not know what the rinse temperature should be; -He/she did not know how often the temperatures and PPM needed to be documented in the log; -If the wash and rinse temperatures were not appropriate, he/she notified the DM; -If the wash and rinse temperatures were not appropriate, the dishes were not getting cleaned or sanitized and could cross contaminate and make residents sick. During an interview on 04/11/25, at 2:06 P.M., [NAME] B said the following: -DAs should document the wash, rinse, and PPM of the dishwashing machine each shift; -If the DAs noticed the temperature or PPM was not correct, they notified the DM; -If the temperatures and PPM was not correct, the dishes would not be cleaned and sanitized and could cause resident illness; -The DM was responsible for ensuring staff documented the temperatures and PPM each shift and ensuring the temperature and PPM were appropriate. During an interview on 04/11/25, at 2:09 P.M., [NAME] A said the following: -The dishwasher temperature should be a minimum of 125 F and he/she did not know what the sanitation PPM should be; -If the DAs noticed the temperature and/or sanitation was not correct, they should notify the DM or maintenance; -If the dishwasher temperature and/or sanitation was not correct, the dishes would not be cleaned or sanitized and this could cause resident illness. During an interview on 04/14/25, at 9:30 A.M., DA E said the following: -The dishwasher runs at 100 F and that was what it should be. He/she assumed that was the appropriate temperature because that was what other DAs wrote on the log. The sanitation should be between 50 to 100 PPM and he knew that because that was what the bottle with the strips on it said; -The temperature gauge says the dishwashing machine should be 120 F for wash and rinse; -If the temperature did not reach 120 F, the dishes were still getting clean and sanitized unless they had stains on them; -If the dishes were not cleaned or sanitized correctly, this could cause resident illness; -The PPM Sanitizer Record Log did not show what the wash and rinse temperature or the PPM should be. During interviews on 04/10/25, at 1:25 P.M., and on 04/14/25, at 9:39 A.M., the DM said the following: -He/she called about the heat booster on the dishwashing machine, but he/she had not heard back; -The dishwasher wash and rinse should be 120 F. He/she did not know what the sanitation level should be; -He/she was not sure how the staff should know what the temperature and sanitation levels should be. The temperature and sanitation levels were not included on the PPM Sanitizer Record Log; -He/she assumed the temperatures were supposed to be 100 F since that was what the log showed since she worked at the facility and no one told him/her anything different; -If the dishwasher temperature and/or sanitation level were not correct, the dishes would not be cleaned and sanitized and could cause cross contamination and resident illness; -He/she was responsible for ensuring staff knew the appropriate temperatures and sanitation, filled out the logs every shift and the dishwasher was working appropriately. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -The dishwasher temperature should be 120 F for wash and rinse cycle and the sanitation should be 50 PPM; -The dishwasher was rented from EcoLab and they came out on 04/10/25 to look at it and told staff to wash each load of dishes twice. The EcoLab said the booster was supposed to be in on 04/15/25; -He/she did not know how long the dishwashing machine had not been the correct temperature; -The PPM Sanitizer Record Log did not have the minimum temperature or PPM on it; -Dietary staff were educated upon hire about the appropriate dishwasher temperatures and sanitation PPM; -The DM knew the appropriate temperatures and sanitation levels by the facility's policies and procedures; -If the dishwasher temperatures and/or sanitation level was not appropriate, DAs told the DM. The DM reported this to the Administrator and he/she called EcoLab; -EcoLab will sometimes increase the sanitation level on the dishwasher but he/she did not know if this would effectively clean or sanitize the dishes; -If the dishes were not cleaned or sanitized appropriately, they could grow bacteria and cause resident illness; -Staff should fill out the PPM Sanitizer Record Log daily for each shift; -The DM was responsible for ensuring staff knew the appropriate temperatures and sanitation, filled out the logs every shift and the dishwasher was working appropriately. 2. Review of the FDA 2013 Food Code showed the following: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests; -A handwashing sink that is properly located is one that is available to food employees who are working in food preparation, food dispensing, and warewashing areas. Handwashing sinks that are blocked by portable equipment or stacked full of soiled utensils and other items, are rendered unavailable for employee use. Nothing must block the approach to a handwashing sink thereby discouraging its use, plus it must be kept clean and well stocked with soap and sanitary towels to facilitate frequent use. Therefore, a handwashing sink that is located in the immediate work area, or between work areas that the Code states must be equipped with handwashing sinks, depending upon the size and function of the facility, would be considered properly located. Such placement of handwashing sinks facilitates frequent handwashing by food employees in all work areas. Review of the facility's policy titled Sanitization, revised 11/2022, showed the following: -The food service area is maintained in a clean and sanitary manner; -All kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects; -All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair; -All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Observation on 04/07/25, at 9:50 A.M., showed the griddle was dirty and needed to be cleaned. Observation on 04/10/25, at 10:02 A.M. showed the following: -The backsplash of the griddle and stove top appeared to have food particles stuck on and there was a brownish film that appeared to be grease stain and a blackish colored film that appeared to be carbon build up. The brownish and blackish film also covered the sides of the stove and griddle; -The handwashing sink had reddish and blackish colored spots around the back edge of the sink either side of the faucet. The base around the faucet had a brownish and greenish residue. Observation on 04/11/25, at 9:13 A.M., showed the following: -The backsplash of the griddle and stove top appeared to have food particles stuck on and there was a brownish film that appeared to be grease stain and a blackish colored film that appeared to be carbon build up. The brownish and blackish film also covered the sides of the stove and griddle; -The handwashing sink had reddish and blackish colored spots around the back edge of the sink either side of the faucet. The base around the faucet had a brownish and greenish residue. A large plastic mug sat on the sink and was approximately 1/3 full of a brownish liquid; -The coffee pot on the coffee maker near the dishwashing room had brownish colored residue built up around the top rim and spout area and the glass carafe had a brownish in color build up on the inside. During an interview on 04/11/25, at 11:53 A.M., DA D said the following: -Each staff member had a cleaning list for the job position they held on any certain day; -All kitchen staff were responsible for cleaning the hand washing sink. The sink should not have the reddish and blackish colored spots or the brownish and greenish colored residue. No drinks should be left on the hand washing sink; -The cooks were responsible for cleaning the stove and griddle. The stove top and griddle should not have food particles, blackish and brownish residue on the back splash or blackish and brownish residue on the sides; -All staff were responsible for ensuring their cleaning duties were completed; -If staff did not clean, the food could become cross contaminated and cause resident illness; -The DM was responsible for ensuring staff completed cleaning tasks. During an interview on 04/11/25, at 2:06 P.M., [NAME] B said the following: -Kitchen staff had lists of cleaning responsibilities; -He/she did not know who was responsible for the hand washing sink; -The cooks were responsible for cleaning the stove and griddle. The stove and griddle needed to be cleaned inside and out; -DAs were responsible for cleaning the coffee pot; -The DM was responsible for ensuring staff completed cleaning assignments. During an interview on 04/11/25, at 2:09 P.M., [NAME] A said the following: -Kitchen staff had assigned cleaning duties; -The hand washing sink was not assigned to a certain staff member. All staff should clean it if it was dirty; -The cooks were responsible for cleaning the stove and griddle. It should not have food particles, carbon or grease build up; -The DAs were responsible for cleaning the coffee pot and it should be cleaned each shift. The coffee pot should not have a brownish residue on it; -If staff did not clean the kitchen, it could lead to resident illness. During an interview on 04/14/25, at 9:30 A.M., the DM said the following: -Kitchen staff had cleaning schedules and assignments; -Cook 2 was responsible for hand washing sink. The sink should not have any stains or residue on it and should not have a mug of liquid sitting on it; -The cooks were responsible for cleaning the stove and griddle. The stove and griddle should not have food particles, grease or carbon build up on the back splash or sides and should be cleaned each shift; -The DAs were responsible for cleaning the coffee pot at least each shift. The coffee pot should not have a brownish residue; -Cook 1 was responsible for making sure staff completed cleaning on their shift; -If the kitchen was not cleaned, this could cause cross contamination and resident illness; -He/she had instructed staff to clean and staff say they will but do not get it done. He/she was responsible for ensuring staff completed cleaning tasks. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -The entire kitchen staff and DM were responsible for cleanliness of the kitchen; -The hand washing sink, stove and griddle and coffee pot should all be clean; -Kitchen staff had sprays they could use to remove carbon build up. 3. Review of the FDA 2013 Food Code showed the following: -Except as specified in this section, an employee shall eat, drink, or use any form of tobacco only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. Review showed the facility did not provide a policy related to designated break areas. Observation on 04/11/25, at 9:30 A.M., showed the following: -DA C obtained cereal from a counter above the prep table and poured some into a bowl; -He/she walked with the bowl to the two door refrigerator located near the entrance of the kitchen and obtained milk and poured milk into the bowl. The DA tipped the bowl up and drank some milk out of the bowl, placed the bowl down, and placed the milk back into the refrigerator; -He/she carried the bowl over to the silverware container in front of the steam table and grabbed a spoon; -He/she carried the bowl and spoon into the dishwashing area and placed on a tray over clean dishes. He/she also had an opened banana on the tray; -He/she ate the cereal and banana over the clean dishes, threw the bowl and banana peel away and placed the spoon on the dirty side of the dishwashing area and walked out of the kitchen; -He/she did not clean the tray or remove the clean dishes he/she ate over from the clean side to the dirty side of the dishwashing area. During an interview on 04/11/25, at 10:01 A.M., DA C said the following: -He/she ate in the dishwashing room or in his/her car; -He/she did not go to the break room; -All the dishes on the rack were clean; -He/she ate above them and ate throughout the kitchen; -The only appropriate place to eat was the break room; -The DM was responsible for ensuring staff did not eat in the kitchen. During an interview on 04/11/25, at 11:53 A.M., DA D said the following: -Staff should eat behind the line where food was not prepared; -Staff should not prepare cereal then obtain milk, pour the milk into a bowl and then drink milk out of a bowl and then stand with the bowl over clean silverware in the kitchen area; -Staff should not eat over clean dishes in the dishwashing area; -If staff ate in the kitchen, prep area or over clean dishes in the dishwashing room they could contaminate surfaces and make residents ill. During an interview on 04/11/25, at 2:06 P.M., [NAME] B said the following: -Staff should eat in the break room or their car; -Staff should not prepare cereal then obtain milk, pour the milk into a bowl and then drink milk out of a bowl and then stand with the bowl over clean silverware in the kitchen area; -Staff should not eat over clean dishes in the dishwashing area; -If a staff member ate in the kitchen or dishwashing area over clean dishes, this could cause cross contamination and spread germs which could cause resident illness. During an interview on 04/11/25, at 2:09 P.M., [NAME] A said the following: -Staff should eat in the designated break room; -Staff should not prepare cereal then obtain milk, pour the milk into a bowl and then drink milk out of a bowl and then stand with the bowl over clean silverware in the kitchen area; -Staff should not eat over clean dishes in the dishwashing area; -The DM was responsible for ensuring staff ate in the designated break room. During an interview on 04/14/25, at 9:30 A.M., DA E said the following: -Staff should eat in the break room; -Staff should not eat over clean dishes because that was not sanitary and they could spill and dirty the dishes; -If he/she saw a staff member do this, he/she would tell that staff member to stop and report it to the DM. During an interview on 04/14/25, at 9:39 A.M., the DM said the following: -Staff should eat in the break room and not in the dishwashing room or kitchen; -Staff should not prepare cereal then obtain milk, pour the milk into a bowl and then drink milk out of a bowl and then stand with the bowl over clean silverware in the kitchen area; -Staff should not eat over clean dishes in the dishwashing area; -He/she told staff over and over to not eat in the kitchen or dishwashing room; -He/she was responsible for ensuring staff knew to eat in the break room and not the kitchen or dishwashing room. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -Staff should eat in the break room and not in the kitchen or dishwashing room; -Staff should have the cook make their tray and not make it for themselves; -If staff ate over clean dishes, this could contaminate all of the dishes and cause resident illness; -The DM was responsible for ensuring staff did not eat in the kitchen or dishwashing room.

Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 104. Review of the facility's job description titled Director of Food Services, dated 2003, showed the following: -The primary purpose of the job position was to assist the dietician in planning organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner; -Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association; -Must be registered as a Food Services Director in this state; -Must be knowledgeable of food services practices and procedures as well as the laws, regulations and guidelines governing food services functions in nursing care facilities. 1. During interviews on 04/10/25, at 10:00 A.M., on 04/11/25, at 10:17 A.M., and on 04/14/25, at 9:39 A.M., the Dietary Manager (DM) said the following: -He/she became the Dietary Manager in 11/2024; -He/she was not a Certified Dietary Manager (CDM); -He/she was not enrolled in a CDM course; -He/she asked the Administrator and Business Office Manager (BOM) several times about the course and they told him/her they were waiting on an e-mail; -The dietician came every two weeks, but was not employed full time at the facility; -He/she was not a certified food services manager, did not have an associates degree or higher in food services management or hospitality, and did not have two or more years experience as a dietary manager; -He/she did not have a serve safe certificate; -The Administrator and BOM were certified dietary managers, but were not employed as the Dietary Manager; -He/she had no training on food temperatures. During an interview on 04/14/25, at 10:28 A.M., the BOM said the following: -The DM did not have his/her CDM; -He/she did not know if the DM was enrolled in a CDM course; -He/she took the CDM course, but did not work in the capacity of the DM; -He/she did not monitor anything in the kitchen, the DM did. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -The DM was not a CDM; -The DM was not currently enrolled in a CDM course; -He/she did not know if the DM was Serve Safe certified; -He/she and the BOM had their CDM, but were not acting as the DM; -He/she did inservices with kitchen staff, but was not the DM; -The DM monitored the kitchen; -The dietician came twice monthly but was not employed full time; -He/she reviewed at the dietician's report; -The DM was responsible for the kitchen; -He/she was responsible for enrolling the DM in a CDM course.

Based on observation, interview, and record review, the failed to establish and maintain an effective infection prevention and control program when the facility failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely for seven staff members (Certified Medication Technician (CMT) F, DA G, Licensed Practical Nurse (LPN) H, Certified Nursing Assistant (CNA) I, CNA J, Registered Nurse (RN) K, and Dietary Aide (DA) E) of ten sampled staff members. The facility staff also failed to wash their hands after providing catheter (a tube that is inserted into the bladder, allowing urine to drain freely) and incontinent care for one resident (Resident #4) The facility census was 104. 1. Review of the facility's policy titled Employee Screening for Tuberculosis, revised 03/2021, showed the following: -All employees are screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease using tuberculin skin test (TST - a skin test used to detect exposure to the bacteria that cause tuberculosis) or interferon gamma release assay (IGRA - a blood test used to diagnose LTBI) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made, but prior to the employee's duty assignment; -Screening included a baseline test for LTBI using either a TST or IGRA and individual risk assessment and symptom evaluation. If the baseline test was negative and individual risk assessment indicated no risk factors for acquiring TB, then no additional screening was indicated. If the baseline test was positive, but the individual risk assessment was negative and the individual was asymptomatic, a second test (either TST or IGRA) was conducted; -The employee health coordinator (or designee) will accept documented verification of TST or IGRA results within the preceding 12 months. If the previous TST or IGRA result was negative and the individual was at low risk of TB infection, the employee would not be retested prior to employment. If the previous TB test was positive, but the individual was at low risk for TB infection, was asymptomatic, and was at low risk of disease progression, a second test would be conducted; -Individuals who have had a Bacillus Calmette-Guerin (BCG - a vaccine that helps prevent TB) vaccination will have an initial screening test. An IGRA is the preferred method of testing for individuals who have received the BCG vaccine; -The decision to perform serial (e.g., annual) testing after baseline is based on individual risk factors of exposure both at work and outside of work; -The infection preventionist determines how to proceed with follow up testing based on individual risk factors and baseline test results. Review of 19 CSR 20-20.100 showed the following: -Long-term care facilities shall screen their residents and staff for tuberculosis; -Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained for all employees and volunteers; -All long-term care facility employees and volunteers who work ten or more hours per week are required to a complete a TB test within one month prior to starting employment in the facility; -If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins; -Employees and volunteers with an initial negative two-step TB test shall be one-step tested annually and the results recorded in a permanent record. 2. Review of CMT F's personnel file showed the following: -Hire date of 03/14/24; -The first TST was administered on 02/17/25 and read on 02/19/25 with a result of 0 millimeters (mm - negative); -The second TST was administered on 02/26/25 and read on 02/28/25 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the Infection Preventionist (IP) said CMT F did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the Assistant Director of Nursing (ADON) said CMT F did not have a negative TST prior to working on the floor. During an interview on 04/11/25, at 11:09 A.M., the Business Office Manager (BOM) said the CMT did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the Director of Nursing (DON) said the CMT did not have a negative TST prior to working the floor. 3. Review of Dietary Aide (DA) G's personnel file showed the following: -Hire date of 12/27/24; -The first TST was administered on 02/17/25 and read on 02/19/25 with a result of 0 mm; -The second TST was administered on 02/26/25 and read on 02/28/25 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said DA G did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said DA G did not have a negative TST prior to working on the floor. During an interview on 04/11/25, at 11:09 A.M., the BOM said the DA did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the DA did not have a negative TST prior to working the floor. 4. Review of LPN H's personnel file showed the following: -Hire date of 10/23/23; -The first TST was administered on 11/02/23 and read on 11/04/23 with a result of 0 mm; -The second TST was administered on 11/30/23 and read on 12/02/23 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said LPN H did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said LPN H did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the LPN did not have a negative TST prior to working the floor. 5. Review of CNA I's personnel file showed the following: -Hire date of 10/29/24; -The first TST was administered on 10/29/24 and read on 10/31/24 with a result of 0 mm; -The second TST was administered on 11/07/24 and read on 11/09/24 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said CNA I did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said CNA I did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the CNA did not have a negative TST prior to working the floor. 6. Review on CNA J's personnel file showed the following: -Hire date on 12/05/24; -The first TST was administered on 12/05/24 and read on 12/07/24 with a result of 0 mm; -The second TST was administered on 12/20/24 and read on 12/22/24 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said CNA J did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said CNA J did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the CNA did not have a negative TST prior to working the floor. 7. Review of Registered Nurse (RN) K's personnel file showed the following: -Hire date of 07/16/24; -The first TST was administered on 07/16/24 and read on 07/18/24 with a result of 0 mm; -The second TST was administered on 08/01/24 and read on 08/04/24 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said RN K did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said RN K did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the RN did not have a negative TST prior to working the floor. 8. Review of DA E's personnel file showed the following: -Hire date of 12/05/24; -The first TST was administered on 12/05/24 and read on 12/07/24 with a result of 0 mm; -The second TST was administered on 12/14/24 and read on 12/16/24 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said DA E did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said DA E did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the DA did not have a negative TST prior to working the floor. 9. During an interview on 04/10/25, at 2:29 P.M., the Business Office Manager (BOM) said the following: -Staff completed the first TST on their date of hire and read the TST two days later; -New staff completed orientation prior to working on the floor; -He/she did not know if newly hired staff needed their first TST read prior to working on the floor; -The ADON was responsible for ensuring newly hired staff's TST was completed prior to working on the floor. During an interview on 04/10/25, at 2:46 P.M., the IP said the following: -He/she had a nurse administer newly hired staff their first TST during orientation; -Orientation lasted one day and then staff trained on the floor for one day; -He/she or a nurse read the first TST two days later; -The first TST should be read prior to staff working on the floor so residents who have are immunocompromised were not exposed to TB disease; -He/she gave the completed form to the ADON; -The DON was ultimately responsible for ensuring the first TST was administered and read prior to staff working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said the following: -New staff completed one day of orientation and then one day on the floor without hands on the residents; -A nurse administered the first TST during orientation and read the TST two to three days later; -He/she did not know new staff could not work the floor prior to their first TST being read until now; -He/she was responsible for ensuring newly hired staff had a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the following: -Newly hired staffs' first TST was administered at orientation and read 48 to 72 hours later; -Newly hired staffs' first TST should be read and be negative prior to working on the floor; -The ADON took care of the TB forms, but he/she was ultimately responsible for ensuring newly hired staff had a negative TST prior to working on the floor. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -Newly hired staff received a TST upon hire and the TST was read within 72 hours; -Newly hired staff should not work the floor until their first TST was read and was negative; -The IP was responsible for administering and reading newly hired staffs TST and the ADON monitored to ensure these were completed. 50185 10. Review of the facility's policy titled Handwashing/Hand Hygiene, revised October 2023, showed the following: -All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors; -Hand hygiene should be performed before applying gloves and after the removal of gloves; -Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, after touching a resident, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal. Review of the facility's policy titled Catheter Care, Urinary, revised August 2022, showed after performing care, staff to discard disposable items into designated containers, remove gloves and discard into designated container, and wash and dry hands thoroughly before repositioning bed covers, handling the call light. Review of Resident #4's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses include heart failure, high blood pressure, diabetes, and pressure ulcers. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 04/07/25, showed the following information: -Cognitively intact; -Dependent on staff for toileting hygiene; -Indwelling catheter use and incontinent of bowel. Review of the resident's care plan, initiated on 04/09/25, showed the following: -Provide peri-care after each incontinent episode; -Provide catheter care each shift. Observation on 04/11/25, at 10:05 A.M., showed Certified Nursing Assistants (CNA)'s Y and Z entered the resident's room, donned gowns and gloves, and performed incontinent and catheter care appropriately. After CNA Y cleansed the resident's catheter, front side, and back side, CNA Y did not change his/her gloves and/or wash his/her hands. CNA Y then adjusted the resident's side rails and placed a new bed pad underneath the resident. CNA Y then unfolded a clean blanket and placed it on top of the resident. CNA Y obtained the resident's call button and bed controller and adjusted the bed height and placed the call light on top of the resident. CNA Y then took off his/her gloves and performed hand hygiene. During an interview on 04/15/25, at 10:51 A.M., CNA Q said the following: -Hand hygiene was expected before, during, and after resident cares; -It would not be appropriate to touch multiple surfaces with soiled gloves and/or hands. During an interview on 04/15/25, at 12:17 A.M., CMT R said the following: -Staff should perform hand hygiene before, during, and after resident cares; -It would not be appropriate to touch multiple surfaces with soiled gloves and/or hands. During an interview on 04/15/25, at 12:49 P.M., RN L said the following: -Staff were expected to perform hand hygiene before, during, and after resident cares; -Staff were expected to removed soiled gloves and perform hand hygiene after performing resident cares and before touching anything else in the resident's room. During an interview on 04/15/25, at 1:17 P.M., the MDS Coordinator/Infection Preventionist said the following: -Staff were expected to perform hand hygiene before, during, and after resident cares; -Anytime gloves need changed, hand hygiene should be performed. During an interview on 04/15/25, at 1:46 P.M., the ADON said the following: -Staff were expected to perform hand hygiene before, during, and after resident cares; -Staff were expected to remove soiled gloves and perform hand hygiene after performing resident cares and before touching anything else in the resident's room. During an interview on 04/15/25, at 2:35 P.M., the DON said the following: -Staff were expected to perform hand hygiene before, during, and after resident cares; -Staff were expected to change their gloves and perform hand hygiene if their gloves become soiled; -The CNA should have removed his/her gloves and performed hand hygiene prior to continuing care. During an interview on 04/15/25, at 3:44 P.M., the Administrator said staff were expected to perform hand hygiene before, during, and after resident cares.

