Every finding on record at Wellsville Health Care Center

Based on interview and record review, facility staff failed to provide the services of a full-time Director of Nursing (DON) 24 hours a day, seven days a week with an average daily occupancy of 60 or more residents. The facility census was 62. 1.Review showed the did not provide a policy for DON coverage. 2.Review of the Facility Assessment, dated 07/07/25, showed staff documented an average daily census of 62.3.Review of the facility nursing staff daily logs and facility daily census showed: -08/08/25: Facility census 66; from 6:00 A.M., to 6:00 P.M., the DON worked as the charge nurse;-08/09/25: Facility census 65; from 6:00 A.M., to 6:00 P.M., the DON worked as the charge nurse;-08/10/25: Facility census 65; from 6:00 A.M., to 6:00 P.M., the DON worked as the charge nurse;-08/14/25: Facility census 64; from 6:00 A.M., to 6:00 P.M., the DON worked as the charge nurse;-08/15/25: Facility census 65; from 6:00 A.M., to 6:00 P.M., the DON worked as the charge nurse;-08/17/25: Facility census 65; from 6:00 P.M., to 08/18/25 6:00 A.M., the DON worked as the charge nurse;-08/21/25: Facility census 63; from 10:00 P.M., to 08/22/25 6:00 A.M., the DON worked as the charge nurse;-08/29/25: Facility census 63; from 10:00 P.M., to 08/30/25 6:00 A.M., the DON worked as the charge nurse;-08/30/25: Facility census 62; from 10:00 P.M., to 08/31/25 6:00 A.M., the DON worked as the charge nurse;-09/01/25: Facility census 63; from 10:00 P.M., to 09/02/25 6:00 A.M., the DON worked as the charge nurse;-09/05/25: Facility census 62; from 6:00 A.M., to 2:00 P.M., the DON worked as the charge nurse;-09/06/25: Facility census 61; from 6:00 A.M., to 2:00 P.M., the DON worked as the charge nurse;-09/07/25: Facility census 61; from 6:00 A.M., to 2:00 P.M., the DON worked as the charge nurse;-09/10/25: Facility census 61; from 2:00 P.M., to 10:00 P.M., the DON worked as the charge nurse;-09/11/25: Facility census 61; from 2:00 P.M., to 10:00 P.M., the DON worked as the charge nurse;-09/19/25: Facility census 63; from 2:00 P.M., to 10:00 P.M., the DON worked as the charge nurse;-09/21/25: Facility census 63; from 2:00 P.M., to 10:00 P.M., the DON worked as the charge nurse;-09/22/25: Facility census 63; from 2:00 P.M., to 10:00 P.M., the DON worked as the charge nurse.During an interview on 09/24/25 at 9:00 A.M., LPN B said he/she took over staffing and scheduling for CNA's and NA's the end of July. LPN B said he/she is responsible to complete the schedule and ensure floor coverage is adequate for the CNA's. He/She said the DON is responsible for staffing and scheduling of nurses along with hiring and terminating any staff. During an interview on 09/24/25 at 1:00 P.M., the Administrator said the DON and LPN B are responsible for the staffing and scheduling of nursing staff. The Administrator said the facility does not have enough staff to adequately cover each shift every day. The Administrator said the DON also works as a charge nurse on the floor to ensure nursing coverage for the facility. During an interview on 09/25/25 at 10:48 A.M., the DON said he/she is responsible for scheduling and staffing of nurses along with hiring new employees. The DON said he/she is aware with the facility census over 60 he/she should not be working as a charge nurse. The DON said he/she has worked as the charge nurse to ensure there is nurse coverage. The DON said he/she has been trying to hire new employees, but the facility still needs more staff. The DON said he/she has placed ads for help on social media, and with online job sites. Complaint#2624554

Based on interview and record review, facility staff failed to ensure three residents' (Resident #3, #4, and #5) out of nine sampled residents remained free from physical abuse when Resident #2 who had a history of physical aggression physically assaulted the residents. The facility census was 65.1. Review of the facility's Abuse and Neglect policy, revised 06/12/24, showed staff are directed as follows:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include residents and staff;-Physical abuse is purposefully beating, striking, wounding, or injuring which includes but not limited to hitting, slapping, punching, biting, and kicking;-Facility will develop a policy for screening and training of employees, protection of residents, prevention of incidents, identification, and reporting of abuse. Facility will identify, correct, and intervene in abuse situations, protect resident from harm, identify and correct by providing interventions, and will take steps to prevent mistreatment. 2. Review Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/13/25, showed staff assessed the resident as admitted on [DATE], had moderate cognitive impairment, exhibits physical and verbal behaviors which interfere with care and put others at risk of physical injury.Review of the resident's care plan, revised 07/24/25, assessed the resident with exhibits emotional distress, impaired coping skills, exhibits behaviors that may create disturbances for other residents, exhibits agitation.Review of the resident's nurse's notes showed staff documented:-On 04/09/25 at 7:43 A.M., resident yelled and became agitated with staff during care and the resident's roommate stated he/she did not feel safe in the room with the resident;-On 04/14/25 at 8:50 A.M., resident had a verbal altercation with another resident at breakfast;-On 04/24/25 at 2:53 A.M., resident verbally aggressive, disrespectful to peers, and got into other people's personal space to intimidate;-On 04/24/25 at 3:35 P.M., resident had a physical altercation with Resident #5 and kicked him/her;-On 06/17/25 at 2:29 A.M., physical altercation occurred on 06/16/25 at 10:40 P.M., between Resident #2 and Resident #4. Staff came to him/her LPN B and stated Resident #2 had beat the shit out of Resident #4. Resident #4 told him/her Resident #2 hit him/her and he/she complained of blurred vision and a headache. Resident #4 sent by ambulance to the hospital for evaluation and Resident #2 sent to the hospital for a psychiatric evaluation.-On 07/23/25 at 10:25 A.M., physical altercation occurred on 07/22/25 at 7:40 P.M. with Resident #3. Resident #2 punched Resident #3 in his/her left side of face causing him/her to fall to the wall behind him/her and hit his/her face on it. Resident #2 punched Resident #3. Staff one to one direct care with the resident until both residents were sent to the hospital for evaluation.During an interview on 07/24/25 at 10:00 A.M., Resident #7 said he/she has lived at the facility for a long time with no concerns until the past several months. The resident said he/she does not feel safe at the facility due to the physical altercations Resident #2 has caused. The resident said he/she is in fear of her safety and is thinking about moving from the facility. 3. Review Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.Review of the resident's care plan, revised 7/22/25, showed staff assessed the resident as high risk for falls, and required assistance due to confusion. Review of the resident's nurse's notes, dated 07/23/25, showed staff documented a physical altercation occurred on 07/22/25 at 7:40 P.M., between Resident #2 and Resident #3. Resident #2 punched Resident #3 in his/her left side of face causing Resident #3 to spin, fall, and hit his/her face on the wall behind him/her. Staff documented the incident unprovoked. Staff took Resident #2 from the incident and stayed one on one direct care with Resident #2 until both residents were sent to the hospital for evaluation. Review of the resident's hospital discharge report, dated 07/22/25, showed the hospital performed a Computed Tomography (CT) (a non-invasive imaging procedure) of cervical spine, CT of head and brain, X-ray of pelvis, X-ray of right knee. Resident sustained a concussion.During an interview on 07/25/25 at 9:00 A.M., LPN B said he/she was the charge nurse on duty when the incident between Resident #2 and Resident #3 occurred. LPN B said he/she witnessed Resident #2 punch Resident #3 in his/her left face and the incident was unprovoked. LPN B said he/she thinks Resident #2 should have been placed on one-on-one direct care upon his/her readmission to the facility, but he/she was not working that day and does not know why he/she wasn't. 4. Review OF Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.Review of the resident's care plan, revised 06/22/25, showed staff assessed the resident feels unsafe in the facility due to a physical altercation with another resident, staff were directed to educate resident to notify staff of any inappropriate behavior from other resident, and at risk for falls. Review of the resident's nurse's notes, dated 06/17/24, showed staff documented a physical altercation occurred on 06/16/25 at 10:40 P.M., between Resident #2 and Resident #4. Nurse documented staff came to him/her stating Resident #2 beat the shit out of Resident #4. Staff documented Resident #4 told him/her Resident #2 hit him/her and he/she complained of blurred vision and a headache. Resident #4 was sent by ambulance to the hospital for evaluation and Resident #2 was sent to the hospital for a psychiatric evaluation. Review of the resident's hospital discharge report, dated 06/17/25, showed the resident was treated at the ER for a concussion. During an interview on 07/24/25 at 10:25 A.M., The resident said he/she has not had any further physical altercations. The resident said after the physical altercation with Resident #2 he/she had a headache for several days. The resident said he/she does not feel safe in the facility and fears Resident #2. The resident said he/she has nightmares while sleeping of the incident still. During an interview on 07/24/25 at 10:28 A.M., Resident #8 said he/she is now roommates with Resident #4. The resident said Resident #4 talks about being afraid of Resident #2 and has nightmares when he/she sleeps about the incident with Resident #2 which wake him/her up when he/she does. During an interview on 07/25/25 at 9:00 A.M., LPN B said he/she was the charge nurse on duty when the altercation between Resident #2 and Resident #4 occurred. LPN B said the altercation happened after Resident #2 urinated on the floor and Resident #4 said he/she should not do that. LPN B said Resident #2 retaliated and hit Resident #4 multiple times before staff could get him/her to stop. 5. Review Resident #5's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's care plan, revised 05/22/24, showed staff assessed the resident at risk for falls, and has impaired hearing.Review of the resident's nurse's notes, dated 04/24/25, staff documented a physical altercation occurred on 04/24/25 at 3:20 P.M., between Resident #2 and Resident #5. Resident #5 was attempting to pass by Resident #2 and said excuse me to Resident #2. Resident #2 began to yell and then kicked Resident #5 in the leg resulting in a golf ball size bruise. Resident #2 placed on one-on-one direct care until the ambulance arrived and took him/her to the hospital for a psychiatric evaluation.During an interview on 07/24/25 at 11:30 A.M., the resident said he/she remembered being kicked by a resident in his/her leg. The resident said he/she had a bruise on his/her leg after the incident. During an interview on 07/24/25 at 2:00 P.M., Registered Nurse (RN) A said he/she was the charge nurse when the altercation occurred between Resident #2 and Resident #5. RN A said he/she came around the corner to witness Resident #2 kick Resident #5. RN A said the incident was unprovoked and he/she immediately separated the residents to provide safety. RN A said he/she reported the incident to the resident's physician who gave orders to send Resident #2 to the ER for an evaluation. RN A said Resident #2 returned to the facility on [DATE] and was not placed on one-on-one direct care. RN A said Resident #2 is a threat for the safety to other residents. 6. During an interview on 07/24/25 at 2:30 P.M., the DON said he/she has been at the facility since prior to Resident #2's admission. The DON said Resident #2 has had three physical altercations with other residents since he/she was admitted to the facility. The DON said the first altercation was on 04/24/25 and the resident was sent to the hospital for a psychiatric evaluation and readmitted to the facility on [DATE]. The DON said he/she did not put the resident on one on one direct care at the time of readmission because this was the first incident. The DON said the second altercation was on 06/17/25 with a different resident. The DON said both residents were sent to the hospital and Resident #2 was admitted for a psychiatric stay. The DON said Resident #2 was readmitted to the facility on [DATE] and he/she did not place the resident on 1:1 direct care because the hospital said the resident was doing better and he/she did not think the resident would need 1:1 care. The DON said the third altercation happened on 07/22/25 with a different resident. The DON said both residents were sent to the hospital after. The DON said Resident #2 continues to be in the hospital on a psychiatric stay currently. The DON said due to the resident's prior history he/she now thinks the facility should have put the resident on 1:1 direct care upon his/her readmission and not gone by what the hospital told them. The DON said the facility is currently looking for alternative placement for the resident, but they don't have an accepting facility at this time. The DON said if the resident must return to the facility, he/she will be put on direct 1:1 care at all times.During an interview on 07/24/25 at 3:00 P.M., the Administrator said he/she started at the facility on 07/07/25 and was not aware of Resident #2's prior history of physical altercations until today. The Administrator said if he/she had known of the prior incidents he/she would have ensured Resident #2 was placed on 1:1 direct care with staff upon readmission to the facility until an alternate placement for the resident could be found. The Administrator said his/her expectations is for staff to always provide safety for all residents in the facility. The Administrator said he/she if an incident occurs, he/she expects staff to respond to the incident, separate the residents and provide safety, complete an assessment of the residents once safety is established, and to contact the resident's physician, responsible party, police if needed, the DON, and him/her to notify them of the incident. The Administrator said the facility would complete an investigation of the incident and he/she would expect interventions to be put in place to prevent the incident happening again. The Administrator said the facility is currently trying to find alternative placement for Resident #2 while he/she is in the hospital. The Administrator said if the facility is unable to find alternative placement and Resident #2 must return to the facility, he/she will ensure Resident #2 is put on 1:1 direct care with staff at all times until the facility can find alternative placement.Incident #2569214

Based on interview and record review, facility staff failed to ensure there was a licensed nurse onsite to provide necessary nursing care and services 24 hours a day, seven days a week. The facility census was 65. 1. Review of the Facility's policies showed staff did not provide a policy for Licensed Nurses. Review of the Facility Assessment, dated 04/18/25, showed staff documented the facility required three Licensed Practical Nurses (LPNs) daily. Review of the Nurse Staff Schedule, dated October 2024, showed staff did not ensure 24-hour a day licensed nurse coverage on: -10/19/24 for 11 hours and 18 minutes; -10/20/24 for 15 hours and 52 minutes; -10/27/24 16 hours; -10/28/24 6 hours. Review of the Nurse Staff Schedule, dated November 2024, showed staff did not ensure 24-hour a day licensed nurse coverage on: -11/02/24 for 17 hours and 26 minutes; -11/03/24 for 9 hours and 30 minutes; -11/06/24 for 6 hours; -11/08/24 for 8 hours and 25 minutes; -11/17/24 for 4 hours and 34 minutes; -11/19/24 for 2 hours and 37 minutes; -11/20/24 for 11 hours and 21 minutes; -11/21/24 for 11 hours and 29 minutes; -11/22/24 for 5 hours and 55 minutes; -11/23/24 for 7 hours and 5 minutes; -11/24/24 for 1 hours and 55 minutes; -11/25/24 for 5 hours and 34 minutes; -11/26/24 for 11 hours and 3 minutes; -11/27/24 for 11 hours and 25 minutes; -11/28/24 for 12 hours; -11/29/24 for 2 hours and 14 minutes; -11/30/24 for 30 minutes. Review of the Nurse Staff Schedule, dated December 2024, showed staff did not ensure 24-hour a day licensed nurse coverage on: -12/1/24 for eight hours and 20 minutes; -12/06/24 for 6 hours; -12/27/24 for 5 hours and 3 minutes; -12/28/24 for 5 hours and 30 minutes. During an interview on 05/08/25 at 1:56 P.M., the staffing coordinator/Social Services Designee (SSD) said he/she has been responsible for scheduling since November. He/She said there were days the facility went without a licensed nurse in the building. He/She said they tried to use agency nurses to fill the holes and but they would not always show up. He/She said when staff wouldn't show up, he/she would contact the Director of Nursing (DON), the administrator or corporate. He/She said he/she knows they need a licensed nurse in the building 24-hours a day, seven days a week. During an interview on 05/08/25 at 2:05 P.M., the administrator said he/she is new as of this week, but said there should always be a licensed nurse in the building. He/She said the staffing coordinator is responsible for ensuring the facility has licensed staff 24-hours a day seven days a week. During an interview on 05/08/25 at 2:33 P.M., the DON said it is his/her responsibility to ensure there are an appropriate number of staff in the building. He/She said they should have a licensed staff in the building 24-hours a day seven days a week. He/She said he/she started in January but took over in February. He/She said they have had licensed staff in the building scheduled since he/she took over. He/She said he/she is not sure what they did before him/her starting.

