Every finding on record at Willard Care Center

Based on observation, interview, and record review, the facility failed to ensure food was protected from possible contamination at all times when fans and vents were free of dirt and dust, when staff failed to discard a box of baking soda in the walk-in cooler with black substance on the container, when staff failed to air dry dishes before stacking, and when staff failed to ensure dishes were clean before stacking. The deficient practice had the potential to harm all residents. The facility census was 57.1. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination.Review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, updated 03/04/23, showed the following:-Facility staff must ensure their proper storage, keeping track of when to discard perishable foods, and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated;-Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen (where applicable), or discarded.Review of the facility policy titled, Refrigerators and Freezers, dated May 2015, showed the following:-Refrigerators and freezers should be cleaned per cleaning schedule:-Fans and fan guards in all refrigerator and freezer units are to be routinely cleaned and be free of dust and dirt at all times.Review of the facility dayshift checklist showed to check air vents for dust and debris, and staff were to sign once tasks were completed. The facility did not provide a signed checklist of tasks completed.Observation of the walk-in cooler and kitchen on 04/06/26, at 10:44 A.M., showed the following:-Fans had substantial dirt and dust build up;-A box of baking soda in the corner was turned on its side and had black spots all over the outside of the box;-One vent in the ceiling near a dish storage rack and entry door had visible dirt and dust.Observation of the kitchen on 04/07/26, at 11:30 A.M., showed the following:-Fans had substantial dirt and dust build up;-A box of baking soda in the corner was turned on its side and had black spots all over the outside of the box;-One vent in the ceiling near a dish storage rack and entry door had visible dirt and dust.Observation of the kitchen on 04/07/26, at 12:10 P.M., showed the vent in the ceiling near a storage rack and entry door had visible dirt and dust. The hall trays were stored in a cart under the vent while preparing serve out.During an interview on 04/07/26, at 1:07 P.M., Dietary [NAME] (DC) H said the following:-There is a cleaning schedule for day and night shift responsibilities and cleaning fans is not on the list;-Kitchen staff are responsible for cleaning fans in the cooler, and they should not have dirt and dust on them;-Cooks are responsible for ensuring the coolers are free of items such as a box of baking soda with black spots all over the outside;-He/she saw the box of baking soda in the cooler a couple of days ago but could not reach it to discard.During an interview on 04/08/26, at 8:32 A.M., DC I said the following:-There is a day and night shift cleaning schedule, but no sign off sheet;-Kitchen staff are responsible for cleaning the fans in the coolers, and they should not have dirt and dust on them;-Cooks are responsible for the condition of items in the walk-in coolers, and there should not be a box of baking soda with black spots all over it in the cooler.During an interview on 04/09/26, at 2:41 P.M., the Dietary Manager (DM) said the following:-There is a weekly cleaning schedule, and staff are to initial and date as duties are completed;-She does not know who is responsible for cleaning the fans in the cooler;-Fans should not have dirt and dust on them;-All kitchen staff are responsible for the items in the cooler being in appropriate condition, and there should not be a box of baking soda with black spots all over it.During an interview on 04/10/26, at 11:36 A.M., the Maintenance Director said the following:-He knew he was responsible for keeping the vents free of rust and painted, but did not know it was his responsibility to keep the vents or the fans clean;-Fans and vents should not have dirt and dust on them.During an interview on 04/14/26, at 8:03 A.M., the Registered Dietician said the following:-Vents and fans should not have dirt and dust on them;-She assumed it is the responsibility of all kitchen staff to ensure items in the cooler are in appropriate condition. There should not be a box of baking soda with black spots all over the outside.During an interview on 04/10/26, at 2:59 P.M., the Administrator said the following:-There is a cleaning schedule for the kitchen, and staff check off the duties as they are completed. The DM is to review the cleaning schedule;-Maintenance is responsible for cleaning vents. There should be weekly checks and clean as needed;-The DM is responsible for cleaning the fans in the cooler;-The DM is responsible for the condition of items in the cooler, and there should not be a box of baking soda with black spots all over it in the cooler.2. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination.Review of the facility policy titled, General Dish Room Sanitation, dated May 2015, showed the following:-All items are checked for cleanliness at the clean end of the dish machine. Items that are not clean will be re-washed;-All items are to be air dried. No moisture can be found on any stacked item.Observation of the kitchen on 04/06/26, at 10:44 A.M., showed the following:-Metal trays of multiple sizes were stacked wet and dirty with leftover food particles inside;-Small plastic cups ready for use were stacked wet.Observation of the walk-in cooler and kitchen on 04/07/26, at 11:00 A.M., showed the following:-Metal trays of multiple sizes ready for use were stacked wet and dirty with leftover food particles inside;-Plastic serving bowls ready for use were stacked with leftover food particles and wet.During an interview on 04/07/26, at 1:07 P.M., DC H said the following:-Staff should ensure all dishes are air dried before stacking;-Staff should inspect all dishes for cleanliness before stacking.During an interview on 04/08/26, at 8:32 A.M., DC I said staff should ensure dishes are air dried and clean before stacking.During an interview on 04/08/26, at 9:06 A.M., Dietary Aide (DA) J said the following:-Staff should ensure all dishes are air dried before stacking;-He/she inspects dishes for cleanliness out of the dishwasher and runs back through another cycle if not clean;-Staff should not stack dishes dirty. During an interview on 04/09/26, at 2:41 P.M., DM said the following:-Staff should ensure dishes are completely air dried before stacking;-Staff should inspect dishes for cleanliness before stacking.During an interview on 04/14/26, at 8:03 A.M., the Registered Dietician said the following:-Staff should ensure dishes are air dried before stacking;-Staff should inspect dishes for cleanliness before stacking.During an interview on 04/10/26, at 2:59 P.M., the Administrator said the following:-Staff should ensure dishes are air dried before stacking;-Staff should inspect dishes for cleanliness before stacking.

Based on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to provide appropriate neurological assessments (evaluation of the functioning of the nervous system, identifying any abnormalities or neurological deficits.) for three residents (Resident #5, Resident #15, and Resident #31) after each resident sustained a fall with potential for head injury. The facility census was 57.Review of the facility policy titled, Condition Change, Resident (Observing, Recording, and Reporting) (Includes Fall or Injury)), undated, showed the following: -Purpose: To observe, record, and report any condition change to the attending physician so that proper treatment can be implemented; -Guidelines: After all resident falls, injuries, or changes in physical or mental function, monitor the following: -Observe for lacerations. If present, clean and apply dry, sterile dressing or dressing of physician's choice. Note size, depth, and amount of bleeding or drainage; -Observe for swelling and discoloration. If present, chart size, site, amount, and color; -Observe for convulsions. Chart time began, precipitating factors, duration, vital signs, and time ended. Also chart whether or not resident had difficulty breathing; -Observe and inquire if resident has headache or pain; -Observe for personality changes; -Observe for alterations in consciousness; -Observe for incontinence; -Observe for sensory disorder; -Observe for generalized weakness; -Observe for speech disorder; -Observe for gait posture or balance disorder; -Observe for stiff neck; -Observe for proper reflexes (response to painful stimuli); -Take vital signs and include temperature; -Observe for abdominal spasms or pain; -Observe for bleeding from ears, nose, and throat; -Observed for unequal pupils; -Observed for dyspnea or variations in respiration (irregular); -Observe for flushing or cyanosis; -Observe for pain; -Observe for abduction, adduction, shortening, or improper position of extremities; -Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the medical director for emergency situations; -Complete an incident, accident, or risk management report per facility guidelines; -Notify the residents responsible party; -Monitor resident's condition frequently until stable; -Notify physician of condition change, need for treatment orders, and/or medication order changes. X. Review of Resident #31's face sheet showed the following: -admission date of 8/05/24; -Primary diagnosis of vascular dementia (a decline in thinking caused by conditions that block or reduce blood flow to the brain). Review of the resident's care plan, revised on 1/26/26, showed the following: -Resident at risk for falls due to unsteady gain, periods of fatigue. Resident ambulates with a walker; -Notify the resident's family and physician of any changes in condition; -Monitor the resident for increased weakness and unsteady gait; -Increased staff supervision with intensity based on the resident's needs; -Encourage the resident to do exercises targeting strength, gait, and balance; -Provide toileting assistance based on needs/patterns; -Fall 3/25/26: Provide the resident with a wheelchair for longer distance ambulation; -Fall 3/27/26: Give the resident verbal reminders not to ambulate/transfer without assistance. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 2/20/26, showed the following: -admitted to the facility on [DATE]; -Resident cognitively intact; -No rejection of care; -Required set-up or clean-up assistance of staff with meals; -Required supervision or touching assistance of staff toileting hygiene and personal hygiene; -Required partial or moderate assistance of staff with showering; -Independent with bed mobility and transfers; -Used walker for mobility; -Occasionally incontinent of bowel and bladder; -Diagnoses of vascular dementia, edema, and atrial fibrillation (irregular heart rhythm); -No history of falls. Review of the resident's progress note, dated 03/25/26 at 6:49 P.M., showed the following: -Resident in the main dining room for the evening meal and lost his/her balance and fell to the floor on his/her back; -Resident's range of motion (ROM) within normal limits, no complaints of pain to the lower extremities; -Resident hit the back of his/her head, resulting in a small 2.5 centimeter (cm) by 2.5 cm bump noted to the top of back of his/her head and a small 2.0 cm laceration to his/her left elbow. Area cleaned; -The nurse notified the resident's physician and family member. The resident's family member feels the resident may need to use a wheelchair for longer distance mobility when feeling weak. Review of resident's progress notes on 3/26/26, show staff did not complete a progress note or follow up on the resident's condition after hitting his/her head and did not document any neurological checks. Review of the resident's form Neurological Assessment Flow sheet, dated 03/27/26, showed the following: -The checklist should be completed at the following intervals for follow-up for all unwitnessed falls or falls where resident hit their head. Any changes in the resident's condition requires a phone call to the primary care physician; -Baseline vital signs (at the time of the fall) then neurological checks every 15 minutes for one hour, every 30 minutes for one hour, every hour for two hours, and every 12 hours for 6 shifts; -Staff documented the resident's level or consciousness, pupil response, motor function of all four extremities (arms and legs), and vital signs at 12:00 A.M., 12:15 A.M., 12:30 A.M., 12:45 A.M., 1:15 A.M., 1:45 A.M., 2:45 A.M., and 3:45 A.M. -Staff did not document under the category of observations (wounds, vomiting, headache). Review of the resident's progress note, dated 3/27/26 at 4:47 A.M., showed the following: -Fall follow up 6p-6a: No injuries or adverse effects noted from recent fall. Vital signs stable. Review of the resident's progress notes, dated 3/27/26 at 9:24 P.M., showed the following: -Staff found the resident in the bathroom; -Resident assessed and assisted to a wheelchair. The resident has a bruise on his/her tailbone. Vital signs stable. Neurological checks are intact; -The nurse notified the resident's family and the physician; -Staff will continue to monitor the resident. No complaints of pain; -Resident is oriented to person and family. Resident is exit seeking. Staff to encourage the resident to use a wheelchair instead of a walker. Review of the resident's form Neurological Assessment Flow sheet, dated 03/27/26, showed the following: -Staff did not document on the resident on the 6:00 P.M. to 6:00 A.M. shift; -On 03/28/26, at 6:00 A.M. to 6:00 .PM. shift, staff documented the resident's level or consciousness, pupil response, motor function of all four extremities (arms and legs), and vital signs. Staff did not document on the form under the category of observations (wounds, vomiting, headache); -On 3/28/26, 6:00 P.M. to 6:00 A.M. shift staff did not document on the resident; -On 3/29/26, 6:00 A.M. to 6:00 P.M. shift and 6:00 P.M. to 6:00 A.M. shift., staff documented the resident's level or consciousness, pupil response, motor function of all four extremities (arms and legs), and vital signs. Staff did not document under the category of observations (wounds, vomiting, headache). -On 3/30/26, 6:00 A.M to 6:00 P.M. shift, staff documented the resident's level or consciousness, pupil response, motor function of all four extremities (arms and legs), and vital signs. Staff did not document under the category of observations (wounds, vomiting, headache). During an interview on 4/10/26 at 10:00 A.M., Registered Nurse (RN) F said when a resident falls, the nurse should assess the resident for injuries, such as bruising and bleeding. The nurse should document the resident's condition in the progress note, and then every shift for three days after a fall. During an interview on 4/10/26 at 10:16 A.M., the Director of Nursing (DON) said the following: -After a resident fall, the nurse should assess the resident for any injuries; -The nurse should assess the resident for any latent injuries every shift for three days following an injury or fall, and the nurse should document the assessment in the resident's progress notes. During an interview on 4/10/26 at 3:50 P.M., the Administrator said the following: -The nurses should document a resident's fall in the progress notes; -The nurse should monitor the resident after the fall for any changes in condition every shift for 4 days and document in the progress notes. X. Review of Resident #5's face sheet showed the following: -admission date of 01/31/25; -Diagnoses of dementia; heart disease; anxiety; depression; repeated falls. Review of resident's quarterly Minimum Date Set (MDS-a federally mandated assessment tool completed by facility staff), dated 03/20/26, showed the following: -Moderate cognitive impairment; -Requires partial/moderate staff assistance with toileting, personal hygiene, and transfers; -Wheelchair for mobility; -Frequent incontinence. Review of resident's Care Plan showed the resident is at risk for falls and has a history of falls. Review of resident's progress notes showed the following: -On 02/05/26, the resident fell, scraping and bruising his/her left eyebrow area. Staff completed a neurological check at the time of the fall. No additional documentation of follow-up neurological checks complete; -On 02/06/26, the resident fell, unwitnessed by staff. Staff found the resident on the floor, halfway under his/her bed. Staff noted a bruise on left temple but indicated it could have occurred during the fall on the previous day. The facility sent the resident to the hospital for evaluation, and they returned the same day. No documentation of neurological checks complete; -On 02/25/26, staff noted Fall follow-up, and neurological checks completed. No progress notes present showing the day or time of a recent fall; -On 04/02/26, the resident fell and had a knot (swollen) on the left side of the forehead. A neurological check was completed at the time of the fall. No additional documentation of follow-up neurological checks complete; -On 04/07/26, the resident fell, unwitnessed by staff. No injuries were noted, and a neurological check was completed at the time of the fall. No additional documentation of follow-up neurological checks complete. X. Review of Resident #15's face sheet showed the following: -admission date of 12/17/24; -Diagnoses of Parkinson's disease; chronic kidney disease; osteoporosis (thinning and weakening of the bones); history of bone fractures; history of falls. Review of resident's comprehensive MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent on staff for personal hygiene; -Requires substantial/maximum staff assistance with toileting and transfers; -Wheelchair for mobility; -Always incontinent. Review of resident's Care Plan showed the resident is at risk for falls and has a history of falls. Review of resident's progress notes showed the following: -On 02/08/26 the resident fell and scraped his/her forehead. A neurological check was completed at the time of the fall. No additional documentation of follow-up neurological checks complete; -On 3/30/26 the resident fell, unwitnessed by staff and had a raised (swollen) and bruised area around one eye, close to the nose. A neurological check was completed at the time of the fall. No additional documentation of follow-up neurological checks complete.

Based on observation, interview, and record review, the facility failed to ensure all food was served at a safe and appetizing temperature when staff failed to hold four pureed meals at an appropriate temperatures prior to serve out. The facility census was 57. Review of the facility policy titled, Food Temperatures, dated May 2015, showed the following:-The Dietary Manager (DM) or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled;-Keep the temperature of hot foods no less than 140degrees Fahrenheit (F) during meal service;-Hot food should be at least 120 degrees F when served to the resident.Review of the facility policy titled, Food Preparation and Distribution, dated May 2015, showed the following:-Food is not placed in the steam table more than 30 minutes before meal service. Food is not held in warm ovens more than 30 minutes before meal service. Do not hold food on a steam table longer than two hours;-Do not hold potentially hazardous foods at room temperature during meal service;-Do not portion out food items such as soup and pureed food ahead of time.Observation on 04/07/26, beginning at 11:12 A.M., showed the following:-Dietary [NAME] (DC) H began pureeing hot dogs and spinach for serve out of four puree meals;-DC H poured the finished pureed hot dogs and spinach in plastic serving bowls and covered them in plastic wrap and placed them directly on the steam table. Observation on 04/07/26, at 11:53 A.M., showed the temperature of the pureed hot dogs on the steam table to be 114 degrees F and the temperature of the pureed spinach to be 110 degrees F.Observation on 04/07/26, at 12:10 P.M., showed DC H served out two puree meals for the memory care unit without reheating the meals.Observation on 04/07/26, at 12:28 PM., showed DC H served out the remaining two puree meals to the dining room without reheating the meals. During an interview on 04/07/26, at 1:07 P.M., DC H said the following:-Foods on the steam table should be at a minimum holding temperature of 140 degrees F;-He/she should not have served the puree meals at the holding temperatures of 114 degrees F and 110 degrees F.During an interview on 04/09/26, at 2:41 P.M. the Dietary Manger (DM) said the following:-Pureed foods should not be portioned out before placed on the steam table;-Foods on the steam table should be holding at a minimum temperature of 155 degrees F;-Food temperatures should never be as low as 114 degrees F and 110 degrees F and should not be served at these temperatures. During an interview on 04/14/26, at 8:03 A.M., the Registered Dietician said the following:-Foods on the steam table should be holding at a minimum of 140 degrees F;-Food temperatures on the steam table of 114 degrees F and 110 degrees F are not appropriate for serve out.During an interview on 04/10/26, at 2:59 P.M., the Administrator said the following:-Foods on the steam table should be holding at a minimum temperature of 145 degrees F;-Staff should not serve food from the steam table holding at 114 degrees F and 110 degrees F.

Based on record review and interview, the facility failed to maintain an effective infection prevention and control program when the facility failed to have processes in place to ensure all new staff were screened prior to employment for tuberculosis (TB - a serious illness that mainly affects the lungs and can be spread when a person with the illness coughs, sneezes or sings) when the facility failed to fully complete TB testing for five staff (Maintenance Director (MD), Medical Records (MR), Housekeeper (HK) C, Certified Nursing Assistant (CNA) A, and Registered Nurse (RN) B). The facility census was 57.Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities showed the following:-Long-term care facilities shall screen their residents and staff for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit (5 TU) test;-Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained for all residents, employees, and volunteers;-All new long-term care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD two-step tuberculin test within one month prior to starting employment in the facility;-If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years;-It is the responsibility of each facility to maintain a documentation of each employee's and volunteer's tuberculin status.Review of facility policy named Tuberculosis Control, undated, showed the following:-Initially, the facility provides a TB test to all employees prior to employment. If the initial skin test result is 0 to 9 mm, a second test should be given at least one week later and no more than three weeks after the first test;-All TB test results will be documented on the employee immunization record including new hires and annual administration;-After the test has been administered, the results will be documented in mm;-Documented evidence of prior PPD will be maintained with facility employee immunization records. 1. Review of the MD's personnel file showed the following:-A hire date of 07/11/25;-The first step of the TB skin test was administered on 12/02/25 (approximately five months after hire, and after contact with residents).2. Review of the MR's personnel file showed the following:-A hire date of 09/23/24;-The first step of the TB skin test was administered 06/26/25 (approximately nine months after hire, and after contact with residents). 3. Review of HK C's personnel file showed the following:-A hire date of 01/29/25;-The first step of the TB skin test was administered on 01/29/25;-The facility failed to complete and document a second-step TB test.4. Review of CNA A's personnel file showed the following:-A hire date of 12/15/25;-The first step of the TB skin test was administered on 12/15/25;-The facility administered the second TB skin test on 01/13/26 (approximately four weeks after the first TB test).5. Review of RN B's personnel file showed the following:-A hire date of 02/17/25;-The first step of the TB skin test was administered on 02/14/25;-The facility administered the second TB skin test on 03/28/25 (approximately six weeks after the first TB test).6. During an interview on 04/10/26, at 1:32 P.M., the Director of Nursing (DON) said all employees should have a TB test or screening prior to starting work at the facility with residents. During an interview on 04/10/26, at 1:52 P.M., the Administrator said all employees should have a negative TB test, or other screening like an x-ray, prior to working in the building.