Based on observation, interview, and record review, the facility failed to ensure each resident received food and drink that was palatable, attractive and at an appetizing temperature when meals were served colder than resident preference and out of recommended service temperature range. The facility census was 104. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Except during preparation, cooking, or cooling, time/temperature control for safety food shall be maintained at 41 degrees Fahrenheit ( F) or less; -Time/temperature control for safety food that is cooked to a temperature and for a time specified and received hot shall be a temperature of 135 F or above. Review of the facility's policy titled Food Preparation and Service, dated 2001, showed the following: -Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices; -Food Distribution means the processes involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service, or delivering meals to residents' rooms or dining areas, etc. When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart; -Proper hot and cold temperatures are maintained during food distribution and service; -The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. Review of the facility's Food Temperature Log, undated, showed minimum holding temperature for hot greater than 135 F (or check specific state requirements) and cold food less than 41 F. 1. Observation on 04/10/25, at 11:58 A.M., showed the following: -Cook A took temperatures of all food on the steam table prior to food service; -Pork and gravy were 180 F, corn casserole and mashed potatoes were 175 F, green beans were 195 F and mechanical soft pork and puree pork were 165 F. Observation on 04/10/25, at 2:00 P.M., showed the following: -The last hall tray was delivered in the Special Care Unit (SCU) at 2:00 P.M.; -A test tray taken from the hall cart at 2:00 P.M.; -The test tray food temperatures showed the pork was 109 F, the corn casserole was 108.3 F, green beans were 107.5 F, and the milk was 52.8 F. During an interview on 04/08/25, at 1:45 P.M., Resident #23 said he/she ate in the dining room and the food was cold at times, especially the french fries. During an interview on 04/09/25, at 10:23 A.M., Resident #77 said the food was always cold regardless if he/she obtained a hall-tray or ate in the dinning room. During an interview on 04/09/25, at 2:56 P.M., Resident #43 said he/she ate in his/her room. The food was always cold and the drinks were always hot. This has been an issue for a long time. During an interview on 04/10/25, at 9:59 A.M., Resident #92 said he/she ate in the room and breakfast was cold. His/her spouse brought in food for lunch and dinner sometimes. He/she only liked the peanut butter and jelly sandwiches from the facility. During an interview on 04/15/25, at 2:00 P.M., Resident #49 said when staff served the resident meals in his/her room, the hot foods arrived cold. He/she did not enjoy eating the cold meals. During an interview on 04/11/25, at 2:06 P.M., [NAME] B said the following: -Hot food should be 165 or hotter and cold food or milk should be 38 F to 40 F. These should be the same temperatures when they reach the resident; -The cooks were responsible for taking temperatures of food each shift. During an interview on 04/11/25, at 2:09 P.M., [NAME] A said the following: -Hot foods should be 145 F for fish and 165 F for all other meats and hot foods. Cold foods and drinks should be 30 F to 38 F; -Hot foods should maintain that temperature on the steam table and cold foods should remain cold when they reach the resident; -The temperatures of 109 F for the pork, 108.3 F for the corn casserole, 107.5 F for the green beans, and 52.8 F for the milk were not acceptable; -The cooks were responsible for taking temperatures of the food on the steam table and ensuring food was delivered to the residents at an appetizing temperature. During an interview on 04/14/25, at 9:39 A.M., the Dietary Manager (DM) said the following: -Hot foods should be kept at 160 F and cold food between 42 F and 45 F; -When a tray reached a resident, hot food should be 145 F and cold food 35 F; -The temperatures of 109 F for the pork, 108.3 F for the corn casserole, 107.5 F for the green beans, and 52.8 F for the milk were not acceptable; -He/she had no training on food temperatures; -He/she was responsible for ensuring trays reached the residents at an appetizing temperature. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -Hot food was held at 140 F to 160 F, cold food less than 40 F, and cold drinks in the 30s F; -When a plate reached a resident the hot food should be at least 120 F and milk not over 40 F; -The temperatures of 109 F for the pork, 108.3 F for the corn casserole, 107.5 F for the green beans, and 52.8 F for the milk were not acceptable; -The cooks should ensure the trays leave the kitchen at an appropriate temperature; -The cooks should take temperatures of the food on the steam table before service, in the middle of service and at the end of service; -The DM was ultimately responsible for ensuring trays reach residents at an appetizing temperature. 34906 49585 50185

Based on observation, interview, and record review, the facility failed to provide activity programs to meet the needs of all residents when failed to to have activities routinely scheduled and provided on the Special Care Unit (SCU) and failed to care plan regarding activities for two residents (Resident #85 and #88) who resided on the SCU. The facility also failed to provide a varied activity program that met the needs of residents and failed to care plan regarding activities for three residents (Resident #49, #57, and #77) who resident outside of the SCU. The facility census was 104. Review of a facility policy titled Activity Programs, dated June 2018, showed the following: -Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well being of each resident; -The activities program is provided to support the well-being of residents and to encourage independence and community interaction; -Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident; -The activities program is ongoing and includes facility-organized group activities, independent, and assisted individual activities; -Activities are designed to encourage maximum individual participation and are geared to the individual resident needs; -Activities are scheduled seven days a week and residents are given the opportunity to contribute to the planning, preparation, conducting, clean up and critique of the programs; -Activities consist of individual, small and large group activities that are designed to meet the needs and interest of each resident and promote self-esteem, comfort, pleasure, education, creativity, success, and independence; -All activities are documented in the resident medical record; -Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board; -Individual and group activities are provided that reflects the schedules, choices, and rights of the residents, are offered at hours convenient to the residents, including evenings, holidays, and weekends reflects the cultural and religious interests, hobbies, life experiences and personal preferences of the residents, appeal to men and women and residents of various age groups, and incorporate family, visitor, and resident ideas of desired activities, -Residents are encouraged, but not required, to participate in activities. 1. Observation of the SCU during survey showed no activity calendar posted. Review showed staff did not provide an activities calendar for the SCU. 2. Review of Resident #85's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included congestive heart failure (CHF - chronic condition where the heart does not pump blood as well as it should), vascular dementia (decline in thinking skills caused by reduced or blocked blood flow to the brain), and depression. Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff), dated 02/06/24, showed the following: -Physical behavioral symptoms (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) directed at others occurred one to three days in look back period; -Behavioral symptoms did not interfere with activity participation or the participation of others; -It was important for resident to listen to music, be around animals, do your favorite activities, be around groups of people, go outside to get fresh air when the weather is good, and participate in religious services or practices; -Limited assistance of one staff person for mobility. Review of the resident's quarterly activities participation review, dated 12/31/24, showed the following: -Resident participated in 75% of group activities and events, and one-to-one activity 100% of the time; -Resident liked to listen to music and rhythm band. Resident liked balloon ball one-on-one and liked to get back rubs; -Activity related focuses remained appropriate/current as per current care plan; -Interventions/approaches have been effective in reaching goals. Review of the resident's care plan, revised on 04/09/25, showed staff did not care plan regarding the resident's preferred activities or participation in activities. Observation on 04/08/25, at 2:38 P.M., showed the resident resting in bed with no television or radio on. No activities were offered at that time. Observation on 04/09/25 10:22 A.M. showed the resident ambulating in hallway. No activities were offered at that time. Observation on 04/09/25, at 12:52 P.M. showed the resident sitting in his/her room. No activities were observed on the unit at that time. Observation on 04/10/25, at 11:20 A.M., showed the resident asleep in his/her room and no activities offered at that time. Observation on 04/11/25, at 9:00 A.M., showed the resident walked down the hall and sat in a dining room chair. No food service or activities were offered at that time. Observation on 04/15/25, at 11:30 A.M., showed the resident walking up and down the hallway with no organized group activity occurring at that time. 3. Review of Resident #88's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia, high blood pressure, and depressive episodes Review of the resident's annual MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Verbal behaviors (threatening, screaming, and cursing) directed at others occurred one to three days; -Other behaviors (hitting, pacing, rummaging, sexual acts, disrobing, throwing or smearing food, or yelling or screaming) not directed at others occurred one to three days in look back period; -Resident preferred listening to music, being around animals, spending time outdoors, and participating in activities; -Behavioral symptoms do not interfere with activity participation or the participation of others; -Independent with mobility, transfers, and dressing. Review of the resident's initial activities review, dated 11/14/24, showed the following: -Resident participated and liked country music, walking with a partner, and short stories; -Resident would like to participate in group and one-on-one activities; -Resident needed encouragement and assistance to attend activities. Review of the resident's care plan, revised on 04/09/25, showed staff did not care plan regarding the resident's preferred activities or participation in activities. Observation on 04/08/25, at 2:32 P.M., showed the resident sitting in wheelchair in the hallway. No activities were offered at that time. Observation on 04/09/25, at 11:32 A.M., showed the resident in his/her wheelchair in the hallway with no activities offered at that time on the SCU. Observation on 04/10/25, at 11:20 A.M., showed the resident sitting in his/her wheelchair roaming around unit. No activities were offered at that time. Observation on 04/11/25, at 9:00 A.M., showed the resident and several other residents sitting in the hallway with no activities offered at that time. Observation on 04/11/25, at 1:23 P.M., showed resident resting in bed with no music or television playing. No activities were offered at that time. 4. During an interview on 04/11/25, at 9:30 A.M., Certified Medication Technician (CMT) P said the Activities Director takes residents to bingo sometimes. There are no scheduled activities on the SCU. During an interview on 04/11/25, at 9:30 A.M., CMT O said the following: -The beautician used to come to the unit to provide activities and provided an activity calendar when not providing hair services; -The beautician quit over a month ago; -More alert residents are taken to bingo which is offered off the unit at times; -No activities are offered on the SCU. During an interview on 04/14/25, at 2:55 P.M., Registered Nurse (RN) M said there was no activity calendar on the SCU. Cognitive residents are taken off the unit to attend bingo offered on Monday, Wednesday, and Friday. During an interview on 04/15/25, at 10:50 A.M., Licensed Practical Nurse (LPN) N they do not do activities on the unit. The Activity Director does not go to the unit. There is no activity calendar on the unit. SCU staff will have residents fold clothes for an activity. During an interview on 04/15/25, at 12:45 P.M., Nurse Assistant (NA) U said the beautician used to come to the unit for activities, but does not come anymore. There was no activity calendar on the unit. Some residents will attend bingo at times. During an interview on 04/15/25, at 12:50 P.M., CMT T said aides provide some activities on the unit and some residents attend bingo off the unit at times. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -There were no activities on the unit; -The beautician provided activities on the unit, but no longer works for the facility; -There is an aide that brought activities at times when he/she worked on the unit; -The Activity Director did not do one-on-one activities in resident rooms. During an interview on 04/15/25, at 2:34 P.M., the Director of Nursing (DON) said the following: -He/she would like to see more activities on the SCU; -There used to be a lot more activities on the unit; -Residents on the SCU just wander so they need activities; -The Activity Director was not doing activities on the unit, and he/she did not know why; -The beautician had been gone about a month and was the one doing activities on the unit. During an interview on 04/15/25, at 3:41 P.M., the Administrator said the following: -There had been no activity person for the unit for four or five weeks; -Unit staff often do activities with SCU residents and keep them busy. 34906 5. Review of Resident # 49's face sheet showed the following: -admitted [DATE]; -Diagnoses included general anxiety disorder. Review of the resident's annual MDS, dated [DATE], preferences for activities section showed the resident said it was very important to him/her to do things with groups of people, to do his/her favorite activities, and to participate in religious services. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Exhibited no behavioral symptoms; -Functional limitation in range of motion to all four extremities; -Used motorized wheelchair for mobility device; -Independent with eating; -Dependent on staff for toileting hygiene, showers, lower body dressing, and with transfers; -Required partial/moderate assistance of staff with personal hygiene; -Required substantial/maximal assistance of staff with upper body dressing, and rolling from left to right. Review of the resident's current care plan showed staff did not care plan related to the resident's preferred activities or attendance. Observation of and interview with the resident on 04/09/25, at 10:45 A.M., showed the following: -The resident lay on his/her bed; -The resident said the facility did not have activities every day; -The Activities Director had bingo on Monday, Wednesday, and Friday and the facility had someone come in and do church service about one time per month; -The residents have talked with the Activities Director about having more and different activities, but the Activities Director just made up excuses as to why he/she will not do other activities; -The resident would enjoy more activities and a different variety of activities; -The residents were bored at times due to not enough activities. 50185 6. Review of Resident #57's face sheet showed the following: -admitted [DATE]; -Diagnoses included schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves), kidney disease, depressive episodes, and anemia (a condition where the blood doesn't carry enough oxygen to the body's tissues.) Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment. -Activity preferences included, listening to music, being around animals, watching the news, participating in group activities, going outside, religious activities, and it was very important to have the opportunity to participate in those activities; -No staff assessment of activity preferences completed. Review of the resident's care plan, revised 04/09/25, staff did not care plan the resident's activity preferences or participation. During an interview on 04/10/25, at 9:48 A.M., the resident said the following: -Bingo was offered three times a week; -No other activity was offered to him/her; -He/she wished there was more to do. Review of the resident's progress notes, dated 02/06/25 through 04/10/25, showed staff did not document regarding the resident's activity preferences or participation. Review of the resident's Electronic Medical Record (EMR) showed staff did not document completion of an activity assessment. 7. Review of Resident # 77's face sheet showed the following information: -admitted [DATE]; -Diagnoses included multiple sclerosis (a chronic autoimmune disease where the body's immune system attacks the protective covering around nerve cells (myelin) in the brain and spinal cord, disrupting nerve signal transmission), high blood pressure, high blood sugar, and double vision. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Activity preferences included being around pets, participating in group activities, going outside, listening to music, reading books, and it is very important to have the opportunity to participate in those activities; -No staff assessment of activity preferences completed. Review of the resident's care plan, revised 04/09/25, showed staff did not care plan related to the resident's activity preferences or participation. During an interview on 04/09/25, at 10:00 A.M., the resident said the only activity that was offered was bingo three times a week. Review of the resident's progress notes dated February 2025 through April 2025, showed staff did not document regarding the resident's activity preferences or participation. Review of the resident's EMR showed staff did not document completion of an activity assessment. 8. During an interview on 04/15/25, at 4:30 P.M., the Activity Director said the following: -He/she did not have enough time to do all activities for every resident in the building; -The facility had a large number of residents for one Activity Director; -The administration expected the Activity Director to chart on everyone and go shopping one day per week; -He/she had never been able to plan for the activities, because he/she was too busy charting; -Sometimes, he/she could not get the nurse aides to help bring the residents to activities; -He/she tried to make up activity packets, including coloring pages, for the residents to use on the weekends and a volunteer came every other weekend on Sunday to do church service, but otherwise, the facility did not offer activities to the residents on the weekends; -The facility did have a beautician that assisted with resident activities in the dementia unit, but he/she quit a few weeks back and had not been replaced. Some of the staff in the unit try to do activities with the dementia residents when they have time. During an interview on 04/15/25, at 12:45 P.M., LPN W said the following: -He/she worked every other weekend and the facility did not offer activities to the residents on the weekends; -The facility needed to do more activities with the residents because activities helped to improve the residents' spirits/moods. During an interview on 04/15/25, at 12:17 P.M., CMT R said the following: -The Activities Director changes the shopping day a lot and does the shopping his/herself, without the residents; -Bingo was the main activity; -He/she was not sure if there were any activities on the weekends, There use to be a couple who would provide religious service, but they stopped coming over four years ago. During an interview on 04/15/25, at 12:49 P.M., RN L said the following: -Bingo was the main activity and it happened a couple times a week; -Shopping occurred once a week and the Activity Director did that herself, without the residents; -He/she had not seen any other, or individual activities going on in the past year in a half. During an interview on 04/14/25, at 2:55 P.M., RN M said different activities were offered in the facility, but he/she did not know the schedule. During an interview on 04/15/25, at 1:46 P.M., the ADON said the following: -There were not enough activities offered to residents; -The Activity Director did not do one-on-one activities in resident rooms; -More activities could be done; -Residents had voiced they are unhappy with the activities. During an interview on 04/15/25, at 2:34 P.M., the DON said the following: -He/she has not seen activities offered for bed bound residents; -No church services were offered on the weekend; -No activities were offered by the nurses on the weekend. During an interview on 04/15/25, at 3:41 P.M., the Administrator said the following: -Resident council had voiced complaints about activities; -The Activity Director was not documenting residents on the daily activity record, he/she was completing quarterly or admit assessments only; -The activity program should be more in-depth and comprehensive; -The Activity Director did not do as much as he/she should for residents in room or bed bound; -Residents have self-initiated activities on weekend; -They facility would love to have activities on weekend if the budget would allow it.

Based on observation, interview, and record review the facility failed to provide the highest quality of care and ensure that all residents receive treatment and care in accordance with professional standards of practice when the facility failed to document care and treatment refusals for one resident (Resident #2) with skin concerns, that ultimately led to infection. The facility census was 98. Review of the facility's undated policy, titled Wound and Skin Care Protocols, showed the following information: -The Director of Nursing (DON) will be responsible for reviewing weekly wound reports and monitoring progress/decline of any wound and assuring compliance with current standards of would care practice; -The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention and/or treatment of impaired skin integrity/pressure injuries. Review of the facility's undated policy, titled Assessment and Documentation, showed the following information: -Assess the wound etiology, resident's overall condition, nutritional needs, pain/pain control, need for pressure reducing devices, and management of infection/bacterial burden. Review of the resident's face sheet (brief look at resident information) showed the following information: -re-admission date to the facility of 09/25/24; -Diagnoses include high blood pressure, obesity, and chronic pain. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff) dated 02/18/25, showed the following: -Cognitively intact; -Required substantial to maximum assistance from staff for mobility; -No open lesions on the skin. Review of the resident's care plan, dated 05/21/25, showed the following: -Measure wounds weekly; -Pressure reducing device to bed and wheelchair; -Provide assistance with mobility; -Wound care per physician order. Review of the resident's skin assessment, dated 04/08/25, showed the following: -During skin assessment, LPN A observed three new open areas to reddened right pannus ( an overhand of excess skin and fat that hands below the abdomen) and one open area to the left abdominal fold; -All areas were cleansed with wound wash, patted dry, nystatin (an antifungal medication that treats infections caused by yeast) was applied to closed gaulded (reddened/ chaffed)areas, and interdry (moisture wicking fabric with antimicrobial silver) was applied to open areas; -The residents Physician was notified; -No measurements included. Review of the resident's April 2025 Physician Order Sheet (POS), showed the following information: -An order dated 04/02/25; Cleanse wound to left side fold with wound cleanser, apply skin prep to peri-wound (skin surrounding wound.) Apply polymem pink (non-adhesive hydrophilic pads that are designed to facilitate healing) and cover with opsite (transparent adhesive film), change on Monday, Wednesday, and Friday; -An order dated 04/01/25; Cleanse would and dry area to right pannus. Apply barrier cream, place interdry (moisture wicking fabric with antimicrobial silver) and change daily; Review of the resident's skin assessment, dated 04/15/25, showed the following: -Left abdominal fold MASD (Moisture Associated Skin Damage) measured 0.8 centimeters (cm) by 1.2 cm depth, and 0.1 cm wound bed; -Wound care performed per orders. No significant changes to left abdominal fold. Area continues to remain fragile; -The resident is up in the wheelchair a significant part of the day; -Right pannus not measured but was extremely gaulded. The resident was educated on keeping the area clean and dry; -Physician aware. Review of the resident's skin assessment, dated 04/22/25, showed the following: -Left abdominal fold MASD measured 0.5 cm in width by 0.8 cm depth, with 0.1 cm wound bed; -Would care performed per orders. Left abdominal fold wound measured smaller. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded; -Physician aware Review of the resident's skin assessment, dated 04/29/25, showed the following: -Left abdominal fold MASD measured 0.4 cm in width by 0.6 cm depth, with 0.1 cm wound bed; -Would care performed per orders. Left abdominal fold wound measured smaller. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded, three open areas to the right groin measuring 0.5 cm x 1.0 cm; -Physician aware. Review of the resident's April 2025 Treatment Administration Record, showed the following: -Right Pannus treatment was not administered on 04/02, 04/09, 04/13, 04/16, and 04/25 due to the resident refusing; -Right pannus treatment was not administered on 04/10, 04/15, 04/17, and 04/28. No supporting documentation of reasoning. -Left abdominal fold treatment was not administered on 04/02, 04/09, 04/16, and 04/25 due to the resident refusing; -Left abdominal fold treatment was not administered on 04/28. No supporting documentation of reasoning. Review of the resident's skin assessment, dated 05/06/25, showed the following: -Left abdominal fold MASD measured 0.4 cm in width by 0.6 cm depth, with 0.1 cm wound bed; -Would care performed per orders. Left abdominal fold wound measured smaller. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded, three open areas to the right groin measuring 0.5 cm x 1.0 cm; -Physician aware. Review of the resident's skin assessment, dated 05/14/25, showed the following: -Left abdominal fold MASD measured 0 cm in width by 0 cm depth, with 0 cm wound bed; -Would care performed per orders. Left abdominal fold wound measured smaller. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded; -Right pannus wound number one measuring 1.5 cm x 1.5 cm with 0.2 cm depth. Right pannus wound number two measuring 1.8 cm x 1.2 cm x 0.2 depth; -Physician aware; -Resident refuses to use inderdry and insists staff place pillowcases under his/her abdominal folds instead. The resident was educated. Review of the resident's POS showed the following: -An order dated 05/15/25, at 10:33 P.M., for Cephalexin (a type of antibiotic called cephalosporin, that works by killing bacteria) 500 milligram (mg) tablet; give one tablet by mouth (po) two times a day (bid) for left abdominal wall cellulitis for seven days. Review of the resident's MAR showed the following: -An order dated 05/16/25 for Cephalexin 500 mg tablet; give one tablet po bid for left abdominal wall cellulitis for 12 administrations. Review of the resident's progress notes dated 05/17/25 through 05/20/25, showed the resident remained on antibiotics for cellulitis. The resident's left abdominal fold continued with redness, pain, and warmth to touch. No physician notification documented, and no new order requests. Review of the resident's May 2025 POS showed the following: -An order dated 05/16/25 to cleanse two wounds to abdominal pannus with wound cleanser, apply skin prep to peri-wound, apply calcium alginate to wound beds, cover with 4x4 island dressing and change daily; Review of the resident's May 2025 MAR showed the following: -Right pannus treatment not administered on 05/07, 05/12-13, 05/16, and 05/27. No supporting documentation as to why; -Right pannus treatment not administered on 05/08 or 05/24 due to the resident refusing; -Two wounds to abdominal pannus treatment not administered on 05/16 or 05/27 due to the resident refusing. -Two wounds to abdominal pannus treatment not administered on 05/24 due to the resident refusing; -Left abdominal treatment not administered on 05/07 or 05/12. No supporting documentation as to why; -Left abdominal treatment not administered on 05/14 due to the resident refusing; -Left abdominal treatment was discontinued on 05/15. Review of the resident's skin assessment, dated 05/21/25, showed the following: -Left abdominal fold MASD measured 0 cm in width by 0 cm depth, with 0 cm wound bed; -Would care performed per orders. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded; -Right pannus wound number one measuring 2.0 cm x 2.0 cm with 0.2 cm depth. Right pannus wound number two measuring 2.0 cm x 1.0 cm x 0.2 depth; -Physician aware; -Resident refuses to use inderdry and insists staff place pillowcases under his/her abdominal folds instead. The resident was educated. Review of the resident's progress note dated 05/24/25 at 7:31 P.M.; showed the resident had a change of condition and was lethargic and had worsening of the cellulitis on his/her pannus. Redness and warmth has spread across the entire abdominal fold. Labs and new antibiotics ordered. Review of the resident's May 2025 POS showed the following: -An order dated 05/24/25 for Cefuroxime (antibiotic that belongs to the class of medications known as cephalosporin antibiotics that treats bacterial infections) 500 mg; take one tablet po bid for cellulitis for seven days Review of the resident's EMR, showed no additional skin assessments after 05/21/25. During an interview on 06/04/25, at 3:23 P.M., The Assistant Director of Nursing (ADON) said the following: -The resident often refuses care; -Skin assessments are not being completed on a consistent basis but she is not aware of any not being completed; -If resident refuses care she expects to see it documented in the progress notes; -She expects skin assessments to be completed weekly. During an interview on 06/05/25, at 10:20 A.M., The resident said the following: -He/she feels like a lot of his/her treatments have not been administered; -When staff do complete his/her treatment, it is only once a day and it should be more often; -The staff save him/her for last because he/she has to be in a seated position in the wheelchair otherwise staff are not able to get to it while he/she lays in bed; -The lack of treatment administration is what he/she believes caused the cellulitis; -He/she does not often refuse, unless he/she is in bed. But he/she always tells the staff to just come back when he/she is up in his/her wheelchair and they do not come back. During an interview on 06/04/25, at 3:55 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she completes skin assessments on residents, along with other charge nurses; -He/she is not sure if skin assessments are getting completed weekly, but they should be; -Resident refusals should be documented. During an interview on 06/05/25, at 1:50 P.M., LPN B said the following: -Any wound assessments should be completed by LPN A or the Director of Nursing (DON); -Staff nurses complete weekly skin assessments when they are scheduled; -The resident has two wounds under the pannus, he/she believes it is due to the amount of weight the abdomen is and that causes pulling; -If he/she was alerted of a new wound, he would follow their wound protocol which includes to document the area and initiate a treatment until it can be assessed by the DON; -If a resident refuses treatments, that should be documented and care planned. During an interview on 06/05/25, at 2:15 P.M., The DON said the following: -Wound assessments that include measurements and descriptors are completed by her and/or LPN A, they are done weekly; -Skin assessments are also expected to be completed weekly by the staff nurses; -The resident has two wounds under the pannus which were caused by the weight of the abdomen and pulling; -If a resident refuses treatment, she expects that to be documented and care planned. During an interview on 06/05/25, at 5:32 P.M., The MDS/Care Plan coordinator said all wounds, wound care, and refusal status should be noted in the care plan. During an interview on 06/05/25, at 5:40 P.M., The Administrator said the following: -Skin assessments are expected to be completed weekly; -All resident refusals, wounds, and wound care should be documented and care planned. MO00255059