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 65. 1. Review of the facility's RN policy, revised on 04/30/24, showed the facility will utilize the services of a RN for at least eight consecutive hours per day, seven days per week. Review of the facility Payroll Based Journal (PBJ), a method to collect auditable and verifiable staffing data from nursing facilities, report for Fiscal Year 2024, Quarter 4 (October 1 through December 31) showed triggers for no RN hours for 10/13, 10/15, 10/19, 10/21, 10/26, 10/27, 11/02, 11/24, and 12/02. Review of the Facility Assessment, dated 04/18/25, showed staff determined one Registered Nurse (RN) should be staffed daily. 2. Review of the facility's RN staff schedule, agency schedule, and PBJ submitted RN hours, dated October 2024, showed the facility did not have an RN in the building, for eight consecutive hours on 10/06/24, Sunday 10/13/24, Tuesday 10/15/24, Saturday 10/19/24, Monday 10/21/24, Saturday 10/26/24, and Sunday 10/27/24. 3. Review of the facility's RN staff schedule, agency schedule, and PBJ submitted RN hours, dated November 2024, showed the facility did not have an RN in the building for eight consecutive hours, on Saturday 11/02/24 and Sunday 11/24/24. 4. Review of the facility's RN staff schedule, agency schedule, and PBJ submitted RN hours, dated December 2024, showed the facility did not have an RN in the building for eight consecutive hours on Monday 12/02/24. 5. During an interview on 05/08/25 at 1:56 P.M., the staffing coordinator/Social Services Designee said he/she has been responsible for scheduling since November. He/She said there were days that the facility went without an RN in the building. He/She said they would use agency nurses to try and fill the holes and then the nurses wouldn't show up. He/She said when staff wouldn't show up, he/she would contact the Director of Nursing (DON), the administrator or corporate. He/She said he/she knows they need a registered nurse at least eight consecutive hours a day, seven days a week. During an interview on 05/08/25 at 2:05 P.M., the Administrator said he/she is new as of this week, but was told the DON at the time was covering the RN shifts but not clocking in. He/She said the staffing coordinator is responsible for ensuring the facility has RN coverage eight consecutive hours a day seven days a week. During an interview on 05/08/25 at 2:33 P.M., the DON said it is his/her responsibility to ensure there are an appropriate number of staff in the building. He/She said they should have a registered nurse in the building for eight consecutive hours a day seven days a week. He/She said he/she started in January but took over in February. He/She said they have had a registered nurse scheduled since he/she took over. He/She said he/she is not sure what the previous administration did prior to him/her starting.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination, out-dated use and the reuse of single-service food containers. Facility staff failed to maintain kitchen equipment and floors clean and in good repair. Facility staff failed perform hand hygiene as often as necessary to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. Facility staff also failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor waste containers remained covered when not in actual use. These failures have the potential to affect all residents. The facility census was 65. 1. Review of the facility's Dietary-Equipment Operations, Infection Control, and Sanitation Policy, dated 02/02/24, showed: -A cleaning schedule shall be posted with task designated to specific positions in the department; -All task shall be addressed as to frequency of cleaning; -General daily and weekly cleaning schedules may be used or Cleaning Schedules by position may be used; -The dietary employee should complete the tasks assigned for the day and shift; -The proper operation temperature for a freezer is zero degrees Fahrenheit (dF) to -10 dF; -The policy did not contain direction to staff related to food storage requirements or how to report or manage equipment in need of repair. Review of the facility's Dietary Manager (DM) Daily Checklist, dated 09/2020, showed the checklist directed the DM to ensure the following within 30 minutes of entering the kitchen: -All food is covered, dated, and labeled; -Food is stored 18 inches from the ceiling and six inches off the floor; -Outdated food is discarded; -All logs are completed and correct (refrigerators, freezers, dish machine, pot and pan sink, cooling, sanitizer part per million, end cook and food service temperatures); -Cleaning schedule posted and initialed as tasks are completed; -Verify the deep clean task from prior day was completed. Review of the facility's Daily Cleaning Schedule, undated, showed the cleaning schedule directed staff to clean the refrigerators inside and out, defrost the deep freezer, and ensure everything is dated and rotated. Observation on 05/05/25 at 10:09 A.M., showed the kitchen service station contained: -an opened and undated one gallon bottle of barbeque sauce in the reach-in refrigerator. Observation also showed the gasket seals on the each of the three doors of the refrigerator torn and multiple areas of dried liquid and food debris on the rack inside the refrigerator which contained trays of drinks; -an undated and unlabeled bulk container of sugar removed from its original package with a scoop stored inside the container with its handle on the sugar; -an undated bulk container of raisin bran cereal, removed from its original package; -an excess of dried food debris on the exterior tops and sides of three plastic containers used for the storage of disposable utensils; -an excess of dried food debris on the exterior tops of six plastic containers used for the storage of various condiments. Observation on 05/05/25 at 10:24 A.M., showed the dry goods pantry contained: -a 22 quart plastic container of powdered milk removed from its original package, dated 12/08/23; -an undated 12 quart container of salt removed from its original package with a scoop stored inside the container with its handle on the sugar; -an opened and undated bag of potato chips; -an opened and undated bag of tortilla chips; -an opened and undated 10 pound bag of dried macaroni noodles; -an undated 20 pound bag of breadcrumbs opened to the air; -an undated 25 pound box of parboiled rice opened to the air; -two opened and undated packages of flour tortillas. During an interview on 05/05/25 at 10:24 A.M., the dietary manager (DM) said he/she did not know how long powdered milk lasts once opened and the powdered milk had been on the shelf for the duration of his/her employment in 2023. Observation on 05/05/25 at 10:30 A.M. showed the gasket seal on the door to the walk-in refrigerator torn. Observation showed the refrigerator contained: -an opened and undated five pound bag sliced pepperoni; -an opened and undated five pound bag of sausage crumbles; -three five pound plastic containers, previously used for manufacturer packaged cottage cheese, dated 5/4 used to store cooked broccoli and cheese, baked chicken and cooked buttered noodles. Observation showed the containers did not contain descriptions or emblems to indicate the containers were not single-service containers. Observation on 05/05/25 at 10:32 A.M., showed the gasket seal on the door to the walk-in freezer torn which prevented the full closure of the door and a water pooled on the floor in front of the freezer. Observation showed food stored inside the freezer and the ambient temperature inside the freezer measured 20 dF. Observation on 05/05/25 at 10:40 A.M., showed the gasket seal torn on the lid to the chest freezer torn. Observation showed the chest freezer contained an undated bag of individually quick frozen (IQF) chicken opened to the air and an undated and unlabeled bag of unidentifiable meat patties. During an interview on 05/05/25 at 10:42 A.M., the DM said opened and prepared food items should be stored labeled, dated and sealed and staff should not leave scoops in the bulk food containers. The DM said the staff that put away the opened or prepared food items are responsible to store them properly and all staff have been trained on food storage requirements. The DM said he/she checks the food storage sometimes and if he/she finds an issue, he/she reeducates the staff. The DM said if staff see something that needs repair, they should notify him/her so that he/she can put in a maintenance request for the repairs and staff have been trained on this procedure. The DM said he/she did not know about the torn gasket seals on the refrigerator and freezer doors. The DM said the temperature inside freezers should be zero dF or below and he/she did not know the temperature inside the walk-in freezer measured greater than zero. Observation on 05/05/25 at 11:06 A.M., showed an undated container labeled as cinnamon sugar covered with aluminum foil that had a hole in it which exposed the contents to the air. Observation on 05/07/25 at 6:45 A.M., showed the dry goods pantry contained: -cases of augratin potatoes, orange juice and apple juice stored on the floor, -an opened and undated 10 pound bag of dried macaroni noodles; -an undated 20 pound bag of breadcrumbs opened to the air; -an opened and undated 25 pound box of parboiled rice; -two opened and undated packages of flour tortillas. During an interview on 05/07/25 at 6:55 AM, the DM said the cases of augratin potatoes, orange juice and apple juice had been on the floor since delivered by the vendor on the morning of 05/05/25. The DM said food should not be stored on the floor, but he/she could not lift the cases from the floor due to an issue with his/her back. The DM said he/she asked the night shift aide to put them on a cart so he/she could put them away but the aide did not put them on the cart. The DM said he/she did not ask any other staff in the facility to help him/her get the cases off the floor. Observation on 05/07/25 at 7:59 A.M., showed the gasket seal torn on the lid to the chest freezer torn. Observation showed the chest freezer contained an undated bag of IQF chicken opened to the air and an undated and unlabeled bag of unidentifiable meat patties. Observation on 05/07/25 at 8:12 A.M., showed the gasket seal on the door to the walk-in freezer torn which prevented the full closure of the door and a water pooled on the floor in front of the freezer. Observation showed food stored inside the freezer and the ambient temperature inside the freezer measured 20 dF. Observation on 05/07/25 08:14 AM showed the gasket seal on the door to the walk-in refrigerator torn. Observation showed the refrigerator contained: -an opened and undated five pound bag sliced pepperoni; -an opened and undated five pound bag of sausage crumbles; -three five pound plastic containers, previously used for manufacturer packaged cottage cheese, dated 5/4 used to store cooked chicken, buttered noodles and broccoli and cheese. Observation showed the containers did not contain descriptions or emblems to indicate the containers were not single-service containers; -a large clear plastic container, dated 5/5 used to stored cooked Italian chicken. Observation showed the container did not contain a description or emblem to indicate the container was not a single-service container. During an interview on 05/07/25 08:24 AM , the DM said food storage containers should be clean and in good repair. The DM said staff had reused the empty manufacturer food packaged containers for food storage for the duration of his/her employment which began in 2023 and he/she did not know they could not be reused. During an interview on 05/08/25 at 10:27 A.M., the administrator said opened and prepared food items should be stored labeled, dated and sealed in approved containers and staff should not leave scoops in the bulk food containers. The administrator said staff should not use old cottage cheese containers to store leftover food. The administrator said powdered milk should be used by the date on its package and if removed from the package staff should find out how long it last and date it with a use-by date. The administrator said he/she did not know how long powdered milk lasts once opened, but powered milk opened in December 2023 would no longer be good for use. The administrator said food should not be stored on the floor and if there if staff are not able to pick up food from the floor due to health reasons, they should ask him/her or other staff for assistance. The administrator said the DM did not ask him/her for assistance. The administrator said staff should be trained on proper food storage requirements, the DM is responsible to monitor food storage daily when on duty and if any staff see something that needs correction, they should fix them immediately. The administrator said staff should clean kitchen equipment daily and if equipment is damaged, staff should put in a work order to maintenance for repairs. The administrator said the temperature of freezers should be zero dF or below, he/she did not know about the torn gasket seals on the refrigerator and freezer doors and he/she did not know the temperature in the walk-in freezer was greater than zero dF. 2. Review of the facility's Dietary-Equipment Operations, Infection Control, and Sanitation Policy, dated 02/02/24, showed: -A cleaning schedule shall be posted with task designated to specific positions in the department; -All task shall be addressed as to frequency of cleaning; -General daily and weekly cleaning schedules may be used or Cleaning Schedules by position may be used; -The dietary employee should complete the tasks assigned for the day and shift; -The policy directed staff to dust mop or sweep the floors and then mop the floors with instruction to make a long stroke with the mop close to the baseboard and then continue to mop the floor in nine feet by 12 feet areas at a time; -The policy did not contain direction as to the frequency for staff to sweep and mop the floors or how damaged floors should be addressed. Review of the facility's DM Daily Checklist, dated 09/2020, showed the checklist directed the DM to ensure the cleaning schedule is posted and initialed as tasks are completed within 30 minutes of entering the kitchen. Observations on 05/05/25 at 10:15 A.M. and 05/07/25 at 8:05 A.M., showed the kitchen did not contain a visible cleaning schedule. Observation showed an excessive accumulation of dirt and food debris underneath the dishwasher and counters in the mechanical dishwashing station and under the counters in the manual dishwashing station. Observations on 05/05/25 at 10:40 A.M. and 05/07/25 at 8:06 A.M., showed an excessive accumulation of dirt, food debris and trash on the floor behind the chest freezer. Observations on 05/05/25 at 10:32 A.M. and 05/07/25 at 8:12 A.M., showed an approximate six feet by one foot section of floor covering removed from in front of the walk-in freezer. Observation showed an accumulation of dirt, food debris and water in the exposed area. During an interview on 05/05/25 at 10:42 A.M., the DM said if staff see something that needs fixed, they should notify him/her so that he/she can put in a maintenance request for the repairs and staff have been trained on this procedure. Review of the facility's Daily Cleaning list, undated, provide by the DM on 05/07/25, showed the cleaning list directed staff to sweep the floors after every meal and to mop the floors each shift. During an interview on 05/07/25 at 8:24 A.M., the DM said he/she did have a cleaning schedule for the kitchen, but he/she did not post. The DM said staff are trained to sweep and mop the floors daily and they should sweep and mop under the counters and equipment. The DM said the floor in front of the walk-in freezer had been that way for a while due and he/she had not put in a maintenance request to repair it. During an interview on 05/08/25 at 10:27 A.M., the administrator said staff should sweep and mop the kitchen floors daily and as needed and staff should sweep and mop under counters and equipment. The administrator said if something needs repairs, staff are to put in a work order to maintenance for repairs. The administrator said he/she just became the administrator and he/she did not know about the issues with the floors. 3. Review of the facility's Dietary-Equipment Operations, Infection Control, and Sanitation Policy, dated 02/02/24, showed the policy directed staff to operate the ice machine in accordance with manufacturer's instructions, wash the exterior of the ice machine daily, and remove ice and washed the inside of the machine monthly. Observation on 05/07/25 at 11:40 A.M., showed the ice machine's cartridge filter (used to remove unwanted particles, pollutants, and other contaminates from the water supply) dated 02/12/24. Observation showed the label on the filter directed that the filter must be replaced every six months. During an interview on 05/07/25 at 12:07 P.M., the maintenance assistant said he/she began work at the facility part-time about three months ago, he/she did not know the ice machine's cartridge filter was outdated and should be replaced every six months, and he/she did not know who is responsible for the maintenance of the ice machine. During an interview on 05/07/25 at 12:07 P.M., the regional maintenance manager said he/she did not know the ice machine's cartridge filter was outdated and should be replaced every six months, and he/she did not know who is responsible for the maintenance of the ice machine. During an interview on 05/08/25 at 10:27 A.M., the administrator said maintenance staff are responsible for maintenance of the ice machine and he/she did not know about the outdated filter. 4. Review of the facility's Hand Hygiene policy, dated 06/26/24, showed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations; -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves; -Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table; -The hand hygiene table directed staff to perform hand hygiene for various situations, which included when hands are visibly soiled, before applying and after removing personal protective equipment, including gloves, and after handling items potentially contaminated with blood, body fluids, secretions, or excretions. Review of the facility's Dietary-Equipment Operations, Infection Control, and Sanitation Policy, dated 02/02/24, showed the policy directed staff to wash and sanitize their hands between dirty and clean areas when they wash dishes. Observation on 05/05/25 at 10:15 A.M., showed Dietary Aide (DA) C washed soiled dishes in the mechanical dishwashing station. Observation showed the DA then, without performing hand hygiene, put away sanitized glasses and cups from the clean side of the station. Observation on 05/05/25 at 11:13 A.M., showed DA C washed soiled dishes in the mechanical dishwashing station with gloved hands. Observation showed the DA then, without removing his/her soiled gloves and performing hand hygiene, put away sanitized plates from clean side of station, touched the trash can with his/her gloved hands and, again without performing hand hygiene, put sanitized plates away from the clean side of the station. Observation on 05/05/25 at 11:21 A.M., showed DA C washed soiled dishes in the mechanical dishwashing station with gloved hands. Observation showed the DA then, without removing his/her soiled gloves and performing hand hygiene, put away sanitized food service trays from clean side of station. During an interview on 05/05/25 at 11:24 A.M., DA C said staff should wash their hands anytime they get dirty. The DA said he/she washes his/her hands when he/she is all done doing the dishes so he/she does not cross-contaminate and did not think he/she needed to wash his/her hands between handling dirty and clean dishes when he/she wore gloves. The DA said a trash can would be considered dirty and he/she should have washed his/her hands after he/she touched the trash can. During an interview on 05/05/25 at 11:26 A.M., the DM said after staff wash dirty dishes, they should remove their gloves and perform hand hygiene before they put sanitized dishes away. The DM said all staff are trained on proper hand hygiene procedures upon hire and as needed, and he/she has in-serviced DA C multiple times on proper hand hygiene as a result of poor hand hygiene observations. During an interview on 05/08/25 at 10:25 A.M., the administrator said staff should remove gloves and perform hand hygiene after they touch anything dirty before they touch anything clean. The administrator said all staff are trained on proper hand hygiene procedures and the DM is responsible to monitor dietary staff hand hygiene daily when on duty and provide correction to staff as needed in accordance with facility policies. 5. Review of the facility's Dietary-Equipment Operations, Infection Control, and Sanitation Policy, dated 02/02/24, showed the policy directed staff to air dry dishes after they are washed. Observation on 05/05/25 at 11:13 A.M., showed DA C stacked together and put away sanitized plates from clean side of station while wet. Observation on 05/05/25 at 11:21 A.M., showed DA C stacked together and put away sanitized food service trays while wet. Observation on 05/05/25 at 11:22 A.M., showed six insulated plate covers and eight additional plastic food service trays stacked together on a metal utility cart. During an interview on 05/05/25 at 11:24 A.M., DA C said clean dishes should be dry before they are put away and guessed he/she just got in a hurry because he/she thought they were dry enough. During an interview on 05/07/25 at 8:37 A.M., the DM said staff should allow clean dishes to air dry before they are put away. The DM said all staff trained on this requirement and he/she has in-serviced DA C on this requirement multiple times. During an interview on 05/08/25 at 10:24 A.M. the administrator said staff should allow clean dishes to air dry before they are put away and all dietary staff should be trained on that requirement. The administrator said the DM is to monitor dish washing and storage procedures daily when on duty and provide correction to staff as needed in accordance with facility policies. 6. Review of the facility's Dietary-Equipment Operations, Infection Control, and Sanitation Policy, dated 02/02/24, showed All food waste must be placed in covered garbage and trashcans. Observation on 05/05/25 at 11:06 A.M., showed the barrel waste containers in the kitchen service station and cook's station, which contained food and paper waste, uncovered and not in use by staff. Observation on 05/06/25 at 1:24 P.M., showed all three barrel waste containers, which contained food and paper waste, uncovered and the areas unattended by staff. Observation on 05/07/25 at 6:47 A.M., showed the barrel waste container in the mechanical dishwashing station uncovered, the lights in the area off and the area unattended by staff. Observation on 05/07/25 at 8:05 A.M., showed the barrel waste container in the mechanical dishwashing station, which contained food and paper waste, uncovered and the area unattended by staff. During an interview on 05/07/25 at 8:34 A.M., [NAME] A said the waste containers should be covered all the time and they had been in-serviced on that requirement repeatedly by the DM. The cook said he/she just gets tired of having to take of the lids all the time. During an interview on 05/07/25 at 8:28 A.M., the DM said waste containers should be covered at all times and all staff have been trained on this requirement. The DM said he/she did not notice staff had not covered the waste containers. During an interview on 05/08/25 at 10:42 A.M., the administrator said waste containers should be covered when not in actual use and staff have been trained on this requirement. The administrator said the DM should monitor the waste containers daily when on duty and provide corrections to staff as needed in accordance with facility policies.

