Every finding on record at Westgate

Based on observation, interview, and record review, the facility failed to provide care to promote the prevention and healing of pressure ulcers when staff failed to assess, monitor, document, and notify the physician for at least 17 days of a newly acquired Stage 4 (full thickness tissue loss with exposed bone) pressure ulcer that developed on one resident's (Resident #1) sacrum (the triangular bone located above the tailbone) which resulted in the resident requiring prolonged antibiotic treatment for probable osteomyelitis (an infection and inflammation of the bone typically caused by bacteria or fungi) and when staff failed to complete a wound treatment per physician order, and timely assess, document and notify the physician of five newly acquired pressure ulcers for one resident (Resident #2) in a selected sample of 10 residents. The facility's census was 100 residents.The Administrator was notified on 06/03/26, at 7:23 P.M., of an Immediate Jeopardy (IJ) which began on 05/05/26. The IJ was removed on 06/04/26, as confirmed by surveyor on-site verification. Review of the facility's Wound and Skin Care Protocol, revised November 2024 showed the following information:-Purpose to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. This protocol serves as a tool for treatment options for the staff member to utilize;-Purpose to prevent pressure injury formation by identifying those residents who are at risk for pressure injury and to develop appropriate interventions;-Purpose to promote healing of pressure injuries in a cost efficient and timely manner;-The Director of Nursing (DON) at each facility is responsible for informing and educating the attending physicians and the facility's Medical Director regarding facility wound care protocols. It will also be the responsibility of the facility DON to ensure that the wound care protocols are instituted and followed for all residents/patients needing wound treatment and have orders for wound care protocol;-The DON will be responsible for reviewing the weekly wound report and monitoring progress/decline of any wound and assuring compliance with current standards of wound care practice;-All residents will be assessed by the charge nurse for risk of skin breakdown using the Braden Scale (a widely used, evidence-based assessment tool used by healthcare professionals to predict a patient's risk of developing pressure injuries) on admission, re-admission, and with any major change in condition. The Resident Assessment Instrument (RAI - a standardized, federally mandated system used by Medicare and Medicaid-certified nursing homes and long-term care facilities to evaluate the health, functional capacity, and individualized care needs of every resident) process to be used for ongoing risk assessment;-The interdisciplinary plan of care will address problems, goals and interventions directed toward the prevention and/or treatment of impaired skin integrity/pressure injury. 1. Review of Resident #1's face sheet (a standardized document that provides a quick, high-level summary of important information) showed the following:-admission date of 03/08/23;-Diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life) and systemic lupus (a chronic autoimmune disease in which the immune system mistakenly attacks healthy tissues throughout the body, causing widespread inflammation and potential damage to the joints, skin, kidneys, heart, lungs, and brain). Review of the resident's current care plan showed on 12/09/24 staff added the following:-The resident was at risk for impaired skin integrity related to limited mobility and incontinence;-Evaluate skin. Review of the resident's Physician Order Summary (POS) showed an order, dated 09/15/25, to apply barrier cream to the resident's groin/perineal area every shift and as needed for incontinence care and skin integrity. Review of the resident's current care plan showed on 01/04/26, staff added the intervention to frequently turn/reposition and offload (reducing or removing pressure from an area of the body to help a wound heal or to prevent one from developing) both feet. Review of the resident's Braden Scale evaluation, dated 03/10/26, showed the resident was at moderate risk for developing pressure ulcers. Review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 04/06/26 showed the following information:-Severe cognitive impairment;-Functional limitation in range of motion: Lower extremity impairment on both sides;-Used a wheelchair for mobility;-Required maximum assistance for bathing, personal hygiene, and rolling left and right in bed;-Dependent on staff for toileting hygiene, lower body dressing, transfers;-Always incontinent of bowel and bladder;-The resident was at risk of developing pressure ulcers;-One Stage 3 pressure ulcer (full thickness tissue loss);-One unstageable pressure ulcer (a severe wound where the base is completely covered by dead tissue making it impossible to determine the true depth or severity until the wound bed is exposed);-Pressure reducing device for bed and chair;-Nutrition or hydration intervention to manage skin problem;-Pressure ulcer care;-Received hospice services. Review of the resident's hospice clinical note, dated 05/05/26, showed Hospice Nurse (HN) G documented the following:-The HN changed the resident's dressing to his/her sacrum;-This was a new pressure sore since the weekend;-The facility's wound care nurse (Licensed Practical Nurse (LPN) J), and the HN coordinated the dressing changes to include calcium alginate (wound dressing made from natural fibers that absorbs heavy fluid, promotes healing, and stops minor bleeding) to the wound bed, sacral mepilex (soft silicone foam dressing), change every other day and as needed for soilage, integrity, and/or excess drainage; -The pressure areas measured 4 centimeters (cm) x 5 cm and 1.5 cm x 2 cm;-Wound order added for sacrum dressing of clean with wound cleanser, pat dry, apply calcium alginate to wound bed and cover with a sacral mepilex, change every other day and as needed for soilage, integrity;-A reportable wound event was identified on 05/04/26. The pressure ulcer was not acquired during hospice care. The pressure ulcer was Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed). The pressure ulcer was found by facility nurse on Monday (05/04/26) and some investigation was done by this nurse and facility wound care nurse (LPN J) on the onset of this wound. LPN J had already applied a dressing to the wound, and the resident was up in chair for lunch at the time (on 05/04/26). Today (05/05/26) the HN assessed the wound. The event was reported to the appropriate provider (hospice physician). Review of the resident's shower sheet, dated 05/05/26, showed the following:-The certified nurse aide (CNA) documented the resident's left big toe was red;-The CNA circled the buttocks on the human diagram and noted open; -The nurse (Registered Nurse (RN) E) signed the form which indicated he/she reviewed the form. During an interview on 06/03/26, at 5:53 P.M., RN E reviewed the resident's shower sheet, dated 05/05/26, and said the following:-The skin on the resident's sacrum was not open like it is now; -He/She did not assess the resident's skin on 05/05/26 as he/she thought the former wound nurse (LPN J) assessed the resident's skin and applied barrier cream to his/her sacrum. Review of the resident's skin issue assessment, completed by the former wound nurse, dated 05/12/26, showed the following:-Reinforced teaching on proper positioning in bed to offload pressure (reducing or removing pressure from an area of the body to help a wound heal or to prevent one from developing) and use of pressure relieving boots when up to prevent further breakdown; -No additional skin concerns at this time.(The wound nurse did not document an assessment of the resident's sacral wound.) Review of the resident's hospice clinical note, dated 05/12/26, showed HN G documented the following:-Upon arrival, the resident was in his/her wheelchair at the dining room table;-There was no wheelchair cushion in the resident's Broda chair (a specialized, highly adjustable medical wheelchair or recliner) and it did not appear that he/she has one available to use; -A wheelchair cushion was ordered at this visit related to wounds on her bottom (sacrum); -A skin assessment could not be completed to the posterior (the back or rear of the body) skin related to the resident positioned in his/her chair;-The resident had a pressure wound on her bottom. Review of the resident's hospice clinical note, dated 05/14/26, showed HN G documented the following:-Wound care provided by this nurse as the facility's wound care nurse was off today. -Pressure area to coccyx (tailbone), tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), has brownish drainage, yellow slough (necrotic (dead) tissue) to wound bed. The resident had a necrotic area next to deep area of wound;-Wound cleanser applied with calcium alginate to wound bed and covered with Mepilex;-The HN told the charge nurse he/she completed the treatment. Review of the resident's shower sheet, dated 05/19/26, showed the following:-The hospice CNA circled the buttocks on the human diagram and noted opening; -The nurse (RN E) signed the form which indicated he/she reviewed the form. During an interview on 06/03/26, at 5:53 P.M., RN E reviewed the resident's shower sheet, dated 05/19/26, and said the following:-He/She did not assess the resident's skin on 05/19/26 as he/she thought the former wound nurse talked to the hospice nurse about the resident's sacral wound;-The hospice nurses talked to the charge nurse about anything going on with the resident;-If the hospice nurse had concerns related to wounds, the RN referred the hospice nurse to the wound nurse, if he/she was at the facility. Review of the resident's shower sheet, dated 05/22/26, showed the following:-The hospice CNA circled the buttocks on human diagram and noted opening; -The nurse (RN E) signed the form which indicated he/she reviewed the form. During an interview on 06/03/26, at 5:53 P.M., RN E reviewed the resident's shower sheet, dated 05/22/26, and said the following:-On 05/22/26, one of the hospice aides asked the nurse to go to the resident's room, which he/she did;-The hospice aide showed the nurse the pressure ulcer on the resident's sacrum;-The wound had no dressing;-No facility CNAs told him/her of the resident's sacral wound;-Since the former wound nurse was not working, the RN asked the Assistant Director of Nursing (ADON) for assistance. During an interview on 06/03/26, at 3:25 P.M., RN E said the following: -He/she observed the resident's skin off and on when he/she assisted with the resident's incontinent care and transfers;-On 5/22/26, one of the hospice aides told RN E of the resident's sacral wound. He/She found the ADON and they assessed the resident's wound;-No one told RN E about the resident's wound prior to 05/22/26.(RN E signed shower sheets dated 05/05/26 and 05/19/26.) Review of the resident's hospice clinical note, dated 05/22/26, showed HN G documented the following:-Facility nurse (RN E) reported the resident had a new wound;-The facility nurse also requested a low air loss mattress (a mattress that provided a constant flow of air in the mattress to help prevent pressure ulcers) and bolsters (long, narrow and often firm cushion of pillow) for the resident;-The resident had the wound on his/her buttock (sacrum) since 05/05/26;-The facility nurse (RN E) claimed to have no knowledge of the wound;-Facility wound care nurse (LPN J) had changed this wound with this nurse (HN G) at least once, probably twice, and they had talked about it a few times. This was not a new wound;-The HN remembered the wound care nurse (LPN J) asking about documentation on the wound; -Hospice had no documentation of the wound prior to 05/05/26, -Orders given to wound care nurse that day (05/05/26). During an interview on 06/04/26, at 11:05 A.M., HN G said the following: -The resident was dependent on staff for all care including bed mobility; -He/she had contractures of both knees and required a mechanical lift for transfers;-On 05/05/26, the former wound nurse told HN G the resident had a wound on his/her sacrum;-The HN observed two pressure ulcers on the resident's bottom area, one on the resident's sacrum and another to the side of the sacral wound. Both wounds were opened with white slough (non-viable yellow, tan, gray, green or brown tissue) covering the wound bed;-The former wound nurse discussed the treatment with the HN and told the HN he/she did not have an order to treat the wound. The HN applied calcium alginate to the wound bed and covered the wound with a silicone dressing, then entered the treatment orders for hospice;-After the HN reviewed his/her note, he/she said that he/she guessed he/she noticed the dressing on the resident's buttocks and changed the dressing. The HN thought he/she entered the order for the treatment on 05/05/26.-When the HN visited the resident, he/she changed the dressing when the resident was in bed but sometimes when the HN visited the resident, the resident sat in his/her wheelchair and the HN could not observe the resident's skin. Review of the resident's progress note dated 05/22/26, at 12:04 P.M., showed RN E documented the following:-Called to the room by the hospice CNAs about an open area on the resident's sacral area;-Upon examination, RN E noted an open area on the resident's sacrum and asked the ADON for assistance; -The open area measured 7.5 cm x 5.5 cm x 3.0 cm and the wound bed was 100% covered with slough; -Notified the hospice physician who ordered treatment for the sacral wound;-Staff educated to turn/reposition the resident every two hours or more frequently; -Hospice asked to provide an air mattress (a low loss air mattress) and the facility awaited delivery of the mattress at that time. Review of the resident's skin issue assessment, completed by the ADON, dated 05/22/26, showed the following:-New skin issue: An unstageable pressure ulcer due to slough and/or eschar (dead or devitalized tissue that is hard or soft in texture) to the resident's sacrum with an onset date 05/05/26 that measured 7.14 cm x 5.53 cm x 3 cm with no undermining (wound open underneath the border of the wound). The wound had a moderate amount of serosanguinous drainage (yellowish drainage with small amounts of blood) with a moderate odor after cleansing;-Additional care (interventions) of mattress with pump. Staff did not mark any other interventions used;-Nursing notified by hospice of new skin concerns. The charge nurse assessed the area and notified the ADON. The pressure ulcer was unstageable due to 100% slough covering the wound bed. Treatment orders received. Hospice provided an air mattress for pressure reduction. Staff educated on turning/positioning frequently. The resident was already seen by the mobile wound Nurse Practitioner (NP) (for his/her other pressure ulcers) and the wound NP would assess the resident's new wound on her next visit. Review of the resident's physician order summary, dated 05/22/26, showed an order for the sacral wound-cleanse with wound cleanser, apply calcium alginate, cover with silicone bordered foam every day and as needed if soiled or missing. Review of the resident's care plan showed staff added the following interventions:-On 05/22/26, hospice to provide air mattress to help with off-loading;-On 05/26/26, provide wound care to coccyx (sacrum) as ordered. Review of the resident's wound assessment, completed by the mobile wound NP, dated 05/26/26 showed the following:-New Stage 4 pressure ulcer on the resident's sacrum acquired on 05/05/26;-The wound measured 7.10 cm x 8.0 cm x 4.20 cm;-The wound bed was 100% covered with slough with exposed bone;-The wound had heavy seropurulent (wound discharge that is a mixture of serum (a clear, thin, watery fluid) and pus (a thick, cloudy fluid containing white blood cells, dead tissue, and bacteria) drainage with a mild odor after cleansing. Review of the resident's progress note dated 05/26/26, at 5:29 P.M., the wound NP documented the following:-New stage 4 pressure ulcer to the resident's sacrum which was initially observed by hospice on 05/05/26;-The first documented assessment in the resident's EMR was on 05/22/26;-Extensive wound with palpable bone with slough and necrotic tissue to the wound base;-Sacral wound had a depth of 4.2 cm with large amount of palpable bone. Epibole (edges of the skin roll inward and curl under instead of migrating across the wound bed) and erythema to wound margins; -Culture taken via facility. Debridement performed, but unable to remove much tissue as the resident displayed signs of pain during procedure;-The resident had frequent incontinence of bowel and bladder; -The resident used an air-fluidized mattress;-Reinforced teaching on a strict turn every 2 two-hour regimen to prevent further tissue breakdown;-Resident up for less than one hour at a time when up to wheelchair for meals. Review of the resident's POS showed the following:-An order, dated 05/26/26, to obtain a wound culture and sensitivity of the sacral wound;-An order, dated 05/26/26, for Meropenem (a potent, broad-spectrum antibiotic), 1 gram intravenously (a needle into the vein to infuse medication) three times a day for wound infection;-An order, dated 05/26/26, for Pro-stat (a ready-to-drink concentrated liquid protein) oral liquid, 30 milliliter (ml) three times a day for wound healing;-An order, dated 05/27/26, to cleanse the sacral pressure ulcer with wound cleanser or normal saline, pat dry, apply skin prep (protective barrier wipes) to the periwound, gently pack with sterile gauze moistened with hypochlorous acid (a weak, naturally occurring acid that your immune system produces to fight off bacteria and viruses) to the wound bed and cover with a silicone bordered dressing. Change every day and as needed for missing or soiled dressing. Review of the resident's progress note dated 05/27/26, at 7:39 A.M., the ADON documented the following:-Stage 4 pressure ulcer to the resident's sacrum that measured length 6.28 cm, width 6.72 cm, depth 3 cm;-Stable, previously deteriorating wound characteristics plateaued; -Wound acquired at the facility on 05/05/26. Review of the resident's sacral culture, dated 05/28/26, showed heavy growth of proteus mirabilis (bacterium found in the human intestines), escherichia coli (a group of bacteria normally found in the intestines) and corynebaterium (bacteria commonly found on skin). Review of the resident's shower sheet, dated 05/29/26, showed the following:-The CNA documented no new issues; -The nurse (RN E) signed the form which indicated he/she reviewed the form. Observation and interview on 06/03/26, beginning at 1:11 P.M., showed the following:-The ADON gathered wound care supplies then she and LPN K entered the resident's room to perform wound care on his/her sacrum;-The resident lay positioned with a pillow behind his/her back on his/her right side on an air mattress. The resident had a green padded heel/foot protector bootie on his/her right foot;-The resident had contractures (a permanent tightening of muscles, tendons, skin, or other tissues that causes joints to become stiff and prevents normal movement) to both of his/her knees; -The ADON removed the dressing that covered the resident's sacral wound and showed a Stage 4 pressure wound that measured 9.5 cm x 6 cm x 3.6 cm; -The skin around the wound, from approximately 6:00 to 12:00 o'clock, extending approximately two to three cm from the wound and immediately around the wound was red. The wound and redness around the wound measured 11.0 cm x 8.0 cm; -The wound bed was red with a thin layer of yellow slough visible on the bottom third of the wound; the wound bed on the deepest area of the wound was not visible with normal room lighting; -Undermining was present from 7:00 to 9:00 o'clock and measured at the deepest area 1.5 cm; -The ADON completed the treatment to the resident's sacral wound per physician's order then positioned the resident on his/her left side then floated his/her heels on a pillow as the pressure relieving bootie was soiled;-The ADON said mobile wound NP assessed, treated, and monitored the resident's sacral wound. During an interview on 06/03/26, at 3:19 P.M., Certified Medication Technician (CMT) N said he/she found out about the resident's sacral wound on Monday (06/01/26) but did not know about it before then. During an interview on 06/03/26, at 4:27 P.M., the ADON said the following:-The ADON did not know of the resident's (sacral) wound until 05/22/26;-On 05/22/26, RN E told her (the ADON) that after hospice showered the resident, they told him/her (the RN) the resident had an open wound (on his/her sacrum);-The resident had a large open area on his/her sacrum that was 100% covered with yellow slough. The nurses cleaned the area and applied a dressing;-Hospice staff notified the former wound nurse of the wound, but the former wound nurse did not complete and/or document an assessment of the wound;-HN G told the ADON that on 05/05/26, he/she and the former wound nurse (LPN J) discussed the resident's sacral wound;-At that time (05/05/26), HN G said the area on the resident's sacrum was not open and the HN thought it looked like a deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear (occurs when underlying tissues and bone shift in opposite directions while the surface skin remains stuck to a surface)); -The HN did not know when the wound opened;-The HN told the ADON they had a treatment order for the wound, but the ADON did not know if the former wound nurse obtained the order from the physician/provider. During an interview on 06/03/26, at 6:43 P.M., the DON said the following:-The resident received Hospice services; -On 05/22/26, RN E found a sacral wound on the resident and asked the ADON to assist him/her with the assessment as the (former) wound nurse did not work that day; -RN E and the ADON assessed the resident's wound and contacted the physician and hospice; -HN G said he/she had known about the wound since 05/05/26 and notified the former wound nurse of the wound that day (05/05/26), and multiple days thereafter; -The resident did not have any treatment orders for the sacral wound (until 05/22/26). During an interview on 06/03/26, at approximately 7:30 P.M., LPN L said the following:-He/she knew the resident had a wound on his/her sacrum prior to 05/22/26; -He/she noticed a dressing on the resident's sacrum but did not remove the dressing to assess it as he/she thought the wound nurse monitored the wound because it had a dressing covering it; -He/she did not change the dressing because the CNAs never told him/her the dressing was soiled or dislodged;-He/she could not remember if there was an order for wound treatment. During an interview on 06/04/26, at 11:20 A.M., the residents' physician said the following:-The resident was wheelchair bound and had a history of pressure ulcers;-The resident developed a Stage 4 pressure ulcer with palpable bone (to his/her spine);-When the former wound nurse first identified the wound, he/she did not notify anyone, did not obtain orders, and changed the dressing without an order;-The physician ordered antibiotics to treat a possible wound infection. The resident's wound culture had positive results, but showed no signs of infection. However, since the resident's wound extended to the bone, and based on the type of organisms the culture showed, it was safe to say the resident had or would develop osteomyelitis (bone infection) to that bone and he would treat it as such;-After talking with the resident's family, they made the decision to discharge the resident from hospice in order to initiate treatment for the pressure ulcer on his/her sacrum. During interviews on 06/10/26, at 9:39 A.M. and 11:09 A.M., the former wound nurse (LPN J) said the following:-Initially the resident ate his/her meals in his/her room, but due to his/her weight loss, they began getting the resident up for meals. He/she started to gain weight but unfortunately him/her sitting in the wheelchair caused the sacral wound. Staff were so focused on getting the resident up for meals, that they did not lay him/her down in bed as much; -The resident was at high risk for developing pressure ulcers and had an air mattress. The Braden scale's total score did not indicate the resident was high risk as he/she only had a moderate risk of friction and/or sheer due to the resident's weight, and staff could fully lift him/her off the bed during a transfer;-When attempting to transfer the resident to his/her wheelchair for a meal (on 05/05/26) the CNAs asked LPN J to look at the resident's sacrum; -The wound nurse observed an open wound with bruising to the resident's sacrum. At first, she thought the resident was developing a Kennedy ulcer (a rapidly developing, non-healing skin wound that appears in some terminally ill patients in their final weeks or hours of life). She cleaned the wound and covered it with a dressing so the CNAs could take the resident to the dining room to eat;-That same day, the (former) wound nurse asked HN G if he/she knew of the wound. The hospice nurse did not. They discussed a wound treatment which consisted of applying calcium alginate to the wound bed and covering it with a 7.0 cm x 7.0 cm bordered sacral dressing. The 7.0 cm x 7.0 cm dressing was the only size that would cover the wound at that time. She did not remember the frequency of the treatment but typically they did not change bordered dressings every day;-HN G entered the order in his/her documentation;-Over the next couple of weeks, either the hospice nurse or wound nurse changed the dressing on the resident's sacrum. The wound nurse knew the hospice nurse changed the dressing because the hospice nurse would ask the wound nurse for wound care supplies;-The wound nurse did not remember if other staff changed the resident's dressing but thought they would have told her if they did;-The wound nurse did not document the assessment because she wanted to ensure the assessment included everything that management wanted documented. She never got the opportunity to report the wound to nurse management or document the assessment. Every day she worked she thought she would talk to the DON about the wound but that never happened; -The wound nurse typically entered wound care orders after she completed and documented a resident's wound assessment, but since she did not document the assessment, she did not enter the treatment order. 2. Review of Resident #2's face sheet showed the following: -admission date of 04/10/24;-Diagnoses included Alzheimer's disease (the most common form of dementia-a brain disorder that slowly destroys a person's memory and thinking skills), chronic kidney disease (CKD-impaired kidney function), and high blood pressure. Review of the resident's care plan, dated 07/29/24, showed the following: -At risk for infection due to history of bilateral heel wound and left heel wound infection;-Staff should monitor the resident for signs and symptoms of infection;-At risk for impaired skin integrity due to immobility;-Encourage the resident to offload heels using pillows or use heel protectors;-Consult the wound nurse as appropriate;-The resident had a left heel pressure wound, wound care orders in place, wound nurse to follow;-The resident used a wheelchair cushion for comfort and skin integrity;-Received a house supplement for wound healing;-Ensure that both heels were elevated or heel protectors were in place;-Turn and reposition the resident frequently to help off load. Review of the resident's POS showed an order, dated 02/08/26, for staff to cleanse the resident's left heel with wound cleanser, apply skin prep to peri-wound, apply calcium alginate and cover with silicone border dressing. Change every other day and as needed, every day shift, every other day for wound care. Review of the resident's Braden Scale assessment, dated 04/15/26, showed the resident was at high risk for skin breakdown. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment;-At risk for pressure ulcers;-One Stage 3 pressure ulcer;-Pressure ulcer/injury care;-Hospice services. Review of the resident's skin issue assessment, dated 05/05/26, showed LPN J documented the resident had a Stage 3 pressure ulcer on the left heel that measured 4.5 cm x 3.7 cm x 0.2 cm. Review of the resident's shower sheet, dated 05/06/26, showed the following:-The CNA circled the buttocks on the human diagram and noted open; -The nurse (LPN H) signed the form which indicated he/she reviewed the form. During an interview on 06/04/26, at 1:47 P.M., LPN H said the following: -On 05/08/26, staff documented on the shower sheet the resident had an open wound on his/her left gluteal region;-LPN H reviewed and signed the shower sheet;-LPN H spoke with the wound nurse about the resident's new skin issue;-The wound nurse provided LPN H with a treatment plan and orders for the resident;-LPN H treated and dressed the resident's gluteal wound;-LPN H did not enter the treatment orders for the resident's gluteal wound;-LPN H did not know if staff completed the treatments for the resident. Review of the resident's hospice interdisciplinary group (IDG) meeting (a mandatory, collaborative team meeting required at least every 15 days to review, update, and manage a patient's holistic plan of care) report, dated 05/19/26, (requested by facility staff on 06/04/26) showed the following: -On 05/06/26, HN G documented the resident had two new areas to his/her bottom, and opened wounds on his/her right and left heel;-The wound nurse (LPN J) changed the dressing to the left heel to once or twice a week, but HN G was under the impression the dressing was to be changed daily;-The facility nurse changed the dressing to the resident's left heel to Hydrofera blue (an antibacterial foam dressing) to the wound bed, cover with an absorbent (ABD) pad, and wrap with Kerlix (woven cotton gauze), change every other day and as needed; -The resident's right heel had several small openings that were almost scabbed over; -The wound on resident's sacrum was very superficial and almost appeared as a skin sheer (occurs when the skin and underlying tissues move in opposite directions, such as when sliding down a bed);-The resident was at high risk for skin breakdown related to age, primary diagnosis, incontinence of bowel and bladder, refusal of cares at times, bed/chair bounded, non-ambulatory, and the presence of current wounds;-Care Plan update: Wound order, dated 05/06/26, for the pressure ulcer on the resident's right heel: Cleanse with wound cleanser, pat dry, apply Allevyn (a multi-layer foam dressing) to the resident's heel, apply tubigrip (an elasticated tubular support bandage), change every three days as needed;-Care Plan update: Wound order, dated 05/06/26, for the pressure ulcer on the resident's left heel: Cleanse with wound cleanser, pat dry, apply Hydrofera blue to the wound bed, apply ABD pad over the Hydrofera blue, wrap in Kerlix and secure with tape. Change every other day and as needed;-Care Plan update: Wound order, dated 05/06/26, for the resident's left gluteal fold (the natural horizontal skin crease that separates the underside of the buttocks from the upper posterior thigh): Cleanse with wound cleanser, pat dry, apply calcium alginate to wound bed, cover with Allevyn. Change every three days and as needed;-Care Plan update: Wound order, dated 05/06/26, for the pressure ulcer on the resident's sacrum, dressing: staff to cleanse with wound cleanser, patch, dry, apply collagen into wound bed, cover with Allevyn; change every three days and as needed. During an interview on 06/04/26, at 11:05 A.M., HN G said the following: -The resident had multiple pressure wounds. He/she had one on the left heel, one on the right heel that waxed and waned, and one on his/her buttocks; -One day (the HN could not recall the date), while the HN visited the resident, the (former)