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) at the initiation, reduction, or termination of Medicare Part A benefits for one of three sampled residents (Resident #1) who remained in the facility upon discharge from Medicare Part A services. The facility census was 57.Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 01/09/09, showed the following information:-The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) issued when all covered Medicare services end for coverage reasons;-If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of SNFABN (form CMS-10055);-The SNFABN provides an estimated cost of items or services in case the beneficiary has to pay for them his/herself or through other insurance they may have;-If the SNF provides the beneficiary with the SNFABN at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination.Review showed the facility did not provide a policy related to giving the residents or resident representative the the SNFABN form CMS-10055.1. Review of Resident #1's SNF Beneficiary Protection Notification Review showed the following information:-On 12/31/25, Medicare Part A skilled services started;-Staff noted 02/09/25 as the last covered day of Medicare Part A service;-A Notice of Medicare Non-Coverage (NOMNC - form CMS-10123) was provided in writing;-Facility staff did not provide the resident or his/her legal representative the SNFABN - form CMS-10055 or alternative denial letter.During an interview on 04/09/26, at 2:15 P.M., the Business Office Manager said she missed sending out the required notification (SNFABN form CMS-10055). The facility should have given the notification to the resident prior to being discharged from therapy.During an interview on 04/09/26, at 2:45 P.M., the Administrator said she didn't know all required forms were not sent to residents after Medicare Part A services were being terminated. The facility should have given the notification to the resident prior to being discharged from therapy.

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, and homelike environment when staff failed to ensure one resident's (Resident #19) room was free of odors. The facility census was 57.1. Review of Resident #19's face sheet (brief resident profile) showed the following:-admission date of 03/20/26;-Diagnoses included fracture of unspecified part of neck of left femur (broken hip), vascular dementia (progressive decline in thinking, memory and behavior caused by impaired blood flow to the brain), heart disease, stroke, and obsessive compulsive disorder (chronic mental health condition characterized by uncontrollable recurring thoughts and repetitive behaviors).Review of the resident's admission Minimum Data Set (MDS-a federally mandated comprehensive assessment tool completed by staff), dated 03/26/26, showed the following:-Cognitively intact;-Required substantial assistance from staff for toileting;-Frequently incontinent of bladder. Observation on 04/06/26, at 2:40 P.M., showed the resident lay in bed eating lunch. The area of his/her room had a very strong odor of urine.Review of the resident's care plan, last revised 04/08/26, showed the following:-Resident experienced occasional bladder incontinence and had a diagnosis of benign prostatic hyperplasia (BPH-common, non-cancerous enlargement of the prostate gland in men that compresses the urethra and disrupts urination);-Resident will maintain current level of bladder and bowel continence through review period;-Provide assistance for toileting;-Provide incontinence care after each incontinent episode;-Use chux (highly absorbent under pads used to protect mattresses), brief when resident is in bed. Use brief when out of bed.Observation on 04/08/26, at 9:08 A.M., showed the resident lay in bed eating breakfast. The area of his/her room had a very strong odor of urine. Observation on 04/08/26, at 2:17 P.M., showed the resident lay in bed. The smell of urine remained very strong. Staff came in to assist the resident with using the urinal. Observation on 04/09/26, at 10:55 A.M., showed the following:-Resident lay in bed with his/her eyes closed;-The resident's urinal sat on the dresser next to his/her bed and contained a small amount of urine;-The urinal had a residue-like substance all over the inside and had an extremely strong odor of urine when up close and caused the room to have a strong odor of urine.Observation on 04/09/26, at 12:30 P.M., showed the resident's room had a strong odor of urine when walking to the resident's side of the room. The urinal on the dresser by the bed, which contained about the same amount of urine continued to have an extremely strong odor of urine up close. During an interview on 04/10/26, at 9:56 A.M., Certified Nursing Assistant (CNA) D said the following:-Staff should provide incontinent care a minimum of every two hours;-Staff should empty urinals as needed when in the room providing care;-He/she emptied the urinal in the toilet and then rinsed it out with water in the sink and emptied it in the toilet again;-The resident used the call light to advise staff when he/she needs to use the urinal;-He/she has noticed the strong smell of urine in the resident's room;-Staff should replace urinals that have residue and odor. During an interview on 04/10/26, at 10:36 A.M., CNA E said the following:-Staff should provide incontinent care every two hours;-Staff should empty urinals when providing incontinent care;-He/she emptied the urinal in the toilet and does not rinse it out;-The resident wanted to use the urinal unassisted but struggled and spilled urine;-He/she had not noticed a strong smell of urine this week or that the resident's urinal had residue inside and a strong odor of urine;-He/she would notify the charge nurse if a urinal had odor and residue.During an interview on 04/10/26, at 12:34 P.M., Registered Nurse (RN) F said the following:-Staff should provide incontinent care and empty urinals every two hours or as needed:-Staff should empty the urinal, rinse the urinal, and empty it again ensuring it is clean;-Staff should replace the urinal if it has an odor and residue;-If there is an odor of urine in a resident room, staff should determine what is causing the odor and correct it. During an interview on 04/10/26, at 1:49 P.M., the Director of Nursing (DON) said the following:-Staff should provide incontinent care every two hours;-Staff should empty urinals every two hours. When staff observe urine in the urinal, or when a resident requests, it should be emptied;-Staff should empty the urinal in the toilet and take it to the soil/utility room to rinse if needed;-Staff should replace urinals that have residue and odors;-The resident has worked with therapy to be able to use the urinal without spilling;-Staff should locate the origin of urine odor and correct the issue;-He/she noticed the odor of urine coming from the room last night and had staff go in to investigate.During an interview on 04/10/26, at 2:59 P.M., the Administrator said the following:-Staff should provide incontinent care a minimum of every two hours;-Staff should empty urinals when they observe urine in it, every two hours, or when a resident requests;-Staff should empty urinals in the toilet, rinse them from the sink, and empty them in the toilet again;-Staff should change urinals out monthly or as needed;-Staff should determine the cause of a urine odor in a resident's room and correct it.

Based on interview and record review, the facility failed to ensure a system in place that clearly and consistently represented each resident's choice of code status (whether or not the resident wished to receive cardiopulmonary resuscitation (CPR - an emergency procedure used during cardiac or respiratory arrest)) when staff failed to ensure two residents' (Resident #1 and Resident #26) code status was consistent throughout the medical record. The facility census was 57.Review of the facility policy titled, Advance Directive, undated, showed the following:-admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive;-Upon admission of a resident, the social service designee will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives;-Information about whether the resident has executed an advanced directive shall be displayed prominently in the medical record under the advanced directive tab. 1. Review of Resident #1's electronic face sheet (brief resident profile) showed the following:-admission date of [DATE];-Code status of do not resuscitate (DNR – does not wish to receive CPR). Review of the resident's current Physician Order Sheet (POS) showed an order, dated [DATE], for code status of DNR. Review of the resident's care plan, last revised [DATE], showed code status of DNR. Review of the binder titled, Resident Face Sheet, located at the nurses' station, on [DATE], showed full code (wished to receive CPR) on the resident's face sheet. The resident's Outside the Hospital Do-Not-Resuscitate Order (OHDNR) signed [DATE], was located behind the resident's face sheet. 2. Review of Resident #26's electronic face sheet showed the following:-admission date of [DATE];-Code status of DNR. Review of the resident's care plan, revised on [DATE], showed a code status of DNR. Review of the resident's current POS, dated [DATE], showed a code status of DNR. Review of the binder titled, Resident Face Sheet, located at the nurses' station, on [DATE], showed full code on the resident's face sheet. The resident's OHDNR signed on [DATE] by resident representative and physician, was located behind the resident's face sheet. 3. During an interview on [DATE], at 9:56 A.M., Certified Nursing Assistant (CNA) D said the following:-Staff can find a resident's code status on the name plate outside the rooms. [NAME] is for full code and red is for DNR;-He/she did not refer to the resident face sheet binder because it belonged to the nurses;-He/she would immediately notify the nurse if a resident was having a code situation. During an interview on [DATE], at 10:36 A.M., CNA E said the following:-Staff can find resident code status on the name tag outside the resident's room. Red is DNR and green is full code;-If a resident's name is not on the name tag, he/she would ask the charge nurse for the code status or refer to the care plan;-He/she would notify the nurse immediately of a code situation. During an interview on [DATE], at 12:34 P.M., Registered Nurse (RN) G said the following:-Staff can find resident code status on the outside of the resident's room on the name plate. Pink is DNR and green is full code. Code status is also located on the resident banner in electronic record system;-He/she printed the face sheet containing the code status from electronic record system and made a copy of the OHDNR from the Resident Face Sheet binder at the nurses' station to send with a resident going to the hospital;-He/she was unaware that Resident #1's and Resident #26's face sheets in the Resident Face Sheet binder showed full code, which was inconsistent with all other documentation of code status for the residents;-All resident records should reflect consistent code status. During an interview on [DATE], at 1:22 P.M., Social Services (SS) said the following:-She was responsible for the accuracy of the information in the Resident Face Sheet binder;-All documented code status for each resident should be consistent;-She recently checked all resident code status for accuracy and checked every couple of months. During an interview on [DATE], at 1:49 P.M., the Director of Nursing (DON) said the following:-Staff can find resident code status on the name plates outside a resident's door, the Resident Face Sheet binder at the nurses' station, or on the resident banner in electronic record system;-All resident records should reflect consistent code status;-She was responsible for the accuracy of code status; however, SS was responsible for the accuracy of the Resident Face Sheet binder;-There was no system in place for audits for code status. During an interview on [DATE], at 2:59 P.M., the Administrator said the following:-Resident code status should be consistent across all records;-SS was responsible for the accuracy of the Resident Face Sheet binder;-The DON and records staff conduct audits of code status on a bi-monthly basis.

Based on observation, interview, and record review, the facility failed to ensure all resident with pressure ulcers received care per standards of practice when staff failed to properly identify, adequately assess, and monitor the skin condition for one resident (Resident #2) with two pressure ulcers, one stage 3 (a full thickness skin loss injury, appearing as a deep crater extending through the dermis into subcutaneous fat), and one unstageable (a full thickness tissue loss where the actual depth is hidden below eschar (tan, brown, or black hardened tissue). The facility census was 57.Review of the facility policy titled, Care and Prevention of Pressure Ulcer, undated, showed:-Treatment of pressure ulcers will vary depending on the orders of the attending physician;-The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measure to prevent pressure ulcers;-Observe skin, any persistent reddened area that remains after pressure is relieved is a high-risk area for a pressure ulcer to begin. Review of the facility policy titled, Charting and Documenting, undated, section for skin lesions, showed documentation should include the following:-Specific location of the skin care problem;-Number, size, degree, and measurement of pressure sores;-Documentation that skin surfaces are looked at regularly for the resident at risk or residents exhibiting any rash, irritation, or other skin problem;-Regular observation of skin surfaces that touch each other;-Clear indication of contributing factors to the development of the skin condition (such as inactivity, incontinence, undernourished);-Documentation of the cause of pressure sores developed in-house, as well as substantiation of preventative interventions;-Turning and positioning schedules to prevent undue pressure, pressure sores, etcetera;-Any changes in the resident's condition or response to treatment;-Progress, deterioration, or the development or new problems;-Use of special creams, lotions, medications, or protective devices;-The cause of any bruise or wound;-Consultation of any bruise or wound;-Other pertinent observations;-Signature and title of person recording the data. 1. Review of Resident #2's face sheet showed:-admission date of 08/20/25;-Diagnoses includedstroke with hemiplegia (paralysis of one side of the body).Review of the resident's current Physician Orders (POS), dated 03/04/26, showed an order for weekly skin assessment completed on Wednesdays, 6:00 P.M. - 6:00 A.M. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/07/26, showed the following:-Moderate cognitive impairment;-Did not reject care;-The resident had no current pressure ulcers ;-At risk for development of pressure ulcers;-Presence of unhealed pressure ulcers;-Pressure reducing device for chair and bed. Review of the resident's March 2026 Medication Administration Record (MAR) showed staff initialed completion of the weekly skin assessment on 03/04/26.Review of the resident's weekly skin assessment, dated 03/05/26, showed a nurse documented the following:-Existing non-foot skin issue;-Edema (swelling of tissue);-Right heel soft;-Left heel soft;-Resident had pressure reducing device for bed and chair;-Left foot and ankle existing issue;-Resident had thin, dry, frail skin, with continued ulcer at foley catheter (a thin, flexible tube inserted into the body to drain fluids (like urine)) site, edema in groin, and intermittent scabs;-Treatment in place and effective;-Continue foley care, apply ointment to ulcer, and monitor for increased edema and any scabbed or open areas.Review of the resident's March 2026 MAR showed staff initialed completion of the weekly skin assessment on 03/11/26.Review of the resident's weekly skin assessment, dated 03/12/26, showed a nurse documented the following:-Existing non-foot skin issue;-Edema;-Right heel firm;-Left heel firm;-Resident had pressure reducing device for bed and chair;-Left foot and ankle, no issues;-Right foot and ankle, no issues;-Continue foley catheter care, apply ointment to ulcer, monitor for increased edema to groin and any scabbed or open areas;-Treatment in place, effective;-Continue foley care, apply ointment to ulcer, monitor for increased edema and any scabbed or open areas. Consult with podiatry as needed for any toenail issues.Review of the resident's care plan, revised 03/16/26, showed the following:-Resident at risk for skin breakdown related to impaired mobility, incontinence, and disease process;-Report any areas of skin breakdown to the physician as needed for appropriate treatment orders;-Weekly skin checks by the licensed nurse with quarterly pressure ulcer risk assessments;-During staff assisted showers, note and report any areas of redness/breakdown to the charge nurse;-Provide resident treatments as ordered. Review of the resident's March 2026 MAR showed staff initialed completion of the weekly skin assessment on 03/18/26.Review of the resident's progress notes showed no entries from 03/18/26.Review of the resident's weekly skin assessment, dated 03/19/26, showed a nurse documented the following:-Existing non-foot skin issue;-Edema;-Right heel firm;-Left heel soft;-Resident had pressure reducing device for bed and chair;-Left foot and ankle, existing issues;-Right foot and ankle, existing issues;-Resident had thin, dry, frail skin, had an ulcer at foley catheter site, edema in groin area, and intermittent scabs;-Treatment in place, effective;-Continue foley care, apply ointment to ulcer, monitor for increased edema and any scabbed or open areas.Review of the resident's progress notes showed no entries from 03/19/26 to 03/25/26.Review of the resident's March 2026 MAR showed staff initialed completion of the weekly skin assessment on 03/25/26.Review of the resident's progress notes showed no entries from 03/26/26 to 03/29/26.Review of the resident's March 2026 MAR showed the following: -An order, dated 03/29/26, for left ankle. Staff to cleanse with pure and cleanse, pat dry, apply calcium alginate (advanced wound care products made from brown seaweed) to base of wound, apply border foam dressing. Change on Tuesday and Friday, 6:00 A.M.-6:00 P.M.;-Staff initialed completion of the treatment one time on Tuesday, 03/31/26.Review of the resident's progress notes showed no entries from 03/29/26 to 03/31/26.Review of the resident's progress note, dated 04/01/26, did not address the condition of the resident's skin. Review of the resident's weekly skin assessment, dated 04/02/26, showed:-Existing non-foot skin issue;-Edema;-Right heel firm;-Left heel firm;-Resident had pressure reducing device for bed and chair;-Left foot and ankle existing issue;-Right foot and ankle existing issue;-Resident had thin, dry, frail skin, has an ulcer at foley catheter site, edema in groin area, and intermittent scabs;-Treatment in place, effective;-Continue foley care, apply ointment to ulcer, monitor for increased edema and any scabbed or open areas.(The assessment did not include a wound assessment of the resident's left ankle wound.)Review of the resident's progress notes showed no entries for 04/02/26 to 04/03/26. Review of the resident's April 2026 MAR showed the following order:-An order, dated 03/29/26, for left ankle, staff to cleanse with pure and cleanse, pat dry, apply calcium alginate to base of wound, apply border foam dressing. Change on Tuesday and Friday, 6:00 A.M.-6:00 P.M.;-Staff did not initial completion of the treatment on Friday 04/03/26 (left blank); Review of the resident's progress notes showed no entry for 04/04/26. Review of the resident's progress note, dated 04/05/26, did not address the condition of the skin or the resident's left heel wound. Review of the resident's progress notes showed no entries for 04/06/26 to 04/07/26.Observation and interview with the resident on 04/07/26, at 1:25 P.M., showed the following:-The resident said he/she had a sore on his/her left heel;-The resident said his/her heels hurt but the padded heel protectors helped relieve the pain;-The resident wore socks with no heel protectors.Review of the resident's April 2026 MAR showed the following:-An order, dated 03/29/26, for left ankle, staff to cleanse with pure and cleanse, pat dry, apply calcium alginate to base of wound, and apply border foam dressing. Change on Tuesday and Friday, 6:00 A.M.-6:00 P.M.;-Staff initialed completion of the treatment on Tuesday, 04/07/26.Review of the resident's progress notes showed no entries for 04/08/26 to 04/09/26.Review of the resident's weekly skin assessment, dated 04/09/26, showed:-Existing non-foot skin issue;-Edema;-Right heel firm;-Left heel other;-Resident has pressure reducing device for bed and chair;-Left foot and ankle existing issue;-Right foot and ankle, no issues;-Resident with dry, fragile, flaky skin. Resident on blood thinners and noted to have scattered bruising to bilateral upper extremities. Resident with wound to left ankle/heel area with dressing in place. Resident with contracture to left lower extremity. Trace to 1+ edema noted. Steri-strips in place to the resident's right forearm due to old skin tear. No signs/symptoms of infection noted. Resident with foley catheter in place. No other skin issues or concerns noted at this time. Continue with current plan of care.-Treatment in place, effective;-Comments regarding treatments and interventions was left blank.(The assessment mentioned the presence of the resident's left ankle wound, but did not include a complete wound assessment of the wound.) Observation and interview on 04/10/26, at 9:55 A.M., showed the following:-The Wound Nurse Practictioner (NP) and Registered Nurse (RN) F entered the resident's room to assess the residents wounds;-RN F removed a dressing from the resident's left lateral heel to expose an open pressure ulcer measuring 1.8 centimenter (cm) by 1.0 cm by 0.20 cm deep;-The wound NP said the wound was a Stage 3 pressure ulcer;-The resident also had a dark brown scabbed area to his/her right great toe;-The NP said the left great toe was an unstageable pressure ulcer measuring 0.25 cm, approximately;-The Wound NP said today, 04/10/26 was the first time the facility had asked him/her to see the resident and assess his/her wounds.Review of the resident's Wound Assessment Report, created 04/10/26, by the Wound NP, showed the following:-Date of service: 04/10/2026-Wound Evaluation Date: 04/10/2026-Location: Left lateral heel. Measurements: Length: 1.80 cm, Width: 1.00 cm, and Depth: 0.20 cm;-Pressure Ulcer/Injury, Stage 3;=Acquired in House: Yes;-Date Wound Acquired: 03/10/26; -Wound Status: First evaluation of existing wound by new provider;100% granulation tissue (healthy pink/red tissue);-Periwound: Fragile;-Exudate (drainage) Amount: Moderate;-Exudate Description: Serosanguineous;-Odor Post Cleansing: None;-Treatment: Dressing change frequency of every other day, clean wound with wound cleanser. Primary treatment of calcium alginate with skin prep surrounding tissue or peri wound. Other dressings of bordered foam.Review of the resident's medical record showed no wound assessment of the resident's left heel (ankle) pressure ulcer or right great toe pressure ulcer prior to skin wound note, dated 04/10/26. During an interview on 04/10/26, at 10:00 A.M., RN F said the following:-He/she suspected the resident developed the left lateral heel pressure ulcer due to his/her left leg contracture and the left heel rubbing against the other leg;-Staff repositioned the resident and applied heel protectors to the resident's feet to try to decrease pressure;-The resident had a left outer heel pressure ulcer for approximately one month;-The resident's left outer heel was scabbed over until about one week ago;-Prior to today 04/10/26, nurses had not been documenting wound assessments on the resident's left outer heel or right great toe. The nurse was not aware of the right great toe area until today;-Prior to today RN F did not realize the resident's wounds would be considered pressure ulcers. During an interview on 04/10/26, at 10:16 A.M., the Director of Nursing (DON) said the following:-The nurses were responsible for completing their assigned weekly skin assessments;-If nurses identified a pressure ulcer, they should notify the DON immediately, but no later than the next business day;-One of the nurses started a treatment on the resident's left outer heel pressure ulcer on 03/29/26, but failed to notify the DON;-The DON was not aware the resident had any pressure ulcers until 04/09/26;-The DON documented the weekly wound assessments in the electronic health record and if the wound company's NP assessed a resident, the DON would use the NP wound measurements/assessments;-The wound company's NP came to the facility weekly and completed assessments on resident's with open wounds;-The wound NP saw the resident for the first time today, 04/10/26.Review of the resident's skin and wound note dated 04/10/26, at 12:43 P.M., showed the Wound NP documented the following:-Reason for visit: First evaluation of existing wound patient by new wound care team;-Consulted for wound to left heel. First noted one month ago. Patient long termresident at facility;-Positive for contractures and edema to the left lower extremity (LLE);-Facility has been using autolytic (a wound dressing that uses the body's own enzymes to clean necrotic (dead) tissue), calcium alginate, and a foam dressing to the wound;-Skin: history of a chronic wound, history of a pressure ulcer;-Wound assessment: Wound: 1, location: Left lateral heel;-Pressure Ulcer/Injury. Stage/Severity: Stage 3;-Wound Status: First Evaluation of existing wound by new provider;-Size: 1.8 centimeter (cm) x 1.0 cm x 0.2 cm. Calculated area is 1.8 sq cm;-Odor Post Cleansing: None;-Peri wound: Fragile;-Wound Base: 100% granulation;-Exudate: Moderate amount of serosanguineous (plasma and blood);-Risk factors: The patient has the following factors that affect wound healing: Hemiplegia, bowel and bladder incontinence, high blood pressure, inability to position self, limited weight bearing status, reduced mobility, risk of pressure ulcer formation, muscle wasting, generalized weakness, and contractures. The following plan is in place to address these factors: behavioral redirection, air Mattress, heel offloading, offload pressure per facility protocol, offloading chair cushion , optimize nutrition, pressure redistribution mattress, protein supplements, and turn and reposition;-Wound treatment: Wound # 1 Left lateral heel Pressure Ulcer/Injury;-Treatment Recommendations: Cleanse with wound cleanser, apply calcium alginate, skin prep surrounding tissue, secure with bordered foam, and change every other day;-Assessment/plan: The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressurereduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. Float heels while in bed with use of the facility's preferred equipment, pillows/boots. Float heels while in bed with use of pressure relieving boots. Continue with turning and repositioning schedule per protocol for pressure prevention. Position patient side to side as tolerated. The resident is incontinent of bowel and bladder. Use appropriate moisture barrier creams per formulary to provide thorough skin care with each incontinent episode. Use formulary briefs when indicated to manage moisture and assess often. Rounded with floor nurse on initial visit today. Consulted for wound to left lateral heel. According to nurse first noted one month ago. Alert to self. Contractures present. Incontinent of bowel and bladder. Wearing heel protectors. Edema present to LLE, need to place tubi grips. Wound to left heel with good granulation tissue. Peri area fragile skin. According to nurse wound has improved since first started. Will start treatment of calcium alginate, border foam, and change every other day. Ensure patient heels are floating and staff should turn the resident every two hours. Frequent incontinence checks. Will reassess next week.During an interview on 04/10/26, at 1:05 P.M., Certified Nurse Assistant (CNA) E said the following:-He/she had not observed the resident's left outer heel open area, but the resident had been wearing a bandage for at least the last two weeks;-He/she thought the resident's pressure ulcer to his/her left outer heel was from lying in bed;-The resident had a scab on his or her right great toe, but the CNA was unsure how long the resident had the right great toe scabbed area. During an interview on 04/10/26 at 1:15 P.M. CNA K said the following:-He/she was aware the resident had an open area to his/her left outer heel, but the area generally had a bandage over it;-He/she was unsure how long the resident had the open area on his/her left outer heel.During an interview on 4/10/26 at 3:50 P.M., the Administrator said the following:-He/she expected nurses to complete and document weekly skin assessments on all residents; -The DON should review all the weekly skin assessments;-If staff observed a resident pressure wound, the CNA should report to the charge nurse, and the charge nurse should report to the DON;-The nurse should document an initial assessment of the wound in the progress notes or wound assessment;-The DON was responsible for completing the weekly wound assessments.