Based on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. Facility staff failed to use enhanced barrier precautions (EBP) (an infection control practice that requires staff to wear personal protective equipment (PPE), gowns, gloves and/or eye protection, for two residents (Resident #6 and #56) of six sampled residents, failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use a barrier, proper hand hygiene and glove usage during wound care for two residents (Resident #18 and #6) of three sampled residents, and failed to store respiratory treatment equipment in a sanitary manner for two residents (Resident #5 and #34) out of three sampled residents. The facility census was 65 with a capacity of 112. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: -The bacterium Legionella can cause a serious type of pneumonia called Legionnaire's Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. -Facilities must have water management plans and documentation that, at a minimum, ensure each facility: *Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; *Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit; *Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Legionella Surveillance Policy, dated 06/26/24, showed: -It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections; -Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems; -The policy included generalized control measures to prohibit the growth of waterborne pathogens and actions to be taken upon identification of the presence of legionella or other opportunistic waterborne pathogens or of a suspected case of LD. -The policy did not contain the facility's water management team, description of the facility's water systems, a risk assessment to identify potential areas for the growth of waterborne pathogens including legionella, control measures specific to the facility's water systems, actions to be taken when the specified control limits are not met, and activities of the water management program including testing results, monitoring activities, and any corrective actions taken. Observations on 05/06/25 and 05/07/25, during the facility tour showed: -The ice machine's cartridge filter (used to remove unwanted particles, pollutants, and other contaminates from the water supply) dated 02/12/24. Observation showed the label on the filter directed that the filter must be replaced every six months; -insect larvae swam in the water of the toilet bowl in room [ROOM NUMBER]. During an interview on 05/07/25 at 12:07 P.M., the maintenance assistant said he/she began work at the facility part-time about three months ago, he/she did not know the ice machine's cartridge filter was outdated and should be replaced every six months, and he/she did not know who is responsible for the maintenance of the ice machine. The maintenance assistance said the 400 hall rooms had been closed off for resident use as long as he/she had worked at the facility, he/she had not ran the water or flushed the toilets in the rooms, he/she did not know if anyone had monitored or circulated the water in the rooms, and residents still had access to the hall without supervision. The maintenance assistance said he/she did not know anything about a water management program. During an interview on 05/07/25 at 12:07 P.M., the regional maintenance manager said he/she did not know the ice machine's cartridge filter was outdated and should be replaced every six months, and he/she did not know who is responsible for the maintenance of the ice machine. The regional maintenance manager said he/she did not know why the facility shut down the rooms on the 400 hall for resident use, he/she did not know if anyone had monitored or circulated the water in the rooms, and residents still had access to the hall without supervision. The regional maintenance manager said the facility should have a binder with complete policies, and documentation related to the management of the facility's water systems, but this was only his/her second time at the facility and he/she could not locate that binder or provide the facility's complete water management program documentation. During an interview on 05/08/25 at 10:27 A.M., the administrator said maintenance staff are responsible for maintenance of the ice machine and he/she did not know about the outdated filter. During an interview on 05/08/25 at 3:15 P.M., the administrator said the maintenance director is responsible for the development and implementation of the facility's water management program. The administrator said he/she just became the administrator in May 2025, he/she could not provide any additional documentation related to the facility's water management program, and he/she did not know the records did not contain all information required. 2. Review of the facility's policy titled Infection Prevention and Control Program, dated 05/07/24, showed all staff are responsible for following all policies and procedures related to the program. All staff shall use PPE according to established facility policy, and hand hygiene shall be performed in accordance with the facility's established hand hygiene policy. Review of the facility policy titled Enhanced Barrier Precautions, dated 05/18/24, showed it is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDROs), microorganisms that are resistant to at least one class of antimicrobial agents including antibiotics. EBP is a strategy in nursing homes to decrease transmission of Centers for Disease Control and Prevention (CDC) targeted and epidemiologically important multidrug-resistant organisms when contact precautions do not apply. EBP uses PPE and recommends gown and glove use for certain residents during specific high-contact resident care activities associated with MDRO transmission that provide opportunities for transfer of MDROs to staff hands and clothing. All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions, and all staff receive training on high-risk activities and common organisms that require EBP. EBP (gown and gloves) must be used for high-contact resident care activities for residents with any of the following: infection or colonization with a CDC-targeted MDROs when contact precautions do not otherwise apply, or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. High contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, indwelling device care or use, or wound care. Wounds that require EBP are chronic wounds including pressure ulcers and diabetic foot ulcers, and wound care requires EBP. Indwelling medical devices include central lines, urinary catheters, and feeding tubes. Make gowns and gloves available immediately near or outside of the resident's room, ensure access to alcohol-based hand rub (ABHR) in every room (ideally both inside and outside of the room), and position a trash can inside the resident room and near the exit for discarding PPE after removal. 3. Review of Resident #18's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/27/25, showed staff assessed the resident as: -Cognitively intact; -At risk for pressure ulcers; -Had one Stage two pressure ulcer (a partial-thickness skin loss, involving the epidermis and potentially the dermis, may appear as a shallow, open ulcer with a red or pink wound bed); -Received pressure ulcer care. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed an ordered dated 4/16/25, cleanse an open area to buttock with generic wound cleanser and apply Calcium alginate (wound dressing) to open areas then cover with dry dressing daily. Observation on 05/05/25 at 11:50 A.M. showed one wall mounted PPE container in the 200 hall did not contain gowns or gloves. Observation on 05/07/25 at 8:55 A.M., showed an EBP sign posted on the resident's door and did not have PPE near. Certified Nurse Aide (CNA) F and CNA H entered the resident's room with a mechanical lift. Observation showed the CNA's did not wear a gown and transferred the resident to his/her bed and removed the resident's brief. During an interview on 05/08/25 at 1:17 P.M., CNA H said PPE should be worn when emptying catheters or colostomy bags, and if the residents are sick. CNA H said he/she did not know why he/she did not wear a gown, and said today is the first time he/she had seen the wall mounted PPE container stocked with gowns and gloves. He/she said gowns were not available and he/she did not know when a gown should be used. CNA H said the signs on the doors do not really tell him/her which resident requires EBP, it could be both residents in the room or only one, but he/she does not know for sure. 4. Review of Resident #56's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Peripherally Inserted Central Catheter (PICC) line (long tube inserted into a large vein in the arm and guided to a larger vein near the heart); -Diagnosis of B-cell lymphoma (a form of cancer), and pneumonia. Review of the resident's care plan, revised 04/03/25, did not contain direction for EBP. Review of the resident's POS, dated 05/05/25, showed: -PICC line dressing change every week on Wednesday; -Saline flush PICC line with 10 milliliters (ml) daily; -Heparin (a blood thinner) flush PICC line with 5 ml daily. Observation on 05/06/25 at 12:41 P.M., showed Licensed Practical Nurse (LPN) D did not wear a gown and flushed the resident's PICC line. Observation showed the resident's room did not have EBP signage. During an interview on 05/08/25 at 1:07 P.M., the infection control/wound nurse said staff should use EBP for residents with PICC lines, catheters, and wounds. He/She said staff should wear gowns and gloves when providing direct care such as transfers and toileting. PPE should be in the PPE storage containers on each hall, but he/she has noticed staff are not using the PPE. He/She said staff have been educated on EBP, but will need more education. He/She said signs should be placed on the residents' door, but residents have changed rooms without him/her being informed and they have gotten a lot of new residents who may need signs. During an interview on 05/08/25 at 1:15 P.M., LPN P said he/she does not know why staff are not using EBP. LPN P said EBP should be used if a resident has a catheter, PICC line, IV line, gastrostomy tube (G-tube), ostomy, or wounds. LPN P said the if a resident requires EBP staff are expected to wear a gown and gloves while providing care. LPN P said there should be a sign on the resident's door to direct staff. LPN P said he/she did not receive EBP training at this facility. During an interview on 05/08/25 at 2:05 P.M., the administrator said he/she expects staff to use PPE when providing prolonged contact incontinence care, bed baths, wound care, and transfers to residents on EBP. He/She said residents with G-tubes, catheters, PICC lines, and wounds should all be on EBP and have a sign outside their door to alert staff. He/She said the DON is responsible for ensuring the signs are placed and staff are using the appropriate PPE. He/She said staff were educated on EBP and the use of PPE. During an interview on 05/08/25 at 2:33 P.M., the Director of Nursing (DON) said he/she expects staff to wear PPE during direct care and transfers for all residents on EBP. He/She said residents who have catheters, PICC lines, colostomy's, or drain tubes should all be on EBP. Residents who are on EBP should have a sign on the door to alert staff and the PPE should be in the wall mounted PPE containers located half way down the resident hall ways. He/She said it is the responsibility of the aides to refill the PPE boxes. He/She said he/she did not know staff were not refilling the boxes, that signs were not hung on some of the resident doors who were on EBP, and staff were not wearing PPE during resident care. 5. Review of the facility policy titled Wound Treatment Management Policy, dated 05/03/24, showed wound treatments will be provided in accordance with physician orders. The policy did not address the use of barriers for wound care supplies during wound care treatments. Review of the facility policy titled Hand Hygiene, dated 06/26/24, showed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as ABHR. The use of gloves does not replace hand hygiene, if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The hand hygiene table indicates hand hygiene should be used when hands are visibly dirty, hands are visibly soiled with blood or other body fluids, after handling contaminated objects, before performing invasive procedures, before applying and after removing PPE, including gloves; before and after handling clean or soiled dressings, before performing resident care procedures, after handling items potentially contaminated with blood, body fluids, secretions or excretions. Hand hygiene should also be performed when during resident care, moving from a contaminated body site to a clean body site, and after assistance with personal body functions (e.g., elimination). Review of the facility policy titled Glove Utilization Policy, dated 05/18/24, showed wash hands after removing gloves, gloves do not replace hand washing. When changing dressings, after the dirty dressing is removed, gloves should be removed, hands washed and clean gloves donned before applying the clean dressing. Gloves should be used when touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin; and gloves need to be used during the removal of wound dressings. After removing gloves wash hands. 6. Review of Resident #18's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Dependent on staff with personal hygiene, toilet hygiene and showers; -Risk for pressure ulcers; -Stage two pressure ulcer; -Diagnosis of type two diabetes mellitus. Observation on 05/08/25 at 9:43 A.M., showed the infection control/wound nurse entered the resident's room to provide wound care. He/She placed his/her gloves and supplies on the resident's side table without a barrier, applied his/her gloves and gown, removed the resident's bedding and wedge and repositioned the resident in bed. With the same gloves on he/she cleansed the resident's right buttock wound with wound cleanser and gauze, placed the dirty bandage on the resident's incontinence pad and then threw it away. The wound nurse removed and replaced his/her gloves did not wash his/her hands. The wound nurse placed a barrier under the resident's bottom, took scissors out of his/her pocket and cut a piece of calcium alginate (wound dressing) to fit the resident's wound with the same gloves on. The wound nurse placed the scissors and cut calcium alginate on the resident's side table. The wound nurse took the calcium alginate from the side table and placed it on the resident's wound and covered it with a dressing with the same gloves on. The wound nurse did not change the resident's incontinence pad before he/she left the resident's room. 7. Review of Resident #6's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Dependent on staff with personal hygiene, toilet hygiene and showers; -Risk for pressure ulcers; -Stage three pressure ulcer (wound extends through the top layers of skin into the subcutaneous fatty layer, where subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed); -Diagnosis of type two diabetes mellitus. Observation on 05/08/25 at 10:34 A.M., showed the infection control/wound nurse entered the resident's room to provide wound care. The infection control/wound nurse placed his/her gloves and wound supplies on the resident's vanity without a barrier. He/She applied his/her gloves and gown, cleansed the top of the resident's right foot with wound cleanser and gauze and placed the gauze in the trash. During an interview on 05/08/25 at 1:07 P.M., the infection control/wound nurse said he/she should have changed his/her gloves and performed hand hygiene from dirty to clean tasks. He/She said he/she didn't think about cleaning his/her scissors, and he/she doesn't usually place wound supplies and gloves on a barrier. He/She said hand hygiene, cleaning scissors, and using barriers are all important to prevent cross contamination and for infection control. He/She said resident #18's incontience pad was contaminated and should have been replaced. 8. During an interview on 05/08/25 at 2:05 P.M., the administrator said it is his/her expectation that anytime the nurse goes from a dirty to clean task that they remove their gloves and perform hand hygiene before replacing his/her gloves, to prevent cross contamination. He/She said he/she expects staff to have a clean barrier and supplies to be placed on a barrier. He/She said he/she would expect staff to clean their scissors before placing them on the clean barrier for use. He/She said staff should not use scissors from their pockets to cut wound dressings because they could be dirty and there is an infection control concern. He/She said staff should never place dirty items on bedding or incontinence pads, and if they do it should changed. He/She said leaving the soiled pad on the bed puts the resident at risk for cross contamination and is an infection control concern. During an interview on 05/08/25 at 2:33 P.M., the DON said he/she expects staff to perform hand hygiene before wound care, from dirty to clean tasks, between wounds, and before leaving the resident's room. He/She said anytime gloves are changed; staff should perform hand hygiene. He/She would expect staff to gather all supplies needed and place the supplies on a moisture proof barrier to prevent the spread of germs. He/She said he/she expects staff to clean scissors to cut wound dressings, and would expect staff to place the scissors on the barrier when not in use. He/She said after cleansing the wound, gauze should be placed in the trash and never be placed on the resident's bed, to prevent the spread of germs. He/She said the resident's incontinence pad should have been changed. 9. Review of the facility's policy titled Oxygen Administration, revised 05/18/24, showed staff are to follow manufacturer recommendations for the frequency of cleaning equipment and filters. Staff are directed to change oxygen tubing and mask/cannula weekly and as needed when if it becomes soiled or contaminated. Staff are directed to change nebulizer tubing and delivery devices every 72 hours or as needed if they become soiled or contaminated. All delivery devices are to be stored covered in a plastic bag when not in use. Staff shall monitor for respiratory infections related to contaminated systems. 10. Review of Resident # 5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/10/25, showed staff assessed the resident as cognitively intact and did not use oxygen. Review of the resident's care plan, revised 01/07/25, showed staff documented the resident received oxygen therapy at night. Review of the resident's Physician Orders Sheet (POS), dated 05/05/25, showed oxygen at two Liters Per Minute (LPM) via nasal cannula at night and date and change oxygen tubing weekly on Sunday. Observation on 05/05/25 at 11:58 A.M., showed nebulizer tubing dated 04/06/25 laid on the nightstand unbagged and uncovered. Observation showed oxygen tubing dated 04/09/24 laid on the concentrator unbagged and uncovered. Observation on 05/06/25 at 7:45 A.M., showed nebulizer tubing dated 04/06/25 laid on the nightstand unbagged and uncovered. Observation showed oxygen tubing dated 04/09/24 laid on the concentrator unbagged and uncovered. Observation on 05/07/25 at 1:12 P.M., showed nebulizer tubing dated 04/06/25 laid on the nightstand unbagged and uncovered. Observation showed oxygen tubing dated 04/09/24 laid on the concentrator unbagged and uncovered. Observation on 05/08/25 at 8:00 A.M., showed nebulizer tubing dated 04/06/25 laid on the nightstand unbagged and uncovered. Observation showed oxygen tubing dated 04/09/24 laid on the concentrator unbagged and uncovered. During an interview on 05/06/25 at 8:30 A.M., the resident said he/she uses oxygen at night and receives nebulizer treatments as needed. He/She said staff do not change the tubing each week like ordered despite him/her asking them to. 11. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, required oxygen and CPAP therapy, and had a diagnosis of paraplegia. Review of the resident's care plan, revised 04/10/25, showed staff documented to administer medications as ordered and provide CPAP. The care plan did not address oxygen use. Review of the resident's POS, dated 05/0/525, showed CPAP at night, Oxygen at three LPM continuously, and change and date oxygen tubing every week on Sunday. Observation on 05/05/25 at 2:13 P.M., showed the resident's CPAP mask laid on the floor of his/her room unbagged and uncovered. The CPAP mask had dried debris in it. Observation showed an oxygen concentrator in the room with oxygen tubing dated 04/06/25 that laid on the floor unbagged and uncovered. Observation showed nebulizer tubing dated 04/06/25 laid in the nightstand drawer unbagged and uncovered. Certified Nurse Assistant (CNA) K answered the resident's call light and left the room. The CNA did not address the CPAP mask on the floor or the unbagged and uncovered tubing. Observation on 05/06/25 at 8:15 A.M., showed the resident's CPAP mask laid on the floor of his/her room unbagged and uncovered. The CPAP mask had dried debris in it. Observation showed an oxygen concentrator in the room with oxygen tubing dated 04/06/25 that laid on the floor unbagged and uncovered. Observation showed nebulizer tubing dated 04/06/25 laid in the nightstand drawer unbagged and uncovered. Observation on 05/07/25 at 7:48 A.M., showed the resident's CPAP mask laid on the floor of his/her room unbagged and uncovered. The CPAP mask had dried debris in it. Observation showed the oxygen concentrator, oxygen tubing dated 04/06/25, laid on the floor unbagged and uncovered. Observation showed nebulizer tubing dated 04/06/25 laid in the nightstand drawer unbagged and uncovered. Observation on 05/08/25 at 8:35 A.M., showed CNA G provided care to the resident. Observation showed the resident's CPAP mask laid on the floor of his/her room unbagged and uncovered. The CPAP mask had dried debris in it. Observation an oxygen concentrator in the room with oxygen tubing dated 04/06/25, laid on the floor unbagged and uncovered. Observation showed nebulizer tubing dated 04/06/25 laid in the nightstand drawer unbagged and uncovered. Observation showed CNA G left the resident's room and did not address the CPAP mask on the floor or the unbagged and uncovered tubing. During an interview on 05/08/25 at 11:55 A.M., CNA G said oxygen tubing, nebulizer tubing, and CPAP masks should be stored in a plastic bag when not in use. CNA G said tubing or masks should not be on the floor due to contamination concerns which could cause a resident to potentially get sick. CNA G said he/she did notice the resident's tubing and mask on the floor unbagged and uncovered. CNA G said he/she should have changed the tubing and cleaned the CPAP mask before the resident used it after being on the floor. 12. During an interview on 05/08/25 at 12:50 P.M. CNA H said the proper way to store oxygen tubing, nebulizer tubing, or CPAP masks not in use by a resident is in a plastic bag. CNA H said this is to prevent contamination that could potentially lead to a resident getting pneumonia. CNA H said tubing and masks should never be on the floor due to germs. CNA H said if found on the floor staff should replace the tubing and clean the CPAP mask. During an interview on 05/08/25 at 1:15 P.M., Licensed Practical Nurse (LPN) P said oxygen tubing, nebulizer tubing, or CPAP masks should never be on the floor. LPN P said if the tubing or masks are found on the floor staff should replace the tubing and clean the mask before resident use. LPN P said the proper way to store tubing and masks when not in use is in a plastic bag. LPN P said the night shift charge nurse is responsible to change oxygen tubing and nebulizer tubing weekly, and it should be dated when it's changed. LPN P said he/she did not know the tubing had not been changed. During an interview on 05/08/25 at 1:50 P.M., the Administrator said the proper way to store oxygen tubing, nebulizer tubing, or CPAP masks not in use by a resident is in a plastic bag. The Administrator said this is to prevent contamination that could potentially lead to a resident getting pneumonia or other respiratory infections. The Administrator said tubing and masks should never be on the floor due to germs causing contamination of the equipment. The Administrator said if found on the floor he/she expects staff to replace the tubing and clean the CPAP mask prior to the resident using it. During an interview on 05/08/25 at 2:30 P.M., the Director of Nursing (DON) said staff are expected to change oxygen tubing and nebulizer tubing weekly. The DON said it is the responsibility of the charge nurse to ensure they are changed. The DON said he/she was not aware staff were not changing the tubing each week. The DON said the proper way to store oxygen tubing, nebulizer tubing, or CPAP mask not in use by a resident is in a plastic bag. The DON said tubing and masks should never be on the floor due to contamination. The DON said this could potentially lead to a resident getting a respiratory infection. The DON said he/she expects staff to replace tubing or clean a CPAP mask if on the floor.