Based on observation, interview, and record review, the facility failed to provide care to promote the prevention and healing of skin breakdown when staff failed to timely and accurately assess and document related to Moisture Associated Skin Damage (MASD-inflammation and skin erosion caused by prolonged exposure to bodily fluids such as urine and feces) for one resident (Resident #3) in a selected sample of 10 residents. The facility's census was 100 residents. Review of the facility's Wound and Skin Care Protocol, revised November 2024, showed the following information:-Purpose to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. This protocol serves as a tool for treatment options for the staff member to utilize;-The Director of Nursing (DON) at each facility is responsible for informing and educating the attending physicians and the facility's Medical Director regarding facility wound care protocols. It will also be the responsibility of the facility DON to ensure that the wound care protocols are instituted and followed for all residents needing wound treatment and have orders for wound care protocol;-The DON will be responsible for reviewing the weekly wound report and monitoring progress/decline of any wound and assuring compliance with current standards of wound care practice;-The Resident Assessment Instrument (RAI - a standardized, federally mandated system used by Medicare and Medicaid-certified nursing homes and long-term care facilities to evaluate the health, functional capacity, and individualized care needs of every resident) process to be used for ongoing risk assessment;-The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention and/or treatment of impaired skin integrity/pressure injury. 1. Review of Resident #3's face sheet showed the following: -admission date of 12/18/24;-Diagnoses included congestive heart failure (CHF - impaired heart function) and pneumonia (infection and inflammation of the lung). Review of the resident's care plan, initiated on 08/29/24, showed the following:-The resident was at risk for impaired skin integrity related to limited mobility and bowel incontinence;-Staff should evaluate the resident's skin integrity. Review of the resident's May 2026 Physician Orders (POS) showed an order, dated 03/25/26, for staff to apply barrier cream to buttocks/perineal area (surface area between the thighs, extending from the pubic bone to tail bone), as needed for incontinence care/skin integrity. Review of the resident's 5-day Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 03/27/26, showed the following information: -Moderate cognitive impairment;-Required substantial/maximum assistance with toileting hygiene-Dependent on staff for bathing;-Occasionally incontinent of bowel and bladder;-The resident had MASD.Review of the resident's shower sheets, dated 05/19/26 and 05/22/26, showed staff documented no new skin issues. Review of the resident's skilled evaluation dated 05/26/26, at 11:34 A.M., showed staff did not document an assessment of the resident's buttocks. Review of the resident's skin check assessment dated [DATE], at 3:44 P.M., showed the following: -New skin issue to right gluteus (buttock);-MASD. Review of the resident electronic medical record (EMR) showed the nurse did not document a skin issue assessment of the MASD including size, description/appearance, cause, and implemented interventions. During an interview on 06/04/26, at 3:40 P.M., Licensed Practical Nurse (LPN) H said the following: -On 05/26/26, one of the nurse managers asked him/her to conduct a skin check (the assessment form used for residents with no skin issues) on the resident. He/she did not know the resident had any skin issues;-When the nurse found the resident had MASD to his/her buttocks, he/she noted it on the skin check form but did not go back and enter a skin issue assessment. Review of the resident's skilled evaluation dated 05/27/26, at 5:12 P.M., showed staff did not document an assessment of the resident's right gluteal MASD. Review of the resident's skilled evaluations dated 05/28/26, at 10:43 P.M., and 05/29/26, at 3:38 A.M., showed a nurse documented MASD, incontinence associated dermatitis (IAD-a painful, irritant contact dermatitis (an itchy rash caused by direct contact with a specific irritant) caused by prolonged skin exposure to urine and/or feces.Review of the resident's skin issue assessment dated [DATE], at 8:38 A.M., showed the following: -Skin issue to buttocks;-MASD, Type IAD that measured 11.74 centimeters (cm) x 8.41 cm;-Primary dressing Triad Paste (a zinc oxide-based paste that creates a protective barrier and moist environment).During an interview on 06/03/26, at 3:47 P.M., LPN H said the following:-The resident had a history of MASD on his/her buttocks;-Staff applied Triad paste to his/her buttocks;-Staff found the reddened MASD on the resident's buttocks a few weeks ago.During an interview on 06/03/26, at 6:43 P.M., the DON said the resident had a history of MASD, but she did not know if the resident currently had any skin concerns on his/her buttocks. Review of the resident's shower sheet, dated 06/03/26, found by Registered Nurse (RN) F on 06/04/26, showed CNA C left the visual assessment of the resident's skin blank. During an interview on 06/04/26, at 4:31 P.M., CNA C said the following: -He/she documented in the EMR when he/she assisted a resident with a shower; -He/she completed the resident's shower sheet on 06/03/26;-He/she forgot to document the resident had a skin issue on his/her buttocks, on the shower sheet. Observation on 06/04/26, at 10:45 A.M., showed the following:-The resident laid in bed on his/her right side with a wedge supporting his/her back and pressure relieving boots on both feet;-The Assistant Director of Nursing (ADON) and current wound nurse (LPN K) entered the resident's room to apply a barrier cream to his/her buttocks;-The ADON removed the resident's disposable brief which showed a softball-sized area of red and flaky skin on the resident's bilateral buttocks.During an interview on 06/03/26, at 3:24 P.M., Nurse Aide (NA) B said the following:-When he/she completed a shower sheet on a resident, he/she documented any abnormal bruising, skin tears, and bleeding;-NA B would also tell the nurse in person if the skin issue looked bad;-Upper management told NA B a couple of days ago that staff should document all skin issues, old or new, on the resident's shower sheet. During interviews on 06/03/26, at 3:50 P. M. and 5:22 P.M., and on 06/04/26, at 4:31 P.M., Certified Nurse Aide (CNA) C said the following: -He/she documented abrasions, skin tears, redness, and bruising on the resident's shower sheets then gave the sheets to the nurse;-Recently management staff told him/her to document all skin issues, old and new, on the resident's shower sheet;-He/she would notify the nurse of any new skin issues. During interviews on 06/03/26, at 3:47 P.M., and 06/04/26, at 3:40 P.M., LPN H said the following:-MASD appeared as redness or galling (a painful skin condition caused by a combination of friction, heat, and moisture) which could lead to open areas due to moisture;-If the nurses noticed a resident had MASD, they would clean the area, pat dry, and apply a moisture barrier cream, and anti-fungal powder if needed;-The nurse also completed a full assessment of the MASD, completed a risk management report and skin issue assessment, and notified the wound nurse, family and physician;-If the resident had orders for preventative treatments such as moisture barrier cream or skin prep, those orders were listed on the nurse medication administration record. If the treatment included medication such as nystatin (a prescription antifungal medication), it was listed on the nurse treatment administration record;-The CNAs completed shower sheets when they assisted a resident with a shower. The aides documented current and new skin issues on the sheet, then gave the sheets to the nurse to review and sign. The nurse then gave the shower sheets to the wound nurse to review;-If the aide documented a skin issue the nurse did not know about, the nurse addressed the issue; -The nurse addressed the new skin issue by assessing the area which included measuring the area and contacting the provider for orders;-The nurse also completed a skin issue assessment and risk management documentation (incident report) in the EMR;-The night shift nurses completed the weekly skin check assessment for residents who were not at high risk for developing pressure ulcers;-The wound nurse completed the skin issue assessments for residents with existing wounds and for residents at high risk for developing pressure ulcers. During an interview on 06/03/26, at 5:45 P.M., LPN L said the following:-If a CNA found a new skin issue, the CNA told the nurse and immediately the nurse assessed the wound, completed a skin issue assessment and incident report (risk management) in the electronic medical record, contacted the physician/provider for treatment orders.-When the nurses enter a new order into the electronic medical record, it alerts the wound nurse and nurse management of the new order;-The CNAs rarely shower residents on the nurse's shift, but when they did, they completed a shower sheet, gave the sheets to the charge nurse who reviewed and signed the sheet. If the CNA documented a new skin issue, the nurse assessed the resident, then placed the completed shower sheets in the wound nurse's office; -The CNAs documented all skin issues on the shower sheet. If the nurse did not know of a skin issue marked on the shower sheet, the nurse reviewed the resident's chart. During an interview on 06/03/26, at 5: 53 P.M., RN E said the following:-If a CNA reported a new skin issue to the nurse or if a nurse found a new wound, that nurse would complete the initial assessment, apply a simple dressing to cover the wound, document the skin assessment, and complete a risk assessment (incident) report, if the wound nurse or management did not complete one for the new wound;-The nurse would then contact the on-call provider for treatment orders;-When a CNA completed the shower sheet, he/she should document all skin issues they observed, not just the new skin issues;-The CNAs should notify the nurse about any skin issues, every time. During an interview on 06/04/26, at 11:05 A.M., Hospice Nurse (HN) G said the following: -When the hospice aides (HA) assisted a resident with a shower, they completed a shower sheet documenting any skin issues on the sheet, then gave the sheet to the charge nurse;-The HA also documented the find in the secured messaging system which the HN reviewed;-The HN assessed the wound then talked to the charge nurse about the assessment. The HN did not know if the charge nurses talked to the wound nurse for orders. During an interview on 06/03/26, at 4:27 P.M., the ADON said the following:-If a CNA found a new wound on a resident when he/she assisted the resident with care, he/she notified the nurse of the new wound, and waited for the nurse to assess the wound before transferring the resident out of bed;-The nurse immediately assessed the resident's wound and followed the treatment protocol approved by the physician;-The wound assessment included the type of wound (pressure injury, skin tear, and other types of wounds), location, wound bed and peri-wound appearance, size, drainage, any signs of infection, treatment, and who the nurse notified;-The nurse documented the wound assessment on the risk management (incident) report which linked to a nurses/progress note;-The nurse also contacted the physician or provider, investigated how the wound developed, implemented interventions for that specific wound, and completed the skin issue assessment in the electronic medical record;-When the nurse obtained specific treatment orders from the physician/provider, the nurse entered the order into the EMR;-The wound nurse also assessed the new wound and its cause, entered the wound treatment order in the EMR, and documented it all in the skin issue assessment;-The CNAs completed a shower sheet after each residents' shower and they documented all skin issues on the shower sheet;-The CNAs gave the completed shower sheets to the nurses to review, and the nurses either gave the reviewed shower sheets to the wound nurse or placed the shower sheets in the wound nurse's office. The wound nurse then reviewed the shower sheets and reported any new skin issues to the DON and ADON during the morning clinical meeting;-The wound nurse completed a skin assessment on each resident weekly, including residents with newly identified wounds;-The former wound nurse (LPN J) should have been able to complete all of the skin assessments including newly identified wounds, as she (the ADON) and the new wound nurse who she was training, had no issues completing the assessments; -In order to assess every resident, the wound nurse had to complete about 20 residents' skin assessments every day;-She and the wound nurse reviewed the risk management reports completed by the nurses the previous day, at the daily (Monday-Friday) morning clinical meeting;-During the morning meeting, the wound nurse gave the DON and ADON updates on residents' skin assessments he/she completed the previous day which included new admits, newly identified wounds, and wounds that had deteriorated;-The facility utilized a mobile wound care company to manage all residents' wounds including pressure ulcers;-When a resident developed a new wound, the nurse contacted the family for consent. Once they received consent, they notified the physician/provider who gave an order for the mobile wound Nurse Practitioner (NP) to see the resident. During interviews on 06/04/26, at 5:00 P.M. and on 06/05/26, at 5:00 P.M., the DON said the following: -MASD was caused by moisture sitting on the skin and the skin would appear moist and red;-The staff member who assisted the resident with a shower was responsible for completing the shower sheet, documenting all skin issues, old and new;-Staff then give the shower sheets to the charge nurse to review;-If the shower sheet showed a new wound, the charge nurse was responsible for assessing the new skin issues. During an interview on 06/03/26, at 6:43 P.M., the DON, Administrator and Corporate Nurse said the following:-The DON said if a CNA found a new wound on a resident, the CNA notified the charge nurse who assessed the wound, followed the wound protocol, completed a risk management report, and contacted the physician. -The DON said the charge nurse also notified the wound nurse. The charge nurse documented the wound assessment including the size, appearance of the wound, the treatment per the wound protocol, family and physician notifications, preventative measures, and how the wound occurred, on the risk management report;-The DON said the charge nurse was ultimately responsible for the initial wound assessment. If the wound nurse was available, he/she could go with the charge nurse to assess the wound, but the charge nurse documented the assessment, completed the risk assessment, and contacted the physician and family;-The DON said the CNAs completed a shower sheet after each residents' shower. The CNA who showered the resident completed the form;-The administrator said the CNAs gave the completed shower sheets to the charge nurse;-The DON said the charge nurse reviewed and signed the shower sheet then gave the sheets to the wound nurse. The nurse who reviewed and signed the sheet should follow up on any new skin concerns;-The Administrator said the wound nurse reviewed the shower sheets and reported any new or deteriorating wounds to nurse management during the morning clinical meeting; -The Administrator said the former wound nurse was supposed to print the weekly wound report and give the report to the Administrator and Corporate Nurse to review, but the former wound nurse did not do this consistently. If the wound nurse did not give the weekly report to her, she asked the wound nurse for the report although the wound nurse did not always comply with her request. The Administrator did not print the weekly wound report if the (former) wound nurse did not give it to her;-The Administrator said the wound nurse reviewed and discussed issues with the DON, ADON, and Administrator every day in the clinical meeting; -The DON said the electronic medical record program generated the wound report, but she did not print the weekly wound report when the wound nurse did not give it to the Administrator, and until recently, she did not know how to generate that report;-The Corporate Nurse said she thought the wound NP assessed and monitored all wounds at the facility. Complaint #3030519