Based on interview, and record review, the facility failed to develop and implement comprehensive care plans for all residents when staff failed to care plan regarding dementia, skin integrity, and multiple medications/diagnoses for two residents (Resident #92 and #61). The facility census was 104. Review of a facility policy titled Dementia-Clinical Protocol, revised November 2018, showed the following: -As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia or otherwise impaired cognition; -For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function of life; -For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life; -Direct care staff will support the resident in initiating and completing activities and tasks of daily living; -The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician; -The IDT will adjust interventions and the overall plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. Review of a facility policy titled Care Plans, Comprehensive Person Centered, dated March 2022 showed the following: -The IDT, the resident, and his/her family develops and implements a comprehensive, person-centered care plan for each resident; -The care plan is developed within seven days of the completion of the Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) assessment, and no more then 21 days after admission; -Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical mental and psychosocial well-being, including services that would be provided for the above; any specialized services as a result of the preadmission screening and resident review (PASARR) recommendations; which professional services are responsible for each element of care. The care plan includes the resident's stated goals and outcomes upon admission, builds on the resident strengths, and reflects standard of practice for problem areas and conditions; -Assessments of residents are ongoing and care plans are revised as resident information changes; -The care plan is reviewed and updated when there is a significant change in condition, the desired outcome is not met, the resident is readmitted to the facility, and at least quarterly. 1. Review of the Resident #92's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included dementia (progressive loss of intellectual functioning that interferes with daily functioning), left hemiplegia (muscle weakness or paralysis on one side of the body), and diabetes mellitus. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Substantial to maximum assistance with dressing, showers, toileting, mobility, and hygiene; -Resident taking an antipsychotic, antianxiety, and antidepressant medications; -No behaviors indicated; -No current skin conditions and not at risk for pressure ulcers. Review of the resident's current Physician Order Sheet (POS) showed the following information: -An order, dated 12/12/24, for Xarelto (blood thinner) 20 milligrams (mg) tablet, give once daily to prevent blood clots; -An order, dated 12/12/24, for Wellbutrin XL (antidepressant) 150 mg tablet, give once daily for major depressive disorder; -An order, dated 12/12/24, for vilazodone (antidepressant) 40 mg tablet, give once daily for major depressive disorder. Review of a resident skin evaluation, dated 02/16/25, showed resident had a stage II (wound with partial thickness skin loss) pressure injury on coccyx (tailbone), measuring 3.9 centimeters (cm) by 2.3 cm by 0.1 cm. Review of a resident's skin evaluation, dated 03/26/25, showed resident had a deep tissue injury (type of pressure ulcer where damage occurs to the underlying soft tissues, like muscle and fat, before the skin shows visible signs of injury) the left outer ankle, measuring 0.8 cm by 0.5 cm and a deep tissue injury to the left heel measuring 0.2 cm by 0.2 cm. Review of the resident's care plan, revised 04/09/25, showed staff did not care plan related to the resident's dementia diagnosis or interventions to maximize the resident's remaining function or quality of life, the resident's depression, the resident's anticoagulant use, or the resident's impaired skin integrity issues. 2. Review of Resident #61's face sheet showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder, depression, dementia, chronic pain, and emphysema (chronic lung disease that progressively damages the alveoli (tiny air sacs) in the lungs). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Substantial to maximum assistance with dressing, showers, toileting, mobility, and hygiene; -Resident taking an antipsychotic and antianxiety medication; -Shortness of breath when lying flat; -Resident on a scheduled pain medication; -No behaviors indicated. Review of the resident's current POS showed the following: -An order, dated 12/23/24, for risperidone (antipsychotic medication) 0.25 mg tablet, give one tablet two times daily for dementia; -An order, dated 12/23/24, for hydrocodone-acetaminophen (opioid pain medication) 5-325 milligram (mg) tablet, give one tablet every six hours as needed for pain; -An order, dated 12/23/24, for morphine sulfate (opioid pain medication) solution 20 mg/milliliters (ml), give 0.5 ml every four hours as needed for pain; -An order, dated 12/23/24, for tramadol (pain medication) 50 mg tablet, give one tablet two times a day related to pain; -An order, dated 03/13/25, for buspirone (antianxiety medication) 5 mg, give one tab twice daily for anxiety. -An order, dated 03/26/25, to ensure head of the bed is elevated to prevent shortness of breath while resident is lying flat due to emphysema; -An order, dated 04/02/25, to cleanse the back of head where staples are with wound cleanser, apply Vaseline, and leave open to air every day for wound. Review of the resident's current care plan showed staff did not care plan related to the resident's dementia diagnosis, anxiety, or interventions to maximize resident remaining function or quality of life, the resident's psychotropic medication, side effects, or targeted behaviors, or the resident's depression, anxiety, chronic pain, emphysema, or impaired skin integrity issues. 3. During an interview on 04/15/25, at 12:45 P.M., Nurse Assistant (NA) U said dementia and interventions should be in the care plan so staff can help care for residents appropriately. During an interview on 04/15/25, at 12:50 P.M., Certified Medication Technician (CMT) V said the care plan book should tell staff about dementia and interventions for residents. During an interview on 04/15/25, at 10:50 A.M., Licensed Practical Nurse (LPN) N said the care plan should include dementia and interventions. Interventions for dementia could include redirection, providing music therapy, and not to argue with the resident. During an interview on 04/14/25, at 2:55 P.M., Registered Nurse (RN) M said pressure ulcers and any skin conditions should be included in the care plan. Care plans should be reassessed for any change in a resident's condition and quarterly. During an interview on 04/15/25, at 1:19 P.M., the MDS Coordinator said the following: -Staff should be aware of information in the care plan to care for the residents; -Dementia care, medications, target behaviors and side effects should be included in the care plan; -Resident care plans are updated annually during the MDS assessment. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she inputs care plan updates sometimes but does not enter new ones; -Care plans should include everything about a resident; -Dementia, psychotropic medications and side effects, behaviors, pressure ulcers or skin condition should be included in the care plan; -Care plans shows resident's needs and how to care for them. -The care plan should be updated daily; -Nurses can update the care plan and have been educated on how to do it. During an interview on 04/15/25, at 2:34 P.M., the Director of Nursing (DON) said the following: -MDS Coordinators should complete and update care plans; -Facility had care plans on paper and in the electronic medical record; -Every resident should have a up to date care plan; -The care plan should show resident goals and interventions to reduce problems for resident. -Each resident should have an up-to-date care plan that includes smoking, dementia, behaviors, and pressure ulcers. -Nurses do not update the care plans. During an interview on 04/15/25, at 3:41 P.M., the Administrator said care plans were not where they should be. It was important for residents to have a care plan. Dementia, psychotropic medication including targeted behaviors and interventions, pressure ulcers, and a resident seat belt should be included on the care plan.

Based on interview, and record review, the facility failed to ensure individuals were appropriately screened prior to being placed in nursing home when the facility failed to obtain and/or maintain documentation of a level one and level two Preadmission Screening and Resident Review (PASARR) for one resident (Resident #56) . The facility census was 104. Review of the document the facility provided as their policy titled Pre-Admission Screening and Annual Review (PASARR), dated 04/03/25, showed the following: -A PASARR form is required in every record. The discharge planner or facility is to be advised by the person taking the inquiry that the PASARR form must be complete prior to any new admission; -PASARR screenings are required on any resident who is placed in a state licensed only bed, who is directly transferred to your Medicaid bed from a Medicaid bed in another facility, and/or transferred from a hospital for placement in a Medicaid certified bed who occupied a Medicaid bed to hospital to Medicaid bed; -Completion of the PASARR form is the level I screening. A level II screening is done on those persons identified at level I who are known or suspected to have serious mental illness, intellectual disabilities, or a related condition; -After the level I screening is completed, place a copy of the screening in the medical record and maintain the original in the business office with the admission packet; -If a level II screening was required, and admission is approved, the resident will be subject to annual resident review (ARR); -When the level II screening is completed by the appropriate state agency, a letter is sent to the individual seeking admission, stating the facility is or is not appropriate. 1. Review of Resident #56's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses include mental and behavioral disorders, intellectual disabilities, and bipolar disorder type II (a mental health condition characterized by periods of hypomania (a less intense form of mania) and major depressive episodes, without a history of full-blown manic episodes). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 03/26/25, showed the following: -Severe cognitive impairment; -Dependent on staff for all cares and mobility; Review of the resident's care plan, revised 04/09/25, showed the resident had a cognitive deficit that affected his/her activities of daily living, such as feeding, bathing, and mobility. Review of the resident's electronic medical record (EMR) showed staff did not have documentation of a level I or level II PASARR completed. During an interview on 04/09/25, at 3:32 P.M., the Social Services Director (SSD) said all residents should have level I and level II PASARR on file, if indicated. He was unable to locate the resident's level I and/or level II. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said she was not sure of anything related to PASARR. During an interview on 04/15/25, at 2:45 P.M., the Director of Nursing (DON) said she was not sure of anything related to PASARR. During an interview on 04/15/25, at 3:44 P.M., the Administrator said level I and level II PASARR, if indicated, should be completed and maintained in the resident chart prior to admission to the facility.

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were thoroughly investigated and the investigation provided to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when possible abuse was witnessed by staff involving two residents (Resident #32 and #57). The facility census was 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: -The facility will not tolerate verbal (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical (not limited to hitting, biting, kicking), or mental (humiliation, harassment, and threat of punishment or deprivation) abuse, corporal punishment, involuntary seclusion (separation of a resident ), neglect, or misappropriation of resident property (deliberate misplacement, exploitation), by employees, family members, visitors, or other residents. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and or injuries of unknown source, shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -The administrator will assign the investigation to an appropriate individual, provide any supporting documents relative to the alleged incident to the person in charge of the investigation, keep the resident and residents representative informed of the progress of the investigation, ensure that any further potential abuse, neglect or mistreatment is prevented, and protect the safety and privacy of the resident; -The individual conducting the investigation will review the completed documentation forms, review the resident's medical record to determine what events led up to the incident, interview the persons reporting the incident, interview any witnesses, interview the resident, interview the resident's physician, interview staff members, interview the residents roommate, and review all events leading up to the alleged incident; -An alleged violation involving abuse will be reported by the facility Administrator to the state licensing agency within two hours, local and state ombudsman, the residents representative, law enforcement officials, the resident's physical, and the facility's medical director. 1. Review of Resident #32's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses include high blood pressure, irregular heartbeat, and diabetes. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 03/26/25, showed the following information: -Moderate cognitive impairment; -Required substantial to maximum assistance from staff for bathing, toileting, and mobility; -No behavioral symptoms such as abusing others sexually, screaming at others, or disrobing. Review of the resident's care plan, revised 04/09/25, showed the resident required assistance from staff to complete daily tasks such as dressing and grooming. Review of the resident's progress note, dated 02/06/25, showed the resident was lethargic, felt sick, and was experiencing vomiting and chest pain. The resident was sent to the hospital via ambulance at 11:51 A.M. Review of the resident's Admission History and Physical from the admitting hospital, dated 02/06/25, showed the following: -History received from the nurse at the long term care facility; -The nurse reports the resident was in a normal state of health until this morning. There was a naked resident who had jumped on top of him/her this morning and after this the resident became altered and was not able to speak; -The nurse also noticed the resident had a cough on this day, the nurse does not believe the naked resident hurt him/her; -The nurse denied the resident having any symptoms prior to this date; -The resident was diagnosed with sepsis (a life threatening medical emergency caused by the body's overwhelming response to an infection, often triggering a chain reaction that can lead to organ failure and death) and pneumonia ( a lung infection that causes inflammation and fluid buildup in the air sacs) while at the hospital and was discharged back to the facility on [DATE]. Review of the resident's progress notes, dated 02/06/25 through 04/06/25, showed staff did not document regarding the resident being involved in a possible sexual abuse allegations/incident. 2. Review of Resident #57's face sheet showed the following information: -admitted [DATE]; -Diagnoses included schizophrenia (a chronic mental disorder that affects a person's ability to think, feel, and behave), depression, and kidney disease. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 02/10/25, showed the following information: -Moderate cognitive impairment; -Requires partial to moderate assistance from staff for bathing and hygiene and is independent for mobility; -No behavioral symptoms such as abusing others sexually, screaming at others, or disrobing. Review of the resident's care plan, revised 04/09/25, showed the resident should be monitored for behaviors every shift related to medication use. Review of the resident's Nurse Practitioner visit note, dated 02/06/25, showed the following: -The resident was being seen for a new admission; -It was noted that this morning (02/06/25) the resident stripped down naked and jumped onto another resident who was lying in bed in his/her own room and this resident was making vulgar statements while on top of the other resident; -Staff reported the resident had been at baseline since the incident and there have been no further behaviors of this nature. Review of the resident's progress notes, dated 02/06/25 through 04/06/25, showed staff did not document regarding the resident being involved in a possible sexual abuse allegations/incident. 3. Review of DHSS records showed staff did not provide a written investigation completed when the potential abuse was occurred involving Resident #32 and Resident #57. 4. During an interview on 04/15/25, at 10:51 A.M., Certified Nursing Assistant (CNA) Q said the following: -He/she is aware of a recent issue between the two residents. He/she was not on staff that day but did hear about it; -He/she was warned to keep an eye on Resident #57, but since the incident, the resident has kept to his/herself; -As far as he/she knows, the incident was investigated appropriately. During an interview on 04/15/25, at 12:17 P.M., Certified Medication Technician (CMT) R said the following; -A resident getting naked and entering another residents room would be a problem; -He/she was aware of the recent issue between the two residents. He/she was on shift during the incident. By the time he/she got to the residents, they were not on top of each other, however it was verbally apparent what Resident #57 wanted, and Resident #32 was stunned; -Staff checked on the resident's often after the incident with no further concerns. During an interview on 04/15/25, at 12:49 P.M., Registered Nurse (RN) L said the following: -He/she was not on shift the day of the incident, but did hear about it; -If he/she were to be the nurse on shift, he/she would have separated both residents, assessed both residents, obtain statements from all staff on shift and both residents, document the occurrence, and contact whoever was on call that day. During an interview on 04/15/25, at 1:46 P.M., the ADON said the following: -The nurse handling the incident is expected to put a progress note in regarding the incident, do an assessment of both residents, document an incident report, notify the physician and family, and report it to the nurse on call. During an interview on 04/15/25, at 2:35 P.M., the Director of Nursing (DON) said the following: -She was on shift the day of the incident and was informed by the nurse; -The nurse reported to her that Resident #57 was found standing in Resident #32's room, but was easily redirected; -She went down to assess Resident # 32 as he/she was feeling ill and needed to be hospitalized ; -She was not aware of the entire situation and had she been, she would have interpreted it as an allegation of sexual abuse; -The nurse handling the incident should have documented the incident, separated the residents, assessed the residents for injuries and/or trauma, started behavior charting, notified her, the resident's families, and the residents physician -After reporting the incident to the state, an investigation should have taken place and been submitted to the state within five days. During an interview on 04/15/25, at 3:44 P.M., the Administrator said the following: -She was not ware of the entire situation and had she been, she would have considered it inappropriate; -The nurse handling the incident should have documented, reported, and investigated the immediately. MO00252718

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when possible abuse was witnessed by staff involving two residents (Resident #32 and #57). The facility census was 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: -The facility will not tolerate verbal (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical (not limited to hitting, biting, kicking), or mental (humiliation, harassment, and threat of punishment or deprivation) abuse, corporal punishment, involuntary seclusion (separation of a resident ), neglect, or misappropriation of resident property (deliberate misplacement, exploitation), by employees, family members, visitors, or other residents. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and or injuries of unknown source, shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -An alleged violation involving abuse will be reported by the facility Administrator to the state licensing agency within two hours, local and state ombudsman, the residents represented, law enforcement officials, the resident's physical, and the facilities medical director. 1. Review of Resident #32's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses include high blood pressure, irregular heartbeat, and diabetes. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 03/26/25, showed the following information: -Moderate cognitive impairment; -Required substantial to maximum assistance from staff for bathing, toileting, and mobility; -No behavioral symptoms such as abusing others sexually, screaming at others, or disrobing. Review of the resident's care plan, revised 04/09/25, showed the resident required assistance from staff to complete daily tasks such as dressing and grooming. Review of the resident's progress note, dated 02/06/25, showed the resident was lethargic, felt sick, and was experiencing vomiting and chest pain. The resident was sent to the hospital via ambulance at 11:51 A.M. Review of the resident's Admission History and Physical from the admitting hospital, dated 02/06/25, showed the following: -History received from the nurse at the long term care facility; -The nurse reports the resident was in a normal state of health until this morning. There was a naked resident who had jumped on top of him/her this morning and after this the resident became altered and was not able to speak; -The nurse also noticed the resident had a cough on this day, the nurse does not believe the naked resident hurt him/her; -The nurse denied the resident having any symptoms prior to this date; -The resident was diagnosed with sepsis (a life threatening medical emergency caused by the body's overwhelming response to an infection, often triggering a chain reaction that can lead to organ failure and death) and pneumonia ( a lung infection that causes inflammation and fluid buildup in the air sacs) while at the hospital and was discharged back to the facility on [DATE]. Review of the resident's progress notes, dated 02/06/25 through 04/06/25, showed staff did not document regarding the resident being involved in a possible sexual abuse allegations/incident. 2. Review of Resident #57's face sheet showed the following information: -admitted [DATE]; -Diagnoses included schizophrenia (a chronic mental disorder that affects a person's ability to think, feel, and behave), depression, and kidney disease. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 02/10/25, showed the following information: -Moderate cognitive impairment; -Requires partial to moderate assistance from staff for bathing and hygiene and is independent for mobility; -No behavioral symptoms such as abusing others sexually, screaming at others, or disrobing. Review of the resident's care plan, revised 04/09/25, showed the resident should be monitored for behaviors every shift related to medication use. Review of the resident's Nurse Practitioner visit note, dated 02/06/25, showed the following: -The resident was being seen for a new admission; -It was noted that this morning (02/06/25) the resident stripped down naked and jumped onto another resident who was lying in bed in his/her own room and this resident was making vulgar statements while on top of the other resident; -Staff reported the resident had been at baseline since the incident and there have been no further behaviors of this nature. Review of the resident's progress notes, dated 02/06/25 through 04/06/25, showed staff did not document regarding the resident being involved in a possible sexual abuse allegations/incident. 3. Review of DHSS records showed staff did not report the allegation of possible abuse involving Resident #32 and Resident #57. 4. During interviews on 04/11/25, at 1:40 P.M. and 2:40 P.M., Licensed Practical Nurse (LPN) W said the following: -Approximately one month ago, Resident #57 got on top of Resident #32; -LPN W could not remember the specifics and could not recall if the residents were clothed or not; -LPN W did not believe there was any sexual penetration and said neither resident had any injuries that he/she recalled; -LPN W said he/she thought he/she documented in the resident progress notes; -The LPN looked in the electronic health record, but was unable to find documentation about the resident to resident interaction in either resident's medical record; -LPN W said he/she guessed he/she did not document in the resident's progress note as he/she should have; -If he/she was working at the time of the situation, he/she would separate the residents from one another, ensure both residents were not injured, notify the residents' next of kin, their physicians, and notify the facility Administrator, Director of Nursing (DON), or the Assistant Director of Nursing (ADON); -The facility would then have two hours to notify DHSS of the events, as this would be an allegation of sexual abuse. During an interview on 4/11/25 at 2:45 P.M., Nurse Assistant (NA) AA said the following: -He/she worked on the day of the interaction between Resident #57 and Resident #32; -Late morning, the NA walked down the hall and observed Resident #57 in Resident #32's room; -Resident #32 was fully dressed sitting in a wheelchair; -Resident #57 was in front of Resident #32 slightly squatted against the resident's legs and was completely naked; -Upon entering the room, Resident #57 asked Resident #32 for sexual intercourse and Resident #32 threw both hands up in the air and said, Help me.; -The NA entered the room and separated the two residents and redirected Resident #57 to return to his/her room and assisted Resident #57 with dressing; -The NA said he/she immediately notified the charge nurse, LPN W and the LPN notified the DON over the phone and then went down the hall to talk to the DON; -This occurrence would be an example of sexual abuse and he/she reported the incident immediately; -The facility should report the allegation of abuse within two hours to DHSS. During an interview on 04/15/25, at 10:51 A.M., Certified Nursing Assistant (CNA) Q said the following: -All allegations of abuse should be reported immediately; -He/she was aware of a recent issue between the two residents. He/she was not on staff that day but did hear about it; -He/she was warned to keep an eye on Resident #57, but since the incident, the resident has kept to his/herself; -As far as he/she knew, the incident was reported; -If he/she were to witness or hear of an allegation of abuse, he/she would report it to the charge nurse, the charge nurse would take it up the ladder from there. During an interview on 04/15/25, at 12:17 P.M., Certified Medication Technician (CMT) R said the following; -A resident getting naked and entering another residents room would be a problem; -He/she was aware of the recent issue between the two residents. He/she was on shift during the incident. By the time he/she got to the residents, they were not on top of each other, however it was verbally apparent what Resident #57 wanted, and Resident #32 was stunned; -He/she reported it to the charge nurse and he/she should have taken it up the ladder from there. During an interview on 04/15/25, at 12:49 P.M., Registered Nurse (RN) L said the following -He/she was not on shift the day of the incident, but did hear about it; -If he/she were the nurse on shift, he/she would have separated both residents, assessed both residents, obtained statements from all staff on shift and both residents, documented the occurrence, and contacted whoever was on call that day; -The Director of Nursing (DON) or Administrator should have reported the incident to the state within two hours. During an interview on 04/15/25, at 1:17 P.M., the MDS Coordinator/Infection Preventionist said the following: -If there was ever a resident to resident reported to him, he would report it to management or call the state himself; -The incident between the two residents would be considered an allegation of sexual abuse and should have been reported to the state within two hours by the Assistant Director of Nursing (ADON), DON, or Administrator. During an interview on 04/15/25, at 1:46 P.M., the ADON said the following: -She was not at the facility when the incident took place, however it could be considered an allegation of sexual abuse; -The nurse handling the incident was expected to put a progress note in regarding the incident, do an assessment of both residents, document an incident report, notify the physician and family, and report it to the nurse on call. The nurse on call should have reported it to the state within two hours. During an interview on 04/15/25, at 2:35 P.M., the DON said the following: -She was on shift the day of the incident and was informed by the nurse; -The nurse reported to her that Resident #57 was found standing in Resident #32's room, but was easily redirected; -She went down to assess Resident # 32 as he/she was feeling ill and needed to be hospitalized ; -She was not aware of the entire situation and had she been, she would have interpreted it as an allegation of sexual abuse and would have reported that to the state within two hours; -The nurse handling the incident should have documented the incident, separated the residents, assessed the residents for injuries and/or trauma, started behavior charting, notified her, the resident's families, and the residents physician. During an interview on 04/15/25, at 3:44 P.M., the Administrator said the following: -She was not ware of the entire situation and had she been, she would have considered it inappropriate; -The nurse handling the incident should have documented, reported and investigated the immediately. MO00252718 34906