Based on observation, interview, and record review, facility staff failed maintain a safe, clean, comfortable and homelike environment, when staff failed to ensure resident areas were in good repair, failed to maintain the interior of the building and failed to maintain equipment. The facility census was 65 with a capacity of 112. 1. Review of the policies provided by the facility showed the records did not contain a policy related to upkeep of the facility's physical environment. 2. Observation on 05/05/25 at 11:33 A.M., showed resident occupied room [ROOM NUMBER] with black scuff marks along the wall under the window. Observation on 05/05/25 at 11:42 A.M., showed resident occupied room [ROOM NUMBER] with damaged drywall between the residents beds around the call light outlet; the light missing above the mirror in the room with capped wires exposed, and several holes and damaged dry wall above the sink. Observation on 05/05/25 at 11:48 A.M., showed resident occupied room [ROOM NUMBER] with four tiles between the two beds with chipped corners and another three tiles in front of bed B's dresser with chipped corners. Observation on 05/05/25 at 12:12 P.M., showed the ceiling vent in the 200 hall between resident occupied rooms [ROOM NUMBERS], with a dark black porous substance on louvers; and flaking paint around the metal edges of the vent cover. Observation on 05/06/25 at 7:05 A.M.,showed multiple deep gouges in the wall in unoccupied room [ROOM NUMBER]. Observation on 05/06/25 at 7:15 A.M., showed resident occupied room [ROOM NUMBER] bathroom door with multiple holes. Observation on 05/06/25 at 7:45 A.M., showed room [ROOM NUMBER] dresser drawer front missing. Observations on 05/06/25 from 8:10 A.M. to 8:20 A.M., showed the 400 hall and rooms: -Toilets in rooms 400, 401, 402, 403, 405 and 406 had brown to black stains in the bowl and they did not contain a tank covers; -Toilet bowl in room [ROOM NUMBER] had brown stains and insect larvae in the water; -Light fixtures and components removed in rooms 400, 402 and 410; -Light switch cover plates removed in rooms 402 and the family room; -The cable box cover removed in room [ROOM NUMBER]; -Electrical receptacle cover plates removed in rooms [ROOM NUMBER]. During an interview on 05/07/25 at 12:07 P.M., the maintenance assistant said the rooms on the the 400 hall had been that way for the duration of his/her employment at the facility and they often use fixtures from the rooms to make repairs in other rooms. The maintenance assistant said he/she did not know if anyone routinely cleaned the rooms or monitored them for hazards. The maintenance assistant said only the maintenance supervisor is authorized to order items to be delivered or purchase items locally to make repairs and the facility had not had a maintenance supervisor for about three weeks. During an interview on 05/07/25 at 12:07 P.M., the regional maintenance manager said he/she did not know of any plans to remodel or repair the rooms on the 400 hall and he/she did not know why the rooms were missing fixtures. The regional maintenance manager said the facility had a credit card to use for purchases, but the maintenance supervisor is the only person authorized to -Light switch cover plates missing in rooms to order items to be delivered or purchase items locally to make repairs and the facility did not have a maintenance supervisor. 3. Observations on 05/06/25 at 8:20 A.M., showed the electrical receptacle cover plates removed from the wall above the computer kiosk across from the 300 hall men's shower room and by the whirlpool tub in the shower room. Observations also showed piles of trash on the floor by the sink and behind the toilet in the shower room. Observation on 05/06/25 at 8:45 A.M., showed the corner of the 300 hall attic access broken off which created an unsealed hole in the ceiling. During an interview on 05/07/25 at 12:09 P.M., the maintenance assistant said he/she did not know about the hole in the ceiling. 4. Observation on 05/06/25 at 8:50 A.M., showed unoccupied room [ROOM NUMBER] did not contain a toilet, the cover of the wall mounted heating/air conditioner unit on the floor and a drawer removed from the dresser. During an interview on 05/07/25 at 12:45 P.M., the maintenance assistant said he/she did not know about the issues in the room. 5. Observation on 05/06/25 at 8:51 A.M., showed a five inch linear hole in the bathroom door of occupied room [ROOM NUMBER]. Observation on 05/06/25 at 8:52 A.M., showed toilet tank cover and light fixture cover removed from unoccupied room [ROOM NUMBER]. Observation on 05/07/25 at 10:55 A.M., showed a large cut out hole and the floor damaged in the dining room closet. During an interview on 05/07/25 at 10:55 A.M., the maintenance assistant said he/she did not know why there was a hole in the closet wall or what happened to the floor. The maintenance assistant said he/she had not been in the closet during his/her employment at the facility. During an interview on 05/08/25 at 1:11 P.M., Certified Medication Technician (CMT) I said he/she would report damaged walls and floors to the maintenance department. He/she thought there is a form to fill out, or would tell the maintenance director in person. CMT I said that honestly, he/she does not really look at the environment as he/she is focused on resident care and usually does not pay attention. CMT I said it would be more homelike for residents to have tile and walls repaired. During an interview on 05/08/25 at 1:17 P.M., Certified Nurse Aide (CNA) H said he/she would put a work order in to maintenance if something needed to be repaired or replaced. He/she did not know if there was a form, he/she thinks there is something on the computer charting system that asks about environmental concerns. CMT H said he/she normally tells the nurse, then fills out a form and gives it to the maintenance director. CMT H said he/she did notice the damaged walls and floors in the rooms on the 200 hall, but thought someone else had reported it, so he/she did not report it. During an interview on 05/08/25 at 1:33 P.M., Registered Nurse (RN) E said if he/she sees something that needs repaired he/she makes a maintenance request, and lets maintenance know. RN E said behind the nurse's desk there is a maintenance folder to put the forms in. RN E said he/she had not noticed the wires in room [ROOM NUMBER], or the tiles in room [ROOM NUMBER], and he/she usually works on the 100 and 300 halls. He/she said those items should be fixed and repaired for the residents to make it more homelike. During an interview on 05/08/25 at 9:45 A.M., the regional maintenance manager said facility maintenance staff, under the direction of the maintenance supervisor and administrator, are responsible for the maintenance of the facility. The regional maintenance supervisor said if something needs repaired staff should submit a work order to maintenance. The regional maintenance manager said he/she could not provide work orders for the items found in disrepair and the facility had not had a maintenance director for about three weeks. During an interview on 05/08/25 at 3:50 P.M., the administrator said the maintenance supervisor is responsible for the building and staff should submit a work order to maintenance if something needs repaired. The administrator said he/she just became the administrator in May 2025 and he/she could not provide work orders for the items found in disrepair, and the facility did not currently have a maintenance supervisor. 6. Observation on 05/06/25 at 7:20 A.M., showed a sign posted on one of two washing machines in the laundry room which read Washing machine out of order 2-6-25. During an interview on 05/06/25 at 7:20 A.M., the laundry aide said the washing machine did not work and he/she did not know if anyone had taken any actions to have it replaced or repaired. The laundry aide said it took a long time to get laundry done without it. During an interview on 05/07/25 at 11:00 A.M., the maintenance assistant said he/she worked part-time at the facility and he/she did not know the washing machine was out of order. The maintenance assistant said he/she did not know of any actions taken to repair or replace the machine. During an interview on 05/07/25 at 11:00 A.M., the regional maintenance manager said he/she did not know the washing machine was out of order and what actions, if any, had been taken to repair or replace the machine. During an interview on 05/08/25 at 3:15 P.M., the administrator said he/she just became the administrator in May 2025, he/she did not know the washing machine was out of order and what actions, if any, had been taken to repair or replace the machine.