Based on observation, interview, and record review, the facility failed to provide services to prevent possible urinary tract infections (UTIs) when staff allowed the resident's urinary catheter (a thin, flexible tube inserted into the body to drain urine) tubing to touch the floor, increasing the risk of infection for one resident (Resident #2). The facility census was 57. Review of the facility policy titled, Catheter, Emptying a Urinary Drainage Bag, undated, showed staff to keep the drainage bag and tubing off the floor, at all times, to prevent contamination and damage. 1. Review of Resident #2's face sheet showed:-admission date of 08/20/25;-Diagnoses included benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/07/26, showed the following:-Moderate cognitive impairment;-Dependent on staff for assistance with toileting hygiene, lower body dressing, taking shoes on and off, personal hygiene, transfers, and bed mobility;-Presence of indwelling urinary catheter. Review of the resident's care plan, updated 03/16/26, showed the following:-Resident required an indwelling catheter related to prostatic hyperplasia and frequent urinary tract infections;-Staff should not allow the resident's catheter tubing or any part of the drainage system to touch the floor;-Avoid obstruction in the drainage; -Position the drainage bag below the level of the bladder. Observations on 04/06/26, at 5:45 P.M. and 6:15 P.M., showed the following:-The resident sat in a wheelchair in the dining room;-The resident's catheter drainage bag hung under the resident's wheelchair in a dignity bag;-The resident's catheter tubing lay on the dining room floor under the wheelchair. Observation on 04/07/26, at 7:35 A.M., showed the following:-The resident sat in a wheelchair in the dining room eating breakfast;-The resident's catheter tubing lay on the floor under his/her wheelchair;-The tubing contained dark yellow urine. Observation on 04/10/26, at 8:10 A.M., showed:-A Certified Nurse Assistant (CNA) J propelled the resident from his/her room down the hallway to the dining room;-The resident's urinary catheter tubing drug the floor under the resident's wheelchair. During an interview on 04/10/26, at 8:12 A.M., CNA J said the following:-When he/she transferred the resident to his/her wheelchair, he/she placed the catheter bag into a cloth dignity bag under the resident's wheelchair;-He/she tried to ensure the catheter tubing did not drag the ground;-If staff allowed the resident's catheter tubing to drag the ground, this could increase the resident's risk of infection. During an interview on 04/10/26, at 9:46 A.M., CNA D said the following:-Some staff did not know to place the resident's catheter bag high enough under the wheelchair, so the tubing did not drag the ground;-He/she tried to elevate the catheter bag high enough under the wheelchair so that the tube did not drag.During an interview on 04/10/26, at 1:05 P.M., CNA E said when the resident's catheter tubing lay on the ground, the staff should raise the catheter bag and hook it in a higher location under the wheelchair or place the excess tubing in the privacy bag.During an interview on 04/10/26, at 10:16 A.M., the Director of Nursing (DON) said the following: -The resident's catheter tubing should not drag the ground;-The CNA or nurse should hang the catheter bag/tubing in a different location under the wheelchair to ensure the tubing does not drag on the floor;-Staff allowing a resident's catheter tube to drag the floor poses an infection risk to the resident. During an interview on 04/10/26, at 3:50 P.M., the Administrator said the following:-Staff should keep the resident's urinary catheter tube off the floor and in a dignity bag;-If staff allow a resident's catheter tube to drag the floor, this could lead to an increased risk of bacteria in the resident's urine.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #6) had physician orders for the care of his/her colostomy (a surgical procedure that creates an opening, called a stoma, in the abdominal wall) . The facility census was 57.Review of the facility policy titled, Colostomy and Ileostomy (a surgical procedure where the end of the small intestine (the ileum) is redirected through a new opening in the abdominal wall, called a stoma) Care, undated, purpose to prevent infection, skin irritation, alleviate unpleasant odors, and to obtain accurate bowel measurement output.1. Review of Resident #6's face sheet showed:-admission date of 02/04/25;-Diagnoses included paraplegia (paralysis of the lower half of the body), anxiety and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 04/02/26, showed the following:-Resident cognitively intact;-Did not reject care;-Dependent on staff for assistance with toileting hygiene and lower body dressing;-Presence of colostomy. Review of the resident's care plan, dated 10/14/25, showed the following:-Resident at risk for constipation related to colostomy, decreased mobility;-Resident had a colostomy. Staff to provide cares each shift and as needed (PRN) and change the resident's bag as needed. Review of the resident's April 2026 Physician Orders showed the following:-An order, dated 11/26/25, for staff to assess the resident's stoma every shift to ensure functioning and color. Staff to document output color, consistency, and stoma color, stoma should be beefy red;-Staff did not document orders to change the resident's colostomy wafer or bag. Observation and interview on 04/06/26, at 11:05 A.M., showed:-The resident lay on his/her left side on the bed;-The resident said he/she had a colostomy and revealed a wafer and colostomy bag to his/her lower abdomen;-The resident said the staff change to colostomy wafer and bag when it leaks. During an interview on 04/09/26, at 9:30 A.M. Registered Nurse (RN) B said the following:-He/she thought the nurses changed the resident's colostomy wafer and bag approximately one time per week and more often if the wafer leaked stool;-The nurse said he/she was not certain of frequency of changes and would need to check the resident's physician's order;-The nurse checked the resident's electronic health record and did not find an order to change the colostomy wafer/stoma.-The resident should have a physician's order for colostomy wafer and bag changes.During an interview on 04/10/26, at 10:10 A.M., RN F said the following:-He/she was not aware the resident needed a physician's order for changing his/her colostomy wafer/bag;-He/she thought changing the wafer/bag was standard ostomy care;-He/she did not change the resident's colostomy wafer/bag unless it was loose or leaking.During an interview on 04/09/26, at 3:20 P.M., the Director of Nursing (DON) said the following:-Nursing staff should have obtained a physician's order for colostomy wafer/bag changes every four days and as needed;-The resident did not have a physician's order for changing of his/her colostomy wafer/bag, prior to 04/09/26. During an interview on 04/10/26, at 3:50 P.M., the Administrator said the following:-Nurses should obtain a physician's order for changing a resident's colostomy wafer/bag;-He/she was unsure how often a colostomy should be changed but thought probably at least every four days and as needed.

Based on observation, interview, and record review, the facility failed to ensure all residents with mental health services as needed when staff failed to consistently notify the physician and failed to develop a care plan regarding statement regarding death made by one resident (Resident #7) that made suicidal comments. The facility census was 57.Review of the facility policy titled, Suicide Threats, undated, showed the following:-Resident suicide threats shall be taken seriously and addressed appropriately;-Staff shall report any resident threats of suicide immediately to the charge nurse;-The charge nurse shall immediately assess the situation and shall notify the Director of Nursing (DON) of such threats;-A staff member shall remain with the resident until the charge nurse arrives to evaluate the resident;-After assessing the resident in more detail, the charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician;-All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately;-As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated;-If the resident remains in the facility, staff will monitor the resident's mood and behavior and updated care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present;-Staff shall document details of the situation objectively in the resident's medical record. 1.Review of Resident #7's face sheet showed:-admission date of 03/13/26;-Resident on hospice services;-Diagnoses included rectal cancer, liver cancer, pain, adjustment disorder, general anxiety disorder, depression, chronic fatigue, and weakness.Review of the resident's progress note dated 03/16/26, at 10:15 P.M., showed a nurse documented the resident had been making morbid jokes this shift. Resident had asked staff to bring him/her a gun and later wrapped a call light cord around his/her neck. Upon assessment the resident stated he/she was joking and denied any suicidal thoughts or ideation. The resident was placed on 15-minute checks out of an abundance of caution. The resident later made a joke to a nurse aide when they were getting him/her fresh linens to bring a body bag. Resident continued to deny suicidal thoughts or ideation. Resident laughing about making jokes. Continued on 15-minute checks out of abundance of caution. The resident was on hospice with rectal [NAME] and ceased cancer treatment prior to admitting to the facility. Resident pain controlled, call light and personal belongings in reach. (The nurse did not document notification of the resident's physician of the resident's comments.)Review of the resident's progress note dated 03/17/26, at 11:30 A.M., showed the Social Service Designee (SSD) documented the Social Services admission Assessment. This resident was admitted on [DATE], on hospice. The resident had stage 4 rectal cancer with chronic severe tumor related pain. Working on pain control. Most of the resident's depression stems from his/her medical condition. The resident stated if not for his/her pain he/she would not be nearly as depressed. Social services will continue to monitor and be available as needed.Review of the resident's progress note dated 03/23/26, at 3:07 A.M., showed a nurse documented the following:-Resident continued to request pain medication and pain medication administered twice;-No joking about death or dying this shift. Will continue to monitor for changes.Review of the resident's progress note, dated 03/23/26 at 11:19 A.M., showed a nurse documented the nurse aide came to the nurse and stated the resident told the aide, If I was strong enough, I would wrap the call light cord around my neck. Upon assessment resident stated he/she was in a lot of pain and no matter what position he/she was in it still hurt. The resident denied suicidal thoughts or ideation. Resident placed on 15-minute checks out of an abundance of caution. Resident received hospice services and had a terminal diagnosis of rectal cancer and had ceased cancer treatment. The resident did have a Fentanyl (a potent synthetic opioid medication used for pain control) topical patch in place and given as needed (PRN) pain medication as prescribed. Resident's safety maintained throughout the shift. Call light, water, and personal belongings within reach. Staff to continue with current plan of care. (The nurse did not document notification of the resident's physician of the resident's comments.) Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 03/27/26, showed:-Moderate cognitive impairment;-Felt down, depressed, hopeless, 2 to 6 days;-Experienced hallucinations.Review of the resident's progress note dated 03/30/26, at 12:11 P.M., showed a nurse documented resident making multiple comments early this shift about wanting to die. When interviewed the resident denied having a plan though admitted feeling down and requested to speak to someone. The nurse contacted hospice and requested the social worker or chaplain come out to see the resident. Hospice social worker came to see the resident and updated this nurse afterward that the resident was struggling with his/her emotions due to uncontrolled pain. The nurse spoke with the medication technician and charge nurse and asked that the as needed pain medication be utilized to get the resident's pain under control The resident also expressed to the hospice social worker about wanting to see a psychologist. This nurse received physician orders for a psychologist referral, and the SSD sent a referral to psychologist. Review of the resident's progress note dated 03/30/26, at 3:13 P.M., showed a nurse documented the resident was very tearful this morning. The resident said, I just want to die. The nurse listened to the resident and offered to get clergy. The resident wanted a psychiatrist. The nurse told the resident he/she would try to find someone to talk with him/her. The resident was reassured. Resident is on as needed pain medication. Will continue to monitor. (The nurse did not document notification of the resident's physician of the resident's comments.) Review of the resident's progress note dated 03/31/26, at 2:08 P.M., showed the SSD documented he/she visited with the resident this afternoon and talked about how things have been very difficult to deal with. SSD asked the resident if that is why he/she makes comments such as wrapping a call light around his/her neck and the resident said yes. The SSD explained to the resident that everyone was working with the resident to get his/her pain under control. He/she asked the resident if he/she would like to talk to someone about everything that was going on regarding his/her cancer, emotions about it, and his/her future and the resident said he/she was willing to. SSD sent a referral to Licensed Clinical Social Worker (LCSW)/therapist to visit the resident. Review of the resident's progress note dated 03/31/26, at 9:19 P.M., showed a nurse documented resident seen by his/her medical physician this shift. The physician ordered Zoloft (an antidepressant), increased the resident's Fentanyl pain patch, and increased the resident's PRN pain pills. The resident notified and agreed with the changes. Review of the resident's care plan, revised 04/01/26 , showed the following:-Resident received antianxiety medication related to diagnosis of rectal cancer and anxiety diagnosis;-Resident received antipsychotic medication.-Assess if the resident's behavioral/mood symptoms present a danger to the resident or others. Intervene as needed;-Attempt non-pharmacological interventions;-Monitor for drug use effectiveness and adverse consequences;-Monitor the resident's mood and response to the medication;-Quantitively and objectively document the resident's behavior/mood. -Monitor the resident's behavior and response to the medication;-Monitor the resident's functional status every 3 months;-Review for continued need at least quarterly.(Staff did not care plan specifically regarding the resident's suicidal comments or any staff interventions specific to suicide prevention.)Review of the resident's Behavioral Health Diagnostic Assessment, signed 04/08/26, showed the Licensed Clinical Social Worker (LCSW) documented the following:-Resident reports worsening depression since cancer diagnosis, stating he/she had been really depressed particularly today as tomorrow was his/her birthday. The resident's primary concern was his/her unrelenting pain, loss of bowel control, and loss of independence after being self-sufficient in his/her entire life. Expressed that pain was the primary driver of distress, noting, If I could get over the pain, I would be 90% better. Goals include managing emotional impact of terminal illness and maintaining quality of life through activities like fishing;-Remote history of suicidal ideation in early 20's following broken engagement; resolved after approximately 5 years. Denies any suicidal ideation since that time. Currently, the resident denied suicidal thoughts, homicidal ideation, or intent to harm self or others. States I got over that and ever since then, no. No current safety concerns identified. Protective factors include spiritual beliefs, supportive relationships with sister and friends, engagement with hospice services, and desire to participate in meaningful activities like fishing. Does not fear something bad happening to him;-Initial plan and recommendations: Patient agreeable to weekly counseling visits. Treatment will focus on coping with terminal illness, managing emotional impact of severe chronic pain, adjusting to loss of independence, and supporting quality of life goals. Will explore opportunities for meaningful activities within physical limitations, particularly fishing outings with friend when feasible. Patient expressed that visits might help. Next appointment is in one week.Review of the resident's care plan, revised 04/01/26 , showed staff did not care plan specifically regarding the resident's suicidal comments or any staff interventions specific to suicide prevention. Observations and interview with the resident on 04/09/26, at 8:52 A.M., showed the following:-The resident sat in his/her room in a wheelchair eating breakfast;-When asked about depression, the resident said that he/she did feel down, despite his/her medication to treat depression;-The resident said his/her pain had improved since his/her pain medications were increased;-The resident said he/she did not have suicidal thoughts, but if he/she decided to commit suicide, no one would ever know until it was over. During an interview on 04/09/26, at 11:01 A.M. Registered Nurse (RN) B said the following:-The resident had pain, but he/she was on a lot of pain medication and was on hospice services;-The resident's pain was not well-controlled on admission;-The resident made suicidal comments, especially when he/she first came to the facility;-RN B had not heard the resident make suicidal comments, but some of the CNAs informed RN B;-The CNA's said the resident would wrap and call cord around his/her neck;-One of the other nurses documented the resident joked about wanting staff to bring a body bag and that he/she wanted to die;-When the CNAs reported the resident's behavior, the nurse placed the resident on every 15-minute checks and notified the DON;-The DON said the resident's comments and actions were his/her way of processing his/her terminal cancer diagnosis;-The nurse said he/she did not think about notifying the resident's physician.During an interview on 04/10/26, at 8:15 A.M., RN F said the following:-The resident made suicidal comments in the past;-The resident did not have a plan to kill him/herself;-The resident's physician knew about the resident's suicidal comments.During an interview on 04/10/26, at 8:16 A.M., the Hospice RN N said the following:-The resident reported depression, but denied suicidal thoughts;-RN N thought the resident might have said something about suicidal thoughts to the hospice admitting nurse and then hospice took steps, like getting the social worker and chaplain involved;-RN N thought when the resident's pain was out of control, he/she was making suicidal comments, but now that the resident's pain was under control, he/she was not making suicidal comments to staff. During an interview on 04/09/26, at 11:23 A.M. the Social Service Designee (SSD) said the following;-The SSD said the resident's comments were on the borderline of being suicidal;-The SSD said he/she and RN B recently discussed the resident's comments and, on a couple of occasions, CNAs reported to RN B the resident's comments and he/she placed the resident on 15-minute checks;-The resident reportedly told the CNA he/she hurt so much he/she wanted to put a cord around his/her neck;-The resident made suicidal comments, but had never attempted suicide; -The resident's pain was now under better control;-The SSD arranged for the resident to see a therapist, Licensed Clinical Social Worker (LCSW);-The LCSW visited the resident on 04/02/26;-The LCSW planned to see the resident weekly. During an interview on 04/09/26, at 3:20 P.M., the DON said the following:-The resident made comments about placing a call light cord around his/her neck and about ending his/her life;-When staff questioned the resident, he/she would say he/she was joking;-The resident denied suicidal ideation/thoughts;-When the resident's pain increased, the staff contacted hospice and was placed on a new pain regimen and since then had not been making comments;-The facility also made a psychology referral;-The resident had been up out of bed and socializing more;-When the resident made suicidal comments, the nurse should have ensured the resident's immediate safety, notified the resident's physician, and documented notification, and any orders in the progress note. During an interview on 04/10/26, at 3:50 P.M., the Administrator said the following:-When the resident makes suicidal comments, the CNAs should notify the nurse, and the nurse should call resident's physician and responsible party;-The nurse should place the resident on 15-minute checks for at least 24 hours and then re-evaluate the resident's condition;-The nurse should document all in the progress notes;-Staff should care plan the resident's suicidal comments with specific interventions;-The facility should monitor the resident and possibly request a psychiatric evaluation.