Based on observation, interview, and record review the facility failed to ensure complete assessments regarding the appropriate use of a restraint before use when the facility failed to document an evaluation and consent for the use of a restraint, failed to obtain a physician order for restraint use, failed to care plan restraint use, and failed to document ongoing re-evaluations of the need for the restraint for one resident (Resident #77). The facility census was 104. Review of the facility's policy, titled Use of Restraints, revised April 2017, showed the following information: -Restraints may only be used if the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention, and a restraint is required to treat the medical symptom, protect the resident's safety, and help the resident attain the highest level of his/her physical and psychological well-being; -Prior to placing the restraint on the resident, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom to determine if there are less restrictive interventions that may improve symptoms; -Restraints shall only be used upon the written order of the physician after obtaining consent form the resident and/or responsible party; -Orders for restraints will not be enforced longer than twelve hours unless the resident's condition requires continued treatment; -Restraints with locking devices shall not be used; -The resident with restraints will be observed at least every thirty minutes by the nursing personnel and an count of the residents condition will be documented in the residents medical record; -Care plans for residents in restraints will reflect interventions that not only the immediate medical symptom, but underlying problems that may be causing the symptom; -Documentation regarding the restraint shall include a full documentation of the reason for use, a description of the resident's medical symptoms, how the restraint is beneficial, the type of restraint that is used, the length of effectiveness of the restraint time, and observation, range of motion, and repositioning flow sheets. 1. Review of the Resident #77's face sheet (brief look at resident information) showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (MS - a chronic autoimmune disease that affects the central nervous system, disrupting communication between the brain and body), high blood sugar, diplopia ( double vision), and edema (swelling). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 02/10/25, showed the following: -Required partial to moderate assistance from staff to dress and undress above the waist, including fasteners; -Required substantial to maximum assistance from staff for mobility; -No physical restraints or alarms are used in or out of bed. Observation on 04/07/25, at 11:00 A.M., showed the resident sat in his/her motorized wheelchair with a seat belt attached around his/her lower abdomen, in his/her room. Observation and interview on 04/09/25, at 10:15 A.M., showed the resident sat in his/her motorized wheelchair with a seat belt attached around his/her lower abdomen. The resident said that he/she had the seat belt as a safety precaution. The resident had MS but did not walk so he/she didn't have any falls. He/she was not asked to sign any kind of consent for the seatbelt and had not been educated on any potential entrapment concerns. Observation on 04/15/25, at 1:00 P.M., showed the resident with his/her eyes closed in his/her motorized wheelchair with a seat belt attached around his/her lower abdomen, outside of the nurses' station on 200 hall. Review of the resident's care plan, revised 04/08/25, showed staff did not care plan related to the use of a restraint. Review of the resident's April 2025 Physician Order Sheet (POS) showed staff did not have a physician's order for the use of a restraint. Review of the resident's progress notes, dated 01/9/25 through 04/15/25, showed staff did not document regarding the use of a restraint and/or the resident's condition requiring need for the restraint. Review of the resident's medical record showed the staff did not have a consent and/or assessment regarding the use of a seatbelt restraint documented for the year of 2024 and the year of 2025. During an interview on 04/15/25, at 10:21 A.M., Certified Nursing Assistant (CNA) Q said the resident used a seatbelt. He/she was not aware of any process that needed to take place for the use of restraints. During an interview on 04/15/25, at 12:17 A.M., Certified Medication Technician, (CMT) R said the following: -Seatbelts can't be in place while the resident is eating; -Seatbelts have to be unbuckled every two hours; -A consent has to be obtained prior to the use of restraints; -Restraint use should be care planned. During an interview on 04/15/25, at 12:49 P.M., Registered Nurse (RN) L said the following: -There was an assessment that needed to be completed by the nurse on duty for restraints; -He/she was not sure what the assessment entailed, he/she had never filled one out; -A consent was needed for restraints; -Restraints should be care planned. During an interview on 04/15/25, at 1:17 A.M., the MDS Coordinator/Infection Preventionist (MDS/IP) said the following: -There had been an issue with care plan updates since changing to another electronic medical records (EMR) system in July 2024; -Restraints should be care planned. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -Staff should be able to tell everything about a resident and their care, by the care plan; -Restraints should be care planned; -She was not aware the resident used a seatbelt restraint; -The seatbelt should be assessed for proper fit, and educated on for strangulation; -Restraints require consents; -The seatbelt should be re-assessed quarterly and the findings should be documented. During an interview on 04/15/25, at 2:35 P.M., the Director of Nursing (DON) said the following: -If a resident had a seatbelt restraint, it should be checked on and removed frequently; -There was an assessment that was done on admission and quarterly for restraints, that should be documented; -A consent should also be completed for the use of restraints. During an interview on 04/15/25, at 3:44 P.M., the Administrator said the following: -An assessment for seatbelt restraints should be completed and documented on admission, for change of conditions, and quarterly; -A consent should be obtained prior to the use of the seatbelt restraint.

Based on interview and record review, the facility failed to protect residents from misappropriation of personal property when a staff member took two narcotic pain medication tablets from Resident #5's supply and when Resident #6, had over $700 of fraudulent purchases on his/her debit card made by a facility employee. The effected two sampled residents. The facility census was 98. Review of the facility policy titled, Abuse Prevention Program, dated 1999, showed the following: -Objective: Zero tolerance of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, or other residents; -To develop and implement a system for identifying, preventing, and reporting any incident, or suspected incident, of abuse, neglect, mistreatment, or misappropriation of resident property; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent; -The Administrator shall keep the resident and/or his/her responsible party informed of the progress and the results of the investigation. 1. Review of Resident #5's face sheet showed: -Diagnoses of chronic pain, low back pain, anxiety disorder, major depression, and stroke. Review of the resident's care plan, revised on 05/25/25, showed: -Resident is at risk for increased pain and discomfort related to a diagnosis of chronic pain; -Follow up with the resident's physician and pain management as needed; -Medication provided as prescribed; -Monitor for effectiveness of medication; -Monitor for increased pain and discomfort; -Provide diversionary activities as needed; -Therapy to screen quarterly and as needed. Review of the resident's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 05/28/25, showed: -Cognitively intact; -Independent with most activities of daily living (ADLs); -No behavioral symptoms; -Diagnoses of schizophrenia, anxiety, and depression; -Staff administered as needed (PRN) pain medication; -Resident expressed frequent complaints of pain and rated his/her pain at an '8' (on a numeric scale of 0-10, with 10 being the most severe pain). Review of the resident's physician orders showed an order, dated 05/16/25, for Hydrocodone-Acetaminophen (Norco- a pain medication) oral tablet 5/325 milligram (mg). Staff to administer one tablet by mouth every 6 hours as needed for pain. Review of the resident's medication administration record for May 2025, showed: -An order for Hydrocodone-Acetaminophen oral tablet 5/325 mg. Give one tablet by mouth every 6 hours as needed for pain; -On 05/19/25 at 8:20 A.M., staff administered a dose of the medication for a pain level of '8' with effective results; -On 05/19/25 at 7:47 P.M., staff documented administration of a dose of the pain medication for a pain level of '9' with effective results; -Staff did not document administration of any other doses of the pain medication on 05/19/25. -Certified Medication Technician (CMT) D did not document he/she administered any doses of the resident's pain medication on the MAR on 5/19/25. Review of the resident's-controlled medication count sheet showed the following information: -Drug name: Norco 5/325 mg; -Directions: one tablet by mouth every 6 hours as needed for pain (PRN). Review of the facility's-controlled drug count signature page showed the following: -On 05/19/25 at 2:00 P.M., CMT D signed as the incoming staff; -On 05/19/25 at 10:00 P.M., CMT D signed as the outgoing staff; -On 05/19/25 at 10:00 P.M., Registered Nurse (RN) E signed as the incoming staff. Review of the resident's progress notes showed: -No entries dated 05/19/25. Review of the resident's Medication Administration Record (MAR) for May 2025 showed: -An order for Hydrocodone-Acetaminophen oral tablet 5/325 mg. Give one tablet by mouth every 6 hours as needed for pain; -On 05/20/25 at 10:45 A.M., a nurse documented administration of one dose of the medication for a pain level of '8' with effective results. Review of the resident's-controlled medication count sheet showed the following information: -Drug name: Norco 5/325 mg; -Directions: one tablet by mouth every 6 hours as needed for pain (PRN); -On 05/20/25 at 10:45 A.M., LPN A signed out one tablet of the medication for administration; On 05/20/25 at 6:45 P.M., LPN A and the ADON destroyed one tablet of the medication and did a corrected count. Review of the resident's progress notes showed: -No entries dated 05/20/25. During a phone interview on 06/05/25 at 1:21 P.M., Registered Nurse (RN) E said the following: -He/she worked full time at the facility 3:00 P.M. to 3:00 A.M., or sometimes until 7:00 A.M.; -On the night of 05/19/25 at around 11:00 P.M., CMT D was preparing to leave for the night (at the end of the CMT's shift); -RN E counted the controlled medications with CMT D and found Resident #6's Norco card contained 2 pills less than what the controlled medication count showed he/she should have in the medication card; -The CMT was unsure what happened to the medications; -RN E refused to take over responsibility for the cart with 2 missing pills; -The CMT went outside to his/her car and returned and said he/she was now ready to count; -The RN thought the CMT might have brought the pills inside from his/her car, but the replaced pills matched the exact appearance and number as the pills already in the card; -The CMT taped the 2 pills into the card and the nurse assumed responsibility for the cart and the CMT went home; -On 05/20/25 at approximately 5:00 P.M., RN E notified the ADON and the Administrator that CMT D taped two pills into Resident #5's Norco card on 05/19/25; -The ADON immediately audited the entire cart and removed the remaining taped in pill; -RN E said he/she did not think about the potential danger of the medication; -RN E said he/she assumed maybe the CMT had stolen and then returned the medications due to the count being short; -RN E said he/she sat in on a meeting with CMT D on 05/20/25 along with the DON, ADON, and Administrator; -During the meeting, CMT D said he/she had a personal prescription for Norco and on the night of 05/19/25, when he/she could not locate 2 of Resident #5's Norco, he/she went to his/her own car and pulled 2 pills from his/her prescription bottle to replace the resident's missing Norco tablets. He/she then taped the 2 pills into the resident's medication card; -CMT D denied taking any of the resident's pain medications, but said he/she was unsure where the two resident Norco tablets were; -In the meeting, the ADON said the nurse was supposed to sign with the CMT when administering PRN pain medications, but he/she was not aware of that before the meeting; -Generally, RN E assessed a resident's pain and documented the administration of the PRN medications on the resident's MAR, as well as the resident's pain level; -The CMTs generally gave residents their PRN pain medication and signed them off on the controlled medication count sheet. During an interview on 06/04/25 at 1:43 P.M., Resident #5 said the following: -He/she had chronic back pain and staff administered as needed (PRN) pain medication to treat the resident's pain; -The resident was not aware of any misappropriation of his/her property or medications. During an interview on 06/04/25 at 3:21 P.M., the Assistant Director of Nursing (ADON) said the following: -On 05/20/25, RN E reported that on the night of 05/19/25 at approximately 10:00 P.M., RN E began his/her shift and started counting the narcotics with off going Certified Medication Technician (CMT), CMT D. At that time, Resident #5's Norco medication card was short by 2 tablets when compared to the narcotic count sheet. RN E refused to accept the cart because of the missing pills. CMT E told the RN E, he/she had a personal prescription for the exact same medication in his/her vehicle and went out to his/her vehicle and came back in with two loose pills. CMT E then taped the pills into the resident's medication card. On 05/20/25, the ADON checked the resident's Norco card and found Licensed Practical Nurse (LPN) A administered one of the taped in pills earlier on 05/20/25 and the ADON and another nurse destroyed the second taped in pill. During a phone interview on 06/05/25 at 11:38 A.M., Pharmacist H, a representative of the facility's local pharmacy said the following: -It is not acceptable practice for an employee to take their personal prescription medication and place that medication in a resident's medication card and/or to administer that medication to a resident. During a phone interview on 06/05/25 at 4:08 P.M., CMT D said the following: -On the night of 05/19/25, he/she counted the cart by him/herself, and the controlled medication count was correct; -CMT D then gave his/her medication cart keys to RN E and finished his/her charting; -Approximately one hour later, he/she returned to count the controlled medications with RN E and at that time Resident #5's Norco card was 2 pills short according to the count sheet; -The CMT said he/she freaked out and went to his/her car and obtained 2 of his/her own personal Norco which were the same exact strength and taped his/her personal medication into the resident's Norco card, so the count would be correct; -When he/she returned to work on the afternoon of 05/20/25, he/she was told by the DON and ADON to come to the office and he/she told the DON, ADON, Administrator what he/she had done; -He/she had never taken any resident medications out of the facility or for personal use; -RN E was aware the CMT went to his/her car and obtained the 2 pills and RN E did not say anything about not doing it at the time; The CMT said he/she had never misappropriated any resident medication, but was unsure what happened to the resident's two Norco; -CMT D said he/she should not have replaced the resident's missing medication with his/her own personal medication and that it was, The dumbest thing I've ever done in my life. During an interview on 06/05/25 at 5:40 P.M., the Administrator said the following: -Two staff (nurses or CMTs), the oncoming and off going, should count the controlled resident medications at the beginning and end of each shift; -If the count is off, staff should do another count with another nurse, if the count is still off, the staff should contact the Administrator, or the ADON, DON, or on call nurse to notify of the situation; -CMT D should not have used personal medications to replace missing resident medications; -RN E should have reported immediately when this occurred. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed: -admitted to the facility on [DATE] from the hospital; -Cognitively intact; -Resident required partial to moderate assistance of staff with toileting, showers, dressing, and transfers; -Resident required use of a walker or a wheelchair for mobility. Review of the resident's January 2025 monthly bank statement for his/her Direct Express card (provided by the facility with erroneous charges highlighted) showed the following charges allegedly not made by the resident: -On 01/03/25 charge for $81.19 at Wal-Mart; -On 01/03/25 charge for $1.61 at Wal-Mart; -On 01/06/25 charge for $162.80 at Amazon.com; -On 01/07/25 charge for $44.42 at Amazon.com -On 01/07/25 charge for $31.36 at Wal-Mart; -On 01/07/25 charge for $36.10 at Amazon.com; -On 01/11/25 charge for $55.31 at Amazon.com; -On 01/24/25 charge for $60.49 at Amazon.com. Total for January 2025 = $473.28. Review of the resident's February 2025 monthly bank statement for his/her Direct Express Card (provided by the facility with erroneous charges highlighted) showed the following charges allegedly not made by the resident: -On 02/01/25 charge for $17.25 at Amazon.com -On 02/02/25 charge for $96.52 at Amazon.com -On 02/02/25 charge for $63.88 at Amazon.com -On 02/06/25 charge for $89.87 at Amazon.com -On 02/06/25 charge for $41.21 at Amazon.com Total for February 2025 = $308.73. January and February 2025 total charges = $782.01 Review of the resident's care plan, revised on 05/31/25, showed: -Resident is at risk for impaired social interactions and disorganized thought process related to a diagnoses of a personal history of traumatic brain injury and bipolar (manic/depression); -Self report made 05/20/25 of money misappropriation by an ex-staff member; -Resident will ask for assistance from Social Services (SS) or the office manager with his/her funds if he/she has any issues or questions; -Assist with financial concerns as needed. Review of the resident's progress notes showed no notes related to the resident's allegations of misappropriation of property. During an interview on 06/04/25 at 11:05 A.M., the Business Office Manager (BOM) said the following: -Resident #6 received a monthly social security benefit and social security placed the resident's money directly on a debit card, called a Direct Express card. -The previous Activity Director (AD) shopped for the residents at the facility and used the resident's Direct Express card for purchasing items for the resident, such as cigarettes; -On the morning of 05/20/25, Resident #6 told a staff member about a financial issue. The resident said sometime in February 2025, he/she had noticed a money shortage on his/her Direct Express money card. The resident requested a card replacement. Shortly after that occurred, the AD at that time came to the resident and said the AD's daughter had mistakenly used the resident's card for personal purchases. The AD and the resident went through the resident's financial statements and figured out which purchases were allegedly made by the AD's daughter. The AD said he/she would pay the money back by purchasing cigarettes and candy for the resident until the amount was paid off. The resident said he/she was okay with that arrangement, but once the former AD was terminated, the resident did not receive any more cigarettes, candy, or payments from the former AD; -Per the resident, the AD reported the allegation to the Administrator; -After discovering the issue, the BOM reviewed all transaction statements with the resident and came up with approximately $700.00 worth of purchases that the resident did not make. Some of these included items like blackout curtains, curtain rods, cleaning supplies, bras, and storage tubs. The resident did not have any of these items in his/her possession. During an interview on 06/05/25 at 11:37 A.M., Resident #6 said the following: -The resident had money taken from his/her debit card; -In December 2024 or January 2025, the resident had given the Activity Director (AD) his/her debit card to purchase the resident cigarettes and candy; -The resident suspected the AD had misappropriated approximately $700.00 dollars by making unauthorized purchases on his/her debit card during January-February 2025; -He/she discovered the unapproved debits on his/her debit card and the former AD admitted using the resident's debit card for his/her own purchases and promised to reimburse the resident by purchasing the resident cigarettes and candy, but once the facility fired the AD, the resident did not hear from the AD again; -The resident reported the situation to CNA G approximately 2 weeks ago; -This surveyor reviewed bank statements for January and February 2025 with the resident; -Resident #6 said he/she and the BOM had reviewed the bank statements and highlighted transactions which the resident did not authorize, this surveyor reviewed statements with resident and unauthorized purchases made in January and February 2025 totaled $782.01 and resident said that was correct and said he/she did not make those purchases. During a phone interview on 06/05/25 at 3:12 P.M., the former AD said the following: -In February 2025, Resident #6 claimed he/she did not make some of the purchases on his/her debit card; -The resident accused the former AD of making the charges for personal purchases; -The former AD said at that time, in February 2025, he/she reported the allegations to Social Services, and they assisted the resident in canceling his/her debit card and obtaining a new one; -The former AD said he/she overheard Resident #6 tell Staff F from the business office that someone was using his/her debit card for Amazon purchases; -The former AD said he/she had used the resident's card for purchases, but only for items the resident requested, and this occurred during December 2024, January 2025, and part of February 2025, but did not occur after the resident had his/her card canceled in February 2025; -The former AD said he/she did not use the resident's debit card for any personal purchases and did give the resident receipts for all purchases he/she made for the resident. During a phone interview on 06/05/25 at 4:23 P.M., Certified Nurse Assistant (CNA) G said the following: -On 05/19/25, Resident #6 informed CNA G that approximately 5-6 months prior, he/she caught the former AD stealing from him. Resident #6 said the former AD was using his/her debit card for purchases the resident had not approved and for items the resident did not receive; -The resident said he/she estimated the AD had stolen approximately $600.00 from his/her debit card; -The resident said at first the former AD said one of the AD's family members had accidentally used the card, but the former AD eventually confessed to using the resident's debit card for personal purchases; -The former AD told the resident he/she would start paying the resident back by purchasing the resident cigarettes and peanut candy; -The resident then said he/she had informed Social Services about the stolen money; -After the resident told CNA G about the stolen money, the CNA immediately reported the situation to another staff, and they called the DON and reported the resident's allegation. During an interview on 06/05/25 at 4:35 P.M., Social Services (SS) said the following: -During February 2025, Resident #6 came to SS and reported someone else was making purchases on his/her debit card; -SS assisted the resident in canceling the current debit card and ordering a new one so no one would use the card; -SS assisted the resident in reporting the fraudulent charges to the Direct Express Hotline; -The resident had recently been in jail and in the hospital before admitting to the facility in December of 2024; -The resident said the charges were from before becoming a resident of the facility; -The SS said he/she notified the facility Administrator of the resident's allegations of card fraud in February 2025; -The SS said he/she did not notify Adult Protective Services or the elder abuse hotline of the allegation and was unsure if the Administrator made a hotline call. During an interview on 06/05/25 at 4:45 P.M., Staff F said the following: -He/she worked in the business office; -In February 2025, Resident #6 reported to Staff F and to the former AD that he/she suspected someone took money from his/her card and the former AD told the resident he/she would review debit card statements with the resident; -Staff F did not report the resident's concerns to anyone, because he/she thought the former AD reported the issue to the Administrator. During an interview on 06/05/25 at 5:02 P.M., the Director of Nursing (DON) said the following: -Staff should not use resident debit cards for personal purchases or take any money from residents; -If a resident needed an item purchased, that transaction would need to go through the business office. During an interview on 06/05/25 at 5:40 P.M., the Administrator said the following: -The former AD was using Resident #6's debit card for resident purchases; -The AD did not notify the facility staff that she had used the resident's debit card to her own personal purchases; -If the resident reported fraudulent charges on his/her debit card to SS, then SS should have reported that allegation to the Administrator, but the SS had not notified the Administrator; -The Administrator became aware that the former AD was misappropriating money from Resident #6 approximately 2 weeks ago, at which time, the facility hotlined the allegation and began an investigation and notified the police; -The facility educated staff to not make any purchases for residents and not to assist resident's with any purchases -If resident's needed to purchase items, all transactions should go through the business office. MO00254534 MO00254563