Based on interviews and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse by staff when one staff (Certified Nursing Assistant (CNA) A) physically pushed the resident's face. The facility census was 109.Based on interviews and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse by staff when one staff (Certified Nursing Assistant (CNA) A) physically pushed Resident #1's face. The facility census was 109. On 01/08/26, facility management became of the noncompliance that occurred on 01/08/26. The facility reported the allegation, began an investigation, took steps to protect the residents, and began facility-wide in-service regarding abuse, neglect, dignity, and respect; began monitoring the resident for any psychosocial changes; and began monitoring the resident's skin for any new bruising, redness, or other concerns. The facility put plans in place to provide training on behavior interventions for the next three months and added the noncompliance to their Quality Assurance Performance Improvement Meeting (QAPI) program. The noncompliance was corrected on 01/09/26. Review of facility policy titled Abuse Prevention Program, undated, showed the following:-The facility will not tolerate verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, visitors, or other residents;-The facility shall maintain an ongoing open dialog with residents to establish an atmosphere where the residents are comfortable reporting any indications of abuse, neglect, mistreatment, or misappropriation of property. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 07/10/21;-Diagnoses included Alzheimer's disease, major depression disorder, anxiety, and delusional disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 09/29/25, showed the following:-Severe cognitive impairment;-Delusion, rejection of care, and wandering were exhibited;-Substantial/maximum assistance with toileting, personal hygiene, and transfers;-Partial to moderate assistance from staff with bed mobility and transfers;-Independent while walking. Review of the resident's care plan, revised 12/31/25, showed the following:-Resident was occasionally physically and verbally aggressive with staff during cares;-Undesirable behavior will be monitored/managed;-Resident has a diagnosis of dementia, depression, and anxiety. Review of the facility's investigative summary, dated 01/12/26, showed the following:-On 01/08/26, at approximately 10:15 A.M., a certified nurse aide (CNA) notified Human Resources (HR) of an alleged incident;-HR immediately contacted the Administrator and Director of Nursing (DON);-CNA A was interviewed said he/she was in the bathroom with the resident and Nurse Aide (NA) B. The resident was combative while staff were toileting him/her. CNA A leaned down to assist with clothing and the resident spit on him/her. The CNA then reached up with his/her hand and made contact with the resident's cheek. The CNA went to HR and notified him/her;-CNA A was immediately accompanied out of the building by HR;-Staff were unable to interview the resident due to cognitive deficits. The resident had not had any change in behavior or mood following the alleged incident. Skin assessment completed with no new skin concerns noted;-The other staff (NA B) in the bathroom said he/she was in the bathroom with the resident and CNA A. NA B was gathering equipment with his/her head turned and heard CNA A say, It was a natural reaction. Review of resident's progress notes, dated 01/08/26, showed staff did not document regarding the allegation of abuse toward the resident. During an interview on 01/14/26, at 10:06 A.M., NA B said the following:-On 01/08/26, sometime during the day shift, NA B took the resident back to his/her room to get changed;-NA B requested assistance from CNA A due to the resident's aggressive behaviors;-The resident was spitting, hitting, and trying to bite staff, but they were able to get him/her on the toilet;-NA B turned around, and his/her back was to the resident and other staff. NA B turned around and heard laughing;-NA B saw CNA A with her hands on either side of the resident's face, telling the resident that he/she was sorry and that it was just a reaction;-CNA A told NA B that he/she (CNA A) needed to report the incident to a nurse;-They cleaned up the resident and CNA A left;-Staff should not hit a resident under any circumstance, as hitting a resident would be considered abuse.During an interview on 01/14/26, at 12:09 P.M., CNA A said the following:-On 01/8/26, around 10:00 A.M, CNA A was assisting NA B toilet the resident;-The resident was very combative, hitting at staff;-CNA A and NA B were able to get the resident on the toilet;-CNA was kneeling in front of the resident, assisting him/her with their pants;-The resident spit on CNA A and he/she (CNA A) pushed the resident's face away, and told the resident not to do that;-CNA A said it was an instant reaction, and there was no thought process behind his/her actions;-CNA A said he/she inappropriately touched the resident's face when he/she pushed the resident's face;-CNA A immediately reported the incident to HR.During an interview on 01/14/26, at 12:35 P.M., HR said the following:-On 01/08/26, around 10:00 A.M., CNA A came to HR's office and advised he/she needed to turn him/herself in;-CNA A said he/she was toileting the resident when the resident spit in his/her face;-CNA said he/she reacted on instinct and smacked her hand over the resident's mouth and told him/her to stop it;-Staff cannot hit push or put hands on resident, as it would be considered abuse. During interview on 01/14/26, at 10:35 A.M., Certified Medication Technician (CMT) C said it was never ok to hit a resident, as it would be considered abuse. During an interview on 01/14/26, at 10:50 A.M., CNA D said abuse could be mental, yelling, hitting, or pushing. It was never ok to hit a resident under any circumstances as it would be considered abuse. During an interview on 01/14/26, at 11:00 A.M., Housekeeping (HK) E said it was never okay to strike a resident as it would be considered abuse. During an interview on 01/14/26, at 11:10 A.M., CMT F said it was never okay to hit a resident as it would be considered abuse. During an interview on 01/14/26, at 11:16 A.M., Licensed Practical Nurse (LPN) G said staff may not strike a resident, even if the resident struck staff first, as it is considered abuse. During an interview on 01/14/26, at 12:19 P.M., CNA H said it was never ok to hit or push a resident as it would be considered abuse. During an interview on 01/14/26, at 12:23 P.M., Registered Nurse (RN) I said it was never okay for staff to push or strike a resident as it is considered abuse. During an interview on 01/14/26, at 12:29 P.M., the DON said the following:-On 01/08/26, CNA A reported an incident with a resident to HR;-HR escorted CNA A to the Administrator's office to speak to the Administrator and DON;-CNA A said he/she was toileting the resident with the assistance of NA B;-The resident was agitated and combative;-As CNA A was adjusting the resident's pants, the resident hit CNA A;-CNA A said he/she then reached up and touched the resident's face;-CNA A acknowledged that he/she should not have touched the resident in that manner;-CNA A was immediately terminated and escorted out of the building;-It was never acceptable to hit or push a resident, as it would be considered abuse. During an interview on 01/14/26, at 12:43 P.M., the Administrator said the following:-On 01/08/26, HR escorted CNA into his/her office;-CNA A said he/she was assisting the resident to the restroom;-The resident was being combative, and as he/she was bent down in front of the resident, the resident spit on him/her;-CNA A said she popped the resident by putting her hand over the resident's mouth and told him/her not to do that;-Staff should never put their hands on a resident in an inappropriate manner;-Staff cannot hit or push residents, as it would be considered abuse. Complaint #2711706

Based on record review, observation, and interview the facility failed ensure all residents were treated with dignity and respect when one staff (Licensed Practical Nurse D) grabbed one resident's arm (Resident #1) and grabbed food out of the resident's hand. The facility's census was 109.Review of the facility's policy titled Dignity, revised February 2021, showed the following:-Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem;-Residents are treated with dignity and respect at all times;-Demeaning practices and standards of care that compromise dignity are prohibited;-Staff are expected to promote dignity and assist residents;-Staff are expected to treat cognitively impaired residents with dignity and sensitivity, addressing underlying motives or root causes for a behavior.1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 04/16/25;-Diagnoses included Alzheimer's (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest of tasks), high blood pressure, anxiety, depression, dementia with agitation, psychotic disturbance, mood disturbance, and anxiety. Review of the resident's care plan, revised 05/01/25, showed the following:-Risk for impaired communication;-Behavior management due to dementia, -Resident needs finger foods offered regularly because he/she does not sit still for meals; -Risk for visual impairment;-At risk for weight loss due to decreased appetite and dementia. Review of the resident's June 2025 Physician Orders showed the resident was on a regular textured diet.` Review of the resident's progress notes showed on 06/12/25, staff noted the resident had behaviors that included this resident trying to take food off of other residents' plates. Review of the camera footage on 07/01/25, at 10:39 A.M., showed the following:-On 06/18/25, at 4:48 P.M., during the dinner meal, Licensed Practical Nurse (LPN) D stood at the kitchen window where meal trays were passed thorough. -The resident approached the area where LPN D was standing and grabbed food off a meal tray;-The resident then with his/her left hand attempted to put food into his/her mouth. LPN D grabbed the resident's right arm with his/her left hand and then with right hand grabbed the food away from the resident; -The residents face appeared distraught and two certified nurse aides (CNA) approached and re-directed the resident from this serve-out area. During an interview on 07/18/25, at 2:35 P.M., CNA E said the following:-The resident was not alert and oriented and was very confused;-The resident cannot express what he/she wants and gets agitated at times;-On the date in question he/she was in the Special Care Unit (SCU) dining room and LPN D was doing the serve out window.-The resident was at the serve-out window and reached over to a plate and tried to get food off the plate;-He/she was not sure if the resident had any food in his/her hand and if the resident did have food staff should have let the resident have the food and should not have taken the food away from the resident;-LPN D yelled out for someone to come and get the resident;-He/she and another CNA approached and redirected the resident away from the serve out area;-He/she would not have taken food away from the resident. He/she would have just given the resident that meal tray;-It was rude to take the sandwich from the resident;-The staff are always supposed to treat the residents with dignity and respect. During an interview on 07/01/25, at 3:27 P.M., CNA C said the following: -If a resident was attempting to take food off a tray, he/she would redirect the resident away from the area;-If the resident had already grabbed food from a tray he/she would let them have it and replace the tray;-He/she would not attempt to grab food from a resident's hands unless it was a safety or choking issue;-He/she thought grabbing food from a resident would be disrespectful.During an interview on 07/01/25, at 2:51 P.M., Registered Nurse (RN) A said the following:-Nurses typically check meal orders coming from kitchen for diet accuracy and the CNA's pass the trays to the residents;-If a resident came to the window and tried to grab food, he/she would redirect them from the area;-He/she would not grab food from the resident if they already had it; -He/she would let the resident have the food and order another tray from the kitchen.During an interview on 07/01/25, at 4:10 P.M., the Director of nursing (DON) said the following:-The resident was not alert and oriented.-LPN D should have let the resident eat the sandwich and ordered another plate;-LPN D should never have grabbed the sandwich or any food away from the resident or any resident;-The resident does not usually sit at the table and eat meals. He/she is usually up wandering;-The resident typically eats finger foods. During an interview on 07/01/25, at 4:10 P.M., the Administrator said the following:-The resident had dementia.-LPN D should never have taken food away from the resident.-LPN D should have let the resident eat the sandwich and order another plate;-All Residents should be treated with dignity and respect. MO00256099