Based on record review and interview, facility staff failed to check the Employee Disqualification List (EDL), Family Care Safety Registry (FCSR), or complete a Criminal Background Check (CBC) for two sampled employees (Certified Nurse Aid (CNA) R, and Nurse Aide (NA) S), out of eight sampled newly hired employees. The facility failed to check the NA Registry for seven employees (Housekeeper T, Dietary Aide U, CNA V, CNA R, Licensed Practical Nurse (LPN) D, NA S and Registered Nurse (RN) E) out of eight sampled employees. The facility census was 65. 1. Review of the facility's policy titled Abuse and Neglect, dated 06/12/24, showed potential employees are screened for a history of abuse, neglect or mistreating of residents. 2. Review of the facility's policy titled Screening - Applicant, Employee, Volunteer and Vendor, date 05/14/24, showed Human Resources (HR) will conduct the following screens on potential employees prior to hire: -Criminal history using the request for Criminal Records Check, a CBC should be done through the Missouri Highway Patrol; -FCSR registration and background check must be completed within 15 days of the first date of employment; -EDL must be checked for every applicant, the results must be printed with the original initialed and dated by the person who conducted the check; -CNA Registry must be checked for all applicants regardless of the position for which they are applying. The results must be printed with the original initialed and dated by the person who conducted the check. 3. Review of CNA R's employee file showed a hire date of 09/30/24 and did not contain a completed EDL, CBC, or FCSR check prior to his/her work in the facility. During an interview on 05/06/25 at 9:40 A.M., the Business Office Manager (BOM) said he/she does not know why the pre-employment screenings were not completed for CNA R. The BOM said CNA R continues works at the facility. 4. Review of NA S's employee file showed a hire date of 05/07/24 and did not contain a completed EDL, CBC, or FCSR check prior to his/her work in the facility. During an interview on 05/06/25 at 9:40 A.M., the BOM said he/she does not know why the pre-employment screenings were not completed for NA S. The BOM said NA S still works at the facility. The BOM said the concern of not doing the pre-employment screenings, is the employee may have a history of abuse and not be able to work in long-term care. 5. During an interview on 05/06/25 at 1:53 P.M., the administrator said all staff have to have an EDL, CBC, FCSR and license check prior to starting at the facility. The administrator said the BOM is responsible for completing the checks. The administrator said it is the administrators responsibility to make sure the BOM completes the pre-employment checks. 6. Review of Housekeeper T's employee file showed a hire date of 03/10/25 and did not contain a CNA registry check prior to him/her starting at the facility. 7. Review of Dietary Aide U's employee file showed a hire date of 06/14/24 and did not contain a CNA registry check prior to him/her starting at the facility. 8. Review of CNA V's employee file showed a hire date of 12/09/24 and did not contain a CNA registry check prior to him/her starting at the facility. 9. Review of CNA R's employee file showed a hire date of 09/30/24 and did not contain a CNA registry check prior to him/her starting at the facility. 10. Review of LPN D's employee file showed a hire date of 01/22/25 and did not contain a CNA registry check prior to him/her starting at the facility. 11. Review of NA S's employee file showed a hire date of 05/07/24 and did not contain a CNA registry check prior to him/her starting at the facility. 12. Review of Registered Nurse E's employee file showed a hire date of 11/05/24 and did not contain a CNA registry check prior to him/her starting at the facility. 13. During an interview on 05/06/25 at 9:40 A.M., the BOM said he/she did not know the CNA Registry should be checked for all positions, he/she thought it was only checked for the CNA position. During an interview on 05/06/25 at 1:53 P.M., the administrator said he/she did not know all staff positions had to be checked against the CNA Registry. The administrator said the BOM is responsible to complete the CNA Registry checks prior to staff starting. The administrator said he/she is responsible to make sure the BOM completes the CNA Registry checks.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for seven residents (Resident #4, #5, #14, #25, #28, #56, and #57) out of 24 residents sampled. The facility census was 65. 1. Review of the facility's policy titled Bed Hold, revised 11/06/23, showed when a resident is discharged to the hospital or goes on therapeutic leave, the facility will provide the resident or their legal representative a copy of the bed hold policy. Review of the facility's policy titled Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave, revised 05/15/24, showed before any resident is transferred or discharged the facility must notify the resident and/or representative the reason for discharge in writing, and a copy of the bed hold policy. Documentation of the bed hold policy being provided to the resident and/or representative must be put in the resident's medical record. The bed hold policy must provide information to the resident that explains the duration of the bed hold, the reserve bed payment policy, and addresses permitting the return of the resident to the next available bed. The facility must also notify the Ombudsman by sending a copy of the discharge/transfer notice monthly. 2. Review of Resident #4's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 11/22/24. Review showed the resident discharged from the facility to the hospital on [DATE] and returned on 01/03/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfers/discharges. 3. Review of Resident #5's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 11/21/24. Review showed the resident discharged from the facility to the hospital on [DATE] and returned on 12/21/24. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfer/discharge. 4. Review of Resident #14's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 02/05/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfer/discharge. 5. Review of Resident #25's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 01/02/25. Review showed the resident discharged from the facility to the hospital on [DATE] and returned on 01/23/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfer/discharge. 6. Review of Resident #28's medical record showed staff documented the resident transferred from the facility to the hospital on [DATE] and returned on 02/08/25. Review showed the resident transferred to the hospital on [DATE] and returned on 05/04/25. The medical record did not contain documentation staff issued a bed hold upon transfer to the resident or the resident's responsible party, and did not notify the ombudsman of the transfers/discharges. 7. Review of Resident #56's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 02/24/25. Review showed the resident discharged to the hospital on [DATE] and returned on 03/12/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfers/discharges. 8. Review of Resident #59's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 04/14/25. Review showed the resident discharged to the hospital on [DATE] and returned on 04/25/25. Review showed the resident discharged to the hospital on [DATE] and returned on 05/06/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfers/discharges. 9. During an interview on 05/08/25 at 9:51 A.M., the Social Service Designee (SSD) said he/she started as the SSD a week ago and has not been trained yet. The SSD said he/she does not know who is responsible to complete bed holds or notify the Ombudsman of a resident transfer and/or discharge. During an interview on 05/08/25 at 1:15 P.M., Licensed Practical Nurse (LPN) P said he/she does not know who is responsible to complete bed holds or notify the Ombudsman of a resident transfer and/or discharge. LPN P said he/she has not completed any bed holds. During an interview on 05/08/25 at 2:05 P.M., the administrator said it is his/her expectation that a bed hold be given to the resident or their responsible party upon discharge or transfer from the facility and the charge nurse is responsible to ensure it is completed. The administrator said the Ombudsman should be notified weekly of each resident discharge by the SSD. The Administrator said if a resident leaves emergently he/she expects the SSD to follow up within 24 hours to obtain the bed hold information. During an interview on 05/08/25 at 2:30 P.M., the Director of Nursing (DON) said the Business Office Manager (BOM) is responsible to ensure the bed holds are completed when a resident is discharged or transferred. The DON said bed holds should be given to the resident or their responsible party at the time of discharge or transfer. The DON said he/she did not know bed holds were not being completed. The DON said he/she is not certain who is responsible to notify the Ombudsman of a resident discharge or transfer, but he/she thought it was the SSD.

Based on observation, interview, and record review, facility staff failed to review and update the plan of care with changes in the residents' care needs for ten residents (Residents #3, #4, #5, #6, #7, #10, #18, #25, #34, and #56) out of 20 sampled residents. Facility staff failed to hold care conferences for three residents (Resident #3, #10, and #21). The facility census was 65. 1. Review of the facility policy titled Comprehensive Care Plans, dated 10/31/24, showed the care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. The comprehensive care plan will be prepared by an interdisciplinary team that includes, but is not limited to the attending physician, a registered nurse, a nurse aide, a member of the food and nutrition services staff, the resident and the resident's representative to the extent practicable, as well as the activities director, social services director, and administration. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS), a federally mandated assessment tool, assessment. The individualized care service plan will be updated with pertinent information needed for nursing staff on the floor to provide the needed care for residents. The policy did not address care plan meetings or timing. 2. Review of Resident #3's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact with diagnoses of Atrial Fibrillation (an irregular heartbeat), heart failure, insomnia, depression and anxiety. Review of the resident's care plan, revised 10/17/24, showed staff are directed to weigh the resident weekly on Monday. Review showed the care plan did not contain direction for anticoagulant (medication used to thin the blood), or antidepressant use or the resident's use of melatonin for sleep. Review of the resident's Physician's Order Sheet (POS), dated 05/05/25 showed: -Eliquis (medication used to thin the blood) 5 milligrams (mg) daily; -Melatonin (medication used for sleep) 6 mg at bedtime; -Remeron (antidepressant medication) 7.5 mg at bedtime; -Celexa (antidepressant medication ) 10 mg daily; -Do not have to obtain monthly weights due to residents' immobility. During an interview on 05/07/25 at 1:37 P.M., the resident said he/she had not been invited to a care plan meeting. 3. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had not fallen since prior assessment; -Diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), depression, Chronic Obstructive Pulmonary Disease (COPD), a group of lung diseases that block airflow and make it difficult to breathe), schizophrenia, and Post Traumatic Stress Disorder (PTSD), a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. Review of the resident's medical record showed staff documented the resident fell on [DATE] and had an abrasion and bruise to his/her leg. Review of the resident's care plan, dated 12/04/24, showed it did not address the resident's fall. 4. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, with diagnoses of heart failure, high blood pressure, anxiety, depression and asthma. Review of the resident's POS, dated 05/05/25, showed: -A specialized cushion in wheelchair for comfort; -Low air loss mattress on bed for comfort; -Eliquis 5 mg two times a day; -Zoloft (antidepressant) 150 mg daily; -Ativan (antianxiety medication) 1 mg at bedtime. Review of the resident's care plan, revised 01/07/24, showed it did not contain direction for a specialized cushion to wheelchair, a low air loss mattress, or anticoagulant, antidepressant, or antianxiety medication use. During an interview on 05/07/25 at 1:12 P.M., the resident said he/she had not been invited to a care plan meeting in quite some time. 5. Review of Resident #6 Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Had one fall since prior assessment; -Had an unhealed pressure injury; -Had one Stage three pressure injury (a deep wound characterized by full-thickness skin loss, where subcutaneous fat tissue is visible, but bone, tend or muscle is not exposed); -Received pressure injury care; -Had application of dressings to feet; -Diagnoses of high blood pressure, diabetes, anxiety, depression, Alzheimer's disease, dementia, and psychotic disorder. Review of the resident's medical record showed staff documented the resident fell on [DATE] and had bruising, and fell on [DATE] with no injuries. Review showed staff documented on 02/13/25 the resident had a wound on his/her right foot Review of the resident's POS, dated May 2025, showed order to cleanse the right foot wound with cleanser and apply skin prep (transparent liquid used to cover skin), related to Pressure Ulcer of other site, Stage 2 (a partial-thickness skin loss, involving the epidermis and potentially the dermis, may appear as a shallow, open ulcer with a red or pink wound bed), dated 05/09/25. Review of the resident's care plan, dated 04/10/25, showed it did not address the resident's two falls or his/her Stage 2 pressure injury. 6. Review of Resident #7's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of Alzheimer's disease, anxiety, and depression; -Did not receive hospice services. Review of the resident's care plan, revised 04/28/25, showed staff documented the resident received hospice services. Review of the resident's POS, dated 05/05/25, showed it did not contain an order for hospice services. Review of the resident's nurse's notes, dated 05/30/24, showed staff documented hospice services will discontinue on 05/31/24. Review of the resident's census showed hospice services were last billed on 05/31/24. During an interview on 05/07/25 at 8:10 A.M., Registered Nurse (RN) O said the resident received hospice services in the past but not now. RN O said the resident's care plan should have been updated when the resident was discharged from hospice. 7. Review of Resident #10 Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -Received antipsychotic, antianxiety, antidepressant, antiplatelet (prevents clots) medication; -Resident participation in assessment and goal setting; -Diagnoses of high blood pressure, diabetes, seizure disorder, anxiety, depression, PTSD, and Schizophrenia. Review of the POS, dated May 2025, showed orders for: -Lisinopril (blood pressure medication) 40 mg; -Plavix (antiplatelet medication) 75 mg; -Seroquel (antipsychotic medication) 50 mg in the morning and 100 mg at bedtime; -Venlafaxine (antidepressant medication) 75 mg; -Hydroxyzine (antianxiety medication) HCL 25 mg; -Topiramate (treats seizure disorder) 100 mg. Review of the resident's care plan, dated 01/14/25, showed it did not address the resident's use of antipsychotic, antianxiety, antidepressant, antiplatelet, seizure disorder, and/or high blood pressure medications. Review of the resident's medical record showed staff did not document a care plan conference had been held. During interview on 05/05/25 at 2:24 P.M., the resident said he/she has never been invited to a care plan meeting. He/She said when he/she asked about meetings, he/she was told they are not doing them because they do not have an MDS coordinator or a social services designee (SSD). 8. Review of Resident #18's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -At risk for pressure injuries; -Had one Stage 2 pressure injury; -Received pressure ulcer care; -Had limited range of motion to the upper and lower extremities on one side; -Dependent on staff for sit to stand, chair/bed to chair transfers, and toilet transfers; -Diagnoses of high blood pressure, diabetes, acid reflux, high cholesterol, stroke, thyroid disorder, dementia, hemiplegia (muscle weakness or partial paralysis on one side of the body), seizure disorder, depression, and Bipolar disease (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's care plan, dated 04/10/25, showed staff documented the resident requires the use of a sit-to-stand lift (requires reliable weight bearing through one or both of the lower extremities) with assistance from two staff for transfers. Review showed the care plan did not address the resident's pressure injury. Review of the resident's POS, dated May 2025, showed Open Area Buttock: Cleanse with generic wound cleanser and apply Calcium alginate (would dressing) to open areas then cover with dry dressing daily every day shift, with a start date of 4/16/2025. Observation on 05/07/25 at 8:55 A.M., showed two staff members assisted the resident from his/her wheelchair to the bed using a hoyer lift (a device used to help caregivers safely lift and transfer patients who have mobility challenges, using a sling-like hammock to support the patient). During an interview on 05/08/25 at 1:17 P.M., CNA H said the resident used to be able to use the sit-to-stand lift but can't any longer due to weakness. The CNA said staff has been using the hoyer lift for a while now. 9. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, Independent with ADL's and participated in assessment and goal setting. Review of the resident's medical record showed staff did not document a care plan conference had been held. During an interview on 05/06/25 at 10:56 A.M., the resident said it has been a while since he/she has been invited to a care plan meeting. He/She has been at the facility for 10 years and things have changed a lot. 10. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with diagnoses of heart failure, high blood pressure, diabetes, high cholesterol, depression, and End Stage Renal Failure (ESRD), a severe condition where the kidneys are no longer able to filter waste and excess fluid from the blood effectively. Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident had a surgical wound. Review of the resident's medical record showed staff documented the resident had been admitted to the hospital on [DATE] and returned to the facility on [DATE] after surgery resulting in a colostomy (a surgical procedure that creates an opening (stoma) in the abdomen, allowing stool to exit the body). Review of the resident's care plan, dated 01/15/25, showed it did not address the resident's new colostomy or surgical wound. 11. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Paraplegia (paralysis of the lower body), hypertension, anxiety, insomnia, depression, bipolar disorder, COPD; -Received hospice services; -Did not use oxygen. Review of the resident's care plan, revised 04/10/25, showed staff documented the resident used assist bars for mobility and positioning while in bed. The care plan did not contain direction for staff in regard to broda chair or shower gurney use, hospice services, antianxiety or mood stabilizing medication use or the resident's need for oxygen. Review of the residents POS, dated 05/05/25 showed: -Lithium (mood stabilizer) 150 mg bedtime; -Lorazepam (antianxiety medication) 2 mg/milliliter (ml) 0.25 mg every 4 hours as needed; -May have assist bars on bed for mobility and positioning; -Oxygen three liters per minute (LPM) via nasal cannula continuously; -Did not contain orders for hospice services. Review of the resident's census showed hospice services started on 03/01/25. Observation on 05/05/25 at 11:29 A.M., showed staff pushed the resident to the shower room on a shower gurney. Observation on 05/05/25 at 12:30 P.M., showed the resident sat in the dining room in a Broda chair. Observation on 05/05/25 at 2:13 P.M., showed the resident's oxygen concentrator on in his/her room with attached tubing. The resident's bed did not have assist bars. Observation on 05/06/25 at 8:15 A.M., showed the resident's oxygen concentrator on in his/her room with attached tubing. The resident's bed did not have assist bars. Observation on 05/07/25 at 1:26 P.M., showed the resident's oxygen concentrator on in his/her room with attached tubing. The resident's bed did not have assist bars. Observation on 05/08/25 at 8:35 A.M., showed the resident's oxygen concentrator on in his/her room with attached tubing. The resident's bed did not have assist bars. 12. Review of Resident #56's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately cognitively impaired; -Diagnosis of Hepatitis B (a viral infection that effects the liver), heart block (an abnormal heartbeat), Atrial Fibrillation, B-cell Lymphoma (a type of cancer), hypertension, anxiety; -Had a Peripherally Inserted Central Catheter (PICC) line (a long tube inserted into a vein in the arm threaded to a larger vein near the heart) access. Review of the resident's care plan, revised 04/03/25, showed it contained direction for staff in regard to antidepressant medication use and non-weight bearing status. Review showed it did not contain direction in regard to the resident's PICC line, roho cushion or anticoagulant medication. Review of the POS, dated 05/05/25, showed order for Eliquis (anticoagulant medication) 5 mg two times a day, roho cushion to wheelchair, and PICC line dressing changes and flushes. The POS did not have an order for antidepressant medication. Observation on 05/05/25 at 2:19 P.M., showed the resident stood with a walker and tossed a ball with members of the therapy department. During an interview on 05/07/25 at 1:37 P.M., the resident said he/she had not been invited to a care plan meeting. The resident said he/she is working with therapy to increase his/her strength. He/She said therapy has him/her standing with a walker to work on balance. 13. During an interview on 05/07/25 at 1:00 P.M., the Dietary Manager (DM) said he/she has worked at the facility since August 2024. The DM said he/she has never been invited to a care plan meeting. During an interview on 05/07/25 at 4:05 P.M., Licensed Practical Nurse (LPN) P said care plans direct staff in regard to resident care. LPN P said a care plan should be individualized and match the resident's POS. LPN P said he/she has never been invited to a care plan meeting. During an interview on 05/08/25 at 9:45 A.M., the Activity Director (AD) said he/she has been employed at the facility since February 2025. The AD said he/she has never been invited to a care plan meeting. During an interview on 05/08/25 at 9:51 A.M., the SSD said he/she transferred to the SSD role last week, and prior to that was the staffing coordinator. The SSD said he/she does not know his/her responsibility regarding care plans and meetings yet as he/she has not been trained. The SSD said he/she did have two families call this week wanting to schedule a care plan meeting, but he/she has not set the meetings up. The SSD said the facility's MDS Coordinator left in January 2025 and the MDSs' are being completed remotely by a corporate nurse. During an interview on 05/08/25 at 1:07 P.M., the infection control/wound care nurse said to his/her knowledge the facility is not providing care plan meetings, and he/she has not been invited to any. He/She said he/she believes the meetings are not being held because the MDS coordinator works remotely. He/She said the SSD is in charge of setting up the meetings and the facility did not have one for a while. He/She said the SSD is new and just started this week. During an interview on 05/08/25 at 1:56 P.M., the SSD said he/she is new to the position and he/she has not been trained yet. He/She said he/she had not set up any care plan meetings and the prior MDS coordinator left in January and the SSD left two months ago. He/She said he/she does not know the process yet or timing but he/she knows the Interdisciplinary team (IDT) should be invited to meetings. He/She said the IDT team should consist of the DON, himself/herself, the resident and their guardian. During an interview on 05/08/25 at 2:05 P.M., the Administrator said he/she began his/her employment at the facility the first day of the survey process. The Administrator said he/she expects care plans to be updated timely, individualized, and to match the resident's POS. The Administrator said he/she did not know if care plan meetings were being held, but he/she expects care plan meetings completed quarterly for all residents. The Administrator said he/she expects the SSD, DM, AD, DON, nurses, hospice, and the resident or their responsible party to be invited to and attend care plan meetings. The Administrator said the MDS Coordinator is responsible for scheduling the care plan meetings for each resident and notifying the team, resident and/or responsible party of the date and time of the meeting. During an interview on 05/08/25 at 2:30 P.M., the Director of Nursing (DON) said the MDS Coordinator is responsible for scheduling care plan meetings for all residents and sending out the schedule. The DON said care plan meetings should be completed quarterly for all residents. The DON said the facility does not currently have an MDS Coordinator. The DON said a corporate nurse has been completing MDSs' remotely since January 2025 and the facility has not held any care plan meetings. Surveyor: [NAME], [NAME]