Based on observation, interview, and record review, the facility failed to protect each resident's right to be free from abuse from staff, when a staff member continued to provide cares to a resident against the resident's wishes and refusals for one resident (Resident #17). The facility had a census of 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: -The facility will not tolerate verbal (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical (not limited to hitting, biting, kicking), or mental (humiliation, harassment, and threat of punishment or deprivation) abuse, corporal punishment, involuntary seclusion (separation of a resident ), neglect, or misappropriation of resident property (deliberate misplacement, exploitation), by employees, family members, visitors, or other residents; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, or good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents,irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including the abuse facilitated or enabled through the use of technology. Willful, laws used in the definition of abuse, means the individual must have acted deliberately, no that the individual must have intended to inflict injury or harm. 1. Review of Resident #17's face sheet showed the following: -admitted [DATE]; -Resident on hospice services; -Diagnoses included stroke with right sided hemiplegia (paralysis of one side of the body) and hemiparesis (partial paralysis on one side of the body), respiratory failure, depression, and osteoarthritis (a degenerative joint disease where the cartilage that cushions the ends of bones wears away over time). Review of the resident's quarterly Minimum Data Set (MDS - a federally-mandated assessment tool completed by facility staff), dated 03/02/25, showed the following: -Cognitively intact; -Did not reject cares of exhibit any behavioral symptoms; -Functional limitation to range of motion in both lower extremities; -Dependent on staff for assistance with toileting hygiene, lower body dressing, and transfers; -Required substantial or maximal mobility assistance of staff with rolling left to right in bed, and with moving from lying to sitting or sitting to lying in bed; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised on 04/11/25, showed the following: -Resident required substantial to dependent staff assistance wish most activities of daily living (ADLs); -Resident was dependent on staff assistance with transfers, lower body dressing, and putting on/taking off footwear; -Resident required substantial assistance with bed mobility; -Resident is noted to be resistive to care, especially during incontinence cares. He/she has multiple bowel movements during the night and does not want to be changed more than a couple of times. He/she believes staff is being rough with him/her if they need to change him/her more that he/she would like; -Resident has noted to swing out at staff during incontinent cares; -Educate the resident/family/caregiver on the possible outcomes of not complying with treatment or care; -Give clear explanation of all care activities prior to and as they occur during each contact; -If the resident resists with ADLs, reassure the resident, leave and return 5 to 10 minutes later and try again; -If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time; -Provide the resident with opportunities for choice during provision; -Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as mush as possible; -Staff to have the charge nurse explain to the resident why changing in necessary due to his/her wound and encourage/assist with changing. Review of the facility's abuse investigation involving the resident showed the following: -On 04/07/25, at 10:30 A.M., a hospice nurse reported the resident said one of the aides, working on the night of 04/06/25, rolled the resident over and the resident said the aide hurt him. The charge nurse and hospice nurse assessed the resident and found no injuries. The resident said the aide wiped his/her buttocks too hard and was rough. The facility began an investigation, notified the Department of Health and Senior Services (DHSS), and suspended the alleged perpetrator (AP), Certified Nurse Assistant (CNA) T. The CNA said he/she was unaware of any issues or concerns with the resident or his/her care of the resident. Other residents and staff interviewed denied any abuse; -On 04/10/25, after completing interviews, the management team met and did not feel this was abuse and that staff needed to involve the charge nurse when the resident was denying cares. Hospice also saw the resident twice per week and had seen no issues with any staff. The hospice aide did say the resident required encouragement to take a shower or a bed bath; -At that time, the facility took CNA T off of suspension and allowed him/her to return to work. The resident said he/she was okay with the CNA taking care of him/her and said, I don't care. I just want to sleep at night. Staff explained to the resident the importance of cleaning up after incontinence for the resident's skin. The resident said, I know, okay, yeah, yeah, I get it. During an interview on 04/14/25, at 11:55 A.M., CNA T said the following: -The facility suspended him/her because the resident said he/she was too aggressive during cares; -He/she recalled a few nights prior when the resident was cranky with CNA T and did not want to be changed after an incontinent episode; -At times, the resident did not like for staff to wake him/her up at night, even to change after incontinence of bowel or bladder; -The aide said when the resident refused to be changed, he/she changed the resident anyway; -The resident would say things like, I'm gonna turn you in, and Leave me alone, I'm trying to sleep, but when the resident said these things the aide continued on with changing the resident; -At times, the resident would yell, No! and would kick at the aide during cares; -When asked if he/she had ever reported the resident's refusals to a nurse, the aide said he/she did not believe so; -The aide said he/she did not want the resident to lay wet or soiled because that would be bad for the resident's skin. Observation and interview of the resident on 04/14/25, at 1:35 P.M., showed the following: -The resident lay on his/her bed. The resident's bed was against the wall one one side; -The resident said there were approximately three aides (unsure of names) on the night shift who insisted on changing his/her incontinent brief/bedding when he/she did not want to be changed; -He refused care at times because these staff wipe his/her buttocks roughly. He/she refused to be changed after incontinent episodes at times due to the aides wiping him/her rough and turn him/her roughly and quickly. -If the staff were not rough, he/she would not refuse to be changed. During an interview on 04/15/25, at 10:16 A.M., Licensed Practical Nurse (LPN) W said the following: -If the resident refused or was resistive to being changed after an incontinent episode, the CNA should notify the charge nurse; -As a charge nurse, LPN W would advise the CNA to step away for a few minutes and attempt to re-approach or get someone else to try to talk with the resident; -Forcing cares on a resident would be considered abuse. During an interview on 04/15/25, at 12:13 P.M., Certified Nurse Aide (CNA) X said the following: -The resident refused to get out of bed at times; -He/she allowed some staff to care for him/her and refused other staff; -The resident said one girl on the night shift was a little rough with cares; -If the resident refused assistance with changing after incontinence, the aide should ask a different co-worker to try; -If the resident refused the second aide, the aides should notify the charge nurse of the resident's refusals; -The resident had the right to refuse cares. During an interview on 04/15/25 at 1:17 P.M., the MDS Coordinator/Infection Preventionist said the following: -He/she worked as an MDS Coordinator and nurse aide educator, but occasionally worked caring for residents; -If a resident refused cares, the aide should stop and notify the charge nurse and the nurse should go in an investigate the reason for the resident's refusal. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -The resident reported CNA T wiped his/her bottom too hard, but did not say staff were forcing care after he/she refused; -If a resident refused care, the CNA should have stopped and reported to the nurse; -The resident has the right of refusal; -The ADON said he/she asked the CNA if he/she rolled the resident too hard or forced him/her to roll over and the aide denied the allegations; -The CNA did not mention the resident was adamantly refusing cares; -It was not appropriate for staff to force a resident to do anything against their will; -The facility suspended the CNA during the investigation, but did not find any abuse. During an interview on 04/15/25 at 2:34 P.M., the Director of Nursing, said the following: -The ADON interviewed the CNA about the resident's allegation and the CNA said the resident had frequent bowel movements; -The aide said the resident declined the cares a lot; -The aide did not report this and he/she continued care after the resident refused; -If the resident refused cares, the aide should have left the room, and asked a different aide to attempt cares and tried a different approach to getting the resident to cooperate or ask the charge nurse for assistance; -Staff should not force cares on the resident because the resident had the right to refuse care and forcing care would be kind of like abuse. During an interview on 04/15/25 at 3:41 P.M., the facility Administrator said the following: -If a resident refused care, the aide should go and get another aide to try and assist the resident; -The aide should never force cares on a resident; -Making a resident do something against their will would be abuse; -The Administrator said the facility would be again suspending CNA T, in light of the new information of him/her allegedly forcing cares and conducting an investigation. MO00252384, MO00252718, MO00252720

Based on observation, interview, and record review, the facility failed to maintain a system that assured full, complete, and separate accounting of each resident's personal funds when one staff (Activity Director) had the money of one resident (Resident #49) placed in his/her own personal account for resident shopping without facility maintained record keeping regarding the transactions. The resident census was 104. Review of the facility policy titled, Management of Resident's Personal Funds, revised March 2021, showed the following: -The resident may manage his or her own personal funds; -The resident may designate a representative to manage his or her personal funds; -The resident may apply to the Social Security Administration to have a representative payee designated for purposes of federal and state benefits to which he or she may be entitled; -The resident may have the facility hold, safeguard, and manage his or her personal funds; -Should the resident elect to have the facility manage his or her personal funds, it is authorized in writing by the resident or the resident's representative, and a copy of such authorization is documented in the resident's medical record; -Should the facility manage the resident's funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident. No service charge is levied against the resident for the management of personal funds. -The resident is informed in advance of any charges imposed to his/her personal funds; -Copies of all financial transactions are filed in the resident's permanent records; -The resident may withdraw his or her request for the facility to manage his or her personal funds at any time by submitting a written notice to the administrator; -Inquiries concerning the facility's management of resident funds are referred to the administrator or to the business office. 1. Review of Resident # 49's face sheet showed admitted [DATE]. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 03/24/25, showed the resident was cognitively intact and exhibited no behavior symptoms. Observation and interview with the resident on 04/14/25, at 1:30 P.M., showed the following: -The resident said on Tuesday of each week, the Activity Director (AD) goes to Wal-Mart and purchases items for some of the residents, but none of the residents were allowed to go shopping; -The resident said he/she typically looks up his/her items on Wal-Mart.com and places the items in the virtual basket to get a total cost for his/her needed items; -The resident said he/she then cash apps the AD his/her money and the AD goes to Wal-Mart and makes the purchases for the resident; -The resident said when the AD returned to the facility, he/she brought the items to the resident and along with a receipt with the total cost. If the resident sent more money to the AD than what the items cost, the AD refunded the difference to the resident's cash app, if the resident owes more money, the resident sent more to the AD's cash app. The resident kept the receipts and the AD did not have the resident sign anything for proof of the transaction. During an interview on 04/15/25, at 4:30 P.M., the AD said the following: -He/she went to Wal-Mart each Tuesday to shop for the residents; -The resident routinely used a cash app to send the AD money for his/her order in advance of the Wal-Mart trip along with a list of items needed; -The resident sent this money to the AD's personal cash app card on his/her phone; -When the AD returns to the resident with the order, the AD and resident review the amount on the receipt and either the resident cash app's the AD more money or the AD returns any extra money to the resident; -The AD left each receipt with the residents and did not ask for a signature of a copy of the receipt; -The AD said she had done this type of transaction with the resident for six months or more. Review of the resident and facility records showed no signed agreement of staff use of resident funds no tracking of the transaction between the resident, the AD, and the store. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she was not aware of any residents sending money to staff via cash applications, but that should not be happening; -In general, staff cannot take resident money; -All resident money transactions must go through the business office. During an interview on 04/15/25, at 2:35 P.M., the Director of Nursing (DON) said the following: -He/she was not aware the AD was accepting resident funds into his/her private account; -The facility's expectation would be for any resident money transactions to be handled through the business office. During an interview on 04/15/25 at 3:44 P.M., the Administrator said the following: -The AD should not have been receiving money from the resident into his/her personal cash app account for purchases; -The business office was not aware the AD was doing this; -A resident fund account would need to be set up or the resident can make his/her own purchases, if he/she preferred.

Based on interview and record review, the facility failed to timely assess, monitor, document, and notify the physician and responsible party of the continued declining medical condition of one resident (Resident #1), when the resident's condition continued to decline after receiving ordered intravenous (IV - administer to a vein) fluids and the resident remained lethargic, demonstrated poor oral intake, and was unable to take ordered oral medications. Additionally, the facility staff failed to follow the physician's order for IV fluids per the physician's order and failed to document the resident's intake and output per facility policy. The resident was sent to the hospital and intubated. The facility census of was 96. The Administrator, Director of Nursing, and Corporate Nurse were notified on [DATE], at 3:00 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Record review of the facility policy titled, Change in a Resident's Condition or Status, revised [DATE], showed: -The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status; -The nurse will notify the resident's physician when there has been a significant change in the resident's physical/emotional/mental condition or need to alter the resident's medical treatment significantly; -A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without interventions by staff or by implementing standard related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review of revision to the care plan; and ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument (RAI - federal assessment instrument completed by facility staff that yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified); -Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status; -Except in medical emergencies, notifications will be made within twenty-four hours of a change in the resident's medical/mental condition or status; -The nurses will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Record review of the facility policy titled, Charting and Documentation, revised [DATE], showed the following: -All services provided to the resident, progress toward care plan goals, or any change in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record; -The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record: objective observations; medications administered; treatments or services performed; changes in the resident's condition; events, incidents, or accidents involving the resident; and progress toward or changes in the care plan goals and objectives; -Documentation in the medical record will be objective, complete, and accurate; -Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting. Record review of the facility policy/procedure titled, 'Intravenous Administration of Fluids and Electrolytes', revised [DATE], showed: -The purpose of this procedure is to provide guidelines for the safe and aseptic (free from contamination) administration of intravenous fluids and electrolytes for hydration; -A physician's order is necessary to give intravenous fluids and electrolytes; -Assess the resident's lung and heart status and vital signs before and during therapy to assess for fluids overload; -Resident should be monitored frequently, per facility policy, when continuous fluids are infusing; -Monitor for signs and symptoms of fluid overload, catheter insertion site complications, and the resident's tolerance of procedure. Fluids may be stopped by a nurse if signs of problems are present; -Prior to administration of intravenous fluids and electrolytes, assess resident's overall health status; cardiovascular and respiratory status; history of allergies. Baseline vital signs; -Document the procedure in the resident's medical record and on the intake/output record; -The following information should be recorded in the resident's medical record: the date and time the infusion was administered; the type of solution administered; the amount of solution administered; the route of administration; the rate of administration; the condition of the IV site before and after administration; notification of the physician if there are any complications; and the signature and title of the person recording the data; -Notify the physician, supervisor, and on coming shift of complications or resident refusal of treatment; -Report other information in accordance with facility policy and professional standards of practice. 1. Record review of Resident #1's face sheet showed the following: -admitted to the facility from the hospital on [DATE]; -Diagnoses of delusional disorder, persistent mood (affective) disorder, and major depression. Record review of the resident's progress notes dated [DATE], at 2:32 P.M., showed the Assistant Director of Nursing (ADON) documented the following: -The resident arrived at the facility at 12:10 P.M. via ambulance. The resident is alert to self only. He/she is able to walk with a slow gait. The resident leans forward and does not raise his/her head when ambulating. The resident ate in the dining room for lunch with a fair appetite. Record review of the resident's admission minimum data set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated [DATE], showed the following: -Severe cognitive impairment; -No altered level of consciousness; -Required extensive assistance of one staff with bed mobility, ambulation, and eating. Record review of the resident's current care plan showed the following interventions: -On [DATE], report changes in alertness or memory to the physician; -On [DATE], assess fluid intake and hydration status. Record review of the resident's progress notes dated [DATE], at 4:08 P.M., showed the ADON documented the following: -Therapy came to this nurse this morning concerned with the resident's awareness. He/she is lethargic and is unable to walk with therapy this morning. The resident is not responding to questions. The physician was notified and the resident's medication list was sent to the physician. The physician sent a new order to hold the resident's noon dose of Thorazine (an anti-psychotic medication). The physician also ordered blood work and a urinalysis. Record review of the resident's physician visit, dated [DATE], showed the following: -Thorazine dose changed to 25 milligrams (mg) in the A.M., 100 mg at lunch, and 100 mg at hour of sleep (HS), labs ordered. Record review of the resident's nurse practitioner's visit, dated [DATE], showed the following: -Resident sitting in the hallway with his/her head down. Resident briefly awakens to verbal stimuli, but then goes back to sleep; -Heart and lungs normal; -Nurse reports resident running down the hall with physical therapy; -No agitation reported; -Urinalysis and labs not yet obtained; -Diagnoses of Alzheimer's, dementia, and agitation. Continue plan of care. Record review of the resident's progress notes showed on [DATE], at 4:18 P.M., the physician was at the facility to see the resident with no new orders. Record review of the resident's (non-fasting) chemistry profile, dated [DATE] (collected at 4:30 P.M.), showed the following abnormal results: -Sodium (high) = 150 milliequivalents/liter (mEq/l) (normal range of 136 mEq/l to 145 mEq/l); -Chloride (high) = 113 mEq/l (normal range 98 mEq/l to 107 mEq/l); -Glucose (blood sugar), serum/plasma (high) = 166 milligrams/deciliter (mg/dl) (normal range of 70 mg/dl to 100 mg/dl); -Blood urea nitrogen (BUN - an indicator of how well kidneys are functioning) (high) = 23 mg/dl (normal range 7 mg/dl to 18 mg/dl); -Creatinine (an indicator of how well kidneys are functioning) (high) = 1.71 mg/dl (normal range 0.67 mg/dl to 1.17 mg/dl); -eGFR (a measure of kidney function) (low) = 39 milliliters/minute/1.73 m2 (mL/min/1.73 m2) (normal range of 60 mL/min or greater) -The resident's nurse practitioner initialed the bottom of the lab report and dated [DATE]. Record review of the facility/physician a secure messaging platform conversation, dated [DATE], showed the following conversation: -Facility staff: Follow-up with resident's lethargy since medication adjustment. He/she is still lethargic at times and does still lean forward and look down when ambulating. Staff is still having to assist with feeding and supervise per resident just plays with food, but he/she is more responsive to prompts and able to follow commands more readily. Also notes he/she not as soft spoken and can speak more clearly; -Physician: Decrease Thorazine to 25 mg in the A.M., 50 mg at lunch, and 50 mg at HS. Report in a week. Report immediately if he/she does not sleep at night. -Facility staff: Will do, thank you. -Physician: Please update (family member) on these changes. -Facility staff: I notified the resident's family member of medication changes and put the resident on every shift behavior charting for a week, then update. Record review of the resident's progress notes dated [DATE] at 1:14 P.M., showed Registered Nurse (RN) M documented the following: -The resident is on behavior charting per decrease of Thorazine medication from 100 mg at noon and HS dose to 50 mg at noon and HS due to lethargy. The resident is being started on behavior charting to monitor for any signs of aggression or sleep disturbances and staff to notify the resident's physician immediately. This nurse called the resident's family and updated on the resident's medication changes. Staff will continue to monitor. Record review of the resident's progress notes dated [DATE], at 10:07 P.M., showed the ADON documented the following: -The resident is on behavior charting after reducing the Thorazine dose. He/she has not had any behaviors this shift will continue to monitor. Record review of resident's progress notes dated [DATE], at 1:17 P.M., (late entry for [DATE]) showed the ADON documented the following: -The resident did not have behaviors. He/she was still very sleepy and did not eat lunch because he/she wanted to sleep, but did eat breakfast and dinner. Resident was calm and cooperative with cares. Record review of the resident's progress notes dated [DATE], at 1:23 P.M., showed the ADON documented the following: -The resident exhibited no behaviors this shift. -The resident had a red eye on the left side with some dry drainage and was rubbing the eye. The resident's physician was notified and ordered eye drops. Staff will continue to monitor. Record review of the resident's (late entry) progress notes, dated [DATE] (untimed), created on [DATE], showed RN M documented the following: -Resident continues on behavior charting per decrease in Thorazine medication. Resident is showing no signs of aggression at this time and is cooperative with staff and cares. He has been more alert and responsive to prompts and verbal commands from staff but still needs assistance with all ADLS (activities of daily living - dressing, grooming, bathing, eating, and toileting) including feeding self at meal times. Resident is also ambulating more steadily, but still needs supervision. Staff will continue to monitor. (Staff added this note to the medical record after the resident had discharged from the facility.) Record review of the resident's progress note dated [DATE], at 4:07 A.M., showed Certified Medication Technician (CMT) Q documented the following: -Resident not experiencing any behaviors/outbursts of anger. Record review of the resident's medical record, dated [DATE] to [DATE], showed staff did not document communication with the physician, per his request, to update on the resident one week after the Thorazine dosage change ordered on [DATE]. Record review of progress notes dated [DATE], at 1:57 P.M., showed the ADON documented the following: -Resident seems to continue to be lethargic and not responding to verbal stimuli very well. Staff was assisting resident with lunch and were unable to keep the resident awake. When the resident would take a bite of food, he/she would chew, but never swallow. Staff were only able to get the resident to drink about one-fourth cup of fluids. Staff received new orders from the physician for speech therapy (ST) to evaluate and treat the resident. Record review of the resident's ST Speech-Language Pathology Evaluation and Plan of Treatment, dated [DATE], showed the following: -Treatment of swallowing dysfunction and/or oral function for feeding; -Evaluation of oral and swallow function; -Dietary Recommendations: Finger foods. ST also recommended fortified liquid diet be provided alone with finger foods to facilitate improved oral intake due to postural deficits at this time. Record review of the resident's record showed staff did not document alerting dietary or the physician of the ST's new dietary recommendations after his/her initial consultation. Record review of the ST Treatment Encounter Note, dated [DATE], showed resident demonstrates poor alertness for oral intake. Retrieves liquids via straw within functional limits, but unable to manage finger food diet items requested and ongoing dietary education required. Resident's oral intake limited. Communication to director of rehabilitation completed. Record review of the resident's progress notes showed nursing staff did not document regarding the resident's condition on [DATE] or [DATE]. Record review of the resident's (late entry) progress note dated [DATE], at 10:03 A.M., created on [DATE], showed the Director of Nursing (DON) documented the following: -Resident placed in bed by staff stating this he/she appears to be declining. Multiple staff at bedside. Resident is alert with sternal rub. Resident continues to be alert during suctioning. There appears to be old food in the resident's mouth. Staff assessed the resident. Staff taking vital signs. Staff checking blood sugar. Crash cart at bedside. Resident is not answering questions or following commands at this time. Resident is still alert. RN D will be notifying the resident's physician. Resident's skin is warm to touch and normal color. Respirations are even and non-labored. (Staff added this note to the medical record after the resident had discharged from the facility.) Record review of the secure messaging platform between RN D and the resident's physician on [DATE] showed the following conversation: -RN D at 10:21 A.M.: The resident in the unit (SCU) is lethargic; blood sugar = 289 mg/dL (elevated); temperature = 98.2 degrees Fahrenheit (F); respirations = 20 (normal is 12 to 25 breaths per minute); blood pressure = ,d+[DATE] millimeters of mercury (mm Hg) (low blood pressure); pulse oximetry = 98% heart rate = 109 (normal range 60 to 80 beats per minute; pupils equal, round, reactive to light, and accommodation (PERRLA); resident was reaching for the wheelchair, just not responding. Resident had a lot of thick green mucous in mouth and gunk around eyes. Lungs clear to auscultation (listening with a stethoscope); -RN D at 10:32 A.M.: Labs, sodium was 150 mEq/l, kidney function slightly elevated, but not peeing, but he/she has not been taking in fluids for the last couple of days; -Physician at 12:01 P.M.: Needs half (0.45%) normal saline (NS) at 125 milliliters (ml) per hour for three liters. -RN D at 12:02 P.M.: Thanks. Record review of the resident's physician orders (POS) showed staff did not enter an order for the normal saline. Record review of the resident's (late entry) progress note dated [DATE], at 10:32 A.M., created on [DATE], showed RN D documented the following: -At 10:32 A.M., nurse notified the physician that the resident's sodium on labs had been 150 mEq/l; -At 12:01 P.M., received new orders from the physician to start an IV and run 0.45 % NS for 3 liters; -At 12:45 P.M., started an IV to the resident's left wrist, IV flushed, good blood return, started 0.45 % NS running at 125 ml/hr. Resident tolerated well; -At 2:30 P.M., the resident remains in bed. Vital Sign (VS) of 97.9 degrees F temperature, respirations of 18 per minute, blood pressure of ,d+[DATE] mm of Hg, heart rate of 106 beats per minute, oxygen saturation of 98% on room air, and lungs remain clear to auscultation. Breathing even and non-labored. No signs and symptoms of pain or distress noted at this time; (The nurse did not document notification of the resident's responsible party. The nurse did not document the quantity of IV fluids infused. Staff added this note to the medical record after the resident had discharged from the facility.) Record review of the resident's electronic treatment administration record (eTAR), dated [DATE], showed a physician's order dated [DATE], at 1:00 P.M., for the following: -Start intravenous (IV) one time dose of one-half normal saline (0.45 % NS) at a rate of 125 ml/hr, staff to administer three liters and then discontinue; -On [DATE], RN E entered an 'N' indicating not administered. Record review of the resident's electronic medical administration record (eMAR), dated [DATE], showed an 'N' on [DATE], indicating staff did not administer the following ordered medications: -Chlorpromazine (for diagnosis of delusional disorder) 50 mg tablet, 12:00 P.M. and 8:00 P.M. doses; -Lamotrigine (for diagnosis of persistent mood affective disorder) 200 mg tablet, 6 P.M. to 11:00 P.M. evening dose; -Mirtazapine (for diagnosis of persistent mood affective disorder) 7.5 mg tablet, 8:00 P.M. dose; -Acetaminophen (for diagnosis of pain) 500 mg, two tablets, 6:00 P.M. to 11:00 P.M. evening dose. Record review showed staff did not document physician notification of medications not received. Record review of the resident's (late entry) progress note dated [DATE], at 12:00 P.M., created on [DATE], showed RN D documented the following: -Resident pulled his/her IV out. This nurse started an IV to the left hand. Resident tolerated well. IV flushed with good blood return. Started second bag of 0.45 % NS at 125 ml/hr. No signs or symptoms of pain/distress noted at this time. VS of 97.5 degree F temperature, blood pressure of ,d+[DATE] mm of Hg, heart rate of 95 beats per minute, andoxygen saturation = 97% on room air. Lungs clear to auscultation. (The nurse did not document the quantity of IV fluids infused. Staff added this note to the medical record after the resident had discharged from the facility.) Record review of the resident's eMAR, dated [DATE], showed an 'N' on [DATE], indicating staff did not administer the following medications: -Chlorpromazine 25 mg tablet, staff to administer every day at 8:00 A.M.; -Chlorpromazine 50 mg tablet, staff to administer every day at 8:00 P.M.; -Escitalopram (for diagnosis of major depressive disorder) mg tablet, staff to administer every day in the morning; -Vitamin D 3 (for diagnosis of vitamin deficiency) 5000 unit capsule, staff to administer every day in the morning; -Proton DR (for diagnosis of gastro-esophageal reflux disorder) 40 mg tablet, staff to administer every day in the morning; -Acetaminophen 500 mg, two tablets staff to administer twice daily; -Lamotrigine 200 mg tablet, staff to administered twice daily; -Mirtazapine 7.5 mg tablet, staff to administer every day at 8:00 P.M. Record review showed staff did not document physician notification of medications not received. Record review of the resident's eTAR, dated [DATE], showed: -On [DATE] at 1:00 P.M., RN E entered a check mark, indicating administration of 0.45 % NS IV fluids at a rate of 125 ml/hour. Record review of the resident's eTAR, dated [DATE], showed: -On [DATE], at 1:00 P.M., RN E entered a check mark, indicating administration of 0.45 % NS IV fluids at a rate of 125 ml/hour. Record review of the resident's eMAR, dated [DATE], showed an 'N' on [DATE], indicating staff did not administer the following medications: -Chlorpromazine 25 mg tablet, staff to administer every day at 8:00 A.M.; -Chlorpromazine 50 mg tablet, staff to administer every day at 12:00 P.M. and 8:00 P.M.; -Escitalopram 10 mg tablet, staff to administer every day in the morning; -Vitamin D 3 5000 unit capsule, staff to administer every day in the morning; -Protonix DR 40 mg tablet, staff to administer every day in the morning; -Acetaminophen 500 mg, two tablets staff to administer twice daily; -Lamotrigine 200 mg tablet, staff to administered twice daily; -Mirtazapine 7.5 mg tablet, staff to administer every day at 8:00 P.M. Record review showed staff did not document physician notification of medications not received. Record review of the resident's eMAR, dated [DATE], showed an 'N' on [DATE], indicating staff did not administer the following medications: -Chlorpromazine 25 mg tablet, staff to administer every day at 8:00 A.M.; -Chlorpromazine 50 mg tablet, staff to administer every day at 12:00 P.M.; -Escitalopram 10 mg tablet, staff to administer every day in the morning; -Vitamin D 3 5000 unit capsule, staff to administer every day in the morning; -Protonix DR 40 mg tablet, staff to administer every day in the morning; -Acetaminophen 500 mg, two tablets staff to administer twice daily; -Lamotrigine 200 mg tablet, staff to administered twice daily. Record review of the resident's progress notes showed RN E documented the following: -On [DATE], at 12:10 A.M., new peripheral IV started in the resident's left forearm. A new bag of NS started per orders. Resident tolerated well. IV flushed without difficulty; (The nurse did not document the quantity of IV fluids infused.) Record review of a (late entry) progress note dated [DATE] (untimed), created on [DATE], showed RN M documented the following: -This nurse was given report for the unit residents and condition after being off work for multiple consecutive days. It was stated the resident was started on one liter of IV NS running at 150 ml/hour in his/her right arm for dehydration and increased lethargy and alertness. The night nurse, RN E said it took multiple attempts to start the resident's IV due to it being discontinued and ripped out and the order was to only run one liter of IV fluids; -This nurse found no documentation or a thread of orders and went to do a quick small assessment of the resident due to being in charge of G hall as well; -Upon assessment, it was noted the resident was very lethargic and had decreased alertness with very small response to physical stimuli such as sternal rubbing. Around 500 milliliters (ml) of fluids had already been received and the resident was lying in bed in his/her room. No edema (swelling) or skin breakdown noted. The resident was incontinent, staff performed incontinent care and resituated resident; -Vital signs were blood pressure of ,d+[DATE] mm of Hg, heart rate of 104 beats a minute and oxygen saturation of 94 % on room air with no dyspnea (difficult) or labored breathing noted. Resident was afebrile (no fever); -This nurse instructed the aides to encourage thickened liquids via spoon or sponge by mouth with head of bed elevated due to decreased alertness per his/her dehydration; -This nurse was unable to round on the unit again until right before the end of the shift change, due to being in charge of two halls, when this nurse unhooked the resident from the IV fluids due to them being completed and left the IV saline locked; -Report was passed on to the evening shift G hall nurse, RN O, of the resident's most recent condition. (Staff added this note to the medical record after the resident had discharged from the facility.) Record review of the facility/physician a secure messaging platform conversation between an (unnamed) facility member and the resident's physician dated [DATE], beginning at 5:28 P.M., showed the following conversation: -Facility staff: Resident is non responsive. -Physician: Is he/she a code? (slang term for a resident with an order for cardiopulmonary resuscitation (CPR), if cardiac rest occurs). This is the first I've heard of this. -Facility staff: Yes, he is a code; -Physician: Send him/her to the emergency room (ER); -Facility staff: He/she has left the building. Last vitals were blood pressure ,d+[DATE] mm of Hg, pulse of 109 beats per minute, respirations of 40 per minute, and oxygen saturation of 88% with oxygen on; -Physician: Thanks, sounds like he/she is not doing so well. Let me know; -Facility staff: He/she is intubated (tube placed down the throat to keep the airway open) and is being shipped to Mercy in [NAME]. Diagnoses of diabetic ketoacidosis (a potentially life threatening complication of diabetes mellitus), hypernatremia (elevated sodium), acute renal failure, and elevated troponin (proteins found in the muscle of the heart, elevation can be indicative of a heart attack); -Physician: Thanks, Please forward to the DON. Record review of the resident's progress notes dated [DATE], at 6:22 P.M., showed Licensed Practical Nurse (LPN) H documented the following: -At approximately 5:20 P.M., this nurse was notified by staff that the resident was hyperventilating (breathing at an abnormally rapid rate). Assessed the resident with temperature of 98.6 degrees F, respirations of 36 per minute, pulse of 113 beats per minute, oxygen saturation of 76% on room air, and blood pressure of ,d+[DATE] mm of Hg. Resident is unresponsive to verbal or tactile stimulation. Skin mottling (blotchy, red-purplish marbling of the skin) to bilateral (both sides) knees. Staff notified the physician and new order received to send the resident to the emergency room ; -At 5:40 P.M., resident's spouse notified of the resident's condition and pending transfer; -At 5:52 P.M. oxygen saturation was 88% with oxygen at three liters, pulse of 109 beats per minute, respirations of 40 per minute, blood pressure of ,d+[DATE] mm of Hg. Resident continues to be unresponsive; -At 5:59 P.M., emergency medical services (EMS) here, gave report and paperwork; -At 6:03 P.M., resident left with EMS. Physician notified of last vital signs and of resident leaving the facility. Record review of the resident's progress notes dated [DATE], at 11:47 P.M., showed: -Received notification at approximately 9:20 P.M., the resident had been intubated and was being transferred to hospital. The resident's physician and DON were notified. During a phone interview on [DATE], at 2:36 P.M., Speech Language Pathologist (SLP) P said the following: -She received an order to evaluate the resident, and saw the resident on [DATE], in the SCU dining room; -On [DATE], the resident was able to drink liquids through a straw. The resident was unable to keep food in his/her mouth. He/she spoke with the aides in the dining room and instructed them to continue to encourage fluids. He/she gave a communication form to either dietary or nursing to add fortified (nutrients added) liquids to the resident's diet; -The following day, on [DATE], the resident was not as alert. He/she spoke with the aides about safely feeding the resident, the resident was not eating, but was drinking some liquids thru a straw. During an interview on [DATE], at 2:45 P.M., the Dietary Manager (DM) said he/she did not receive a dietary communication form regarding ST's recommendation to provide the resident with fortified liquids. The resident remained on a regular diet until discharge. During an interview on [DATE], at 2:48 P.M., and on [DATE], at 2:55 P.M., RN D said the following: -He/she worked at the facility on Fridays and Saturdays each week and only saw the resident on [DATE] and [DATE]; -On Friday, [DATE], the SCU certified medication technician (CMT) and aides called the nurse to come to the unit. The resident appeared lethargic, was pocketing food in his/her mouth, instead of swallowing. Staff assisted the resident to bed. The nurse checked the resident's vital signs, assessed the resident, and called the physician; The physician knew the resident's sodium was high, in the 150s, so the physician ordered one-half (0.45 %) NS times three liters; -He/she put the order for the IV fluids on the eTAR; -He/she started the resident's IV on [DATE] and the IV infused on Friday, [DATE], and Saturday, [DATE]; -The nurse believed the resident received all three liters; -The resident's blood pressure was soft, like 80s over 40s, none of the resident's other VS were abnormal; -The nurse thought he/she made a progress note, but was unsure. The nurse said the facility has newer computers and sometimes the progress notes do not save; -The nurse did not remember whether or not he/she notified the resident's family; -The resident took a turn for the worse the last couple of days he/she was at the facility. The resident was not eating. The resident did not eat on [DATE]. Staff suctioned the resident, but there was nothing in the resident's mouth or throat. The resident was breathing okay, his/her lungs were clear, and his/her pupils were reactive to light; -On [DATE], in the morning, RN E reported the resident's IV had been accidentally pulled out sometime during the night; -On [DATE], mid-morning, RN D started a new IV and hung a second bag of IV fluids; -RN D said he/she may have forgotten to sign off the administration on the eTAR; -He/she was not notified the resident was not taking his/her medications; -If the CMT had notified RN D that the resident was not taking his/her medications, RN D would have assessed the resident and called the physician that same day; -The nurse said he/she did not know what the resident's normal baseline was because the nurse did not usually care for the resident; -When there are two nurses working in the facility, one on G hall and one on C hall, it is unclear which nurse is responsible for what functions in the SCU; -It was unclear who was responsible for assessment and documenting on an SCU resident when a change of condition occurred; -If something happens with one of the residents in the SCU, he/she does not feel comfortable being responsible for G hall and the SCU, because it is quite far away. During an interview on [DATE], at 3:00 P.M., RN E said the following: -He/she usually does not work on the SCU; -On [DATE], at 12:10 A.M., CMT F informed RN E that the day nurse had mentioned to CMT F, earlier in the day, that the resident should have IV fluids. The CMT said there was an order for IV fluids, but staff had not administered them. RN E checked the resident's eTAR and saw an order for three (one liter) bags of IV fluids. RN E went to the SCU and found the resident's IV site was blown with no IV fluids in the resident's room. RN E inserted and started a new IV on the resident and hung a bag of fluids. The IV fluids were infusing when the nurse