Based on interview and record review, the facility failed to establish a system of record keeping to ensure all controlled substances (substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) were accurately accounted for when staff did not accurately document all administrations of and could not easily reconcile the balance of a controlled medication for one resident (Resident #1) out of four sampled residents. The facility census was 110. The facility Administrator and the Assistant Director of Nursing (ADON) were notified of the Past Non-Compliance which occurred on 11/28/24. The facility staff began an investigation on 12/12/24 when the medication reconciliation error was found. The facility began immediate in-servicing of all staff who were on-site and as they arrived for work prior to beginning their shift. The facility also notified the Department of Health and Senior Services (DHSS) and the local law enforcement agency of the event. The facility completed medication audit, drug testing of staff who had access to controlled substances, and implemented additional medication procedures. The noncompliance was corrected on 12/12/24. Review of the facility's policy titled Controlled Substances, revised 11/2022, showed the following: -The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976); -Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises; -Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record; -If the count is correct, an individual resident controlled substance record is made for each resident who will be receiving a controlled substance. Do not enter more than one prescription per page. This record contains: name of the resident, name and strength of the medication, quantity received, number on hand, name of prescriber, prescription number, name of issuing pharmacy, date and time received, time of administration, method of administration, signature of person receiving medication, and signature of nurse administering medication; -Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; -The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the records of personnel access and usage; medication administration records, declining inventory records and destruction, waste; and return to pharmacy records; -Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; -The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services; -The Director of Nursing Services (DON) documents irreconcilable discrepancies in a report to the Administrator; -If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the DON notifies the Administrator and consultant pharmacist immediately; -The Administrator, consultant pharmacist, and/or DON determine whether other action(s) are needed, e.g., notification of police or other enforcement personnel; -The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met (example: a resident receiving a pain medication complains of unrelieved pain); -The DON consults with the provider pharmacy and the Administrator to determine whether any further legal action is indicated. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance)showed the following: -admitted [DATE]; -Diagnoses included chronic respiratory failure with hypoxia (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period, resulting in persistently low levels of oxygen in the blood (hypoxia) due to impaired lung function), pneumonia, and heart failure. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/18/24, showed the following: -The resident was cognitively intact; -The resident received scheduled and as needed (PRN) pain medications and non-medication interventions for pain; -The resident occasionally had pain; -The resident's pain occasionally effected the resident sleep and interfered with therapy and day to day activities; -The resident rated his/her pain at 4 on a scale of 0 to 10. Review of the resident's care plan, revised 12/10/24, showed the resident had acute and chronic pain related to chronic back pain. Interventions included staff to evaluate the resident's pain. Review of the resident's December 2024 Physician's Order Sheet (POS) showed the following: -An order, dated 10/14/24, for morphine sulfate (a prescription opioid analgesic drug that treats moderate to severe pain) oral solution 20 milligrams (mg)/milliliter (ml). Staff to administer .5 ml by mouth every two hours as needed for anxiety or air hunger (a sensation of shortness of breath or difficulty breathing). Review of the resident's November 2024 Medication Administration Record (MAR) showed on 11/27/24, at 9:17 P.M., the staff administered .5 ml morphine sulfate. Review of the resident's controlled drug record for morphine sulfate showed on 11/27/24, at 9:17 P.M., staff administered .5 ml with a balance of 40 ml. Review of the resident's November 2024 MAR showed on 11/28/24, at 10:55 P.M., the staff administered .5 ml morphine sulfate. Review of the resident's controlled drug record for morphine sulfate showed on 11/28/24, at 10:55 P.M., staff administered .5 ml with a balance (that was written over several times) of 39.5 ml (unable to determine the original documented balance). Review of the resident's November 2024 MAR showed on 11/29/24, at 5:33 A.M. and 9:05 P.M., staff administered .5 ml. morphine sulfate. Review of the resident's controlled drug record for morphine sulfate showed the following: -On 11/29/24, at 5:33 A.M., staff administered .5 ml with a balance (that was written over several times) of 39 ml (unable to determine the original documented balance); -On 11/29/24, at 9:05 P.M., staff administered, .5 ml with a balance (that was written over several times) of 38.5 ml (unable to determine the original documented balance). Review of the resident's December 2024 MAR showed on 12/01/24, at 4:00 P.M., staff administered .5 ml morphine sulfate. Review of the resident's controlled drug record for morphine sulfate showed on 12/01/24, at 4:00 P.M., staff administered .5 ml with a balance (that was written over several times) of 38 ml (unable to determine the original documented balance). Review of the resident's December 2024 MAR showed on 12/02/24, at 8:57 P.M., staff administered .5 ml morphine sulfate. Review of the resident's controlled drug record for morphine sulfate showed on 12/02/24, at 9:00 P.M., staff administered .5 ml with a balance (that was written over several times) of 37.5 ml (unable to determine the original documented balance). Review of the resident's December 2024 MAR showed on 12/03/24, at 9:27 P.M., staff administered .5 ml morphine sulfate. Review of the resident's controlled drug record for morphine sulfate showed on 12/03/24, at 9:28 P.M., staff administered .5 ml with a balance (that was written over several times) of 37 ml (unable to determine the original documented balance). Review of the resident's December 2024 MAR showed staff did not document administration of the resident morphine sulfate on 12/04/24. Review of the resident's controlled drug record for morphine sulfate showed on 12/04/24, at 10:00 P.M., staff administered .5 ml given with a balance (that was written over several times) of 36.5 ml(unable to determine the original documented balance). Review of the resident's December 2024 MAR showed staff did not document administration of the resident morphine sulfate on 12/05/24. Review of the resident's controlled drug record for morphine sulfate showed the following: -On 12/05/24, at 1:30 A.M., staff administered .5 ml with a balance (that was written over several times) of 36 ml (unable to determine the original documented balance); -On 12/05/24, at 10:00 P.M., staff administered .5 ml with a balance (that was written over several times) of 35.5 ml (unable to determine the original documented balance). Review of the resident's December 2024 MAR showed on 12/06/24, at 8:43 P.M., staff administered .5 ml morphine sulfate. (Staff did not document a second dose administered.) Review of the resident's controlled drug record for morphine sulfate showed the following: -On 12/06/24, at 1:00 A.M., staff administered .5 ml with a balance (that was written over several times) of 35 ml (unable to determine the original documented balance); -On 12/06/24, at 9:00 P.M., staff administered .5 ml. with a balance (that was written over several times) of 34.5 ml (unable to determine the original documented balance). Review of the resident's December 2024 MAR showed on 12/07/24, at 9:17 P.M., staff administered .5 ml morphine sulfate. (Staff did not document a second dose administered.) Review of the resident's controlled drug record for morphine sulfate showed the following: -On 12/07/24, at 2:00 P.M., staff administered .5 ml with a balance (that was written over several times) of 34 ml (unable to determine the original documented balance); -On 12/07/24, at 9:00 P.M., staff administered .5 ml given with a balance of 29.5 ml. The balance had a single line through it and new balance of 33.5 ml written in. Review of the resident's December 2024 MAR showed on 12/08/24, at 9:34 P.M., staff administered .5 ml morphine sulfate. (Staff did not document a second dose administered.) Review of the resident's controlled drug record for morphine sulfate showed the following: -On 12/08/24, at 1:45 A.M., staff administered .5 ml with a balance of 29 ml. The balance had a single line through it and new balance of 33 ml written in; -On 12/08/24, at 9:00 P.M., staff administered .5 ml with a balance of 28.5 ml. The balance had a single line through it and new balance of 32.5 ml written in. Review of the resident's December 2024 MAR showed on 12/09/24, at 9:07 P.M., staff administered .5 ml morphine sulfate. Review of the resident's controlled drug record for morphine sulfate showed on 12/09/24, at 9:00 P.M., staff administered .5 ml. with a balance of 28 ml. The balance had a single line through it and new balance of 32 ml written in. Review of the resident's December 2024 MAR showed staff did not document administration of the resident morphine sulfate on 12/10/24. Review of the resident's controlled drug record for morphine sulfate showed on 12/10/24, at 6:00 A.M., staff administered .5 ml. with a balance of 27.5 ml. The balance had a single line through it and new balance of 31.5 ml written in. Review of the resident's December 2024 MAR showed on 12/11/24, at 10:24 P.M., staff administered .5 ml morphine sulfate. (Staff did not document a second dose administered.) Review of the resident's controlled drug record for morphine sulfate showed the following: -On 12/11/24, time illegible, staff administered .5 ml with a balance of 27 ml. The balance had a single line through it and new balance of 31 ml written in; -On 12/11/24, at 9:30 P.M., staff administered .5 ml. with a balance of 26.5 ml. The balance had a single line through it and new balance of 30.5 ml written in. Review of the resident's December 2024 MAR showed on 12/12/24, at 1:35 A.M. and 9:47 P.M., staff administered .5 ml morphine sulfate. Review of the resident's controlled drug record for morphine sulfate showed the following: -On 12/12/24, at 1:30 A.M., staff administered .5 ml. with a balance of 26 ml. The balance had a single line through it and new balance of 30 ml written in.; -On 12/12/24, 26 ml of morphine sulfate was destroyed (a discrepancy of 4 ml). Review of the facility's investigation, received by Department of Health and Senior Services (DHSS) on 12-17-24, showed the following: -Narcotic count reviewed by Licensed Practical Nurse (LPN) B on 12/12/24, at approximately 8:00 A.M. Incorrect documentation was noted in narcotic count for morphine sulfate on 11/27/24. Documentation recorded 35.5 ml and the correct documentation was 39.5 ml. The Assistant Director of Nursing (ADON) was notified and reviewed the documentation. The medication was destroyed and medication was then pulled from the emergency kit. The resident did not miss any doses of medication; -On 12/12/24, at 6:37 P.M., the facility notified [NAME] Police Department; -On 12/12/24, at 6:47 P.M., staff notified the medical director; -The DON was unable to determine a cause of the missing medication due to insufficient information; -A written statement from LPN B, dated 12/12/24, showed he/she noticed at approximately 8:00 A.M. that there was an error in the documentation with the morphine count start on 11/27/24. He/she notified the ADON and he/she and the ADON then corrected the documentation. The ADON then notified the DON. During an interview on 12/31/24, at 9:52 A.M., Certified Medication Technician (CMT) A said licensed nurses passed narcotics at the facility. If he/she noticed missing medications, he/she first looked in the medication room and then notified the charge nurse if he/she could not find them. During interviews on 12/31/24, at 11:39 A.M. and 1:06 P.M., LPN B said the following: -On 12/12/24, he/she noticed a discrepancy in the resident's count of morphine sulfate in the narcotic book. A nurse deducted 1 ml when they should have deducted .5 ml; -He/she immediately reported this to the ADON; -He/she and the ADON looked and found the error and attempted to correct the count; -He/she should have drawn a single line through the original documentation and initialed it with two nurses, then wrote the correct amount out to the side; -He/she did not do this because there was not much room on the form; -Other nurses should have found the discrepancy earlier if they completed the count correctly and actually laid eyes on the bottle of medication; -He/she did not know if the resident's medication was accounted for. -When nurses completed shift change, they completed a count of the narcotics; -One nurse counts the medication while the other nurse verifies the amount in the narcotic log; -If a resident had two bottles of morphine sulfate opened, he/she used out of the bottle with the least amount first; -Nurses should not combine bottles of medication because this could cause the count to be inaccurate if they could not get all of the liquid out of the bottle. The ADON educated him/her on this and controlled medication procedures when the discrepancy was found. During interviews on 12/31/24, at 11:54 A.M. and 1:09 P.M., LPN C said the following: -When nurses completed shift change, they counted controlled medications together; -One nurse counts the medication and the other compares against the narcotic book; -If he/she noticed a discrepancy, he/she notified the DON immediately and did not accept the cart until it was resolved; -If an error was made in the narcotic log, he/she put a single line through the original documentation and the correct documentation to the side. Two nurses initialed this; -If a resident had two open bottles of a liquid medication, he/she used from the bottle with less medication in it; -He/she never combined the medications because there was a risk of spillage or not getting all of the medication out of one bottle. Also, he/she was not a pharmacist; -If there was a discrepancy between the medication count and the narcotic book documentation, it should be noticed immediately and not take 15 to 16 days to notice if nurses completed the count correctly and actually laid eyes on the medication. During interviews on 12/31/24, at 9:08 A.M. and 1:14 P.M., the ADON said the following: -LPN B started correcting the resident's narcotic log when the LPN brought the log to him/her; -He/she told the LPN they needed to put a single line through the original documentation and the correct documentation out to the side and initial this; -When he/she took over, he/she completed the correction correctly; -He/she could not tell what the original documentation was from 11/28/24 through 12/07/24; -He/she did not know where the 4 ml of morphine sulfate went; -At shift change, nurses completed report and counted controlled substances; -The on-coming nurse counted the pills, liquids and patches and the off-going nurse verified the amount in the narcotic book; -If the nurses noticed a discrepancy, they notified the ADON or DON immediately to investigate and the on-coming nurse did not take control of the medication cart until it was resolved; -If a resident had two open bottles of the same medication, the bottles were counted separately and had their own narcotic record; -Nurses should not combine the bottles because this could lead to an error in the count due to not being able to get all of the liquid out of the bottle. Also, they were not pharmacist; -Nurses should notice a discrepancy immediately if they completed the controlled substance count correctly. They should not take 15 to 16 days to notice a discrepancy. During an interview on 12/31/24, at 1:47 P.M., the Administrator said the following: -Nurses completed count of the controlled substances when they completed shift change; -Both nurses should go to the drawer, one nurse counted the medication and the other confirmed the amount on the narcotic log and both sign to verify the count was correct; -The nurses should look at the amount of liquid medication in the bottles; -The nurses should notice a discrepancy immediately and not 15 to 16 days later; -If the nurses noticed a discrepancy, they notified the ADON or DON immediately; -If a resident had two open bottles of liquid medication, they should not combine them because the medications could have different lot numbers and they were not pharmacists; -Each bottle of liquid medication should have it's own narcotic log. MO00246513

Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to maintain the cleanliness of the the bathrooms of six residents (Resident's #51, #89, #32, #36, #39 and #102). The facility census was 108. Review showed the facility did not provide a policy that related to cleaning and maintain the bathrooms in residents' rooms. Review of the facility's cleaning sheet titled, Housekeeping 3 (300 hall), undated, showed the following: -Five step procedure for rooms included pull trash/sanitize can/replace liner, horizontal surfaces, vertical surfaces, dust mop, and damp mop; -Seven step procedure for bathrooms included check/refill supplies, pull trash/sanitize can/replace liner, dust mop/sweep, clean sink area/tub, clean commode/base, clean walls/partitions, and damp mop; -At 8:15 A.M., begin regular day cleaning on resident rooms 301, 303, 305, and 307 using five step/seven step procedure; -At 10:00 A.M., continue regular day cleaning on resident rooms [ROOM NUMBER] using five step/seven step procedure; -At 10:45 A.M., continue regular day cleaning on resident rooms 302, 304, 306, 308, 310, 312, 314 and 316 using five step/seven step procedure; -Wednesdays focus cleaning schedule bath floors and focus on corners and edges. 1. Review of Resident #51's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia, anxiety, and syncope (fainting). Review of Resident #51's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 04/12/23, showed the following: -Severe cognitive impairment; -Dependent on staff with toileting hygiene. Review of Resident #89's face sheet showed the following: -admitted [DATE]; -Diagnoses included bradycardia (slower than normal heartbeat), syncope, dementia, anxiety, chronic kidney disease. Review of Resident #89's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent on staff with toileting hygiene. Observation on 06/04/24, at 10:43 A.M., of Resident #51's and Resident #89's shared bathroom showed brown fecal-like substance smeared on the toilet seat. Observation on 06/05/24, at 9:20 A.M., of Resident #51's and Resident #89's shared bathroom showed brown fecal-like substance smeared on the toilet seat. The room had a strong urine-like odor when entering. 2. Review of Resident #32's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia, cognitive communication deficit, hypokalemia (low potassium), and schizophrenia (mental health condition that affects how people think, feel and behave). Review of the Resident #32's quarterly MDS), dated [DATE], showed the following: -Severe cognitive impairment; -Set-up and clean up assistance required for toileting hygiene. Review of Resident #36's face sheet showed the following: -admitted [DATE]; -Diagnoses included chronic kidney disease, dementia, anxiety, and depression. Review of the Resident #36's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with toileting hygiene. Observation on 06/04/24, at 9:59 A.M., of Resident #32's and Resident #36's shared bathroom showed the following: -The walls were dirty with soap and grime dried dripping down the wall under the soap dispenser; -The wall behind a three-drawer dresser had several small brown spots; -The bottom quarter of the mirror was dirty with grime; -The room had a strong urine-like odor upon entering and was stronger in the bathroom; -The toilet had a brown fecal-like matter smeared down the front of the toilet, in between the toilet seats and all inside the toilet; -The bathroom floor was dirty and had debris. Observation on 06/06/24, at 9:25 A.M., of Resident #32's and Resident #36's shared bathroom showed the following: -The bathroom walls were dirty with soap and grime dried dripping down the wall under the soap dispenser; -The wall behind a three-drawer dresser had several small brown spots; -The bottom quarter of the mirror was dirty with grime; -The room had a strong urine-like odor upon entering and was stronger in the bathroom; -There was a large amount of brown fecal like matter splatter all over the inside of the toilet, all down the side of the toilet to the base of the toilet, on the floor next to the toilet, and on the wall next to the toilet. Observation on 06/06/24, at 1:42 P.M., of Resident #32's and Resident #36's shared bathroom showed the following: -The bathroom walls were dirty with soap and grime dried dripping down the wall under the soap dispenser; -The wall behind a three-drawer dresser had several small brown spots; -The bottom quarter of the mirror was dirty with grime; -The room had a strong urine-like odor upon entering and was stronger in the bathroom; -The side of the toilet had a large amount of brown fecal-like matter smeared from the top to the base of the toilet, on the floor next to the toilet, and on the wall next to the toilet. Observation on 06/07/24, at 9:40 A.M., of Resident #32's and Resident #36's shared bathroom showed the following: -The bathroom walls were dirty with soap and grime dried dripping down the wall under the soap dispenser; -The wall behind a three-drawer dresser had several small brown spots; -The bottom quarter of the mirror was dirty with grime; -The side of the toilet had a large amount of brown fecal-like matter smeared from the top to the base of the toilet, on the floor next to the toilet and on the wall next to the toilet. During an interview on 06/07/24, at 9:52 A.M., Certified Nurse Aide (CNA) B/Activities Director said the following: -The toilet and wall should not have smeared brown fecal-like substance on them; -He/she could smell the strong odor of urine when entering the room; 3. Review of Resident #39's face sheet showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), high blood pressure, major depressive disorder, chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart disease. Review of the Resident #39's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent on staff for toileting hygiene. Review of Resident #102's face sheet showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia, anxiety disorder, depression, cognitive communication disorder, COPD, and heart disease. Review of the Resident #102's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Partial/moderate assistance required from staff for toileting hygiene. Observation on 06/06/24, at 9:22 A.M., of Resident #39's and Resident #102's shared bathroom showed the following: -Brown fecal-like substance smeared on the back of the toilet seat; -The wall next to the toilet had small brown spots and dried substances; -The floor around the toilet area was dirty and had several small brown spots. Observation on 06/06/24, at 1:30 P.M., of Resident #39's and Resident #102's shared bathroom showed the following: -Brown fecal-like substance smeared on the back of the toilet seat; -The wall next to the toilet had small brown spots and dried substances; -The floor around the toilet area was dirty and had several small brown spots. Observation on 06/07/24, at 9:40 A.M., of Resident #39's and Resident #102's shared bathroom showed the following: -Brown fecal-like substance smeared on the back of the toilet seat; -The wall next to the toilet had small brown spots and dried substances. 4. During an interview on 06/06/24, at 1:42 P.M., CNA A said housekeeping cleans room daily. He/she notifies housekeeping of any cleanliness issues in a resident's bathroom. 5. During an interview on 06/07/24, at 9:52 A.M., CNA B/Activities Director said housekeeping cleans rooms daily, including the bathrooms. Housekeeping is responsible for cleaning brown fecal-like matter on the toilets, walls and floors. 6. During an interview on 06/07/24, at 10:30 A.M., Housekeeping C said staff should clean every room in the facility once per day, which includes sanitizing everything such as doorknobs and light switches, dust, dry mop and damp mop the room floor, take out the trash from the room and then clean the bathroom including sink, dresser, walls if dirty, mirror, and all of the toilet, including the floor around and sides. Housekeeping is responsible for cleaning smeared brown fecal-like matter, and there should be no smeared brown fecal-like matter in the bathroom. The walls should not have brown spots, dirt, or grime on them. 7. During an interview on 06/07/24, at 10:47 A.M , the Housekeeping Supervisor said the following: -Staff should clean every room in the facility one time per day, utilizing the five and seven step cleaning process on the cleaning sheet; -Staff should start with the light switches, doorknobs, windowsills, and closets, disinfecting all surfaces. Staff then gather trash, clean the floor in the room up to the bathroom, and then change out cleaning cloth and start cleaning the bathroom; -Staff should clean the sink, the mirror, soap and hand sanitizer dispensers, the toilet from top to the bottom. and the floor; -The walls should be cleaned if visibly dirty and any smeared brown fecal-like matter should clean thoroughly; -Toilets, walls, and floors should not have smeared brown fecal-like matter on them. 8. During an interview on 06/07/24, at 1:06 P.M., the Administrator said the following: -Staff should clean resident rooms daily and deep clean them monthly; -The daily cleaning of the bathroom should include cleaning all of the toilet, floor around toilet, walls if dirty, sink, and mirror and mop all of the floor; -There should be no smeared brown fecal-like substances on the toilet, walls, or floor; -There should be no dirt or grime on the walls.

Based on observation, interview, and record review, the facility failed to ensure all medications were stored per standards of practice when staff walked away and out of view of an unlocked medication cart containing resident medications. The facility census was 108. Review of the facility policy titled Administering Medications, revised 12/12, showed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse 1. Observation on 06/05/24, beginning at 2:45 P.M., showed Certified Medication Technician (CMT) D prepared medications for multiple residents and placed the cups containing the medication in the top drawer of the medication cart. The CMT then walked away from the medication cart without locking the care. The CMT walked to dining room approximately twenty-five feet away and turned his/her back to medication cart to check a blood pressure of a resident. The CMT was in not in line of sight of the unlocked medication cart. During an interview on 06/06/24, at 9:00 A.M., CMT E said he/she always locks the medication cart before walking away from the cart. During an interview on 06/06/24, at 11:00 A.M., Licensed Practical Nurse (LPN) J said he/she always locks the medication cart before walking away from the cart. During an interview on 06/06/24, at 2:01 P.M., CMT G said he/she locks his/her cart before walking away from it. During an interview on 06/06/24, at 2:53 P.M., LPN K said he/she always locks the medication cart before walking away. During an interview on 06/06/24, at 3:09 P.M., CMT F said he/she would always lock his/her medication cart before walking away from it. During an interview on 06/07/24, at 8:30 A.M., CMT H said he/she always locks the medication cart before walking away. During an interview on 07/07/24, at 8:45 A.M., the Director of Nursing (DON) said that he/she expects staff to lock their medication cart prior to walking away from them. During an interview on 07/07/24, at 9:00 A.M., the Administrator said that he/she expects staff to always lock their medication carts prior to walking away from them.

Based on observation, interview, and record review, the facility failed to ensure all medical records were maintained in a confidential fashion when staff left the computer on medication cart unlocked, unattended, and visible to other for one resident (Resident #5). The facility census was 108. 1. Review of Resident # 5's face sheet showed the following information: -admitted [DATE]; -Diagnosis included hypertension (high blood pressure), diabetes, and chronic kidney disease. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/06/24, showed the resident had moderate cognitive impairment. Observations on 06/05/24, starting at 2:45 P.M., showed Certified Medication Technician (CMT) D prepared medication for the resident. CMT D then walked away from the medication cart with the computer screen showing patient information, including medication orders. CMT D walked to dining room approximately twenty-five feet away and turned his/her back to medication cart to check the resident's blood pressure. The resident' medical information would be visible to any staff, residents, or visitors passing by. During an interview on 06/06/24, at 9:00 A.M., CMT E said he/she always locks his/her computer screen before walking away from the cart. During an interview on 06/06/24, at 11:00 A.M., Licensed Practical Nurse (LPN) J said he/she always locks the computer screen before walking away from the cart. During an interview on 06/06/24, at 2:01 P.M., CMT G said he/she locks computer before walking away from it. During an interview on 06/06/24, at 2:53 P.M., LPN K said he/she always locks the computer screen before walking away. During an interview on 06/06/24, at 3:09 P.M., CMT F said he/she would always lock computer screen before walking away from it. During an interview on 06/07/24, at 8:30 A.M., CMT H said he/she always locks the computer screen before walking away. During an interview on 07/07/24, at 8:45 A.M., the Director of Nursing (DON) said he/she expects staff to lock their computer screen prior to walking away from them. During an interview on 07/07/24, at 9:00 A.M., the Administrator said that he/she expects staff to always lock computer screens prior to walking away from them.