Based on interview and record review, facility staff failed to communicate pharmacy recommendations to the physician for four residents (Resident #6, #10, #18, and #34) to prevent or minimize adverse consequences related to medication therapy to the extent possible out of 20 sampled residents. The facility census was 65. 1. Review of facility policy titled Pharmacy Services Policy, dated 05/18/24, showed the facility will employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility. The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support resident's healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements. Review of the facility policy titled Medication Monitoring Policy, dated 05/18/24, showed this facility takes a colloborative, systematic approach to medication management, including monitoring of medications for efficacy and adverse consequences. Each resident's medication regimen is reviewed by a licensed pharmacist at designated intervals, and whenever changes in condition that could be related to medications are noted. Irregularities are reported and addressed in accordance with facility policy for medication regimen reviews (MRRs) and addressing irregularities. Review of the policies provided by the facility did not contain a policy for MRRs. 2. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/25/25, showed staff assessed the resident as severely cognitively impaired with diagnoses of high blood pressure, diabetes, anxiety, dementia, and psychotic disorder (a group of serious mental illnesses that all have signs of psychosis, and losing touch with reality). Review of the pharmacist's MRR notes showed: -On 09/24/24 MRR-Chart reviewed for Irregularities Recommendations made to Medical Doctor see report for details; -On 01/25/24 MRR-Chart reviewed for Irregularities Recommendation made to Psychiatric Medical Doctor see report for details; -On 03/23/25 MRR-Chart reviewed for Irregularities Recommendation made to Medical Doctor see report for details. Review of the resident's medical record showed the record did not contain documentation of the pharmacist's report or physician responses. 3. Review of Resident #10 Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively Intact with a diagnoses of high blood pressure, diabetes, seizure disorder, anxiety, depression, post traumatic stress disorder (PTSD), a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, and Schizophrenia. Review of the pharmacist's MRR note showed: -On 11/25/24 MRR-Chart reviewed for irregularities recommendation made to Medical Director see report for details and nursing see report for details; -On 03/23/25 MRR-Chart reviewed for irregularities recommendation made to Medical Doctor see report for details. Review of the resident's medical record showed the record did not contain documentation of the pharmacist's report or physician response. 4. Review of Resident #18's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively Intact with diagnoses of high blood pressure, diabetes, acid reflux, high cholesterol, stroke, thyroid disorder, dementia, hemiplegia (muscle weakness or partial paralysis on one side of the body), seizure disorder, depression, and Bipolar disease (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the pharmacist's MRR note,dated 04/03/25, showed chart reviewed for Irregularities Recommendation made to Medical Doctor see report for details. Review of the resident's medical record showed the record did not contain documentation of the pharmacist's report or physician response. 5. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of Paraplegia, anxiety, depression, bipolar disease; -Received antipsychotic, antidepressant, and antianxiety medications. Review of the pharmacist's MRR note, dated 03/24/25, showed chart review for irregularities, recommendations made for physician review, see report for details. Review of the resident's medical record showed the record did not contain documentation of the pharmacist report or physician response. 6. During an interview on 05/07/25 at 8:30 A.M., the Director of Nursing (DON) said he/she started at the facility in January, and he/she does not have any documentation of pharmacy recommendations prior to that. The DON said he/she does not know where the recommendations would be if not scanned in the system. He/She said he/she is responsible for ensuring the recommendations are addressed by the physician. He/She said if the recommendations are not in his/her book they may be scanned into the computer, if they are not there he/she does not know where the recommendations are. During an interview on 05/08/25 at 2:18 P.M., the administrator said the pharmacy should review medications monthly and on admission, and if there are recommendations they complete a progress note and send the recommendation letters. The letters get emailed to the DON, and then the facility has three days to get with the physician. The administrator said he/she found out they could not find them. He/she said the DON sent the recommendations to the doctor to sign either agreeing or disagreeing and the doctor is horrible about signing and sending back, so staff have to follow up otherwise they just do not do it. The Administrator said he/she has only been the administrator at the facility for four days.

Based on interview and record review, facility staff failed to ensure nurse aides (NA) received the required 12 hours of training annually. The facility census was 65. 1. Review of the facility's policies showed staff did not provide a policy for staff training. Review of the Facility Assessment, dated 04/18/25, showed staff were to have the following trainings annually: Preventing, Recognizing, and Reporting Abuse; Resident Rights; Health Insurance Portability and Accountability Act (HIPAA); Culture change- person centered care; Infection control; Dementia management; Disaster planning and procedures; and Caring for residents with Alzheimer's, dementia, mental illness, and specialized care. Review of the facility's Census and Condition of Residents, dated 05/06/25, showed staff documented twelve residents resided in the facility with diagnoses of dementia and/or Alzheimer's disease. Review of the facility's Training log, dated June 2024, showed the log did not contain documentation that NAs had been provided or completed further education. During an interview on 05/08/25 at 11:36 A.M., the Director of Nursing (DON) said he/she just started in this position in January, and is not sure what has or has not been completed prior to him/her taking over. The DON said he/she does not have records of the education completed previously. He/She said staff attend in-services every other Friday, but the topics do not cover the 12-hour required education. The DON said the topics were not covered because he/she did not know the required education until this week. During an interview on 05/08/25 at 12:05 P.M., the Regional Nurse said the facility uses online training for their 12 hours of yearly education. He/She said he/she checked online and the required education has not been completed. He/She said the DON is responsible for ensuring the required education is done. He/She said he/she is not sure why it is not completed. During an interview on 05/08/25 at 1:07 P.M., the infection control/wound nurse said to his/her knowledge the facility had not provided education over the required trainings. He/She said every pay period there are in-services provided over various subjects/updates that staff are required to come attend. During an interview on 05/08/25 at 1:35 P.M., Certified Nurse Aide (CNA) H said he/she does not know of any required online trainings. The CNA said staff attend in-services every pay period over various updates or reminders. During an interview on 05/08/25 at 2:05 P.M., the Administrator said he/she knows staff should be completing 12 hours of yearly education and it should be complete online. He/She said he/she is new this week, so he/she is unsure of why the education is not completed. He/She said it is the responsibility of the DON to ensure the required education is completed yearly.

Based on observation, interview, and record review, facility staff failed to accommodate resident needs and preferences, when staff failed to supply the correct size briefs for one resident (Resident #3) of four sampled, and failed to maintain a sit-to-stand lift (mechanical lift used for residents who can bear their own weight) in good repair for one resident (Resident #5) of four sampled residents. The facility census was 65. 1. Review of the facility's policy titled Resident Rights - Missouri, revised 07/05/23, showed residents have the right to reside and receive services with reasonable accommodation of individual needs and preferences, and the right to participate in his/her care. 2. Review of Resident #3's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/05/25, showed staff assessed the resident as cognitively intact, diagnoses of an irregular heartbeat, heart failure, insomnia, depression, anxiety and diabetes, and incontinent of bowel and bladder. Review of the resident's care plan, revised 10/17/24, showed staff documented the resident required assistance with all Activities of Daily Living (ADL's). Review of the facility's supply orders showed: -04/10/25 order placed; 04/10/25 order approved. Review showed the order did not contain 3XL briefs; -04/16/25 order placed; 04/17/25 order approved. Review showed the order contained three boxes of size 3XL briefs; -04/22/25 order placed; 04/22/25 order approved: Review showed the order did not contain size 3XL briefs; -05/02/25 order placed; 05/07/25 order approved: Review showed the order contained two boxes of size 3XL briefs. During an interview on 05/05/25 at 11:35 A.M., the resident said he/she requires an 3XL brief and the facility rarely has any available. He/She said staff put an 2XL or smaller size brief on him/her most days and this causes his/her groin to become irritated, red, and painful. The resident said sometimes the staff have to use even small briefs on him/her and the briefs will not fasten, so staff have to tuck the briefs between his/her legs which causes leakage. The resident said this makes him/her uncomfortable and he/she feels embarrassed by this. Observation on 05/06/25 at 12:00 P.M., showed the supply closet did not contain any 3XL briefs. The supply closet did not contain any briefs larger than a size large. During an interview on 05/06/25 at 12:00 P.M., Nurse Aide (NA) N said the facility runs out of supplies frequently. NA N said the Social Service Designee (SSD) is responsible to order the nursing supplies. NA N said the facility does not usually have 3XL briefs in house supply. During an interview on 05/07/25 at 9:00 A.M., the SSD said he/she is responsible for ordering the nursing supplies needed in the facility and has been responsible since March 2025. The SSD said he/she is aware the facility has very little briefs. The SSD said he/she is aware the facility currently did not have any briefs larger than a size large available for the residents needs. The SSD said corporate allows him/her to order supplies the first and third week of the month. The SSD said the process he/she follows for ordering supplies is to submit his/her request for supply needs to the corporate office, the corporate office must then approve his/her order request, and once approved supplies are delivered on Thursday. The SSD said sometimes it takes one to two weeks to get the supply order approved by corporate. The SSD said the first order he/she made did not have enough supplies and he/she said that was his/her fault due to being his/her first order and not knowing how much the facility required. The SSD said the second order he/she submitted to corporate was much larger and corporate denied the approval of that order. The SSD said if a resident does not have the correct size brief it could cause the resident to develop skin breakdown, be uncomfortable, have leakage, and could be a dignity issue. During an interview on 05/07/25 at 9:25 A.M., the Director of Nursing (DON) said the SSD is responsible for ordering the nursing supplies. The DON said the facility has trouble getting supplies and due to an increase in census the facility has had trouble getting enough supplies. The DON said he/she is aware the facility has very little briefs. The DON said he/she is aware the facility currently has no briefs larger than a size large available for the residents needs. During an interview on 05/07/25 at 1:40 P.M., Certified Nurse Assistant (CNA) F said the facility frequently does not have supplies the residents and staff need to provide care. The CNA said the facility rarely has 3XL briefs in supply. The CNA said the facility census has increased but the number of supplies has not therefore the facility is not able to accommodate the resident needs at times. Observation on 05/07/25 at 4:05 P.M., showed the supply closet did not contain any 3XL briefs. During an interview on 05/07/25 at 4:05 P.M., Licensed Practical Nurse (LPN) P said the facility has been very low on supplies for quite a while. LPN P said the facility census has increased but the supplies have not. During an interview on 05/07/25 at 4:10 P.M., Registered Nurse (RN) O said said the nursing supplies have be very limited for several months. RN O said the facility has had an increase in census but have not had the supplies to accommodate the residents and the increase. RN O said the past two to three months is the worst he/she has seen it since he/she began working at the facility Observation on 05/08/25 at 9:20 A.M., showed the supply closet did not contain any 2XL briefs. During an interview on 05/08/25 at 2:05 P.M., the administrator said if a resident wears a brief that is too small it could be uncomfortable, and it could potentially cause skin breakdown. He/She said if staff run out of supplies, he/she expects them to report it and the facility has a credit card to use for emergency purchases. 3. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with diagnoses of heart failure, high blood pressure, anxiety, depression, and asthma. Review of the resident's care plan, revised 01/07/24, showed staff documented the resident required the use of a sit-to-stand lift for transfers including toileting. Review of the resident's medical record showed staff documented the sit-to-stand lift did not work on 03/13/25, 04/24/25, and 05/04/25. Observation on 05/06/25 at 12:00 P.M., showed the sit-to-stand lift sat in the shower room with one leg loose to touch which caused the lift to be unstable. Observation showed when attempted to make the lift go up and down the lift stuttered and stopped midway. During an interview on 05/06/25 at 8:30 A.M., the resident said he/she tries to be as independent as possible and likes to stay active in the facility. The resident said he/she uses the sit-to-stand lift to transfer and the lift allows him/her to be toileted in his/her bathroom. The resident said the lift has frequently been broken over the past couple of months which has affected his/her quality of life. The resident said when the sit-to-stand lift is not working he/she can't use a bed pan instead of actually being taken to the bathroom. He/She the bed pan spills and makes a mess. The resident said this is embarrassing and degrading for him/her. The resident said he/she has reported the lift being broken multiple times to four different administrators. The resident said he/she has not gotten any follow up regarding his/her reports of the lift being broke or if it can or will be fixed. The resident said the facility only has one sit-to-stand lift and that lift has one leg that is extremely loose and has been for a long time. He/She said over the past several weeks the sit-to-stand lift has started having other mechanical issues and one time stopped working while he/she was in the lift during a transfer. The resident said due to the sit-to-stand lift being broke he/she has had to resort to using the hoyer lift for transfers which causes him/her pain due to rubbing on his/her leg from a prior fracture and does not allow her to use an actual toilet. During an interview on 05/06/25 at 12:00 P.M., NA N said the facility only has one sit-to-stand lift and it is broken. NA N said the lift has had a loose leg for months, and the maintenance director looked in to fixing it but the manufacturer didn't make parts for the lift anymore. The NA said over the past several weeks the lift has begun to stutter midair and is not usable. During an interview on 05/06/25 at 2:02 P.M., the DON said he/she knows the sit-to-stand lift is broken, and has been for a while. The DON did not know if the facility planned to order a new lift. During an interview on 05/07/25 at 12:00 P.M., the DON said the facility ordered a new sit-to-stand lift today. During an interview on 05/07/25 at 1:40 P.M., CNA F said the facility has one sit-to-stand lift and the leg has been loose on it for two years, and he/she said the management team has been aware of it being broken. CNA F said since staff have to use the Hoyer lift to transfer the resident he/she now has to use a bed pan instead of actually going to the bathroom, and the resident does not like it. During an interview on 05/07/25 at 4:05 P.M., LPN P said he/she knew the sit-to-stand lift was not working properly. LPN P said he/she worked the day it broke last and said he/she made administration aware of that. LPN P said the facility had two residents who used the sit-to-stand lift at the time it broke. LPN P said not having the sit-to-stand lift effected this resident most as the resident uses the toilet normally and is not able to when the sit-to-stand lift is not working, and the resident does not like having to use the bed pan instead. During an interview on 05/08/25 at 8:40 A.M., the maintenance director said he/she knew the sit-to-stand up lift was broken and has had a loose leg on it for quite a while. During an interview on 05/08/25 at 2:05 P.M., the Administrator said he/she started this week and had been informed during the survey of the sit-to-stand lift being broken. The Administrator said he/she expects the facility to have equipment in working order to provide care for the residents. MO00253198