Based on observation, interview, and record review the facility failed to appropriately monitor, document and evaluate the impact of physician-ordered nutritional interventions according to their weight loss protocol, acceptable nursing practices and resident preferences for two residents (Resident #1 and #2). The facility failed to effectively address the weight loss for Resident #2, who experienced a severe weight loss of 28 pounds (19.3% loss) in 30 days. Staff failed to clarify with the physician the 2 Cal (high calorie supplement) amount to be administered to the resident, failed to provide the fortified (200 extra calories added to food at each meal) diet, failed to ensure staff administered the ordered house shakes (high calorie, high protein) twice a day and document the percentages the resident consumed. The facility failed to follow physician-ordered nutritional interventions for Resident #1. Seventeen residents were selected for review. The facility had a census of 98 residents. Federal guidelines for suggested parameters for evaluating significance of unplanned & undesired weight loss are: -Significant Loss: -1 month 5%; -3 months 7.5%; -6 months 10%; -Severe Loss: -1 month = greater than 5%; -3 months = greater than 7.5%; -6 months = greater than 10%. Record review of the facility policy for unplanned weight variance of 5% or greater dated 2003, showed, in part, the following information: -Assess: -Percentage of food consumed, tolerance and compliance of diet; -Interview the resident if able; -Amount of assistance provided at meals; -Review with nursing assistants any change in resident behavior or mood; -Review current lab work; -Notify: -Dietary department of the weight variance; -The physician with relevant information and interdisciplinary recommendations; -Action: -Implement physician's orders; -Provide additional nursing assistance; -Monitor progress or decline by documenting accurate meal/fluid intake, weight and elimination patterns;-Document: -Assessment notification to the above parties, physician orders and response to additional measures in the medical record. 1. Record review of Resident #2's significant change minimum data set (MDS) a federally mandated assessment to be completed by facility staff, dated 7/15/11, showed the following information: -Severely impaired cognitive decision-making skills;-Independent with mobility, ambulation, personal hygiene and transfers;-No falls since admission or prior assessment;-No nutritional approached in place;-No signs and symptoms of possible swallowing disorders;-Weight 139 pounds;-No pressure sores. Record review of the medical record showed the resident was walking independently and had a fall on 8/25/11. Staff received orders to send the resident to the hospital for evaluation. The hospital admitted the resident to the hospital with [DIAGNOSES REDACTED]. Record review of the September 2011, physician's orders showed orders for: -Activity as tolerated; -Diet order of pureed with honey thickened liquids; -[MEDICATION NAME] (antipsychotic medication) 0.25 milligrams (mg) twice a day. Record review of the vital sign and weight record showed staff noted the resident's admittance weight as 145 pounds on 9/9/11. Record review of the nurse's notes showed the staff noted the following information: -On 9/9/11, the resident was able to communicate his/her needs and required extensive staff assistance; -On 9/11/11, the resident ate 20% of lunch and 240 cubic centimeters (cc) of fluids. The resident expressed that he/she was not hungry; -On 9/12/11, staff noted the resident had difficulty swallowing;-On 9/13/11, the resident ate 25% of meal and 420 cc of fluids consumed;-On 9/14/11: -Day shift noted new orders for Speech therapy to evaluate and treat;-At 2:00 P.M., the resident was unable to eat or drink anything for 72 hours. The resident's current weight was 145 pounds. The staff faxed the physician for a new [DIAGNOSES REDACTED].M., new orders per the physician related to nutritional status: -2 Cal (a nutritionally complete, high-calorie liquid food) three times a day between meals; -Continue to encourage fluids as needed;-At 7:45 P.M., the resident's responsible party requested the resident be taken off of [MEDICATION NAME] (an anti-psychotic medication), "the resident had never taken medication and he/she would do better without medication". Fax sent to the physician. Record review of the physician's order sheet showed orders, dated 9/14/11, for 2 Cal three times a day between meals (the staff did not indicate or clarify with the physician how much 2 Cal to administer to the resident three times a day). Record review of the medication record showed the following: -Order dated 9/14/11, for 2 Cal three times a day between meals (the staff did not indicate or clarify with the physician how much 2 Cal to administer to the resident three times a day);-Staff initialed they administered the first dose of 2 Cal to the resident on 9/15/11, at 3:00 P.M. Record review of the significant change MDS dated [DATE], showed the following information: -Extensive staff assistance for bed mobility, transfers, dressing, eating, personal hygiene and toileting;-Mechanically altered diet;-Swallowing problems;-Weight 145 pounds. Record review of the care plan, dated 9/16/11, showed the following information: -Decreased intake since returning from the hospital. The resident needs a lot of encouraging to eat and has some swallowing concerns;-Monitor meal percentages;-Monitor weight per facility protocol;-2 Cal between meals. Record review of the nurse's notes showed the following information: -On 9/15/11, unable to get resident to eat any food, spits it out. The resident does drink minimal amounts of water; -On 9/16/11 at 3:00 P.M., the Director of Nursing (DON) noted the resident weighed 145 pounds, will monitor weekly. Physician faxed today due to resident had not been eating or drinking;-At 8:00 P.M., fax received to encourage oral intake as much as possible, nursing reports eating better. (The DON just noted at 3:00 P.M., the resident had not been eating or drinking). Add 2 calorie three times a day between meals (the staff already received the same order on 9/14/11, and administered the first dose on 9/15/11. The staff still did not indicate or clarify with the physician how much 2 Cal to administer to the resident three times a day);-On 9/17/11, the resident has a poor appetite, though drinks moderate amounts;-On 9/18/11, at 8:30 A.M., the speech therapist noted the resident responded to low demand greetings, limited responses to additional questions. Oral intake poor, unable to move food and swallow;-At 2:20 P.M., the resident had no signs of improvement in swallowing. Staff notified the physician and received new orders as follows: -Start an intravenous line and administer normal saline (a salt-water solution) at 75 cc per hour; -Administer [MEDICATION NAME] (Partial [MEDICATION NAME] nutrition (PPN) intravenous solution of amino acids and maintenance electrolytes) one liter at 75 cc per hour and 10% lipids (additionally acids added); -Discontinue [MEDICATION NAME] (requested to be discontinued by resident's responsible party on 9/14/11); -Staff notified the responsible party regarding the new orders. He/she expressed concern stating, "Is he/she still receiving the [MEDICATION NAME]? I have told them that once he/she was off of the [MEDICATION NAME], he/she will wake up and eat. It is what happened in the hospital". Record review of the website "Encyclopedia of Nursing & Allied Health" showed the following information:-Partial [MEDICATION NAME] nutrition (PPN) is normally prescribed for patients who can tolerate some oral feedings but cannot ingest adequate amounts of food to meet their nutritional needs. It is usually administered through a peripheral intravenous catheter;-For those on short-term [MEDICATION NAME] therapy, the goal is to provide adequate nutritional supplementation until the patient can transition back to solid foods. Record review of the nurse's notes showed the following information:-On 9/19/11 at 8:30 A.M., the DON spoke with the resident's responsible party and discussed the PPN and the option of hospice. The responsible party to come and see the resident to ask the resident his/her wishes;-At 11:15 A.M., the responsible party and spouse present. The resident responded to them and stated, "Tired of living". The decision was made to start PPN, to "give him/her a fighting chance because he/she has always been a fighter. If he/she fails at least we know we gave him/her a chance and tried";-At 4:15 P.M., the physician was notified of the family's wishes. The physician stated this was not a life-altering medication that would make him/her better and they would give it for seven days only. This was to sustain his/her life long enough for the responsible party to decide whether they wanted a feeding tube or hospice. New order for [DIAGNOSES REDACTED]. The medication will take several days to arrive from pharmacy;-At 6:00 P.M., the speech therapist stated the resident had no problems noted with chewing or swallowing. The resident did well with soup and crackers;-On 9/20/11, faxed the physician related to the responsible party's wishes to have the tube feeding placed. The responsible party does not want hospice. Record review of the data collection/evaluation-nutritional dated 9/21/11, showed the registered dietitian (RD) noted the following information: -Recently readmitted with [MEDICAL CONDITION]. The resident returned with decreased alertness and was not eating;-Reviewed the resident's chart and potential plans for PPN, intravenous fluids running now;-Apparently started to "wake up" today and did eat lunch with fair intake;-Diet order: Puree, thick liquids, 2 Cal three times a day (the RD did not indicate any recommendation for the amount of 2 Cal to be administered or for staff to clarify the amount with the physician);-Recommendations: Suspect weight loss is unavoidable however noted hospice consult (the staff noted the family declined hospice on 9/20/11). Encourage intake and monitor. Record review of the nurse's notes showed the following information: -On 9/22/11, the DON noted the resident eating well the last few days (the staff had infused normal saline fluids from 9/18/11 to 9/22/11, to hydrate the resident while waiting for the PPN to arrive from the pharmacy). The staff called the physician and notified him of the improvement and asked if he still wanted to do the PPN. The physician stated that he wanted to give the [MEDICATION NAME] for seven days to make sure the resident "won't start getting better, before he/she gets worse". The physician felt that with the resident eating better and up in the wheelchair, the tube feeding at this time was not warranted. Record review of the weekly weight meeting dated 9/23/11, showed the DON noted the resident weighed 140 pounds, down five pounds from last week however resident had condition change where he/she had no intake. Physician ordered intravenous fluids and [MEDICATION NAME] for seven days. In the last few days resident has had increased intake. (the DON did not indicate that she clarified with the physician the amount of 2 Cal to be administered to the resident). Record review of the medication record showed the following information: -Between 9/23/11 to 9/30/11, the staff administered the PPN [MEDICATION NAME] to the resident as ordered;-Between 9/15/11 to 9/30/11, the staff initialed they administered the 2 Cal to the resident three times a day. (the staff still did not indicate they clarified with the physician the amount of 2 Cal to be administered to the resident); Record review of the vital sign and weight record showed on 9/25/11, the resident weighed 145 pounds. Record review of the nurses' notes showed the following information: -On 9/27/11, evening shift staff noted the resident had 4+ [MEDICAL CONDITION] (observable swelling from fluid accumulation in body tissues.) New orders received to schedule an ultrasound and to administer [MEDICATION NAME] (a diuretic) 40 mg one daily for three days;-On 9/28/11, staff noted the resident had 1+ [MEDICAL CONDITION]. Record review of the weekly weight meeting dated 9/30/11, showed the staff noted the resident weighed 145 pounds (this weight was from 9/25/11. Between 9/27/11 to 9/29/11, staff noted the resident had 1 to 4+ [MEDICAL CONDITION] and administered [MEDICATION NAME] to the resident for three days) up five pounds from last week (from 9/18/11 to 9/30/11, staff administered five days of intravenous fluids and seven days of PPN. Meal intake record showed from 9/24/11 to 9/30/11, average intake 5 to 10% with six refusals). Continue to encourage oral intake;-Staff did not document regarding the resident having [MEDICAL CONDITION] and receiving the [MEDICATION NAME];-Staff did not indicate they reweighed the resident on 9/30/11, for an accurate weight after the resident received the [MEDICATION NAME];-Staff did not indicate they clarified with the physician the amount of 2 Cal to be administered to the resident. Record review of the weekly weight meeting dated 10/4/11, the DON noted the resident weighed 134 pounds, down 11 pounds from last week (severe loss of 7.5% in one week). The resident's appetite was poor, but not enough to warrant a feeding tube. Will try house shakes (high caloric protein supplement) twice a day;-The DON did not indicate she clarified with the physician the amount of 2 Cal to be administered to the resident. Record review of the nurse's notes showed on 10/6/11 (two days after the weekly weight meeting), staff added a change of diet form with new diet orders for fortified (added calories to food) and house shake (the word "shake" was singular and the order did not indicate how many times a day). Record review of the facility form titled fortified food table (no date given) signed by the RD, instructed staff to add at least 200 extra calories per meal for fortified diets. During an interview and record review on 10/26/11, at 1:45 P.M., the dietary manager and cook said when dietary received the diet change form from nursing they added the changes to the resident's diet card. The cook said he/she did not remember seeing a diet change form that said "fortified", does remember sending a shake around 10:00 A.M.; -At 2:25 P.M., the dietary manager said she found the diet change form from 10/6/11. She only knew it was for the resident because she could see the resident's patient number. Observation showed the diet change form had an oily substance that had saturated all but one corner of the slip. On the corner not covered with the oily substance was the date 10/6/11, resident number and the word "shake". The dietary manager said the fortified foods were never started on the resident and she was not sure how many shakes were sent for the resident. Record review of the meal intake record between 10/6/11 to 10/14/11, showed staff did not record the intake for any A.M., P.M., or bedtime snacks for the resident. Record review of the vital signs and weight record showed on 10/10/11, the resident weighed 123 pounds. Record review of the nutritional progress notes dated 10/11/11, showed the RD noted the resident continued to lose weight, 123 pounds, down 11 pounds over last month (record review showed staff recorded over the last month the resident had lost 22 pounds from 145 to 123). The resident had variable intake, generally poor. Puree diet with honey thick liquids, fortified foods, house shakes offered as well as 2 cal. Noted the resident did receive [MEDICATION NAME] for seven days. Wound care provided to left heel;-Recommendations: continue to encourage intake, offer bites and sips often throughout the day. Continue current interventions. Suspect weight loss may be unavoidable;-The RD did not indicate any recommendation for amount of 2 Cal to be administered or for staff to clarify amount with the physician;-The RD did not indicate she reviewed the meal and snack intake record for meal percentages (Staff had not documented any snack percentages in the month of October);-The RD did not indicate she reviewed the resident's dietary card or follow-up with dietary staff to ensure implementation of the fortified foods and house shakes. During an interview on 10/27/11, at 10:30 A.M., the RD said she comes to facility once a month. When she comes to the facility, the staff generally have information for her that included the skin report, any new admissions, residents due for an annual assessment, residents with weight loss, and any resident the staff was worried about;-She reviews the resident's chart and looks at the resident's diet;-She talks to the staff about the residents;-She then writes notes in the resident's chart and leaves recommendations with the administrator, DON and dietary manager;-She does remember that the resident had a time when he/she was saying "I'm ready to go";-When she writes that a resident has an avoidable or unavoidable weight loss she takes many things into consideration like: the resident's diet, intake, supplements that were in place and whether effective, as well as the resident's age and if on hospice; -Regarding the resident's order for 2 Cal three times a day, some facilities have a protocol in place for how much 2 Cal for staff to administer to a resident. She cannot speak for this facility, she just "assumed" the staff administered 120 cc;-Resident #2's 2 Cal was ordered as a supplement between meals;-The surveyor informed the RD about the staff not clarifying with the physician the 2 Cal amount to be administered to the resident, the fortified diet not started on 10/6/11, staff not recording snack percentages, and staff administering only one health shake to the resident instead of the two ordered;-The RD said he/she was not aware of the above, and she "feels sick on her stomach". The RD said she reviewed the weekly weight notes and said she assumed things were in place. The RD said she usually tried to check up on things that were in place for residents;-The RD said the former dietary manager left several months back. The RD said when she came into the facility the last few months, she was "never sure who was in charge". Record review of the weekly weight meeting dated 10/14/11, showed the DON noted the resident weighed 123 pounds, down 11 pounds from last week (22 pounds lost since admission. The resident experienced severe weight loss of 15% since admission and 8.2% loss in one week). Physician notified of weight loss and resident not eating, he/she clamps his/her mouth shut and will not eat;-The DON did not document she followed-up with staff and/or dietary staff regarding the implementation of previous recommendation for the fortified foods and house shakes;-The DON did not document she reviewed the resident's meal intake record for meal and snack percentages (staff had not recorded any snack percentages);-The DON did not document she clarified with the physician the amount of 2 Cal to be administered to the resident (the medical record still showed 2 Cal three times a day with no amount indicated since 9/14/11);-The DON did not document any further recommendations. Record review of the nurse's notes showed, in part, on 10/14/11, at 3:50 P.M., the resident complained of chest pain and staff received orders to send the resident to the hospital for evaluation. At 7:24 P.M., the resident returned to the facility with a [DIAGNOSES REDACTED]. Record review of the weekly weight note dated 10/19/11, the DON noted the resident weighed 117 pounds, down 6 pounds from the last week (28 pound loss since admission, severe weight loss of 19.3% and loss of 4.8% in one week). Physician faxed back 10/18/11, feedings are to be recorded for five days, clarification sent back to physician due to inability to read fax 10/18/11, awaiting clarification. Record review of the physician orders showed a new physician order dated 10/19/11, for recommendation of feeding five times daily: breakfast, A.M. snack, lunch, P.M. snack and supper. Record review of the nursing home progress note dated 10/21/11, showed the physician assistant student (PA-S) noted the resident was napping in a chair but easily aroused. Quiet, no complaints at this time;-Weight 117 pounds;-[DIAGNOSES REDACTED]. the resident's weight loss. Observation on 10/24/11, showed the following information: -At 2:50 P.M., the resident sat in the recliner in his/her room. The resident appeared tall, frail and thin. His/her face had a sunken in appearance and the resident's skin appeared dry and fragile;-At 5:35 P.M., certified nurse assistant (CNA) C assisted the resident to walk to the dining room. CNA C said the resident's pants were too big and about to fall down. Assisted the resident to sit in a chair at the dining room table;-At 5:39 P.M., registered nurse (RN) E sat by the resident at the dining room table. The resident had a divided plate with pureed meat, a rice/potato dish and broccoli, thickened water, fruit punch and a dish of super pudding (high calorie, high protein). RN E encouraged the resident to take bites of food and bites of the super pudding. RN E said, "that's a bird bite";-At 6:10 P.M., RN E continued to encourage the resident to eat. The resident ate 50% of the super pudding, and 50% of the thickened water. Observation on 10/25/11, showed the following information: -At 7:15 A.M., the resident responded appropriately to basic questions. Surveyor said, "You don't have much of an appetite lately". The resident said, "Well, I think I do";-At 7:25 A.M., certified medication technician (CMT)/CNA D entered the room and assisted the resident to walk to the dining room. The aide told the resident they were having pancakes and bacon for breakfast. Resident said,"Oh that's good. I love bacon. I could eat a ton of pancakes";-At 8:08 A.M., the staff set up the resident's breakfast tray. The divided plate had pureed pancakes and eggs. The resident picked up the spoon and took a small bite of the pancakes;-At 8:16 A.M., licensed practical nurse (LPN) H gave the resident thickened orange juice and fruit punch. LPN H poured sugar-free pancake syrup on the resident's pancakes (the staff had regular full calorie syrup on the table next to the sugar free syrup.) LPN H assisted the resident with pancakes and eggs. LPN H offered the resident a drink of the fruit punch. CMT/CNA D told LPN H that the resident liked the thickened water better;-At 8:29 A.M., the resident told CMT/CNA D he/she was "full". The resident did drink more water. The aide told other residents in the dining room about an ice social in the afternoon. The resident said he/she could "eat and eat ice cream". Staff did not check with dietary or the charge nurse to see if the resident could have some ice cream;-At 1:40 P.M., therapy staff asked the resident if he/she got enough to eat. The resident said, "Yes". Record review of the physician's orders dated 10/25/11, showed an order to change diet to mechanical soft with honey thick liquids. Observation and interview on 10/26/11, showed the following information: -At 6:15 A.M., CMT/CNA D assisted the resident out of bed and into the recliner. The aide asked the resident if he/she was hungry. The resident said he/she was "hungry as a horse";-At 8:30 A.M., CMT/CNA D said speech therapy changed the resident's diet to mechanical soft and he/she ate all of his/her breakfast and fed him/herself. The aide said last night the resident had a hamburger and fries. Interview and record review on 10/26/11, showed the following information: -LPN E said house shakes came from the kitchen and the aides gave the shakes to the residents. The aides then recorded the percentage on the meal intake record. LPN E looked at the resident's October 2011, meal intake record and said, "they haven't recorded any snack intake, but should have"; -LPN E looked at the resident's order for 2 Cal and said he/she usually gave 30 to 60 cc. (The medication record showed LPN E initialed he/she administered 2 Cal this morning). LPN E said he/she gave the resident 30 cc this morning. Surveyor asked the nurse to review the 2 Cal order and asked how did the nurse know how much to administer. LPN E looked at the resident's order and said, "Oh my, I see, there's no order for how much to give. But look I'm not the only one who's done it"; -At 11:40 A.M., nurse assistant (NA) I said the resident got a shake at 10:00 A.M., and 3:00 P.M.. NA I said the resident loved the shakes and would drink the whole thing. NA I said staff should document the snack percentage on the resident's meal intake record. NA I said the resident never liked the pureed food; he/she would eat two to three bites then say he/she did not want it. NA I said the resident always reached for other resident's plates of regular food. During record review and interview on 10/26/11, at 2:45 P.M., showed the following information: -The resident's medication record showed the order remained the same for the 2 Cal three times a day. LPN E initialed he/she administered the 2 Cal at 12:00 P.M.;-Surveyor asked LPN E if there were any changes to the resident's 2 Cal order. LPN E said he/she administered 60 cc of 2 Cal to the resident at 12:00 P.M. LPN E said CMT/CNA D looked at the resident's record and found the order to give the 60 cc;-At 2:50 P.M., CMT/CNA D said he/she had not looked in the resident's chart today and had not talked to LPN E regarding the resident's 2 Cal order. CMT/CNA D said he/she did not know the resident's orders. CMT/CNA D said if a resident had a 2 Cal order, he/she was told to give 120 cc. If an order says 2 Cal three times a day with no specified amount, staff really would not know how much to give to the resident and should clarify with the physician. During an interview on 10/26/11, at 6:50 P.M., the speech therapist (ST) said when Resident #2 was readmitted he/she was in "horrible" condition. The resident was on intravenous fluid, was "out of it", and could not carry on a conversation. The staff just tried to get anything in him/her. The ST said he/she was not sure what supplements the resident received. ST had been working with the resident. The plan for the resident would be the same plan with or without the [DIAGNOSES REDACTED]. When he/she was "with it" he/she did well. Record review of the medication record showed a new order dated 10/27/11, for 2 Cal 30 cc three times a day. During an interview on 10/27/11, at 1:30 P.M., with the resident's physician and the DON, the physician said he comes to the facility to see all residents monthly. Staff can call and fax his office during business hours and can call his home phone and cell phone after hours. After the facility readmitted the resident, he/she was very much debilitated. He gave the order for the PPN to give the resident's responsible party time to make a decision (about end of life care). The physician said he just assumed the facility had a protocol in place for the amount of 2 Cal to be administered. The DON said she thought they usually gave 30 to 60 cc but was not for sure. The physician said he was not aware that the supplements and diet were not given as ordered. He expected staff to follow the orders. During an interview on 10/28/11, at 10:35 A.M., the administrator and DON said staff thought the resident was at the end of life until last week then he/she perked up. They have weekly weight meetings. The DON said she assumed things were being done and she assumed follow-up was done with things that were implemented during the meeting. Record review on 10/31/11, at 1:10 P.M., showed a note by the DON which instructed staff that all snacks were to be documented on the meal intake sheets every shift. 2. Record review of Resident #1's face sheet (admitted ) showed the facility originally admitted the resident on 09/17/10, with [DIAGNOSES REDACTED]. Record review of the dietary intake sheets showed the resident's average intake per day was approximately 50-75 percent. Record review of the resident's MDS dated [DATE], showed the following: -Moderately cognitive impaired; -Totally dependent on staff for transfers, toilet use; -Extensive assistance by staff for bed mobility, dressing, and personal hygiene; -Supervision needed for eating; -Height 64 inches; -Weight 92 pounds; -Loss less than five percent in the past month or 10 percent in the last six months; -Therapeutic diet; -Resident has greater than stage one pressure sore; -Resident had the most severe tissue type for any pressure sore with eschar, black brown tan tissue with possible tissue death. Record review of a physician's order dated 09/19/11, showed the physician ordered the staff to provide the resident with protein shakes every day. Record review of the resident's care plan, dated 09/21/11, showed the following information: -At risk for weight loss due to [DIAGNOSES REDACTED]. -Has own teeth in poor condition, no problems identified at this time; -Regular diet fortified food; -Monitor meal percentage and offer a substitute as needed; -Monitor sign and symptoms of stomach upset; -Monitor bowel movement every shift and give laxative if no bowel movement in three days; -Offer prune juice to help with constipation; -Feeds self in main dining room with staff set up only; -Has own teeth care to care for; -Medications with lots of water; -Will request salad in place of meals. Will also request strawberry milk shake in place of house shake; -Loves sweets especially cookies. Record review of the resident's nutritional assessment, completed by the registered dietitian (RD), dated 09/21/11, and showed the following information: -Current weight 92 pounds; -Teeth fair to poor; -Resident confused; -Unintentional undesirable weight loss (wound being treated); -11 pounds weight loss past yea,r as low as 85 pounds; -Regular fortified shakes daily, poor intake does not feed self in main dining room, sometime picky, confused at times; -Weight loss perhaps unavoidable; -Continue to encourage intake. Record review of the resident's nutritional note completed by the RD, dated 10/11/11, and showed the following information: -Resident continues to lose weight, current weight 88 pounds; -Multiple interventions in place: fortified foods, frequent snacks, protein shakes (the RD did not know these interventions were not in place); -Suspect weight loss unavoidable, continue current plan of care. Record review of the weekly weight records showed the following weights recorded by staff: -09/07/11, 94 pounds (lbs); -09/11/11, 94 lbs; -09/12/11, 92 lbs; -09/21/11, 86 lbs (8.5 percent weight loss in 14 days); 09/26/11, 88 lbs; 10/05/11, 88 lbs; 10/12/11, 84 lbs (10.6 percent weight loss in 35 days); 10/17/11, 86 lbs; 10/26/11, 85 lbs ( 9.5 percent wt loss in 49 days). Observation on 10/24/11, at 1:00 P.M., showed the resident ate approximately 75 percent of diet and consumed approximately 240 milliliters (ml) of fluids. At 6:10 P.M., the resident ate approximately 50 percent and consumed approximately 120 ml of fluids. Observation on 10/25/11, at 1:00 P.M., showed the resident ate approximately 75 percent of diet and consumed approximately 240 ml of fluids. During an interview on 10/25/11, at 9:30 A.M., the dietary manager said the resident's diet card that informed staff of the diet the resident received showed regular fortified food. No shakes or snacks were shown on the diet card. The resident requested no fish but liked chicken breasts and salads. During an interview on 10/26/11, at approximately 11:00 A.M., the resident's physician said he expected staff to follow his orders. Sometimes they are just missed. During an interview on 10/26/11, at 3:00 P.M., the care plan coordinator (CPC) said the dietary manager was new and management