Based on observation, interview, and record review, the facility failed to ensure a physician ordered medication was available for resident use for one resident (Resident #6) when staff did not obtain and did not administer his/her ordered bladder spasm medication for approximately four weeks. The facility census was 57.Review of the facility policy titled, Medications, Errors and Drug Reactions, undated, showed, in part, the following:-Purpose to safeguard the resident and provide emergency care as necessary;-Report all medication errors immediately to the resident's physician, Director of Nursing (DON), and Administrator;-Document and follow the physician orders. 1. Review of Resident #6's face sheet showed:-admission date of 02/04/25;-Diagnoses included overactive bladder, neuromuscular dysfunction of the bladder, anxiety and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 04/02/26, showed the following:-Resident cognitively intact;-Dependent on staff for assistance with toileting hygiene and lower body dressing;-Presence of indwelling urinary catheter (a thin, flexible tube inserted into the body to drain fluids) and colostomy (a surgical procedure that creates an opening, called a stoma, in the abdominal wall).Review of the resident's care plan, dated 03/11/26, showed:-Resident had an indwelling urinary catheter related to a diagnosis of paraplegia and cauda equina syndrome (compression of the nerves at the base of the spine leading to paralysis of the lower body);-Resident will have his/her catheter care managed appropriately as evidenced by no signs of infection or trauma;-Administer medications. Evaluate, record, report effectiveness and any adverse side effects;-Assess the drainage every shift. Observe for leakage. Review of the resident's care plan, dated 03/11/26, showed:-Resident required a suprapubic catheter (a flexible tube surgically inserted through a small abdominal incision directly into the bladder to drain urine) related to a diagnosis of paraplegia and cauda equina syndrome;-Resident will have suprapubic catheter care managed appropriately as evidenced by not exhibiting obstruction, signs of infection, dislodgement of catheter, bowel perforation, or trauma;-Assess the drainage every shift. Observe for leakage;-Report complications. Review of the resident's March 2026 Physician Orders showed an active order, dated 02/09/26, for tolterodine (a bladder spasm medication), staff to administer 2 milligrams (mg) one tablet by mouth, two times per day, morning and night. Review of the resident's March 2026 Medication Administration Record (MAR) showed the following:-An order dated 02/09/26, for staff to administer tolterodine 2 mg one tablet two times per day, 6:00 A.M.-10:00 A.M. and 7:00 P.M.-10:00 P.M.;-On 03/11/26, 7:00 P.M.-10:00 P.M., medication not administered due to drug/item unavailable. Not in the stat safe (emergency medication);-On 03/12/26, 6:00 A.M.-10:00 A.M., medication not administered due to drug/item unavailable;-On 03/12/26, 7:00 P.M.-10:00 P.M., medication not administered due to drug/item unavailable and not in the stat safe;-On 03/13/26, 6:00 A.M.-10:00 A.M., medication not administered and discontinued. Medication was only for 30 days;-On 03/13/26, 7:00 P.M.-10:00 P.M., not administered due to drug/item unavailable and not in the stat safe;-On 03/14/26, 6:00 A.M.-10:00 A.M., not administered due to not in E-Kit (emergency medication);-On 03/14/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/15/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 03/15/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/16/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 03/16/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/17/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 03/17/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/18/26, 7:00 P.M.-10:00 P.M., not administered due to drug/item unavailable;-On 03/19/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 03/19/26, 7:00 P.M.-10:00 P.M., not administered due to drug/item unavailable and not in the stat safe;-On 03/20/26, 6:00 A.M.-10:00 A.M., not administered due to drug/item unavailable;-On 03/20/26, 7:00 P.M.-10:00 P.M., not administered due to drug/item unavailable and not in E-kit;-On 03/21/26, 6:00 A.M.-10:00 A.M., not administered due to drug/item unavailable;-On 03/21/26, 7:00 P.M.-10:00 P.M., not administered due to drug/item unavailable. Not in stat safe;-On 03/22/26, 6:00 A.M.-10:00 A.M., not administered due to drug/item unavailable and not in the stat safe;-On 03/22/26, 7:00 P.M.-10:00 P.M., not administered due to drug/item unavailable and not in the stat safe;-On 03/23/26, 6:00 A.M.-10:00 A.M., not administered due to drug/item unavailable;-On 03/23/26, 7:00 P.M.-10:00 P.M., not administered due to drug/item unavailable;-On 03/24/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 03/24/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/25/26, 6:00 A.M.-10:00 A.M., not administered due to refused;-On 03/25/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/26/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 03/26/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/27/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued.Review of the resident's progress note, dated 03/27/26, at 4:47 P.M., showed a nurse documented the following:-The resident's catheter was not flushing well with sediment noted in the tubing;-Resident noted to have yellow urine in the catheter bag, but stated, Maybe that is why I have been leaking a lot.;-The nurse changed out the resident's catheter using sterile technique;-After changing the catheter, the nurse noted urine as well as a moderate amount of sediment;-Nurse to continue with current plan of care. Review of the resident's March 2026 MAR showed the following: -An order, dated 02/09/26, for staff to administer tolterodine 2 mg one tablet two times per day, 6:00 A.M.-10:00 A.M. and 7:00 P.M.-10:00 P.M.;-On 03/27/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/28/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 03/28/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/29/26, 6:00 A.M.-10:00 A.M., not administered due to drug/item unavailable;-On 03/29/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/30/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 03/31/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 03/31/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued.Review of the resident progress notes, dated March 2026, showed staff did not document an order to discontinue the medication, physician notification of the missed doses, or pharmacy notification and follow-up regarding the medication not received. Review of the resident's April 2026 Physician Orders showed an active order, dated 02/09/26, for tolterodine staff to administer 2 mg one tablet by mouth, two times per day, morning and night. Review of the resident's April 2026 MAR showed:-An order dated 02/09/26, for staff to administer tolterodine 2 mg one tablet two times per day, 6:00 A.M.-10:00 A.M. and 7:00 P.M.-10:00 P.M.;-On 04/01/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 04/01/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 04/02/26, 6:00 A.M.-10:00 A.M., not administered due to waiting on clarification;-On 04/03/26, 7:00 P.M.-10:00 P.M., not administered due to drug/item unavailable;-On 04/04/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 04/04/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 04/05/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued;-On 04/05/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 04/06/26, 6:00 A.M.-10:00 A.M., not administered due to drug/item unavailable. Observation and interview with the resident on 04/06/26 at 11:05 A.M., showed the following:-The resident lay on his/her left side on the bed;-The resident had two urinary catheters, a Foley catheter and a suprapubic catheter;-The resident said his/her catheters leak urine at times due to bladder spasms.Review of the resident's April 2026 MAR showed:-An order dated 02/09/26, for staff to administer tolterodine 2 mg one tablet two times per day, 6:00 A.M.-10:00 A.M. and 7:00 P.M.-10:00 P.M.;-On 04/06/26, 7:00 P.M.-10:00 P.M., not administered due to drug/item unavailable;-On 04/07/26, 6:00 A.M.-10:00 A.M., not administered due to drug/item unavailable;-On 04/07/26, 7:00 P.M.-10:00 P.M., not administered due to discontinued;-On 04/08/26, 6:00 A.M.-10:00 A.M., not administered due to discontinued.Review of the resident progress notes, dated April 2026, showed staff did not document an order to discontinue the medication, physician notification of the missed doses, or pharmacy notification and follow-up regarding the medication not received. During an interview on 04/09/26, at 9:30 A.M. Registered Nurse (RN) B said the following:-The resident had an issue with bladder spasms due to his/her diagnosis of paraplegia;-The resident had both a suprapubic catheter and a foley catheter;-The resident's urine leaked from his/her urethra due to bladder spasms, and that issue had not improved despite the use of medications to help with bladder spasms. The physician had increased the bladder spasm medication;-The resident's urine leaking adversely affected the resident's wound healing;-He/she was not aware the certified medication technicians (CMT) had not administered the resident's tolterodine as ordered;-If a medication was not available for administration to the resident as ordered, the CMT should notify the nurse, verbally or leave a note for the nurse;-Some of the CMTs would call the pharmacy, but if not, the nurse should call the pharmacy and check on the status of the medication;-Re-ordering medication was a simple process and could be re-ordered by hitting a button in the resident's electronic health record (EHR) to 're-supply' and the pharmacy would usually send out the medication;-The nurse should notify the resident's physician to see if the physician wanted to discontinue the medication or wanted to order something comparable. During an interview on 04/09/26, at 11:16 A.M., CMT L said the following:-If a resident medication was not available for administration, he/she would first check the emergency kit (E-Kit). If the medication was not available in the E-Kit, the CMT would notify the charge nurse. The nurse or CMT would then call the pharmacy. If the pharmacy did not plan to deliver the medication that same day, the CMT would re-order the medication;-The CMT said he/she thought the physician had discontinued the resident's tolterodine, but the nurses had not had a chance to remove the medication from the resident's physician order sheet;-The CMT said one of the other CMTs had placed a note on the resident's electronic medication administration record (eMAR) stating the medication was discontinued.During an interview on 04/10/26, at 10:05 A.M. CMT M said the following:-He/she thought the resident's physician had discontinued the tolterodine medication;-He/she was unsure why the medication was still listed as an active order on the MAR;-He/she always told the nurse when any resident medication was not available for administration;-The nurses were aware the resident did not have a supply of tolterodine.During an interview on 04/10/26, at 10:10 A.M., RN F said the following:-He/she was aware the resident did not have a current supply of tolterodine;-The nurse had been working with the pharmacy for approximately two weeks to attempt to get a substitute medication for the tolterodine due to insurance coverage issues;-He/she needed to address the medication issue again today, 04/10/26, with the pharmacy/physician. During an interview on 04/09/26, at 3:20 P.M., the Director of Nursing (DON) said the following:-If a CMT could not locate a resident medication, the CMT should check with the pharmacy to confirm the facility re-ordered the medication;-The CMT should then look for the medication in the stat safe;-If the facility did not have the medication on hand, the CMT should notify the nurse;-The CMT should notify his/her nurse each time the CMT did not have a resident medication dose;-The nurse should notify the resident's physician and document the notification of the physician in the resident's progress notes;-The DON said he/she tried to check the resident MARs to ensure staff were administering resident medications as ordered, but he/she had not checked the resident MARs in approximately 2-3 weeks. During an interview on 04/10/26, at 3:50 P.M., the Administrator said the following:-If staff did not have an ordered medication available for a resident, the CMT or nurse should call the pharmacy;-If the insurance company did not want to pay for the medication, the nurse should contact the physician to see if the physician wanted to order another medication or discontinue the order.

Based on observation, interview, and record review, the facility failed to complete regular inspections of the bed frame and side rails for risk of entrapment for one resident (Resident #51) whose side rails were loose. The facility census was 57.Review of the facility policy, titled Bed Rails, undated, showed the following:-Bed rails are constructed of metal or plastic, and are available in various sizes (full length, half, or quarter rails). Bed rails may be positioned in various locations on the bed: upper or lower, one or both sides;-When installing or maintaining bed rails, staff should follow manufacturer's recommendations and specifications for applicable bed rails, mattresses and bed frames;-Staff will conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. When bed rails and mattresses are used in purchases separately from the bed frame, the facility will select equipment such as bed rails, mattresses, and bed frames that are compatible.1.Review of Resident #51's face sheet (brief resident profile) showed the following:-admission date of 10/21/25;-Diagnoses included stroke, hemiplegia (severe or total paralysis of one side of the body cause by stroke or spinal cord injuries), type two diabetes mellitus (chronic condition here the body develops insulin resistance or fails to produce enough insulin, causing high blood sugar), depression, mixed anxiety disorders, insomnia, and contracture of left hand.Review of the resident's current physician order sheet showed an order, dated 11/21/25, for quarter upper bed rails for positioning.Review of the resident's bed rail and assessment consent, dated 11/21/25, showed the facility completed an assessment, including measurements, a clinical assessment, alternative attempts before considering bed rail use, and risks and benefits. Review of the resident's care plan, revised 03/16/26, showed the following:-Resident required bed rails;-Type: half rail;-Medical symptoms that warrant the use of side rails: hemiplegia to left side related to stroke;-Assess reasons for rail usage;-Assess resident's response to rails;-Re-evaluate the need for bed rails every three months. Review showed the facility did not provide documentation of regular safety checks for bed rails.Observation and interview on 04/07/26, at 2:52 P.M., showed the resident in bed with approximately quarter-size bilateral bed rails in the raised position. The resident said he/she asked staff to install the bed rails and used them for bed mobility. The right-side bed rail was extremely loose. It could be moved liberally up and down and side to side and was nearly at a 45-degree angle at the top due to being loose.Observation on 04/08/26, at 2:05 P.M., showed the following:-The resident lay in bed with quarter size bilateral bed rails in raised position;-The right bed rail was to be extremely loose and could be moved up and down and side to side liberally;-The top of the right bed rail was nearly at a 45-degree angle due to being loose.Observation on 04/09/26, at 3:30 P.M., showed the following;-The resident lay in bed with quarter size bilateral bed rails in raised position;-The right bed rail continued to be extremely loose and could be moved up and down and side to side liberally;-The top of the right bed rail was nearly at a 45-degree angle due to being loose.During an interview on 04/10/26, at 9:56 A.M., Certified Nursing Assistant (CNA) D said the following:-Residents use bed rails for bed mobility and transfers and it was unsafe for them to be loose;-Staff should notice if a bed rail was very loose;-Staff should notify the nurse and Maintenance Director of a loose bed rail and document in the maintenance book behind the nurses' station.During an interview on 04/10/26, at 10:36 A.M., CNA E said he/she would notify the nurse of a loose side rail because it was not safe for a resident to use it for bed mobility.Observation and interview on 04/10/26, at 11:36 A.M. showed the following:-The Maintenance Director said he installed bed rails after conducting appropriate measurements;-He conducted weekly safety checks on bed rails;-Staff should notify him of issues, including loose bed rails by writing in the maintenance log at the nurses' station;-Staff had not written any concerns about the resident's bed rails in the maintenance log;-The Maintenance Director checked the resident's bed rail and said it should not have been that loose and was a safety issue.During an interview on 04/10/26, at 12:23 P.M., Registered Nurse (RN) F said staff should notice if a bed rail is loose during cares and document it in the maintenance book.During an interview on 04/10/26, at 1:49 PM, the Director of Nursing (DON) said the following:-Residents use bed rails for independence with positioning and assisting with cares;-Residents must be assessed appropriately for risks and benefits and measurements must be completed before side rails can be installed;-All staff are responsible for observing if bed rails are loose and should notify both the nurse and maintenance;-Maintenance conducts quarterly safety checks and also checks the bed rails during mattress changes.During an interview on 04/10/26, at 2:59 P.M., the Administrator said the following:-Maintenance completed measurements and installation for bed rails;-Staff should observe loose bed rails and document in the maintenance book;-The Housekeeping Supervisor conducted weekly audits on the bed rails and notified maintenance of concerns.

Based on interview and record review, the facility failed ensure notification to the resident's family/responsible party of changes of condition for all when residents when staff failed to document family/responsible party notification of four residents (Resident #1, #2, #3, and #4) for resident change in health condition, resident falls, and/or new physician orders. The facility had a census of 58.Review of the facility provided Patient [NAME] of Rights as provided by the Long-Term Care Ombudsman (advocate for residents in nursing homes and assisted living facilities who helps protect their rights, health, and quality of life) Program, showed the resident had the right to:-Be fully informed of services available to you;-Participate in planning your care and being informed of all aspects of your care.Review showed the facility did not provide a policy provided related notifications of resident change in condition to responsible party or family members. 1. Review of Resident #1's face sheet showed the following: -admission date of [DATE];-Hospice admission date of [DATE];-Resident had an emergency contact and durable power of attorney (DPOA - legal document allowing someone to make decisions on your behalf) listed with name and phone number;-Diagnoses included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with agitation, heart failure, and cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain).Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated [DATE], showed the following:-Moderate cognitive impairment;-Partial to moderate assistance required with showering, toileting hygiene;-Supervision required with personal hygiene.Review of the resident's care plan, last updated [DATE], showed the following:-Resident at risk for falls related to generalized weakness, decreased cognition, and disease process;-Staff should notify the resident's doctor and family or guardian of a fall;-Resident did not want cardiopulmonary resuscitation initiated (CPR - emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped);-Staff should notify the resident's family and physician of any changes in condition.Review of the resident's [DATE] Physician Order Sheet (POS) showed an order, dated [DATE], for ceftriaxone (a powerful, broad-spectrum antibiotic used to treat a wide variety of bacterial infections) reconstituted solution, 1 gram injection once per day, for diagnosis of cellulitis;Review of the resident's nursing progress note dated [DATE], at 3:25 A.M., showed resident started antibiotic treatment for cellulitis (common, serious bacterial infection of the skin's deeper layers and underlying tissue, often causing redness, swelling, warmth, pain, and tenderness). He/she was free of side effects or adverse reaction related to this treatment. Review of the resident's [DATE] progress notes showed staff did not document notification the resident's family or responsible party of the new medication order. Review of the resident's [DATE] POS showed the following:-The order, dated [DATE], for ceftriaxone was discontinued [DATE];-An order dated [DATE] and discontinued [DATE], for cefuroxime axetil (semisynthetic, broad-spectrum, antibiotic used to treat a wide variety of bacterial infections) tablet, 250 mg, 1 tablet twice daily for diagnosis of cellulitis.Review of the resident's [DATE] progress notes showed staff did not document notification the resident's family or responsible medication order changes2. Review of Resident #2's face sheet showed the following: -admission date of [DATE];-Hospice admission date of [DATE];-Emergency contact and legal guardian listed with name and number;-Diagnosis included dementia, repeated falls, heart disease, and chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should).Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Partial to moderate assistance required with personal hygiene, showering.Review of the resident's care plan, updated [DATE], showed the following:-Resident preferred no life saving measures;-Staff should communicate with resident family, hospice, and physician if any changes in condition.Review of the resident's nursing progress notes showed the following:-On [DATE], at 12:30 P.M., staff noted while assessing resident during lunchtime this nurse noticed resident had a small bruise to his/her right side of his/her mouth. When asking resident what happened he/she stated, I fell on my trash can yesterday. Certified nurse aide (CNA) reported no falls this shift. No other injuries noted. Neuros (a series of questions and tests used by healthcare providers to assess how well a person's nervous system is working) and range of motion within normal limits. Vital signs stable. Neuros initiated. No complaints of pain or discomfort noted. On call nurse notified. Residents' safety maintained throughout shift. Call light, water and personal items within reach. Continue with current plan of care. (Staff did not document notification or the resident's family or responsible party regarding the bruising and reported fall.)-On [DATE], at 12:30 P.M., staff noted this nurse was notified by the aide in the back that resident reported to him/her that he/she fell last night on the floor and hit his/her head and the male CNA picked him/her up. Upon assessment resident noted to have dime sized bump to right side of his/her forehead above his/her eye. Neuros and range of motion within normal limits. Vital signs stable. Resident was trying to get self out of bed. Neuros initiated. No other injures noted. (Staff did not document notification or the resident's family or responsible party regarding the injury or reported fall.)-On [DATE], at 1:45 P.M., the resident was using the restroom and while the aide was in there with him/her trying to help assist him/her transfer the resident freaked out and slipped and hit his/her head on the bar. No injury noted to head. Neuros intact. Range of motion within normal limits. Vital signs stable. Neuros initiated. Resident safely assisted back into wheelchair. Resident's safety maintained. (Staff did not document notification or the resident's family or responsible party regarding the fall.);-On [DATE], at 6:30 A.M., resident was in the bathroom and tried to get up off the toilet by self and fell and hit his/her head. Resident noted to have dime sized goose egg to middle of forehead. No other injuries noted. Vital signs stable. Neuros and range of motion within normal limits. Neuros initiated. Resident educated to utilize call light in bathroom to ask for help. Resident verbalized understanding. No complaints of pain or discomfort. Resident's safety maintained. (Staff did not document notification or the resident's family or responsible party regarding the fall.)3. Review of Resident #3's face sheet showed the following : -admission date of [DATE];-Emergency contact listed with name and phone number;-Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe),and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)). Review of the resident's admission MDS, dated [DATE], showed the following:-Moderate cognitive deficit;-Substantial to maximal assistance required for showering, dressing;-Partial to moderate assistance required for personal hygiene.Review of the resident's care plan, updated [DATE], showed the following:-Resident did not want CPR and had services with hospice since admission;-Staff should notify the resident's family, hospice, and physician of any changes in condition.Review of the resident's nursing progress notes dated [DATE], at 12:00 A.M., showed resident was found at the foot of his/her bed at 3:00 P.M. No apparent injury. Assisted into his/her wheelchair and taken to the television room to be observed for safety. His/her oxygen concentrator plugged in and on 5 liters. Attempted to be redirected without understanding of the situation. Oriented to person only. This is not new. He/she is at baseline for him/her. Staff to continue to monitor for safety. (Staff did not document notification or the resident's family or responsible party regarding the fall.)4. Review of Resident #4's face sheet showed the following:-admission date of [DATE];-Emergency contact listed with name and phone number;-Diagnoses included dementia, chronic pain, reduced mobility, and anxiety disorder.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive deficit;-Partial to moderate assistance with personal hygiene, showering.Review of the resident's care plan, last updated [DATE], showed the following:-Resident at risk for falls related to impaired safety awareness, impaired mobility, general debility, and disease processes;-Staff should notify the resident's family and doctor for falls;-Staff should complete documentation as per facility protocol;-Resident wanted life saving measures;-Staff should notify the resident's family and physician of any changes in condition.Review of the resident's nursing progress notes showed staff documented the following:-On [DATE], at 3:10 P.M., the resident was wandering and went into another resident's room. The other resident hit him/her and knocked him/her to the ground. Staff called both residents to the desk to counsel them. Staff notified the Director of Nursing (DON), and he/she will arrive shortly. There appeared to be no injuries to the resident. Resident was sitting quietly at the desk. (Staff did not document notification or the resident's family or responsible party regarding the altercation.)-On [DATE], at 3:25 P.M., staff noted fall - this nurse was called back to the memory care unit due to the resident being found on the floor. Upon assessment the resident was found in the hallway on the floor on his/her back. Resident did hit the back of his/her head. Resident unable to tell nurse what he/she was trying to do. Resident's shoes were untied. Resident safely assisted up by two staff members. This nurse assisted the resident in tying his/her shoes. Neuros and range of motion within normal limits. Vital signs stable. Physician notified. No new orders received. Neuros initiated. Resident with poor safety awareness. Resident's safety maintained throughout shift. Staff to continue with current plan of care. (Staff did not document notification or the resident's family or responsible party regarding the fall.)5. During an interview on [DATE], at 11:25 A.M., CNA D said if a resident had a change of condition, he/she would report to the nurse. If the nurse did not respond he/she would tell the DON and continue the chain of command if no response. He/she said the nursing staff call the resident's family for change of health.During an interview on [DATE], at 12:00 P.M., CNA E said if a resident had a change from their baseline, he/she would contact the charge nurse. The nurse contacted the families. It was not in the scope of the aide to contact families.During an interview on [DATE], at 11:50 A.M., Certified Medication Tech (CMT) C said if he/she noted a change in resident condition or resident fall, he/she would notify the nurse. He/she said he/she did not make calls to resident families; the nurses call the families and physicians.During an interview on [DATE], at 10:25 A.M., Licensed Practical Nurse (LPN) A said that if a resident had any change of health condition, anything that was outside of their baseline health, he/she would notify the family or emergency contact about the change. He/she said that if the resident was on hospice, the hospice staff generally call the residents family, but he/she would still contact the family for verification and would document who was contacted. During an interview on [DATE], at 10:50 A.M., LPN B said that when a resident had a change in health condition, falls, or new physician orders the nursing staff should notify the family or responsible party and the nurse should document in the progress note who was contacted. If hospice noted the change in condition, the facility nurse should still contact the resident's contact person and document.During an interview on [DATE], at 12:15 P.M., the MDS Coordinator said staff should notify the charge nurse of any resident change in condition. The nurse should assess and notify the physician and follow any new orders. The nurse should contact the family of any and all changes, even if the resident was their own person or on hospice, the family should be notified. If there was a non-injury 3:00 A.M. fall the family may not be notified until the morning if they requested but this should be documented. Resident #2 had multiple falls, but staff should document family contact with each fall and document the contact. The staff should contact Resident #1's family for all changes including medication changes.During an interview on [DATE], at 11:00 A.M., the DON said she did not find a specific policy related to notification of resident family or responsible party about change in health condition, but it was included in the resident rights. The nursing staff should notify the physician and family of health changes and resident falls. If there are new medication orders the nursing staff should contact the family. The nursing staff should document all contact with family in the progress notes. All families should be contacted regardless of resident cognitive status, unless there were previous plans made with the emergency contact, or the resident did not have an emergency contact. If it was not charted it was not done. Resident #2 had multiple falls, and family should have been contacted after each fall. Resident #1's family should have been contacted about medication changes or new orders. Staff should be documenting contact with resident family members.During an interview on [DATE], at 12:10 P.M., the Administrator said that the facility staff should notify the charge nurse of falls and any change in health condition. Hospice should also notify the facility nurse of change in condition. The nurse should evaluate the resident and let the DON and physician know of change of health. The nurse should notify the family of health condition changes, falls, and new orders including medication orders within the first few hours of the change condition, this is for all residents. The nursing staff should make a progress note that identifies who was notified. Resident # 2 family should be contacted each time that he/she had a fall, and it should be documented they were contacted. Resident #4, the family should be contacted for change in health condition and the information should be documented. Resident #1 family should be notified of medication changes and information documented. Resident #3 family should be notified of change of health and information should be documented.Complaint 2665069