Based on interview and record review, the facility failed to ensure residents' right to share a room with his or her roommate of choice and the right to receive written notice of the room change, including the reason, were protected when staff moved one resident (Resident #1) to a room on a different hall without a written notice issued or documentation of the resident's consent to the change. The facility had a census of 105. Review of the facility's policy titled, Room Change/Roommate Assignment, revised March 2021, showed the following information: -Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered; -Room changes initiated by the facility are limited to moves within the same building in which the resident currently resides, unless the resident voluntarily agrees to move to another building within the same facility; -Residents have the right to share a room with their roommate of choice, including a spouse, domestic partner, or friend, as long as both parties live in the same facility, and consent to the arrangement; -Residents may not demand to displace a current roommate to accommodate a roommate request; -Prior to changing a room or roommate assignment all parties involved in the change are given a verbal notice of such change; -Verbal notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his/her new roommate; -Residents have the right to refuse to move to another room in the facility if the purpose of the move is to relocate the resident from a skilled nursing unit within the facility to one that is not a skilled nursing unit and to relocate the resident from a nursing unit within the facility to one that is a skilled nursing unit; -Documentation of a room change is recorded in the resident's medical record; -Inquiries concerning room changes should be referred to social services or designated staff. (The policy did not address the requirement of a written notice to be provided.) 1. Review of Resident #1's face sheet (basic information sheet) showed the following: -admitted [DATE]; -Diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and mild cognitive impairment. Review of the resident's Durable Power of Attorney (DPOA -a written authorization of an appointed individual to represent or act on another's behalf in private affairs, business, or some other legal matter that includes the appointed individuals ability to maintain their role as power of attorney in the event the initial individual is incapacitated and unable to make decisions for themselves) paperwork, dated 03/29/13, showed the two individuals were designated as DPOA for the resident. Review of the resident's record showed the facility did not provide documentation the resident was deemed incapacitated or unable to make his/her own decisions. The record did not indicate the DPOA was enacted. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/14/24, showed the following: -Moderate cognitive impairment; -Mild depression; -Verbal and physical behaviors indicated one to three days; -Rejection of care four to six days. Review of the resident's care plan, current as of 03/15/24, showed the following: -At times resident may have delusions and/or hallucinations and may exhibit behaviors that are inappropriate for the situation at hand. Physician is aware of these behaviors. -Socially inappropriate/disruptive behavior. The resident will tell staff his/her medications are not what they are supposed to be. Two staff when giving medication. Resident also has conflicts with neighbors if he/she feels they do not give him/her the attention he/she wants and will cry and yell to anyone who will listen. He/She has difficulty maintaining healthy relationships with peers. Remind resident when behavior is not appropriate; -Verbally aggressive behavior. The resident will often yell at staff when they do not respond immediately to requests. He/She will often yell at staff if they do not give a response that he/she does not agree with. Review of the resident's departmental notes showed the following: -On 02/29/24, at 10:40 A.M., the Social Services Director (SSD) documented he/she spoke with both DPOA's regarding a care plan meeting for 03/01/24, at 1:30 P.M., regarding the resident's behaviors surrounding staff, visitors, and other peers; -On 03/01/24, at 2:05 P.M., the SSD documented one of the residents DPOA's called to inform the facility he/she would not be able to meet for the scheduled meeting and requested rescheduling. The meeting was rescheduled for 03/06/24, at 3:00 P.M The facility was fine with moving the meeting to review the residents behavior. The facility wanted to discuss the need to move the resident rooms that day. The SSD went into brief detail regarding how the resident treats staff and the stress he/she caused to all who have cared for him/her. The facility wants permission to move the resident versus relocating all of the staff that work on the hall. The DPOA agreed it was easier to move one resident versus relocating numerous staff so he/she agreed to the room change from 400 hall to 100 hall. (Staff did not document any written notice.); -On 03/01/24, at 2:21 P.M., the SSD documented he/she and the Assistant Director of Nursing (ADON) spoke with the resident regarding his/her behavior and the reason a room move needed to occur on 03/01/24. The SSD documented the resident is aware the facility had been speaking with the DPOA's and informed the resident the care plan meeting had been rescheduled to 03/06/24, at 3:00 P.M., and that they are fine with the room move. One of the two DPOA is requesting calls when the resident's behavior and responses are not appropriate of affect others. The SSD documented the resident apologized regarding his/her negative behaviors involving a staff member. (Staff did not document the resident agreed to the room move or any written notice issued regarding the move.) -On 03/01/24, at 6:19 P.M., the SSD documented one of the DPOA came to the facility to requesting to speak to the facility regarding the room move as he/she had not been notified by the other DPOA. -On 03/02/24, at 3:27 A.M., a nurse documented the resident has been upset all evening about his/her room move. The resident stated he/she cannot handle his/her roommate and will not be able to survive staying in the room. The resident has been up in the dining room most of the shift due to the roommate talking throughout the night. The resident was informed these was not much staff would do as the roommate had his/her medications but was not sleeping well. The resident was informed it was their room as well and cannot make the roommate go to sleep. The resident remains unhappy with staff and the situation. Review of the resident's record showed the facility did not document resident consent to the room change or written notice provided. During an interview on 03/14/24, at 1:34 P.M., the resident said the following: -He/She has resided at the facility for approximately one year; -He/She is responsible for himself/herself; -He/She was brought into the ADON office a few days ago to speak to the ADON and SSD; -The ADON and SSD told him/her that he/she had been rude to staff and they wanted to move him/her to 100 hall; -He/She told the ADON and SSD that he/she did not want to move rooms; -He/She was roommates with Resident #2; -He/She was moved to 100 hall with another resident. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses including Alzheimer's disease and dementia; -The resident is responsible for himself/herself. Review of the resident's annual MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's departmental notes showed the following: -On 02/14/24, at 9:14 A.M., the SSD documented he/she visited with the resident at length regarding a report from hospice that he/she complained to them about his/her roommate. The resident said he/she got along with his/her roommate and reported he/she does not want to move and wanted his/her roommate to remain his/her roommate. During an interview on 03/14/24, at 1:02 P.M., Resident #2 said the following: -He/She has resided at the facility for approximately one year; -Resident #1 was his/her roommate until one to two weeks ago; -He/She did not know why Resident #1 was moved to another room; -He/She did not request Resident #1 to be moved to another room; -He/She did not know how Resident #1 felt about moving rooms; -He/She did not have issues with Resident #1 being his/her roommate. 3. During an interview on 03/14/24, at 2:36 P.M., Certified Nurses Assistant (CNA) A said the following: -Resident #1 used to reside on 400 hall, but was moved approximately one month ago; -Resident #1 did not want to move off 400 hall and was upset about the room change; -The Administrator is responsible for room changes. 4. During an interview on 03/15/24, at 10:26 A.M., Certified Medication Technician (CMT) B said the following: -He/She was unaware of why Resident #1 moved rooms; -Room changes is typically a group effort between multiple staff, but the administrative staff ultimately decide what room changes are needed. 5. During an interview on 03/15/24, at 10:45 A.M., CNA C said the following: -He/She believes Resident #1 is not happy with being moved rooms and there have been issues with each roommate he/she has had since; -The Administrator and ADON are responsible for room changes. 6. During an interview on 03/15/24, at 11:02 A.M., Licensed Practical Nurse (LPN) D said the following: -Resident #1 was moved from 400 hall a few weeks ago; -He/She did not know why Resident #1 was moved from 400 hall; -Room changes are handled by the administrative staff. 7. During an interview on 03/15/24, at 12:39 P.M., Registered Nurse (RN) E said the following: -He/She works 400 hall; -Resident #1 did not want to move rooms and had apologized for his/her behaviors; -The SSD handles room changes. 8. During an interview on 03/15/24, at 12:52 P.M., the SSD said the following: -The room change process started for Resident #1 due to reports he/she was making residents on 400 hall uncomfortable and report from hospice staff that Resident #1 was not nice to his/her roommate (Resident #2); -He/She spoke to Resident #2 who reported everything was fine and declined need to move Resident #1; -On 03/01/24 he/she spoke to Resident #1's family regarding the need to facilitate a room change due to behavioral issues, stress to staff, and issues with peers. The family approved the room change; -He/She and the ADON spoke with Resident #1 regarding the room change following speaking with the resident's family. The resident was agreeable with the room change; -Resident #1 wanted to go back to his/her room after the arrangement did not work out well with the new roommate but the room had already been filled; -Resident #1 would not have been moved rooms without his/her agreement; -Room changes are to be documented in the social services notes or nurses notes; -The facility does not have a written room change notice or room change consent form for the resident or responsible party to sign. During an interview on 03/15/24, at 1:29 P.M., the ADON said the following: -Resident #1 did not get along with other residents residing on 400 hall; -Hospice staff reported Resident #1 talked down to his/her roommate (Resident #2); -He/She spoke to Resident #2 who reported Resident #1 talked to him/her like he/she was a child; -He/She redirected Resident #1 regarding this behavior and there had not been issues between them after he/she spoke to Resident #1; -He/She and the SSD spoke with Resident #1 regarding a room change in his/her office (specific date and time not known); -They offered the room move to the resident due to issues with staff and other residents; -Resident #1 agreed to the room change and understood the reason for the room change; -Resident #1 is responsible for himself/herself. During an interview on 03/15/24, at 2:19 P.M., the DON said the following: -Resident #1 had behaviors including asking resident families to purchase goods for him/her, talking down to his/her roommate, and had behaviors directed toward RN E; -The DON, Administrator, ADON, Nurse Educator, and SSD discussed and decided it was best for a room change for Resident #1; -The SSD and ADON spoke to Resident #1 who agreed to moving rooms; -Consent to room changes should be documented; -The SSD is responsible for documenting room change and consent to the room change. During an interview on 03/15/24, at 2:19 P.M., the Administrator said the following: -Resident #1 had behaviors including asking resident families to purchase goods for him/her, talking down to his/her roommate, and had behaviors directed toward RN E; -The Administrator, DON, ADON, Nurse Educator, and SSD discussed and decided it was best for a room change for Resident #1; -The SSD and ADON spoke to Resident #1 who agreed to moving rooms; -Consent to room changes should be documented; -The SSD is responsible for documenting room change and consent to the room change. MO00232685 and MO00232774

Based on interview and record review, the facility failed to ensure all residents received adequate supervision to prevent possible accidents when staff failed to respond to an alarm when one resident (Resident #1) left the facility at night, was found by a neighboring facility's staff, and suffered a fall with injury, and when the facility staff failed to have a process in place, and ensure all staff were trained on the process, to routinely check wander prevention devices to ensure they worked correctly for two residents (Resident #1 and Resident #2). The facility had a census of 101. Review of a facility policy titled, Wandering and Elopements, revised March 2019, showed the following information: -The facility is to identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; -Residents identified as at risk for wandering, elopement, or other safety issues will have strategies and interventions to maintain the residents safety documented in the care plan; -If a resident is missing staff are to initiate elopement/missing resident emergency procedures. Review of a facility policy titled, Elopement Precautions/Missing Resident, revised in 2007, showed the following information: -All exit doors from the facility that are not under direct observation shall be alarmed; -Egress doors alarmed in the facility include the front entrance, 100 hall, 200 hall, 300 hall, 300 hall patio door, 400 hall, and employee hall; -If the facility has an electric monitoring system. Any resident who has been identified as an elopement risk shall have a device placed on their wrist or ankle; -The monitoring device is to be inspected according to manufacturer specifications to ensure proper function of the device; -The facility has electronic monitoring system areas that are activated by personal electronic monitoring system devices at the front entrance, 100 hall, 200 hall, 300 hall, 400 hall, 300 hall patio door, and employee hall; -When the door alarm sounds, the charge staff assigned to the area where the door is located, or their designee, will immediately investigate; -If the cause of the alarm is not immediately known, the area outside the door will be checked at the same time an accounting of the residents inside the facility occurs; -An alarm is never to be shut off without verifying how the alarm was activated or verifying that all resident whereabouts are known; -Residents considered an elopement risk are to have their whereabouts confirmed at least every 30 minutes; -Residents demonstrating agitation and elopement attempts are to remain under constant surveillance until the period of agitation resolves; -Increased whereabouts checks shall be maintained until staff is assured the resident is thoroughly redirected and is safe to return to 30 minute checks; -Residents who are assessed to be elopement risks shall have specific care plan interventions that identify how to manage the resident's elopement behavior; Review of the manufacturer's manual for the facility wanderguard devices titled, ID-TAD, undated, showed the following information: -The ID-TAD is the device that activates, deactivates, and tests the wanderguard tags placed on residents; -The ID-TAD utilizes an display screen to provide information of the tags including, tag type, tag number, warranty date, and a battery test of the wanderguard tags; -If the battery displays GOOD the tag can continue to be used; -If a battery LOW flag displays the tag needs to be replaced; -Tags should be tested a minimum of once per week. 1. Review of Resident #1's face sheet (basic information sheet) showed the following: -admitted [DATE]; -Diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), depression (a group of conditions associated with the elevation or lowering of a person's mood, such as depression or bipolar disorder), and adult failure to thrive. Review of the resident's care plan, dated 05/02/23, showed the following: -The resident had wandering behaviors including roaming halls in his/her wheelchair or rolling walker; -Interventions included monitoring the resident related to wandering. (Staff did not care plan related to a wanderguard or maintenance of the device.) Review of the resident's Minimum Data Sheet (MDS- a federally mandated assessment tool completed by facility staff), dated 08/04/23 , showed the resident had severe cognitive impairment. Review of the resident's current Physician's Order Sheet (POS), as of 09/28/23, showed the following: -The resident did not have documented orders for a wanderguard; -The resident did not have documented orders for monitoring of the wanderguard for location and function. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for September 2023 showed no orders or record of inspection of location and function of his/her wanderguard device. Review of the resident's progress notes showed the following: -On 09/28/23, at 4:39 A.M., Licensed Practical Nurse (LPN) D documented he/she was notified by phone that the resident had fallen in the parking lot of a neighboring facility. The resident was returned to the facility. The resident had an abrasion to his/her left thumb and palm area. The resident had bruising noted as well (not specified). The resident reported he/she was looking for his/her family. Review of facility's videos of the resident's elopement on 09/28/23 showed the following: -At 12:58 A.M., the resident wheeled him/herself to the front lobby of the facility in his/her wheelchair. No staff were visible in the area; -At 12:59 A.M., the resident approached the front door to the facility, stood from his/her wheelchair, pushed the front entrance door open, walked through the front door, held the front door open while pulling his/her wheelchair past the front door, and exited the facility seated in his/her wheelchair. No staff were visible in the area; -At 1:37 A.M., LPN D exited the front door of the facility and stood outside next to the entrance; -At 1:44 A.M., LPN D returned inside the facility; -At 2:11 A.M., three staff (Certified Nurses Assistant (CNA) F, CNA H, and CNA G) exited the facility through the front entrance; -At 2:21 A.M., the resident returned to the facility through the front entrance being wheeled by CNA F and accompanied by CNA H and CNA G. During an interview on 09/28/23, at 2:37 P.M., LPN A said the following: -The resident wears a wanderguard; -He/She was unaware of any other residents who have a wanderguard; -The resident's wanderguard went off frequently due to him/her getting too close to the exit doors; -If the wanderguard alarm goes off staff are to immediately go to the wanderguard alarm panel to see which location to respond to; -Staff are to immediately respond to the area indicated on the alarm panel to search for the resident; -If the resident cannot be located staff are to implement measures indicated in the elopement policy; -The wanderguard alarm is not supposed to be shut off until staff are confirmed to be responding to the alarm. During an interview on 09/28/23, at 2:44 P.M., Registered Nurse (RN) B said the following: -The resident has a wanderguard; -If the wanderguard alarm sounds at the nurses' station staff are to respond immediately to the area indicated on the alarm panel to search for the resident; -If the resident cannot be located staff are to implement measures indicated in the elopement policy; -The wanderguard alarm is not supposed to be reset until staff verify the residents location; -The resident is exit seeking and often states he/she is looking for his/her family. During an interview on 09/28/23, at 4:43 P.M., Certified Nursing Assistant (CNA) C said the following: -The resident had a wanderguard; -He/She was unaware of any other residents with a wanderguard in place; -The resident paces the halls, but he/she had never observed the resident trying to get out of the doors; -If the wanderguard alarm panel sounds staff are to respond to the area designated on the panel immediately to search for the resident. During an interview on 09/28/23, at 8:51 P.M., LPN D said the following: -He/She was working as the charge nurse on the resident's hall when he/she eloped from the facility; -He/She did not know what time the resident eloped from the facility; -He/She last observed the resident in the facility at 12:00 A.M.; -The wanderguard alarm panel went off twice during his/her shift; -He/She could not recall what time the alarms went off or how much time passed between the first and second alarm; -The first time the wanderguard alarm went off the resident was located on 400 hall and was redirected; -He/She did not know how long the alarm went off for the first time; -The second time the wanderguard alarm went off he/she was in the medication room with LPN E; -He/She came out of the medication room and did not see staff; -He/She silenced the alarm and went to pass medications; -He/She assumed other staff addressed the wanderguard alarm; -He/She did not verify staff addressed the alarm before silencing; -He/She did not instruct staff to conduct a count of residents to ensure all residents were accounted for; -He/She went outside to smoke sometime after the second alarm went off and did not see anyone outside; -Only residents wearing a wanderguard will set off the wanderguard system alarm; -Staff are to immediately respond to the wanderguard alarm by checking all exit doors; -The wanderguard alarm panel is not supposed to be reset until the resident is located; -If the resident is not located staff are to implement the elopement policy; -The charge nurse is responsible for conducting a head count of residents with wanderguards if the alarm goes off; -He/She should have verified location of wanderguard residents when the alarm went off instead of assuming the alarm was being addressed. During an interview on 09/28/23, at 9:09 P.M., CNA F said the following: -The resident had a wanderguard; -The resident wandered often, but did not try to leave the facility; -The wanderguard went off twice during his/her shift; -He she did not know what time the alarms went off; -The first time the alarm went off the resident was located on 400 hall by LPN D who redirected the resident; -The second alarm went off approximately 10 to 15 minutes after the first alarm; -The second alarm sounded for approximately 3 seconds and then stopped; -He/She was in a room providing care when the second alarm went off; -No guidance or instruction was given by the charge nurse staff to verify resident locations or search for a resident; -He/She did not ask anyone if the alarm had been addressed; -If the wanderguard alarm sounds staff are to immediately respond to the alarm and location of the alarm to conduct a search for the resident; -On 09/28/23, at 2:00 A.M., a neighboring facility called and reported to LPN D that the resident was at their facility; -He/She immediately went to the neighboring facility and brought the resident back to the facility; -The resident said he/she was looking for his/her family; -The resident had a cut on his/her left hand. During an interview on 09/28/23, at 9:22 P.M., LPN E said the following: -He/she was working as the charge nurse for 100 and 400 hall when the resident eloped from the facility on 09/28/23; -The resident had a wanderguard; -The resident is often awake at night and wanders around the facility; -The resident was not exit seeking, but did like to sit at the exits and look out the window; -The wanderguard alarm sounded twice during his/her shift; -He/She could not recall what time the alarms sounded; -The first time the alarm sounded Resident #1 was located on 400 hall and was redirected; -The second alarm went off while he/she and LPN D were in the medication room; -He/She did not know how long the second alarm sounded; -LPN D came out of the medication room and silenced the alarm; -The wanderguard alarm did not sound again after being reset and he/she assumed the resident who set off the alarm had been brought back to their room; -He/She did not verify the alarm had been addressed and the resident that triggered the alarm had been located; -If the wanderguard alarm sounds all staff available are to respond to the alarm and search for the resident; -The alarm is not supposed to be reset until the resident is located or it is confirmed staff are addressing the alarm; -Charge nurse staff are responsible for coordinating searching for residents and confirming locations when the alarm goes off; -No instruction was given to staff to address the alarm or confirm resident locations; -He/She did not know if LPN D addressed the alarm or confirmed another staff had addressed the alarm; -On 09/28/23, at 2:00 A.M., a neighboring facility called and reported they had the resident; -The resident was brought back to the facility immediately; -The resident had a scrape on his/her hand. During an interview on 09/28/23, at 9:40 P.M., CNA G said the following: -He/She was working when the resident eloped from the facility on 09/28/23; -The resident had a wanderguard; -Two wanderguard system alarms sounded during his/her shift; -The first alarm sounded around 12:00 A.M.; -The second alarm sounded approximately 10 to 15 minutes after the first alarm; -The resident was located on 400 hall immediately following the first alarm and redirected; -He/She was in a resident room providing care when the second alarm sounded; -He/She did not know how long the alarm sounded the second time; -The second alarm had been turned off by the time he/she left the room he/she was providing care in; -He/She assumed staff had addressed the alarm since it had been silenced; -No instructions or guidance was give to him/her by any staff to search for or locate a resident; -He/She did not ask any staff if the alarm had been addressed; -On 09/28/23, at 2:00 A.M., a neighboring facility called and reported they had found the resident and brought him/her inside; -He/She and two additional staff immediately went to the neighboring facility and brought the resident back to the facility; -The resident reported he/she fell (unknown when or how) and hurt his/her hand; -All available staff are to respond to wanderguard alarms immediately and begin searching for the resident that triggered the alarm. During an interview on 09/29/23, at 9:49 A.M., LPN H said the following: -The resident had a wanderguard; -If the wanderguard alarm sounds staff are to immediately respond to the area indicated on the alarm panel to search for the resident that triggered the alarm; -If the resident identified cannot be located the staff are to implement the elopement policy immediately; -Nursing staff typically address the wanderguard alarm, but CNA staff do as well; -CNA staff are to report to the charge nurse if they address the alarm; -The wanderguard alarm is not to be silenced unless it is verified staff addressed the alarm; -Nursing staff are to verify location of wanderguard devices on residents that wear them. During an interview on 09/29/23, at 9:58 A.M., RN I said the following: -Resident #1 had a wanderguard; -If the wanderguard alarm sounds staff are to check the alarm panel and respond to the area that was triggered; -Staff are to search the area for the resident that triggered the alarm; -If the wanderguard resident cannot be located staff are to immediately implement the elopement policy. During an interview on 09/29/23, at 12:26 P.M., the Regional Nurse Consultant said the following: -Staff are to immediately respond to wanderguard alarms and conduct a resident count to verify resident location; -If a resident cannot be located the facility is to immediately implement the elopement policy; -The wanderguard alarm panel sounds until silenced or reset by someone; -The wanderguard alarm should only be silenced once staff are confirmed to be addressing the alarm; -The charge nurse is responsible for coordinating the search for residents when the wanderguard alarm is triggered. During an interview on 09/29/23, at 12:30 P.M., the Director of Nursing (DON) said the following: -Residents with wanderguards should have an physician's order documented in the medical record; -The resident had a wanderguard; -The wanderguard alarm panel indicates which area is triggered; -The charge nurse is to direct staff to the triggered area to address the alarm; -Staff should respond immediately to the alarm; -If the resident who triggered the alarm cannot be located the facility staff are to implement the facility elopement/missing resident procedures. During an interview on 09/29/23, at 12:59 P.M., the Administrator said the following: -The resident had a wanderguard; -If the wanderguard alarm panel sounds staff are to immediately respond to the location triggered and indicated on the alarm panel to conduct a search for the resident that triggered the alarm; -The alarm should not be silenced or reset until staff verify the alarm is being addressed; -Staff should conduct a head count and implement the elopement policy immediately if the resident cannot be located; -The charge nurse is responsible for the initial response to the alarm. 2. Review of Resident #2's face sheet showed the following information: -admitted [DATE]; -Diagnoses including dementia, depression, and insomnia (a sleep disorder causing difficulty sleeping). Review of the resident's care plan, dated 03/27/23, showed staff care planned a monitoring device placed on the resident that sounds when the resident leaves the facility. Review of the resident's MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's current POS, as of 09/28/23, showed an order, dated 05/18/23, for a wanderguard device (arm bracelet) for safety at all times to be inspected for placement and function each shift starting 05/18/23. Review of the resident's September 2023 MAR showed staff documented regular inspection of the wanderguard device. During an interview on 09/28/23, at 9:09 P.M., CNA F said the resident had a wanderguard. During an interview on 09/28/23, at 9:22 P.M., LPN E said the resident had a wanderguard. During an interview on 09/28/23, at 9:40 P.M., CNA G said the resident had a wanderguard. During an interview on 09/29/23, at 9:49 A.M., LPN H said the resident had a wanderguard. During an interview on 09/29/23, at 9:58 A.M., RN I said the resident had a wanderguard. During an interview on 09/29/23, at 12:30 P.M., the DON said residents with wanderguards should have a physician's order documented in the medical record. The resident had a wanderguard. 3. Review of the facility's maintenance log document titled, Check Operation of Door Monitors and Patient Wandering System, showed the following: -Areas inspected included the front entrance, 100 hall, 200 hall, 300 hall, 400 hall, 300 hall patio door, and employee hall; -The areas were inspected on 08/10/23 and 09/07/23 with pass indicated to each area; -The inspection form did not list wanderguard devices worn by residents or inspection of those devices. During an interview on 09/28/23, at 2:28 P.M., the Maintenance Director said the following: -He checks the wanderguard system; -He takes an extra wanderguard alarm and walks out of each wanderguard exit to verify the wanderguard system alarm sounds at the nurses station; -He has never checked the wanderguard devices that each resident wears to ensure they function appropriately with the wanderguard system; -Nursing staff are responsible for verifying the wanderguard devices the residents wear are functioning. During an interview on 09/28/23, at 2:37 P.M., LPN A said he/she did not know of any process for checking the placement or function of the wanderguards that residents wear. During an interview on 09/28/23, at 2:44 P.M., RN B said he/she was unaware of a process for inspecting wanderguards for appropriate function. During an interview on 09/28/23, at 4:43 P.M., CNA C said he/she did not know who is responsible for inspecting the wanderguards residents wear to ensure they function properly. He/She did not know how to inspect the wanderguard devices. During an interview on 09/28/23 at 8:51 P.M., LPN D said he/she did not know what residents had a wanderguard device. He/she did not know if the facility had a system for inspecting the wanderguard devices residents wear. During an interview on 09/28/23, at 9:09 P.M., CNA F said he/she did not know if the facility had a process for inspecting the wanderguard devices for appropriate function. During an interview on 09/28/23 at 9:22 P.M., LPN E said he/she did not know if the facility had a procedure for inspecting wanderguard devices residents wear for appropriate function. During an interview on 09/28/23, at 9:40 P.M., CNA G said he/she did not know if the facility had a process for inspecting the wanderguard devices. During an interview on 09/29/23, at 9:49 A.M., LPN H said he/she did not know how to verify the function of the wanderguard devices or who is responsible. During an interview on 09/29/23, at 9:58 A.M., RN I said the following: -Nursing staff are to inspect the wanderguard devices at least daily or more often for location and function; -Nursing staff are to bring the resident wearing the wanderguard device near an egress to verify the alarm sounds. During an interview on 09/29/23, at 12:26 P.M., the Regional Nurse Consultant said the following: -Staff are to have a designated staff to inspect wanderguard devices at least weekly for function and daily for placement; -The inspections for function and location should be documented in the residents medical record. During an interview on 09/29/23, at 12:30 P.M., DON said the following: -Nursing staff are to inspect the wanderguards for placement and function each shift; -Maintenance staff is responsible for inspecting the wanderguard door alarms for appropriate function. During an interview on 09/29/23, at 12:59 P.M., the Administrator said the following: -Nursing staff are to check the wanderguard devices residents wear weekly for location and function; -The wanderguard device inspection should be documented in the log book. MO00225097 31464