Based on observation, interview and record review, the facility failed to assure staff appropriately monitored, developed and implemented appropriate interventions to maintain the resident's maximum mental and psychosocial functioning for one resident (Resident #15) who had symptoms of depression and verbalized to staff multiple times, that he/she wanted to kill him/herself. The staff failed to implement a care plan with problems, goals and approaches to address the resident's depression and suicidal thoughts. A sample of 17 residents was selected for review in this facility with a census of 98. 1. Record review of the Resident #15' s nurse's notes showed the following information: -On [DATE], the resident refused occupational therapy, not working well with therapies. Resident said "too tired to do therapy or go home and just wants to die" Social services talked to resident about discharge and possible hospice. New orders for [MEDICATION NAME] (antidepressant) 20 milligrams (mg) daily and [MEDICATION NAME] (appetite stimulant);-On [DATE], care plan coordinator interviewed resident. Denied little interest in things. Denied feeling depressed however started on [MEDICATION NAME]. Visual signs are noted. Chart reviewed and staff interviewed. Record review of the physician's progress notes dated [DATE], showed the physician noted the resident made comments to staff about dying. Resident did not feel well and refused therapy. New orders for [MEDICATION NAME], encourage to continue therapy and follow-up with psychologist. Record review of the social service progress notes on [DATE], showed the social service director (SSD) noted the resident was alert and oriented. Resident jumped from one thought to another during interview. Stated had a good appetite, but had not been eating, put on an appetite stimulant. Resident responsible for self. Resident worked well with therapy today. SSD did not document regarding the resident's statements on [DATE], of wanting to die, regarding new orders for an antidepressant and about possible hospice. The SSD did not document regarding follow-up with the psychologist as ordered by the physician on [DATE]. Record review of the 30 day minimum data set (MDS) a federally mandated assessment completed by facility staff dated [DATE], showed the following information: -Short and long-term memory problems;-Little interest or pleasure in doing things. Symptoms occurred half or more than half of the last 7 to 11 days;-Feeling down, depressed or hopeless. Symptoms occurred several days in the last 2 to 6 days;-Feeling tired of having little energy. Symptoms occurred half or more than half of the last 7 to 11 days.Record review of the care plan developed on [DATE] and reviewed on [DATE], showed staff did not include problems, goals and approaches/interventions to address the resident's complaints of wanting to die, refusal of therapies and the new orders for antidepressants started on [DATE]. Record review of the nurse's notes (narrative notes written by the nurse) showed the following information: -Between [DATE] to [DATE], staff did not document they monitored the resident for possible side effects of the [MEDICATION NAME];-On [DATE], the staff found the resident on the floor. New orders for urinalysis (UA) and other labs;-On [DATE], new orders for Bactrim (antibiotic) twice a day for 10 days for urinary tract infection [MEDICAL CONDITION];-On [DATE], resident lost his/her balance and staff lowered the resident to the floor;-On [DATE], found resident on the floor beside the bed. Resident continued to be restless. As needed medication given to the resident for agitation and restlessness. Urology appointment cancelled related to storms. Staff to call the resident's physician about changing the resident's urinary catheter (tube insert into the bladder to help drain urine) at the facility and possibly moving room closer to nurse's station;-On [DATE], resident has shown a decline, unable to feed self or help with cares. Resident said he wanted to die. Physician notified. Record review of the physician's progress notes dated [DATE], showed the physician noted the resident admitted to not feeling well. Nursing staff reported increased falls, weakness, confusion and hallucinations. Mental status change. New orders to discontinue [MEDICATION NAME] and obtain labs (UA). Record review of the 60 day MDS dated [DATE], showed the following information: -Short and long-term memory problems;-Little interest or pleasure in doing things. Symptoms occurred half or more than half of the last 7 to 11 days;-Feeling down, depressed or hopeless. Symptoms occurred half or more than half of the last 7 to 11 days;-Feeling tired of having little energy. Symptoms occurred half or more than half of the last 7 to 11 days.Record review of the nurse's notes showed the following information: -On [DATE], lab results called to the physician. Orders received for culture of the urine, Bactrim (antibiotic) twice a day for 10 days for UTI. Record review of the physician's progress notes dated [DATE], the physician noted the resident had mental status changes, depression and anorexia. New orders for CAT scan of the brain to rule to a stroke, attempt to discontinue the urinary catheter. Record review of the daily skilled nurse's notes (a form used by staff for charting. One side was for staff to check mark all applicable boxes and to document concerns and changes on side two), showed the following information: -On [DATE], usually incontinent, on toileting program. Little interest, feeling down and depressed, tired/has little energy;-On [DATE], [DATE], [DATE], [DATE], little interest, feeling down and depressed, tired/has little energy;-On [DATE], resident confused, unable to make basic decisions on his/her own. Physician "ok'd" for hospice when power of attorney in place;-On [DATE], feeling depressed;-On [DATE], little interest, feeling down and depressed;-On [DATE], aide notified nurse that resident said, "just get a knife and cut my throat. I'm not worth anything". This nurse spoke with the resident. Asked if he/she was serious about the knife. Resident stated, "No, I have too many things to think about". Record review of the social service progress notes dated [DATE], [DATE], and [DATE], showed the SSD did not document regarding the resident having little interest, feeling down and depressed. The SSD did not document she follow-up on the resident's comment about wanting a knife to cut his/her throat. Record review of the physician progress notes [REDACTED]. The resident complained of being unable to get up without assistance. Stated he/she wanted to "run away". The physician did not document regarding the resident wanting a knife to cut his/her throat. Record review of the nurse's notes showed the following information:-Staff did not document in the notes between [DATE] to [DATE], regarding the resident comments on [DATE];-On [DATE], significant change MDS completed. Resident interviewed. The resident had recently been admitted on to hospice services ([DATE]). The resident exhibits signs and symptoms of increased depression and does not understand why he/she is still here, "I should have been buried [AGE] years ago". Record review of the social service progress notes dated [DATE], showed the SSD said the resident had a recent decline and had been put on hospice care. When mood interview completed, the resident voiced feelings of depression. He/she also feels like he/she would be better off dead. When asked if he/she would hurt him/herself, the resident stated, "Oh, I don't know". Asked if he/she had a plan, he/she stated, "I guess this is just part of it". Will talk to hospice to set-up chaplain consult. Will continue to monitor for any further changes and psychosocial well-being. Record review of the significant change MDS dated [DATE], showed the following information: -Cognitively intact;-Feeling down, depressed or hopeless. Symptoms occurred nearly every day for the last 12 to 14 days;-Thoughts that you would be better off dead, or of hurting yourself in some way. Symptoms occurred nearly every day for the last 12 to 14 days;Record review of the resident care area assessment (CAA-the section of the MDS that identifies potential problem areas according to the data entered into the MDS. Staff review triggered CAA areas to determine care planning needs) dated [DATE], showed the following information:-Psychological well-being assessment. See nurse's notes regarding depressive comments regarding death;-Staff did not complete the area for care plan considerations. Record review of the care plan dated [DATE], showed staff did not include problems, goals and approached/interventions to address the resident's having thoughts he/she would be better off dead, or of hurting self in some way nearly every day for the last 12 to 14 days as indicated on the MDS and having increased signs and symptoms of depression. Record review of nurse's notes showed the following information: -Between [DATE] to [DATE], staff did not document on the resident;-Between [DATE] to [DATE], the resident had a fall, staff obtained a UA and received new orders to administer antibiotics to the resident for a UTI;-On [DATE], at 1:00 P.M., the resident was very upset stating, "please kill me. I want to die. This is like being in a prison. This is no way to live. I haven't done anything wrong." Pounding fists on legs and crying. Encouraged to verbalize feelings. Yelling and threatening other residents. As needed [MEDICATION NAME] (antianxiety) given. At 1:00 P.M., the resident was calmer;-At 5:05 P.M., resident found lying on floor. Staff assisted the resident up to the wheelchair. The resident said, "just give me a 22 (gun). I'll take care of this." When asked what he/she meant, he/she replied, "kill myself". The day shift nurse stated the resident had similar comments to staff earlier today. Assured resident we did not want that;-At 5:10 P.M., nurse notified Director of nursing (DON) and assistant director of nursing (ADON) of resident's fall (the nurse did not document he/she reported the resident's wanting to kill him/herself);-At 5:33 P.M., the administrator and physician notified of fall and interventions (the nurse did not document he/she reported the resident's wanting to kill him/herself);-Between [DATE] to [DATE], staff did not document regarding the resident's comments about wanting to kill him/herself on [DATE];-On [DATE], the resident returned from the hospital. The resident alert and stated, "my spouse just passed away". Then made a motion with his/her hand similar to a gun and pulled the trigger. Staff assisted the resident to the bed. Nurse administered the as needed [MEDICATION NAME] as ordered;-Between [DATE] to [DATE], staff did not document regarding the resident's spouse passing away and/or the resident using the hand motion of a gun and pulling the trigger;-On [DATE], hospice called in regards to obtaining additional pastoral care for resident due to spouse recently passing. Record review of the social service progress notes showed the following information: -The SSD did not document between [DATE] to [DATE];-On [DATE], visited with resident related to spouse passing, it was also his/her desire to pass on. Reported to charge nurse. SSD did not document regarding the resident wanting to kill him/herself on [DATE] and [DATE]. Record review of the monthly summary dated [DATE], showed the resident was frequently depressed and requesting to die. Resident recently lost spouse, noted to be very tearful. Record review of the hospice social worker notes dated [DATE], showed the resident had been allowed to spend final moments with spouse and did understand that he/she had died . In talking with him/her, resident appeared more confused than usual. Facility staff noted no changes with resident today, nor did his/her chart reveal any changes, either (the resident's medical record showed the resident made comments about wanting to kill him/herself with a 22 on [DATE]). Record review of the physician's progress notes dated [DATE], the physician noted the resident had no complaints. Forgetful, does not seem to remember recent death of spouse. Continue plan of care. The physician did not document regarding the resident making comments about wanting to kill him/herself with a 22 on [DATE], and using hand motions of pulling the trigger of a gun on [DATE]. Observation and interview on [DATE], showed the resident sat in the recliner in the common area across from the nurse's station. The resident had periods of confusion at times, but had appropriate responses during the conversation. The resident said his/her spouse had been a resident at the facility, gestured head toward special care unit, but he/she had passed away. The resident told about his/her life. The resident said he/she really did not belong here; "feels like I'm in prison". The resident repeatedly told about his/her spouse passing and of his/her life. The resident was not sure why he/she had lived this long. The resident became tearful when speaking about spouse. During an interview and record review on [DATE] at 9:00 A.M., the care plan coordinator said they normally do a mood care plan if the areas triggered on the MDS. He/she was not sure why one was not completed. He/she was not sure about the [MEDICATION NAME], knew it was discontinued. He/she was sure the resident's physician was aware of the resident's comments. Record review of the nurse's notes showed the following information: -Between [DATE] to [DATE], staff did not document regarding the resident's depression, wanting to kill him/herself and spouse passing on [DATE];-On [DATE] 8:00 P.M., staff were assisting the resident up from the recliner. The resident became agitated, yelling and swinging arms. The nurse attempted to calm resident and explain they were trying to help so he/she would not fall and hurt him/herself. The resident said, "my spouse died and I wanna die". He/she then let staff assist with care. Will continue to monitor. Staff did not document they administered any as needed medication and/or notified the physician;-At 10:35 P.M., the nurse was called to the resident's room, staff stated the resident was twisting his/her head saying he/she was going to break his/her neck. Resident upset, again talking about spouse dying. The resident said he/she was not going to be here tomorrow, then took his/her fist and hit him/herself on the right eyebrow. Staff asked resident why he/she did that, "I don't want to be here. The food is not fit to eat. I'll not eat another meal here";-At 11:30 P.M., staff notified the physician of the two incidents. [MEDICATION NAME] given per orders. Record review of the daily skilled nurse's notes showed the following information: -On [DATE], no documentation and/or follow-up by day and night shift staff regarding the incidents on [DATE]. Evening shift staff check marked the resident was feeling down. No further documentation and/or follow up by evening shift staff. Record review of the social service progress notes dated [DATE], showed the SSD received a report that the resident had not only been verbalizing the wish to die but also punching self in face and turning head stating, "I'm trying to break my neck". Nursing notified the physician and awaiting orders. Resident has a history of making negative self harm statement, however since resident's spouse has passed away the resident had now started hurting him/herself by hitting him/herself. The resident also made a statement that he/she would not eat another bite. Nursing will monitor meal intake; Record review of the physician's progress notes on [DATE] at 12:00 P.M., showed he physician noted the resident stated, "why don't you just shot me in the head". On [DATE], the resident was hitting self in the head and twisting neck, in order to break neck, wanting to die. Resident treated with [MEDICATION NAME], by the next day initially seemed okay but since then had made additional comments about wanting to die and expressing grief over spouse's death. Resident is forgetful, see [DATE] note-last week did not seem to remember that spouse had died . Assessment: Depression with suicidal thoughts. Plan: resident had significant adverse reactions to [MEDICATION NAME]. Will start [MEDICATION NAME] (antidepressant). Monitor of adverse reactions. Record review of the daily skilled notes showed the following information:-On [DATE]:-No documentation and/or follow-up by day and evening shift staff regarding the incidents on [DATE];-Evening shift staff did not document regarding the new physician' s orders;-Night shift staff check marked the resident had little interest, and feeling down, depressed, hopeless. No further documentation and/or follow up by night shift staff;-On [DATE]-Day shift staff noted the resident was friendly this shift without any negative statements about wishing he/she was dead. No further documentation regarding monitoring for adverse reactions to [MEDICATION NAME];-No documentation and/or follow-up by evening and night shift staff. Record review of the social service progress notes dated [DATE], showed the SSD received report that the physician ordered a psychology consult and started the resident on [MEDICATION NAME]. Will fax information to the psychologist. No documentation of self harm over the weekend. During an interview on [DATE] at 7:30 A.M., certified medication technician (CMT) L said the resident has "spells". The last time he/she made comments, he/she had a UTI. Then there was time he/she was walking much and also dealing with the death of his/her spouse. The charge nurse tells him/her of any changes with medications or changes with resident. He/She would report any signs or symptoms of depression or behaviors to the charge nurse. CMT L said he/she knew the [MEDICATION NAME] had been discontinued by was not sure why. During an interview on [DATE] at 7:40 A.M., certified nurse assistant (CNA) M said the resident had been depressed because his/her spouse passed away. The resident was depressed prior to the spouse passing, it came and went. He/she had good and bad days. During an interview and record review on [DATE] at 7:42 A.M., charge nurse, licensed practical nurse (LPN) F, said the resident's spouse passed away not too long ago and now the resident had some depression. Prior to the spouse passing, the resident's behaviors were hit and miss, once every few weeks or so. There was a time he/she would slam the walker down. Surveyor showed the charge nurse the resident's chart. The charge nurse said, "Wow", he/she was not aware of all of the negative comments the resident had made over the last few months. He/she "bounces" around from unit to unit. If a resident made negative statements, he/she would document in the notes, and notify the physician and DON. During an interview on [DATE] at 7:50 A.M., registered nurse (RN) G said the resident came to visit his/her spouse at the facility every day. The resident had a [MEDICAL CONDITION] and was admitted to the facility. The resident was depressed about coming to the nursing home. RN G said the physician knew about the depression. During an interview and record review on [DATE] at 8:02 A.M., the social service director (SSD) said the resident made negative comments. She was told that was "normal" for the resident. The resident does not recognize that he/she needed to be at the facility. The other night ([DATE]), the resident was twisting his/her head, that was new. Surveyor went over the resident' s record with the SSD. The SSD said the staff were not reporting to her about the resident' s negative comments. The SSD said she had not had any contact or collaboration the hospice staff. She does invite them to the care plan meetings. If she had known sooner about some of the resident' s behaviors and negative comments, she would have called the physician and requested a psych consult sooner. During an interview on [DATE] at 9:25 A.M., with the DON and ADON. The DON said when the resident came to the facility for rehab his/her mood declined. The physician ordered the [MEDICATION NAME] and his/her mood improved then the resident's spouse passed away. The [MEDICATION NAME] was discontinued and the resident did well then recently declined. The other day ([DATE]) the resident made comments to staff and was twisting his/her neck. The physician was notified. The DON and ADON said they had not had any collaboration with the SSD regarding the resident. The DON and ADON said they were not aware of the resident's prior mood issues and comments of wanting to kill him/herself.