Based on interview and record review, the facility failed to keep all residents free from significant medication errors when staff administered one resident's (Resident #1) medication (ferrous sulfate - iron supplement) at the incorrect frequency for 82 days.A sample of four residents was reviewed for medication administration in a facility with a census of 56. Review of the facility policy entitled, Physician Orders, undated, showed medication orders should include type, route, dosage, frequency, and strength of the medication ordered. Review of the facility policy entitled, Medication Administration, revised 02/07/13, showed the following information:-Medications are given to benefit a resident's health as ordered by the physician;-Read the label three times before administering the medication. First when comparing the label with the medication sheet. Second when setting up the medication. Third when preparing to administer medication to the resident;-Administer medication and record the medication given on the medication sheet.Review of the ferrous sulfate tablet package insert/prescribing information, dated 03/25/25, showed the following: -In case of accidental overdose, call a doctor or poison control center immediately;-Recommended dosage of one tablet daily as a dietary supplement, preferably with a meal or as directed by a doctor. Do not exceed 2 tablets in 24 hours. Not for frequent or prolonged use except on the advice of a doctor. Do not exceed recommended dosage;-Since oral iron products interfere with absorption of certain antibiotics, these products should not be taken within two hours of each other. Discontinue use and consult your doctor if any adverse reactions occur;-Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug;-Tell your doctor or get medical help right away if you have any of the following signs or symptoms: signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat;-Other side serious side effects include black, tarry, or bloody stools; fever; very upset stomach or throwing up; very bad belly pain; or throwing up blood or throw up that looks like coffee grounds. 1. Review of Resident #1's face sheet (gives basic profile information at a glance) showed the following information:-admission date of 07/18/25; -Diagnoses included atrial fibrillation (a-fib - irregular heart function), pneumonia due to inhalation of food, severe protein-calorie malnutrition, high blood pressure, stroke, peripheral vascular disease (PVD - circulatory disorder of the arteries and veins outside of the heart and brain leading to reduced blood flow to the limbs and organs), acute respiratory failure, gastro-esophageal reflux disease (GERD - stomach acid backs up into the throat), altered mental status, symptoms involving cognitive functions and awareness, pain, emphysema (lung disorder with loss of lung elasticity, reduces oxygen supply in the blood), shortness of breath, and inflamed stomach lining with bleeding. Review of the resident's care plan, updated 08/22/25, showed the following:-At risk for ineffective breathing pattern related to disease process;-Resident had high blood pressure. Staff to explain the benefits of consuming a nutritionally balance diet;-Administer medications as ordered;-At risk for inadequate nutrition related to frequent inadequate intake. Determine, in collaboration with the dietitian as appropriate, the number of calories and type of nutrients needed to meet my nutritional requirements. Review of the resident's hospital Discharge summary, dated [DATE], an order for ferrous sulfate 142 milligrams (mg) (45 mg iron) tablet, sustained release; take 142 mg by mouth, one each Friday to be taken with 500 mg Vitamin C. Review of the resident's facility physician order sheet (POS), current as of the resident's discharge on [DATE], showed the following orders, dated 07/18/25:-Ascorbic acid (vitamin C) tablet for diagnosis of emphysema 500 mg, one oral, once a day on Friday, 06:00 AM - 10:00 AM;-Ferrous sulfate tablet, delayed release, 324 mg (65 mg iron), 1/2 tab oral for diagnosis of severe protein-calorie malnutrition, take every Friday with vitamin C 500 mg. Review of the resident's electronic Medication Administration Record (eMAR), dated 07/18/25 to 08/17/25, showed the following:-An active order for ascorbic acid tablet 500 mg, administer 1 oral once a day on Fridays;-An active order for ferrous sulfate tablet delayed release (DR), 324 mg (65 mg iron), administer 1/2 oral, take every Friday with vitamin C 500 mg;-Staff documented administration of the ferrous sulfate on 07/19/25, 07/20/25, 07/21/25, and 07/22/25; -On 07/23/25, 07/24/25, 07/25/25, 07/26/25, and 07/27/25 staff documented ferrous sulfate not given due to resident in hospital;-Staff documented administration of the ferrous sulfate daily on 07/28/25 through 08/17/25. Review of the resident's eMAR, dated 08/18/25 to 09/17/25, showed the following:-An active order for ascorbic acid tablet 500 mg, administer 1, oral, once a day on Friday;-An active order for ferrous sulfate tablet delayed release, 324 mg (65 mg iron); administer 1/2, oral, take every Friday with vitamin C 500 mg;-Staff documented administration of the ferrous sulfate daily on 08/18/25 to 09/17/25. Review of the resident's eMAR, dated 09/18/25 to 10/07/25 (resident's date of discharge), showed the following:-An active order for ascorbic acid tablet 500 mg, administer 1, oral once a day on Friday;-An active order for ferrous sulfate tablet delayed release 324 mg (65 mg iron); administer 1/2 oral, take every Friday with vitamin C 500 mg;-Staff documented administration of the ferrous sulfate daily on 09/18/25 to 10/07/25. During an interview on 10/31/25, at 2:00 P.M., Certified Medication Technician (CMT) A and CMT B both said it the charge nurse's responsibility to input the physician orders. They said the POS entries automatically populates the eMAR, and the eMAR then triggers the scheduled medication doses. CMT A and CMT B reviewed the closed record eMAR for the resident and said they could view the ordered frequency of the vitamin C and ferrous sulfate but had not noticed the discrepancy prior. They said the documentation showed staff had administered the vitamin C on Fridays as ordered, but the ferrous sulfate had been administered on a daily basis. CMT A and CMT B said if they noticed discrepancies or required clarification, they should notify the charge nurse or the Director of Nursing (DON). During an interview on 10/31/25, at 2:35P.M., Registered Nurse (RN) C said the charge nurse should enter the medication orders from the hospital discharge orders. That information would then populate into the eMAR. Each medication should pop up on the screen when it is scheduled to be given or pop up when as needed medications are accessed. On the eMAR, the CMT/nurse would see the scheduled dose/time for each specific medication and should see the ordered dosing frequency on the left side of the screen. For a medication not scheduled at that time or was too soon to given per the frequency ordered, they should see a message showing No Administration Available and showing the last dose date/time given. If there is a discrepancy noted, the CMT should tell the charge nurse. The nurse should get physician order clarification if needed. During an interview on 10/31/25, at 2:07 P.M., the DON said medication orders for newly admitted residents are received with the hospital discharge summary or via the resident's home medication list. The charge nurse is responsible for inputting the orders in the POS, which automatically populates the eMAR. The physician then approves the POS, and the pharmacy reviews the medication list. The DON reviewed the POS for the resident and verified the order was given as ferrous sulfate DR 324 mg; 1/2 tablet by mouth every Friday, give with vitamin C. The DON reviewed the hospital discharge orders and said the order was ferrous sulfate 142 mg, give every Friday with vitamin C. The DON reviewed the resident's eMAR and confirmed the ferrous sulfate was scheduled daily. Staff documented they gave the ferrous sulfate daily; there were no gaps. The eMAR shows the medication orders and each pop up when they are due. The DON said the screen does show the ordered frequency on the due screen seen by the CMTs and/or nurses, although the information is off to the side and separate from the box showing the scheduled time for the dose. If the order had been input correctly, the CMTs/nurses would see a message on the non-scheduled dose days reading No Administration Available and showing the date and time of the last dose given. During an interview on 10/31/25, at 4:10 P.M., the Administrator said staff should follow the POS for medication administration. The charge nurse is responsible for inputting the orders, or the DON can enter the orders if the nurse does not have sufficient time to do so. The eMAR populates from the information in the POS; medications come up on the screen when they are due to be given. The Administrator said the ordered frequency is not very prominent on the administration screen, and CMTs might not notice that information. They are looking at the dosing time and at the information showing when the medication was last given, including any message stating it is not due or is to too soon for an as needed medication. Complaint 2651756