Based on interview and record review, the facility failed to provide care in accordance with standards of practice when staff failed to document a fall or complete post fall monitoring for one resident (Resident #3's) who suffered fall, resulting in a possible delay of identification of injury of a hip fracture. The facility census was 101. Review of a facility policy titled, Accidents and Incidents-Investigating and Reporting, revised July 2017, showed the following: -All accidents and incidents involving residents are to be investigated and reported to the Administrator; -The nurse supervisor, charge nurse, department director, or supervisor shall promptly initiate and document investigation of the accident or incident; -The incident will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and analyze any individual resident vulnerabilities. 1. Review of Resident #3's face sheet (basic information sheet) showed the following information: -admitted [DATE]; -Re-admitted [DATE]; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance, polyarthritis (five or more of a person's joints have arthritis (swelling or inflammation of the joints) at the same time), schizoaffective disorder (a mental health condition including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and mood disorder symptoms, altered mental status, and lack of coordination. Review of the resident's Minimum Data Sheet (MDS- a federally mandated assessment tool completed by facility staff), dated 07/28/23, showed the following: -The resident was rarely or never understood; -The resident was totally dependant on staff for care; -The resident had a history of falls. Review of the resident's September 2023 progress note dated 09/02/23, at 12:24 A.M., showed a nurse documented the resident finished fall follow-up from a previous fall. Review of the resident's Physician Order Sheet (POS), as of 09/12/23, showed an order, dated 05/23/21, for assessment of pain each shift. Review of the resident's September 2023 Medication Administration Record (MAR) showed the following: -Pain assessments scheduled for 8:00 A.M., and 8:00 P.M.; -Pain assessment on 09/02/23, at 7:21 A.M., of other with no specific information noted; -Pain assessment on 09/02/23, at 8:58 P.M., of moaning/gasping, other was noted; -Pain assessment on 09/03/23, at 7:08 A.M., of other with no specific information noted; -Pain assessment on 09/03/23, at 7:36 P.M., of other with no specific information noted; -Pain assessment on 09/04/23, at 9:14 A.M., of resident noted to be sitting comfortably in his/her Broda chair (wheelchair that offers tilt-in-space positioning) with no noted signs of pain or discomfort; -Pain assessment on 09/04/23, at 10:09 P.M., of moaning/gasping, other was noted; -Pain assessment on 09/05/23, at 8:21 A.M., of as other with no specific information noted; -Pain assessment on 09/06/23, at 2:27 A.M., of other with no specific information noted; -Pain assessment on 09/06/23, at 1:14 P.M., of other with no specific information noted. Review of the resident's September 2023 progress notes showed the following: -On 09/06/23, at 7:13 P.M., a nurse documented x-ray orders were received from the physician for left hip and left knee due to pain and swelling; -On 09/06/23, at 7:45 P.M., a nurse documented orders were received for ibuprofen (pain medication) 400 milligrams (mg) to be given every six to eight hours as needed for pain. If pain was not under control the facility may send the resident to the emergency room ; -On 09/06/23, at 9:17 P.M., a nurse documented a technician arrived to the facility at 8:00 P.M., to complete x-rays. The resident was noted to have a left hip fracture. The resident was sent to the hospital and left the facility at 8:40 P.M. Review of the resident's September 2023 Medication Administration Record (MAR) showed the following: -Pain assessment on 09/06/23, at 9:20 P.M., of grimacing/wincing, body stiffening, clenched teeth or jaw was noted. Staff documented administration of two tablets of 200 mg ibuprofen (noted as not effective). Review of the resident's care plan for falls, revised 09/06/23, showed the following information: -The resident had potential for falls with continued risk due to cognitive deficits and lack of safety awareness; -Interventions included frequent rounds to ensure he/she was in a safe position in bed, fall mat at bedside, low bed position, use of a positioning wedge for optimum bed placement, and repositioning; -Intervention, added 09/06/23, for two person assist for all cares. Review of the resident's hospital record, dated 09/06/23, showed the following: -The resident was noted to be in pain while at the facility following being readjusted by family; -X-rays were completed at the facility indicating a left hip fracture; -The resident was assessed in the emergency department at the hospital and had a left hip fracture; -The resident admitted to the hospital on 09/06/23. Review of the resident's September 2023 progress notes showed the following: -On 09/07/23, at 9:02 A.M., Licensed Practical Nurse (LPN) L documented a late entry dated 09/02/23, at 9:45 A.M. LPN L was called into the resident's room regarding the resident rolling out of bed onto the floor mat. The nurse noted the resident lying on the floor mat on his/her side (not specified which side). The resident was assessed for injury and none were apparent. The resident was assisted up and placed in his/her Broda chair. The family and physician were notified; -Review of the resident's progress notes showed the facility did not document any notes regarding the fall on 09/02/23 at the time of the fall and no follow-up or monitoring was noted in the progress notes from 09/02/23 to 09/06/23. Review of the facility investigation, dated 09/08/23, regarding the resident having an injury of unknown origin (acute fracture), identified on 09/06/23, showed the following: -On 09/06/23, the resident began showing signs and symptoms of pain during the dinner meal; -The resident was sent to the emergency room for evaluation and treatment on 09/06/23 related to the pain; -The resident received a left hip x-ray that identified an acute fracture of the hip; -The facility conducted an investigation and found the resident had a fall on 09/02/23 that had not been reported or documented by LPN L; -The resident was unable to be interviewed due to cognitive impairment; -The facility noted the injury likely occurred during the fall on 09/02/23; Review of the resident's hospital discharge records, dated 09/11/23, showed the following: -The resident was non-verbal; -The resident received x-rays at the facility prior to admission to the hospital; -The resident had a left hip fracture that required surgery; -Surgery was completed on 09/07/23. During an interview on 09/22/23, at 1:57 P.M., Certified Nurses Assistant (CNA) M said if a resident is observed on the floor a nurse is to be notified .The nurse is to complete an immediate assessment of the resident and take action as appropriate. The nurse is supposed to document assessments and nursing notes regarding falls. During an interview on 09/22/23, at 2:27 P.M., Certified Medication Technician (CMT) N said the resident had a history of falls. The resident gets anxious and tries to throw himself/herself out of bed. Staff are to report falls immediately to the charge nurse for immediate assessment. The nurse is supposed to document all information for the fall in the resident's medical record. During an interview on 09/28/23, at 2:38 P.M., CNA I said on 09/02/23, at approximately 6:00 P.M., the resident was on his/her bed, and the CNA was changing the resident's incontinent brief. The CNA turned away from the bed to retrieve an item, and the resident rolled off of the bed onto the floor. CNA I said he/she quickly went to get the charge nurse, LPN L, who assessed the resident and noted no injuries. LPN L told CNA I, CMT J, and CMT K to put the resident back into bed. CNA I said the resident did not show any indication of pain at that time. Two to three days later, he/she noticed the resident had facial grimacing and was making vocal noises; possibly indicative of pain. He/she informed the charge nurse on duty, LPN A, who administered pain medication to the resident. The aides do not complete documentation regarding falls or other incidents; the nurses should do that. During an interview on 09/28/23, at 4:40 P.M., LPN A said if a resident has a fall, the nurse should assess them for injury, complete an incident report, notify the resident's family or responsible party and the physician, document in the nurses' notes in the medical record, and notify management. The nurses should document neurological checks and vital signs for the next 72 hours, unless the resident is sent out to the hospital for evaluation. LPN A said nobody had told him/her about the resident's fall from the bed on 09/02/23 and nothing was documented on the nurses' report book. During an interview on 09/28/23, at 4:43 P.M., CNA C said falls are to be reported to the charge nurse immediately. The nurse is supposed to complete an immediate assessment of the resident for injuries. The nurse is supposed to document all assessments and notes related to falls. During an interview on 09/29/23, at 9:58 A.M., Registered Nurse (RN) O said staff are to report falls immediately to their charge nurse. The nurse should complete an immediate assessment of the resident for any signs of injury. The nurse should document an incident report, nurses note, notification of the family and physician, initial assessment, and follow-up in the resident's medical record. During an interview on 09/29/23, at 10:50 A.M., CMT J said on 09/02/23, right at the evening shift change around 6:00 P.M., he/she entered the resident room as the charge nurse was exiting. LPN L told CNA I, CMT J, and CMT K to go ahead and put the resident back in bed. During an interview on 09/29/23, at 10:55 A.M., CMT K said on 09/02/23, shortly after 6:00 P.M., CNA I stuck his/her head out of the resident's room and informed him/her that the resident had rolled from the bed and was on the floor. LPN L came to assess the resident and checked his/her vital signs. No injuries were noted, and the LPN told them (CNA I, CMT J, and CMT K) to put the resident back in bed. During an interview on 09/29/23, at 11:40 A.M., LPN L said on 09/02/23, he/she thought during the morning shift change, CNA I reported that the resident had rolled off of the bed onto the floor. LPN L assessed the resident, including arm and leg movement, and did not find any injuries. The resident showed no signs of pain. The LPN said falls and other incidents are documented by the nurse in nurses' notes in the electronic chart. LPN L said the system was down at the time of that fall, so he/she wrote a paper report showing notification to the on-call physician and the resident's family; he/she either handed the report to the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) or put it in their in-box; he/she wasn't sure which. If a fall or other incident occurs, the nurse should give a verbal report to the next shift, but may also write a report in the book at the desk. He/she did not remember if he/she wrote anything in the report book or who he/she reported to. During an interview on 09/29/23, at 12:26 P.M., the Regional Nurse Consultant said changes in condition are to be assessed by the charge nurse immediately. If a resident falls the nurse should document a nurses note, incident report, and follow up. An investigation was completed related to the resident having a fracture identified during an x-ray. The investigation showed staff did not document a fall that occurred for the resident. During an interview on 09/29/23, at 12:30 P.M., the DON said if a resident falls, the nurse should complete an Incident Report and notify the DON. During an interview on 09/29/23, at 12:59 P.M., the Administrator said if a fall occurs staff are to immediately report to the charge nurse. The charge nurse is to immediately assess the resident for injuries. The charge nurse should document an incident report, nurses note, assessment, neurological checks when needed, and notifications to the responsible party and physician. Falls are reviewed daily by an administrative team consisting of the Administrator, DON, ADON, Social Services Director (SSD), MDS Coordinator, and Medical Records. The nurse that initially responds to the fall is responsible for ensuring the fall is documented. The resident had a fall on 09/02/23 that was not documented by the responsible nurse LPN L. On 09/06/23, the resident began having signs of pain and received an x-ray revealing a fracture. The Administrator said she believes the resident sustained the fracture on 09/02/23 that progressively became worse leading to pain on 09/06/23. MO00224083, MO00224964