Based on observation, interview, and record review, licensed staff failed to ensure medications were monitored and stored in a safe and effective manner. Licensed staff failed to remove and discard discontinued medication and improperly labeled medication from one sampled medication cart. The facility census was 65. 1. Review of the facility's policy titled Medication Storage Policy, dated 05/18/25, showed all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed. Review of the facility's policy titled Administration of Insulin Policy, dated 05/14/25, showed insulin pens once opened should be disposed of after 28 days or according to manufacturer's recommendation. When administering insulin check the date on the pen and discard if expired. 2. Observation on 05/05/25 at 9:02 A.M., showed the nurse's medication cart contained: -Two Vials of Vitamin B Intramuscularly (IM) injection 1000 Micrograms (MCG)/milliliter (ml) with an expiration date of 12/11/24; -Lidocaine Hydrochloride 1% vial, 20 ml injection a 10 day supply, filled 12/26/24, opened and did not have an open date; -One vial of Lantus 100 Units/ml opened and did not have an open date; -One Vial of Fiasp (Insulin Aspart) 100 unit/ml with an open date of 03/04/25. -One vial of Lantus 100 units/ml opened and did not have an open date; -One vial of Fiasp 100 unit/ml vial opened and with an open date of 03/09/25. During an interview on 05/05/25 at 9:05 A.M. RN E said once a vial of insulin is opened, it should be used within 30 days. The RN said the insulin vials in the medication cart that were opened over 30 days ago should be destroyed. The RN said the insulin with no open dates, there is no way to tell if they are still within the 30 day period. The RN said he/she does not know why some of the insulin do not have open dates, or initials, because they should. The RN said on one probably noticed the expired medications. The RN said whoever has the keys for the nurse medication cart, is responsible to ensure the medications in the cart are not expired. The RN said staff should look at the open date before they administer insulin. The RN said he/she does not know how the nurses are looking at the open dates, when there isn't one on several vials of insulin. During an interview on 05/06/25 at 1:16 P.M., Licensed Practical Nurse (LPN) D said staff should clean the medication cart monthly, or when a medication is discontinued. The LPN said staff should check dates on the insulin vials during administration. The LPN said staff should date and initial insulin when they open it, since it has a 28-day shelf life. During an interview on 05/06/25 at 1:33 P.M., the Director of Nursing (DON) said he/she expects staff to check medication carts for expired meds weekly, he/she doesn't have an assigned day or shift for this to be completed. The DON said he/she expects staff to monitor dates when they administer medications. The DON said staff should date an insulin vial upon opening it. The DON said he/she thinks insulin can be used for 28 to 30 days once it has been opened. The DON said he/she does not know why staff are not taking expired medications out of the medication cart. The DON said ultimately it would be him/her, that is responsible to make sure staff are taking the expired medications out of the medication cart. The DON said he/she doesn't know why there are outdated open vials of insulin on the cart. The DON said he/she doesn't know why staff are not dating or initialing insulin when opened, because they should be. During an interview on 05/06/25 at 1:53 P.M., the administrator said staff should check the medication carts at least once a week for expired medications. The administrator said staff should date and initial insulin vials when they are opened. The administrator said insulin can be used for 30 days after it's opened. The administrator said he/she is not sure why there is expired medications on the cart. The administrator said he/she doesn't know why staff are not dating and initialing the insulin vials upon opening like they should be. The administrator said the DON is responsible to ensure the nurses are dating insulin and removing expired medications from the medication cart.

Based on interviews and record review, facility staff failed to report an allegation of sexual abuse between two residents (Resident #1 and Resident #2) to the Department of Health and Senior Services (DHSS) within the two hour timeframe. The facility census was 57. 1. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed an alleged violation of abuse, neglect, exploitation, or mistreatment, including injuries of an unknown origin and misappropriation of resident property will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury and twenty four hours is the alleged violation does not involve abuse and has not resulted in serious bodily injury. Review of the DHSS complaint/facility self-report database showed facility staff did not report the resident's allegation of sexual abuse to DHSS after the resident reported his/her allegation to facility staff. During an interview on 3/18/25 at 12:00 P.M., the Director of Nursing (DON) said the incident was reported to the state agency when the allegation was Resident #2 went in Resident #1's room while he/she slept and rubbed lotion on his/her legs and abdomen. He/She said he/she did not report to DHSS when Resident #1 changed his/her story to the peri area because he/she did not believe the allegations. During an interview on 3/18/25 at 1:10 P.M., the administrator in training said he/she was not here when the allegations were made but was told it was reported. He/She said Resident #1 changed his/her story after the original allegation, to sexual assault, the facility policy was not followed to report to DHSS and he/she does not know why. During an interview on 3/18/25 at 1:41 P.M., the regional nurse said the incident should have been reported when Resident #1 changed the allegations from rubbing soap on his/her legs to sexual assault and he/she does not know why it was not done. During an interview on 3/18/25 at 1:47 P.M., the interim administrator said the original allegations of Resident #2 rubbing lotion on Resident #1's legs and abdomen were reported because state agency was on site but once the allegations changed to sexual assault it should have been reported to DHSS within two hours. He/She said he/she expects the designee to follow the policy at all times and does not know why it was not done. MO00251208

Based on interview and record review, facility staff failed to follow their Abuse and Neglect Policy when staff failed to investigate an allegation of resident to resident sexual abuse. The facility census was 57. 1. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed an alleged violation of abuse, neglect, exploitation, or mistreatment, including injuries of an unknown origin and misappropriation of resident property will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury and twenty four hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. It directs the Administrator or designee will at a minimum: -Investigate all allegations and types of incidents; -Call 911; -Notify the attending physician, resident's family/legal representative, and medical director; -Monitor and document the resident's condition, including response to medical treatment or nursing interventions; -Document actions taken in the medical record; -Revise the resident's care plan; -Personal statements from staff and residents; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; -Review root cause of the incident; -Each interview and the investigation will be handled privately as possible. 2. Review of Resident #1's Annual Minimum Data Set, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of Depression. Review of the residents medical record did not contain documentaion of an allegation of sexual assault or action taken by the facility. During an interview on 3/18/25 at 12:23 P.M., the resident said almost two weeks ago in the middle of the night Resident #2 came in to his/her room while he/she was sleeping and started to rub soap all over him/her. He/She said he/she thought the aides were coming to clean him/her up in the middle of the night until he/she felt rubbing in between his/her thighs and fingers inside. He/She said he/she has never felt so violated in his/her whole life. He/She said he/she felt like staff was not taking it seriously because they never did anything about it, he/she said he/she talked to staff multiple times after the allegation and they made it seem like it was ok because Resident #2 has dementia. He/She said they never called his/her family or his/her doctor. He/She said he/she called the cops because the facility never did anything and he/she feels unsafe at the facility. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately cognitively impaired; -Alzheimer's (progressive disease that destroys memory and other important mental functions), Traumatic brain injury, Anxiety, and Depression. Review of the residents medical record did not contain documentaion of an allegation of sexual assault or action taken by the staff. 4. During an interview on 3/18/25 at 12:00 P.M., the Director of Nursing (DON) said he/she said he/she did not investigate when the resident changed his/her story to the peri area because he/she did not believe the allegations. During an interview on 3/18/25 at 1:10 P.M., the administrator in training said he/she was not here when the allegations were made but was told it was investigated. He/She said when the resident changed his/her story after the original allegation of just lotion being applied to sexual assault, the facility policy was not followed in regard to investigating and he/she does not know why. During an interview on 3/18/25 at 1:41 P.M., the regional nurse said the incident should have been investigated when he/she changed the allegations from rubbing soap on his/her legs to sexual assault and he/she does not know why it was not done. During an interview on 3/18/25 at 1:47 P.M., the interim administrator said once the allegations changed to sexual assault there was nothing done. He/She said the DON was in charge of the investigations and documenting in the medical records and he/she does not know why that was not done. He/She said he/she expects the designee to follow the policy at all times and does not know why it was not done. MO00251208

Based on interview and record review, facility staff failed to prevent the misappropriation of funds for one resident's (Resident #1) when the former administrator requested and accepted $800 from the resident's digital wallet service application account into the administrators personal digital wallet service application account. The facility census was 47. The administrator was notified on 10/22/24 of past Non-Compliance which occurred on 4/29/24. On 10/11/24 Resident #1 reported he/she sent the former Administrator $800 to his/her personal digital wallet service application account to pay a bill owed to the facility and the money was not applied to the resident's bill. Upon discovery on 10/11/24 staff reported the allegation of misappropriation, started an investigation, and inserviced staff on misappropriation of resident funds. Staff corrected the deficient practice on 10/18/24. 1. Review of the facility's Abuse and Neglect Policy, revised 11/28/16, showed misuse of funds/property defined as the misappropriation or conversion of a consumer's funds or property for another person's benefit. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/20/24, showed staff assessed the resident as: -Cognitively intact; -Did not exhibited behaviors of inattention; -No disorganized thinking or altered levels of consciousness. Review of the facility's investigation, dated 11/6/24, showed Resident #1 said he/she sent $800 from his/her digital wallet service application account to the digital wallet service application account of the former administrator and showed evidence of this transaction on his/her cell phone. The resident said he/she never received a receipt or statement showing this money was applied to his/her account. The resident said this transaction occurred when the previous owners had the facility. The facility reported the allegation to the Department of Health and Senior Services (DHSS) and inserviced staff on misappropriation of resident money. During an interview on 10/22/24 at 11:07 A.M., the resident said he/she paid the former administrator $800 through his/her digital wallet service application account. The resident said he/she did not have any physical documentation of the transfer but showed the surveyor the transaction documented on his/her cell phone. The resident said someone told him he/she owed the facility money. The resident said he/she reported he/she did not receive receipts from the former administrator for any payments he/she had paid to him/her from his/her digital wallet service application account. Observation on 10/22/24 at 11: 07 A.M. of the resident's digital wallet service application account on his/her cell phone showed a transaction on 4/29/24 at 8:38 A.M., where $800 transferred from the resident's digital wallet service application account to the former administrator's personal digital wallet service application account. During a telephone interview on 10/31/24 at 10:40 A.M., the former administrator said $800 from the resident's digital wallet service application account was applied to his/her personal digital wallet service application account on 4/30/24 at 10:18 A.M. The former administrator said he/she withdrew the $800 from a bank but didn't remember which US Bank. Initially, the former Administrator said he did not remember how the cash was applied or who it was given to. Later in the interview the former administrator said he/she gave it to one of three people in the business office at the facility, but he/she was not sure which one and said one person was the current Activity Director. The former administrator said he/she worked for the facility from March 1, 2024 through the end of May 2024 and the previous corporate staff were responsible for the billing at that time. He/She said the corporate office should have records to show the $800 was applied. Review of an e-mail, dated 10/25/24 at 12:21 P.M., showd the facility's former owner's Director of Revenue showed the facility did not receive money from the resident and the resident was in a Medicaid pending status in their system. Review of the resident's account receivable statement, dated March 31, 2024, showed the resident owed $765.00 and it did not contain a credit for $800 paid by the resident. Review of the resident's account receivable statement, dated April 30, 2024 showed it contained the billing for both April and May 2024 the resident owed $765.00 for April 2024 and an additional $765.00 for May 2024 and did not contain a credit for $800 paid by the resident. In the previous information it should he was paid up. During a telephone interview on 10/31/24 at 11:22 A.M., the Activity Director said he/she helped in the business office when the former business office manager left in March 2024. He/She said a different company owned the facility at the time. He/She said the previous owner was doing the billing and any money received was sent to the other company. He/She said the resident had a digital wallet service application account and paid through digital wallet service application account to the former Administrator. He/She said the former Administrator said he/she would write a receipt to the resident for funds received from the resident's digital wallet service application account but he/she never saw the receipts or any money. He/She did not recall the former administrator bringing in any cash to apply against the resident's bills. He/She said any payment of check or cash received would have been received by the former Administrator or another former employee, as it was not his/her role to receive payments. During a telephone interview on 11/1/24 at 2:24 P.M., the former administrator said he/she did not find any receipt showing the money was applied to the resident's bill. During an interview on 11/6/24 at 11:00 A.M., the Activity Director said he/she did not recall any cash brought in to pay the resident's bill. During an interview on 11/6/24 at 10:03 A.M., the administrator said digital wallet service application account is not an appropriate means to accept resident payments and funds should never be received into personal accounts. She said if payment is received from a resident, she would expect there to be accounting records and receipts to show the money was received and it should be reflected on the resident's statement. MO00243430

Based on observation, interview and record review, facility staff failed to provide a clean, comfortable and homelike environment for residents, when staff failed to maintain floors, windows, and equipment in resident rooms clean and in good repair. The facility census was 45. 1. The facility did not provide a policy for staff to report environmental concerns. 2. Observation on 9/17/24 at 10:30 A.M, showed the 100 hall floors contained multiple areas of debris. Observation on 09/25/24 at 9:09 A.M., showed the 100 hall floors contained dead bugs, a dried sticky substance, and debris. 3. Observation on 9/17/24 at 10:32 A.M, showed the 200 hall floors contained multiple areas of debris. Observation on 09/25/24 at 9:12 A.M., showed the 200 hall floors contained dead bugs, a dried sticky substance, and debris. 4. Observation on 9/17/24 at 10:34 A.M, showed the 300 hall floors contained debris. Observation on 09/25/24 at 9:20 A.M., showed the 300 hall floors contained dead bugs, a dried sticky substance, and debris. 5. Observation on 9/17/24 at 10:37 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, contained debris, and multiple areas with black and brown stains in front of the sink. The toilet in the bathroom contained yellow stained areas on the toilet seat and a black substance on the floor around the base of the toilet. During an interview on 9/17/24 at 10:37 A.M., Resident #1 said he/she does not remember the last time his/her room was cleaned and it makes him/her feel dirty. Observation on 09/25/24 at 9:25 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, multiple areas with black and brown stains contained debris. During an interview on 09/25/24 at 9:25 A.M., Resident #10 said he/she does not remember when his/her floor was mopped. 6. Observation on 9/17/24 at 10:42 A.M., showed occupied resident room [ROOM NUMBER]'s floors sticky with brown stains. Observations showed the privacy curtain with a brown stain. The bathroom in room [ROOM NUMBER]'s toilet handle was unable to flush with fecal matter in the toilet bowl, the lid and seat with multiple brown stains and a strong odor. During an interview on 9/17/24 at 10:42 A.M., Resident #2 stated the room had not been cleaned in some time and the toilet had been broken for days. He/She told staff and nothing had been done. 7. Observation on 9/17/24 at 11:16 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, with multiple stains and debris. The bathroom floor sticky contained yellow stains and a black substance at the base of the toilet. Observation on 09/25/24 at 9:13 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, multiple areas with black and brown stains and contained debris. 8. Observation on 9/17/24 at 11:20 A.M., showed occupied resident room [ROOM NUMBER]'s floor and bathroom floor sticky with debris 9. Observation on 9/17/24 at 11:22 A.M., showed occupied resident room [ROOM NUMBER]'s floor and bathroom floor sticky, and contained debris During an interview on 9/17/24 at 11:22 A.M., Resident #3 stated he/she does not remember the last time his/her room was cleaned but it was sometime last week. He/She has had to take his/her trash out because it had gotten full. He/She says there is only one housekeeper and some days no housekeeper. He/She said it makes him/her feel dirty and unkempt. 10. Observation on 9/17/24 at 11:32 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky and contained debris. During an interview on 9/17/24 at 11:32 A.M., Resident #4 stated his/her room was cleaned sometime last week. 11. Observation on 9/17/24 at 11:39 A.M., showed occupied resident room [ROOM NUMBER]'s floor and bathroom floor sticky with debris. During an interview on 9/17/24 at 11:39 A.M., Resident #5 said his/her room was cleaned last Wednesday. He/She said his/her room used to be cleaned daily but they only have one housekeeper and some days no housekeeper. He/She said it makes him/her feel like he/she is living in a pig pen. 12. Observation on 9/17/24 at 12:00 P.M., showed occupied resident room [ROOM NUMBER] floor sticky with debris. The bathroom toilet contained stains on the toilet seat and rim. Observation on 09/25/24 at 9:09 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, multiple areas with black and brown stains and contained debris. During an interview on 9/17/24 at 12:00 P.M., Resident #6 said he/she does not know the last time his/her room was cleaned. He/She had to take out his/her trash because it was overflowing. He/She said he/she is military and likes to have things neat and in order and does not like the fact it's been days since his/her room has been cleaned. He/She will take a rag to try and mop the floor himself/herself because it's not being done. 13. Observation on 09/25/24 at 9:00 A.M., showed the front door to the facility with dead bugs and cobwebs. 14. Observation on 09/25/24 at 9:10 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, contained debris, and multiple areas with black and brown stains. 15. Observation on 09/25/24 at 9:11 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, and contained debris. 17. Observation on 09/25/24 at 9:14 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, multiple areas with black and brown stains and contained debris. 18. Observation on 09/25/24 at 9:15 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, multiple areas with black and brown stains and contained debris. 19. Observation on 09/25/24 at 9:22 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, multiple areas with black and brown stains and contained debris. Observation showed the bed sheets with multiple brown stains on the bed. 20. Observation on 09/25/24 at 9:33 A.M., showed the dining room floor sticky, contained food, and debris. 21. Observation on 09/25/24 at 10:38 A.M., showed occupied resident room [ROOM NUMBER]'s floor sticky, contained debris, and multiple areas with black and brown stains. During an interview on 09/25/24 at 10:38 A.M., Resident #7 said he/she had not had his/her room deep cleaned for a few months. He/She said staff do not clean or mop his/her room daily but he/she would like staff to do this. 23. During an interview on 9/17/24 at 10:30 A.M., Housekeeper A said at times there is not a housekeeper and today he/she was the only housekeeper for the entire building. He/She they are not able to keep up with the cleaning checklist and rooms have not been deep cleaned since July. He/She said it's rare to have two housekeepers and knows they have been advertising to hire a housekeeping supervisor. He/She said the resident's rooms should be cleaned daily and the privacy curtains are cleaned as needed. Staff are to put in work orders for items in disrepair. During an interview on 9/17/24 at 12:39 P.M., the administrator said staff are supposed to fill out work orders for items needing repaired or sometimes he tells the maintenance director directly. He/She said he/she is unsure of how often resident ' s rooms are cleaned but know they are on a rotation. He/She said the maintenance director is currently over housekeeping and laundry as well and they are advertising for a housekeeping supervisor. If a housekeeper was to call in he/she does not know what would be done. During an interview on 9/17/24 at 12:46 P.M., Certified Nurse Aide (CNA) B said he/she knows the housekeepers try to clean as many rooms as possible each day along with the common areas and nurses station. He/She said the aides help by taking the trash out when they can. He/She said sometimes there is not a housekeeper because they are pulled to work another position on the floor. The rooms have not been deep cleaned in months. During an interview on 9/17/24 at 3:12 P.M., the maintenance director said he/she was not aware of any toilets in disrepair. During an interview on 09/25/24 at 9:20 A.M., the Housekeeping Supervisor said he/she started on Monday of this week. He/She said he/she is the only housekeeper on duty and is in laundry as well. The Housekeeping Supervisor said the facility is short staffed for housekeeping. The Housekeeping Supervisor said he/she plans to strip all the floors once he/she hires more staff. He/She said all the floors desperately need it. The Housekeeping Supervisor said the residents deserve to live in a much cleaner environment, and the condition of the facility is not to his/her standards. During an interview on 09/25/24 at 1048 A.M., the administrator said he/she knows the facility needs to be cleaned and he/she is trying to hire staff to get this done. The administrator said the corporate team is supposed to be coming to help clean the facility but he/she did not have a date for their arrival. MO00241755 MO00242461 MO00242447