Based on observation, interview, and record review, the facility failed ensure all residents maintained acceptable parameters of nutritional status with the facility failed to follow-up and implement Registered Dietitian (RD) recommendations for two residents (Resident #1 and #4) with wounds and for three residents (Resident #2, #3, and #4) who were identified as under body weight. The facility census was 37. Review of the facility's House Supplement Guidelines, dated May 2015, showed supplements are indicated when resident's intake at meals is not adequate to maintain weight, weight gain is needed, or weight loss is too rapid. Review of the facility's Supplement Guidelines, dated May 2015, showed the following: -Physician ordered supplements should be prepared and delivered by the dietary department; -Supplementation should be regular food and beverage items when possible before fortified liquid products are tried; -All individual supplements to be documented on the supplement list by the Dietary Manager (DM) or designee; -When the physician ordered a supplement, the order would be discussed with the resident with likes and dislikes taken into account; -Supplements were not to be served with meals unless prescribed by the physician. 1. Review of Resident #1's face sheet showed: -admission date of 02/04/25; -Diagnoses included sacral (lower base of spine) pressure ulcer, paraplegia (paralysis of bilateral lower limbs), anxiety, and depression. Review of the resident's admission Minimum Data Set (MDS - a federally-mandated assessment tool completed by facility staff), dated 02/05/25, showed the following: -Cognitively intact; -No behavioral symptoms; -Independent with eating; -Diagnosis of sacral (lower base of spine) pressure ulcer, stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle, slough (dead tissue that accumulates in the wound, generally yellow, white, or gray in color) or eschar (dead tissue, usually brown or black in color] may be present in parts of the wound bed)); -Height of 5 foot 11 inches and weight of 242 pounds; -No swallowing problems. Review of the resident's care plan, dated 02/10/25, showed the following: -Resident was admitted to the facility with a stage 4 pressure ulcer to his/her coccyx (tailbone), related to morbid obesity and decreased mobility; -Serve diet per physician orders; -Diet of level 7 (L7 - easy to chew), regular. Review of the resident's physician orders showed an active order, dated 02/04/25, for Level 7 (easy to chew) regular diet. Review of the resident's initial comprehensive nutrition assessment, dated 02/13/25, completed by the RD showed the following: -Diagnoses of anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and obesity; -Resident able to make preferences known; -Location of most meals was resident room; -Resident's current height of 71 inches and current weight of 248 pounds; -Resident independent with eating and drinking; -Resident had dentures/partial; -Resident had pressure ulcer, stage 4; -Pressure wound to buttocks with wound vac (a medical device that uses negative pressure (suction) to help wounds heal by removing fluid and dead tissue, promoting new tissue growth, and improving blood flow). Review of the resident's progress note dated 02/13/25, at 8:35 A.M., showed the following: -Resident received a regular diet without additional supplementation; -Resident dined in his/her room per preferences with good appetite. Meal intake had been variable but about 50% on average. -Resident had dentures and no difficulty chewing/ swallowing; -Resident had pressure wound to buttock with wound vac in place; -Current weight was 248 pounds with BMI (body mass index) of 34.6 (optimum range is 18.5 to 24.9); -Recommend adding 30 milliliter's (mL) Pro-Stat (a concentrated liquid protein) twice per day (BID) to support wound healing; -RD will continue to monitor and follow up as needed (PRN). Review of the form, RD Recommendations Requiring Physician Order, dated 02/13/25, showed a list of residents with recommendations including the resident with a concern of wound healing and a recommendation of 30 mL of Pro-stat BID. The column titled date completed was left blank. Review of the resident's progress note dated 03/07/25, at 5:28 P.M., showed a new order received via fax from the resident's nurse practitioner (NP) for fortified foods (foods enriched with additional nutrients, vitamins/minerals) with meals. Review of the resident's physician orders (including current and discontinued orders) showed an active order, dated 03/07/25, for fortified foods with meals every day. (The physician orders did not show an order for Pro-Stat.) Review of the form titled, RD Recommendations Requiring Physician Order, dated 03/14/25, showed a list of residents with recommendations including the resident with a concern of wound healing and a recommendation of continued: 30 mL of Pro-stat BID to support wound healing. The column titled date completed was left blank. During an interview on 03/25/25, at 3:34 P.M., the Dietary Manager (DM) said the following: -He/she retrieved the white meal tray cards, as well as an index card box containing pink diet order slips; -He/she said the previous DM said the index card box contained the current resident diet orders; -The meal tray cards and diet slips should match; -The cook used the white meal tray cards when preparing/serving the resident meals; -The resident's white meal tray card, dated 03/01/25, showed a regular diet; -The resident's pink diet order slip, dated 03/07/25, showed fortified foods with meals. During an interview on 03/25/25, at 4:02 P.M., [NAME] A said he/she was not giving the resident any type of supplement or fortified foods and was not aware of any recommendations to do so. During an interview on 03/26/25, at 11:17 A.M., the resident said the Director of Nursing (DON) told the resident earlier today, on 03/26/25, that the facility was going to start giving him/her increased protein at each meal for wound healing. He/she had not received fortified foods or protein supplements before today. During an interview on 03/26/25, at 12:30 P.M., the DON said on 03/14/25, the RD recommended Pro-Stat, but the DON had not obtained physician orders and had not implemented the RD recommendations. The increased protein could help with the resident's pressure ulcer wound healing. 2. Review of Resident #2's face sheet showed the following: -admission date of 02/26/25; -Diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease with narrowing of the airways), Parkinson's disease, dementia, anxiety, depression, and dysphagia (difficulty swallowing). Review of the resident's admission MDS, dated [DATE], showed the following: -Moderately impaired cognitive skills; -Independent with eating, oral hygiene, toileting hygiene, transfers, and upper and lower body dressing; -Exhibited coughing or choking during meals of medication administration; -Height of 5 foot, 7 inches and weight of 74 pounds; -No significant weight loss of gain; -At risk for development of pressure ulcers. Review of the resident's physician orders showed an order, dated 02/26/25, for Level 7 regular diet. Review of the resident's weight record showed the following: -On 02/28/25, staff recorded a weight of 78.6 pounds; -On 03/03/25, staff recorded a weight of 77.4 pounds; -On 03/07/25, staff recorded a weight of 74.0 pounds; -On 03/10/25, staff recorded a weight of 73.1 pounds. Review of the resident's initial comprehensive nutrition assessment, dated 03/14/25, completed by the RD showed the following: -Diet was L7; -Resident able to make food preferences known; -Resident ate most meals in his/her room; -Current weight of 73 pounds; -Resident required assist/supervision to eat/drink; -Resident has his/her own teeth; -Greater than 5% weight change in the last month; -Resident's skin was intact. Review of the resident's progress note, dated 03/14/25 at 8:15 A.M., showed the following: -Resident received a regular diet with poor appetite. Meal intake had been less than 50% on average; -He/she took amortization (an antidepressant medication used to help resident's gain weight) which can help increase appetite; -Resident had his/her own teeth with no difficulty chewing/swallowing; -Current weight was 73 pounds, with an underweight BMI of 11.45; -The 03/06/25 skin assessment showed skin intact with no edema; -Given underweight BMI and poor intake, recommend super cereal (nutrient rich and fortified) with breakfast and house shakes three time per day; -RD will continue to monitor and follow up as needed. Review of the form titled, RD Recommendations Requiring Physician Order, dated 03/14/25, showed a list of residents with recommendations including the resident with a concerns of underweight and poor intake and recommendations of super cereal with breakfast and house shakes TID. The column titled date completed was left blank. Review of the resident's care plan, updated 03/18/25, showed the following: -Resident at risk for inadequate nutrition related to poor intake, and disease process; -Determine in collaboration with the RD, as appropriate, the number of calories and type of nutrients needed to meet my nutritional requirements; -Resident was currently level 7 regular diet; -Resident preferred to eat meals in his/her room, but will at times go to the dining room for meals, depending on mood and behaviors at mealtime; -Snacks as appropriate; -Weigh resident as ordered and inform physician of any significant changes. Review of the resident's weight record showed the following: -On 03/19/25, staff recorded a weight of 76.2 pounds; -On 03/25/25, staff recorded a weight of 76.4 pounds. Observation and interview of the resident on 03/25/25, at approximately 12:30 P.M. showed the following: -The resident sat in a wheelchair in his/her room with visitors; -Staff served the resident lunch in his/her room. The resident had smothered steak with gravy, mashed potatoes, peas, a roll, and angel food cake for dessert; -The resident consumed approximately 50% of his/her meal. Staff did not serve the resident a health shake or any other supplements; -The resident said he/she was not getting shakes and was unsure about super cereal. During an interview on 03/25/25, at 3:34 P.M., the DM said the following: -He/she retrieved the white meal tray cards, as well as an index card box containing pink diet order slips; -He/she said the previous DM said the index card box contained the current resident diet orders; -The resident's pink diet order slip, dated 02/27/25, showed a regular diet; -The resident's printed white meal tray card, dated 03/01/25, showed a regular diet; -The resident did not have any listed supplements on either card; -The pink order slips and white meal tray cards should list all supplements and should match. During an interview on 03/25/25, at 4:02 P.M., [NAME] A said the following: -He/she was not aware of the 03/14/25 dietary recommendations for the resident; -He/she was not giving the resident super cereal or house shakes. During an interview on 03/26/25, at 12:30 P.M., the DON said on 03/14/25, the RD recommended super cereal and health shakes for the resident, but the DON had not implemented these recommendations until today 03/26/25. The increased calories could potentially help the resident gain weight. 3. Review of Resident #3's face sheet showed the following: -admission date of 06/17/24; -Diagnoses of anemia and dementia. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognitive skills; -Dependent on staff assistance for eating and other activities of daily living (ADLs); -No swallowing issues; -Height of 5 foot, 2 inches and weight of 91 pounds; -No significant weight loss or gains; -Provided mechanically altered diet; -Expressed mouth or facial pain/discomfort or difficulty with chewing; -At risk for development of pressure ulcers. Review of the resident's weights showed the following: -On 09/03/24, staff recorded a weight of 96.0 pounds; -On 10/03/24, staff recorded a weight of 81.6 pounds; -On 10/14/24, staff recorded a weight of 87.0 pounds; -On 10/15/24, staff recorded a weight of 87.2 pounds; -On 10/31/24, staff recorded a weight of 81.0 pounds; -On 11/11/24, staff recorded a weight of 82. 0 pounds; -On 12/30/24, staff recorded a weight of 90.0 pounds; -Staff did not record a weight in January 2025. Review of the resident's physician order sheet an order, dated 01/02/25, for diet L5 (minced and moist). Review of the resident's care plan, dated 01/16/25, showed the following: -Resident at risk for inadequate nutrition related to poor intake, need for mechanically altered diet, and disease process; -Communicate with family regarding any food and wight issues; -Create a pleasant and relaxing atmosphere [NAME] eating to increase intake. Required one assist for eating; -Determine, in collaboration with the RD, as appropriate, the number of calories and type of nutrients needed to meet his/her nutritional requirements; -Encourage fluid intake; -Resident was a slow eater. Allow sufficient time to eat; -Resident currently on a mechanical diet; -Prefers to eat in the main dining room; -Nutritional supplements as appropriate; -Snacks as appropriate; -Weigh the resident as ordered and inform the physician of any significant changes. Review of the form titled, RD Clinical Reminders and Recommendations for Facility Staff, dated 02/13/25, showed a list of residents including the resident with a concern of no monthly weight (last weight in December). Review of the resident's weights showed: -On 02/28/25, staff recorded a weight of 90.8 pounds; -On 03/11/25, staff recorded a weight of 88.0 pounds. Review of the resident's progress note dated 03/14/25, at 9:25 A.M., showed the RD documented the following: -Resident received an MM5 diet and was assisted by staff at mealtimes; -Appetite was fair and meal intake had been about 50% on average; -Current weight was 88 pounds, indicated a 3% loss in the last week, but a desired 8% gain the last 5 months; -BMI remained underweight at 16.1; -Recommend providing 237 ml of Boost Breeze (supplement) with breakfast daily in place of juice to provide additional calories; -RD will continue to monitor and follow up as needed. Review of the form titled, RD Recommendations Requiring Physician Order, dated 03/14/25, showed a list of residents with recommendations including the resident with a concern of under weight and weight loss and a recommendation of providing 237 mL of Boost Breeze with breakfast daily in place of juice. The column titled date completed was left blank. Review of the resident's weights on 03/19/25, staff recorded a weight of 90.0 pounds. Review of the resident's nutrition quarterly review, dated 03/24/25, completed by the RD, showed: -Current diet of MM5; -Current weight of 90 pounds; -Weight change of 10% gain in 6 months; -Average intake percentage of 51%-75%; -Assistance provided; -Primary dining location was main dining room. Review of the resident's progress note dated 03/24/25, at 9:13 A.M., showed the RD documented the following: -RD completed quarterly review; -Resident received MM5 diet and was assisted by staff at mealtimes; -Resident appetite was fair and meal intake had been about 50% on average; -Current weight was 90 pounds and indicated a desired 10% gain in the last 5 month; -Resident remained underweight, BMI = 16.5; -Continue the recommendation to provide Boost Breeze with breakfast daily in place of juice to provide additional calories; -RD will continue to monitor and follow up as needed. Observation on 03/25/25, at 12:15 P.M., showed the Housekeeping Supervisor seated at the resident's table assisting the resident to eat. The resident did not appear to have any dietary supplements. During an interview on 03/25/25, at 3:34 P.M., the DM said the following: -He/she retrieved the white meal tray cards, as well as an index card box containing pink diet order slips; -He/she said the previous DM said the index card box contained the current resident diet orders; -The resident's printed white meal tray card, dated 03/01/25, showed a MM5 (minced and moist) diet, but did not list any supplements; -The resident had a total of three pink order slips in the index card box; -The first pink order slip, dated 06/17/24, showed a regular diet; -The second pink order slip, dated 07/02/24, showed mechanical soft diet; -The third pink order slip, dated 12/16/24, showed an order to discontinue house shakes, with no other information; -The DM said the resident should only have one pink order slip with current diet order including any supplements. During an interview on 03/25/25, at 4:02 P.M., [NAME] A said he/she generally gave the resident fortified cereal at breakfast. He/she was not aware of recommendations to give the resident Boost Breeze. During an interview on 03/26/25, at 9:19 A.M., the Housekeeping Supervisor said the following: -He/she assisted the resident with breakfast and lunch, approximately 3-4 times per week for the past 6 months; -The resident ate 50-75% of meals and drinks all fluids; -Over the last approximate 6 months when he/she was assisting the resident with his/her meal, dietary did not provide the resident with super cereal at breakfast, any shakes, or any Boost Breeze supplements. During an interview on 03/26/25, at 10:20 A.M. Certified Nurse Assistant (CNA) B said he/she assisted the resident at mealtime. Staff did not provide the resident with any shakes or Boost Breeze supplements. Observation and interview on 03/26/25 at 12:15 P.M., showed the following: -CNA C assisted the resident with eating his/her lunch; -The resident had a chocolate health shake; -CNA C asked the resident if he/she wanted to try the shake and the resident said yes. The CNA held the shake up to the resident mouth with a straw in it and the resident drank; -The CNA said this was the first time he/she had seen dietary provide a health shake to the resident. During an interview on 03/26/25, at 12:30 P.M., the DON said the following: -On 03/14/25, the RD recommended Boost Breeze, but the DON did not follow up on the RD's recommendations; -The added calories could help with weight gain; -The resident has expressed a desire to gain weight. 4. Review of Resident #4's face sheet showed the following: -admission date of 02/13/25; -Diagnoses included spastic quadriplegia cerebral palsy (a congenital disease affecting the muscles and movement of both the arms and legs and often the torso and face), and malnutrition. Review of the resident admission MDS, dated [DATE], showed the following: -Moderately impaired cognitive skills for daily decision making; -Dependent on staff assistance for eating and all other ADLs; -Swallowing disorder. Resident exhibited coughing or choking during meals, or administration of medications; -Height of 5 foot, 4 inches and weight of 127 pounds; -No significant weight loss or gain; -Provided mechanically altered diet. Review of the resident's physician order sheet showed the following diet order, dated 02/13/25, showed Level 4 pureed diet with nectar thick liquids. Review of the resident's weights showed the following: -On 02/17/25, staff recorded a weight of 126.6 pounds; -On 02/24/25, staff recorded a weight of 115.4 pounds. Review of the resident's initial comprehensive nutrition assessment, dated 02/25/25, and completed by the RD, showed the following: -Current diet order L4 puree with nectar consistency thickened liquids; -Unable to make food preferences known; -Location of most meals was in the main dining room; -Current height 5 foot 4 inches and current weight of 115 pounds; -Totally dependent on staff for assistance with eating and drinking; -No significant weight change; -Oral food intake 0%-25%. Review of the resident's progress note dated 02/25/25, at 9:01 A.M., showed the RD documented the following: -Resident was on a puree diet with nectar thick liquids; -Resident assisted to eat by staff at meals with poor appetite; -Resident had limited speech and could not make preferences known; -Meal intake had been less than 50% on average; -Current weight was 115 pounds with a low BMI of 19.8; -Given low BMI and poor intake, recommend adding 90 ml of VHC (very high calorie, a supplement) three times per day (TID); -RD will continue to monitor and follow up as needed. Review of the form titled, RD Recommendations Requiring Physician Order, dated 02/25/25, showed a list of residents with recommendations including the resident with a concern of poor intake and low BMI and a recommendations of 90 mL of Pro-stat TID. The column titled date completed was left blank. Review of the resident's care plan, dated 02/26/25, showed the following: -Resident at risk of inadequate nutrition related to dental concerns, poor intake, need for mechanically altered diet, and disease process; -Communicate with family regarding any food and wight issues; -Create a pleasant and relaxing atmosphere while eating to increase intake; -Determine, in collaboration with the RD, as appropriate, the number of calories and type of nutrients needed to meet his/her nutritional requirements; -Encourage fluid intake; -Resident currently on a pureed diet with nectar thick liquids; -Preferred to eat in the main dining room; -Required assist of one with eating -Nutritional supplements as appropriate; -Snacks as appropriate; -Weigh the resident as ordered and inform the physician of any significant changes. Review of the resident weights showed the following: -On 03/03/25, staff recorded a weight of 114.8 pounds; -On 03/07/25, staff recorded a weight of 107.6 pounds; -On 03/10/25, staff recorded a weight of 106.2 pounds. Review of the resident's progress notes, dated 03/14/25 at 8:47 A.M., showed the RD documented the following: -Resident was on pureed diet with nectar thick liquids; -Resident was assisted at meals with eating with poor appetite; -Resident had been refusing all meals as of late; -Resident had noted limited speech and could not make preferences known. Staff anticipated needs; -Current weight of 106 pounds with underweight BMI of 18.2; -Weight showed a 16% loss of 20 pounds in one month; -Skin stage 4 pressure ulcer to sacrum; -Continue recommendation to add 90 ml of VHC TID with medication pass; -Also recommend adding 30 mL of Pro-stat BID to support wound healing -Honor preferences and provide support/encouragement; -RD will continue to monitor and follow up as needed. Review of the form titled, RD Recommendations Requiring Physician Order, dated 03/14/25, showed a list of residents with recommendations including the resident with concerns of wound, weight loss, and underweight and a recommendation to continue recommendation to add 90 mL of Pro-stat TID with medication pass. Also recommended adding 30 mL Pro-stat BID to support wound healing. The column titled date completed was left blank. Review of the resident's weights showed the following: -On 03/19/25, staff recorded a weight of 106.0 pounds; -On 03/25/25, staff recorded a weight of 104.0 pounds. During an interview on 03/25/25, at 3:34 P.M., the DM said the following: -He/she retrieved the white meal tray cards, as well as an index card box containing pink diet order slips; -He/she said the previous DM said the index card box contained the current resident diet orders; -The resident's pink diet order slip, dated 02/13/25, showed a pureed diet with thickened liquids; -The resident's printed white meal tray card, dated 03/01/25, showed a pureed diet with nectar thick liquids. During an interview on 03/25/25, at 4:02 P.M., [NAME] A said the resident was challenging because he/she would not each much. He/she tried fortified foods, shakes, pudding, or ice cream in the past, but the resident would refuse those items. During an interview on 03/26/25, at 9:19 A.M., the Housekeeping Supervisor said the following: -He/she assisted the resident with breakfast and lunch 3 to 4 days per week; -He/she received thickened liquids and a pureed diet; -Dietary used to give the resident shakes, but their have been shakes for approximately 2 weeks; -The resident had a poor appetite, but would drink thickened coffee and tea. During an interview on 03/26/25, at 12:30 P.M., the DON said the RD had made recommendations for the resident to receive VHC and Prostat, but the DON had failed to follow up on the recommendations. The increased protein could help with the healing of the resident's pressure ulcer. 5. During an interview on 03/25/25, at 3:34 P.M., the DM said the following: -Management had not instructed him/her to review any recommendations from the RD; -He/she had not seen any recommendations from the RD; -He/she was unsure what fortified foods and super cereal were; -The diet order cards should match the tray cards and each resident should have one order card with current orders for meal/supplements. During an interview on 03/25/25, at 4:02 P.M., [NAME] A said the following: -Generally, if the RD made recommendations, the DON would bring the pink order slips to the DM; -Sometimes the RD made recommendation to the DM and he/she would go to nursing to obtain the physician order for diet changes/additions; -The index box of pink diet orders, was his/her, Bible and should contain the current orders for diet/supplements for each resident; -He/she made shakes at times, but he/she/he had not made any shakes for the past week; -The facility had not had a weight loss meeting that he/she could recall since January 2025; -For approximately the last month, he/she had not had time to update the resident diet cards. During an interview on 03/28/25, at 9:20 A.M., the RD said the following: -He/she visited the facility two times per month; -He/she followed up by sending all dietary/supplement recommendations in an e-mail to the DON and to the DM; -He/she expected the facility to follow up with the physician regarding implementation of his/her recommendations; -He/she sent the recommendations on the day of his/her visits/consults; -He/she checked to see if dietary recommendations from the previous visit were followed and if not, he/she documented continue the recommendation; -He/she had noticed issues, on occasion, with the facility not following up on his/her recommendations. During an interview on 03/26/25, at 12:30 P.M., the DON said the following: -The RD generally came to the facility two times per month; -He/she had not yet met the RD, because the RD came on days when the DON was not in the facility; -He/she did not get an e-mail of RD recommendations, but the Administrator printed off the RD recommendations and placed on the DON's desk; -He/she reviewed all resident progress notes daily Monday through Friday, when he/she was at work; -He/she was aware from reading progress notes, that the RD had made several recommendation for changes/supplements, but he/she was waiting on the printed off list of recommendations from the Administrator before making any dietary changes; -He/she generally reviewed the recommendations and notified the physician and placed the orders onto the physician order sheet and filled out pink dietary order slip and give to the DM; -Residents should have one dietary pink sheet containing all the current orders for diet and supplements; -The DON pulled the recommendations out of his/her desk and said he/she had not reviewed or implemented the recommendation form 02/13/25 or from 03/14/25; -Review and follow up on the RD recommendations was his/her responsibility, but he/she did not get it done; -He/she reviewed resident weights and mentioned residents with weight loss at morning stand-up meeting with department heads, but could not say that the facility had a formal weight loss meeting since he/she started in December 2024; -He/she planned to begin weekly weight meetings to discuss weight loss and any recommendations. During an interview on 03/25/25, at 4:28 P.M., the Administrator said the following: -The RD generally came to the facility two times per month; -The RD reviewed resident weights; -He/she received the RD recommendations via email and printed the recommendations; -He/she then placed the RD recommendations on the DON's desk; -The DON was responsible for reviewing the recommendations and obtaining physician orders and sending the orders/recommendations to the DM; -The DON should add the dietary orders to the resident's medical record or assign and nurse to do so; -The DM was responsible for adding to the meal ticket; -The Administrator was unsure if the DON had reviewed the 03/14/25 RD recommendations; -The Administrator was unsure if he/she gave a copy of the 03/14/25 RD recommendations to the DM; -The DON should review and address the RD recommendations within 24 to 48 hours; -The current DM had not yet received training; -The facility conducted a weekly at risk meeting on Thursday, but on 03/13/25, the staff did not have any RD recommendations and at the 03/20/25 meeting, staff failed to discuss residents with weight loss or the RD recommendations; -The pink diet order slip should be the most current diet order for each resident and each resident should have one card. MO00250213