Based on interview and record review, the facility failed to provided showers as preferred for nine residents (Resident #5, #13, #16, #39, #41, #68, #69, #74, and #78). The facility census was 89. Record review of the facility's policy titled Resident Bathing, undated, showed the staff shall provide person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. 1. During the resident group meeting held on 7/18/22, at 1:55 P.M., showed the following: -There were eight residents who attended the meeting; -The residents all agreed that they did not receive showers/baths on a regular basis and did not get two showers a week; -Resident #74 said he/she went three weeks without a shower and was finally given one last Wednesday or Thursday. He/she would really like to have a bath at least two times a week; -Resident #13 said he/she finally received a shower on Saturday but it had been nine days since his/her last shower and he/she would like to have a shower two times a week; -Resident #41 said one time it took six weeks to get a shower and as of today it has been three weeks since he/she has had a shower. He/she was scheduled to get a shower on Tuesdays and Thursdays, but never receives showers on those days. It seems like when the Hospice staff are in the facility we don't get showers. He/she would prefer a shower at least two times a week. His/her hair and skin itches so bad; -Resident #68 said he/she had a shower one to two weeks ago and the staff said he/she would be getting one this last Saturday and then again on Sunday, but no one ever came. He/she usually receives a shower every two to three weeks. The resident said he/she would like to have a shower two times a week especially since he/she has several appointments during the week. The resident said he/she does not like smelling bad; -Resident #39 said his/her last shower was two and half weeks ago and sometime he/she goes longer without a shower. He/she would like a shower at least once a week; -Resident #69 said when the lady who passes the medication has time she will give him/her a shower. The resident said he/she has not had a shower for one to two weeks and he/she would like to receive a shower two times a week. Today before he/she came to this meeting the certified medication technician (CMT) sprayed him/her down with perfume so he/she would not stink so bad. The resident said his/her head was itching all the time he/she thought he/she may have bugs; -Resident #16 said the last time he/she had a shower was at a minimum of two weeks ago and he/she wants a shower at least one shower a week. He/she will ask about showers and staff will tell residents they don't have enough help. If residents are not feeling well the staff document the residents refuse the shower or bath. 2. Record review of Resident #78's 5-day admission MDS, dated [DATE], showed the following information: -admitted [DATE] with readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Presence of catheter (to drain the bladder) and [CONDITION(S)]/ostomy (to drain waste from the colon/bowels); -Required assistance for bed mobility, toileting, bathing, and personal hygiene. Record review of the resident's care plan, last updated 7/19/2022, showed the following: -Required assistance to complete daily activities of care safely; -Resident will maintain self care, assisting with bathing face and upper/lower body; -Provide resident with assistance to gather items for bathing and assist with bathing area as needed; -Encourage resident to wash, rinse, and dry the areas of the body that are within physical ability. Record review on 7/21/2022, of the resident's paper and electronic shower records, dated June and July 2022, showed staff documented showers as follows: -On 6/19/2022; -On 6/22/2022; -On 6/30/2022 (eight days since last documented shower); -On 7/6/2022 (six days since last documented shower); -On 7/17/2022 (11 days since last documented shower). (Staff did not document any other showers.) During an interview on 7/20/2022, at 1:50 P.M., the resident said he/she only gets showers weekly or sometimes only every other week. He/she was not aware of any set shower schedule for residents and did not think his/her showers were scheduled. The resident said staff does not offer him/her showers, but he/she will sometimes ask for one when he/she feels he/she can't stand feeling dirty any longer. 3. Record review of Resident #5's face sheet showed the following: -admitted on [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of one staff for bed mobility, transfers, dressing, and personal hygiene. Record review of the resident's care plan, dated 7/21/2022, showed the following information: -Provide resident with assistance to gather items for bathing and assist to bathing area as needed; -Make bathing process pleasant by ensuring a non-hurried atmosphere; -Encourage me to wash, rinse, and dry the areas of my body that are within my physical ability; -Assist the resident with his/her hair; -Assist the resident with brushing teeth/oral care; (Staff did not care plan regarding shower schedule or preferences.) Record review of the resident's electronic medical record and paper documents provided by the facility showed shower sheets for the following dates: -On 5/7/22; -On 5/20/22 (13 days since prior shower); -On 6/16/22 (27 days since prior shower); -On 6/22/22; -On 7/3/22 (11 days since prior shower); -On 7/17/22 (14 days since prior shower). Observation and interview on 7/17/2022, at 11:45 A.M., showed the resident said that he/she has to pursue staff to get a shower one time per week. There is no regular rotation or schedule for a shower. 4. During an interview on 7/20/2022, at 2:33 P.M., Certified Nurse Aide (CNA) H said that he/she had not seen the recent shower schedule. The float staff completes resident showers and scheduled aides stay on the floor. Some certified medication technicians (CMTs) help with showers as well. He/she said the beautician often helps with resident nail cleaning and trimming for male and female residents when he/she had time. 5. During an interview on 7/21/22, at 1:00 P.M., CNA C said the following: -Those requesting showers will get one then, if possible, but many are waiting; -He/she said they did do six showers today and then said three of those showers were done by hospice; -Staff is busy and there is not enough staff to give showers. 6. During an interview on 7/21/22, at 1:00 P.M., Licensed Practical Nurse (LPN) D said the following: -Showers need to be given twice a week; -He/she said they are trying to get aides to get the showers done and expects at least a couple done every day. 7. During an interview on 7/21/22, at 1:20 P.M., LPN A said the following: -Care plans should show what the resident prefers for bathing, such as a whirlpool or a shower and if they want it at night or early morning; -Residents are supposed to get at least two showers a week. 8. During an interview on 7/21/22, at 1:45 P.M., CMT B, said the following: -He/she does not often shower a resident, but will at times if there is time between passing medications; -Showers should be given every two weeks. 9. During an interview on 7/21/2022, at 2:35 P.M., the Assistant Director of Nursing (ADON) said that currently they did not have a shower schedule for the staff to follow. He said they did not have a dedicated shower aide, and had tried two different schedules in the past several months that did not work.

Based on interview and record review, the facility failed to complete criminal background checks (CBC) or Family Care Safety Registry (FSCR) for two staff (Dietary Aide (DA) S and Licensed Practiced Nurse (LPN) R); failed to completed employee disqualification list (EDL) checks for four sampled staff (Registered Nurse (RN) Q, DA S, LPN R, and Housekeeper U); and failed to complete the Nurse Aide (NA) Registry (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility) check for three sampled staff (DA S, LPN R, Housekeeper U), to ensure the staff did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility, out of ten sampled newly hired staff since last survey. The facility census was 89. Record review of the facility policy Payroll and Personnel, dated February 2022, showed the following information: -Prior to employment, the facility will submit an online request to the Missouri Health Care Association for a Criminal Background Check to determine if the applicant has a conviction for a crime that makes him/her a potential threat to the nursing home resident; -If the facility verifies that the prospective employee is on the Family Care Safety Registry, the payroll clerk can contact the registry to complete the background check; -Prior to employment, the facility will contact Health and Senior Services to verify that the employee is not on the Employee Disqualification List (EDL). Indicate on the employee's completed application the date that the contact was made; -Volunteers who have direct contact with residents must pass a criminal background check. Complete the Volunteer Employee Disqualification List (EDL); -Check the CNA registry for all employees, no matter the position. This report will indicate if there is a federal indicator for that employee; -The bookkeeper will start a new hire check list when an employee is hired; -The administrator will verify that all items are completed in a timely manner. 1. Record review of RN Q's personnel record showed the following information: -Date of hire of 4/6/2022; -Facility staff did not document an EDL check for RN Q. 2 Record review of LPN R's personnel record showed the following information: -Date of hire of 2/16/2021; -Facility staff did not document completing a check of the FCSR, CBC, EDL, or NA registry check for the LPN. 3. Record review of DA S' personnel record showed the following information: -Date of hire of 7/15/2021; -Facility staff did not document completing an FCSR check on the DA; -Facility staff did not document a check of the EDL and NA Registry until 7/4/2022 (eleven months and eighteen days after his/her hire date). 4. Record review of Housekeeper U's personnel record showed the following information: -Date of hire of 4/25/2022; -Facility staff did not document completion of an EDL or NA check. 5. During an interview on 7/21/2022, at 11:35 A.M., Human Resources said that she had been trying to clean up the employee records since starting four months ago. She said that she overlooked completing the EDL check for RN Q. 6. During an interview on 7/21/2022, at 11:45 A.M., Housekeeping Manager said that she completed a request form for new housekeeping staff, for Family Safety Care Registry and Criminal Background Check, and faxed it to the corporate office for completion. She was not aware of the requirement for the Nurse Aide Registry or EDL checks. 7. During an interview on 7/21/2022, at 4:00 P.M., the Administrator said that staff should complete all required pre-employment checks before a new employee works in the facility.

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan, that includes measurable objectives to meet the resident's medical and nursing needs identified in the comprehensive assessment for three residents (Residents #5, #50, and #78). The facility census was 89. Record review of a facility policy entitled Care Plan, Comprehensive Person-Centered, revised December 2016, showed the following information: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan will: -Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Describe services that would otherwise be furnished, but are not based on resident's refusal; -Include resident's stated goals upon admission; -Incorporate identified problem areas and risk factors; identify the professional services that are responsible for each element of care; -Reflect the resident's expressed wishes regarding care and treatment goals; -Aid in preventing or reducing decline in the resident's functional status and/or functional levels; -Reflect currently recognized standards of practice for problem areas and conditions; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. Record review of Resident #78's 5-day admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 6/24/022, showed the following information: -admitted [DATE] with a readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Presence of catheter (to drain the bladder) and [CONDITION(S)]/ostomy (to drain waste from the colon/bowels); -Required assistance for bed mobility, toileting, bathing, and personal hygiene. Record review of the resident's July 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, last updated 7/18/2022, showed the following: -Assist resident with toileting as needed; -Occasionally incontinent of bowel and assist with incontinence care as needed. (Staff did not document information pertaining to the [CONDITION(S)] or its care.) During an interview on 7/18/2022, at 12:45 P.M., the resident said he/she requires assistance from staff to empty his/her [CONDITION(S)] bag once or twice daily and to change it whenever needed. 2. Record review of Resident #5's face sheet showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident required extensive assistance of one staff for bed mobility, transfers, dressing, and personal hygiene; -The resident had a feeding tube while he/she was a resident. Record review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -Orders for medications to be administered per orders by G-Tube (tube that provides medication and food directly to stomach) throughout the day. Record review of the resident's care plan, last updated 7/21/2022, showed the following: -Assist resident with brushing teeth/oral care; -Assist resident with meals as needed. (Staff did not document information pertaining the G-Tube for feeding, medication administration, or its care). During an interview on 7/17/2022, at 11:30 A.M., the resident said that he/she received tube feedings, water, and medications four to six times per day through the G-tube. 3. Record review of Resident #50's face sheet showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment; -Resident had an indwelling catheter; -Resident had an ostomy (artificial opening in an organ of the body); -Resident required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; -Resident required extensive assistance of one staff for personal hygiene. Record review of the July 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 6/1/22, to change ostomy as needed. Record review of the resident's care plan, last updated 7/19/2022, showed the following: -Provide the resident with incontinent care after each episode; -Assist resident with toileting as needed. (Staff did not document information pertaining the ostomy or care of the [CONDITION(S)]). During an interview on 7/19/2022, at 9:57 A.M., the resident said that a nurse changed his/her [CONDITION(S)] bag about every three days, but that he/she had to ask for it to be changed, there was no schedule. The resident said he/she requested the [CONDITION(S)] to be changed about every three days. The staff empty the bag about two to three times per day. During an interview on 7/21/2022, at 10:28 A.M., Licensed Practical Nurse (LPN) G said that [CONDITION(S)] changes should be charted on the eTAR and information regarding the care should be in the resident's care plan. The LPN said that the [CONDITION(S)] was generally changed once per week but that the resident requested almost daily changes due to the location in his/her skin folds. 4. During an interview on 7/21/22, at 2:00 P.M., the MDS Coordinator said that resident care plans should include basic information about the resident. It should also include, pain, falls, skin issues, weight, oxygen, antipsychotics, and behaviors. Resident ADLs and basic assistance needs should be on care plan. She said ostomy, tube feeding, and/or [CONDITION(S)] should be included on the care plan. Anything on the treatment sheet should be on the resident's care plan.

Based on interviews and record reviews, the facility failed to provide weekend activities that met the needs and interests of the residents in and out of the SCU (specialized care unit in long-term care facilities developed to provide specialized care for individuals living with dementia). Facility census was 89. Record review of the facility's policy for resident activities titled Group Programs and Activity Calendar, dated June 2018, showed the following: -Group activities are available in this facility and an activity calendar is completed and maintained to inform residents, families, and staff of the activity opportunities available; -Both large and small group activities are part of the activity programs; -The activity calendar states all activities available for the entire month, which may also include scheduled in-room activities; -Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and physical, mental and emotional needs; -Activities professionals plan scheduled activities for the month and post the activities on a large board in a prominent location of the facility; -Monthly activity calendars are placed in each resident room; -Calendar development and changes are discussed with resident council to keep them informed. The Activity Director (AD) periodically reviews current types of activity programs in terms of current facility population and changes are made based on analysis with input from resident council and the interdisciplinary team. 1. Record review of the facility's activity calendars for SCU and the main part of the facility for June 2022 and July 2022 showed the following: -No scheduled activities for Saturdays or Sundays for the month of June 2022; -One scheduled activity on Sunday 07/03/2022, at 10:00 A.M., for Parade Sit outside on the patio; -There were no other scheduled activities for Saturday or Sundays for the rest of the month of July 2022. During the resident group meeting on 7/19/22, at 1:55 P.M., the residents said the following: -Activities are done during the week (Monday to Friday), but sometimes the activity on calendar is changed without residents knowing the AD changed it; -There are no activities on the weekends, just a flyer with puzzles word searches riddles, but they are locked up in the activity room; -All the residents said they would like to have activities on the weekends or at the least have the activity room opened up. During an interview on 7/2022, at 1:26 P.M., Certified Nurse Aide (CNA) X said the following: -The AD tries to get back to the SCU about three times a week once a day around lunch; -There are no scheduled weekend activities; -Monday through Friday there are scheduled activities; -The residents used to be able to go into the activity room to do puzzles crafts cards etc.; -The activities room is locked up all the time since the new AD started. During an interview on 7/20/22, at 1:50 P.M., Licensed Practical Nurse (LPN) V said the following: -Activities are not scheduled for weekends and the AD doesn't work weekends; -The activities room is always locked the room is not open to residents. During an interview on 7/20/22, at 2:12 P.M., CNA W said the following: -The AD does not come back to the SCU every day; -The AD delivers resident mail every day; -There are no activities on the weekends; -It would benefit the residents as they get pretty bored; -The residents wander usually because they are bored; -There's was no directives or directions for floor staff to do activities with residents. During an interview on 7/21/22, at 1:55 P.M., the AD said the following: -She works Monday through Friday 8:00 A.M. to 5:00 P.M.; -She does not work weekends; -There is no other activity staff assigned to provide activities for the residents on weekends; -There are no scheduled activities on the calendar for the weekends; -The activity room is off limits to residents unless she is present. During an interview on 7/21/22, at 4:55 P.M., the Administrator said staff should be doing activities on the weekends and should be resident appropriate. The residents should be allowed in the activity room.

Based on observation, record review, and interview, the facility failed to document a pre-use assessment, obtain informed consent, and obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to care plan the use of side rails for four residents (Residents #46, #50, #51, and #72) The facility census was 89. Record review of a facility policy entitled Proper Use of Side Rails, revised December 2016, showed the following information: -The purposes of these guidelines are to ensure the safe use of side rails as resident mobility; -Side rails are only permissible if they are used to treat a resident's condition and circumstances; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails; -The use of side rails as an assistive device will be addressed in the resident care plan; -Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks; -Manufacturer instructions for the operation of side rails will be adhered to; -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment. 1. Record review of Resident #51's 5-day admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 6/2/2022, showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Moderately impaired cognition; -Required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Record review of the resident's paper chart and electronic medical record (EMR) showed staff did not document pertaining to the pre-use evaluation or informed consent for the use of a bed rail/grab bar. Record review of the resident's July 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, last updated 7/19/2022, showed staff did not document a care area of bed mobility and the use of a grab/positioning bar. Observation on 7/20/2022, at 10:25 A.M., showed a U-shaped grab bar attached to the outer/right side of the resident's bed. Physical Therapy Aide (PTA) F placed a gait belt (secured belt for assistant to hold on to during a transfer, standing, or walking) around the resident. While the staff grasped the gait belt, the resident grasped the grab bar with his/her left hand to assist him/herself to stand. 2. Record review of Resident #22's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognition intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance of two persons for bed mobility, transfers, dressing, and toileting needs. Record review of the resident's paper chart and EMR showed staff did not document pertaining to a pre-use evaluation or informed consent for the use of bed rails. Record review of the resident's July 2022 POS showed no order pertaining to the use of bed rails. Record review of the resident's care plan, last updated 7/18/2022, showed the resident had requested the use of 1/4 transfer assist/turn bars to aide in bed mobility. Observation on 7/18/2022, at 3:13 P.M., showed 1/4 length side rails attached to and in the raised position on both sides of the resident's bed. During an interview on 7/19/2022, at 10:15 A.M., the resident said maintenance staff replaced one of the bed rails right after he/she admitted to the facility, as it was the wrong rail for the bed and his/her needs. The resident said he/she used the rails for positioning him/herself in bed. 3. Record review of Resident #46's quarterly MDS, dated [DATE], showed the following information: -admitted [DATE]; -Cognition intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required supervision or one person assistance with bed mobility and transfers. Record review of the resident's paper chart and EMR showed staff did not document pertaining to a pre-use evaluation or informed consent for the use of bed rails. Record review of the resident's July 2022 POS showed no order pertaining to the use of bed rails. Record review of the resident's care plan, last updated 7/18/2022, showed staff did not document a care area of bed mobility and the use of grab bars for positioning and bed mobility. During observation and an interview on 7/18/2022 U-shaped grab bars were attached to both sides of the bed. The resident said he/she liked the grab bars and used them for re-positioning him/herself in bed. 4. Record review of Resident #50's face sheet showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment; -Resident required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; -Resident required extensive assistance of one staff for personal hygiene. Record review of the resident's paper chart and EMR showed staff did not document pertaining to a pre-use evaluation or informed consent for the use of bed rails. Record review of the resident's July 2022 POS showed no order pertaining to the use of bed rails. Record review of the resident's current care plan showed staff did not address side rails in use. Observations on 7/17/2022, at 10:45 A.M., showed bilateral quarter size side rails was on the the resident's bed in the up position. Interview and observation on 7/19/2022, at 9:57 A.M., showed bilateral quarter size side rail in the up position. The resident was seated on the edge of the bed. The resident said the bed rails were already on the bed when he/she was admitted to the facility. The resident said he/she used the side rail for the call light and to sit up in the bed. He/she did know if the facility discussed any consent for side rail use with his/her responsible party. During an interview on 7/21/2022, at 1:43 P.M., PTA F said that he/she did not complete an evaluation on side rails for risks and benefits for the resident. 5. Record review of Resident #72's face sheet showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/she required extensive assistance of one staff for bed mobility and personal hygiene; -He/she required extensive assistance of two staff for transfers, toilet use, and dressing. Record review of the resident's paper chart and EMR showed staff did not document pertaining to a pre-use evaluation or informed consent for the use of bed rails. Record review of the resident's July 2022 POS showed no order pertaining to the use of bed rails. Record review of the resident's current care plan showed staff did not address side rails in use. Observations on 7/17/2022, at 11:15 A.M., showed bilateral one-half size side rails was on the resident's bed in the up position. The resident was in the bed resting with eyes closed. Interview and observation on 7/18/2022, at 3:31 P.M., showed bilateral one-half size side rails in the up position. The resident was laying in the bed watching television. The resident said he/she used the side rail for the call light and to assist with repositioning in bed. The resident did not remember signing or discussing any information regarding informed consent or risk and benefit of side rails. On 7/21/2022, at 1:43 P.M., PTA F said that he/she did not complete an evaluation on side rails for risks and benefits for the resident. 6. During interviews on 7/21/2022, at 11:20 A.M. and 1:55 P.M., PTA F said therapy does the evaluation to see if a resident qualifies for use of an enabler/bed mobility rail, then notifies nursing. Therapy reviews risks with residents during the side rail use assessment, but do not obtain written or verbal consents from the responsible parties 7. During an interview on 7/21/2022, at 1:37 P.M., the Director of Nursing (DON) said the facility did not currently obtain consent for the use of bed rails used as enablers, because they were not considered restraints.