Based on observation, record review, and interview the facility failed to appropriately and accurately assess, monitor, and medicate two residents (Resident #4, and #3) to provide adequate pain control. Staff failed to report and treat the resident's verbal and non-verbal signs of pain. Staff failed to provide coordination of care with interventions to minimize the resident's pain during treatments and care out of 17 sampled residents in a facility with a census of 98. 1. Record review of the facility's skin and wound care protocol (undated) regarding pain assessment and management showed the following information: -The goal of pain management in the pressure sore resident is to eliminate the cause of the pain, to provide [MEDICATION NAME] or both;-Assess all residents for pain related to the pressures sore or its treatment. Caregivers should not assume that because a resident cannot express or respond to pain that it does not exist;-Manage pain by eliminating or controlling the source when possible (wound coverings, support surfaces, repositioning);-Try to prevent or relieve pain associated with or made worse during dressing changes and debridement (removal of dead tissue). -Assess and care plan pain management (i.e., [MEDICATION NAME] 30-45 minutes prior to dressing change) when appropriate. 2. Record review of Resident #3's admission assessment showed the facility readmitted the resident from the hospital with [DIAGNOSES REDACTED]. (The pressure sore presented as an intact blister). Record review of the physician's orders [REDACTED]. Record review of the resident's care plan, dated 8/15/11, showed the following information: -Staff did not develop problems, goals and approaches/interventions to address the resident pressure sores; -Staff did not develop problems, goals and approaches/interventions to address the potential for pain associated with the resident's pressure sore. Record review the licensed nurse weekly skin assessment showed the assistant director of nursing (ADON) noted the following information:-On 8/25/11, the resident's left heel had 4.0 centimeters (cm) by 3.0 cm brown center with 3 cm by 2 cm light brown blister' -The right heel had 3.5 cm by 3.0 cm open blister with 1.5 cm by 1.2 cm brown area. -Continue with skin prep and floating heels (heels suspended so there is no direct pressure); -Between 8/30/11 to 9/27/11, the staff documented the resident had pressure sores on the left and right heels. Record review of the website of Smith and Nephew (the manufacturer of SKIN-PREP) showed the following information: -SKIN-PREP should only be used on intact skin;-For external use only. Do not apply directly to open wounds or in deep puncture wounds. Record review of the physician's orders [REDACTED]. -On 8/25/11, an order or Tylenol 500 milligrams two tablets by mouth every four hours as needed for pain;-On 9/7/11, an order to float both heels and keep heel protectors on at all times;-On 9/8/11, new orders for Santyl (ointment with active enzymes to remove necrotic/dead tissue from wounds at the microscopic level);-10/6/11, an order for [REDACTED]. Record review of the physical therapist (PT) notes dated 9/30/11, showed the resident received wound care to bilateral heels for pressure sores. Staff performed a sharp debridement (removal of dead or necrotic tissue or foreign material from and around a wound to expose healthy tissue using a sterile scalpel, scissors or both) to right and left heels. Staff removed eschar (dead tissue) removed from right heel and slough (dead tissue) from left heel. Both feet had good capillary refill surrounding wound bed, suggesting good blood flow for optimal healing. Record review of the medication record dated 9/30/11, showed staff did not initial they administered any as needed pain medication to the resident before or after the PT performed the sharp debridement. Record review of the Minimum Data Set (MDS) a federally mandated assessment tool required to be completed by facility staff, dated 10/11/11, showed the following information: -Short and long-term memory problems;-Moderately impaired cognitive decision-making skills;-Extensive staff assistance for transfers, mobility, personal hygiene and toileting;-One Stage II pressure sore (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater); -One unstageable pressure sore (a pressure sore that cannot be staged due to coverage of wound bed by slough and/or eschar or suspected deep tissue injury in evolution. Record review of the resident's care plan showed the following information: -Staff had not developed problems, goals and approaches/interventions to address the resident pressure sores; -Staff had not developed problems, goals and approaches/interventions to address the potential for and/or actual pain associated with the resident pressure sores. Record review of the skilled nurse's notes dated 10/17/11, showed the following information: -At 11:45 A.M., open areas to bilateral heels. Treatment done as ordered. The resident denies pain but does "wince" when touching wounds;-Pain: numeric, 0 - 10 (a scale that can be used to rate the resident's pain level with 10 being severe to 0 as mild to no pain) staff marked a "0" zero with a line through it;-Pain: verbal, staff marked "none". Record review of the medication record on 10/17/11, showed staff did not administer the as needed Tylenol for the resident's non-verbal signs of pain. Record review of the skilled nurses' notes showed the following information:-On 10/19/11, treatment as ordered. Therapy debrided the pressure sore areas today. Resident denies pain;-On 10/21/11, registered nurse (RN) E noted bilateral pressure sores to heels, "PAIN: verbal, none". Record review of the medication record on 10/21/11, showed the following information:-Assess pain every shift using 0-10 scale. RN E marked a "0" zero for no pain;-At 9:05 A.M., RN E administered Tylenol two tablets to the resident. The reason was for "wounds" with results as effective (no time given). Observation on 10/25/11, showed the following information:-At 8:55 A.M., physical therapist assistant (PTA) entered the resident's room to take the resident for whirlpool treatment to the feet. He/she does the whirlpool Monday through Friday. The resident would be in therapy for several hours with physical and occupational therapy;-At 11:10 A.M., the resident lay in bed. Registered nurse (RN) E entered the room to complete the treatment to the resident's right and left heel pressure sores. The resident's left heel was dry and flaky. The outer left side of the heel had a brownish-red area that measure 1.4 centimeters (cm) by 0.6 cm and the area around measured 3.1 cm by 1.6 cm. The resident's right heel was dry and flaky. The outer right side of the resident's heel was a pale pink colored wound bed that measured 2.9 cm by 1.8 cm and had a thick whitish-colored wound edge that measured 3.1 cm by 2.4 cm;-RN E completed the treatment to the resident's left heel;-RN E removed the dressing that covered the resident's right heel (dry dressing had been placed as a protective covering by therapy after the whirlpool treatment). As RN E removed the dressing the resident's pulled back his/her foot and "winced." RN E asked the resident if he/she was "ticklish" RN E continued to remove the dressing; How well is this resident able to communicate?-RN E gestured to the right heel and said "that one's deeper". The resident "winced" again. RN E said he/she would be "easy". RN E continued with the treatment;-RN E started to place a gauze pad with Santyl ointment onto the wound and the resident said, "Oh" when the gauze touched the pressure sore. RN E continued with the treatment. RN E wrapped the resident's heel with a dressing. RN E removed his/her gloves, washed his/her hands and exited the room;-At 1:35 P.M., the resident lay in bed. The staff did not float the resident's heels and did not place heel protectors on the resident's feet;-At 1:55 P.M., the resident sat in the recliner in his/her room. The resident's feet and heels hung off the edge of the recliner. The staff did not place heel protectors on the resident's feet;-Between 2:15 P.M., to 2:30 P.M., RN E assisted Resident #3's roommate. The resident sat in the recliner with his/her eyes closed. The resident's feet and heels hung off the edge of the recliner. The staff did not place heel protectors on the resident's feet; -At 2:35 P.M., RN E was still present in the room. Resident #3 opened his/her eyes and said, "Oh my heels were hurting bad". Surveyor asked, "Oh really, they hurt?" Resident said, "Oh yeah, bad but some better now". RN E finished assisting the roommate and exited the room. Record review of the skilled nurse's notes dated 10/25/11, showed the following information: -Day shift (no time given) RN E noted the resident was alert and oriented to self and surroundings. Pleasant and cooperative with all care, requires extensive assistance with all care. The resident was able to walk to therapy today with one assist. Wound care and dressing change complete. "PAIN: verbal, none"; -RN E did not document regarding the resident's verbal and non-verbal signs of pain during the dressing change and treatment;-RN E did not document regarding the resident's verbal complaint of heel pain and complaints of hurting "bad". Record review of the medication record on 10/25/11, showed the following information:-Assess pain every shift using 0-10 scale. RN E marked a "0" zero for no pain;-RN E did not initial he/she administered the as needed Tylenol for the resident's verbal and non-verbal signs of heel pain. During an interview on 10/26/11, at 6:35 A.M., CNA J said if he/she needed to know anything about a resident, he/she asked the previous shift aide during verbal report or could ask the charge nurse. CNA J said Resident #3 "always tells staff that his/her feet hurt". He/she reports the resident's complaints to the charge nurse and oncoming aides. During an interview on 10/26/11, licensed practical nurse (LPN) K said staff at times can ask Resident #3 if he/she was in pain. If the resident says no, staff should use different methods to assess pain or see if he/she "grimaces". During an interview on 10/27/11, at 2:30 P.M., the PTA said the following: -He/she had been doing the resident's whirlpool treatments for about three weeks;-The physical therapist first debrided the resident's heel awhile back, and again a week ago;-The PTA said the resident had complained of pain on the heels. He/she reported the resident's pain to the therapist and to the nurse;-The PTA said he/she told them several times in the last week or so that the resident had pain. A couple of times the resident would "wince" when he/she was drying the areas;-Today the resident complained of his/her legs hurting and the PTA called down to the nurse's station and had the nurse bring the resident a pain pill; -The PTA said he/she had never asked the charge nurse to pre-medicate the resident before therapy;-Prior to today, the PTA had never had the nurse bring the resident a pain pill to therapy;-The PTA said he/she did not know the resident had not gotten pain medication after he/she reported the resident's pain to the nurse. Record review of the medication record showed on 10/27/11, staff administered the as needed Tylenol to the resident. Staff noted the resident complained of his/her legs hurting during therapy. Record review of the skilled nurse's notes dated 10/28/11, showed the following information: -At 1:30 P.M., treatment as ordered. Resident denies pain except during treatment, but when finished with treatment denies pain. No documentation that staff administered the as needed Tylenol to the resident for pain. No documentation that staff stopped the treatment when the resident complained of pain and notified the physician at that time of the resident's complaints of pain during treatments;-At 2:30 P.M., therapy voiced concerns of resident having pain during therapy. Physician notified by fax with request for increase in pain medication or possible pre-medication before treatments;-Pain: numeric, 0 -10, staff marked a "0" zero with a line through it;-Pain: verbal, staff marked "none". Record review of the physician's orders [REDACTED]. Record review of the nurses' notes dated 10/28/11, night shift staff noted the resident was up in the wheelchair and complained of pain in his/her feet. Staff administer the as needed pain medication as ordered. The resident voiced no more complaints of pain or discomfort;-PAIN: numeric, 5;-PAIN: verbal, moderate. Record review of the medication record showed staff administered the as needed [MEDICATION NAME] to the resident for complaints of pain. 2. Record review of Resident # 4's hospital admission history and physical dated 10/05/11, showed the resident was admitted to the hospital with [REDACTED]. Record review of the resident's face sheet (admission data) showed the facility admitted the resident on 10/08/11, with [DIAGNOSES REDACTED]. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of the resident's pressure sore record dated 10/13/11, showed the resident had three open areas to his/her buttocks. -Pressure sore number one staff measured 2.1 centimeters (cm) by 1.2 cm. on his/her left buttock. -Pressure sore number two staff measured at 0.2 cm by 0.3 cm on his/her left buttock. -Pressure sore number three staff measured at 2.2 cm by 1.2 cm on his/her right buttock. Record review of the resident's MAR indicated [REDACTED]. Staff medicated the resident with Tylenol 500 milligrams (mg) two tablets by mouth for pain. Record review of the resident's admission comprehensive MDS assessment dated [DATE], showed the following information: -Severe cognitive impairment; -Total dependence on bed mobility, transfers, locomotion on and off corridor, dressing, toilet use, personal hygiene; -No scheduled pain medication; -No non medication interventions for pain reduction; -Resident had pain at least two times a week; -Showed facial expression, grimaces and protected body movement. Record review of the resident's care plan, dated 10/24/11, showed the following information: -Potential for pain; -Medicate as ordered- extra-strength Tylenol; -Remind resident to ask for pain medication as needed before pain gets intense; -Have resident rate pain on a scale from 1-10; -Be observant to non-verbal signs and symptoms of pain or discomfort. During an observation and interview during the initial tour on 10/24/11, at 10:20 A.M., the resident was heard from the hallway yelling and cussing at staff. The ADON said she was not sure why the resident yelled out at staff but believed it was a behavior and possibly anxiety related. Observation on 10/24/11, at 3:05 P.M., showed the resident in the lounge watching television. Staff placed a wastebasket under the recliners' foot rest. On several occasions, the resident pulled on the catheter tubing and yelled and cussed. Staff did not ask the resident if he/she had pain. The resident sat in the same position in the recliner that applied direct pressure to the pressure sores on his/her buttocks and coccyx. At 3:30 P.M., and 4:10 P.M., the resident remained in the same position. The resident was restless and yelled several times. At no time did staff ask the resident if he had pain. The resident sat in the same position. At 5:25 P.M., the resident remained in the same position in the recliner. The resident yelled and cussed, trying to get out of the recliner. Staff did not ask the resident if he had pain and at 5:40 P.M., staff had not given the resident pain medication. Record review of a physician order [REDACTED]. Staff received orders to give [MEDICATION NAME] (antianxiety) one mg but only give with extreme agitation. Staff did not assess the resident for pain. Observation on 10/26/11, at 9:40 A.M., showed CNA N, CNA M and LPN B cleaned the catheter and genital area without pulling back the foreskin or cleaning the urethra (where the catheter was inserted into the penis). Staff turned the resident to his side and cleaned feces from the resident. The resident had three open areas to his coccyx (tail bone). The resident complained of pain and cussed at staff while they cleaned him. Staff did not ask the resident if he needed something for pain. After staff cleaned the feces, the CNAs positioned the resident on his back and pulled the foreskin back to clean the catheter urethra opening. Staff found two small open areas on the resident's penis under the foreskin. The resident complained of pain at least three times during the cleaning of his penis. Staff did not offer the resident pain medication. Staff transferred the resident to his wheelchair and the resident started cussing and yelling concerning pain to his coccyx area. Staff offered the resident no pain medication. During an interview on 10/31/11, at: 2:00 P.M., CNA O said he/she did not see the open areas to the resident's penis when providing penial and catheter care. Record review of the resident's MAR indicated [REDACTED] -On 10/26/11, staff documented the resident rated his pain as a zero (no pain) but administered Tylenol for pain. -On 10/27/11, staff documented the resident rated his pain as a zero but administered Tylenol for pain. -On 10/30/11, staff documented the resident rated his pain as a zero but administered Tylenol for pain. During an interview with care plan coordinator (CPC) P on 10/27/11, beginning at 7:30 A.M., staff should assess the resident every shift and rate his pain with the numerical scale. If the resident yelled and complained of pain, he needed something different. Staff needed to report an increase in pain to the charge nurses. 3. According to Brunner and Suddarth's Medical Surgical Nursing textbook: Pain is whatever bodily hurt a patient reports existing, whenever the patient reports it. The cardinal rule in the care of patients with pain is that all pain is real. The validation of the existing of pain is based simply on the patient's report that it exists. What the patient "says" about pain is not limited to verbal statements. Nursing assessment for monitoring pain should include observing nonverbal behaviors.