Based on observation, record review, and interview, the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and physical, mental, and psychosocial well-being for residents when the facility to provide meaningful activities for all residents, including two residents (Resident #1 and #2), and failed to care plan one resident's (Resident #2) specific activity interest. A sample of 8 residents was selected for review. The facility census was 31. Review of the facility's policy titled Role of the Activity Director, dated 03/2012, showed the following: -The activity director provides a key role in enhancing the quality of a resident's daily life. The activity director plans and promotes meaningful activities based on the resident's interests and desires to provide a more homelike atmosphere in the facility; -Chart daily checklist of each resident's activities; post calendar of events where everyone can see it; secure entertainment well in advance and check with entertainers the day before; and schedule activities that will involve as many residents as possible. Review of the facility's policy titled Documentation, dated 03/2012, showed the following: -The following records must be kept by the activity director: progress notes maintained in resident's clinical record; participation attendance records maintained in resident's clinical record (when the form is complete; until form is complete activity director may keep in their office); activity calendar required to keep one year; and assessments - includes initial assessment, quarterly assessment, annual assessment and significant change. Review of the facility's policy titled Activity Programming, dated 03/2012, showed the following: -The activities services of each facility will plan, organize, and carry out a program of activities to meet individual resident needs. The program is designed to give residents entertainment, communication, exercise, relaxation and an opportunity to express their creative talent. Through the activities, residents can fulfill basic psychological, social and spiritual needs; -The activity director plans and organizes a program of approved activities for residents on a group level and for individuals, to meet the needs of the residents. A calendar of events will be posted on the activity bulletin board to inform residents, visitors and staff of scheduled activities. All staff is responsible for assisting residents to activities of their choice; -An activity program is planned for each resident as part of their total resident care by the activity director, in cooperation with nursing service and with physician approval; -The activity director will develop a monthly activity calendar based on the resident's needs and interests. The calendar should include a wide variety of activities to meet all aspects of daily living. activities should include, physical, spiritual, emotional, cognitive, sensory, work service related and fun recreational. Activities should be planned for both large and small groups; -When movies and trips are planned, the activities staff is responsible for obtaining film, VCR/DVD, TV, arranging transportation, arranging supervision of the activity, and encouraging resident participation. 1. Review of the facility's activity calendar, posted at the end of 400 Hall near the activities office, dated 02/2025, showed the following: -On 02/02/25, 02/03/25, 02/06/25, 02/07/25, 02/10/25, 02/13/25, and 02/14/25 no activities were scheduled; -On 02/01/25 and 02/08/25, movie was listed with no time noted; -On 02/04/25 and 02/11/25, Bingo was listed with no time noted; -On 02/05/25, at 2:00 P.M., birthday party; -On 02/05/25, pet therapy listed with no time noted; -On 02/09/25, at 1:00 PM., church; -On 02/12/25, from 1:00 P.M. to 2:00 P.M., pet therapy. 2. 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 04/24/24; -Diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures), diabetes, and peripheral vascular disease (a condition where the blood vessels outside the heart and brain become narrowed, blocked, or damaged). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/01/25, showed the following: -The resident was cognitively intact; -The resident did not have little interest or pleasure in doing things or feel down, depressed or hopeless; -The resident had social isolation sometimes; -The resident's preferences for customary routine and activities was not completed. Review of the resident's care plan, revised 01/09/25, showed the following: -He/she preferred activities that identified with his/her prior lifestyle, such as flea market shopping, outings with family, bingo, special events, and watching A&E (a television channel); -Encourage resident to become involved with activities. Provide him/her a monthly activity calendar and assist him/her to and from activities. Remind him/her about activities; -Spend one-on-one time with him/her as needed; -His/her family comes in and visits him/her often. When the resident's kids, grandkids, and great grandkids were here to visit him/her, he/she did not want to go to any group activities. He/she only wanted to visit with his/her grandbabies. Please respect his/her wishes and privacy. -He/she went out frequently with his/her family. His/her family member came in and had supper with him/her or brought his/her food almost every evening. Assist him/her with calling his/her kids or other family members as needed; -He/she liked to attend some group activities. Review showed the facility did not provide documentation related to the resident's activity attendance from 01/01/25 to 02/14/25. Review of the resident's progress notes, dated 01/01/25 through 02/14/25, showed no documentation by the Activity Director (AD). During an interview on 02/07/25, at 1:28 P.M., Certified Nursing Assistant (CNA) B said the following: -The resident complained about not having activities; -The CNA told the charge nurse and Administrator. The Administrator said they would figure something out, but had not done anything about it. During an interview on 02/07/25, at 2:45 P.M., the resident said the following: -The old AD moved to another facility; -The facility had no activities since the old AD left except a church group every now and then; -He/she would go to activities if the facility had them; -He/she missed participating in activities; -He/she now had nothing to do but watch TV and did not like this; -He/she had no quality of life without activities. During an interview on 02/14/25, at 7:34 A.M., the MDS Coordinator said the following: -The resident participated in activities when the facility had activities; -The resident mentioned they were tired of nothing going on. During an interview on 02/14/25, at 8:45 A.M., the Administrator said he/she had no documentation for the resident's participation in activities since 01/01/25. 3. Review of Resident #2's face sheet showed the following: -admission date of 07/01/24; -Diagnoses included dementia, anemia (a condition in which the body does not have enough healthy red blood cells or hemoglobin, the protein in red blood cells that carries oxygen) and heart failure. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident did not have little interest or pleasure in doing things or feel down, depressed or hopeless; -The resident's preferences for customary routine and activities was not completed. Review of the resident's care plan, revised 12/03/24, showed the following: -He/she was involved in activities most of the time related to increase in socialization. -Adjust activity to accommodate his/her energy level. Involve him/her with those who have shared interests. Provide activities that resembled his/her prior lifestyle. Provide opportunity for his/her expression of individuality. Provide opportunity to express spiritual needs and beliefs as he/she desired. Provide a setting in which activities were preferred. (Staff did not care plan related to specific activities for the resident.) Review of the resident's progress notes, dated 01/01/25 through 02/14/25, showed no documentation by the AD. Review showed the facility did not provide documentation related to the resident's activity attendance since 01/01/25. During an interview on 02/14/25, at 5:07 A.M., Registered Nurse (RN) F said the resident asked him/her the other day to put a movie on and he/she was not able to do this due to not having the equipment to play a movie at this time. During an interview on 02/14/25, at 7:14 A.M., the resident said the following: -The facility did not have an AD; -He/she liked activities, but the facility had not had any recently that he/she was aware of; -The facility did not have Bingo or movies and he/she liked to participate in both of those activities; -He/she just watched TV now, but he/she thought it would be nice to have something else to do. During an interview on 02/14/25, at 7:34 A.M., the MDS Coordinator said the following: -The resident participated in activities when the facility had activities; -The resident told him/her it was no use coming out of the room since there was nothing going on. During an interview on 02/14/25, at 8:45 A.M., the Administrator said the following: -The resident comes out of his/her room to talk to the staff; -He/she had no documentation of the resident's participation in activities since 01/01/25. 4. During an interview on 02/07/25, at 1:18 P.M., CNA A said the following: -The facility had not had an AD since 01/2025; -The residents had no activities except pet therapy; -When the old AD left, he/she showed staff where the Bingo items were to do with the residents; -The Administrator did not do any activities with the residents and floor staff did not have time to do activities with the residents. During an interview on 02/07/25, at 1:28 P.M., CNA B said the following: -The facility had no AD since the old AD left in 01/2025; -The residents had no activities unless floor staff did them and they did not have the time; -Department heads did not do activities with the residents; -The residents did not have activities unless an outside church came in the facility. During an interview on 02/14/25, at 4:00 A.M., CNA C said the following: -He/she did not know if the facility had an AD; -Residents had puzzles and books accessible to them. During an interview on 02/14/25, at 4:27 A.M., CNA D said the following: -The facility did not have an AD; -The AD used to do activities with the residents; -Residents complained about being bored. During an interview on 02/14/25, at 7:56 A.M., CNA H said the following: -The facility had no AD and no consistent activities; -Staff did not follow the activities calendar. During an interview on 02/14/25, at 4:57 A.M., [NAME] E said the following: -The facility did not have an AD, but he/she did not know how long ago the old AD left; -The facility had not done any scheduled activities with the residents since the AD left except pet therapy on Wednesdays. During an interview on 02/14/25, at 8:05 A.M., Licensed Practical Nurse (LPN) I said the following: -The facility had not had an AD since around the holidays; -The kitchen staff did paint nails the other day and CNAs try to play ball on the halls; -He/she did not know the last time the facility had a Bingo game; -The Administrator and Director of Nursing (DON) were responsible for ensuring activities were completed. During an interview on 02/14/25, at 5:07 A.M., RN F said the following: -The facility had not had an AD for 1 to 1.5 months; -The residents did not have activities like they were before the old AD left; -Staff had no way to play a movie for the residents since the old AD took the DVD player that belonged to him/her when he/she left; -He/she did not know who was responsible for completing activities with the residents; -The Administrator and DON were responsible to ensure the activities were completed. During an interview on 02/14/25, at 7:34 A.M., the MDS Coordinator said the following: -The facility had not had an AD for five to six weeks; -Since the AD left, the facility had Bingo once; -The residents were beginning to complain about nothing to do; -The Administrator did not complete any activities with the residents; -The Administrator was responsible for ensuring activities were provided for the residents. During an interview on 02/14/25, at 8:22 A.M., the DON said the following: -The facility had not had an AD for two to three weeks; -The facility had pet therapy and church on Wednesdays and Sundays; -Some CNAs painted fingernails the other day; -No staff played Bingo with the residents; -It was not appropriate to not have activities scheduled Mondays, Thursdays and Fridays. There should be activities mornings and afternoons daily; -The activity calendar was scarce; -He/she was not aware staff had no DVD player to play movies for residents; -The Administrator was responsible for ensuring activities were completed with residents. During interviews on 02/14/25, at 5:05 A.M. and 8:45 A.M., the Administrator said the following: -The facility had not had an AD for about a month; -Each department was completing an activity every once in awhile, churches came in and hospice did too; -The facility had puzzles for the residents; -The facility had not had Bingo for the last couple weeks; -It was not appropriate to not have any activities scheduled for the residents; -Normally the AD had documentation of residents participation in activities, but he/she did not believe they had any of this documentation since 01/01/25; -He/she was responsible for ensuring activities were completed with the residents and currently activities were not completed as often as he/she would like them to. MO00249151, MO00249180

Based on interview and record review, the facility failed to ensure all allegation of possible abuse were were reported to the state survey agency (Department of Health and Senior Services-DHSS) within the required time frame when staff did not report an allegations of possible abuse involving two residents (Resident #1 and Resident #2). The facility had a census of 39. Review of the facility's Abuse and Neglect policy titled, Reporting, undated, showed the following: -It is the policy of the facility that each resident will be free from abuse: -Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property, exploitation, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties; -It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The term abuse (abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation) will be used throughout this policy unless specifically indicated; -An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator; -The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements; -All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources, and misappropriation of resident property by facility employees, contract employees, volunteers, contract services, consultants, physicians, visitors, family members, or other individuals will be reported immediately but no later than the following timeframes. If abuse is alleged or the allegation results in serious bodily injury, the allegation must be reported within two hours after the allegation was made. If the allegation does not allege abuse or result in serious bodily injury, the report must be made within 24 hours after the allegation was made; -All employees of the facility are mandated reporters; -The facility will ensure that all reports are made within two hours (abuse or serious bodily injury) or 24 hours (non-abuse). The twp-hour timeframe must be met even during the night shift or during the weekend. 1. Review of Resident #1's face sheet showed the following: -admission date of 02/26/25; -Diagnoses included of chronic obstructive pulmonary disease (COPD - blocks airflow making if difficult to breathe), dementia, anxiety, depression, Parkinson's disease (an age-related degenerative brain condition, meaning it causes parts of the brain to deteriorate. It ' s best known for causing slowed movements, tremors, balance problems), psychosis, alcohol abuse, marijuana abuse, restlessness, and agitation. Review of the resident's admission Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 03/07/25, showed the following: -Clear speech; -Exhibited moderate cognitive impairment; -Experienced disorganized thinking (behavior fluctuates comes and goes, changes in severity); -Experienced delusions (misconceptions or beliefs that are firmly held, contrary to reality); -Exhibited verbal behaviors directed toward others (threatening, screaming, cursing) on one to three days of review period; -Exhibited physical behaviors not directed toward others on one to three days of review period; -Overall presence of behavioral symptoms; -Behaviors put the resident at a significant risk of physical illness or injury; -Behaviors had no impact on others; -Rejected cares on one to three days of review period; -Exhibited wandering on one to three days of review period (did not significantly intrude on privacy of activities of others); -Used walker for mobility device; -Able to independently go from lying to sitting, from sitting to standing, and transfer from chair to bed independently; -Independent with ambulation, once standing able to ambulate at least 150 feet. Review of the resident's care plan, dated 03/18/25, showed the following: -Resident may have socially inappropriate/disruptive behaviors at times, especially at night secondary to diagnosis; -Staff to administer medications, monitor and record side effects, and report any adverse side effects; -Allow the resident to have control over situations, if possible; -Avoid over-stimulation, do not try to redirect his/her delusion; -Do not engage the resident in sensitive topics that may trigger behaviors; -Resident occasionally wanders into other resident rooms. Staff to redirect the resident as quickly as possible and orient the resident to his/her current room; -Maintain a calm environment and approach with the resident; -Observe and report socially inappropriate/disruptive behaviors when around others; -Staff to remove the resident from other resident rooms and unsafe situations; -Set expectations and limits for the resident; -When the resident begins to become socially inappropriate/disruptive, provide comfort measures or basic needs (such as pain, hunger, toileting, too hot/cold food, etcetera). Review of the resident's progress note dated 04/11/25, at 5:03 A.M., showed staff documented the following: -At approximately 1:30 A.M., the nurse notified the on-call physician due to resident's behavior issues. the resident in the hallway with no pants urinating on the carpet. Certified nurse assistants (CNAs) and registered nurse (RN) were working with another resident at the time. The resident was redirected to his/her room and tucked back into bed. He/she was noted to be entering the room next door, turning on the lights and yelling at the resident to Get out of the bed! He/she was again redirected and was soon found on the bed next to her (he/she was on the resident's bed numerous times) and putting a tied gown around his/her roommate's (Resident #2) head and neck. Staff gave the resident a haldol injection and moved the resident to a vacant room. The resident bit a CNA during this process. The nurse contacted the resident's physician, the Director of Nursing (DON) and emergency medical services (EMS) and EMS transported the resident to the hospital. Review of resident and facility records showed staff did not document reporting the allegation of possible abuse to DHSS. Review of DHSS records showed staff did not report the allegation of possible abuse. Review of the resident's progress note dated 04/12/25, at 8:49 A.M., showed staff documented the following: -This shift the resident tried biting and hitting staff and screamed at various residents, chased them down the hallway and cursed at them for no reason. The resident continually tried to eat food off other resident's dirty plates as they are being prepared to be returned to the kitchen, takes food and drinks from trays that are in the process of being passed out to other residents. This is happening during shift change, report, the finishing of dinner and is despite constant redirection. He/she entered another resident's room numerous times and handled that resident's belongings. The resident touched the other resident, no inappropriate touching, but was unwelcome by the other resident. The resident went into several other resident rooms and tried to use other resident restrooms. The resident rummaged through other resident's belongings and yelled. He/she cursed at other residents and staff. Review of resident and facility records showed staff did not document reporting the allegation of possible abuse to DHSS. Review of DHSS records showed staff did not report the allegation of possible abuse. 2. Review of Resident #2's face sheet showed: -admission date of 03/26/25; -Diagnoses included dementia, recent urinary tract infection, and pneumonia. Review of the resident's admission MDS, dated [DATE], showed the following: -Resident admitted from the hospital on [DATE]; -Resident had unclear speech; -Severely impaired cognitive skills for daily decision making; -Short-term and long-term memory problem; -No behavioral symptoms; -No rejection of care; -Dependent on staff for dressing and mobility; -Required a wheelchair for a mobility device. Review of the resident's April 2025 progress notes showed no entries related to encounters or interactions with his/her roommate (Resident #1). 3. During an interview on 04/30/25, at 2:53 P.M., the MDS Coordinator/Care Plan Coordinator said the following: -Resident #1 and Resident #2 were roommates; -Staff reported Resident #1 was pulling the privacy curtain open and closed and telling staff he/she needed to care for Resident #1; -Resident #1 mistakenly thought Resident #2 was his/her child and would call out to Resident #2 using Resident #1's child's name; -Staff moved Resident #1 to another room temporarily due to Resident #1 keeping Resident #2 awake; -He/she was not aware of any physical contact or abuse between Resident #1 and Resident #2; -He/she was not aware of the progress note about Resident #1 placing a gown on the resident's head/neck; -If Resident #1 placed a gown around Resident #2's head and neck, the nurse should have reported to the DON or Administrator and the facility should have called the incident to DHSS as an allegation of possible physical/verbal altercation; -Staff have reported in morning meeting that Resident #1 yelled and cursed at other residents; -The facility should call in all allegations of resident abuse to the DHSS hotline within two hours. During an interview on 05/01/25, at 10:20 A.M., Nurse Assistant (NA) A said if a resident yelled or cursed at, or struck another resident, he/she would move the aggressive resident away from the other residents and immediately notify the charge nurse of the situation. During an interview on 05/01/25, at 10:28 A.M., RN B said the following: -On 04/11/25, during the night shift, Resident #1 had yelled, Shut up, shut up, shut up, while standing in the room with Resident #2; -Later that same night, the RN and a NA, heard Resident #1 yelling and entered the room; -Upon entering the room, Resident #2 was lying on his/her own bed on his/her back and Resident #1 was on top of Resident #2, straddling him/her; -Resident #1 had removed his/her hospital gown and wore only an incontinent brief; -Resident #1 was pressing the tied neck string of his/her hospital gown using both hands against the front of Resident #2's neck; -Resident #2 was dressed in pajamas and under covers; -Staff immediately intervened and removed Resident #1 from Resident #2's bed and assisted Resident #1 to another room; -The RN said he/she contacted the DON and told him/her about the incident, but could not recall exactly what details he/she relayed during the phone conversation; -The nurse then contacted the physician who gave an order to send Resident #1 to the hospital for evaluation; -The RN did not feel this incident was an example of resident to resident abuse because he/she did not think Resident #1 was trying to injure Resident #2, but instead was trying to get Resident #2 dressed; -If he/she observed the same scenario with residents that did not have dementia, he/she said that would be an allegation of resident to resident abuse and should be reported; -He/she did not hotline the incident to DHSS because he/she did not believe abuse, but did report the incident to the DON. During an interview on 05/01/25, at 11:25 A.M., Nurse Assistant (NA) C said the following: -If he/she observed resident to resident abuse or any type of abuse, he/she would immediately intervene and removed the resident from the situation; -He/she would then immediately report any allegation of abuse to his/her charge nurse; -Resident #1 had a history of becoming agitated in the evening; -Resident yelled and cursed at other residents at times, particularly if the other resident was in his/her way of moving forward; -At times, Resident #1 wandered into other resident rooms; -Staff intervene and redirect Resident #1 when he/she becomes agitated; -The NA notified his/her nurse of the resident's agitation, yelling, and cursing. During an interview on 05/03/25, at 6:13 A.M., Certified Nurse Assistant (CNA) G said the following: -He/she worked on the night shift on 04/11/25; -Resident #1 thought his/her roommate, Resident #2, was his/her child; -The CNA had been in the residents' room several times and each time Resident #1 appeared more aggravated and was yelling out his/her child's name to the roommate, Resident #2; -Resident #2 was, chattering, not making any sense just saying random words, per his/her usual; -He/she and the other staff working heard a noise and entered the room of Resident #1 and Resident #2; -Resident #1 was sitting on top of Resident #2 on Resident #2's bed, he/she was straddling Resident #2; -Resident #1 was yelling the name of his/her child over and over; -Resident #1 had the bottom edge of his/her hospital gown draped over Resident #2's head and face; -Staff immediately intervened and assisted Resident #1 off of Resident #2's bed and into another room; -The nurse on duty, RN B observed the entire situation; -He/she thought RN B notified the DON of the situation: -RN B sent the resident out to the hospital for evaluation; -If he/she observed resident to resident abuse, he/she would immediately intervene and attempt to stop the abuse and report to the charge nurse; -The facility was responsible for reporting all allegations of abuse to DHSS within two days. During an interview on 05/01/25, at 11:29 A.M., Certified Medication Technician (CMT) D said if he/she observed abuse, he/she would immediately report to the charge nurse. During an interview on 05/01/25, at 11:30 A.M., Licensed Practical Nurse (LPN) E said the following: -If he/she were notified of an allegation of abuse, he/she would assess the situation, removed the alleged perpetrator of the abuse, notify the Administrator, DON, or designated RN on call immediately; -He/she would notify the residents families and their physician; -All allegations of abuse should be reported to DHSS within 2 hours; -The resident was verbally abusive to others, residents and staff when he/she yelled and cursed at others; -The nurse reported to the resident's behaviors to the DON in the past; -He/she had never observed the resident being physically abusive to any resident; -He/she was not aware the resident got in bed with another resident; -If the nurse was aware of Resident #1 getting into bed with Resident #2 or of the interaction, he/she would have intervened and notified the DON. During an interview on 05/01/25, at 12:13 P.M., the DON said the following: -He/she received a phone call from the charge nurse on duty at the facility on 04/11/25 at approximately 1:11 A.M.; -The DON did not recall exactly what the charge nurse reported about the incident between Resident #1 and Resident #2; -The nurse did tell the DON that Resident #1 was pressing anything against the front of Resident #2's neck, if the DON were aware of that, he/she would have immediately came to the facility, notified the Administrator, and hotlined the incident to state (DHSS); -The DON said he/he would have called the hotline about the issue because it would have been an allegation of potential resident to resident physical abuse; -The DON said no one told him/her Resident #1 was holding a hospital gown against Resident #2's neck. During an interview on 05/01/25, at 12:52 P.M., the Administrator said the following: -Regarding the 04/11/25 incident between Resident #1 and Resident #2, staff told the Administrator Resident #1 was attempting to dress Resident #2; -Resident #1 thought Resident #2 was his/her child at times and wanted Resident #2 to get up out of bed; -Staff did get a physician's order and send Resident #1 out to the hospital for an evaluation; -The Administrator said, if he/she was aware of the incident between Resident #1 and Resident #2 on 04/11/25, he/she would have hotlined the incident to DHSS as an allegation of resident to resident physical abuse within two hours of the time of the incident; -All allegations of abuse should be reported to the DON or myself immediately and reported to DHSS within two hours.