Based on interview, observation, and record review, the facility failed to keep food safe from potential contamination when food contact surfaces (dishes) were stacked wet instead of air dried, potentially causing bacteria growth and when staff failed to date or label stored food after opening. The facility census was 89. 1. Record review of the facility policy titled Dishwashing: Machine Operation, by Health Technologies, Inc. Guideline and Procedure Manual, 2016 Edition, showed the following information: -Use clean, washed hands to pull out clean racks, and allow to dishes to air dry before putting dishes away for storage; -The pots and pans will be drained and air dried on the drain counter. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; - Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Observation on 7/17/2022, at 10:03 A.M., showed the following dishes wet and stacked together, trapping water inside: -Thirty-two large, clear, plastic drinking glasses; -Eight small, clear plastic juice glasses; -Three plastic, divided plates; -Four metal pans from the steam table. During an interview on 7/21/22, at 1:35 P.M., Dish Aide J said the following: -He/she understood how the glasses with water trapped inside is a problem; -He/she is unsure how long this has been happening, but did not know otherwise until now. During an interview on 7/21/22, at 1:40 P.M., the Certified Dietary Manager (CDM) said the following: -He/she did not know the dishes were being put away wet and stacked up on top of one another. During an interview on 7/21/22, at 4:54 P.M. the Administrator said the following: -Dishes are to air dry and not put away wet. 2. Record review of the facility's policy titled Labeling and Dating Foods (Date Marking), Guideline and Procedure Manual, 2016 Edition, showed the following information: -The facility will follow the first in-first out method; -Once opened, all ready to eat, potentially hazardous food will be re-labeled with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date; -Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Observation of the reach-in refrigerator on 7/17/22, at approximately 10:40 A.M., showed the following items opened, but not labeled or dated: -Half-full, large bag of salad mix; -A large bag of shredded cheese; -Plastic bag containing sliced onions; -Plastic bag containing three bacon strips; -Plastic bag containing approximately two pounds of sliced ham; -Plastic bag containing sliced turkey breast, 2.5 pound package; -Plastic bag containing three boiled eggs. Observation of the walk-in refrigerator on 7/17/22, at approximately 10:55 A.M., showed the following items opened, but not labeled or dated: -Package of six bagels; -Package of five, opened cinnamon rolls; -Package of eleven waffles; -Package of twelve pancakes; -A plastic bag of three slices of tomatoes; -A plastic bag of shredded cheese. Observation of the walk-in freezer on 7/17/22, at approximately 11:15 A.M., showed the following items opened, but not labeled or dated: -Large package of chicken strips; -Large package of frozen biscuits, with frosted ice covering them. During an interview on 7/21/22, at 1:15 P.M., Cook I said the following: -He/she knows that food items should be labeled and dated. During an interview on 7/21/22, at 1:40 P.M., the Certified Dietary Manager (CDM), said the following: -The CDM observed the unlabeled/undated items with the surveyor and said he/she went in and just tossed the undated items away in the trash because there was no way to know how long any of the items have been there.

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to hand washing when providing personal hygiene care for two residents (Residents #51 and #72) and during a medication pass for five observed residents (Resident #5, #16, #41, #50, and #72). The facility census was 89. Record review of a facility policy entitled Handwashing/Hand Hygiene, revised August 2019, showed the following information: -The facility considers hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands are visibly soiled; -Use an alcohol-based hand rub or soap and water before and after direct contact with residents; before preparing or handling medications; before donning sterile gloves; before handling clean or soiled dressings; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with objects in the immediate vicinity of the resident; and after removing gloves. Record review of a facility policy entitled Perineal Care, revised October 2010, showed the following information: -The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Steps in the procedure include wash and dry hands thoroughly; complete the care per procedure; remove gloves and discard; wash and dry your hands thoroughly; reposition the bed covers; make the resident comfortable; place the call light within reach; and wash and dry hands thoroughly. 1. Record review of Resident #51's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's 5-day admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 6/2/2022, showed the following information: -Moderately impaired cognition; -Required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Record review of the resident's care plan, last updated 7/19/2022, showed the resident was occasionally incontinent of bladder and incontinent of bowel. Observation on 7/20/2022, at 9:48 A.M., showed the following: -Certified Nurse Aide (CNA) A washed his/her hands, donned gloves, and assisted another staff to transfer the resident from a wheelchair to the bed; -CNA A unfastened the resident's incontinence brief and cleaned his/her perineal area of urinary incontinence using pre-moistened wipes; -Wearing the same gloves, CNA A placed a new brief on the resident; -Without performing hand hygiene or changing gloves, CNA A placed a clean pillow case on a pillow and placed it under the resident's ankles, pulled up the sheet and blanket over the resident's legs, picked up the controller to raise the head of the bed, and positioned the call light within the resident's reach on the bed. 2. Record review of Resident #72's face sheet showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of one staff for bed mobility and personal hygiene; -Required extensive assistance of two staff for transfers, toilet use, and dressing. Observations on 7/20/2022, at 2:10 P.M., showed the following: -CNA H and CNA O enter the resident's room with the sit to stand lift (assistive device that allows patients in to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power); -The CNAs washed their hands at the sink and applied gloves. The staff prepared the resident's room and the bed for the resident transfer. The CNAs applied the sit to stand lift pad to the resident's back, secured the buckle to the chest area and placed the lift pad onto the lift hooks; -The CNAs transferred the resident from his/her wheelchair to the edge of the bed. The staff removed the lift pad and removed the sit to stand from bedside; -CNA O removed the resident shoes; -CNA H held the resident's upper body and CNA O held the resident's leg while they assisted the resident to lay down in the bed; -CNA O moved the resident's bed out from the wall and pulled the window shades down; -The CNAs removed the resident's pants and unhooked the resident's incontinent brief; -CNA H opened the wet wipes and wiped the resident's front private area with wipe. With the same gloved hands CNA H assisted the resident to roll toward CNA O. CNA O helped the resident stay on his/her side; -With the same gloved hands CNA H removed the wet brief from under the resident and wiped the resident's buttock region with a wet wipe; -CNA H then opened the barrier cream with the same gloved hands and applied to the resident's buttock skin. Without changing gloves, CNA H picked up the clean incontinent brief and placed it under the resident. -The CNAs assisted the resident to roll to his/her back side and pulled the brief into place and taped closed. -With the same gloved hands, CNA O pulled up the resident's blanket and opened the shades, then moved the bed back to the wall; -CNA H removed his/her gloves, removed trash from the trashcan, handed the resident the call light, and put oxygen tubing in place on the resident's face. The CNA then placed the pillow under the resident's head. The CNA did not complete hand hygiene during this;. -CNA O pushed the curtain back into place and went to the sink to wash hands; -CNA H moved the sit to stand lift and trash bags to the doorway and went to sink to wash hands. During an interview on 7/20/2022, at 2:20 P.M., the CNA H said hand hygiene should be done before entering a resident room, after completing cares in a resident room, and any time that the hands were soiled. 3. During an interview on 7/19/2022, at 12:00 P.M., Licensed Practical Nurse (LPN) P said staff should use hand sanitizer when entering and exiting a resident room. During an interview on 7/21/2022, at 4:54 P.M., the Director of Nursing (DON) said staff should perform hand hygiene during incontinent care. They should remove their gloves and perform hand hygiene after cleaning a resident and before proceeding to another task or touching anything else in the room. 4. Record review of Resident #5's face sheet showed the following: -admitted on [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of one staff for bed mobility, transfers, dressing, and personal hygiene. During observation on 7/19/2022, at 11:20 A.M., LPN P prepared Glucerna (brand name of a meal replacement shake) and a glucometer (hand held machine used to check blood sugar levels) and entered the resident's room; -He/she applied gloves without completing hand hygiene; -He/she entered the resident's bathroom and picked up the tube feeding syringe and dropped the syringe on the bathroom floor; -He/she picked up the syringe and threw it away. He/she removed his/her gloves and left the room to get a new syringe without performing hand hygiene; -He/she re-entered the resident's room and applied gloves without completing hand hygiene; -The LPN entered the bathroom and opened the Glucerna and poured it into the measured container to 360 milliliters (ml) and put water into a cup; -He/she moved to the resident room and placed the items on the table next to the resident. He/she opened the resident's tube and put the syringe into tube; -The LPN checked the placement of the tube and then removed syringe and placed on the table; -With the same gloved hands the LPN checked the resident's blood glucose with the glucometer; -He/she then removed his/her gloves; -Without completing hand hygiene, the LPN applied new gloves. He/she then connected the syringe to the tube and poured the Glucerna into the syringe; -After completing the bolus (single dose of a drug or other medicinal preparation given all at once) feeding, he/she flushed the syringe and tube with 30 ml water; -He/she closed the tube and removed syringe; -The LPN removed his/her gloves and washed his/her hands at sink; -The LPN took the glucometer to the medication cart and applied gloves and cleaned the glucometer with wet disinfectant wipe and removed his/her gloves; -The LPN then verified the [MEDICATION(S)] (brand name of insulin) dose to administer to the resident; -He/she opened a new insulin vial and wiped the top with an alcohol wipe; -The LPN prepared the dose and entered the resident's room; -He/she applied gloves without completing hand hygiene; -The LPN administered the insulin to the resident and then removed his/her gloves; -He/she returned to the medication cart, disposed of the insulin syringe and needle, charted in the computer, and without completing any hand hygiene began the next task. 5. Record review of Resident #50's face sheet showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; -Required extensive assistance of one staff for personal hygiene. Observation on 7/19/2022, at 1:50 P.M., of LPN P showed the following: -LPN prepared pain medication for the resident at the medication cart. Without completing hand hygiene, he/she entered the resident's room, asked questions about pain location, intensity, and handed the resident his/her water cup and the pill cup; -The LPN replaced the resident's water cup to the bedside table. The LPN left the resident room and returned to the medication cart. He/she did not complete hand hygiene; -The LPN prepared medication for the resident, crushed the pills to be given by gastrostomy tube, and entered the resident's room and without completing hand hygiene; -The LPN applied his/her gloves and gathered supplies for the G-Tube; -The LPN opened the resident's G-tube, attached the syringe and added the pills mixed with water to the syringe. The LPN allowed the medication and water to gravity drain, flushed the syringe, and tube with water. -The LPN removed gloves and washed hands before exiting the room. 6. Record review of Resident #16's face sheet showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with dressing, personal hygiene, and transfers; -Required limited supervision of one staff for toileting and bed mobility. Record review of Resident #41's face sheet showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with dressing, personal hygiene, and transfers; -Required limited supervision of one staff for toileting and bed mobility. Observation on 7/20/2022 showed the following: -At 10:35 A.M., without completing hand hygiene Certified Medication Technician (CMT) L prepared medications for Resident # 50. The CMT popped out two pills into his/her hand and put the pills into a medication cup. He/she entered the resident room and provided the resident with a water cup and the medication cup. The CMT left the resident room without completing hand hygiene and returned to the medication cart; -At 10:45 A.M., the CMT, without performing hand hygiene, began preparing nine medications for Resident #41. The CMT popped each pill out of the medication cards directly into his/her hand, one at a time, and then placed the pills into the medication cup. The CMT took a medication cup with nine tablets, a cup with water mixed with a powder medication, and a nose spray to the resident's room. The CMT handed the resident the medications and water cup, after the resident completed administration of medications the CMT put one spray of nose spray to the resident's left nostril. The CMT put a pulse oximeter (non-invasive method for monitoring a person's pulse and oxygen levels) onto the resident's right hand to obtain the resident's pulse. He/she then returned to the medication cart and without completing hand hygiene, he/she entered information into the computer, and popped out a blood pressure pill into his/her hand and put it into a medication cup and returned to the resident room. The CMT did not complete hand hygiene; -At 11:00 A.M., the CMT continued preparing resident medications without hand hygiene between residents. He/she popped Resident #16's medications out of the medication cards and put into his/her hand and then placed into the medication cup. He/she entered Resident #16's room with a medication cup, a cup of water, eye drops, and an inhaler. After he/she completed medication administration, he/she returned to the medication cart and dropped the inhaler onto the floor. The CMT picked up and the inhaler and put the eye drops and inhaler into the medication cart. 7. Record review of Resident #72's face sheet showed the following information: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of one staff for bed mobility and personal hygiene; -Required extensive assistance of two staff for transfers, toilet use, and dressing. Observation on 7/20/2022, at 2:00 P.M., showed the following: -CMT L entered Resident #50 and Resident #72's room without completing hand hygiene and without putting on gloves. The CMT placed a glucometer and supplies on Resident #72's bedside table and turned to Resident #50 and administered an injection; -The CMT then turned to Resident #72, without completing hand hygiene, and with the used syringe still in his/her hand wiped the resident's finger with an alcohol wipe and used the lancet to obtain blood sample for the glucometer; -The CMT was not wearing gloves and did not perform hand hygiene between residents. 8. During an interview on 7/19/2022, at 12:00 P.M., LPN P said staff should use hand sanitizer when entering and exiting a resident room and should complete hand hygiene before and after medication administration. During an interview on 7/20/2022, at 2:20 P.M., CNA H said hand hygiene should be done before entering a resident room, after completing cares in a resident room, and any time the hands were soiled. During an interview on 7/21/2022, at 2:25 P.M., the DON said staff should complete hand hygiene before and after every resident care, before and after medication administration for each resident, and any time their hands are soiled. During an interview on 7/21/2022, at 2:35 P.M., the Assistant Director of Nursing (ADON) said staff receive various in-services and training on every payday, this included the process to clean hands before and after resident cares, before and after medication administration for each resident, any time their hands are soiled. During an interview on 7/21/2022, at 4:54 P.M., the Administrator said the staff should complete hand hygiene before preparing medications and when exiting the room, if the staff leaves the room for any reason they should complete hand hygiene upon entering the room again.

Based on observation, interview, and record review the facility to be adequately equipped with a full call light system when staff stored emergency call light pull cords where residents could not access the pull cord to call for staff assistance. The facility census was 89 residents. Record review of the facility's policy titled Answering the Call Light, dated March 2021, showed the following: -The purpose of this procedure is to ensure timely responses to the resident's requests and needs; -Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident; -Ask the resident to return demonstration; -Explain to the resident that a call system is also located in his/her bathroom; -Be sure that the call light is plugged in and functioning at all times; -Report all defective call lights to the nurse supervisor promptly. 1. Observations on 7/19/22, beginning at 11:45 A.M., showed the following on the Special Care Unit (SCU); -Room #301's bathroom, where two residents reside, had a three foot red call light cord wrapped around the grab bar next to the toilet: -Room #302 was locked and vacant, unable to make observation; -Room #303's bathroom, where one resident resided, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Room #304's bathroom, where two residents reside, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Room #305's bathroom, where two residents reside, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Room #306's bathroom, where two residents reside, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Vacant Room #307's bathroom, where two residents could reside, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Room #308's bathroom, where one resident resided and one vacant bed, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Room #309's bathroom, where one resident reside, had a three foot red call light cord wrapped around the grab bar next to the toilet. -Room #310's bathroom, where one resident resided and one vacant bed, had a three foot red call light cord wrapped around the grab bar next to the toilet. The surveyor attempted to pull the accessible part of the cord to activate the call light. The call could not be pulled in a manner to activate the call light; -Room #311's bathroom, where two residents reside, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Room #312's bathroom, where two residents reside, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Room #313's bathroom, where two residents reside, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Room #314's bathroom, where one resident resided and one vacant bed, had a three foot red call light cord wrapped around the grab bar next to the toilet; -Facility staff and surveyor attempted to pull cord to check functioning of call light which was restricted by the grab bar. During an interview on 7/20/22, at 1:26 P.M., Certified Nurse Aide (CNA) X said the following: -There are at least five residents in the SCU who can use the call lights; -He/she does not know why the call lights in the resident bathrooms are wrapped around the grab bars; -He/she said the call lights have been like for at least the last three months. During an interview and observation on 7/20/22, at 1:50 P.M., Licensed Practical Nurse (LPN) V said the following: -There are eight residents who can toilet themselves and maybe seven of these residents that can use the call lights on the SCU; -He/she doesn't know why the call lights in the residents bathrooms were wrapped around the grab bar and he/she had not noticed them; -LPN V attempted to pull cord to check functioning of call light which was restricted by the grab bar in Room #310. During an interview on 7/20/22, at 2:12 P.M., CNA W said the following: -There are at least seven residents in the SCU who can use the call lights; -He/she said he/she knew about the call lights being wrapped around the grab bars and he/she believed it was because the cords were so long; -He/she believes all the call lights are that way in all the resident bathrooms. 2. Observation on 7/20/2022, at 2:25 P.M., showed the bathroom emergency call light cord (room 207) wrapped around the hand rail one time. The surveyor pulled on the cord length hanging below the rail, but the cord did not slide and, therefore, did not activate the call light. During an interview on 7/20/2022, at 2:26 P.M., the resident who resided in room 207, said he/she and his/her roommate used the bathroom call light to let staff know when they needed assistance after using the toilet. 3. During an interview on 7/21/22, at 4:55 P.M., the Administrator and the Director of Nursing (DON) both said all call lights should be functioning appropriately and should not be wrapped around the grab bar in the bathroom.

Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a hospital transfer for two residents (Resident #1 and Resident #50) out of 23 sampled residents. The facility census was 89. Record review of the facility policy Transfer or Discharge Notice, dated March 2021, showed the following information: -The resident and representative are notified in writing of the following information: -The specific reason for the discharge or transfer -The effective date of the transfer or discharge; -The location to which the resident is being transferred or discharged ; -An explanation of the resident's rights to appeal the transfer or discharge to the state; -The facility bed-hold policy; -The names and contact information for the Office of the State of Long-term Care Ombudsman; -The reason for the transfer or discharge are documented in the resident's medical record. Record review of the facility form letter, titled Notice of Resident Transfer/Discharge, undated, showed the following information: -This correspondence is to inform you that the resident was transferred/discharged to location on written date for the following reasons; -Please find attached a statement of the resident appeal rights. 1. Record review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 6/17/2022, showed the following information: -Cognitively intact; -Required limited assistance of one staff for bed mobility, transfers, dressing, personal hygiene, and toilet use. Record review of the resident's nurses' progress notes showed the following information: -On 7/18/2022, at 11:47 A.M., staff documented the physical therapy department notified the nurse the resident was experiencing increased tremors. Upon physical assessment, it was noted that tremors were becoming more frequent. Due to the resident's higher risk for strokes and currently having signs of neurological (disorders of nerves and the nervous system) impairments the nurse notified the physician and received a new order to send the resident to the emergency room (ER) for further evaluation. The nurse called report to the ER and notified family. Record review of the resident's medical record showed the staff did not have a copy of a written notice provided to the resident or resident's representative regarding the hospital transfer on 7/18/2022. 2. Record review of Resident #50's face sheet showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; -Required extensive assistance of one staff for personal hygiene. Record review of the resident's nurses' progress notes, dated 7/2/2022, showed the facility sent the resident to the ER for urinary tract infection symptoms; Record review of the resident's medical record showed the staff did not have a copy of a written notice provided to the resident or resident's representative regarding the hospital transfer on 7/1/2022. 3. During an interview on 7/21/2022, at 3:00 P.M., the social worker said a copy of the bed hold policy is sent with the resident when transferred to the hospital. He/she did not send a written notice of transfer to the resident or resident's representative. He/she did not know of the regulation that required this to be completed. 4. During an interview on 7/21/2022, at 3:15 P.M., the Administrator said a written notice of transfer was not sent to the resident or resident's representative.