Based on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 38. 1. Review of facility provided policies showed staff did not provide a policy related to the qualifications of kitchen staff. Review of the Dietary Manager's (DM) personnel record showed the DM hire date as a part time cook in February 2023. Review showed the record did not contain documentation of when the DM assumed the DM role. The record did not contain documentation of previous food service experience or food service management certification. During an interview on 04/02/24 at 9:22 AM , the DM said he/she started as a part time cook in February of 2023 and became the DM in March of 2024. The DM said he/she worked as a DM for a couple of years in another facility. The DM said he/she was not a Certified Dietary Manager and never completed any type of food service training. The DM said he/she did not receive assistance or consultation from any other facility staff. During an interview on 04/03/24 at 9:40 A.M. the Business Office Manager (BOM) said the administrator was responsible for ensuring staff had qualifications for positions. The BOM said he/she was not familiar with the DM completing any food service related training. During an interview on 04/03/24 at 10:15 A.M., the administrator said the DM should be certified. The administrator said he/she told the DM to look into classes toward certification. The administrator said he/she did not know if the DM had identified any certification courses. The administrator said he/she was not aware of any other qualified staff in the facility. The administrator said he/she just started at the facility on 03/01/24 so he/she hasn't had time to fix everything.

Based on observation, interview and record review, facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus. Facility staff failed to ensure meal substitutions were reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy. The census was 38. 1. Review of facility provided policies showed they did not contain a policy related to food service. 2. Observation on 04/02/24 at 9:00 A.M., showed an always available menu posted in the resident dining room. The menu showed: -Hamburger or cheeseburger; -Grilled cheese special (sandwich with a side of cottage cheese); -Peanut butter and jelly special (sandwich with a side of cottage cheese); -Deli meat and cheese sandwich; -Side dishes included vegetable of the day, cottage cheese and salad of the day. Review of the facility's Week At a Glance menu showed on 04/02/24, staff were to serve spaghetti with meat sauce, parmesan baked zucchini, [NAME] fruit crisp, breadstick and a beverage for the lunch meal. Observation on 04/02/24 at 12:41 P.M., showed two residents on pureed diets received pureed spaghetti and green beans. Observation showed the residents did not receive fruit or bread. Observation showed residents on regular diets received spaghetti, green beans and baked apples. Observation showed the residents on regular diets did not receive bread. During an interview on 04/02/24 at 12:44 P.M., Cook F said he/she was in a hurry and forgot about pureed fruit. Cook F said staff were not serving bread sticks because they did not have any. Cook F said there was not enough bread to serve all residents but if a resident asked, they could have a slice of bread. During an interview on 04/02/24 at 12:45 P.M., the DM said he/she was responsible for ordering foods. The DM said the facility vendor had been out of some items, so staff were making substitutions. The DM said he/she never spoke with the dietician about meal substitutions. Review of the facility's Week At a Glance Menu, showed on 04/02/24 staff were to serve deluxe potato ham bake, mixed vegetables, frosted cake, dinner roll and a beverage for the supper meal. Review of the menu substitution form showed on 04/02/24 staff served a hot dog on a bun, cheesy fries and creamy cole slaw for the supper meal. Review showed the DM signed off on the meal in the column designated for the Registered Dietician review signature. Review of the facility's Week At a Glance Menu, showed on 04/03/24 staff were to serve two ounces of protein, one grain, 2 vegetables, one fruit and a beverage as a Resident's Choice supper meal. Review of the menu substitution form showed the form did not contain documentation of the meal provided on 04/03/24 and did not contain documentation the meal was reviewed by a registered dietician. During an interview on 04/04/24 at 9:55 A.M., the DM said the resident's choice meal consisted of a can and a frozen bag of chicken and dumplings. The DM said he/she could not remember what vegetables and sides were served. The DM said the dietician did not review the meal. Review of the facility's Week At a Glance Menu, showed on 04/04/24, staff were to serve roast pork, cornbread stuffing, buttered corn, glazed applesauce cake, dinner roll and a beverage for the lunch meal. Observation on 04/04/24 during the lunch meal, showed staff served the residents a cheeseburger on a bun, french fries, baked beans, cookies and a beverage. During an interview on 04/04/24 at 12:25 P.M., Cook F said the menu was switched yesterday. He/She said the residents were to receive the fried chicken meal today, but the food delivery did not come. Cook F said the residents were being served cheeseburgers and fries instead. During an interview on 04/04/24 at 9:35 A.M., RN B said some residents expressed concerns about food portions and the kitchen running out of food or milk. RN B said he/she did not pass these concerns to anyone. During an interview on 04/02/24 at 2:34 P.M., The DM said he/she was responsible for meal substitutions, and he/she kept a substitutions log. The DM said he/she had not been able to keep up with the log. The DM said he/she did not know the last time the dietician was in the building or if the dietician reviewed meal substitutions. The DM said staff had not been able to provide planned meals quite a few times since he/she started as the DM in March of 2024. The DM said staff used food from the emergency food supply a couple of weeks ago because there was not enough food. The DM said there was no lettuce in the kitchen but they were expecting a delivery the next day. The DM said residents had never missed a meal because of food shortages. The DM said he/she was still trying to figure things out since there were no historical records or documents in the dietary office when he/she started. During an interview on 04/03/24 at 10:15 A.M., the administrator said he/she would expect kitchen staff to follow prepared menus. The administrator said he/she would expect the dietician to review any meals that were not on approved menus. The administrator said he/she had not seen a dietician in the facility since he started on 03/01/24. The administrator said the dietician should come in monthly to review diets and perform kitchen inspections and staff education. The administrator said he/she reviewed the new resident's admission paperwork and he/she did not see any documentation stating the resident was on a gluten free diet. During an interview on 04/03/24 at 11:40 A.M., the administrator said he/she was informed by staff a short time ago, food had not been delivered due to the vendor not being paid. The administrator said he/she resolved the issue and the food delivery should arrive on 04/04/24.

Based on interview and record review, the facility staff failed to ensure one resident (Resident #1) remained free from abuse when Nurse Assistant (NA) A brought [MEDICATION(S)] (a synthetic opioid) into the facility and sold the drug to the resident for his/her use. Staff assessed the resident was lethargic and called Emergency Medical Services (EMS). EMS staff utilized [MEDICATION(S)] (used for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 47. The administrator was notified on [DATE] at 5:08 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. 1. Review of the facility's policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, undated, showed the facility is committed to protecting residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual. Review showed every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. Additional review showed: -Mistreatment, neglect, or abuse of residents is prohibited by the facility; -Class I neglect, failure of an employee to provide reasonable and necessary services to maintain the physical and mental health of any consumer when that failure presents imminent danger to the health, safety, or welfare of a consumer, or a substantial probability that death or physical injury would result. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as cognitively intact. Additional review showed the resident had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility investigation, dated [DATE], showed staff documented a staff member and residents on the behavioral health unit said NA A gave the resident [MEDICATION(S)] earlier in the evening the day they sent the resident to the hospital. Review showed the Director of Nursing (DON) and administrator were notified of the incident. Staff documented the resident reported he/she paid NA A $15 for the [MEDICATION(S)]. Review showed staff interviewed NA A and suspended the staff member pending the investigation. Review showed staff interviewed all residents and staff who were involved. Review showed they terminated NA A from the facility for abuse or neglect, soliciting and/or acceptance of a loan of money from a resident, and engaging in an indecent or illegal act on facility property. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 1:00 P.M., the resident said he/she did use [MEDICATION(S)] which he/she thought was heroin. NA A brought the drug into the facility to him/her. The resident paid $15 for what he/she thought was heroin, but later found out at the hospital it was actually [MEDICATION(S)]. He/she took the entire amount which was a half gram. He/She said within about a half an hour he/she began to feel dizzy and the next thing he/she remembered, staff placed him/her in bed, he/she passed out, and then woke up in the ambulance. During an interview on [DATE] at 12:30 P.M., the Administrator said he/she was notified on [DATE] the resident was shipped out to the hospital and there were rumors the resident received heroin from NA A. He/She instructed the DON who was still at the facility to start the investigation and suspend NA A until the investigation was completed. The Administrator said when he/she arrived to work the next morning, they conducted interviews and the resident reported he/she paid NA A $15 to bring him/her heroin. The Administrator had spoken to NA A who denied it, but he/she terminated the employee after the interview. During an interview on [DATE] at 1:17 P.M., Resident #2 said Resident #1 told him/her earlier in the day he/she had heroin that would be brought in and asked if he/she wanted to do some- because if he/she did then he/she would pay for it. Resident #2 declined and then at the 8:00 P.M. smoke break when he/she went to his/her room to inform Resident #1 it was smoke break time- the resident came out of his/her room stumbling and was out of it so he/she alerted staff. Resident #2 said Resident #1 was gray and looked bad so he/she knew it was an overdose so he/she yelled the resident got ahold of heroin and overdosed to the paramedics when they arrived. During an interview on [DATE] at 2:00 P.M., Resident #3 said NA A had offered to bring him/her heroin that day, but he/she doesn't do heroin, so declined. The employee had offered a couple of other times as well over the past month and he/she refused. The resident said he/she made a mistake when he/she told Resident #1 that NA A had offered it, because the resident got some, which caused Resident #1 to overdose. During an interview on [DATE] at 2:22 P.M., the Administrator said he/she was notified by the DON the resident was found unresponsive and had been sent to the hospital. He/She then called back and reported there were rumors that a staff member was seen in the resident's room with the door closed and money was exchanged. The administrator said he/she requested a drug screen on the resident and the resident tested positive for [MEDICATION(S)] at the hospital. The administrator said the employee was immediately suspended until completion of the investigation and was terminated on [DATE]. During an interview on [DATE] at 2:37 P.M., the DON said Licensed Practical Nurse (LPN) B notified him/her Resident #1 was acting weird and then hung up so he/she knew something was emergent. When LPN B called back, he/she said the resident had been sent to the hospital and had received [MEDICATION(S)]. The DON said he/she was instructed by the Administrator to start an investigation. During an interview on [DATE] at 2:47 P.M., paramedic E said they responded to the facility for a resident unresponsive and were under the impression he/she was actively receiving Cardiopulmonary Resuscitation (CPR) (emergency procedure consisting of chest compressions often combined with artificial ventilation). When they arrived they found him/her in bed with oxygen via nasal cannula, agonal breathing (when someone is not getting enough oxygen and is gasping for air), and snoring respirations. The resident did have a pulse. He/She said the facility staff reported they did not know what was wrong with the resident. The resident presented with pin point pupils as well. He/She said the police officer onsite said he/she had heard another resident say it was heroin and from his/her experience the resident symptoms were classic signs of overdose so they administered [MEDICATION(S)] and the resident began to respond and was loaded on the ambulance. During an interview on [DATE] at 3:09 P.M., Certified Nursing Assistant (CNA) C said he/she had worked the unit with NA A several times and had not witnessed any unusual behaviors before. That night however, NA A went in and out of several residents' rooms and would shut the door behind him/her. CNA C said when he/she went room-to-room to do a soda run for all the residents he/she opened Resident #1's door to ask if he/she needed something and saw Resident #1 at the sink area and NA A stood next to him. Resident #1 was counting money and NA A was watching him/her. He/She said, I thought it was odd, but went ahead and did the soda run. At smoke break time as he/she passed out cigarettes he/she saw Resident #2 in Resident #1's doorway and when Resident #1 went to step out he/she grabbed the rail and his/her eyes rolled back in his/her head, so they grabbed a chair to sit him/her down and alerted the nurse. During an interview on [DATE] at 2:06 P.M., LPN B said staff called him/her to the unit to assess a resident. When he/she arrived he/she saw Resident #1 at the door where they smoke and two other residents had ahold of the resident to help him/her stand up. At first the resident would answer questions, but then he/she began to stare through him/her, so they got a chair and sat the resident in it and he/she left the unit to call 911. While he/she went to call 911, the staff put the resident in his/her bed. LPN B said the first time he/she heard anything about heroin was when the police officer was in the room and said he/she was told the resident had obtained heroin and was overdosing. During an interview on [DATE] at 3:40 P.M., NA A said he/she was alerted while he/she was on a smoke break that something was wrong with Resident #1 and he/she needed to go in. When he/she arrived to the unit the resident was in a chair and he/she assisted to put him/her to bed. The resident was sweaty, snoring, had a pulse, and kept asking for a cigarette, but the nurse wouldn't let him/her smoke. The nurse checked his/her vital signs, but he/she wasn't sure what they were. NA A said he/she does not do drugs and that he/she did not give the resident anything and he/she had no explanation for how or where the resident got the [MEDICATION(S)]. During an interview on [DATE] at 10:01 A.M., police officer F said he/she was dispatched to the facility on [DATE] for a medical call on a resident with altered mental status and who was supposed to be in code status. When they arrived one of the residents yelled out the resident had got ahold of heroin. He/She said the paramedics administered [MEDICATION(S)] and the resident immediately started to respond. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 718