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were fully and timely investigated when staff did not complete investigations of allegations of possible resident to resident abuse involving two residents (Resident #1 and Resident #2). The facility census was 39. Review of the facility abuse policy titled, Investigation, undated, showed the following: -It is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated; -The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. When an incident or suspected incident of abuse is reported, the Administrator or Designee will investigate the incident with the assistance of appropriate personnel. -The investigation will include who was involved; residents' statements (for non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings); resident's roommate statements (if applicable); interviews obtained from three to four residents who received care from the alleged staff; interviews obtained from three to four different department staff, (if applicable); involved staff and witness statements of events; a description of the resident's behavior and environment at the time of the incident; injuries present including a resident assessment; observation of resident and staff behaviors during the investigation; and environmental considerations. All staff must cooperate during the investigation to assure the resident is fully protected. 1. Review of Resident #1's face sheet showed the following: -admission date of 02/26/25; -Diagnoses included of chronic obstructive pulmonary disease (COPD - blocks airflow making if difficult to breathe), dementia, anxiety, depression, Parkinson's disease (an age-related degenerative brain condition, meaning it causes parts of the brain to deteriorate. It ' s best known for causing slowed movements, tremors, balance problems), psychosis, alcohol abuse, marijuana abuse, restlessness, and agitation. Review of the resident's admission Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 03/07/25, showed the following: -Clear speech; -Exhibited moderate cognitive impairment; -Experienced disorganized thinking (behavior fluctuates comes and goes, changes in severity); -Experienced delusions (misconceptions or beliefs that are firmly held, contrary to reality); -Exhibited verbal behaviors directed toward others (threatening, screaming, cursing) on one to three days of review period; -Exhibited physical behaviors not directed toward others on one to three days of review period; -Overall presence of behavioral symptoms; -Behaviors put the resident at a significant risk of physical illness or injury; -Behaviors had no impact on others; -Rejected cares on one to three days of review period; -Exhibited wandering on one to three days of review period (did not significantly intrude on privacy of activities of others); -Used walker for mobility device; -Able to independently go from lying to sitting, from sitting to standing, and transfer from chair to bed independently; -Independent with ambulation, once standing able to ambulate at least 150 feet. Review of the resident's care plan, dated 03/18/25, showed the following: -Resident may have socially inappropriate/disruptive behaviors at times, especially at night secondary to diagnosis; -Staff to administer medications, monitor and record side effects, and report any adverse side effects; -Allow the resident to have control over situations, if possible; -Avoid over-stimulation, do not try to redirect his/her delusion; -Do not engage the resident in sensitive topics that may trigger behaviors; -Resident occasionally wanders into other resident rooms. Staff to redirect the resident as quickly as possible and orient the resident to his/her current room; -Maintain a calm environment and approach with the resident; -Observe and report socially inappropriate/disruptive behaviors when around others; -Staff to remove the resident from other resident rooms and unsafe situations; -Set expectations and limits for the resident; -When the resident begins to become socially inappropriate/disruptive, provide comfort measures or basic needs (such as pain, hunger, toileting, too hot/cold food, etcetera). Review of the resident's progress note dated 04/11/25, at 5:03 A.M., showed staff documented the following: -At approximately 1:30 A.M., the nurse notified the on-call physician due to resident's behavior issues. the resident in the hallway with no pants urinating on the carpet. Certified nurse assistants (CNAs) and registered nurse (RN) were working with another resident at the time. The resident was redirected to his/her room and tucked back into bed. He/she was noted to be entering the room next door, turning on the lights and yelling at the resident to Get out of the bed! He/she was again redirected and was soon found on the bed next to her (he/she was on the resident's bed numerous times) and putting a tied gown around his/her roommate's (Resident #2) head and neck. Staff gave the resident a haldol injection and moved the resident to a vacant room. The resident bit a CNA during this process. The nurse contacted the resident's physician, the Director of Nursing (DON) and emergency medical services (EMS) and EMS transported the resident to the hospital. Review of the resident and facility records showed staff did not document an investigation completed of the allegation of possible abuse to DHSS. Review of DHSS records showed staff did not provide an investigation of the allegation of possible abuse. Review of the resident's progress note dated 04/12/25, at 8:49 A.M., showed staff documented the following: -This shift the resident tried biting and hitting staff and screamed at various residents, chased them down the hallway and cursed at them for no reason. The resident continually tried to eat food off other resident's dirty plates as they are being prepared to be returned to the kitchen, takes food and drinks from trays that are in the process of being passed out to other residents. This is happening during shift change, report, the finishing of dinner and is despite constant redirection. He/she entered another resident's room numerous times and handled that resident's belongings. The resident touched the other resident, no inappropriate touching, but was unwelcome by the other resident. The resident went into several other resident rooms and tried to use other resident restrooms. The resident rummaged through other resident's belongings and yelled. He/she cursed at other residents and staff. Review of resident and facility records showed staff did not document investigation of the allegation of possible abuse to DHSS. Review of DHSS records showed staff did not provide an investigation of the allegation of possible abuse. 2. Review of Resident #2's face sheet showed: -admission date of 03/26/25; -Diagnoses included dementia, recent urinary tract infection, and pneumonia. Review of the resident's admission MDS, dated [DATE], showed the following: -Resident admitted from the hospital on [DATE]; -Resident had unclear speech; -Severely impaired cognitive skills for daily decision making; -Short-term and long-term memory problem; -No behavioral symptoms; -No rejection of care; -Dependent on staff for dressing and mobility; -Required a wheelchair for a mobility device. Review of the resident's April 2025 progress notes showed no entries related to encounters or interactions with his/her roommate (Resident #1). 3. During an interview on 05/01/25, at 10:20 A.M., Nurse Assistant (NA) A said if a resident yelled or cursed at, or struck another resident, he/she would move the aggressive resident away from the other residents and immediately notify the charge nurse of the situation. During an interview on 05/01/25, at 11:25 A.M., Nurse Assistant (NA) C said the following: -If he/she observed resident to resident abuse or any type of abuse, he/she would immediately intervene and removed the resident from the situation; -He/she would then immediately report any allegation of abuse to his/her charge nurse; -Resident #1 had a history of becoming agitated in the evening; -Resident yelled and cursed at other residents at times, particularly if the other resident was in his/her way of moving forward; -At times, Resident #1 wandered into other resident rooms; -Staff intervene and redirect Resident #1 when he/she becomes agitated; -The NA notified his/her nurse of the resident's agitation, yelling, and cursing. During an interview on 05/03/25, at 6:13 A.M., Certified Nurse Assistant (CNA) G said the following: -He/she worked on the night shift on 04/11/25; -Resident #1 thought his/her roommate, Resident #2, was his/her child; -The CNA had been in the residents' room several times and each time Resident #1 appeared more aggravated and was yelling out his/her child's name to the roommate, Resident #2; -Resident #2 was, Chattering, not making any sense just saying random words, per his/her usual; -He/she and the other staff working heard a noise and entered the room of Resident #1 and Resident #2; -Resident #1 was sitting on top of Resident #2 on Resident #2's bed, he/she was straddling Resident #2; -Resident #1 was yelling the name of his/her child over and over; -Resident #1 had the bottom edge of his/her hospital gown draped over Resident #2's head and face; -The CNA said both Resident's were clothed, and he/she did not think Resident #1 was holding the gown against Resident #2's neck/face; -Staff immediately intervened and assisted Resident #1 off of Resident #2's bed and into another room; -RN B sent the resident out to the hospital for evaluation; -If he/she observed resident to resident abuse, he/she would immediately intervene and attempt to stop the abuse and report to the charge nurse. During an interview on 05/01/25, at 11:29 A.M., Certified Medication Technician (CMT) D said if he/she observed abuse, he/she would immediately report to the charge nurse. During an interview on 05/01/25, at 11:30 A.M., Licensed Practical Nurse (LPN) E said the following: -If he/she were notified of an allegation of abuse, he/she would assess the situation, removed the alleged perpetrator of the abuse, notify the Administrator, Director of Nursing, or designated RN on call immediately; -He/she would notify the residents families and their physician; -The resident was verbally abusive to others, residents and staff when he/she yelled and cursed at others; -The nurse reported to the resident's behaviors to the DON in the past; -If the nurse was aware of Resident #1 getting into bed with Resident #2 or of the interaction, he/she would have intervened and notified the DON. During an interview on 05/01/25, at 10:28 A.M., RN B said the following: -On 04/11/25 during the night shift, Resident #1 had yelled, Shut up, shut up, shut up, while standing in the room with Resident #2; -Later that same night, the RN and a nurse assistant, heard Resident #1 yelling and entered the room; -Upon entering the room, Resident #2 was lying on his/her own bed on his/her back and Resident #1 was on top of Resident #2, straddling him/her; -Resident #1 had removed his/her hospital gown and wore only an incontinent brief; -Resident #1 was pressing the tied neck string of his/her hospital gown using both hands against the front of Resident #2's neck; -Staff immediately intervened and removed Resident #1 from Resident #2's bed and assisted Resident #1 to another room; -The RN said he/she contacted the DON and told him/her about the incident, but could not recall exactly what details he/she relayed during the phone conversation; -The nurse then contacted the physician who gave an order to send Resident #1 to the hospital for evaluation; -The nurse did not feel this incident was an example of resident to resident abuse because he/she did not think Resident #1 was trying to injure Resident #2, but instead was trying to get Resident #2 dressed; -If he/she observed the same scenario with residents that did not have dementia, he/she said that would be an allegation of resident to resident abuse and should be reported. During an interview on 04/30/25, at 2:53 P.M., the MDS Coordinator/Care Plan Coordinator said the following: -Resident #1 and Resident #2 were roommates; -Staff reported Resident #1 was pulling the privacy curtain open and closed and telling staff he/she needed to care for Resident #1; -Resident #1 mistakenly thought Resident #2 was his/her child and would call out to Resident #2 using Resident #1's child's name; -Staff moved Resident #1 to another room temporarily due to Resident #1 keeping Resident #2 awake; -He/she was not aware of any physical contact or abuse between Resident #1 and Resident #2; -He/she was not aware of the progress note about Resident #1 placing a gown on the resident's head/neck; -If Resident #1 placed a gown around Resident #2's head and neck, the nurse should have reported to the DON or Administrator and the facility should have called the incident to DHSS as an allegation of possible physical/verbal altercation; -Staff have reported in morning meeting that Resident #1 yelled and cursed at other residents; -The facility administrator should investigate all allegations of resident abuse and submit to DHSS within five days. During an interview on 05/01/25, at 12:13 P.M., the DON said the following: -He/she received a phone call from the charge nurse on duty at the facility on 04/11/25 at approximately 1:11 A.M.; -The DON did not recall exactly what the charge nurse reported about the incident between Resident #1 and Resident #2; -The nurse did not tell the DON that Resident #1 was pressing anything against the front of Resident #2's neck, if the DON were aware of that, he/she would have immediately came to the facility, notified the Administrator, and hotlined the incident to state (DHSS); -The DON said the Administrator completed abuse investigations within five days and submitted to DHSS; -This allegation was not investigated, to his/her knowledge. During an interview on 05/01/25, at 12:52 P.M., the Administrator said the following: -Regarding the 04/11/25 incident between Resident #1 and Resident #2, staff told the Administrator Resident #1 was attempting to dress Resident #2; -Resident #1 thought Resident #2 was his/her child at times and wanted Resident #2 to get up out of bed; -Staff did get a physician's order and send Resident #1 out to the hospital for an evaluation; -The Administrator said, if he/she was aware of the incident between Resident #1 and Resident #2 on 04/11/25, he/she would have hotlined the incident to DHSS as an allegation of resident to resident physical abuse within two hours of the time of the incident; -He/she expected the nurse to moved Resident #1 away from other residents and ensure Resident #2 was safe and not injured, call and notify Resident #2's family, physician, and notify the Ombudsman; -For any allegation of resident abuse, he/she would investigate the abuse, to include interviews with staff and residents, and notify DHSS of results of the abuse investigation within five days per the facility policy.

Based on observation, record review, and interview, the facility failed to provide care to all pressure ulcers per standards of practice when the facility failed to have a system in place to obtain wound care orders, ensure timely implementation of new wound care orders, to ensure timely physician notification of wounds, and to document and track wounds timely and completely for one resident (Resident #3) who admitted with stage 2 pressure ulcers (a partial thickness skin loss, appearing as a shallow open sore or a blister, where the top layer of skin (epidermis) and potentially the deeper layer (dermis) are damaged, resulting in a red or pink wound bed without exposed muscle or bone; it can also present as an intact or ruptured blister) on his/her buttocks. A sample of 8 residents was reviewed in the facility with a census of 31. Review of the facility's policy titled Wound Protocol, dated 2018, showed the following: -Chronic wounds should be dressed using a clean technique unless physician's orders state otherwise; -Wounds should be cleansed with a non-toxic agent; -Select a dressing that keeps the wound bed moist and the periwound skin dry, it should be at least 2 larger than the affected area; -Reevaluate dressing and skin integrity every shift. -Reevaluate the wounds response to the prescribed treatment on a regular basis, and when needed make recommendations for treatment changes and inform the physician of changes in wound status; thoroughly document all wound information such as type, location, stage (if applicable), length, width, depth, drainage, notation of tunneling (wound that extends from the surface of the skin into deeper layers of tissue, forming a narrow channel or tunnel) or undermining (tissue under the wound has eroded, creating a pocket beneath the skin), description of tissue (necrotic, granulating, etc.), state of periwound area, treatment of wound, etc.; notify appropriate personnel of all new pressure ulcers, or if you have any questions; and educate residents families, friends and staff on interventions (such as weight shifting in bed or chair) to prevent skin breakdown. Review of the facility's Nursing admission Checklist, undated, showed nurse to complete initial skin assessment, use the weekly skin assessment observation, update the wound management tab, and obtain any treatment orders if necessary. 1. Review of Resident #3's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 01/17/25; -Diagnoses included fractured rib, altered mental status, and diabetes. Review of the resident's 5-day, Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), showed the following: -The resident had severe cognitive impairment; -The resident was dependent for all Activities of Daily Living (ADL - dressing, eating, bathing, etc.) and bed mobility; -The resident had a stage 1 (the earliest stage of a pressure sore, characterized by a localized area of non-blanchable redness on intact skin, usually over a bony prominence, which may appear red, blue, or purplish and feel warm to the touch, but without any open wounds or skin breakdown) or greater, a scar over bony prominence, or a non-removable dressing/device. -The resident was at risk for developing pressure ulcers. -The resident had one or more unhealed pressure ulcer(s) at Stage 1 or higher. -The resident had one Stage 2 pressure ulcer that was present upon admission. -The resident had a pressure reducing device for chair and bed, pressure ulcer care, application of nonsurgical dressings (with or without topical medications) other than feet, and application of ointments. Review of the resident's baseline care plan, dated 01/17/25, showed the following: -Staff to monitor medications, condition, and report changes to Director of Nursing (DON)/physician as applicable and lab values and report to physician. -Follow skin/wound treatment orders. Review of the resident's initial and weekly wound documentation, dated 01/18/25, showed the following: -The resident had pressure sore on bilateral buttocks that was present upon admission; -Current measurement showed see wound management; -The pressure ulcer was stage 2 and did not show tunneling, undermining, or sinus tract; -The pressure ulcer had granulation tissue (new, pink or red, fleshy tissue that forms over a healing wound) that was pink or red tissue with shiny, moist, granular appearance; -The pressure ulcer had no exudate (fluid that drains from a pressure ulcer as part of the healing process) and no odor; -The surrounding tissue/periwound area had erythema (redness of the skin); -Interventions included pressure reducing device for bed, turning and repositioning program, pressure ulcer care, and application of nonsurgical dressings (with or without topical medications) other than the feet; -Staff took measures including cleansing the wound and applying a mepilex (foam dressing for wound care) dressing; Continue treatment with no change, the physician was notified, and plan of care initiated. Review of the resident's January 2025 Physician's Order Sheet (POS), dated 01/2025, showed the following: -An order, dated 01/20/25, for the wound care provider to eval and treat; -Staff did not document obtaining order for treatment of the the stage 2 pressure ulcer on the resident's bilateral buttocks. Review of the resident's January 2025 Medication Administration Record (MAR) showed staff did not document treatments completed to the resident's stage 2 pressure ulcer. Review of the resident's wound management showed staff did not document measurements of the resident's stage 2 pressure ulcer. Review of the resident's nurses' progress notes, dated 01/17/25 through 01/23/25, showed the following: -On 01/17/25, at 6:27 P.M., the resident arrived to the facility via emergency medical services (EMS). He/she had multiple bruises and two small open areas to his/her bottom. His/her bilateral heels were firm and intact; -On 01/18/25, at 5:17 A.M., bilateral buttocks pressure wounds stage 2 noted. Staff cleansed and mepilex dressings applied until further orders are received. These were present on admission. Excoriated skin in groin folds cleansed and moisture barrier cream applied; -On 01/18/25, at 10:42 P.M., resident was taken to shower room and given good pericare with warm, soapy water. Groin area treated with zinc moisture barrier paste and bilateral buttock wounds treated with TAB ointment (an antibiotic ointment). Staff noted facility had no calcium alginate (a wound dressing) that could be found and added to supply request form. New dressings applied to bilateral buttocks and arm wounds cleansed and redressed; -On 01/20/25, at 3:12 P.M., (recorded as a late entry on 01/22/25 at 3:12 P.M.) the resident had two open areas to his/her bottom. Referral to wound care provider obtained and consent signed; -On 01/20/25, at 5:00 P.M., through 01/23/25, at 2:13 A.M., showed staff did not document regarding the stage 2 pressure ulcers on the resident's buttocks nor any treatment for the stage 2 pressure ulcers. (Staff did not document physician notification to request orders, or follow-up on an orders request.) During an interview on 02/14/25, at 7:09 A.M., Certified Nursing Assistant (CNA) B said the resident had open areas on his buttocks and the nurses did treatment on the wounds from what he/she remembered. During interviews on 02/07/25, at 1:28 P.M., and 02/14/25, at 7:09 A.M., CNA B said if he/she noticed a new area on a residents skin, he/she reported this to the charge nurse and the nurse assessed the resident. During an interview on 02/14/25, at 4:00 A.M., CNA C said the following: -If he/she noticed a new area on a residents skin, he/she told the charge nurse; -The charge nurse assessed the resident and started a treatment if needed; -He/she believed the charge nurse called the physician to get physician's orders for wound care if the resident did not have them. During an interview on 02/14/25, at 4:27 A.M., CNA D said the following: -If he/she noticed a new reddened area on a resident, he/she told the charge nurse; -The charge nurse assessed the resident and started a treatment; -He/she believed the nurse got an order for treatment of pressure ulcers from the physician. During an interview on 02/14/25, at 7:56 A.M., CNA H said the resident had wounds and he/she believed the wounds were treated. If he/she noticed a new area on a residents skin, he/she notified the charge nurse immediately, cleaned the area and applied cream if needed. The charge nurse assessed the resident. During an interview on 02/14/25, at 7:00 A.M., Certified Medication Technician (CMT) G said the following: -If he/she noticed a new area on a resident's skin, he/she reported this to the charge nurse; -The charge nurse assessed the resident and notified the physician to obtain physician's orders. During an interview on 02/14/25, at 8:05 A.M., Licensed Practical Nurse (LPN) I said the following: -The resident had wounds on his/her buttocks, but no wound care orders for those wounds; -The resident should have had orders for treatment of these wounds; -Nurses should have completed treatments on the resident's wounds. -If the aides noticed a new area on a resident's skin, they notified the charge nurse immediately; -He/she assessed and measured the wound and notified the physician to obtain wound care orders; -If a resident admitted with stage 2 pressure ulcers and did not have orders, the charge nurse notified the physician to obtain treatment orders; -The charge nurse was responsible for obtaining wound care orders from a residents physician. During an interview on 02/14/25, at 5:07 A.M., Registered Nurse (RN) F said the following: -The resident admitted with two open areas on his/her buttocks; -The resident had an order for wound care provider to evaluate and treat, but did not have any treatment orders for a treatment of the wounds on the resident's buttocks; -The resident should have had physician's orders for a treatment of his/her buttocks; -He/she saw a note written on 01/18/25 the wound was cleansed and mepilex applied until further instructions; -He/she did not see any physician's orders entered for treatment of the pressure ulcer; -If the aides noticed a new area on a resident's skin, they should notify the charge nurse immediately; -The charge nurse assessed the resident and, if the area needed a treatment, contacted the physician to get treatment orders; -If a resident was admitted with a stage 2 pressure ulcer and did not have treatment orders, he/she called the physician and received treatment orders; -He/she knew a resident had wound treatment orders by looking at the progress notes, through report or looking at the MAR; -The charge nurse was responsible for obtaining physician's orders for treatment of a pressure ulcer from the resident's physician. During an interview on 02/14/25, at 7:34 A.M., the MDS Coordinator said the following: -The resident had open area on his/her buttocks that were stage 2; -The charge nurse did not document anything in the wound management tab; -The resident had no orders for wound care of the stage 2 pressure ulcers on his/her buttocks; -The resident had an order for wound care provider, but they did not get to see the resident before he/she declined; -The resident should have orders for wound care on his/her stage 2 pressure ulcer on his/her buttocks; -If a resident was admitted with a pressure ulcer, the charge nurse should assess the wound, measure the wound, check for physician's orders and clarify them if needed and ensure the resident had any special equipment if needed; -If the resident did not have any wound care orders, the charge nurse called the physician to obtain the orders; -The charge nurse and DON were responsible for ensuring a resident had wound care orders. During an interview on 02/14/25, at 8:22 A.M., the DON said the following: -The resident admitted with open area on his/her buttocks; -The resident had an order for wound care provider to evaluate and treat, but no treatment orders for the pressure ulcers; -The charge nurse should have obtained treatment orders from the resident's physician; -He/she could not say if treatment was done due to the resident had not orders for treatment. -If a resident was admitted with pressure ulcers, the charge nurse referred to wound care provider and until they saw the resident, followed the orders from the hospital or obtained treatment orders from the resident's physician; -He/she was responsible for ensuring the charge nurses obtained treatment orders for pressure ulcers. During an interview on 02/14/25, at 8:45 A.M., the Administrator said the following: -The nurse should have obtained treatment orders for the resident's pressure ulcers; -He/she did not know if the resident's pressure ulcers were treated, but nurse's should have completed them; -The resident did not have wound care orders for his/her pressure ulcers on his/her buttocks but the nurse's should have obtained orders from the resident's physician. -If a resident admitted with a pressure ulcer, the charge nurse ensured the facility had the supplies on hand if they knew about it before the resident admitted ; -The charge nurse assessed the pressure ulcer, obtained orders for treatment from the resident's physician and obtain orders for wound care plus or an outside wound care clinic if needed; -If the charge nurse obtained an order for wound care plus, they should still obtain orders for treatment and complete the treatments until wound care plus could see the resident; -The charge nurse was responsible for obtaining wound care orders and completing the treatments and the DON was responsible for ensuring this was completed. MO00249151